Panic disorder

Causes

The cause is unknown. Genes may play a role. If one identical twin has panic disorder, the other twin will also develop the condition 40% of the time. However, panic disorder often occurs when there is no family history.

Panic disorder is twice as common in women as it is in men. Symptoms usually begin before age 25, but may occur in the mid 30s. Although panic disorder may occur in children, it is often not diagnosed until they are older.

Symptoms

A panic attack begins suddenly, and most often peaks within 10 - 20 minutes. Some symptoms may continue for an hour or more. A panic attack may be mistaken for a heart attack.

Panic attacks may include anxiety about being in a situation where an escape may be difficult (such as being in a crowd or traveling in a car or bus).

A person with panic disorder often lives in fear of another attack, and may be afraid to be alone or far from medical help.

People with panic disorder have at least four of the following symptoms during an attack:

• Chest pain or discomfort
• Dizziness or faintness
• Fear of dying
• Fear of losing control or impending doom
• Feeling of choking
• Feelings of detachment
• Feelings of unreality
• Nausea or upset stomach
• Numbness or tingling in the hands, feet, or face
• Palpitations, fast heart rate, or pounding heart
• Sensation of shortness of breath or smothering
• Sweating, chills, or hot flashes
• Trembling or shaking

Panic attacks may change behavior and function at home, school, or work. People with the disorder often worry about the effects of their panic attacks.

People with panic disorder may have symptoms of:

• Alcoholism
• Depression
• Drug abuse

Panic attacks cannot be predicted. At least in the early stages of the disorder, there is no trigger that starts the attack. Recalling a past attack may trigger panic attacks.

Exams and Tests

Many people with panic disorder first seek treatment in the emergency room, because the panic attack feels like a heart attack.

The health care provider will perform a physical examination, including a psychiatric evaluation.

Blood tests will be done. Other medical disorders must be ruled out before panic disorder can be diagnosed. Disorders related to substance abuse should be considered, because symptoms can mimic panic attacks.

Treatment

The goal of treatment is to help you function well during everyday life. A combination of medication and cognitive-behavioral therapy (CBT) works best.

Antidepressant medicines called selective serotonin reuptake inhibitors (SSRIs) are most often prescribed for panic disorder. These include:

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Other SSRIs

Other medications that may be used include:

• Other types of antidepressants, such as serotonin-norepinephrine reuptake inhibitors (SNRIs)
• Antiseizure drugs in severe cases
• Benzodiazepines, including diazepam (Valium), alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan) (for a short time)
• Monoamine oxidase inhibitors (MAOIs) (only used when the other drugs do not work, because they can have serious side effects)

Your symptoms should slowly get better over a few weeks. Talk to your doctor if they do not. Do not stop taking your medications without talking with your health care provider.

Cognitive-behavioral therapy helps you understand your behaviors and how to change them. You should have 10 to 20 visits over a number of weeks. During therapy you will learn how to:

• Understand and control distorted views of life stressors, such as other people's behavior or life events.
• Recognize and replace panic-causing thoughts, and decrease the sense of helplessness.
• Manage stress and relax when symptoms occur.
• Imagine the things that cause the anxiety, starting with the least fearful. Practice in the real-life situation to help you overcome your fears.

The following may also help reduce the number or severity of panic attacks:

• Eating at regular times
• Exercising regularly
• Getting enough sleep
• Reducing or avoiding caffeine, certain cold medicines, and stimulants

Outlook (Prognosis)

Panic disorders may be long-lasting and hard to treat. Some people with this disorder may not be cured with treatment. However, most people get better with a combination of medicine and behavioral therapy.

Possible Complications

Substance abuse can occur when people who have panic attacks try to cope with their fear by using alcohol or illegal drugs.

People with panic disorder are more likely to be unemployed, less productive at work, and to have difficult personal relationships, including marriage problems.

Agoraphobia is when the fear of future panic attacks causes someone to avoid situations or places that are thought to cause the attacks. This can lead a person to severely limit where they go or who they are around. See: Panic disorder with agoraphobia

Dependence on anti-anxiety medications is a possible complication of treatment. Dependence involves needing a medication to be able to function and to avoid withdrawal symptoms. It is not the same as addiction.

When to Contact a Medical Professional

Call for an appointment with your health care provider if panic attacks are interfering with your work, relationships, or self-esteem.

Prevention

If you get panic attacks, avoid the following:

• Alcohol
• Stimulants such as caffeine and cocaine

These substances may trigger or worsen the symptoms.

Alternative Names

Panic attacks

References

Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69:621-632.

Taylor CT, Pollack MH, LeBeau RT, Simon NM. Anxiety disorders: Panic, social anxiety, and generalized anxiety. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 32.

Pollack MH, Kinrys G, Delong H, Vasconcelos e Sá D, Simon NM. The pharmacotherapy of anxiety disorders. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 41.

Stein MB, Goin MK, Pollack MH, Roy-Byrne P, Sareen J, Simon NM, et al. Practice guideline for the treatment of patients with panic disorder. Arlington, VA: American Psychiatric Association, 2009.

Update Date: 3/25/2012

Updated by: Timothy Rogge, MD, Medical Director, Family Medical Psychiatry Center, Kirkland, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.