Panic Disorder: Sweaty Palms, Week Knees, & Heavy Arms

It is three in the afternoon, and you are getting ready to rap the best bars ever written and prove yourself to be better than your opponents. Though you know you have adequately prepared, your palms are sweaty, your knees grow weak, and your arms become heavy. You are experiencing nervousness. While this is a normal reaction to a stressful situation, for three percent of Americans, even in seemingly non-stressful environments, the nervous feelings turn into panic attacks (Locke 2015).

Panic disorder (PD) is characterized by episodic, unexpected panic attacks that occur without a clear trigger and are defined by the rapid onset of intense fear (typically peaking within 10 minutes) (Locke 2015). To be diagnosed with PD, one has to have at least four of the symptoms in the DSM-5 diagnostic criteria (see figure 1), followed by persistent concern over additional panic attacks and maladaptive change in behavior related to the panic attacks ( e.g., avoiding unfamiliar places for fear it might trigger a panic attack) (Locke 2015). 

Figure 1. Showcases criteria used to diagnose people with Panic Disorder (Figure from Locke 2015).

While the cause of PD has yet to be identified, symptoms are thought to be partly the result of disruption in the activity in the “emotional centers” of the brain (Martin 2009). In a study by Lee (2006), using single-photon emission computed tomography (SPECT), they investigated regional cerebral blood flow (rCBF) in twenty-nine participants with panic disorder and compared it to twenty-five healthy controls. In addition to performing a SPECT, researchers gave the participants a panic disorder severity scale (PDSS), a rating scale that measures the severity of a person’s panic attacks and panic disorder symptoms. They found that participants with PD have decreased rCBF on the right superior temporal lobe.​​ They also found an inverse relationship between the blood flow of the right superior temporal lobe and the panic disorder severity, with increased severity correlating to decreased rCBF on the right superior temporal lobe.

Figure 2. The left graph showcases the cerebral blow flow in the superior temporal lobe in patients with PD and healthy controls. The right graph showcases the inverse relationship between panic disorder severity and cerebral blood flow in the temporal lobe (Figure from Lee 2006).

This study, plus other studies showing structural abnormalities of temporal lobes in patients with panic disorder (Fontaine 1990), supports the idea that disruption in the temporal lobes causes or at least correlates with the symptoms of PD. 

Treatments for PD usually fall within two categories: medication and therapy. Some of the most common medications taken as a first line of defense for PD are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs)(Locke 2015). Besides medication, people with PD often undergo cognitive behavioral theory, which applies many techniques like relaxation, exposure therapy, breathing, cognitive restructuring, or education (Locke 2015). 

While medication or psychotherapy is usually an initial treatment option for PD, some studies suggest that combining medication and psychotherapy may be more effective for patients with severe symptoms. A study by Kolek (2019) investigated the effectiveness of combining antidepressants with cognitive behavioral therapy in patients with treatment-resistant panic disorder. In this study, the researchers gave one hundred five participants who were pharmacoresistant (patients who were unsuccessfully treated by antidepressants for a minimum of three months)  their usual antidepressant dosage range combined with cognitive-behavioral therapy. 

The researcher also gave the participants several rating scales before and after the 6-week experiment. The four rating scale that are of importance were  a Clinical Global Impression (CGI), which is an assessment of the severity of psychopathology, Beck Anxiety Inventory (BAI), which is an assessment of anxiety symptoms in the last week, Beck Depression Inventory (BDI), which is an assessment of depressive symptoms, and Panic Disorder Severity Scale (PDSS), which is an assessment of the severity of the panic disorder. Researchers found that adding cognitive behavioral therapy decreases the score for all 4 rating scales, supporting the use of both therapy and antidepressant in patients with treatment-resistant panic disorder.

Figure 3. The top left graph showcases the results of the Clinical Global Impression assessment. The top right graph showcases the results of the Panic Disorder Severity Scale. The bottom left showcases the results of the Beck Anxiety Inventory. The bottom right showcases the results of the Beck Depression Inventory (Figure from Kolek 2019).

