(See also Overview of Anxiety Disorders Overview of Anxiety Disorders Everyone periodically experiences fear and anxiety. Fear is an emotional, physical, and behavioral response to an immediately recognizable external threat (eg, an intruder, a car spinning on... read more .)
Panic attacks are common, affecting as many as 11% of the population in a single year. Most people recover without treatment; a few develop panic disorder.
Panic disorder affects 2 to 3% of the population in a 12-month period. Panic disorder usually begins in late adolescence or early adulthood and affects women about 2 times more often than men.
Symptoms and Signs of 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 Symptoms of a Panic Attack . Symptoms usually peak within 10 minutes and dissipate within minutes thereafter, leaving little for a physician to observe. Although uncomfortable—at times extremely so—panic attacks are not medically dangerous.
Panic attacks may occur in any anxiety 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 termed 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 where they have previously panicked. People with panic disorder often worry that they have a dangerous heart, lung, or brain disorder and repeatedly visit their family physician 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.
Many people with panic disorder also have symptoms of major depression Major depression (unipolar disorder) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more .
Diagnosis of Panic Attacks and Panic Disorder
Panic disorder is diagnosed after physical disorders that can mimic anxiety are eliminated and when symptoms meet diagnostic criteria stipulated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
Patients must have recurrent panic attacks (frequency is not specified) in which ≥ 1 attack has been followed by one or both of the following for ≥ 1 month:
Persistent worry about having additional panic attacks or worry about their consequences (eg, losing control, going crazy)
Maladaptive behavioral response to the panic attacks (eg, avoiding common activities such as exercise or social situations to try to prevent further attacks)
Treatment of Panic Attacks and Panic Disorder
Often antidepressants, benzodiazepines, or both
Often psychotherapeutic measures (eg, exposure therapy, cognitive-behavioral therapy)
Some people recover without treatment, particularly if they continue to confront situations in which attacks have occurred. For others, especially without treatment, panic disorder follows a chronic waxing and waning course.
Patients should be told 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 drug therapy combined with more intensive psychotherapy.
Many drugs can prevent or greatly reduce anticipatory anxiety, phobic avoidance, and the number and intensity of panic attacks:
Antidepressants: The different classes— selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors (SSRIs) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (SSRIs), serotonin-norepinephrine reuptake inhibitors Serotonin-Norepinephrine Reuptake Inhibitors Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (SNRIs), serotonin modulators Serotonin Modulators (5-HT2 Blockers) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more , tricyclics Heterocyclic Antidepressants Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (TCAs), and monoamine oxidase inhibitors Monoamine Oxidase Inhibitors (MAOIs) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (MAOIs)—are similarly effective. However, SSRIs and SNRIs offer a potential advantage of fewer adverse effects in comparison with other antidepressants.
Benzodiazepines: These anxiolytics work more rapidly than antidepressants but are more likely to cause physical dependence and such adverse effects as somnolence, ataxia, and memory problems. (See the table Benzodiazepines in Generalized Anxiety Disorder: Treatment Treatment Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that is present more days than not for ≥ 6 months. The cause is unknown, although... read more .) For some patients, long-term use of benzodiazepines is the only effective treatment.
Antidepressants plus benzodiazepines: These drugs are sometimes used in combination initially; the benzodiazepine is slowly tapered after the antidepressant becomes effective (although some patients respond only to the combination treatment).
Panic attacks often recur when drugs are stopped.
Different forms of psychotherapy are effective.
Exposure therapy, in which patients confront their fears, helps diminish the fear and complications caused by fearful avoidance. For example, patients who fear that they will faint during a panic attack are asked to spin in a chair or to hyperventilate until they feel dizzy or faint, thereby learning that they will not faint during an attack.
Cognitive-behavioral therapy involves teaching patients to recognize and control their distorted thinking and false beliefs and to modify their behavior so that it is more adaptive. For example, if patients describe acceleration of their heart rate or shortness of breath in certain situations or places and fear that they are having a heart attack, they are taught the following:
Not to avoid those situations
To understand that their worries are unfounded
To respond instead with slow, controlled breathing or other methods that promote relaxation