Title: Panic Disorder
Authors: Harith Al-Azzawi, Ghadeer Al-Qaq
Editor: Fadlullah M. F. Al-Saleem
Reviewer: Philip J. Sweidan
Keywords: Antidepressants, CBT, Cognitive Behavior Therapy, Panic Attack, Panic Disorder.
Panic disorder is a prevalent mental illness that affects up to 5% of the population at some time in their lives. It is frequently debilitating, especially when accompanied by agoraphobia, and is associated with significant functional morbidity and worse quality of life. The condition is also expensive for people and society, as seen by higher healthcare utilization, absenteeism, and decreased workplace productivity. Some medical conditions (for example, asthma) are frequently associated with panic disorder, and some lifestyle variables (for example, smoking) enhance the risk for the disorder, although the causative pathways are yet unknown. There are additional genetic and early experience susceptibility factors, although their exact nature and pathophysiological processes are unclear. Despite an incomplete, but growing, understanding of the etiology, significant evidence supports the use of various successful therapies (For example, pharmaceutical, cognitive-behavioral). The adaption and diffusion of these therapies to the frontlines of medical care should be top priorities for the public health community.
According to the DSM-5, panic disorder is recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak level within minutes.
It is a common mental disorder that affects up to 5% of the population at a point in life. It can be disabling especially when complicated by agoraphobia, which is associated with substantial functional morbidity and reduced life quality. This disorder is costly for individuals and society, as shown by increased use of health care, absenteeism, and reduced workplace productivity. 
The exact cause of panic disorder has not been determined, although some factors can play a role in this disorder such as family history, drug abuse, brain abnormalities, and stress are some of the factors that can trigger panic attack episodes attributed to this disorder. 
The central nervous system’s neurotransmitters and peptides appear to have a vital influence on physical symptoms. Brain imaging studies have revealed distinct alterations in certain geographic locations, such as the limbic and frontal regions, including enhanced flow and receptor activity. The amygdala is thought to be the primary source of malfunction.Medical sickness and panic disorder are highly connected from a pathophysiological and psychological standpoint. Two basic theories try to explain why patients are more prone to panic episodes. The first hypothesis proposes that vulnerable patients lack the neurochemical mechanisms that would usually regulate serotonin and that this elevated serotonin produces changes in the autonomic nervous system’s fear network model. 
Presentation and Diagnosis
Panic disorder is characterized by episodic, unexpected attacks that occur with no obvious trigger, although many patients with this disorder have expected panic attacks, to occur in response to a known trigger. The most common physical symptom occurring with panic attacks is palpitations. 
Below are 13 symptoms in which four or more occur combined and they are :
- Accelerated heart rate.
- Shaking or trembling.
- Shortness of breath.
- The feeling of choking.
- Chest pain and discomfort.
- Abdominal distress
- Feeling light-headed, dizzy, unsteady, or faint.
- A sensation of chills or heat.
- Paresthesias (tingling or numbness).
- Depersonalization (being detached from oneself) or derealization (feelings of unreality).
- Losing control.
- Fear of death.
The frequency of panic attacks varies widely. There may be moderately frequent attacks; for months at a time, or short bursts of more frequent attacks separated by weeks or months without any attacks or with less frequent attacks over many years. In terms of severity, individuals with panic disorder may have both full-symptom attacks, which include four or more symptoms, and limited-symptom attacks, which include fewer than four symptoms. The type and number of symptoms differ from one panic attack to the other. However, more than one unexpected full-symptom panic attack is necessary for the diagnosis. 
Symptoms of the disorder often start late in teens or in early adulthood and affect women more than men. Many factors may increase the risk of developing panic attacks or panic disorder including: 
- Familial history of panic attacks or disorder
- Major life stress, such as a loved one’s death or critical illness
- A traumatic occurrence, such as sexual assault or a serious automobile accident
- Significant life events, such as a divorce or the birth of a child
- Smoking or excessive caffeine use
- A history of physical or sexual abuse as a child
Panic disorder is a chronic condition with a wide range of symptoms. In more than 85 percent of instances, appropriate pharmacologic therapy and cognitive-behavioral therapy (CBT), either alone or in combination, are beneficial. Patients with good premorbid functioning and symptoms that last for a short time have a better prognosis. Approximately 10-20% of people continue to experience substantial symptoms.
