# Motivation and emotion/Book/2021/Panic

* Multimedia presentation (3 min)

## Overview

* Case study 1
* Emma has a panic disorder which means she experiences repetitive and unexpected panic attacks. She lives in absolute fear of experiencing unwanted panic attacks. Emma’s daily life is restricted because she actively avoids social interaction since it tends to produce panic attacks. When Emma experiences a panic attack she reacts with the flight-or-fight response which results in her quickly leaving social interactions. Therefore, when she has plans with friends, she experiences panic.
There are multiple types of emotions, however, when confronting danger, panic is a helpful survival emotion. It helps people to avoid external dangers. Although, the fear and anxiety that comes from panic can be so intense that it becomes hazardous[grammar?]. It can inhibit people’s daily lives and cause health issues. Panic disorder influences individuals’ bodily functions and behaviours, unfortunately, it is common[grammar?]. However, there are multiple options available to help manage panic. Thus, it is important to understand panic and how to manage it.
* Focus questions:
* What is panic?
* What are the emotional components of panic?
* How can panic be managed?

## Panic

Panic is defined by a sudden overpowering terror or fear that prevents logical thoughts or behaviour, with the potential to spread through a group of people (Rogsch et al., 2010).

### What causes panic?

Panic is an emotional response to deal with an imminent threat created by stressful or fearful external sensory signals, such as vision, smell and hearing (Johnson et al., 2012). However, it is an individual’s assessment of a situation that is more important to determine an appropriate emotional response, it is the individual’s perspective that creates the panic response (Levine, 2003)[grammar?]. For example, a person with arachnophobia will experience panic upon seeing a spider close to them, however, a person without arachnophobia may be conscious of the spider but will not panic (see Figure 1).

### Panic attack

Panic attack is a sudden surge of intense terror or discomfort that reaches a peak within minutes and during which four or more of the follow symptoms occurs:
* Palpitations, pounding heart, or accelerated heart rate
* Sweating
* Trembling or shaking
* Sensations of shortness of breath or smothering
* Feeling of choking
* Chest pain or discomfort
* Nausea or abdominal distress
* Feeling dizzy, unsteady, lightheaded or faint
* Derealization (feelings of unreality) or depersonalization (detached from oneself)
* Fear of losing control or going crazy
* Fear of dying
* Paraesthesia (numbness or tingling sensations)
* Chills or hot flushes
(Rogsch et al., 2010).
Panic attacks can occur in two different forms:
* Unexpected: no obvious triggers and can happen in different situations.
* Situationally bond: occurs because of a certain trigger (e.g., the presence of a spider for someone with arachnophobia).
Furthermore, there is a subtype of panic attack where an individual can be triggered by a certain cue, however, it is not necessitated by it. For example, an individual may experience panic attack symptoms when they face a social situation but in other cases, they are fine (Cane, 2011).

### Panic disorder

Panic disorder is a common mental disorder that affects around 5% of the population (Roy-Byrne et al., 2006). The main feature of panic disorder is repetitive and unexpected panic attacks. These panic attacks are not restricted to any situation or set of circumstances, they are unpredictable (Taylor, 2006).
Ter is unknown for the most part, however, there appears to be a genetic susceptibility (rne et al., 2006). Although, the exact genes or functions related to genetics remain unknown[grammar?]. Children of parents with depressive, anxiety and bipolar disorders have an increased risk of developing panic disorder[factual?]. Furthermore, an individual must experience persistent concern for panic attacks or a significant maladaptive change in behaviour related to the panic attacks to be diagnosed. For example, the concern of losing control or behaviours that avoid panic attacks[grammar?]. Moreover, panic attacks are not due to the physiological effects of a substance or other medical conditions (American Psychiatric Association, 2013). People who are prone to negative emotions are at greater risk for the onset of panic attacks (American Psychiatric Association, 2013).

