Chapter 18 Anxiety disorders

• Anxiety disorders are the most common mental disorder in the community.

• People with an anxiety disorder are less likely to seek treatment than people with a mood disorder.

• Every nurse should be able to recognise the different presentations of the various anxiety disorders and refer clients to appropriate services.

• All nurses should possess the skills to manage a panic attack in any setting.

• Mobilising appropriate coping skills and implementing stress-management techniques is a core nursing skill.

• The major psychotherapeutic methods of treating anxiety disorders include cognitive behavioural therapy (CBT) and stress-management techniques such as progressive muscle relaxation.

• The major classes of drugs used in the treatment of anxiety disorders are antidepressants and anxiolytics.

Key terms

• acute stress disorder (ASD)

• adjustment-related disorders

• generalised anxiety disorder (GAD)

• post-traumatic stress disorder (PTSD)

• obsessions

• obsessive-compulsive disorder (OCD)

Introduction

Nurses frequently interact with anxious clients who are facing threats to their health and wellbeing. Experienced nurses become adept at reassuring and supporting clients in coping with the threat and crisis posed by ill health and trauma. Anxiety is a normal emotion experienced in varying degrees by everyone. Carpenito (2002, p 113) defines anxiety as ‘a state in which the individual/group experiences feelings of uneasiness (apprehension) and activation of the autonomic nervous system in response to a vague, non-specific threat’. Anxiety may manifest as:

• thought, e.g. excessive worry or an intrusive, unwanted idea

• feeling, e.g. a feeling of impending doom

• behaviours, e.g. performing repetitive actions or avoiding objects or situations

• physical change, e.g. increased heart rate, trembling.

However, the presence of anxiety does not signify that the client has an anxiety disorder. Anxiety disorders are specific diagnostic entities that are the primary problem.

Anxiety disorders are the most common mental disorders. They disrupt the individual’s everyday life yet often go unrecognised by clients and health professionals alike. There is a tendency for clients, health professionals and others to dismiss the symptoms of anxiety disorders as nerves, worry or excessive shyness. As a result, anxiety disorders often go untreated, undertreated or inappropriately treated.

If this situation is to be reversed it is imperative that all nurses have an accurate understanding of anxiety and its relationship to anxiety disorders. A sound appreciation of the prevalence, causes, assessment, treatment and nursing management of anxiety disorders will enable the nurse to provide evidence-based nursing care. In addition, a sound knowledge base will facilitate the accurate dissemination of information about anxiety disorders to clients, families and communities. Increased mental health literacy about anxiety disorders may facilitate early intervention for people with anxiety disorders, which could, with appropriate treatment, reduce the incidence of anxiety disorders in the Australian and New Zealand populations.

Critical thinking challenge 18.1

Consider the following client scenarios and ask yourself:

Is this anxiety normal or does it constitute a disorder?

How long must anxiety persist before it is classified as a disorder?

What level of anxiety constitutes a disorder?

What more needs to be known, to be sure that the individual has met the diagnostic criteria for a specific anxiety disorder?

Scenarios:

Sharon organises her clothes according to fabric type and colour.

Michael continues to have nightmares five years after he was robbed at a petrol station.

Seb has never liked spiders.

Alicia stays at home all day every day.

Glenda worries about everything and has done so for years.

Nick avoids eating in public.

The common link in these presentations is excessive anxiety. In order to make this assessment we need to know how long the symptoms have been occurring. We also need to know how much time is devoted to the behaviours and to what degree they interfere with the individual’s daily functioning.

For example, in examining Sharon’s situation, if we found that Sharon organises her clothes after cleaning the wardrobe, then this would not be regarded as a disorder. If Sharon rigidly arranged her clothes after completing the laundry but spent no more than a few minutes on the task, this behaviour may indicate a personality trait but not a disorder. However, if Sharon spends considerable time each day rearranging her clothes, feels distressed if she cannot complete the ritual and cannot leave the house until she has repeatedly checked that the clothes are in order, her behaviour may be considered a disorder.

Epidemiology

Anxiety disorders are the most common mental disorder experienced by adults in Australia and New Zealand, with a 12-month prevalence of 9.7% in Australia (ABS 1998) and 14.8% in New Zealand. An examination of the contemporary epidemiology of anxiety disorders reveals that they are highly prevalent, disabling, largely unrecognised and under-treated. In 1997 the Australian Bureau of Statistics (ABS) conducted the National Survey of Mental Health and Wellbeing (NSMHW) to determine the rate of mental disorders in the Australian community. The ABS interviewed a representative sample of the Australian population—comprising 10,641 community-dwelling Australians. The survey was the first national study to provide information on the prevalence and patterns of mental disorders in the Australian adult population.

