That intense feeling of fear is back. Your pulse races, you begin to sweat, and you feel you’re losing control. It’s another panic attack.

Once it’s over, your fear doesn’t subside, though. You’re now fearing fear itself. You start looking for ways to avoid another episode, even if this means changing most of your routines.

Fear of panic attacks is now a central focus of your life.

If this is familar, and you can’t stop worrying about having another panic attack, you might be living with panic disorder.

Although overwhelming, this condition can be managed and treatment is available. A path to recovery might begin with learning about the disorder’s possible causes.

Anxiety and panic disorder are closely related, Gene Beresin, MD, MA, told Psych Central.

In fact, panic disorder is considered an anxiety disorder.

An anxiety disorder is a mental health condition characterized by excessive and intense fear and changes in behavior based on such fear. There are a few types of anxiety disorder.

“Any of the anxiety disorders can trigger a panic attack,” says Beresin, executive director of The Clay Center for Young Healthy Minds at The Massachusetts General Hospital in Boston.

But not all anxiety disorders are panic disorders. When you live with panic disorder, you have recurrent panic attacks. Or you may live in fear of having attacks. Consequently, you change your behavior to prevent the occurrence of another one.

“One of the problems, when panic attacks strike, is that they become associated with the place or situation where they occur,” Beresin says.

Once a place is linked to a panic attack, you tend to do everything possible to avoid that place.

For someone living with panic attacks, even thinking about these triggering places or situations might be enough to bring on “anticipatory anxiety,” the fear that another panic attack will occur.

Sometimes this fear alone is enough to cause you to experience a panic attack. When you have multiple panic attacks and persistently avoid certain scenarios, you may have crossed the threshold into panic disorder.

You may wonder if there is one specific cause of panic disorder. Was there an event you witnessed? A genetic trait you have? Did past circumstances lead you here?

You might say that anxiety causes panic disorder. But it’s not that straightforward. In fact, many people who experience panic attacks don’t develop panic disorder.

As with many mental health conditions, the root causes of panic disorder are not well understood yet.

Many factors may come into play. In some rare cases, underlying medical conditions can also explain the condition.

“It’s important to have a complete medical examination. What may appear to be panic disorder could be a medical illness, such as thyroid or other hormonal diseases, cardiac disorder, seizures or other illnesses that present themselves as panic disorder,” says Beresin.

Once an underlying medical condition has been ruled out, other contributing factors are taken into consideration, including:

  • genetics
  • biology
  • psychosocial influences
  • presence of other mental health conditions

Genetics and biological causes

Genetics appears to have a link to panic disorder in some cases.

A 2018 literature review found a few studies that suggested that having first-degree relatives who live with panic disorder increases the chance of developing the condition.

The same review found that females may have a higher genetic predisposition to panic disorder.

In fact, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) notes that panic disorder is more often diagnosed in females than males at a rate of approximately 2:1.

The manual also states that children of parents living with mental health conditions such as anxiety, bipolar, and depressive disorders might have an increased chance of developing panic disorder.

Although it’s believed that some genes might be at play, there’s still no scientific evidence that points to specific ones or certain genetical functions.

Changes in parts of the brain such as the amygdala, temporal lobe, and medial temporal lobe may also contribute to the development of panic disorder.

Psychosocial and environmental causes

Psychosocial factors refer to how the things and people in your environment affect your thoughts and emotions.

When it comes to the causes of panic disorder, life experiences, childhood observations, and parental influences may all increase what is known as anxiety sensitivity.

A 2018 study showed that anxiety sensitivity is a suspected contributing cause of panic disorder.

When you live with anxiety sensitivity, you tend to believe that any sign or symptom of anxiety poses a serious risk to your health.

For example, if you feel tightness in your chest, you might immediately think you’re having a heart attack. If you experience shortness of breath, you might believe you’re about to faint.

This fear, in turn, increases your anxiety levels and might lead you to experience recurrent panic attacks.

If you have anxiety sensitivity, you’re also more likely to fear panic attacks. This might cause you to experience more of these episodes, and so a vicious cycle begins.

Other possible environmental causes of panic disorder include:

  • sexual and physical abuse
  • trauma during childhood or adulthood
  • significant childhood or adult losses
  • use of prescription or illicit substances
  • chronic physical illnesses

Presence of other mental health conditions

Berensin notes that the development of panic disorder may be associated with the occurrence of other mental health conditions such as:

  • PTSD
  • substance use disorders
  • withdrawal syndromes from addictive substances
  • depressive disorder
  • bipolar disorder

Some external and internal factors can increase your chances of developing a panic disorder, including:

  • chronic stress
  • repeated personal losses
  • phobias
  • fear of going places for reasons other than fear of a panic attack
  • social isolation
  • performance anxiety
  • significant lifestyle changes (such as moving to a new country that has a different language and culture)

Living with panic disorder can affect many aspects of your life.

The exact cause of panic disorder is still unknown. Still, the condition is often linked to anxiety sensitivity and having a first-degree relative with the same or other mental health condition.

Although overwhelming, panic disorder is treatable. Symptoms can be managed with the help of a mental health professional.