Panic attacks are unexpected, overwhelming waves of the emotional and physical manifestations of anxiety: a tight chest, an upset stomach, and paralyzing fear. People feel their chests pound and their breath shorten. Sensations of doom and dying race through their minds. All of this terror comes on rapidly, without warning, and climaxes in 10-20 minutes.
When panic strikes, it can be so immediately disabling that unknowing bystanders may suspect the sufferer is choking or having heart trouble. These sensations so closely mimic medical emergencies that they lead many people to the emergency room. In fact, almost a third of people coming to the emergency room with non-heart trouble chest pain actually have Panic Disorder. Outward signs are relatively nonspecific, and the person may appear to have an activated ‘fight-or-flight’ response, like increased general tension, cold, sweaty skin, and rapid breathing. If these people have had panic attacks before, they may feel one coming and quickly find an excuse to leave a public situation. As Panic Disorder progresses, friends and family are left in the dark as the person tries seclusion in order to avoid the possibility of a public panic attack.
Left untreated, Panic Disorder varies in intensity, and panic attacks can be separated by mere hours or up to several weeks. Though a small number of people develop Panic Disorder during childhood and adolescence, it most often begins in the early 20s. However, in retrospect, people with Panic Disorder often report having suffered panic-like episodes in childhood that did not fully meet criteria for panic attacks. For most patients, Panic Disorder is at its worst in the middle 30s and gradually subsides in intensity by age 50.
Causes and Risk Factors
History and environment
In a given year, 2.4% of American adults will be diagnosed with Panic Disorder, and two-thirds of them are women. People with family histories of psychiatric disorders like anxiety, depression, suicidality, and Alcohol Use Disorder are at higher risk of developing Panic Disorder. Traumatic events during childhood, such as separation from either parent, parents’ marital issues, violence in the household, and sexual abuse also draw people closer to Panic Disorder.
Stressful circumstances early in life can prime the brain for Panic Disorder by increasing “anxiety sensitivity”. This is the tendency for anxiety sufferers to believe panic attacks can permanently physically or mentally harm them. Furthermore, panic attacks themselves increase anxiety sensitivity, creating a mounting spiral of worry. During the first few panic attacks that someone endures, the physical sensations, such as increased heart rate and breathing, become so associated with anxiety and fear that the later occurrence of those bodily symptoms alone (like with exercise) can trigger an attack.
According to twin studies, the risk of Panic Disorder is about 50% attributable to genetics. Most of this is due to genes associated with anxiety disorders in general. However, some subtypes, such as panic with agoraphobia, co-occurring panic and bipolar disorder, and the association of panic with smoking have unique genetic underpinnings.
Associated mental illness
Depression is the most common disorder that accompanies Panic Disorder, and it occurs in roughly a third of those people diagnosed. Second in line, Agoraphobia (fear of public situations) strikes 20-30% of people with Panic Disorder. This is usually because they start to associate specific locations with their panic attacks and ultimately build a large list of places to avoid. Other anxiety disorders, depressive disorders, and Alcohol Use Disorder also commonly co-occur. Even when accounting for these other disorders, a diagnosis of Panic Disorder in the past 12 months increases the odds of suicide by four during that same time frame.
Diagnosing Panic Disorder
Unpredictable, rapid-onset panic attacks are the hallmark feature of Panic Disorder. During these episodes, sufferers are beset by rapid waves of fear climaxing in a matter of minutes. To qualify as a full panic attack, the episodes must include at least four of the following symptoms.
- Increased heart rate or sensation of pounding chest
- Transient tremor
- Shortness of breath
- Tightness in the throat or choking sensations
- Chest pain or tightness
- Dizziness and unsteadiness when walking
- Abnormal hot or cold sensations
- Numbness or tingling in unpredictable locations
- Feeling like what they are experiencing is not real or that they are not themselves
- Fear they are losing control of their thoughts
- Feel they are going to die imminently
Number and frequency of panic attacks can vary widely even among people with similar demographics and risk factors, though they must have at least two panic attacks to be diagnosed.