A more recent survey, Te Rau Hinengaro: The New Zealand Mental Health Survey, used a similar methodology (Oakley Browne, Wells & Scott 2006). The New Zealand survey found that mental disorders were common, with a 12-month prevalence of 20.7%. Females had a higher prevalence of anxiety disorders than males. Māori and Pacific Island people generally had higher rates of mental disorder but, after adjusting for other sociodemographic differences, there was no difference in the 12-month prevalence of anxiety disorders between ethnic groups. Pacific Island and Māori people were less likely to seek treatment for mental health concerns, indicating the continuing presence of service access barriers in New Zealand.

Among the major findings of the Australian survey were that people who live alone have a higher rate of anxiety disorder than people who live with one or more others. Women who live outside capital cities have a higher rate of anxiety disorder than females residing in cities (ABS 1998). Half of females with a mental disorder had an anxiety disorder, 31% had a mood disorder

Table 18.1 Prevalence of mental disorders in Australian adults (1997)

and 19% had a substance-use disorder (see Fig 18.1). Males with a mental disorder were most likely to have a substance-use disorder (49%), an anxiety disorder (32%) or a mood disorder (19%) (see Fig 18.2).

Figure 18.1 Prevalence of anxiety disorders compared to other mental disorders in Australian females (from ABS 1998)

Figure 18.2 Prevalence of anxiety disorders compared to other mental disorders in Australian males (from ABS 1998)

Different types of anxiety disorders had different prevalence rates. Post-traumatic stress disorder (PTSD) was the most common anxiety disorder, followed by generalised anxiety disorder (GAD). The least common anxiety disorder was obsessive-compulsive disorder (OCD). All anxiety disorders were more common in females than males (see Fig 18.3).

Figure 18.3 Prevalence (%) of anxiety disorders by type and gender (from ABS 1998)

The prevalence of anxiety disorders varied with age. Anxiety disorders were most prevalent in the 18–54 year age groups. Prevalence declined after age 55 in both males and females (see Fig 18.4).

Figure 18.4 Prevalence (%) of anxiety disorders by gender and age (from ABS 1998)

Individuals with anxiety disorders were more likely to be widowed, divorced or separated. The amount of education an individual had undertaken did not influence the likelihood of having an anxiety disorder.

Individuals frequently had more than one anxiety disorder at a time and many also had another mental disorder. About a quarter of individuals with an anxiety, mood or substance-use disorder had at least one other mental disorder. Mood disorders and anxiety disorders were the most common comorbid conditions. The combination of anxiety and mood disorder made the largest contribution (56%) to disability from mental disorder in Australia (Teesson & Byrnes 2001, p 29). People with anxiety disorders reported an average of 2.1 days out of role—that is, they were unable to perform their usual roles of, for example, mother or worker, during the four weeks preceding the survey. This rate was higher than reported by people with a mood or substance-use disorder (ABS 1998).

Comorbidity is the rule rather than the exception with mental disorders. Once again there are gender differences, with more males suffering from a substance-use disorder in combination with an anxiety or mood disorder, while females are more likely to suffer from anxiety and have a concurrent mood or substance disorder. These gender differences have been simplistically referred to as ‘women think, men drink’. In women, thinking is channelled into worry, while men may drink to cover their worries.

Critical thinking challenge 18.2

What do you think about the statement ‘women think, men drink’? Is it a simplistic statement pandering to gender stereotypes? Would mental disorders be more evenly distributed between the sexes if males reduced their substance abuse? Without the cover of a substance, would more anxiety disorders emerge in males?

Approximately 6.4 % of Australia’s total health budget is spent on specialist mental health services (Mental Health Council of Australia 2005). About half the mental health budget is allocated to psychotic and substance-use disorders. So although anxiety disorders afflict more than double the number of Australians with psychosis and substance dependence, they receive far less funding (Tolkien II Team 2006). Andrews, Issakidis & Slade (2001) liken this situation to salinity in comparison to floods. They note that governments swing into action to deal with dramatic events such as floods but ignore less dramatic events like salinity, which is more prevalent, can be arrested if managed early and causes considerable damage if ignored.

