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Panic Attacks and Panic Disorder

by John H. Greist, MD

A panic attack is the sudden onset of a discrete, brief period of intense discomfort, anxiety, or fear accompanied by somatic and/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 11% 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 about 2 times more often than men.

Symptoms and Signs

A panic attack involves the sudden onset of intense fear or discomfort accompanied by at least 4 of the 13 symptoms listed in 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.

Symptoms of a Panic Attack

Cognitive

Fear of dying

Fear of going crazy or of losing control

Feelings of unreality, strangeness (derealization), 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). Such panic attacks are termed expected. Unexpected panic attacks are those that occur spontaneously, without any apparent trigger.

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

  • Clinical criteria

Panic disorder is diagnosed after physical disorders that can mimic anxiety are eliminated and when symptoms meet diagnostic criteria stipulated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Patients must have recurrent panic attacks (frequency is not specified) in which ≥ 1 attack has been followed by one or both of the following for ≥ 1 mo:

  • Persistent worry about having additional panic attacks or worry about their consequences (eg, losing control, going crazy)

  • Maladaptive behavioral response to the panic attacks (eg, avoiding common activities such as exercise or social situations to try to prevent further attacks)

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.

Drugs

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: 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.

Psychotherapy

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

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