Following panic attacks, people with Panic Disorder will experience at least one month of unrelenting worry about the prospect of having additional panic attacks or change their behavior in an attempt to avoid future attacks. They are fearful that the attacks are a sign of underlying physical maladies and worry about the potential embarrassment of having an attack in public.
Out of the blue
Panic Disorder specifically refers to panic attacks that are not easily attributable to triggers. The attacks cannot be due to a medical condition (such as hyperthyroidism or pheochromocytoma, a hormonally active tumor), side effects of a medication (stimulants), or another psychiatric diagnosis. Panic attacks triggered by known circumstances, such as a specific phobia, do not warrant a diagnosis of panic disorder. Though not a part of the diagnostic criteria, panic attacks can occur at night, waking patients from sleep, in up to a third of Panic Disorder patients, underscoring the unpredictable nature of these episodes.
Treating Panic Disorder
Antidepressants for panic
As with many other anxiety disorders, the first choice medications for Panic Disorder are selective serotonin reuptake inhibitors (SSRIs). The Food and Drug Administration has approved Paxil (paroxetine), Prozac (fluoxetine), and Zoloft (sertraline) specifically for Panic Disorder. Antidepressants are also very convenient because they also treat the depressive disorders that frequently accompany Panic Disorder.
The question of benzodiazepines
Benzodiazepines can help for the first several weeks of antidepressant treatment because they act rapidly and can be used as needed only when panic attacks occur. People receiving this combination improve more rapidly than with antidepressants alone. They can be tapered off the benzodiazepines once enough time has passed for the antidepressant to take effect. However, doctors will avoid prescribing benzodiazepines to patients with substance abuse histories because of their addictive potential.
Other possible medications
Two other medications that may help when antidepressants and benzodiazepines are ineffective are anti-seizure medications like Depakote (valproic acid) and Neurontin (gabapentin). However, they are not as well studied and are lower on the list of preferred medications.
Cognitive Behavioral Therapy
CBT is the most effective form of therapy for Panic Disorder, and, when combined with medication, they are more effective than either treatment alone. Combined therapy is especially helpful in preventing relapse after stopping medication (the rates of relapse range from 25% to 85% in patients treated just with medication).
CBT should start soon after the first appearance of panic attacks and lasts for 10 to 15 weeks. The focus will be the physical and psychological symptoms of panic, rather than any outside trigger. CBT teaches people new approaches for when they initially feel anxiety. They learn to replace their old reactions (fear they are losing control or dying) with acceptance and acknowledge that these feelings will soon subside.
Managing Panic Disorder
People with Panic Disorder are four times as likely as others to report negative side effects from medications. Furthermore, the steps of CBT requiring them to confront anxiety triggers can also temporarily increase anxiety. These circumstances can lead them to skip therapy sessions or discontinue medications without their doctor’s supervision. Therefore, the most helpful action they can take is to be as forthcoming as possible when starting treatment.
Under-recognized and under-treated
Anxiety disorders, including Panic Disorder, are grossly under-diagnosed in primary care settings. Primary care physicians accurately recognize anxiety disorders in only 20% of people with anxiety disorder on first presentation. Furthermore, only 22% of those diagnosed are prescribed appropriate medication, and only 12% get CBT.
Believing in treatment
People with Panic Disorder tend to have self-defeating beliefs about the nature of Panic Disorder and expectations about treatment. They are often reticent to see their doctor about it, and even when they do, they often hold fast to the belief that their symptoms will subside once life stressors go away. However, Panic Disorder is a chronic condition that requires dedication to treatment; having concrete expectations about treatment and outcomes is also a key step.
Reducing consumption of alcohol, tobacco, and stimulants (such as caffeine) can help reduce the severity and frequency of panic attacks. Furthermore, although it is not as powerful as medication, aerobic exercise (running) does have a positive effect on anxiety.
Support groups, though they do not take the place of psychotherapy, can be helpful by providing a source of camaraderie, reminding people that there are others struggling with panic attacks.