Overall, the long-term prognosis for panic disorder is generally favorable, with over 65 percent of patients experiencing remission within six months. However, as discussed under History, trigger factors can cause panic attacks; several of these triggers have been linked to poor outcomes, including severe illness at the time of the initial assessment, high interpersonal sensitivity, low social class, separation from a parent due to death when young, divorce, and single status. 
Patients with panic disorder have a significantly increased incidence of coronary artery disease. Panic can cause myocardial ischemia in patients with coronary artery disease. Reduced heart rate variability and increased QT interval variability may theoretically raise the risk of sudden death. 
Individuals with panic disorder have a suicide rate that is many times greater than the overall population. 
In general, panic disorder can be treated effectively with pharmacological and psychological treatments, like cognitive-behavioral therapy and mindfulness interventions. 
Although pharmacological treatments are proven to be potent in panic disorder therapy, their potential side effects can be obstacles to binding to treatment and the long-term maintenance of achieved treatment goals. So, providing effective psychological interventions is important for this disorder either as a supportive or stand-alone treatment. However, the availability of treatment places is limited to conventional face-to-face mental health centers. 
Various effective medications are available for treating this disorder, but results have been unsatisfactory in some patients, suggesting the effectiveness of expanding the array of anti-panic medications and improving the quality of response to currently recommended treatments. 
Treatment choices are listed below:
Antidepressant medications have proved to reduce panic attack severity, eliminate attacks, and improve the overall life quality measures in patients with panic disorder. 
Two recent meta-analyses , found that TCAs (tricyclic antidepressants) and SSRIs (selective serotonin reuptake inhibitors) are effective equally in reducing the number and severity of the attacks. The choice of antidepressant medication should be based on the patient’s choices according to side effect profiles. MAO inhibitors (Monoamine oxidase inhibitors) also are effective in the treatment of panic disorders, but their use is limited due to safety concerns. 
Benzodiazepines have been proven to be useful in the treatment of various forms of anxiety for decades. These anxiety expressions have recently been separated into categories and diseases, such as generalized anxiety disorder and panic disorder.  The use and efficacy of benzodiazepine receptor agonists in individuals with these different diagnoses have been explored by researchers. Clinical research on generalized anxiety disorder and panic disorder typically shows that benzodiazepine agonists have similar efficacy, while true comparison studies with two or three medications are rare. The differences in side effects, pharmacokinetics, and withdrawal reactions for benzodiazepines require more research. Concerns regarding benzodiazepine reliance, whether justified or not, and cessation effects have prompted researchers to look for novel benzodiazepines that do not have these issues. This study addresses recent breakthroughs in research on novel benzodiazepine compounds and reviews the efficacy and comparative studies of benzodiazepines that are already accessible. 
Along with drug therapy for panic disorder, neuromodulation techniques including TMS (Transcranial Magnetic stimulation) are used in panic disorder with varying results. 
- Cognitive Behavior Therapy
Cognitive behavior therapy (CBT) includes many techniques, for instance, exposure in vivo, applied relaxation, panic management, exposure through imagery, breathing retraining, and cognitive restructuring. Meta-analyses encourage the efficacy of CBT in relieving panic symptoms and overall disability.
It’s uncertain if cognitive treatment (e.g., detecting mistaken feelings, educating patients about panic episodes) or behavior therapy is more important in CBT (e.g., breathing exercises, exposure, relaxation). However, in patients with panic disorder, particularly in patients with agoraphobia, the efficacy of exposure approaches alone, in which the patient repeatedly encounters the anxiety-provoking stimulus through visualization or in vivo, is well documented. Referral to an expert exposure therapist is suggested whenever possible. 
Some panic disorder sufferers, especially men, self-medicate with alcohol, which interferes with therapy. In a single trial of people with alcohol addiction with panic disorder, adding CBT to an alcohol treatment program had no more effect on reducing panic symptoms than alcohol therapy alone. 
