Panic Attacks (Panic Disorder)

Panic attacks may be symptoms of an anxiety disorder. Historically, panic has been described in ancient civilizations, as with the reaction of the subjects of Ramses II to his death in 1213 BC in Egypt, and in Greek mythology as the reaction that people had to see Pan, the half man, half goat god of flocks and shepherds. In medieval then Renaissance Europe, severe anxiety was grouped with depression in descriptions of what was then called melancholia. During the 19th century, panic symptoms began to be described as neurosis, and eventually the word panic began being used in psychiatry.

These episodes are a serious health problem in the U.S. At least 20% of adult Americans, or about 60 million people, will suffer from panic at some point in their lives. About 1.7% of adult Americans, or about 3 million people, will have full-blown panic disorder at some time in their lives, women twice as often as men. The most common age at which people have their first panic attack (onset) is between 15 and 19 years of age. Panic attacks are significantly different from other types of anxiety, in that panic attacks are very sudden and often unexpected, appear to be unprovoked, and are often disabling.

Yes, panic attacks are real and potentially quite emotionally disabling. Fortunately, they can be controlled with specific treatments. Because of the disturbing physical signs and symptoms that accompany panic attacks, they may be mistaken for heart attacks or some other life-threatening medical problem.

In fact, up to 25% of people who visit emergency rooms because of chest pain are actually experiencing panic. This can lead to people with this symptom often undergoing extensive medical testing to rule out physical conditions. Sadly, sometimes more than 90% of these individuals are not appropriately diagnosed as suffering from panic.

Loved ones, as well as medical personnel, generally attempt to reassure the panic attack sufferer that he or she is not in great danger. However, these efforts at reassurance can sometimes add to the patient's struggles. If the doctors say things like, "it's nothing serious," "it's all in your head," or "nothing to worry about," this may give a false impression that there is no real problem, they should be able to overcome their symptoms without help, and that treatment is not possible or necessary.

More accurately, while panic attacks can undoubtedly be serious, they are not organ-threatening. Therefore, for people who might wonder what to do to help the panic sufferer at the time of an anxiety attack, a more effective approach tends to acknowledge their fear and the intensity of their symptoms while reassuring the person having the panic attack that what is occurring is not life-threatening and can be treated.

Although there are no specific causes for panic attacks, like most other emotional symptoms, panic is understood to be the result of a combination of biological vulnerabilities, ways of thinking, and environmental factors like social stressors. According to one theory of panic disorder, the body's normal "alarm system," also described as the body's fight or flight system, the set of mental and physical mechanisms that allows a person to respond to a threat, tends to be triggered when there is no danger.

Scientists don't know specifically why this happens or why some people are more susceptible to the problem than others. Panic disorder has been found to run in families, and this may mean that inheritance (genetics) plays a role in determining who will develop the condition. However, many people who have no family history of the disorder develop it. Studies differ as to whether drugs like marijuana or nutritional deficiencies like zinc or magnesium deficiencies may also be risk factors for developing panic disorder.

Poverty and low education level tend to be associated with anxiety, but it is unclear if those factors cause or are caused by anxiety. While some statistics suggest that disadvantaged ethnic minorities tend to suffer from internalizing disorders like panic disorder less often than the majority population in the United States, other research shows that may be the result of differences in how ethnic groups interpret and discuss signs and symptoms of intense fright, like panic attacks.

Also, panic and other anxiety disorders are thought to persist more in some ethnic minorities in the United States. Difficulties the examiner may have in regards to appropriately recognizing and understanding ethnic differences in symptom expression are also thought to play a role in ethnic differences in the reported frequency of panic and other internalizing disorders.

Psychologically, people who develop panic attacks or another anxiety disorder are more likely to have a history of what is called anxiety sensitivity. Anxiety sensitivity is the tendency for a person to fear that anxiety-related bodily sensations (like brief chest pain or stomach upset) have dire personal consequences (for example, believing that it automatically means their heart will stop or they will throw up, respectively).

