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A panic attack occurs when an individual feels unexpectedly intense anxiety. Panic disorder is a persistent condition in which the individual experiences reoccurring panic attacks as well as the continuous preoccupation with the anxiety about their return to the point that it is incapacitating and paralyzing.  The intensity of the anxiety can vary every time. It can range from mild to extremely high.  Panic attacks are usually accompanied with uncomfortable physical sensations which may include: a rapid heart rate, sweating, breathlessness, trembling or shaking, dizziness, painful chest, feeling of choking ,nausea, numbness or tingling sensations feeling  faint and sick, derealisation (feeling ‘unreal’) or depersonalisation (detached from yourself), chills or hot flushes and abdominal pain. These symptoms peak within 10 minutes and are often accompanied by irrational actions and thoughts.

Panic disorder involves intense worry and fear that the presence of the attacks is evidence of catastrophic mental and physical illness and the loss of control. Individuals with panic disorder tend to avoid situations that might trigger a panic attack or tend to escape situations as a way of ending the panic attack. Panic disorder can come with or without agoraphobia. Agoraphobia involves the severe and continuous avoidance of any places and situations that might lead to anxiety and the reoccurrence of a panic attack. It can be the avoidance of public places, public transportation, crowded places, traveling far from home, lifts, highways, physical exertions i.e. running, social activities etc. Any situation or place from which an escape might be difficult, help may not be directly available and / or even the mere presence of potential observers and the exposure of criticisms/ ridicule causes anxiety.

Panic disorder causes major behavioural changes such as avoidance, safety behaviours and high self-focus, which are motivated by the idea that it might be a good coping or prevention methods. By avoiding situations and places the individual puts many restrictions on his functioning abilities and life in general. The longer the avoidance continues the more dreadful and daunting the situations seem to appear, which lead to the even more avoidance. By avoiding the situation one denies oneself the chance of knowing whether or not one is capable of coping and overcoming the anxiety and difficulties, which in turns reduces self- efficacy and maintains the pathology. An individual may also adapt certain safety behaviours such as not leaving the house alone or always sitting down when feeling anxiety or holding on to something, due to a belief that it helps reduce anxiety. In the short term it might indeed give relief but in the long term it not helpful as the individual grows over-reliant on these safety behaviours and prevents oneself from learning more adaptive and effective coping methods.

Another behaviour which maintains the panic disorder is an increase self- focus. The individual is hyper- vigilant and constantly alert to every little physical change in the body. The attention is focused on common and the smallest bodily changes that under ‘normal’ conditions will not even be noticed. The purpose of this behaviour is to notice the changes that relate to the panic attack and to ‘catch it in time’ when the anxiety is still low in intensity and before it rises to a full-blown panic attack. As a result of noticing it, more safety and avoidant behaviours take place. The focus on the bodily sensations generates a preventive feeling in the mind of the individual. The more one focuses on the body, however,  the more changes and sensations get noticed, the physical symptoms get stronger which increases the anxiety and consequently a vicious cycle begins.  

It is the way in which the individual interprets these bodily sensations and the accompanying thoughts that lead to development and continuation of the panic attacks rather than the context or situation in which they occur. Interpreting the symptoms of anxiety as dangerous and catastrophic (e.g.  I am having a heart attack; I will faint and everyone will laugh; I am going crazy) makes the individual more anxious and increases the intensity and frequency of the symptoms. Some beliefs entail prediction of the future and predicting the worst situation possible. For example, if once an attack occurred while going shopping then going shopping again in a busy and crowded street must mean that another attack will occur and if it will happen then all control will be lost and it will be totally embarrassing.  There is also an element of generalization. If something happened once, it does not imply nor grantees that it will occur again in the future. However, the avoidance due to these expectations makes it impossible for the individual to actually test these negative predictions. Individuals with panic disorder constantly worry about the reoccurrence of the panic attacks and they form restrictive rules by which they think they need to live in order to minimize anxiety. For example, I should always be nearby my house or I must not go to the cinema because I might not be able to get out quickly or I cannot go to a party because I might not be able to hide my symptoms and then everyone will see how panicky and weak I am.  The negative, irrational and unhelpful thoughts in combination with the misinterpreted perception of anxiety as a source of catastrophe / danger and  in addition to the behavioural changes lead to an increase in frequency and intensity of anxiety as well as maintaining the vicious cycle of panic disorder.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th. ed. Text revision). Washington DC: Author

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