While researching this topic, I found it interesting that a combination of therapy and antidepressants is not the first line of defense after PD, but it is usually either medication or therapy. I wonder why doctors do not offer both options off-front. Since both therapy and medication are equally effective at combating PD (Locke 2015), I wonder if patients’ (and cultural) attitude toward therapy and medication is a deciding factor on whether a psychiatrist advises their patients to go to therapy or take medication for their PD. 

Additionally,  education as a form of therapy for PD really surprised me, but patient education itself can help reduce anxiety in people with PD (Shearer 2007). This makes sense as some of the symptoms of PD are fear of losing control and fear of dying (many often perceive their panic attack to be a heart attack) (Locke 2015). Knowing what is happening to you and the pathways you can take to possibly get better may reduce these symptoms and contribute to the decrease in anxiety seen in patients educated on PD.

Work cited 

Locke, A. B., Kirst , N., & Shultz, C. (2015). Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. American Family Physician , 1(19), 617–624. Retrieved April 21, 2020, from American Family Physician.

Martin, E. I., Ressler, K. J., Binder, E., & Nemeroff, C. B. (2009). The Neurobiology of Anxiety Disorders: Brain Imaging, genetics, and psychoneuroendocrinology. Psychiatric Clinics of North America, 32(3), 549–575. https://doi.org/10.1016/j.psc.2009.05.004

Engel, K., Bandelow, B., Gruber, O., & Wedekind, D. (2008). Neuroimaging in anxiety disorders. Journal of Neural Transmission, 116(6), 703–716. https://doi.org/10.1007/s00702-008-0077-9

Lee, Y. S., Hwang, J., Kim, S. J., Sung, Y. H., Kim, J., Sim, M. E., Bae, S. C., Kim, M. J., & Lyoo, I. K. (2006). Decreased blood flow of temporal regions of the brain in subjects with panic disorder. Journal of Psychiatric Research, 40(6), 528–534. https://doi.org/10.1016/j.jpsychires.2005.08.012

Fontaine, R., Breton, G., Déry, R., Fontaine, S., & Elie, R. (1990). Temporal Lobe Abnormalities in panic disorder: An MRI study. Biological Psychiatry, 27(3), 304–310. https://doi.org/10.1016/0006-3223(90)90004-l 

Shearer SL. Recent advances in the understanding and treatment of anxiety disorders.  Prim Care. 2007;34(3):475–504, 5-4. 

Kolek, A. Prasko, J. Ociskova, M. Holubova, M. Vanek, J. Grambal, A. (2019). Slepecky M. Severity of panic disorder, adverse events in childhood, dissociation, self-stigma and comorbid personality disorders Part 2: Therapeutic effectiveness of a combined cognitive behavioral therapy and pharmacotherapy in treatment-resistant in patients. Neuro Endocrinol Lett, 40(6):271-283. PMID: 32200586.

8 thoughts on “Panic Disorder: Sweaty Palms, Week Knees, & Heavy Arms

  1. I love the topic of your blog post! I am also very surprised that a combination of therapy and medicine is not recommended as initial treatment. I feel like this is the most logical and effective initial approach. I’m interested in the difference between anxiety attacks and panic attacks. These terms are used pretty interchangeably in daily life, but from your blog post, I’ve gathered that these two instances refer to different situations. To me it sounds like that there are amygdala abnormalities associated with PD, especially since these attacks come out of nowhere.

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  2. Hi!
    Thank you from the bottom of my heart for explaining your figures with detail that makes sense to even low-level psychology students! It’s very refreshing and made your blog post all the stronger. I have PD and have seen a lot of success with CBT and antidepressants, but I really feel for the people who are unable to have success with those treatments. The fear of a panic attack is a major component in the panic attack itself; the sensations escalating and being out of control just re-emphasizes the anxiety you were feeling in the first place. I have rescue medications to use when the antidepressants can’t quite handle the rush of hormones which does a lot to calm the anxiety about having one (I know that I have the tools to cope with it so it’s not as scary). I wonder if that has a similar effect as education? In other words, if the peace of mind from knowing I’m in possession of the necessary tools to get through it is a form of education, or if the education itself is a tool. Great post!

