The Characteristics, Causes, and Prevalence of Panic Disorder, an Anxiety Disorder

In the study of psychology, it is important to understand and notice that culture affects the prevalence, diagnosis, and treatment of psychological disorders. Cross-cultural psychology sheds light on which aspects of the human condition are universal and which are bound to specific cultures. Every culture has the own way of measuring psychological disorders, from the Diagnostic and Statistical Manual of Mental Disorders version five (DSM-5) in the United States to no standards at all in many indigenous cultures. However, some abnormal psychological disorders are universal in the sense that all humans are capable of expressing the symptoms, yet different cultures deal with these symptoms in different ways. This in turn affects the prevalence, accuracy, and amount of diagnoses of psychological disorders as well as the treatments and stigmas for the afflicted. One psychological disorder in particular, panic disorder, which is characterized by intense episodes of fear that manifest in both physical and mental symptoms, is an abnormal psychological disorder that is identified and handled differently cross-culturally as well as between genders. Panic disorder is a condition universal to humans, but it is not universal within the study of psychology because Western cultures have a higher prevalence of reported cases of people with panic disorder, and women tend to suffer from it more frequently than men.

Panic disorder is an abnormal psychological disorder in which people suffer episodes of extreme fear. This fear causes them to express various physical symptoms including heart palpitations, accelerated heart rate, sweating, trembling, sensations of shortness of breath, feelings of choking, chest pain, nausea, feeling dizzy or faint, chills or hot flashes, and even paresthesia. It also causes mental symptoms including feelings of unreality or depersonalization, fear of losing control or going crazy, and the fear of dying (Katzman, 2014; Lambert, 2015). According to the DSM-5, in order to be diagnosed with panic disorder, the individual needs to suffer from at least four of those symptoms, as well as have unexpected panic attacks of which at least one leads to at least one month of extreme concern that he/she will have another panic attack or one month of negative behavioral change (Katzman, 2014). However, an individual may still have panic disorder if the panic attacks are expected. Both expected and unexpected panic attacks can cause agoraphobia, in which the afflicted fears panic inducing environments (Johnson). The amount of symptoms and different ways panic disorder can be expressed makes it complicated to diagnose to begin with. There are over 13 symptoms and therefore “over 700 possible combinations of four symptoms” which means that it is difficult to create a framework for classifying the disorder (Lambert, 2015). All people experience some combination of the symptoms at one time or another, but panic disorder is not universal even in the diagnostic stage because the criteria that need to be met in order to make a concrete diagnosis varies.

The causes and prevalence of panic disorder are also various. Panic tends to be “an adaptive survival response” to a perceived threat which leads to deciding between fight or flight. The body reacts physically to the threat so that it can be strong enough to fight or run away (Johnson). When this response happens as a reaction to something that is not immediately threatening, then a person is having a panic attack. If these attacks are frequent and affect daily living, then he/she is suffering from panic disorder. Sometimes, however, someone can have frequent panic attacks and not have an anxiety disorder at all (Na, 2011). This causes the statistics for panic attacks and panic disorder to be separate. It is estimated that panic attacks occur sometime in the life of 22.7 percent of people, while actual panic disorder only occurs in 4.7 percent (Na, 2011; Katzman, 2014). Approximately 10 percent “of the general public will have a panic attack without ever developing” panic or another disorder (Katzman, 2014). If we take risk into account, we find that the theoretical risk of developing panic disorder is higher than the experimental reality, and that the risk varies between cultures. The “projected lifetime risk is proportionally between 17% and 69% higher than estimated lifetime prevalence… with the highest ratios in countries exposed to sectarian violence (Israel, Nigeria, and South Africa), and a general tendency for projected risk to be highest in recent cohorts in all countries” (R). Another skewing factor of panic disorder is that the average age of onset is relatively early, and children who develop the disorder usually also develop other psychological disorders (Katzman, 2014). This causes panic disorder to be underdiagnosed and misunderstood.

Panic disorder is caused by both nature and nurture factors including genetics and child development. This is the primary reason that the disorder is not cross-culturally universal. Most cultures have different societal contexts, and genes do not usually cross inter-racial boundaries. More than six studies have shown a correlation between a gene and a 5.7 to 17.3 percent increase in the risk of having panic disorder in subjects with family members who have it. Goldstein et al. determined that first-degree relatives of people with panic disorder are 17 times more likely to have panic disorder by the age of 20, and 6 times more likely over the age of 20, than non-relatives, and that there is approximately an 11 percent chance that they will develop it (Na, 2011; Johnson, 2014). Psychologists have determined that there are more than “1000 polymorphisms and 350 candidate genes” that are associated with panic disorder (Johnson, 2014). This further emphasizes that panic disorder is not universal yet widespread and possible for all humans, because it can be expressed due to a number of different genetic combinations, yet there are numerous genetic sequences that can cause panic disorder.

