Panic Attack and Panic Disorder

A panic attack is the sudden onset of a discrete, brief period of intense discomfort or fear accompanied by somatic or cognitive symptoms. Panic disorder is occurrence of repeated panic attacks typically accompanied by fears about future attacks or changes in behavior to avoid situations that might predispose to attacks. Diagnosis is based on history. Isolated panic attacks may not require treatment. Panic disorder is treated with drug therapy, psychotherapy (eg, exposure therapy, cognitive-behavioral therapy), or both.

Geriatric Essentials

• Panic attacks in the elderly are rare.
• Symptoms of panic attacks in the elderly tend to be less severe. However, some elderly present with new-onset panic disorder manifesting as chest pain.

Panic disorder is characterized by recurrent panic attacks (periods of intense fear or discomfort during which the onset of anxiety symptoms is abrupt). Symptoms typically begin in late adolescence or early adulthood and typically recede later in life. Panic attacks in the elderly are rare and, if they occur, are usually less severe than those in younger adults. However, some elderly patients, despite lacking evidence of coronary artery disease, have new-onset attacks manifesting as chest pain.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR), defines a panic attack as a period of intense fear that develops abruptly and peaks within 10 min. By definition, the attack must include >= 4 symptoms. Ten of the possible symptoms are somatic: palpitations or pounding heart, sweating, trembling or shaking, shortness of breath, feeling of choking, chest pain, nausea or abdominal distress, dizziness or lightheadedness, paresthesias, and chills or hot flushes. Three are cognitive: depersonalization (sense of being detached from oneself) or derealization (feelings of unreality), fear of losing control, and fear of dying.

Panic disorder is diagnosed after physical disorders that can mimic anxiety are eliminated and symptoms meet diagnostic criteria stipulated in DSM-IV-TR. To meet these criteria, a patient must experience recurrent and unexpected panic attacks, and at least one of the attacks must have been followed by >= 1 mo of some combination of concern about having additional attacks, worry over the implications of the attacks, and significant change in behavior related to the attacks. Panic disorder is commonly associated with agoraphobia.

Elderly patients with panic disorder typically benefit from education about anxiety and encouragement to continue to return to and remain in places where panic occurs.

Two forms of psychotherapy are proven effective: exposure therapy, in which patients confront fears, and cognitive-behavioral therapy, in which patients are taught to recognize and control their reaction to whatever triggers the panic and to modify their behavior so that it is more adaptive than simply avoiding the trigger.

In cases when panic attacks cause elderly patients to avoid certain places or situations, treatment is likely to require drug therapy in addition to psychotherapy. Antidepressants are often used. SSRIs and serotonin-norepinephrine reuptake inhibitors offer a potential advantage of fewer adverse effects in comparison with tricyclic antidepressants. Intermediate-acting benzodiazepines (eg, alprazolam) can be used if other therapies are ineffective.

This topic was last updated September 2005.