Panic is acute, short-lived, extreme anxiety with accompanying physical symptoms.

• Panic attacks can cause such symptoms as chest pain, 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, cognitive-behavior therapy, and supportive psychotherapy.

Panic attacks may occur in any anxiety disorder, usually in response to a specific situation tied to the main characteristic of the disorder. For example, a person with a phobia of snakes may panic when encountering a snake. However, situational panic attacks differ from the spontaneous, unprovoked ones that define a person's problem as panic disorder.

Panic attacks are common, occurring in at least 10% of adults each year. Women are 2 to 3 times more likely than men to have panic attacks and panic disorder. Most people recover from panic attacks without treatment, but a few develop panic disorder. Panic disorder is present in 2 to 3% of the population during any 12-month period. Panic disorder usually begins in late adolescence or early adulthood.

Symptoms

A panic attack involves the sudden appearance of at least four of the following symptoms:

• Chest pain or discomfort
• 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 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.

Symptoms peak within 10 minutes and usually dissipate within minutes, leaving little for a doctor to observe except the person's fear of another terrifying attack. Because panic attacks sometimes are unexpected or occur for no apparent reason, especially when people experience them as part of panic disorder, people who have them frequently anticipate and worry about another attack—a condition called anticipatory anxiety—and try to avoid places where they have previously panicked.

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. Thus, they may seek help from a doctor or 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.

Panic disorder is diagnosed when people experience at least two unprovoked and unexpected panic attacks, which are followed by at least 1 month of fear that another attack will occur. 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.

Treatment

Some people recover without formal treatment. For others, panic disorder waxes and wanes over years.

People with panic disorder are more receptive to treatment if they understand that the disorder involves both physical and psychologic processes and that treatment must address both. Drug therapy and behavior therapy can generally control the symptoms.

Drugs: Drugs that are used to treat panic disorder include antidepressants and antianxiety drugs such as benzodiazepines. Most types of antidepressants—tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and serotonin/norepinephrine reuptake inhibitors (SNRIs)—are effective (see Drugs Used to Treat Depression). Benzodiazepines work faster than antidepressants but can cause drug dependence (see Drug Use and Abuse: Antianxiety Drugs and Sedatives) and are probably more likely to cause sleepiness, impaired coordination, and slowed reaction time. SSRIs 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 that can last a week or more. Initially, people may be given a benzodiazepine and an antidepressant. When the antidepressant starts working, the dose of benzodiazepine is decreased, then stopped.

When a drug is effective, it prevents or greatly reduces the number of panic attacks. A drug may have to be taken for a long time because panic attacks often return once the drug is stopped.

Psychotherapy: Exposure therapy, a type of behavior therapy in which people are exposed repeatedly to whatever triggers a panic attack, often helps to diminish the fear. Exposure therapy is repeated until people become very comfortable with the anxiety-provoking situation. In addition, people who are afraid that they will faint during a panic attack can practice an exercise in which they spin in a chair or breathe quickly (hyperventilate) until they feel faint. This exercise teaches them that they will not actually faint during a panic attack. Practicing slow, shallow breathing (respiratory control) helps many people who tend to hyperventilate.

Cognitive-behavior therapy also may 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, its treatment, realistic hope for improvement, and the support that comes from a trusting relationship with a doctor.

What Is Exposure Therapy? Unlike systematic desensitization, which pairs relaxation with gradual exposure to the sources of anxiety, exposure therapy purposefully permits anxiety to occur (although sometimes it does not occur). By being repeatedly exposed to the feared object or situation, either literally or using imagination, people experience the anxiety over and over until the feared stimulus eventually loses its effect. This process is called habituation. 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. Graduated exposure gives people a greater degree of control over the length and frequency of exposures. Both types of exposure treatment may use the most feared stimulus first, unlike systematic desensitization, which begins with the least feared stimulus.

Last full review/revision August 2007 by John H. Greist, MD; James W. Jefferson, MD