Another example of how panic disorder is universally non-universal is that a study in Europe found that the genetic sequence rs7309727-rs11060369 is directly related to panic disorder. However, this genetic sequence did not cause panic disorder when it was present in Japanese subjects, only European subjects. The gene TMEM132D had a high correlation to causing panic disorder in Europeans, but did not cause panic disorder in any Japanese subjects (Erhardt, 2012). This means that nature and nurture must combine in order for a gene to have a certain expression. Genetics alone do not cause disorders, but culture in combination with family history and susceptibility do. Panic disorder “develops within a developmental and a social context, where childhood learning and experiences such as separation and the associated anxiety can predispose a child to later [panic disorder]… Environmental influences both within the family, and in more general working and social environments can also influence levels of anticipatory or reactive anxiety” (Lambert, 2015). Panic disorder can occur anywhere, but it only occurs in certain cultures and in individuals in those cultures who have specific genetic codes that lead to this particular psychological disorder.

There is also a marked gender difference in the prevalence of panic disorder regardless of culture. More women have panic disorder than men, and they start to express it at a younger average age. Women ate two times more likely to have panic disorder than men (Katzman, 2014; Na, 2011; Johnson, 2014). Women have it at earlier ages because of hormonal fluctuations as well as “factors such as early life stress or higher incidence of trauma such as sexual abuse or domestic violence” (Johnson, 2014). Women are also genetically predisposed to panic disorder because of the high-activity COMT 158val allele in females (Na, 2011). This extreme difference between men and women in regards to frequency of panic disorder makes it difficult to conduct universal studies because most subjects are typically women. 70 percent of panic disorder subjects in one study were women, and their average age was relatively 40 years old (Teachman, 2010). Gender is not the only varying factor among panic disorder patients. Cultural diversity, age of onset, false suffocation alarms, whether someone is fearful or not on a classification system, their respiratory and hyperventilation subtypes, personalities, and inhibitions all also affect the likelihood that an individual will have panic disorder (Lambert, 2015). While these different factors are universal in that all people fall somewhere on a scale for each one, the fact that panic disorder is only found in certain combinations of these factors makes it is not universal.

Panic disorder is more prevalent in women “who are middle-aged, widowed/divorced, and those of low income.” However, a study conducted by the Canadian Community Health Survey found that there is no difference in the prevalence of panic disorder in rural versus urban societies (Katzman, 2014). While the urbanization of the culture does not necessarily play a role in panic disorder, the race of the afflicted does. A study showed that out of a group of subjects with panic disorder, 91 percent were Caucasian, 5 percent were African-American, 2.3 percent were biracial, and 2.3 percent reported that their race was other than those three options (Teachman, 2010). Psychologists have also determined that there are genetic differences between Caucasians and Asians with panic disorder. The COMT 158val and 158met alleles vary in subjects of these cultures (Na, 2011). Therefore, not only do different cultures lead to a different level of frequency for panic disorder but they also lead to different genetic expressions which changes whether or not panic disorder is linked to certain deoxyribonucleic acid sequences within each culture or, more broadly, each race.

Cultures have different values and beliefs that also lead to different ways of perceiving psychological disorders as well as different prevalence levels of panic disorder specifically. In Asian cultures, some of the symptoms of panic disorder including dizziness, unsteadiness, choking, and feeling terrified are more often reported than the other symptoms. Asian subjects also reported these specific symptoms more often than Caucasian subjects. Also, African Americans with panic disorder do not report nervousness as much as Caucasian subjects (Barrera, 2010). However, the symptoms themselves are not more severe in any culture because the disorder does the same thing to all humans who have it. In this sense panic disorder is universal, but still remains not universal because of the way the different cultures report the symptoms and how negatively they view each symptom. Some cultures, including the African Americans, do not think that some symptoms are as severe as the Caucasians and Asians did while experiencing the same symptoms, which shows that cultural context is vital to understanding whether someone is suffering from panic disorder and how to classify his/her symptoms. Additionally, “African Americans tend to be more ashamed of their panic symptoms than Caucasians. It may be that individuals identifying as African American are hesitant to admit to interference and distress related to panic symptoms for fear that they would be labeled “crazy” (Barrera, 2010).

The African American culture and its subcultures are particularly notable when it comes to the way they deal with panic disorder. “[I]ndividuals who identify as African American were more likely to experience tingling sensations and numbness in their extremities, as well as fears of dying or going crazy during panic attacks than individuals who identify as European American. It has been suggested that tingling and numbness in the extremities may be of particular concern for individuals identifying as African American due to the high rates of diabetes, hypertension, and foot amputations within this group” (Barrera, 2010). Predispositions to different symptoms in different cultures explain why panic disorder varies cross-culturally even though it manifests with the same symptoms regardless of the individual human. There are social as well as biological predispositions. “[M]any African American children are socialized to expect hostility, irrational restrictions, insults and unfair treatment based on the color of their skin. To counteract these predictable trends, African American children are taught to develop high levels of tolerance for unfair acts” (Levine, 2013). This is relevant because it causes African Americans to be more thick-skinned, and less likely to have a panic attack in situations where they might be confronted by a hostile person. All people are capable of building this tolerance, but it is stronger in some cultures than others which means that it is not universal.

