Panic disorder

Introduction
Panic disorder is a type of anxiety disorder characterized by recurrent,
unexpected panic attacks. It involves the experience of sudden and intense episodes of
fear or discomfort that reach their peak within minutes. These panic attacks can be
accompanied by various physical and psychological symptoms.
Panic disorder is diagnosed in people who experience spontaneous seemingly out-of-
the-blue panic attacks and are very preoccupied with the fear of a recurring attack.
Panic attacks occur unexpectedly, sometimes even when waking up from sleep. Panic
disorder usually begins in adulthood (after age 20), but children can also have panic
disorder and many children experience panic-like symptoms.
About 2-3% of Americans experience panic disorder in a given year and it is twice as
common in women than in men. Panic disorder can interfere a lot with daily life, causing
people to miss work, go to many doctor visits, and avoid situations where they fear they
might experience a panic attack. The interference is greatest when people also have
agoraphobia, as well as panic disorder.
Many people don't know that their disorder is real and highly responsive to treatment.
Some are afraid or embarrassed to tell anyone, including their doctors and loved ones,
about what they experience for fear of being considered a hypochondriac. Instead they
suffer in silence, distancing themselves from friends, family, and others who could be
helpful or supportive.

Types of panic disorder

Panic disorders are often classified into six types, including anxiety disorders, phobias
and more.
1. Generalized Anxiety Disorder (GAD):
When you are disturbed by bad things but the
chances of them actually happening are very slim, you may have generalized anxiety
disorder. Under such conditions, you may also simply feel worried all the time without
any justification. These anxieties are so abnormal they become an impediment to your
daily routines and your ability to unwind.
2. Obsessive-Compulsive Disorder (OCD):
Another example of panic or anxiety
disorder is obsessive-compulsive disorder. Characteristics include unwanted behaviors
and thoughts that overwhelm your self-control. For instance, your mind can’t help but
worry if you have turned off the iron or stove before leaving the house. You may also
feel the compulsion to excessively repeat certain routines such as the simple washing of
hands.
3. Phobias:
The fearing of specific objects, activities and scenarios to an exaggerated
degree are phobias. Your fright tends to be out of proportion even if the things you fear
hardly pose any danger. Common examples are fear of heights, flying, insects and
snakes. People with phobias often desperately avoid the things that frighten them, as
the confrontation of the things often makes their condition even worse.
4. Social Anxiety Disorder:
Also called social phobia, social anxiety disorder is
characterized by the extreme fear of getting a bad reputation. This condition tends to
make individuals very shy and causes them to steer clear of social interactions for fear
of getting embarrassed in public. Stage fright is a prime example of social phobia.

5. Post-Traumatic Stress Disorder (PTSD):

Traumatic events such as near-death
experiences or participation in a war may cause people to feel sad, frightened and
detached from other people. With post-traumatic stress disorder, such negative effects
persist for long periods and lead to hypervigilance and an inability to live normally.

Symptoms of panic disorder

Anxiety:
Anxiety is a feeling of unease. It can range from mild to severe, and can
include feelings of worry and fear. Panic is the most severe form of anxiety.
You may start to avoid certain situations because you fear they'll trigger another attack.
This can create a cycle of living "in fear of fear". It can add to your sense of panic and
may cause you to have more attacks.
Panic attacks:
During a panic attack you get a rush of intense mental and physical
symptoms. It can come on very quickly and for no apparent reason.
A panic attack can be very frightening and distressing.
Symptoms include:

 Sudden and intense fear or discomfort

 Rapid heart rate or palpitations
 Chest pain or tightness
  Shortness of breath or feelings of suffocation
 Choking sensations or difficulty swallowing
 Sweating or cold/clammy hands
 Trembling or shaking
 Dizziness or lightheadedness
 Nausea or stomach discomfort
 Hot flashes or chills
 Tingling or numbness in the extremities
 Feeling detached from oneself or reality (depersonalization or derealization)
 Fear of losing control or going crazy
 Fear of dying or impending doom
 Intense anxiety or a sense of terror
 Restlessness or feeling on edge
 Muscle tension or stiffness
 Difficulty concentrating or experiencing a mental fog
 Irritability or mood swings
 Sleep disturbances, such as insomnia or restless sleep
 Fatigue or exhaustion
 Headaches or migraines

Most panic attacks last between 5 and 20 minutes. Some have been reported to last up
to an hour.
The number of attacks you have will depend on how severe your condition is. Some
people have attacks once or twice a month, while others have them several times a
week.
Although panic attacks are frightening, they're not dangerous. An attack will not cause
you any physical harm, and it's unlikely you'll be admitted to hospital if you have one.
Be aware that most of these symptoms can also be symptoms of other conditions or
problems, so you may not always be experiencing a panic attack.