Critical thinking challenge 18.3

What do you think about the current funding allocation? Is it a prudent or fair way to distribute funding, given that anxiety disorders are the most prevalent mental disorders, are associated with a greater degree of disability than mood or substance disorders and respond well to effective treatment? Could the incidence of mental disorders in the Australian population be reduced by spending more on anxiety disorders?

According to the NSMHW, only 28% of people with an anxiety disorder sought treatment. This is half the rate of people who sought help for a mood disorder. Of those who did seek professional help, most sought it from a general practitioner. Women were more likely than men to seek treatment for their anxiety disorder (see Fig 18.5) (ABS 1998).

Figure 18.5 Percentage of people who used a health service for an anxiety disorder (from ABS 1998)

Issakidis & Andrews (2002) examined data from the NSMHW (ABS 1998) to determine service utilisation and perceived need for care. Nearly 55% of respondents stated that they preferred to manage themselves. The reasons given by clients with an anxiety disorder for not accessing services were:

• ‘I preferred to manage by myself.’

• ‘I didn’t think anything could help.’

• ‘I didn’t know where to get help.’

• ‘I was afraid to ask for help or of what others would think of me.’ (stigma)

• ‘I couldn’t afford it.’

• ‘I asked but didn’t get help.’

• ‘I got help from another source.’

Issakidis & Andrews (2002) concluded that attitudinal barriers were more significant than structural barriers in seeking help. This study revealed a pressing need for public and professional education about the recognition and treatment of anxiety disorders.

Australian-born adults exhibit marginally higher rates of anxiety disorder than overseas-born Australians. This difference could be due to the healthy-migrant effect whereby people who are interested in migration and are accepted for migration are mentally healthier than those who are rejected (Andrews et al 1999).

The National Survey of Mental Health and Wellbeing contained insufficient numbers of respondents of an Aboriginal and Torres Strait Islander background to provide reliable estimates of their mental health (ABS 1998).

Aetiology

There is no definitive cause of anxiety disorders. A number of theories have been postulated to explain why some people are more vulnerable than others to the development of an anxiety disorder. These theories represent the ‘nature versus nurture’ debate and include stress, biological, personality, psychodynamic, interpersonal and behavioural theories.

Stress theory

Stress theory was developed by Hans Selye (1956, 1974), an endocrinologist. Selye identified three stages of stress: alarm reaction, resistance and exhaustion. Alarm reaction is the physiological response to stress. In resistance the physiological response continues as the ‘flight or fight’ reaction. The person may adapt to this heightened state of arousal and begin to relax, or they may be unable to relax and deplete their physiological and emotional resources, leaving little in reserve. This last phase is exhaustion.

Analysis of data collected from the study indicates that a shy, inhibited temperament is associated with anxiety problems in adolescence (Prior et al 2000). The ATP study participants are currently in their late teens, and therefore it is not yet possible to tell whether the presence of an anxiety disorder in adolescence will progress into adulthood. However, other researchers have found that the presence of an anxiety disorder in adolescence increased the risk of having an anxiety or depressive disorder in adulthood (Pine et al 1998).

In reviewing the factors contributing to the development of anxiety disorders, Rapee (2002) concluded that a shy, inhibited temperament was the strongest predictor of the development of an anxiety disorder.

Psychoanalytic theory

Psychoanalytic theory postulates that anxiety occurs when the individual represses unacceptable thoughts and emotions. These unacceptable ideas and emotions then re-emerge in the form of anxiety. Freud (1936) believed that individuals mobilise defence mechanisms to control anxiety.

A psychoanalytic therapist would work with the individual to uncover the repressed material (the source of the anxiety) and bring it to a conscious level, so that it can then be dealt with and resolved. Resolution of the repressed material results in resolution of the anxiety.

Interpersonal theory

Sullivan (1952) believed that anxiety was generated by interpersonal problems; for example, insecure parents may transmit anxiety to their children, or anxiety may arise when people do not conform to social norms. Rapee (2002) found that an overprotective parenting style was associated with an inhibited temperament and anxiety disorders in offspring (Rapee 2002).

