A panic attack is the sudden onset of a discrete, brief period of intense discomfort, anxiety, or fear accompanied by somatic and/or cognitive symptoms. Panic disorder is the 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 clinical criteria. Isolated panic attacks may not require treatment. Panic disorder is treated with pharmacotherapy, psychotherapy (eg, exposure therapy, cognitive-behavioral therapy), or both.
(See also Overview of Anxiety Disorders.)
Panic attacks are common, affecting as much as 11% of the population in a single year (1). Most people recover without treatment; some develop panic disorder.
Panic disorder affects 2 to 3% of the population in a 12-month period (2). Panic disorder usually begins in late adolescence or early adulthood and affects women about 2 times more often than men.
General references
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition,Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, pp 244.
2. Kessler RC,WT Chiu, Jin R, et al: The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry 63(4):415-424, 2006. doi: 10.1001/archpsyc.63.4.415
Symptoms and Signs of Panic Disorders
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. The panic symptoms may last minutes to an hour. Although uncomfortable—at times extremely so—panic attacks are not medically dangerous.
Panic attacks may occur in any psychiatric 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 called "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 in which they have previously panicked. People with panic disorder often worry that they have a dangerous heart, lung, or neurologic disorder and repeatedly visit their primary care clinician 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.
Panic disorder is often accompanied by at least one other comorbid condition. Other anxiety disorders, major depression, bipolar disorder, and mild alcohol use disorder are the most common psychiatric comorbidities. Common comorbid medical conditions include cardiac arrhythmias, hyperthyroidism, asthma, and chronic obstructive pulmonary disease (COPD).
Diagnosis of Panic Disorders
Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria
Medical evaluation to exclude physiologic effects of a substance or a general medical condition
Panic disorder is diagnosed after general medical disorders that can mimic anxiety are eliminated, and when symptoms meet diagnostic criteria stipulated in the DSM-5-TR.
Patients 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 (1):
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)
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC, pp 235-250.
Treatment of Panic Disorders
Antidepressants, benzodiazepines, or both
Psychotherapy
Some patients recover without treatment, particularly if they continue to be exposed to situations in which attacks have occurred. For others, especially without treatment, panic disorder follows a chronic waxing and waning course.
Patients should be informed 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 pharmacotherapy combined with more intensive psychotherapy.
Pharmacotherapy
Many medications can prevent or greatly reduce anticipatory anxiety, phobic avoidance, and the number and intensity of panic attacks (1):
Antidepressants: The different classes—selective serotonin reuptake inhibitors (SSRIs), (SNRIs), serotonin modulators, tricyclics (TCAs), and monoamine oxidase inhibitors (MAOIs)—are similarly effective. However, SSRIs and SNRIs offer the advantage of fewer potential 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. For some patients, long-term use of benzodiazepines is successful without significant adverse effects.
Antidepressants plus benzodiazepines: These medications 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 medications are discontinued.
Psychotherapy
Most psychotherapies that target anxiety disorders, including panic disorder, involve teaching techniques that promote relaxation. These strategies are an important component of therapy since they both reduce the anxiety and allow for the continuation of a psychotherapy that may be anxiety provoking. Relaxation strategies include mindfulness, meditation, hypnosis, exercise, and slow, steady breathing.
Cognitive-behavioral therapy (CBT) is a general term that refers to talk therapies that focus on dysfunctional thinking (cognition) and/or dysfunctional behaviors. CBT has been shown to be effective for panic disorder (2).
Patients may have their own distinct but dysfunctional cycle of thinking that can induce anxiety and/or panic. For example, a person might have a baseline worry about having a heart attack, and they might spend an inordinate amount of time scanning their bodies for signs of a heart attack. If they feel a twinge in their chest, they might then begin a cycle that quickly leads to a panicky, mistaken belief that they are about to die. CBT involves clarifying these cycles and then teaching patients to recognize and control their distorted thinking and false beliefs. They are then better able to modify their behavior so that it is more adaptive. In addition, the treatment encourages them to gradually expose themselves to situations that might be likely to induce the panic, thereby desensitizing their assumed association between the setting and the symptoms.
Treatment references
1. Quagliato LA, Freire RC, Nardi AE: Risks and benefits of medications for panic disorder: A comparison of SSRIs and benzodiazepines. Expert Opin Drug Saf 17(3):315-324, 2018. doi: 10.1080/14740338.2018.1429403
2. Papola D, Ostuzzi G, Tedeschi F, et al: Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. Br J Psychiatry 221(3):507-519, 2022. doi: 10.1192/bjp.2021.148