When to see a doctor

If you have panic attack symptoms, seek medical help as
soon as possible. Panic attacks, while intensely uncomfortable, are not dangerous. But
panic attacks are hard to manage on your own, and they may get worse without
treatment.
Panic attack symptoms can also resemble symptoms of other serious health problems,
such as a heart attack, so it's important to get evaluated by your primary care provider if
you aren't sure what's causing your symptoms.

Causes of panic disorder

Genetic predisposition:
Individuals with a family history of panic disorder or other
anxiety disorders may be at a higher risk.

Neurochemical imbalances:
Disruptions in neurotransmitters, such as serotonin,
norepinephrine, and gamma-aminobutyric acid (GABA), can impact the brain's
regulation of emotions and contribute to panic disorder.

Traumatic experiences:
A history of trauma, such as physical or emotional abuse, can
increase the likelihood of developing panic disorder.

Chronic stress:
Long-term exposure to high levels of stress can contribute to the
development of panic disorder.

Major life transitions:

Significant life changes, such as moving, getting married, or
starting a new job, can trigger panic disorder in susceptible individuals.

Substance abuse:
Misuse or withdrawal from substances like drugs, alcohol, or certain
medications can induce panic attacks and potentially lead to panic disorder.

Medical conditions:
Certain medical conditions, such as hyperthyroidism, mitral valve
prolapse, or heart conditions, may be associated with panic disorder.

Respiratory conditions:
 Conditions that affect breathing, like asthma or chronic obstructive pulmonary disease
(COPD), can contribute to the development of panic disorder.

Sensitivity to physical sensations:

Individuals who are highly sensitive to bodily
sensations or have a heightened awareness of physical symptoms may be more prone
to panic disorder.

Phobias:
Specific phobias, such as a fear of heights, enclosed spaces, or flying, can
trigger panic attacks and potentially lead to panic disorder.

Cognitive factors:
Distorted thought patterns, catastrophic thinking, or a tendency to
interpret benign physical sensations as dangerous can contribute to panic disorder.

Lack of coping mechanisms:

Inadequate strategies for managing stress or anxiety
may contribute to the development of panic disorder.

Personality traits:
Certain personality characteristics, such as neuroticism, high levels
of anxiety, or a tendency to be highly self-critical, may increase the risk of panic
disorder.

Childhood adversity:
Adverse childhood experiences, such as neglect, abuse, or a
chaotic home environment, can contribute to the development of panic disorder later in
life.

Learned behavior:
Observing or experiencing panic attacks in others, particularly during
childhood, can contribute to the development of panic disorder through a process
known as observational learning.
It's important to remember that panic disorder is a complex condition, and not all
individuals with these factors will develop the disorder. A combination of these factors,
along with other individual and environmental factors, contributes to its onset. Seeking
professional help from a mental health provider is crucial for an accurate diagnosis and
effective treatment.

Panic disorder in children

Panic disorder is more common in teenagers than in
younger children.Panic attacks can be particularly hard for children and young people to
deal with. Severe panic disorder may affect their development and learning.
If your child has the signs and symptoms of panic disorder, they should see a GP.
After taking a detailed medical history the GP will carry out a thorough physical
examination to rule out any physical causes for the symptoms.
They may refer your child to a specialist for further assessment and treatment. The
specialist may recommend a course of CBT for your child.
Screening for other anxiety disorders may also be needed to help find the cause of your
child's panic attacks.
Read more about anxiety disorders in children or find out about mental health services
for children and young people.

