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Panic Attacks and Panic Disorder

By

John W. Barnhill

, MD, Weill Cornell Medical College and New York Presbyterian Hospital

Last full review/revision Apr 2020| Content last modified Apr 2020
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A panic attack is a brief period of extreme distress, anxiety, or fear that begins suddenly and is accompanied by physical and/or emotional symptoms. Panic disorder involves recurrent panic attacks that lead to excessive worry about future attacks and/or behavior changes intended to avoid situations that might trigger an attack.

  • Panic attacks can cause such symptoms as chest pain, a sensation of choking, dizziness, nausea, and shortness of breath.

  • Doctors base the diagnosis on the person's description of attacks and fears of future attacks.

  • Treatment may include antidepressants, antianxiety drugs, exposure therapy, and psychotherapy.

Panic attacks may occur as part of any anxiety disorder. Panic attacks may also occur in people with other psychiatric disorders (such as depression). Some panic attacks occur in response to a specific situation. For example, a person with a phobia of snakes may panic when encountering a snake. Other attacks occur without any apparent trigger.

Panic attacks are common, occurring in at least 11% of adults each year. Most people recover from panic attacks without treatment, but a few develop panic disorder.

Panic disorder is when people worry that they will have more panic attacks and/or change their behavior to try to avoid attacks. Panic disorder is present in 2 to 3% of the population during any 12-month period. Women are about 2 times more likely than men to have panic disorder. Panic disorder usually begins in late adolescence or early adulthood (see Panic Disorders in Children and Adolescents).

Symptoms

A panic attack involves the sudden appearance of intense fear or discomfort plus at least four of the following physical and emotional symptoms:

  • Chest pain or discomfort

  • A sensation of choking

  • Dizziness, unsteadiness, or faintness

  • Fear of dying

  • Fear of going crazy or of losing control

  • Feelings of unreality, strangeness, or detachment from the environment

  • Flushes or chills

  • Nausea, stomachache, or diarrhea

  • Numbness or tingling sensations

  • Palpitations or an accelerated heart rate

  • Shortness of breath or a sense of being smothered

  • Sweating

  • Trembling or shaking

Did You Know...

  • Although panic attacks cause symptoms involving the heart and other vital organs, they are not dangerous.

Many people with panic disorder also have symptoms of depression.

Symptoms usually peak within 10 minutes and disappear within minutes, leaving little for a doctor to observe except the person's fear of another terrifying attack. Because panic attacks may occur for no apparent reason, people who have them frequently anticipate and worry about another attack—a condition called anticipatory anxiety—and try to avoid situations that they associate with previous panic attacks.

Because symptoms of a panic attack involve many vital organs, people often worry that they have a dangerous medical problem involving the heart, lungs, or brain. For example, a panic attack can feel like a heart attack. Thus, people may repeatedly visit their family doctor or a hospital emergency department. If the correct diagnosis of panic attack is not made, they may have the additional worry that a serious medical problem has been overlooked. Although panic attacks are uncomfortable—at times extremely so—they are not dangerous.

The frequency of attacks can vary greatly. Some people have weekly or even daily attacks that occur for months, whereas others have several daily attacks followed by weeks or months without attacks.

Diagnosis

  • A doctor's evaluation, based on specific criteria

Because serious physical disorders often cause some of the same physical and emotional symptoms as panic attacks, doctors first make sure people do not have a physical disorder.

Panic disorder is diagnosed when people have repeated unprovoked and unexpected panic attacks plus at least one of the following for at least 1 month:

  • Persistent worry that they will have more panic attacks or worry about the consequences of the attack (for example, that they will lose control or go crazy)

  • Changes in behavior due to the panic attacks (for example, avoiding situations that may cause an attack)

Once doctors are confident that a person's symptoms are caused by a panic disorder, they try to avoid doing extensive tests when future panic attacks occur unless the person's symptoms or physical examination results suggest a new problem.

Treatment

  • Antidepressants and/or antianxiety drugs

  • Psychotherapy, including exposure therapy

Without formal treatment, some people recover, particularly if they continue to confront situations in which attacks have occurred. For others, symptoms wax and wane for years.

However, if people have had frequent attacks and have changed their behavior to avoid future attacks, treatment with drugs and/or psychotherapy is usually necessary. People with panic disorder are more receptive to treatment if they understand that the disorder involves both physical and psychologic processes and that treatment can usually control the symptoms.

Drugs

Drugs that are used to treat panic disorder include

  • Antidepressants

  • Antianxiety drugs such as benzodiazepines

Most types of antidepressants—tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), serotonin modulators, and serotonin- norepinephrine reuptake inhibitors (SNRIs)—are effective (see table Drugs Used to Treat Depression).

Benzodiazepines work faster than antidepressants but can cause drug dependence and are probably more likely to cause sleepiness, impaired coordination, memory problems, and slowed reaction time.

SSRIs or SNRIs are the preferred drugs because they are as effective as the other drugs but usually have fewer side effects. For example, they are much less likely to cause sleepiness, and they do not cause drug dependence, although if stopped abruptly most SSRIs and SNRIs can cause uncomfortable withdrawal symptoms.

Initially, people may be given a benzodiazepine and an antidepressant. When the antidepressant starts working, the dose of benzodiazepine is typically decreased, then stopped. However, for some people, a benzodiazepine is the only effective long-term treatment.

Drug treatment may prevent or greatly reduce the number of panic attacks. However, without psychotherapy, drugs may not help people worry less about future attacks and stop avoiding situations that cause panic attacks.

A drug may have to be taken for a long time because panic attacks often return once the drug is stopped.

Psychotherapy

Different forms of psychotherapy are effective.

Exposure therapy involves exposing people gradually and repeatedly—in their imagination and/or in reality—to whatever triggers a panic attack. Exposure therapy is repeated until people become very comfortable with the anxiety-provoking situation. To increase the likelihood of comfortable exposure, people are often taught relaxation techniques to use before confronting the anxiety-provoking situation. For example, doing steady, slow, breathing is a reliable way to reduce the anxiety that can lead to a panic attack.

In exposure therapy, people are repeatedly exposed to the feared situation or object, either literally or using their imagination. They experience the anxiety over and over until the feared stimulus eventually loses its effect. This process is called habituation.

Typically, doctors begin with the lowest level of exposure that people can easily tolerate. For example, people may be asked to look at the feared object from a distance. Doctors then instruct people to reassure themselves that the remote object is unlikely to harm them. If their heart starts to race or they feel short of breath, they are instructed to respond with slow, deep breaths or to do other relaxation exercises (such as picturing a peaceful scene).

When people feel comfortable at one level of exposure, they are gradually exposed to closer contact with the situation or object—but just to the point that symptoms become uncomfortable. Then, they are instructed to again reassure themselves that harm is unlikely and to repeat the relaxation exercises. People are exposed to closer and closer contact until they can tolerate normal interaction with the situation or object.

Sometimes only a few sessions of exposure are needed.

Two variants of exposure therapy are flooding and graduated exposure.

  • Flooding exposes people to the anxiety-producing stimulus for as long as 1 or 2 hours. This technique tends to be unpleasant and is often not well tolerated.

  • Graduated exposure gives people a greater degree of control over the length and frequency of exposures.

Cognitive-behavioral therapy may also help. People are taught the following:

  • Not to avoid situations that cause panic attacks

  • To recognize when their fears are unfounded

  • To respond instead with slow, controlled breathing or other techniques that promote relaxation

Supportive psychotherapy, which includes education and counseling, is beneficial because a therapist can provide general information about the disorder and its treatment, realistic hope for improvement, and the support that comes from a trusting relationship with a doctor.

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