Panic Disorder

What a panic attack feels like

A panic attack is a sudden surge of intense fear or discomfort that peaks within minutes. The DSM-5-TR lists 13 possible symptoms; at least 4 are present:

• Pounding or racing heart (palpitations)
• Sweating
• Trembling or shaking
• Shortness of breath or a smothering feeling
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness, light-headedness or feeling faint
• Chills or heat sensations
• Numbness or tingling
• Feeling detached from yourself or reality
• Fear of losing control or "going crazy"
• Fear of dying

Many people go to the ER during their first attacks, convinced they are having a heart attack. See panic attack for more about individual attacks.

Panic disorder vs a single panic attack

Around 1 in 4 people have at least one panic attack in their lifetime, often during stress. Panic disorder is diagnosed only when:

• attacks are recurrent and unexpected (not only triggered by a specific feared situation), and
• for at least a month, there is persistent worry about more attacks or their consequences, or changes in behavior to avoid them, such as avoiding exercise, travel or being alone, and
• attacks are not caused by a substance, medical condition or another mental disorder.

Panic attack vs heart attack

Symptoms overlap considerably. If you are unsure, call 911. Doctors would rather check a panic attack than miss a heart attack.

Causes and risk factors

• Genetics: panic disorder runs in families
• Brain function: an oversensitive fear response and misinterpretation of normal body sensations as dangerous
• Stressful life events: loss, illness, relationship breakdown
• Childhood adversity
• Temperament: high anxiety sensitivity
• Substances: caffeine, nicotine, stimulants, cannabis and alcohol withdrawal can trigger attacks
• Medical conditions that mimic or trigger panic: hyperthyroidism, heart rhythm problems, asthma, low blood sugar, and rarely pheochromocytoma

The panic cycle

A physical sensation, such as a skipped heartbeat, is interpreted as dangerous ("I'm having a heart attack"). This causes fear, which releases adrenaline, which increases the sensations, which deepens the fear. Fast breathing (hyperventilation) adds dizziness and tingling. Avoiding situations prevents the person from learning that the sensations are not dangerous, which keeps the disorder going.

Agoraphobia

Many people with panic disorder develop agoraphobia: fear and avoidance of situations where escape might be difficult or help unavailable during an attack, such as crowds, public transport, shops, bridges or being away from home. In severe cases, people may become housebound.

Diagnosis

A primary care doctor or mental health professional will:

1. Take a detailed history of attacks, triggers, worry and avoidance.
2. Rule out physical causes, often with an ECG, blood tests for thyroid function, blood sugar and blood count, and a review of medicines and substances.
3. Screen for depression, other anxiety disorders and substance use.

Treatment

Cognitive behavioral therapy (CBT)

CBT is the first-line treatment and usually involves 12 to 16 sessions:

• Education about panic and the fight-or-flight response
• Cognitive restructuring: challenging catastrophic interpretations of sensations
• Interoceptive exposure: deliberately bringing on mild sensations (such as spinning or breathing through a straw) to learn they are safe
• Situational exposure: gradually facing avoided places
• Breathing retraining

Many people improve significantly, and gains tend to last.

Medicines

• SSRIs (such as sertraline, escitalopram or paroxetine) and SNRIs (such as venlafaxine) are first-line medicines. They take 4 to 6 weeks to work and are usually continued for at least 6 to 12 months after improvement.
• Benzodiazepines act quickly but carry risks of dependence, sedation and falls. They are generally used only short term, if at all.
• Beta-blockers are not effective for panic disorder.

Self-help

• Learn slow breathing: breathe in through the nose for 4 seconds, out for 6 to 8 seconds
• Use grounding: name 5 things you can see, 4 you can hear, 3 you can touch
• Remind yourself that attacks peak and pass, usually within minutes
• Reduce caffeine, nicotine and alcohol
• Exercise regularly
• Keep a regular sleep schedule
• Avoid avoiding: gently re-enter feared situations

Outlook

With treatment, most people with panic disorder improve substantially, and many become symptom-free. Without treatment, it can become chronic, with agoraphobia, depression and substance use. Relapse can occur under stress, but skills learned in CBT help manage it.

Frequently asked questions

What are the symptoms of panic disorder?

Panic disorder involves repeated, unexpected panic attacks with symptoms like a racing heart, chest pain, breathlessness, sweating, trembling, dizziness, tingling and fear of dying, plus at least a month of worry about more attacks or avoiding situations because of them.

How do I know if it's a panic attack or a heart attack?

Panic attacks usually peak within 10 minutes and pass within 30, often with tingling and intense fear. Heart attacks cause pressure-like pain that persists or worsens, often with sweating and nausea. Symptoms overlap, so if in doubt, call 911.

What causes panic disorder?

It results from a mix of genetics, an oversensitive fear system, stressful life events, childhood adversity and a tendency to interpret body sensations as dangerous. Caffeine, stimulants and alcohol withdrawal can trigger attacks.

What is the best treatment for panic disorder?

Cognitive behavioral therapy is the most effective treatment, helping people understand and face their symptoms. SSRIs or SNRIs are also effective. Many people do best with CBT alone or a combination of therapy and medicine.

How can I stop a panic attack?

Slow your breathing with longer exhales, ground yourself by focusing on your surroundings, and remind yourself that the symptoms are not dangerous and will pass. Avoid fleeing the situation if possible. Regular CBT practice reduces how often attacks happen.