Treatment for panic disorder

Panic disorder is a treatable condition. There are a
number of effective treatments available, including medication and therapy. With
treatment, most people with panic disorder can learn to manage their symptoms and
live a full and normal life.
The two main treatments for panic disorder are medication and therapy.
1. Medication:
There are a number of medications that can be effective in treating panic
disorder. These medications work by increasing the levels of certain brain chemicals,
such as serotonin and norepinephrine. Some of the most commonly prescribed
medications for panic disorder include:

 Selective serotonin reuptake inhibitors (SSRIs): SSRIs are a type of

antidepressant that is often used to treat panic disorder. Some examples of
SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).
  Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs are another
type of antidepressant that can be effective in treating panic disorder. Some
examples of SNRIs include venlafaxine (Effexor) and duloxetine (Cymbalta).
 Beta-blockers: Beta-blockers are medications that are typically used to treat
high blood pressure. However, they can also be effective in treating panic
disorder by reducing the physical symptoms of a panic attack, such as racing
heart and sweating. Some examples of beta-blockers include propranolol
(Inderal) and nadolol (Corgard).
2. Therapy:
Cognitive-behavioral therapy (CBT) is a type of therapy that is specifically
designed to treat panic disorder. CBT helps people to change the way they think about
and react to their panic attacks. CBT can be very effective in helping people to manage
their symptoms and live a full and normal life.

Other therapies that can be helpful for people with panic disorder include:

 Relaxation training: Relaxation training helps people to learn how to relax their
bodies and minds. This can be helpful for reducing the physical symptoms of a
panic attack.
 Mindfulness-based therapies: Mindfulness-based therapies help people to
focus on the present moment and to let go of negative thoughts and emotions.
This can be helpful for reducing anxiety and panic.
If you think you may have panic disorder, it is important to see a doctor or mental health
professional for diagnosis and treatment. There are a number of effective treatments
available, and with treatment, most people with panic disorder can learn to manage their
symptoms and live a full and normal life.

Some additional tips for managing panic disorder:

 Get regular exercise. Exercise can help to reduce stress and anxiety.
 Get enough sleep. When you're well-rested, you're better able to cope with
stress.
 Practice relaxation techniques. Relaxation techniques, such as deep breathing
and meditation, can help to reduce anxiety and panic.
  Avoid caffeine and alcohol. Caffeine and alcohol can worsen anxiety symptoms.
 Talk to someone you trust. Talking about your fears and worries can help to
reduce their power.
If you are struggling with panic disorder, please know that you are not alone. There are
a number of effective treatments available, and with treatment, you can learn to manage
your symptoms and live a full and normal life.

Complications of panic disorder

Panic disorder can have several complications that can affect a person's overall well-
being and quality of life. Here are some common complications associated with panic
disorder:
Avoidance behavior:
Panic attacks can be highly distressing and overwhelming,
leading individuals to develop avoidance behaviors. They may start avoiding certain
situations or places where they have previously experienced panic attacks. Over time,
this can restrict their activities, limit their social interactions, and negatively impact their
daily functioning.

Agoraphobia:
Agoraphobia is an anxiety disorder that often coexists with panic
disorder. It involves a fear of being in situations where escape might be difficult or help
might not be available, leading to avoidance of crowded places, public transportation, or
open spaces. Agoraphobia can significantly limit an individual's ability to engage in
regular activities and may lead to social isolation.

Depression:
Panic disorder is often comorbid with depression. The chronic stress and
anxiety associated with panic attacks can contribute to the development of depressive
symptoms, such as persistent sadness, loss of interest in activities, changes in appetite
or sleep patterns, and feelings of hopelessness.

Substance abuse:
Some individuals with panic disorder may turn to substance abuse as
a way to cope with their symptoms. Drugs or alcohol may temporarily alleviate anxiety
or provide a distraction from panic attacks. However, substance abuse can lead to
addiction and further exacerbate the underlying mental health condition.
Interference with daily life:
Panic attacks can be disruptive and unpredictable, making
it challenging to maintain regular routines or meet responsibilities at work, school, or
home. The fear of having panic attacks can cause constant worry and preoccupation,
impairing concentration and productivity.
Health complications:
Panic disorder can contribute to physical health issues.
Frequent panic attacks can lead to elevated blood pressure, rapid heart rate, chest pain,
headaches, digestive problems, and other stress-related physical symptoms. Over time,
these symptoms may increase the risk of developing cardiovascular problems or other
health conditions.
Impact on relationships:
Panic disorder can strain relationships with family, friends,
and romantic partners. The avoidance behaviors, mood fluctuations, and difficulties in
engaging in social activities can lead to misunderstandings, frustration, and strained
communication.
Increased risk of other anxiety disorders:
People with panic disorder have an
increased vulnerability to developing other anxiety disorders, such as generalized
anxiety disorder (GAD), social anxiety disorder, or specific phobias.
Financial burden: Seeking treatment for panic disorder, including therapy and
medication, can be costly. The expenses associated with managing the disorder, along
with potential work-related disruptions, can lead to financial strain.