Behavioural theory

Anxiety can be learned through experience and can be unlearned through new experiences. It makes sense that if a dog bites you, you can develop a fear of dogs. However, can people develop fears by watching others or by hearing about dangerous situations? Gerull & Rapee (2002) conducted a study to determine whether children learned to be fearful by watching others display fear. They showed toddlers a toy snake or spider paired with a picture of their mothers displaying either a positive, negative or neutral expression. Children were more likely to show fear of the toy when their mother displayed a negative expression. Mineka & Zinbarg (2006) argue that contemporary learning theory and research have the potential to explain the complex interplay between stressful learning events and contextual variables in the development and subsequent course of anxiety disorders.

Anxiety disorders

Anxiety disorders may be classified as either primary or secondary anxiety disorders. Primary anxiety disorders are those in which the anxiety disorder is the principal disorder. Secondary anxiety disorders result from another cause—for example, anxiety secondary to a medical condition, or a substance-induced anxiety disorder.

The major presenting symptoms of anxiety disorders are panic, fear, stress, worry and ritualistic behaviours. These symptoms can be used to group the anxiety disorders:

• panic:

o. panic attack—can occur in any of the anxiety disorders

o. panic disorder without agoraphobia

o. panic disorder with agoraphobia

• fear:

o. adjustment disorder with anxiety

o. acute stress disorder

o. post-traumatic stress disorder

• worry:

o. generalised anxiety disorder

o. obsessions and rituals

o. obsessive-compulsive disorder.

Panic attacks

A panic attack is not a discrete anxiety disorder. It can occur in any anxiety disorder and in many different mental disorders and medical conditions. A panic attack is defined as ‘a discrete period of intense fear or discomfort in the absence of real danger’ (DSM-IV-TR, APA 2000, p 430). Panic attacks have an abrupt onset and reach a peak within 10 minutes or less. To qualify as having a panic attack the individual must experience at least four of the classic somatic or cognitive symptoms listed in Box 18.1.

Panic-like symptoms are even more common than full-blown panic attacks. Panic-like symptoms are a subclinical condition consisting of a discrete period of intense fear accompanied by up to three of the classic symptoms of a panic attack.

There are three types of panic attack:

• unexpected—un-cued or ‘out of the blue’; that is, there is no associated trigger

• situationally bound—cued; that is, occurring on exposure to, or in anticipation of, a trigger

• situationally predisposed—similar to situationally bound panic attacks, but the symptoms do not occur every time the individual is exposed to a trigger (APA 2000).

Recurrent ‘unexpected’ attacks are required for a diagnosis of panic disorder. The unexpected nature of panic is illustrated in the case study of Danni.

Nursing interventions

A panic attack can occur in any setting, and therefore nurses must be prepared for a range of situations, from delivering first aid for a panic attack in a shopping centre, to managing the panicked client in a fully equipped clinical environment.

The presenting symptoms of a panic attack may include palpitations, chest pain, sweating and shortness of breath. Consequently clients often present to the nearest accident and emergency department with their first panic attack. In this environment clients are assessed for physical problems and when none can be found they are frequently told that there is ‘nothing’ wrong and are discharged from the department without follow-up. A valuable opportunity to teach the client about their condition and its management is missed. Early recognition and appropriate treatment can, at best, prevent the development of an anxiety disorder and, at the least, ensure that clients do not make continual visits to health professionals seeking a physical reason for their symptoms.

During a panic attack

Stay with the client during the panic attack, as the panic will escalate if they are left on their own (Schultz & Videbeck 2002). The presence of another individual has a calming effect on the panicking client. An unattended client in panic may try to escape their current situation, and in doing so put themselves in danger.

If the clinical environment in which the client has presented with a panic attack is a high-stimulus area, take the client to a calmer, more private setting. Avoid very small rooms or areas were the client might feel trapped. Avoid public areas where the vulnerable client can be observed by passers-by.

Some people lose control of their limbs or become dizzy during a panic attack and are unable to walk independently to another venue. In such a situation it is preferable to modify the environment (reduce noise, lighting, people moving and talking), rather than insist that the client relocate. The panic attack will pass with time, whereas attempting to move a dizzy, fainting client could result in injury to the client should they fall, or muscle-strain for the helper.

In a first-aid situation it may be beneficial to help the client overcome the panic attack in the environment that triggered it. The client’s first response will be to flee the situation. In engaging in this behaviour they reinforce avoidance as a coping strategy.

