Panic Attacks and Panic Disorder

A panic attack involves the sudden onset of intense fear or discomfort accompanied by at least 4 of the 13 symptoms listed in the table Symptoms of a Panic Attack. The panic symptoms may last minutes to an hour. Although uncomfortable—at times extremely so—panic attacks are not medically dangerous.

Panic can include emotional, cognitive, and somatic elements. This complexity can complicate the diagnosis. For example, in addition to anxiety, the patient might experience chest pain, shortness of breath, sweats, and shakes. Such a cluster of symptoms can and often should lead to a general medical evaluation, especially in people with preexisting medical conditions or in those who have not been previously evaluated for this symptom cluster.

Panic attacks may occur in any psychiatric 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 called "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 in which they have previously panicked. People with panic disorder often worry that they have a dangerous heart, lung, or neurologic disorder and repeatedly visit their primary care clinician 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.

Panic disorder is often accompanied by at least 1 other comorbid condition. Other anxiety disorders, major depression, bipolar disorder, and mild alcohol use disorder are the most common psychiatric comorbidities. Common comorbid medical conditions include cardiac arrhythmias, hyperthyroidism, asthma, and chronic obstructive pulmonary disease (COPD).

Overview of Panic Disorder

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• Psychiatric assessment

• General medical evaluation to exclude physiologic effects of a substance or a general medical condition

Panic disorder is diagnosed after general medical disorders that can mimic or cause anxiety are eliminated and when symptoms meet diagnostic criteria stipulated in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) (1):

Patients have recurrent and unexpected panic attacks (frequency is not specified). At least 4 of the following symptoms must be present:

• Palpitations

• Diaphoresis

• Trembling

• Sensation of shortness of breath

• Sensation of choking

• Nausea or abdominal pain

• Dizziness

• Chills or heat

• Paresthesias

• Derealization or depersonalization

• Fear of losing control

• Fear of death

In addition,≥ 1 attack has been followed by one or both of the following for ≥ 1 month (1) by:

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

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

Finally, the symptoms must not be better explained by a general medical condition (such as hyperthyroidism or an acute coronary syndrome) or by substance use or withdrawal, or by another psychiatric disorder; the symptoms must not only occur in circumstances better explained by another psychiatric disorder (such as a specific phobia).

• Antidepressants, benzodiazepines, or both

• Psychotherapy (cognitive-behavioral therapy, including exposure therapy and interpersonal psychotherapy)

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

Patients should be informed 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 pharmacotherapy combined with more intensive psychotherapy.