A panic attack is the sudden onset of a discrete, brief period of intense discomfort, anxiety, or fear accompanied by somatic or cognitive symptoms. Panic disorder is occurrence of repeated panic attacks typically accompanied by fears about future attacks or changes in behavior to avoid situations that might predispose to attacks. Diagnosis is clinical. Isolated panic attacks may not require treatment. Panic disorder is treated with drug therapy, psychotherapy (eg, exposure therapy, cognitive-behavioral therapy), or both.

Panic attacks are common, affecting as many as 10% of the population in a single year. Most people recover without treatment; a few develop panic disorder. Panic disorder is uncommon, affecting 2 to 3% of the population in a 12-mo period. Panic disorder usually begins in late adolescence or early adulthood and affects women 2 to 3 times more often than men.

Symptoms and Signs

A panic attack involves the sudden onset of at least 4 of the 13 symptoms listed in Table 3: Anxiety Disorders: Symptoms of a Panic Attack. Symptoms usually peak within 10 min and dissipate within minutes thereafter, leaving little for a physician to observe. Although uncomfortable—at times extremely so—panic attacks are not medically dangerous.

Table 3
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Symptoms of a Panic Attack Cognitive Fear of dying Fear of going crazy or of losing control Feelings of unreality, strangeness, or detachment from the self (depersonalization) Somatic Chest pain or discomfort Dizziness, unsteady feelings, or faintness Feeling of choking Flushes or chills Nausea or abdominal distress Numbness or tingling sensations Palpitations or accelerated heart rate Sensations of shortness of breath or smothering Sweating Trembling or shaking

Panic attacks may occur in any anxiety disorder, usually in situations tied to the core features of the disorder (eg, a person with a phobia of snakes may panic at seeing a snake). In pure panic disorder, however, some of the attacks occur spontaneously.

Most people with panic disorder anticipate and worry about another attack (anticipatory anxiety) and avoid places or situations where they have previously panicked. People with panic disorder often worry that they have a dangerous heart, lung, or brain disorder and repeatedly visit their family physician or an emergency department seeking help. Unfortunately, in these settings, attention is often focused on general medical symptoms, and the correct diagnosis sometimes is not made. Many people with panic disorder also have symptoms of major depression.

Diagnosis

Panic disorder is diagnosed after physical disorders that can mimic anxiety are eliminated and symptoms meet diagnostic criteria stipulated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR).

Treatment

• Often antidepressants, benzodiazepines, or both
• Often nondrug measures (eg, exposure therapy, cognitive-behavioral therapy)

Some people recover without treatment, particularly if they continue to confront situations in which attacks have occurred. For others, especially without treatment, panic disorder follows a chronic waxing and waning course.

Patients should be told that treatment usually helps control symptoms. If avoidance behaviors have not developed, reassurance, education about anxiety, and encouragement to continue to return to and remain in places where panic attacks have occurred may be all that is needed. However, with a long-standing disorder that involves frequent attacks and avoidance behaviors, treatment is likely to require drug therapy combined with more intensive psychotherapy.

Many drugs can prevent or greatly reduce anticipatory anxiety, phobic avoidance, and the number and intensity of panic attacks:

• Antidepressants: The different classes—SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin modulators, tricyclics (TCAs), and monoamine oxidase inhibitors (MAOIs)—are similarly effective. However, SSRIs and SNRIs offer a potential advantage of fewer adverse effects in comparison with other antidepressants.
• Benzodiazepines: These anxiolytics—(see Table 2: Anxiety Disorders: Benzodiazepines) work more rapidly than antidepressants but are more likely to cause physical dependence and such adverse effects as somnolence, ataxia, and memory problems. For some patients, long-term use of benzodiazepines is the only effective treatment.
• Antidepressants plus benzodiazepines: These drugs are sometimes used in combination initially; the benzodiazepine is slowly tapered after the antidepressant becomes effective (although some patients respond only to the combination treatment).

Panic attacks often recur when drugs are stopped.

Different forms of psychotherapy are effective. Exposure therapy, in which patients confront their fears, helps diminish the fear and complications caused by fearful avoidance. For example, patients who fear that they will faint during a panic attack are asked to spin in a chair or to hyperventilate until they feel dizzy or faint, thereby learning that they will not faint during an attack. Cognitive-behavioral therapy involves teaching patients to recognize and control their distorted thinking and false beliefs and to modify their behavior so that it is more adaptive. For example, if patients describe acceleration of their heart rate or shortness of breath in certain situations or places and fear that they are having a heart attack, they are taught the following:

• Not to avoid those situations
• To understand that their worries are unfounded
• To respond instead with slow, controlled breathing or other methods that promote relaxation

Last full review/revision July 2012 by John H. Greist, MD