The client experiencing a panic attack may present with apparent cardiac symptoms. In a first-aid situation the nurse will not have access to monitoring equipment that can help exclude a cardiac cause for the symptoms. However, if the chest pain eases when the client slows their breathing it is unlikely to be due to a heart attack. Nevertheless the nurse must be ready to activate an emergency plan, while at the same time remaining calm and presenting an image of confidence and control. An anxious client can make a nurse anxious and in turn an anxious nurse can make an anxious client more anxious. This ability to transmit anxiety from one person to another has been referred to as infectious anxiety. At its most extreme, infectious anxiety can cause mass hysteria.

Speak to the client in short, simple and audible sentences. A client at panic-level anxiety can only process one detail at a time and their sense of hearing can also be reduced (Stuart 2005a). During the panic attack take a directive approach; instruct the client to ‘Please sit down’ rather than asking, ‘Would you like to sit down?’. The client experiencing panic will not be able to decide what to do when offered the choice of whether to sit or not, and needs direction at this time. When the client has regained control they can resume responsibility for their own decisions.

Continue with a calm, reassuring tone: ‘You are having a panic attack’ and ‘I will stay with you’.

Case study: Danni

Danni [15] … was an outgoing, active teenager. ‘Then one day I went to school and this overwhelming fear came over me—to this day I can’t explain why … I started hyperventilating and my heart was racing. I felt sick and I had to go home.’ She said that was the start of a downhill slide … Danni tried many treatments, and became addicted to Serepax after being prescribed a series of medications (Mayer 2001, p 2).

Instruct the client to take a slow, medium breath (not a deep breath) through their nose and to hold it briefly before exhaling slowly through their nose. Aim to reduce the client’s respiration rate to 10 breaths per minute by using a 6-second cycle per respiration—for example, say ‘in-2–3, out-2–3’ (Andrews & Garrity 2000). Instruct the client to breathe using their diaphragm, not their chest. Continue coaching the client until their anxiety subsides. Some clients are aware that they are hyperventilating and try to slow their breathing, whereas others are not aware and make no attempt to reduce their respiration rate. Shallow, increased breathing or deep breathing results in the client exhaling too much carbon dioxide, which will manifest as dizziness and tingling or pins and needles in the extremities. To correct this you can ask the client to breathe into a paper bag. They will then re-breathe the carbon dioxide and regain the correct balance. However, some people find the prospect of having a bag over their mouth and nose too smothering or embarrassing and will become more panicky. Also, your chances of obtaining a paper bag in a first-aid situation in this age of plastic will be slim. You must be prepared to modify any anxiety reduction intervention to the individual concerned.

Continue to coach the client in the slow-breathing technique because it is important for them to learn that the panic attack will pass and that reducing their breathing rate has helped them to regain control. As the client’s panic subsides, try and encourage them to stay and further reduce their anxiety rather than fleeing as soon as they can. This is an important step in proving to the client that they can regain their composure, which is empowering, rather than reinforcing the idea that the current environment is a dangerous place. A client who experiences a panic attack in a specific setting may come to associate that setting with danger and thus avoid it in future. This is how panic attacks can lead to agora phobia, as the client has another panic attack in another venue and adds this to the list of places to be avoided.

In a clinical setting, if the above techniques fail or the client is experiencing disorganised thoughts, perceptual disturbances or agitation that could escalate to aggression, consider administering a prescribed anti-anxiety medication that can be given as necessary. Even in a clinical situation, medication should only be used as a last resort because it communicates to the client that they are incapable of regaining control and sets up a future expectation that anxiety can be eliminated by medication. An oral dose from the benzodiazepine group (Therapeutic Guidelines Limited 2003), preferably in syrup form, followed by a glass of water will have a quicker onset of action than an intramuscular injection (Therapeutic Guidelines Limited 2003). Although benzodiazepines are very effective at reducing anxiety, they are associated with dependence and should only be used in the short term (preferably no longer than two weeks). Long-term use can result in withdrawal symptoms that mimic the anxiety symptoms that precipitated the client taking them in the first place, thus convincing the client that they cannot do without their ‘pills’ (National Prescribing Service 1999a).

A small minority of clients experiencing very severe symptoms may require intravenous administration of a benzodiazepine by a medical practitioner.

After a panic attack

Once the panic attack has abated, tell the client again that what they just experienced was a panic attack. Be aware that most of the information given to the client during the panic attack will not have been retained. Continue to keep your explanations short and simple. Ask the client if they have previously experienced a panic attack and, if so, when the last attack occurred, how many previous attacks they have had, and whether there is anything in particular that triggers them.