From a social standpoint, a risk factor for developing panic disorder as an adolescent or adult is a history of being physically or sexually abused as a child. This is more so the case for panic disorder when compared to other anxiety disorders. Often, the first attacks are triggered by physical illnesses, another major life stress, or perhaps medications that increase activity in the part of the brain involved in fear reactions.

As described in the first example above, the symptoms of a panic attack develop suddenly, without any apparent cause. They may include physical and emotional symptoms like

• racing or pounding heartbeat (palpitations);
• chest pains;
• stomach upset;
• dizziness, lightheadedness, nausea;
• hyperventilation;
• difficulty breathing, a sense of feeling smothered;
• a choking sensation;
• hand tingling or numbness;
• hot flashes/sweating or cold flashes/chills;
• trembling and shaking;
• dreamlike sensations or perceptual distortions like a feeling of detachment;
• intense fear of terror, a sense that something unimaginably terrible is about to occur and one is powerless to prevent it;
• a need to escape;
• worrying about not knowing how to control their symptoms, leading to them doing something embarrassing;
• fear of dying.

Although how long a panic attack lasts can vary greatly, its duration is typically more than 10 minutes. Panic is one of the most distressing conditions that a person can endure, and its symptoms can closely mimic those of a heart attack. Typically, most people who have one panic attack will have others, and when someone has repeated attacks with no other apparent physical or emotional cause and it negatively changes their behavior due to the attacks or feels severe anxiety about having another attack, he or she is said to have panic disorder.

A variety of medical and mental health professionals are qualified to assess and treat panic disorders. From purely medical professionals like primary care doctors, emergency room physicians to practitioners with mental health training like psychiatrists, psychologists, and social workers, a variety of health care providers may be involved in the care of panic disorder sufferers.

Some practitioners will administer a self-test of screening questions to people whom they suspect may be suffering from panic disorder. In addition to looking for symptoms of repeated panic attacks using what is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), asking detailed questions about the sufferer's history and conducting a mental-status examination, mental health professionals will explore the possibility that the individual's symptoms are caused by another emotional illness instead of or in addition to the diagnosis of panic disorder.

For example, people with an addiction often experience panic attacks, but those symptom characteristics generally only occur when the person is either intoxicated or withdrawing from the substance. Someone who has post-traumatic stress disorder (PTSD) may have panic attacks when reminded of trauma they experienced and in a person with obsessive-compulsive disorder, panic attacks may be triggered by their being unable to perform a compulsive behavior.

The practitioner will also likely ensure that a physical examination and any other appropriate medical tests have been done recently to explore whether there is any medical problem that could be contributing to the occurrence of panic attacks. That is particularly important since many medical conditions may have panic attacks as a symptom and therefore require that the underlying medical condition be treated in order to alleviate the associated anxiety. Examples of that include the need for treatment with antibiotics for infections like Lyme disease or vitamin supplements to address certain forms of anemia.

As the result of years of research, there are a variety of treatments available to help people who suffer from panic attacks learn how to control the symptoms. This includes several effective medical treatments, and specific forms of psychotherapy.

In terms of medications, specific members of the selective serotonin reuptake inhibitor (SSRI), the selective serotonin and norepinephrine reuptake inhibitors (SSNRI), and the benzodiazepine families of medications are approved by the U.S. Food and Drug Administration (FDA) for effective treatment of panic disorder.

Examples of anti-anxiety medications include:

SSRIs

• fluoxetine (Prozac)
• sertraline (Zoloft)
• paroxetine (Paxil)
• escitalopram (Lexapro)
• citalopram (Celexa)
• vortioxetine (Brintellix)
• vilazodone (Viibryd)

SSNRIs

• duloxetine (Cymbalta) 
• venlafaxine (Effexor) 
• desvenlafaxine (Pristiq) 
• levomilnacipran (Fetzima) 

Benzodiazepines

• clonazepam (Klonopin)  
• lorazepam (Ativan) 

Although alprazolam (Xanax) is often used to treat panic attacks, its short duration of action can sometimes result in having to take it several times per day. Medications from the beta-blocker family (for example, propranolol [Inderal]) are sometimes used to treat the physical symptoms, like racing heart rate associated with a panic attack.

