Fight the Fear: Your Guide to Panic Attacks & Panic Disorder

Thirty-two-year-old Rajesh (name changed for privacy) was on track for a promotion to project lead at his company. He had just returned from a relaxing three-day vacation with his wife and was spending his Sunday playing football with his two young sons. On the surface, life seemed perfect, right?

But even on that open, sunny field, Rajesh suddenly felt he couldn't breathe. A chill ran down his spine, and he recognised the growing tide of fear threatening to overwhelm him. It was a secret he kept well hidden, but as the episodes occurred more often, it became more difficult to do so. 

Rajesh was battling an invisible enemy — a panic disorder that he could not control. Read on to understand more about the condition.

A diagnosis of a panic disorder is not given lightly. It usually starts with a rising number of panic attacks. Let's understand what happens during these brief terror spells. 

Panic attacks often occur unexpectedly. It is a sudden, intense episode of fear or anxiety that manifests physical reactions when there is no real danger or apparent cause.

While not dangerous themselves, panic attacks can be very disruptive. These attacks are a hallmark of panic disorder but can also occur with other anxiety disorders, which are pretty common in India. Around 74% of Indians experience stress, and an even higher number, 88%, experience some form of anxiety disorder. The number of cases has risen significantly since the pandemic.

While panic attacks hit hard and fast, anxiety attacks tend to build gradually in response to stress. Both can cause physical symptoms like a racing heart, but panic attack symptoms are very intense but brief, lasting between 5 and 20 minutes. Anxiety attacks may be less intense but can last longer.

If you experience frequent panic attacks, it's important to seek help, as they can significantly impact your quality of life. Rajesh first experienced a panic attack while driving to work. His heart raced; he felt dizzy and struggled to breathe. The fear made him pull over to the side of the road. He thought he was having a heart attack. After a few minutes, he managed to get to a doctor, where a battery of tests revealed normal heart functions — both on an ECG and blood work. This terrifying episode marked the beginning of his journey with panic attacks.

After several more episodes, Rajesh realised that his condition was more than just occasional stress. He was referred to a psychiatrist, who diagnosed him with panic disorder.

"Not every individual who has a panic attack will go on to have panic disorder," says Dr Aditi Chandrashekar Acharya, a Mumbai-based psychiatrist. "It's important to understand the difference between the two."

A panic disorder (PD) is characterised by recurrent, unexpected panic attacks and the ever-present fear of experiencing another attack. It affects a small but significant portion of the Indian population.

Around 0.5% of Indians will experience PD at some point in their lives, which is similar to rates in China and Japan. This number is lower than in Western countries and the United States, where lifetime prevalence can be as high as 3.7%.

While panic disorder affects people across demographics, some factors seem to influence risk. Older adults, those who are unmarried or widowed, and people living in urban areas tend to have higher rates. This suggests that life stage, social support, and possibly the stresses of city life can play a role. Interestingly, men and unemployed individuals appear to have a lower risk of developing PD.

Panic disorders often go hand-in-hand with other mental health conditions, including mood disorders, phobias, and even substance abuse. Agoraphobia (an intense fear and avoidance of situations where one might feel trapped, helpless, or embarrassed), depression, and generalised anxiety disorder (GAD) are the most common co-occurring issues. A concerning finding is that almost 3% of people with panic disorders also experience suicidal thoughts.

Many experience some degree of disability, affecting both work and social life. Despite the clear need for help, there is a lack of treatment for panic disorders in India. Over 70% of those with panic disorders don't receive any form of treatment, with the gap being even wider for women and those living in rural areas. A major obstacle is the social stigma associated with mental health conditions, which makes people hesitant to seek help.

After several more episodes, Rajesh realised that his condition was more than just occasional stress. His doctor recommended a visit to a psychiatrist, who diagnosed him with a panic disorder. Unwilling to try medications at first, he began therapy sessions to help him deal with his symptoms. Like most patients with a panic disorder, his persistent worry about having another panic attack began to dominate his thoughts.