Ratio in Pakistan

The ratio of panic disorder in Pakistan is estimated to be between 2% and 4% of the

population. This means that about 2 to 4 million people in Pakistan may have panic
disorder. The prevalence of panic disorder is higher in women than in men, with a
female to male ratio of about 2 to 1.

A study published in the journal Psychiatric Quarterly in 2012 found that the prevalence
of panic disorder in Pakistan was 3.2%. The study also found that panic disorder was
more common in urban areas than in rural areas.
Another study, published in the journal Pakistan Journal of Medical & Health Sciences
in 2019, found that the prevalence of panic disorder in Karachi was 4.3%. The study
also found that panic disorder was more common in people with a history of mental
illness.

These studies suggest that the prevalence of panic disorder in Pakistan is similar to the
prevalence in other countries. However, more research is needed to better understand
the prevalence and impact of panic disorder in Pakistan.

Long term Plan for panic disorder :

Developing a long-term plan for managing panic disorder can help you reduce the
frequency and intensity of panic attacks and improve your overall well-being. Here are
some steps you can consider:

Seek professional help: Consult a mental health professional, such as a psychologist

or psychiatrist, who specializes in anxiety disorders, including panic disorder. They can
provide an accurate diagnosis, recommend appropriate treatment options, and guide
you throughout your journey.

Psychotherapy: Cognitive-behavioral therapy (CBT) is often considered the first-line

treatment for panic disorder. CBT helps identify and modify negative thought patterns
and behaviors that contribute to panic attacks. It also involves exposure therapy to
gradually confront and desensitize yourself to feared situations. Work with a therapist
experienced in treating panic disorder to develop coping strategies and address
underlying factors.

Medication: In some cases, medication may be prescribed to manage panic disorder

symptoms. Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are
commonly used medications. Consult with a psychiatrist to determine if medication is
appropriate for you and to discuss potential benefits and risks.

Lifestyle adjustments: Incorporate healthy lifestyle habits that can support your overall
well-being and help manage panic disorder. These may include:

Regular exercise: Engaging in physical activity can reduce anxiety and improve mood.

Stress management: Practice stress reduction techniques such as deep breathing,

meditation, or mindfulness to help calm your mind and body.
Healthy sleep habits: Prioritize adequate sleep and establish a consistent sleep
routine to support better overall mental health.

Limit caffeine and stimulants: Reduce or avoid substances like caffeine, nicotine, and
alcohol, as they can trigger or exacerbate panic symptoms.

Self-care practices: Engage in activities that promote self-care and relaxation, such as
hobbies, creative outlets, spending time in nature, or engaging in activities you find
enjoyable and calming. Taking care of your overall well-being can contribute to
managing panic disorder.

Support system: Build a strong support system of understanding and supportive

individuals who can offer emotional support. This may include friends, family, or joining
support groups where you can connect with others who have experienced similar
challenges.

What’s the longest a panic attack can last?

Most panic attacks last only a few minutes
— though they often feel like a lifetime when you’re experiencing one. Symptoms
typically peak within 10 minutes and then begin to fade away.
It’s possible to have a panic attack that’s especially long or short. Some attacks can
peak in a few seconds, with the entire attack lasting just minutes, while others may last
longer.
Most research has described single panic attacks lasting up to 30 minutes. Some
reports by individuals have described attacks lasting hours or even days.
According to some experts, if symptoms don’t peak within 10 minutes, it’s not
considered a panic attack (which has a sudden onset of panic). Instead, it’s considered
high anxiety. While this is still incredibly uncomfortable and unpleasant, it may not be
diagnosed as a panic attack.
It’s also possible to experience multiple panic attacks that occur in waves for an hour or
longer.