Some individuals who suffer from severe panic attacks may benefit from treatment with gabapentin (Neurontin), which was initially found to treat seizures, or benefit from a neuroleptic medication like risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris), iloperidone (Fanapt), or lurasidone (Latuda).

Before SSRIs and SSNRIs became available, medications from the group known as tricyclic antidepressants (TCAs) were often used to address panic disorder. Although TCAs (like doxepin [Sinequan], and amitriptyline [Elavil]) have been found to be equally effective in treating panic attacks, SSRIs and SSNRIs have been proven to be safer and better tolerated. Therefore, TCAs are used much less often than they were previously.

When used in the appropriate person with close monitoring, medications can be quite effective as part of treatment for panic disorder. However, as anything that is ingested carries a risk of side effects, it is important for the individual who has panic attacks to work closely with the prescribing health care professional to decide whether treatment with medications is an appropriate intervention and, if so, which medication should be administered. The person being treated should be closely monitored for the possibility of side effects that can vary from minor to severe, and in some cases, even be life-threatening.

The psychotherapy component of treatment for panic disorder is at least as important as medication. In fact, research shows that psychotherapy alone or the combination of medication and psychotherapy treatment is more effective than medication alone in the long-term management of panic attacks. In overcoming anxiety, cognitive behavioral therapy is widely accepted as an effective form of psychotherapy treatment, for both adults and children.

This form of psychotherapy seeks to help those with panic disorder identify and decrease the irrational thoughts and behaviors that reinforce panic symptoms and can be done either individually, in group therapy, in partner-assisted therapy, or even over the Internet. Behavioral techniques that are often used to decrease anxiety include relaxation techniques (like breathing techniques or guided imagery) and gradually increasing exposure to situations that may have previously triggered anxiety in the panic disorder sufferer.

Helping the person with anxiety understand how to handle the emotional forces that may have contributed to developing symptoms (panic-focused psychodynamic psychotherapy) has also been found to be effective in teaching an individual with panic disorder how to prevent an anxiety attack or how to calm down in order to decrease or stop a panic attack once it starts.

People with panic disorder may also need treatment for other emotional problems. Depression has often been associated with panic disorder, as have alcohol and drug abuse. Fortunately, with proper treatment, these problems associated with panic disorder can be overcome effectively, just like panic disorder itself.

Sadly, many people with panic attacks do not seek or receive appropriate treatment.

Without treatment, panic attacks tend to occur repeatedly for months or years. While they typically begin in young adulthood, the symptoms may arise earlier or later in life in some people.

Complications, which are symptoms that can develop as a result of continued panic attacks and develop into other mental illnesses, may include specific irrational fears (phobias), especially of leaving home (agoraphobia) and avoidance of social situations. Other possible complications can include depression, work or school problems, suicidal thoughts or actions, financial problems, and alcohol or other substance abuse.

For children and adolescents, panic disorder can even interfere with normal development. Panic disorder and other anxiety disorders also predispose sufferers to developing heart or gastrointestinal diseases, high blood pressure or diabetes, having more severe symptoms if they have a respiratory disease, and of dying prematurely.

If left untreated, anxiety may worsen to the point at which the person's life is seriously affected by panic attacks and by attempts to avoid or conceal them. In fact, many people have had problems with friends and family, failed in school, and/or lost jobs while struggling to cope with this condition. There may be periods of spontaneous improvement in the episodes, but panic attacks do not usually go away unless the person receives treatments designed specifically to help people with these symptoms.

Often, a combination of psychotherapy and medications produces good results in the treatment of panic disorder. Improvement is usually noticed in about two to three months. Thus, appropriate treatment for panic disorder can prevent panic attacks or at least substantially reduce their severity and frequency, bringing significant relief to 70%-90% of people with the illness. More than 18% of people who are assessed but not treated for this condition tend to relapse in less than two years.

As these statistics indicate, access to appropriate mental health care is key to a positive prognosis for people who suffer from panic attacks. Therefore, it is imperative to alleviate the well documented economic and racial disparities that exist in having and using access to care. Combating other social disparities, like educational, employment, housing, and criminal justice, is also seen as being important to improving the prognosis for recovering from panic attacks and other health problems.