Give the client a list of the classic symptoms of a panic attack. Ask them to put a tick next to each symptom that they have experienced (Treatment Protocol Project 2004). Discuss the list with the client to determine whether they agree that what they have experienced was a panic attack. Some clients may continue to believe that they have a physical problem that has yet to be diagnosed.

However, if this was the client’s first panic attack, and it has occurred in a community environment, it is important to refer the client to a health professional for

Nurse’s story: Dealing with panic attack in A&E

Kerryn Morgan is an accident and emergency nurse with many years of experience. Kerryn recounted an incident the previous weekend of a young mother who presented on a very busy night at the department. She was assessed and appointed a triage rating of 3 (seen within half an hour of presentation). The rationale for this rating was that the young mother had complained of chest pains and an irregular heart rate and although it looked as if she was having a panic attack, Kerryn was not willing to assume this without further investigation. The young woman was very flushed and kept fanning herself and dousing herself with water to cool down. She was very frightened and did not want to be left alone. Further questioning revealed that she had had a previous episode in her early teens and another during her pregnancy. Her pulse was regular but rapid.

Although Kerryn was unable to attend to her immediately, she responded to the young woman’s distress by allowing the client to remain near her while she attended to more urgent issues. Kerryn instructed the young woman to slow her breathing rate and explained that the tingling in her fingers was due to over-breathing and would abate once she was able to slow her breathing down. No further treatment other than empathy, respect and instruction on reducing the respiration rate was needed to resolve the panic attack.

a thorough physical examination to exclude a physical cause for their symptoms. Once a physical cause for the client’s symptoms has been excluded and the diagnosis of panic attack has been confirmed, no further follow-up is warranted, as one panic attack does not constitute an anxiety disorder. However, the client should be informed that if they have further panic attacks they should seek appropriate help early.

Panic disorder

Panic disorder is defined as ‘the presence of recurrent, unexpected panic attacks followed by at least one month of persistent concern about having another panic attack, or a significant behavioural change related to the attacks’ (APA 2000, p 433). The individual must have experienced at least two unexpected panic attacks to be diagnosed with panic disorder. There are two types of panic disorder: panic disorder without agoraphobia and panic disorder with agoraphobia. The frequency and severity of panic disorder varies widely from one panic attack per week for months, to daily panic attacks, separated by weeks or months without an attack. The characteristics of panic disorder are:

• fear that attacks indicate the presence of an undiagnosed, life-threatening illness

• remaining unconvinced by repeated negative medical tests and positive reassurance

• fear that they are going crazy or have a weak character

• development of avoidance behaviours

• fear of having another attack.

The associated features of panic disorder include: a constant or intermittent anxiety that is not focused on anything specific; apprehension about routine activities; and anticipation of catastrophic consequences related to mild symptoms (for example, worrying that a headache is really an undiagnosed brain tumour). The client may also be hypersensitive to medication side effects.

Panic disorder can lead to damage or loss of interpersonal relationships. The individual can be so disabledby the panic that they are no longer able to fulfill their usual roles.

Comorbid disorders to panic disorder include depression, with rates varying from 10% to 65%. In one-third of clients, depression precedes the panic disorder. In two-thirds of clients, depression coincides with panic disorder. Clients will often self-medicate with alcohol or other medication and are at high risk of developing a substance-use disorder. Other anxiety disorders and numerous general medical conditions are also common in panic disorder (APA 2000). The case study of Ian illustrates role impairment and comorbidity associated with panic disorder.

The prevalence of mental disorders is much higher in clinical populations (ABS 1998). Panic disorder occurs in 10% of clients in mental health settings, in 10–30% of general medical clients (especially in vestibular, respiratory and neurology settings) and in up to 60% of clients in cardiology settings (APA 2000).

Panic disorder has a peak onset in adolescence and a smaller peak in the mid-thirties. It is rare in children and people over 45 years of age. Panic disorder has a chronic, fluctuating course. Agoraphobia usually develops within the first year of panic attacks.

Panic disorder is more common in families. A client with a first-degree relative with panic disorder is eight times more likely to develop panic disorder than the general population. If the onset of symptoms occurs before the individual is 20 years old, then the likelihood is twenty times higher than in the general population.

The outcome of treatment in panic disorder is varied. Six years after treatment, 30% of clients were well, 40–50% improved, and 20–30% were the same or worse (APA 2000).