There is no guarantee that panic episodes or panic disorders will not occur. However, these suggestions might be useful:
- To prevent panic attacks from getting worse or becoming more common, seek treatment as soon as feasible.
- To avoid relapses or worsening panic attack symptoms, stick to your treatment plan.
- Maintain a regular physical activity regimen, which may help to reduce anxiety. 
Panic disorder is a common condition with an unclear origin. To begin adequate therapy, the disease must be detected early. There are two methods of therapy that are indicated. One or both are chosen based on the patient’s desire and the intensity of the panic attack. CBT is typically the first-line treatment for panic disorder, followed by at least a year of antidepressant medication. Patients suffering from this disease should be provided counseling to help them overcome their concerns. It is vital to consult a psychologist regularly to ensure that the panic attack is under control.
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"Mwandishi wa kitabu hiki ni Harith Al-Azawi, Mhariri wa Ghadeer Al-Quaq, Fadlullah M.F. Al-Saleem, Mhakiki wa Philip J. Sweidan, na Mtaalamu wa Matibabu ya Utamaduni wa Kisayansi, na Mtaalamu wa Matibabu ya Utamaduni wa Utamaduni wa Utamaduni wa Utamaduni wa Utamaduni wa Utamaduni wa Utamaduni wa Utamaduni.""" Ugonjwa wa hofu ni ugonjwa wa akili unaoathiri hadi asilimia 5 ya watu katika kipindi fulani cha maisha yao. Mara nyingi ni dhaifu, hasa wakati unaambatana na agoraphobia, na inahusishwa na ugonjwa mkubwa wa kazi na ubora mbaya wa maisha. Hali hiyo pia ni ghali kwa watu na jamii, kama inavyoonekana na matumizi ya juu ya huduma za afya, kukosa kazi, na kupungua kwa uzalishaji wa mahali pa kazi. Hali fulani za matibabu (kwa mfano, pumu) mara nyingi huhusishwa na ugonjwa wa hofu, na baadhi ya mabadiliko ya mtindo wa maisha (kwa mfano, kuvuta sigara) huongeza hatari ya ugonjwa huo, ingawa njia za kusababisha bado hazijulikani. Kuna mambo ya ziada ya maumbile na uzoefu wa mapema wa kuathiriwa, ingawa asili yao halisi na michakato ya pathophysiological haijulikani. Licha ya ufahamu usio kamili, lakini unaoongezeka, wa etiolojia, ushahidi mkubwa unaunga mkono matumizi ya matibabu mbalimbali yenye mafanikio (Kwa mfano, dawa, utambuzi-maadili). Kuunganisha na kueneza matibabu haya kwa mstari wa mbele wa huduma ya matibabu inapaswa kuwa kipaumbele cha juu kwa jamii ya afya ya umma. Kulingana na DSM-5, ugonjwa wa hofu ni mara kwa mara mara mara kwa mara mara mara kwa mara mara kwa mara. Mshtuko wa hofu ni mshtuko wa ghafula wa hofu kali au usumbufu mkubwa ambao hufikia kiwango cha juu ndani ya dakika chache. Ni ugonjwa wa akili unaosababisha matatizo ya akili kwa asilimia 5 ya watu katika kipindi fulani cha maisha. Inaweza kuwa na nguvu hasa wakati ni ngumu na agoraphobia, ambayo ni kuhusishwa na morbidity kubwa kazi na kupunguzwa kwa ubora wa maisha. Ugonjwa huo unagharimu watu na jamii gharama kubwa, kama inavyoonyeshwa na kuongezeka kwa matumizi ya huduma za afya, kukosa kazi, na kupungua kwa uzalishaji kazini. Sababu halisi ya ugonjwa wa