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  3. Hi Bashaina! I really appreciate your scholarly and academic-focused approach to this topic, mentioning DSM diagnoses in tandem with scientific studies. I also find it interesting that doctors choose to treat PD with either medication or therapy, but not both. Perhaps there should be a greater movement to implement these treatments simultaneously to best help patients. Maybe we can even run studies in the future to see if using both at the same time is MORE beneficial in treating symptoms! Even if certain patients are better fit for one treatment or another, I don’t see much reason in holding back additional treatment, especially therapy. Also, the idea of education as therapy is really fascinating to me. This really highlights the importance of advocating these mental health issues in larger population settings and popular media. Perhaps if people better understand the drivers and effects of mental illnesses such as PD, we can lower incidence rates in the future. Great post!

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  4. This was both an incredibly informative and very engaging post, Bashaina! I really enjoyed the way that you began with a popular culture reference, it made me want to read further. Before reading your post, I did not know much about Panic Disorder (PD), so your inclusion of the DSM-5 criteria was very useful in helping me to expand my knowledge. I also found it interesting that the use of both therapy and medication has shown to be effective for those with more serious symptoms. Many of the psychological disorders that I am more familiar with use only one or the other, so this combination and previous research is intriguing. Overall, this was a great post.

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  5. I found this blog really interesting! I liked your contribution about the effectiveness of both therapy and medication for treating panic disorders. I thought your take about psychiatrists avoiding advising patients to undertake therapy or medication was interesting. This insinuates that there may be a culture barrier between who is given the best treatment for PD and who is not. Knowing this I wonder how psychiatrist can address this issue, knowing their perception on their patient might influence the information they express to them.

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  6. Hi Bashaina,

    I really enjoyed reading your post. I appreciated your comments at the end regarding the use of pharmacotherapy, psychotherapy, and combination treatments for PD. I agree that a client’s background plays a large role in deciding which treatment option to pursue. In my clinical interventions seminar, we talked a lot about client buy-in to the treatment method. Some clients may view treatment for psychological disorders as more of a healing practice, while others may view it as more of a scientifically-backed medical treatment. If a person views treatment as a healing practice, they may opt for psychotherapy alone. Meanwhile, the latter group may show a stronger preference for pharmacotherapy alone. Ultimately, I think whichever treatment method the client will buy into will be the most effective.

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  7. Wow, what an informative and fascinating post! I thought the structure of this post was perfect- starting out with a description of what PD is (including the DSM-5 criteria), then investigating possible causes or physiological manifestations, and finishing off with common treatments of PD. As someone who has struggled with panic attacks in the past, I’m personally not surprised that education about PD can help people with the disorder. I have found that the biggest in-the-moment struggle is convincing myself that I’m not actually dying, so knowing exactly what is causing the physical symptoms seems like it would be very helpful. It also was surprising to me that both medication and therapy are not initially recommended in tandem; maybe someone with PD would feel more anxious if they were put on a new medication AND starting therapy (seems like lots of novel experiences). I’m thinking this could be a reason why starting off with just one of these treatments could be more helpful.

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  8. This is a very clear, well-informed post! I enjoyed reading about the research on treatment for panic disorder and how medication such as SSRIs can be beneficial. I also liked reading about alternatives or co-treatment to medication, such as cognitive-behavioral theory and techniques like relaxation, exposure therapy, breathing, and cognitive restructuring. In PS254 I learned about a similar method of treatment for Major Depressive Disorder and Generalized Anxiety Disorder, and research also showed that while medication or psychotherapy is usually an initial treatment option for these disorders, combining medication and psychotherapy has proven to be the most effective for patients and can help manage both physical and mentally challenging symptoms. I am interested to learn more about how the comorbidities of these disorders might contribute to overlapping in their treatment. I also find it interesting that you made a point about how a patient’s attitude toward therapy and medication could be a deciding factor on whether a psychiatrist advises their patients to go to therapy or take medication for their PD–I definitely think it plays a role in treatment, and research has even shown that patients who indicate their preferred form of treatment and receive it tend to have longer-term and more effective positive outcomes.

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