Conclusion
In conclusion, panic disorder is a challenging and disruptive mental
health condition characterized by recurrent and unexpected panic attacks. It can have a
significant impact on a person's daily life and well-being. However, with appropriate
diagnosis and treatment, it is possible to manage and alleviate the symptoms of panic
disorder.
The key to addressing panic disorder is seeking professional help from mental health
experts who specialize in anxiety disorders. Psychotherapy, particularly cognitive-
behavioral therapy (CBT), is often recommended as a primary treatment approach. CBT
helps individuals identify and challenge negative thought patterns and behaviors that
contribute to panic attacks. Exposure therapy, a component of CBT, gradually exposes
individuals to feared situations, allowing them to develop coping mechanisms and
reduce anxiety.

Case Report: An Atypical Presentation of Panic Disorder

Masquerading as Possession Trance
This case report demonstrates an atypical presentation of panic disorder which
masqueraded as episodes of possession trance. Patient X is a 62-year-old Chinese
female who presented with recurrent episodes of uncontrollable screaming and shaking
of all four limbs. During these episodes, she reported auditory hallucinations (Buddhist
chanting) and visual hallucinations (a rotting corpse) which she attributed to the
influence of “evil spirits.” She was diagnosed with panic disorder with culture-specific
symptoms on a background of major depressive disorder. With an understanding of the
patient's belief system and an empathetic approach during psychoeducation, she
eventually accepted the use of pharmacotherapy. She was prescribed escitalopram
(started at 2.5 mg OM) and clobazam (10 mg ON) with good clinical effect and
cessation of episodes afterward
Introduction
Possession trance is a common culture-bound syndrome in Singapore. Owing to
phenomenological similarities, possession trance disorders are classified under
dissociative identity disorder (DID) in DSM V(1–4). It describes a state with an alteration
in the level of consciousness, amnesia during the trance, a stereotyped behavior
characteristic of a deity, duration of less than an hour, normal behavior in between
trances, and fatigue upon termination (5). Due to their similar presentations,
differentiation between possession trances and panic disorders with culture-specific
symptoms can be diagnostically challenging. This case report demonstrates an atypical
presentation of panic disorder which had masqueraded as episodes of possession
trance, highlighting the subtle differences between the two.