hofu haijulikani, ingawa kuna sababu ambazo zinaweza kuathiri ugonjwa huu, kama vile historia ya familia, matumizi mabaya ya dawa za kulevya, matatizo ya ubongo, na mkazo ni baadhi ya sababu zinazoweza kusababisha matukio ya hofu ya hofu. Inaonekana kwamba vitu vinavyopitisha neva na peptidi za mfumo wa neva wa kati vina uvutano mkubwa juu ya dalili za kimwili. Uchunguzi wa picha za ubongo umeonyesha mabadiliko tofauti katika maeneo fulani ya kijiografia, kama vile mikoa ya limbic na ya mbele, ikiwa ni pamoja na mtiririko ulioimarishwa na shughuli ya receptor. Amygdala ni chanzo kikuu cha matatizo ya afya na ugonjwa wa hofu ni uhusiano mkubwa kutoka pathophysiological na kisaikolojia mtazamo. Nadharia mbili za msingi hujaribu kueleza kwa nini wagonjwa huwa na mwelekeo zaidi wa kuwa na hofu. Nadharia ya kwanza inadai kwamba wagonjwa walio hatarini wanakosa utaratibu wa neurokemia ambao kwa kawaida unadhibiti serotonini na kwamba serotonini hii iliyoinuka inazalisha mabadiliko katika mfumo wa neva wa mfumo wa wasiwasi. Ugonjwa wa hofu ni ugonjwa wa kipekee ambao hutokea mara kwa mara bila sababu ya wazi, ingawa wagonjwa wengi wenye ugonjwa huu wanatarajia mashambulizi ya hofu kutokea kwa sababu ya sababu inayojulikana. Dalili ya kawaida ya kimwili inayotokea wakati wa mashambulizi ya hofu ni kupiga moyo. Kuna dalili 13 ambazo zinaonekana kwa pamoja, na ni pamoja na: - Kutetemeka au kutetemeka. - Upungufu wa pumzi. - Hisia ya kuzimia. - Maumivu ya kifua na usumbufu. - Mkazo wa tumbo - Hisia ya kizunguzungu, kizunguzungu, kutokuwa imara, au kuzimia. - Hisia ya baridi kali au joto. - Paresthesias (kuchoma au kutokuwa na hisia). - Kupoteza utu (kujitenga na mtu mwenyewe) au kuondoa hisia (hisia za kutokuwa halisi). - Kupoteza udhibiti. - Hofu ya kifo. Mzunguko wa mashambulizi ya hofu hutofautiana sana. Huenda ikawa na mashambulizi ya mara kwa mara kwa miezi kadhaa au mashambulizi mafupi ya mara kwa mara, yaliyotenganishwa kwa wiki au miezi bila mashambulizi yoyote au mashambulizi yasiyo ya mara kwa mara kwa miaka mingi. Kwa upande wa ukali, watu walio na ugonjwa wa hofu wanaweza kuwa na mashambulizi ya dalili kamili, ambayo ni pamoja na dalili nne au zaidi, na mashambulizi ya dalili ndogo, ambayo ni pamoja na dalili chache kuliko nne. Aina na idadi ya dalili hutofautiana kutoka kwa mshtuko mmoja wa hofu hadi mwingine. Hata hivyo, zaidi ya mshtuko mmoja usiotazamiwa wa hofu wenye dalili kamili ni muhimu kwa utambuzi. Dalili za ugonjwa huo mara nyingi huanza mwishoni mwa ujana au mapema katika utu mzima na huathiri wanawake zaidi kuliko wanaume. Kuna sababu nyingi zinazoweza kuongeza hatari ya kuambukizwa na mshtuko wa hofu, ikiwa ni pamoja na: historia ya familia ya mshtuko wa hofu au shida, shinikizo kubwa la maisha, kama vile kifo cha mtu mpendwa au ugonjwa mbaya, tukio la kiwewe, kama vile unyanyasaji wa kingono au ajali mbaya ya gari, matukio muhimu ya maisha, kama vile talaka au kuzaliwa kwa mtoto, kuvuta sigara au matumizi ya kupita kiasi ya kafeini, historia ya unyanyasaji wa kimwili au wa kingono kama mtoto. Katika zaidi ya asilimia 85 ya kesi, tiba ya dawa sahihi