### The inability to process emotions

Those with panic disorder or prone to panic have difficulties with processing emotions which increases their likelihood of having a panic attack and experiencing fear (Baker et al., 2004).
* Research Study
* Individuals with panic disorder or prone to panic have difficulties with processing emotions which increases their likelihood of having a panic attack (Baker et al., 2004). Baker et al. (2004) studied 531 participants with panic disorder and showed significantly greater awareness of their feelings and uncertainty in labelling strong emotions. Panic prone individuals are distressed by emotional uncontrollability.
* The findings point towards emotional processing as a precursor or vulnerability factor for panic. Failure of emotional processing is a predisposing factor along with other genetic factors for panic disorder. The emotional processing model has offered potential in the following areas:
* Testable explanation of subjective experiences of individuals with panic attacks. To explain why some individuals’[grammar?] experience panic when faced with certain stressors while others faced with the same stressors do not panic.
* New elements in therapy for panic to focus on emotional processing.
* Panic suffers[spelling?] could learn more efficient ways of processing emotions from therapy. This could prevent relapse and offer long-term treatment.
* However, Baker et al. (2014) only compared panic disorder patients to regular patients, thus, is not able to demonstrate whether the effect is specific to panic disorder or to broader elements[grammar?].
Review Question
Which symptom is not experienced in a panic attack?
Sweating
Palpitations
Headaches
Hot flushes :

## The emotional components of panic

Some common symptoms of panic are emotional experiences, for example, fear of dying or fear of losing control. Overall, panic is strongly related to fear. Panic has three key emotional components, they are subjective, physiological and behavioural responses.

### Subjective

Assessment of situations is part of experiencing emotions, which are varied and not universal (Cane, 2011). For example, individuals’ perspectives of a party will vary, some might enjoy the loud music and the social interactions while others may experience anxiety or discomfort. The individual assessment is the first step in experiencing panic and why some individuals panic upon seeing a spider and others will not. Panic results from the assessment that one is in danger. This causes the need for immediate wellbeing and survival; thus, panic is experienced. Furthermore, not all emotions, [grammar?]such as love, guilt and shame, are related to immediate wellbeing and survival (Cane, 2011). Panic triggers are linked to the emotional state of individuals (Cane, 2011).

### Physiological

After an individual assesses the situation to be dangerous, the fight-or-flight response is engaged. Fight is to confront the threat while flight is to avoid the threat. Changes immediately occur within the body to allow the individual to react (Koren, 2006). The fight-or-flight response allows people to respond to immediate danger automatically and quickly, however, it is unhelpful regarding non-physical threats. For example, stressful social situations (Young et al., 2011)[grammar?]. The body shuts down functions that are not needed for a quick reaction. This includes digestion, sexual function and even excess waste can be eliminated (Koren, 2006). The psychological symptoms include (see Figure 2) (Young et al., 2011) :
* Increased heart rate
* Sexual dysfunction
* Digestion stops
* Immune system is temporarily turned off
* Increased blood pressure
* Hormones are released, particularly adrenalin (also known as epinephrine)([[{{{1}}} talk:{{{2}}}|T]]·[{{fullurl:{{{1}}}:{{{2}}}|action=edit}} E]·[{{fullurl:{{{1}}}:{{{2}}}|action=history}} H]·[[Special:Whatlinkshere/{{{1}}}:{{{2}}}|L]]·[[Special:Recentchangeslinked/{{{1}}}:{{{2}}}|R]]) [[{{{2}}}]]
* Dilated pupils which can cause blurred vision
The fight-or-flight response releases stress hormones which can cause an individual to become aggressive and anxious. Eventually, an individual in this state can have a weakened immune system, less energy and develop stress-related disorders. For example, heart disease, insomnia and depression (Koren, 2006)[grammar?]. This can negatively affect an individual’s wellbeing.
Every emotional response has a hormonal component. Adrenaline is the key hormone associated with fear (Mezzacappa, 1999), panic is intense fear. Furthermore, a research study conducted by Zijderveld et al. (1999) found that 45% of participants with panic disorder had a panic attack after receiving adrenaline. Therefore, adrenaline is a substance that causes anxiety in patients with panic disorder (Zijderveld et al., 1999).
There have been multiple studies that suggest the amygdala plays a vital role in linking external stimuli to defensive behaviour, hence, the processing of negative emotions like fear and panic (Herdade et al., 2006)[grammar?]. The amygdala is hyperactive while in emotional conflict and spontaneous panic attacks (Demenescu et al., 3023). Furthermore, a smaller volume of the amygdala is associated with anxiety in panic disorder (Hayano et al., 2009). Additionally, abnormal cooperation of the brainstem and cortical is seen to result in heightened amygdala activity which leads to panic attacks (Perna et al., 2004).