Case Presentation
A 62-year-old Chinese female, referred here as patient X, was admitted for recurrent
episodes of uncontrollable screaming and shaking of all four limbs.
These episodes began 4 days before admission, occurring two to three times daily.
Each episode was abrupt in onset, lasting several minutes to an hour. Onset was
characterized by an uncomfortable coldness in the chest spreading outwards to both
arms and legs, transforming into a tingling sensation followed by involuntary tremors.
Patient X described a lack of control, oscillating between laughing and crying whilst
shouting incomprehensibly and flailing her limbs against her surroundings. She
experienced fatigue and diaphoresis with no loss of consciousness nor amnesia during
these episodes. She had persistent concerns over future episodes, which she described
as unbearable.
In the emergency department, patient X suffered an episode and was given
intramuscular haloperidol 5 mg with cessation of the episode within minutes. She was
able to sit up and apologize, before cooperating with further investigations. After 10 min,
she suffered another episode and was given intravenous midazolam 1 mg with the
resolution of symptoms within minutes.
Similar episodes had occurred 3 years ago after having undergone a left open radical
nephrectomy for xanthogranulomatous pyelonephritis. Morphine was administered intra-
operatively and tramadol post-operatively for pain control and the neurologist's
impression was “episodic hyperkinetic movement disorder possibly secondary to
opioids.” Investigations including electroencephalography (EEG) and MRI brain imaging
were normal. Tramadol was discontinued and she was started on oral clobazam 10 mg
TDS. These episodes ceased after 2 weeks and she was discharged with a tailing
regimen of Clobazam. During the same post-operative period, she reported low mood
and fleeting suicidal thoughts resulting from her various medical conditions. She was
diagnosed with Major Depressive Disorder (MDD) and started on escitalopram 5 mg ON
which was titrated upwards to 10 mg ON during her follow-up appointments. She
remained stable on this dose for 2 years before discontinuing her medications.
Patient X had no significant personal or family history of neurological or psychiatric
illnesses. Her other medical conditions include essential hypertension, hyperlipidemia,
and diabetes mellitus. She had a good relationship with her husband and two children.
Her pre-morbid personality was described by her husband as “optimistic and sensitive”
and during interviews, she was found to be agreeable with no evidence of having
histrionic or borderline personality disorder traits. She underwent formal schooling till
the age of thirteen and worked blue-collar jobs before becoming a housewife. She
denied smoking, alcohol consumption, and other illicit substances misuse.
On admission, vital signs were normal with no neurological deficit on physical
examination. Patient X was neatly dressed with good eye contact and a pleasant
disposition. She was euthymic with a reactive affect. Her speech was relevant,
coherent, and appropriately paced. There was no evidence of formal thought disorders,
hallucinations, or delusions. Investigations were unremarkable: computed tomography
scan of her brain, EEG, and blood tests (thyroid function test, electrolytes, renal panel,
liver panel, full blood count, folate, and vitamin B12 serum levels).
During her inpatient stay, patient X verbalized new passive suicidal ideations secondary
to the distressing nature of these episodes. She denied features of depression and
anxiety before admission and a corroborative history from her husband did not reveal
any significant psychosocial stressors or depressive/anxious features. With rapport
building and exploration of her personal spiritual beliefs, she revealed concerns of “evil
spirits.” She opined that her radical nephrectomy operation in 2017 was delayed
because “the evil spirits were after me.” She had previously heard the chanting of
Buddhist mantras for an entire week following her operation and had also seen a
“rotting corpse” on her bed. She believed supernatural forces had caused these
episodes, which resolved after taking medications and having received blessings from
her religious leaders. During subsequent reviews, she revealed these episodes first
began 30 years ago after an abortion and had lasted for a week. While her husband
supported her decision, she nonetheless felt guilt and shame, citing financial constraints
as the reason for the abortion.
Patient X was diagnosed with panic disorder with culture-specific symptoms on a
background of MDD. She was restarted on escitalopram 2.5 mg OM (with plans to
increase the dose further at follow-up clinics) and clobazam 10 mg ON and responded
well-before being discharged.