na tiba ya utambuzi wa tabia (CBT) peke yake au kwa mchanganyiko ni muhimu. Wagonjwa wenye utendaji mzuri wa kabla ya ugonjwa na dalili ambazo huendelea kwa muda mfupi wana utabiri bora zaidi. Karibu 10-20% ya watu wanaendelea kupata dalili kubwa. Kwa ujumla, utabiri wa muda mrefu wa ugonjwa wa hofu ni mzuri, na zaidi ya asilimia 65 ya wagonjwa hupata kupona ndani ya miezi sita. Hata hivyo, kama ilivyojadiliwa chini ya Historia, sababu za kuchochea zinaweza kusababisha mashambulizi ya hofu; kadhaa ya sababu hizi zimeunganishwa na matokeo mabaya, ikiwa ni pamoja na ugonjwa mbaya wakati wa tathmini ya awali, unyeti wa juu wa watu, tabaka la chini la kijamii, kutenganishwa na mzazi kwa sababu ya kifo wakati mdogo, talaka, na hali ya moja. Wagonjwa wenye ugonjwa wa hofu wana ongezeko kubwa la ugonjwa wa mishipa ya damu. Hofu ya hofu yaweza kusababisha ischemia ya myocardium kwa wagonjwa wenye ugonjwa wa mishipa ya moyo. Kupunguzwa kwa kutofautiana kwa msimu wa moyo na kuongezeka kwa kutofautiana kwa muda wa QT kwa nadharia kunaweza kuongeza hatari ya kifo cha ghafula. Watu walio na ugonjwa wa hofu hujiua mara nyingi kuliko watu wengine wote. Kwa ujumla, ugonjwa wa hofu unaweza kutibiwa kwa ufanisi na matibabu ya dawa na kisaikolojia, kama vile tiba ya utambuzi wa tabia na uingiliaji wa akili. Ingawa matibabu ya dawa ni kuthibitika kuwa na nguvu katika matibabu ya ugonjwa wa hofu, athari zao za uwezekano zinaweza kuwa vizuizi kwa kushikamana na matibabu na kudumisha kwa muda mrefu malengo ya matibabu yaliyopatikana. Kwa hivyo, kutoa uingiliaji mzuri wa kisaikolojia ni muhimu kwa ugonjwa huu kama matibabu ya kusaidia au ya kujitegemea. Hata hivyo, upatikanaji wa nafasi za matibabu ni mdogo kwa vituo vya kawaida vya afya ya akili vya uso kwa uso. Dawa mbalimbali za ufanisi zinapatikana kwa ajili ya kutibu ugonjwa huu, lakini matokeo yamekuwa yasiyo ya kuridhisha kwa baadhi ya wagonjwa, na kuashiria ufanisi wa kupanua safu ya dawa za kupambana na hofu na kuboresha ubora wa majibu kwa matibabu ya sasa ilipendekeza. Dawa za kukandamiza zimethibitika kupunguza ukali wa mashambulizi ya hofu, kuondoa mashambulizi, na kuboresha vipimo vya jumla vya ubora wa maisha kwa wagonjwa wenye ugonjwa wa hofu. Uchunguzi wa hivi karibuni unaonyesha kuwa TCA (tricyclic antidepressants) na serotonin reuptake inhibitors (SSRI) ni sawa katika kupunguza idadi na ukali wa mashambulizi. Uchaguzi wa dawa za kukandamiza unapaswa kutegemea uchaguzi wa mgonjwa kulingana na maelezo ya athari za upande. Inhibitors ya MAO (Monoamine oxidase inhibitors) pia ni ufanisi katika matibabu ya matatizo ya hofu, lakini matumizi yao ni mdogo kutokana na wasiwasi wa usalama. Kwa miongo mingi, dawa za benzodiazepini zimethibitika kuwa zenye manufaa katika kutibu aina mbalimbali za wasiwasi. Maonyesho hayo ya wasiwasi hivi karibuni yamegawanywa katika makundi na magonjwa, kama vile ugonjwa wa wasiwasi wa jumla na ugonjwa wa hofu. Matumizi na ufanisi wa agonists ya receptor ya benzodiazepine katika watu wenye utambuzi huu tofauti wamechunguzwa na watafiti. Utafiti wa kliniki juu ya shida ya wasiwasi wa jumla na