### Behaviour

Emotions can relate to certain adaptive functions, for example, disgust protects us from eating potentially poisonous substance. Regarding panic, fear motivates us to avoid dangerous stimuli (Cane, 2011). Panic helps individuals be alert and perform avoidance behaviour to escape from danger. For example, people who experience panic attacks from driving, manifest avoidant behaviours towards driving, such as refusal to enter cars (Cane, 2011)[grammar?]. Furthermore, once an individual experiences a panic attack they tend to become concerned over following attacks or the implications of them which leads to a change of behaviour (Cane, 2011). Individuals avoid stimuli related to the panic attack (Baker et al., 2004). However, avoidance behaviour is one of the vital features that prevent people from functioning normally (Taylor, 2006). The anxiety from panic attacks can have negative impacts on social and physical wellbeing (Fava & Morton, 2009).
* Case study 2
* An individual was anxious about eating food because they were scared that the food would become stuck in their throat and choke. Thus, they eat less than normal and mostly liquid food. The physical consequence of this is that they lose a lot of weight. Furthermore, because they feared choking and ate very slowly, they would avoid going out to dinner. Thus, they become more isolated (Fava & Morton, 2009).

## Management of panic

Being able to control and manage panic is vital. Panic is a negative emotion that can hinder people’s daily lives and wellbeing. Fortunately, there are multiple different techniques to help people manage their panic.

### Changes to lifestyle

Approximately 80% of the world’s population consumes caffeine daily and it can be found in coffee, tea, chocolate, soft drinks and medicine (Vilarim et al., 2011). Multiple journal articles studied the association between panic disorder and consumption of caffeine, [grammar?] it was found that caffeine increases anxiety and panic attacks (Vilarim et al., 2011). Thus, it is recommended for those prone to panic attacks to reduce their consumption of caffeine.
Broocks et al. (1998) found that regular aerobic exercise, such as running, has a significant improvement in participants with panic disorder. Konstantinidou and Dratcu (2006) found that even anaerobic forms of exercise, such as weightlifting, can reduce panic symptoms. However, both studies found clomipramine, a type of tricyclic antidepressant, to be more effective for treating panic disorder. Additionally, aerobic exercise can promote anxiety and panic symptoms, although, regular aerobic exercise reduces such symptoms (Lattari et al., 2018). Therefore, it is recommended for individuals suffering from panic disorder to exercise regularly.

### Controlled breathing

Controlled breathing is common (Meuret et al., 2003)[explain?]. Hyperventilation often occurs in panic attacks; therefore, controlled breathing can counteract the stress from incorrect breathing. Controlled breathing prevents the symptoms of anxiety from becoming more severe and provides a distraction from disastrous thoughts when experiencing panic (Young et al., 2011). The recommended action for controlled breathing is:
* Breathe 8 to 12 times in a minute. Thus, it should take about 5 to 7 seconds for each cycle of breathing.
* Relax the mind
* Close eyes
* Concentrate on breathing
However, this technique is not for everyone (Young et al., 2011). There are claims that the controlled breathing technique is lacking supportive evidence but should not be rejected prematurely (Meuret et al., 2003). Breathing control has shown to prevent a panic attack, but it is not effective for reducing the symptoms in the middle of one (Eifert & Heffner, 2003)

### Distraction techniques

Distraction techniques is a method used to reduce panic symptoms. It decreases self-focus and anxiety (Young et al., 2011). Instead, it draws attention to:
* What is going on in the environment
* What one can see, hear and smell
* The people nearby
The goal is to make the individual focus on anything besides the anxiety and fear they experience during a panic attack. For example, visualising a holiday and the experiences of the holiday. This can be achieved by picturing the sand, the sun and even imaging the sound of the sea (Young et al., 2011). The distraction technique can take 3 to 4 minutes to be effective (Young et al., 2011). However, Clark and Salkovski (2009) found that reading pairs of words that represent panic, such as dying and palpitations, can create sensations similar to panic attacks[this sentence seems to be out of place?].
* Case study 3
* Annie was at home alone when she became fearful and started to have a panic attack. Her stepfather called Annie to arrange a visit and stay for the next several weeks. Annie was reluctant to have her stepfather visit for a long period of time and the delicate discussion on the phone required Annie’s full attention. By the end of the conversation, Annie noticed her fear and panic attack was gone. The conversation had distracted her from the sensations related to the panic attack
* (Clark & Salkovskis, 2009).

