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Panic Attacks and Panic Disorder

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by John H. Greist, MD

Panic is acute, short-lived, extreme anxiety with accompanying physical symptoms.

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

  • In panic disorder, people have many spontaneous panic attacks and usually worry about having future attacks.

  • 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. However, situational panic attacks differ from the spontaneous, unprovoked ones that often occur in panic disorder.

Panic attacks are common, occurring in at least 10% of adults each year. Women are 2 to 3 times more likely than men to have panic attacks and panic disorder. 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. Panic disorder usually begins in late adolescence (see Panic Disorder in Children and Adolescents) or early adulthood.

Symptoms

A panic attack involves the sudden appearance of at least four of the following physical and emotional symptoms:

  • Chest pain or discomfort

  • 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.

Symptoms peak within 10 minutes and usually dissipate 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

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 experience at least two unprovoked and unexpected panic attacks, which are followed by at least 1 month of fear that another attack will occur. 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

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

People with panic disorder are more receptive to treatment if they understand that the disorder involves both physical and psychologic processes and that treatment must address both. Drug therapy and behavioral therapy can usually control the symptoms.

Drugs

Drugs that are used to treat panic disorder include antidepressants and antianxiety drugs such as benzodiazepines. Most types of antidepressants—tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), 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, and slowed reaction time.

SSRIs 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.

When a drug is effective, it prevents or greatly reduces the number of panic attacks. A drug may have to be taken for a long time because panic attacks often return once the drug is stopped.

Psychotherapy

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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