shida ya hofu kwa kawaida huonyesha kuwa agonists za benzodiazepine zina ufanisi sawa, wakati masomo ya kweli ya kulinganisha na dawa mbili au tatu ni nadra. Tofauti katika athari za upande, pharmacokinetics, na athari za kujiondoa kwa benzodiazepines zinahitaji utafiti zaidi. Kwa sababu ya wasiwasi kuhusu kutegemea benzodiazepine, iwe ni halali au la, na athari za kuacha, watafiti wamekuwa wakitafuta benzodiazepines mpya ambazo hazina masuala haya. Utafiti huu unazungumzia mafanikio ya hivi karibuni katika utafiti juu ya misombo mpya ya benzodiazepine na hukagua ufanisi na masomo ya kulinganisha ya benzodiazepines ambazo tayari zinapatikana. Pamoja na matibabu ya dawa kwa ugonjwa wa hofu, mbinu za neuromodulation, ikiwa ni pamoja na TMS (Transcranial Magnetic Stimulation), hutumiwa katika ugonjwa wa hofu na matokeo tofauti. Tiba ya tabia ya utambuzi (CBT) inajumuisha mbinu nyingi, kwa mfano, mfiduo katika vivo, kupumzika kwa kutumika, usimamizi wa hofu, mfiduo kupitia picha, mafunzo ya kupumua, na muundo wa utambuzi. Uchambuzi wa meta unahimiza ufanisi wa CBT katika kupunguza dalili za hofu na ulemavu wa jumla. Ni uhakika kama matibabu ya utambuzi (kwa mfano, kugundua hisia makosa, kuelimisha wagonjwa kuhusu vipindi vya hofu) au tiba ya tabia ni muhimu zaidi katika CBT (kwa mfano, mazoezi ya kupumua, mfiduo, kupumzika). Hata hivyo, kwa wagonjwa wenye ugonjwa wa hofu, hasa wagonjwa wenye agoraphobia, ufanisi wa mbinu za kuambukizwa peke yake, ambapo mgonjwa hukutana mara kwa mara na kichocheo cha wasiwasi kupitia taswira au in vivo, ni vizuri kumbukumbu. Uelekezo kwa mtaalamu wa matibabu ya mfiduo unapendekezwa kila inapokuwa na uwezekano. Baadhi ya wagonjwa wa ugonjwa wa hofu, hasa wanaume, hujitibu kwa kutumia kileo, ambacho huingilia kati matibabu. Katika jaribio moja la watu wenye uraibu wa pombe na ugonjwa wa hofu, kuongeza CBT kwa mpango wa matibabu ya pombe haikuwa na athari zaidi ya kupunguza dalili za hofu kuliko matibabu ya pombe peke yake. Hakuna dhamana kwamba matukio ya hofu au matatizo ya hofu hayatatokea. Hata hivyo, madokezo haya yaweza kuwa yenye manufaa: - Ili kuzuia mashambulizi ya hofu yasizidi kuwa mabaya au kuwa ya kawaida zaidi, tafuta matibabu upesi iwezekanavyo. - Ili kuepuka kurudia au kuzidisha dalili za mshtuko wa hofu, shikamana na mpango wako wa matibabu. - Endelea kufanya mazoezi ya mwili kwa ukawaida, ambayo yaweza kusaidia kupunguza wasiwasi. Ugonjwa wa hofu ni hali ya kawaida ambayo haijulikani chanzo chake. Ili kuanza matibabu ya kutosha, ugonjwa huo lazima ugunduliwe mapema. Kuna njia mbili za tiba zinazopendekezwa. Moja au zote mbili huchaguliwa kulingana na tamaa ya mgonjwa na nguvu ya shambulio la hofu. CBT ni matibabu ya kwanza ya ugonjwa wa hofu, ikifuatiwa na angalau mwaka mmoja wa dawa za kukandamiza. Wagonjwa wanaopatwa na ugonjwa huo wanapaswa kupewa ushauri ili kuwasaidia kushinda wasiwasi wao. Ni muhimu kumwona mwanasaikolojia kwa ukawaida ili kuhakikisha kwamba mshtuko wa hofu unadhibitiwa. Tunasikitika kwamba makala hii haikuwa na manufaa kwako! Hebu tuboresha Makala hii! Tuambie jinsi tunaweza kuboresha makala hii?