African subcultures vary between one another as much as they vary from entirely other racial cultures. Africans in the Caribbean and Cambodian cultures exhibit unique statistics and beliefs. Black men are more likely to develop panic disorder in the Caribbean than they are in American culture, but black women in America are more likely to develop panic disorder than in the Caribbean culture. Overall, 3.5 percent of African Americans have panic disorder, but 4.1 percent of Caribbean blacks have it (Levine, 2013). The African culture’s internal diversity strengthens the fact that panic disorder is not a universal psychological disorder though it exists globally. The Cambodians have unique beliefs that skew their recognition of panic symptoms. The Cambodians believe in khyâl which is an energy force that moves through the circulatory system, so they panic when they get dizzy because they think this force is going to kill them. Westerners, however, view dizziness as a sign of a stroke or other health concern (Barrera, 2010). Thus some cultures are much more fearful of certain symptoms because of the beliefs that their culture holds.

There are also differences between the Hispanic cultures and Caucasian cultures. Hispanics report physical symptoms more than Caucasians, who tend to report more mental symptoms. This does not mean that they do not recognize the mental symptoms, but rather that their society looks down upon mental ailments while physical ailments are part of an accepted normality (Barrera, 2010). Certain symptoms are accepted broadly among cultures but others are distinctly perceived negatively in isolated cultures which causes a lack of reported symptoms and skews data. However, 4.8 percent of Hispanic whites have panic disorder, which is more than both Caribbean and African American blacks, but less than Caucasians (Levine, 2013). This means that, despite the stigma behind it, either Hispanics do report panic disorder when they have it, or they report the physical symptoms enough and there are enough physical symptoms to report. Hispanics tend to be low-income workers in America, and the risk of developing panic disorder is also greater for those below the poverty line (Levine, 2013). The fact that two people, both suffering from panic disorder, one Hispanic and the other Caucasian, but one reports only physical symptoms and the other includes mental symptoms signifies that panic disorder is neither diagnosed nor treated similarly cross-culturally.

Cultures also vary as far as whether they are collectivist or individualistic. Collectivist cultures “tend to be more prevention focused” than individualistic cultures (Tannenbaum, 2015). Collectivist cultures in East Asia such as South Korea, Japan, and Taiwan also tend to recognize dizziness, unsteady feelings, feelings of terror, and feelings of choking, more than Western cultures (Barrera, 2010). Western individualistic cultures such as Australia, Canada, and the United States, therefore focus on determining what the problem is and how to fix it, rather than figuring out what the cause is and eliminating it (Tannenbaum, 2015). Not only do these cultures differ on the prevalence and expression of panic disorder, but they also put emphasis on different stages of the treatment of the disorder.

Panic disorder has a different level of risk and prevalence in each culture, a different way of being perceived and reported, and of being treated. Since the disorder can affect anyone, anywhere in the world, it is universally non-universal because it is not understood the same cross-culturally. It is universal in the sense that anyone can have it regardless of cultural boundaries, and it is manifests with the same symptoms regardless of race or culture. It is not universal because everybody does not have an equal opportunity of suffering from panic disorder as women and Caucasians have a much higher likelihood of developing it. It is also not universal because different cultures interpret the symptoms differently and then think of the afflicted people differently. Therefore, panic disorder is not universal overall.

Works Cited

1. Barrera, T. L., Norton, P. J., & Norton, G. R. (2010). Panic disorder in African Americans, Caribbean blacks, and non-Hispanic whites. Journal of Anxiety Disorders, 24(4), 441-448.
2. Erhardt, A., Czibere, L., Roeske, D., Lucae, S., Unschuld, P. G., Ripke, S., ... & Keck, M. E. (2012). TMEM132D, a new candidate for anxiety phenotypes: evidence from human and mouse studies. Molecular Psychiatry, 17(8), 840-850.
3. Johnson, M. R., & Ost, L. G. (2014). Panic disorder and agoraphobia: Consequences of cultural differences in symptomatology and illness behaviour. Clinical Psychology Review, 34(3), 208-218.
4. Katzman, M. A. (2014). Panic disorder. New England Journal of Medicine, 371(6), 583-584.
5. Lambert, R. (2015). Cross-cultural aspects of panic disorder. In Handbook of Cultural Psychiatry (pp. 269-277). Academic Press.
6. Levine, R. E., & Kinlock, T. W. (2013). Panic disorder prevalence rates in African American men and women. Journal of Anxiety Disorders, 27(1), 47-52.
7. Na, C. (2011). The genetic basis of panic disorder and agoraphobia: symptoms and subtypes. Journal of Anxiety Disorders, 25(7), 835-843.
8. Teachman, B. A., & Clerkin, E. M. (2010). Perceived mastery and interpretation bias interact to contribute to the racial disparity in panic disorder. Journal of Anxiety Disorders, 24(6), 562-568.
9. Tannenbaum, M. B., Hepler, J., Zimmerman, R. S., Saul, L., & Jacobs, S. (2015). Appealing to fear: A meta-analysis of fear appeal effectiveness and theories. Psychological Bulletin, 141(6), 1178-1204.
10. World Health Organization. (2019). ICD-11: International Classification of Diseases 11th Revision. Retrieved from https://icd.who.int/browse11/l-m/en