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Panic Attacks and Panic Disorder

By John H. Greist, MD

A panic attack is a brief period of extreme distress, anxiety, or fear that begins suddenly and is accompanied by physical and/or emotional symptoms. Panic disorder involves spontaneous panic attacks that occur repeatedly, worry about future attacks, and changes in behavior to avoid situations that are associated with an attack.

  • Panic attacks can cause such symptoms as chest pain, a sensation of choking, dizziness, nausea, and shortness of breath.

  • Doctors base the diagnosis on the person's description of attacks and fears of future attacks.

  • Treatment may include antidepressants, antianxiety drugs, exposure therapy, and cognitive-behavioral therapy.

Panic attacks may occur in any anxiety disorder, usually in response to a specific situation tied to the main characteristic of the disorder. For example, a person with a phobia of snakes may panic when encountering a snake. Such attacks are called expected attacks. However, such situational panic attacks differ from the spontaneous, unexpected ones that often occur in panic disorder. These attacks occur without any apparent cause.

Panic attacks are common, occurring in at least 11% of adults each year. Most people recover from panic attacks without treatment, but a few develop panic disorder.

Panic disorder is present in 2 to 3% of the population during any 12-month period. Women are about 2 times more likely than men to have panic disorder. Panic disorder usually begins in late adolescence or early adulthood ( Panic Disorder in Children and Adolescents).

Symptoms

A panic attack involves the sudden appearance of intense fear or discomfort plus at least four of the following physical and emotional symptoms:

  • Chest pain or discomfort

  • A sensation of choking

  • Dizziness, unsteadiness, or faintness

  • Fear of dying

  • Fear of going crazy or of losing control

  • Feelings of unreality, strangeness, or detachment from the environment

  • Flushes or chills

  • Nausea, stomachache, or diarrhea

  • Numbness or tingling sensations

  • Palpitations or an accelerated heart rate

  • Shortness of breath or a sense of being smothered

  • Sweating

  • Trembling or shaking

Did You Know...

  • Although panic attacks cause symptoms involving the heart and other vital organs, they are not dangerous.

Many people with panic disorder also have symptoms of depression.

Symptoms usually peak within 10 minutes and disappear within minutes, leaving little for a doctor to observe except the person's fear of another terrifying attack. Because panic attacks sometimes are unexpected or occur for no apparent reason, especially when people experience them as part of panic disorder, people who have them frequently anticipate and worry about another attack—a condition called anticipatory anxiety—and try to avoid situations that they associate with previous panic attacks.

Because symptoms of a panic attack involve many vital organs, people often worry that they have a dangerous medical problem involving the heart, lungs, or brain. Thus, they may repeatedly visit their family doctor or a hospital emergency department. If the correct diagnosis of panic attack is not made, they may have the additional worry that a serious medical problem has been overlooked. Although panic attacks are uncomfortable—at times extremely so—they are not dangerous.

The frequency of attacks can vary greatly. Some people have weekly or even daily attacks that occur for months, whereas others have several daily attacks followed by weeks or months without attacks.

Diagnosis

  • A doctor's evaluation, based on specific criteria

Because serious physical disorders often cause some of the same physical and emotional symptoms as panic attacks, doctors first make sure people do not have a physical disorder.

Panic disorder is diagnosed when people have repeated unprovoked and unexpected panic attacks plus at least one of the following for at least 1 month:

  • Persistent worry that they will have more panic attacks or worry about the consequences of the attack (for example, that they will lose control or go crazy)

  • Changes in behavior due to the panic attacks (for example, avoiding situations that may cause an attack)

Once doctors are confident that a person's symptoms are caused by a panic disorder, they try to avoid doing extensive tests when future panic attacks occur unless the person's symptoms or physical examination results suggest a new problem.

Treatment

  • Antidepressants and/or antianxiety drugs

  • Psychotherapy, including exposure therapy

Some people recover without formal treatment. For others, panic disorder waxes and wanes over years.

For some people, encouragement to return to and remain in places where panic attacks have occurred may be all that is needed.

However, if people have had frequent attacks and have changed their behavior to avoid future attacks, treatment with drugs and psychotherapy is usually necessary. People with panic disorder are more receptive to treatment if they understand that the disorder involves both physical and psychologic processes and that treatment can usually control the symptoms.

Drugs

Drugs that are used to treat panic disorder include

  • Antidepressants

  • Antianxiety drugs such as benzodiazepines

Most types of antidepressants—tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), serotonin modulators, and serotonin- norepinephrine reuptake inhibitors (SNRIs)—are effective (see Table: Drugs Used to Treat Depression).

Benzodiazepines work faster than antidepressants but can cause drug dependence (see Antianxiety and Sedative Drugs) and are probably more likely to cause sleepiness, impaired coordination, memory problems, and slowed reaction time.

SSRIs or SNRIs are the preferred drugs because they are as effective as the other drugs but usually have fewer side effects. For example, they are much less likely to cause sleepiness, and they do not cause drug dependence, although if stopped abruptly most SSRIs and SNRIs can cause uncomfortable withdrawal symptoms that can last a week or more.

Initially, people may be given a benzodiazepine and an antidepressant. When the antidepressant starts working, the dose of benzodiazepine is decreased, then stopped. However, for some people, a benzodiazepine is the only effective long-term treatment.

When a drug is effective, it prevents or greatly reduces the number of panic attacks. It can also help people worry less about future attacks and stop avoiding situations that cause panic attacks. A drug may have to be taken for a long time because panic attacks often return once the drug is stopped.

Psychotherapy

Different forms of psychotherapy are effective.

Exposure therapy, a type of psychotherapy, often helps diminish the fear. Exposure therapy involves exposing people gradually and repeatedly—in their imagination or sometimes in reality—to whatever triggers a panic attack. Exposure therapy is repeated until people become very comfortable with the anxiety-provoking situation. In addition, people who are afraid that they will faint during a panic attack can practice spinning in a chair or breathing quickly (hyperventilate) until they feel faint. This exercise teaches them that they will not actually faint during a panic attack. Practicing slow, shallow breathing (respiratory control) helps many people who tend to hyperventilate

Cognitive-behavioral therapy may also help. People are taught the following:

  • Not to avoid situations that cause panic attacks

  • To recognize when their fears are unfounded

  • To respond instead with slow, controlled breathing or other techniques that promote relaxation

Supportive psychotherapy, which includes education and counseling, is beneficial because a therapist can provide general information about the disorder and its treatment, realistic hope for improvement, and the support that comes from a trusting relationship with a doctor.

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