### Medication

There are multiple medication to treat and manage panic. One option is benzodiazepines which were prescribed for panic attacks, however, they are prescribed less often because of their side effects such as slurred speech, fatigue and memory loss (Batelaan et al., 2011). Antidepressant treatment is another option for panic attacks. These include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and Monoamine oxidase inhibitors (MAOIs). SSRIs, in particular, tend to be the first drug treatment used to treat panic attacks. SSRIs and TCAs appear similar for short-term efficacy (Batelaan et al., 2011). According to Marchesi (2008), SSRIs are the first-choice to treat panic disorder because of the lack of side effects. It starts at a low dosage to prevent side effects and then slowly increases until the recommended dose is reached. The medication is discontinued slowly to prevent withdrawal syndrome. It can maintain treatment for at least 12 months. TCAs are like SSRIs because they share many advantages, however, TCAs come with more side effects like weight gain and cognitive disturbances. They are also easier to overdose on (Marchesi, 2008). MAOIs are suggested for patients who have not responded to other forms of treatment (Marchesi, 2008). Generally, medication is successful when treating panic attacks, however, it is also recommended that individuals attend a form of therapy, especially cognitive-behaviour therapy (Taylor, 2006). Medication is used until the patient is free of symptoms for at least six weeks and it is safest to withdraw while undergoing therapy (Taylor, 2006). Overall, medication is promising, however, there’s an increased risk of suicide while taking medications (Marchesi, 2008).

### Cognitive-behaviour therapy

Cognitive behaviour therapy (CBT) focuses on changing behaviours and cognitive concepts (Benjamin et al., 2011). It can improve emotional regulation and coping strategies (McKay et al., 2015) (see Figure 3). Individuals with panic disorder were found to benefit from CBT (Meulenbeek et al., 2010). Furthermore, a randomised controlled trial of 312 participants with panic disorder compared CBT to an antidepressant called imipramine. It was found that both treatments were effective, however, CBT was found to be more durable (Barlow et al., 2000). Additionally, CBT is an excellent option for those who are pharmacotherapy resistant. Heldt et al. (2006) studied 63 patients who were pharmacotherapy resistant and found an improvement after CBT, including long term improvement despite reductions in medication use. The study was consistent with other findings that indicated the CBT is an optimal strategy for pharmacotherapy resistant patients. It is an effective treatment with low cost and should be considered for patients with panic disorder and pharmacotherapy resistant (Heldt et al., 2006).

## Conclusions

The purpose of this book chapter was to focus on panic, its emotional components and how it is managed. With the addition of panic disorder and how it can negatively affect an individual’s life[grammar?]. Panic is a sudden and powerful fear that can aid in coping with threatening situations, however excessive panic prevents individuals from functioning. Panic is an emotional response to a perceived threat. Panic attacks have many negative symptoms and can occur as situationally or unexpectedly. Panic disorders are a common mental disorder, their main feature is repetitive and unexpected panic attacks[grammar?]. The cause of panic disorder is unknown, however, there is a genetic susceptibility. Furthermore, those suffering from panic disorders develop avoidance behaviours and experience negative consequences. The emotional components of panic are subjective, physiological and behavioural. Individual assessment is the first step of experiencing panic, followed by bodily functions such as fight-or-flight. After, individuals then avoid dangerous stimuli through their behaviour. However, avoidance behaviour can inhibit individuals’ lives. Fortunately, there are many options available to manage panic. There are simple solutions such as changing lifestyle, controlled breathing and distraction techniques. Furthermore, there are more extreme options such as medication and cognitive behaviour therapy. It is encouraged for those suffering from panic to seek appropriate treatment.