Panic attacks and panic disorder may be due to genetic, biological, environmental, and psychological factors. The exact reason behind panic attacks remains unclear; however, several contributing factors have been pinpointed by researchers:

• Brain and nervous system: The amygdala, which processes fear and emotions, might malfunction. Imbalances in brain chemicals like GABA, cortisol, and serotonin are suspected to play a role.
• Genetics: Having a close relative (parent, sibling, child) with panic disorder increases your risk by 40%.
• Mental health conditions: Existing anxiety disorders, depression, or other mental health conditions can make you more prone to panic attacks.
• Adverse Childhood Experiences (ACEs): ACEs, which are traumatic events between ages 1–17, can contribute to panic attacks and disorder development.

While panic attacks can strike without warning, some potential triggers include:

• Phobias: Fear of specific things, like a fear of needles or heights, can trigger attacks in those who have them.
• Fear of another attack: Ironically, the fear of having another panic attack can sometimes trigger one.

Some researchers believe panic attacks are like ‘false alarms’ of the body's natural fight-or-flight response. Imagine a real life-threatening situation (like a bear attack) that triggers a rapid heartbeat and fast breathing. These same reactions can occur during a panic attack, even without a real threat.

So, is feeling panic a mental illness? While panic itself is not classified as a mental disorder, it may manifest as a symptom of a mental health condition, for example, panic disorder.

One of the most common questions asked about panic attacks is — at what age do panic attacks start? Panic attacks can start at any age but often in late adolescence or early adulthood. People often experience: 

• Rapid heart rate
• Sweating
• Trembling or shaking
• Shortness of breath
• Tightness in the throat
• Chills or hot flashes
• Nausea
• Chest pain
• Dizziness or lightheadedness
• Fear of losing control or dying

Cognitive-behavioural therapy (CBT) helps identify and change the thought patterns that trigger panic attacks.

"CBT offers a toolbox of strategies to address panic disorder at its core," says Dr Aditi Chandrashekar Acharya. "It empowers individuals with panic disorder to take back control of their thoughts, emotions, and reactions."

Here are some specific techniques used in CBT for panic disorder:

This method aids in identifying and confronting harmful or skewed thought patterns that contribute to anxiety and panic attacks. For example, if you experience a racing heart and think, "I'm having a heart attack, and I'm going to die!" then CBT can help you reframe that thought to something more realistic, like "This is a panic attack, it's uncomfortable but not dangerous, and it will pass."

This technique involves gradually exposing oneself to situations that instigate panic attacks in a safe and controlled environment. By repeatedly facing these triggers, one can learn to manage anxiety and reduce the fear associated with them. For example, if you experience panic attacks in crowded places, exposure therapy might involve practising relaxation techniques while gradually spending more time in crowded areas.

CBT frequently includes relaxation techniques like deep breathing methods, mindfulness meditation, and progressive muscle relaxation. These techniques can help calm physical symptoms of anxiety and panic attacks.

• Medications are often prescribed to manage symptoms.
• Lifestyle Changes: Maintaining a regular exercise routine, eating a nutritious diet, and getting sufficient sleep enhance one's overall health.

When Rajesh finally confided in his family about his diagnosis, they naturally had a lot of questions. They wanted to know:

With proper support and treatment, many individuals see a significant improvement in managing panic disorder. While some may recover completely, others may need to continue treatment to keep symptoms at bay.

There's no guaranteed way to stop panic attacks permanently, but consistent treatment and coping strategies can help manage and reduce their frequency. Most find that combining therapy, medication, and lifestyle changes work well. 

While panic disorder can be intimidating to deal with, it is treatable. Recognising the symptoms of panic attacks early and seeking professional help are key to regaining control. If you or someone you know is struggling, don't hesitate to seek help. Caring for one's mental well-being is equally crucial as looking after physical health; it reflects courage rather than vulnerability.