Effective means of panic attack prevention for people who have had them include avoiding triggers for panic, including

• alcohol or
• stimulants like
  • caffeine,
  • diet pills, or
  • cocaine.

Getting adequate sleep and engaging in stress-reducing activities like yoga or other exercises can also help avoid the occurrence of panic attacks.

A number of other emotional problems can have panic attacks as a symptom. Some of these illnesses include posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, schizophrenia, and intoxication or withdrawal from alcohol and certain other drugs of abuse.

Some medical conditions, like thyroid abnormalities and anemia, as well as certain medications, can produce severe anxiety. Examples of such medications include:

• stimulants like methylphenidate (Ritalin) or amphetamine salts (Adderall),
• diabetes medications like metformin (Glucophage) and insulin,
• antimalarial medications like quinine, as well as
• corticosteroid withdrawal, such as withdrawal from dexamethasone (Decadron).

As individuals with panic disorder seem to be at higher risk of having a heart valve abnormality called mitral valve prolapse (MVP), this possibility should be investigated by a doctor since MVP may dictate the need for special precautions when the individual is being treated for any dental problem. While the development of panic attacks has been attributed to the use of food additives like aspartame, alone or in combination with food dyes, more research is needed to better understand the role such substances may have on this disorder.

Anxiety attacks that occur while sleeping, also called nocturnal panic attacks, occur less often than panic attacks during the daytime but affect about 40%-70% of those who suffer from daytime panic attacks. This symptom is also important because people who suffer from panic symptoms during sleep tend to have more respiratory distress associated with their panic. They also tend to experience more symptoms of depression and other psychiatric disorders compared to people who do not have panic attacks at night.

Nocturnal panic attacks tend to cause sufferers to wake suddenly from sleep in a state of sudden fear or dread for no apparent reason. In contrast to people with sleep apnea and other sleep disorders, sufferers of nocturnal panic can have all the other symptoms of a panic attack. The duration of nocturnal panic attacks tends to be less than 10 minutes, but it can take much longer to fully calm down for those who experience them.

While panic disorder in adolescents tends to have similar symptoms as in adults, symptoms of this condition in younger children are less likely to include the thought-based or so-called cognitive aspects. Specifically, teenagers are more likely to feel unreal or as if they are functioning in a dream-like state (derealization) or be frightened of going crazy or of dying.

Symptoms of panic attacks in women tend to include more avoidance of anxiety-provoking situations, more frequent recurrence, and more often result in the use of medical care compared to panic attack symptoms in men. The frequency of panic attacks may increase, decrease, or remain unchanged during pregnancy.

American Academy of Child and Adolescent Psychiatry
http://www.aacap.org

American Counseling Association
http://www.counseling.org

American Psychiatric Association
http://www.psych.org

American Psychological Association
http://helping.apa.org

Anxiety Disorders Association of America
8730 Georgia Ave., Ste. 600
Silver Spring, MD 20910
Voice: 240-485-1001
Fax: 240-485-1035
http://www.adaa.org/

Council on Anxiety Disorders
Route 1, Box 1364
Clarkesville, GA 30523
Phone: 706-947-3854
Fax: 706-947-1265
[email protected]

Freedom From Fear
http://www.freedomfromfear.org

National Anxiety Foundation
3135 Custer Dr.
Lexington, KY 40517-4001
606-272-7166

Depression and Related Affective Disorders Association
2330 West Joppa Road, Suite 100
Lutherville, MD 21093
Phone: 410-583-2919
Fax: 410-614-3241
[email protected]

National Alliance on Mental Illness (NAMI)
3803 N. Fairfax Dr., Suite 100
Arlington, VA 22203
Main: 703-524-7600
Fax: 703-524-9094
Member services: 888-999-NAMI (6264)

National Institute of Mental Health
9000 Rockville Pike
Bethesda, Maryland 20892
301-496-4000
[email protected]

Mental Health America
2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Phone: 703-684-7722
Toll free: 800-969-6642
Fax: 703-684-5968