Discussion
The distinction between possession trance and panic disorder is crucial as management
is vastly different.
A Singapore study (5) on trance states showed that trance possessions were
precipitated by anger and frustration, which are also known triggers for panic attacks.
This is based on the theory that trances embody and convey distress arising from
feelings of anger, grief, fear, and vulnerability precipitating from stressful experiences.
The treatment of trance possessions targets such issues through counseling and
psychotherapy (6–9) exploring underlying stresses and alternative coping strategies. On
the contrary, panic disorders are treated with pharmacotherapy and/or psychotherapy.
First-line treatment includes selective serotonin reuptake inhibitors (antidepressants) as
recommended by the NICE 2011 guidelines (10) and a short course of benzodiazepines
by the American Psychiatric Association guidelines (11).
In Singapore, 22% of Chinese psychiatric patients (12) felt that they were possessed by
spirits that had caused them to behave and think abnormally and amongst patients with
trance (5) 40% experienced auditory hallucinations and 32.7% had visions of spirits and
shadows. The religious and cultural overlay to psychiatric presentations is not unique to
Singapore and has been observed in other parts of the world: Bourguignon (13)
analyzed samples from 488 societies and found that 90% of societies displayed trance
and/or possession. Bragazzi NL (7) also described a clinical case of a Muslim girl
reporting possessions and panic attacks in Italy. Djinns are “evil creatures” as described
in the Qur'an and in the case study, the 19-year-old Muslim Italo-Tunisian girl reported
panic attacks with djinns invading her body and mind soon after she emigrated to a
different country. The patient was successfully treated with fluoxetine 20 mg/daily and
psychological counseling and psychotherapy.
At first glance, it may seem that patient X's professed religious beliefs and episodes of
uncontrollable screaming, shaking of all four limbs, and hallucination are typical of a
trance possession, however, a closer examination of her symptoms reveals otherwise.
Each episode was characterized by an abrupt surge of intense fear that reached a peak
within minutes and was accompanied by 6 of 13 DSM V criteria (2) for panic disorder:
sweating, trembling and shaking, chest discomfort, chills sensations, paraesthesia in
her limbs and fear of losing control. These episodes were recurrent and unexpected
with patient X showing a persistent concern of additional attacks. These episodes were
not attributable to the physiological effects of a substance or another medical or mental
condition. While there were no clear traumatic experiences behind her current episodes,
her previous abortion and nephrectomy may be potential triggers of deep psychological
disturbances that may act as a precipitating factor for her panic attacks. Hecker (14, 15)
found that pathological spirit possession might be seen as a trauma-related disorder,
culturally determined through the interpretation of dissociative symptoms related to
traumatic exposure. In a similar parallel, patient X's reporting of supernatural
possessions as explanations for her episodes could be a culturally determined
phenomenon through her interpretation of her panic disorder symptoms. In the context
of her Buddhist beliefs, the hallucinations of a rotting corpse may be interpreted as a
symbol of the guilt and shame she experiences over her previous abortions and
chanting of Buddhist mantras a corresponding prayer for help. Attending to the patient's
phenomenological experiences in future sessions would aid in managing her panic
disorder.
In addition, there was no disruption in identity, alteration of consciousness, or gaps in
the recall of events, making a diagnosis of possession trance even less likely. The fact
that she had a recollection of her idiosyncratic behaviors is in stark contrast with most
possession trance episodes, which is usually accompanied by amnesia. Therefore, the
uncontrollable screaming, hyperkinetic movements, auditory and visual hallucinations
on a background of espoused religious beliefs was a red herring. In the context of her
other symptoms, these should instead be interpreted as culture-specific symptoms of a
panic attack. Depression with psychotic features is less likely given the absence of
depressive symptoms, with the onset of passive suicidal ideations only after panic
attacks began. Her Montgomery-Asberg Depression Rating Scale score of 8
(depressive symptoms absent) also goes against a diagnosis of MDD. Furthermore, the
transient nature of each episode (less than an hour) with an immediate return to
baseline mental status and retained insight is uncharacteristic of a brief psychotic
episode. Her normal EEG findings (during both current and previous admissions) and
normal brain imaging findings, make a diagnosis of temporal lobe epilepsy or other
intracranial organic pathologies less likely.
Limitations of this study include a lack of toxicology screen performed (patient and
corroborative history from husband suggested no natural herbs/substance misuse and
hence it was not performed) and its nature as a case report.

Concluding Remarks
While there has been one other case study describing possessions and panic attacks in
a Muslim girl, this is the first case study to our knowledge of a Chinese patient with
Buddhist beliefs presenting with an atypical presentation of panic disorder with culture-
specific symptoms masquerading as possession trance.
There are race-ethnic differences in the rates of panic disorder, panic attacks, and
certain panic attack symptoms (16) (e.g., White Americans have a higher frequency of
heart-racing than Asian Americans) and possible reasons for cross-cultural differences
lies in the different meaning and emotional salience of panic attack symptoms within the
context of each culture (17). Therefore, an empathetic and clear understanding of the
patient's cultural beliefs would allow the attending psychiatrist to better appreciate the
varied presentations of common psychiatric conditions.
In Asian societies, psychiatric patients commonly consult traditional healers rather than
western-trained doctors. Seeking spiritual help may help rather than hinder a patient's
mental health and various studies have supported this claim (18). For example, patients
with schizophrenia who spent more time in religious activities tended to have a better
prognosis at a 2- and 5-year mark in follow-up studies (19, 20). van Duijl et al. (21)
found that explanatory models based on spirit possession with traditional healing
processes of spirit possessions eventually led to significant improvement for 99% of
patients, highlighting the important complementary role traditional healers can play in
the provision of local mental health care services. In this case, we acknowledged her
plans to seek a religious consult and worked alongside her belief system while
counseling on the benefits of complementing her treatment with prescribed
pharmacotherapy to aid with the anxiety surrounding each attack. By demonstrating an
acceptance of the patient's interpretation of her symptoms, rapport was further built and
she was agreeable to re-initiate pharmacotherapy immediately and reconsider
psychotherapy at subsequent follow-up appointments.
In summary, this case report highlights the importance of recognizing the patient's
cultural beliefs and how they may lead to culture-specific symptoms with unique
presentations of common psychiatric conditions. Demonstrating an understanding of the
patient's belief system can lead to a therapeutic alliance and increase a patient's
compliance with the prescribed management plans.