Panic Attack and Panic Disorder

What happens during a panic attack

The amygdala, the brain's threat detector, triggers the fight-or-flight response: adrenaline is released, heart rate and breathing speed up, and blood is diverted to the muscles. In a panic attack this alarm fires when there is no real danger. Fast breathing lowers carbon dioxide in the blood, which causes tingling, lightheadedness and chest tightness. These sensations are then interpreted as signs of catastrophe ("I'm having a heart attack"), which drives more fear and more symptoms. This cycle is called the panic spiral.

For what an attack feels like and step-by-step ways to calm one, see panic attack symptoms.

Panic attacks vs panic disorder

Panic attacks can also occur within other conditions: phobias, social anxiety disorder, PTSD, depression and substance use.

Causes and risk factors

• Genetics: panic disorder runs in families; first-degree relatives have several times the usual risk.
• Temperament: high "anxiety sensitivity", the belief that anxiety symptoms are harmful.
• Stressful life events: bereavement, illness, relationship breakdown, childbirth.
• Childhood adversity and trauma.
• Substances: caffeine, nicotine, cannabis, stimulants and withdrawal from alcohol or sedatives.
• Medical conditions: asthma and COPD are associated with higher rates of panic.
• Sex: women are about twice as likely as men to develop panic disorder.

Panic disorder usually starts in late adolescence or early adulthood.

Conditions that can mimic panic attacks

Doctors check for physical causes, particularly with a first attack or atypical features:

• heart rhythm problems such as supraventricular tachycardia, and angina
• hyperthyroidism
• asthma attacks and pulmonary embolism
• low blood sugar
• pheochromocytoma, a rare adrenal tumor causing surges of adrenaline
• seizures (especially temporal lobe)
• medicine side effects and drug intoxication or withdrawal

Diagnosis

A doctor or mental health professional will ask about the attacks, triggers, avoidance, mood, alcohol and drug use and family history. Questionnaires such as the Panic Disorder Severity Scale track severity.

Physical tests depend on the picture and may include:

• an ECG, and sometimes a heart rhythm monitor
• blood tests for thyroid function, blood count, glucose and electrolytes
• further tests if symptoms do not fit typical panic

Treatment

Cognitive behavioral therapy

CBT is the first-line treatment and produces lasting benefit. Typically 8 to 16 sessions, it includes:

• education about the fight-or-flight response and the panic spiral
• cognitive restructuring: testing catastrophic beliefs about sensations
• interoceptive exposure: deliberately bringing on harmless sensations (spinning, breathing through a straw, running on the spot) so they lose their power
• situational exposure: gradually returning to avoided places
• dropping safety behaviors, such as always carrying water or sitting near exits

Guided self-help books and online CBT programs also work for many people.

Medicines

• SSRIs (such as sertraline, escitalopram, paroxetine) and SNRIs (venlafaxine) are first-line. They are started at a low dose, because they can briefly increase jitteriness, and take 4 to 8 weeks to work fully. Treatment usually continues for at least 6 to 12 months after improvement.
• Benzodiazepines (such as clonazepam) work quickly but carry risks of dependence, sedation and falls. They are generally limited to short-term use or specific situations.
• Tricyclic antidepressants such as imipramine or clomipramine are alternatives.

Combining CBT and medicine is reasonable for severe panic disorder.

Lifestyle measures

• Regular aerobic exercise, which also teaches the body that a fast heartbeat is safe
• Reducing caffeine, alcohol and nicotine
• Regular sleep
• Relaxation practices and slow breathing

Complications

Without treatment, panic disorder can lead to agoraphobia, depression, alcohol or sedative misuse, frequent emergency visits, and restricted work and social life. People with panic disorder have a higher risk of suicidal thoughts, especially with depression.

Outlook

Panic disorder is one of the most treatable anxiety disorders. Most people who complete CBT have far fewer or no attacks. Symptoms can return during stressful periods, but the skills learned in therapy usually allow people to manage them quickly.

Frequently asked questions

What causes panic attacks?

Panic attacks are caused by the body's fight-or-flight alarm firing without real danger. Genetic sensitivity, stress, past trauma, stimulants such as caffeine, withdrawal from alcohol or sedatives, and learned fear of body sensations all contribute. Sometimes there is no clear trigger.

What is the difference between a panic attack and panic disorder?

A panic attack is a single episode of intense fear with physical symptoms. Panic disorder is diagnosed when unexpected attacks recur and are followed by at least a month of worry about more attacks or changes in behavior to avoid them.

What is the best treatment for panic disorder?

Cognitive behavioral therapy that includes exposure to feared sensations and situations is the most effective long-term treatment. SSRIs and SNRIs are effective medicines. Many people do best with CBT alone; others benefit from combining therapy with medicine.

Can panic disorder go away?

Yes. With CBT, many people become free of attacks or have only occasional mild ones. Without treatment, panic disorder often fluctuates for years. Even after recovery, symptoms can return under stress, but the skills from therapy help people regain control quickly.

Are panic attacks a sign of a heart problem?

Usually not, but some heart rhythm problems and angina can feel similar. Doctors often do an ECG and blood tests after a first attack. Once a heart problem has been ruled out, recognizing that the symptoms are panic is itself an important part of recovery.