Panic Disorder

What is panic disorder?

A panic attack is an uncontrollable and terrifying response to ordinary, nonthreatening situations. People who experience recurrent panic attacks, have persistent anxiety or fear regarding their panic attacks and change their behavior in an attempt to avoid further panic attacks may have panic disorder.

Individuals with panic disorder are likely to experience some combination of the following symptoms during a panic attack: sweating, hot or cold flashes, choking or smothering sensations, racing heart, labored breathing, trembling, chest pains, faintness, numbness, nausea or disorientation. They may feel like they are dying, losing control or losing their mind. Panic attacks typically last about five to 10 minutes but can vary from only a few minutes to almost an hour in some cases. During the attack, the physical and emotional symptoms increase quickly in a wave-like fashion and then slowly subside. A person may feel anxious and jittery for many hours after experiencing a panic attack.

Panic attacks can occur in anyone. Chemical or hormonal imbalances, drugs or alcohol, stress, poor sleep or other situational events can cause panic attacks. In some people, panic attacks are mistakenly interpreted as heart attacks or respiratory problems, as these can cause similar symptoms. Therefore, prior to the diagnosis of panic disorder, a thorough evaluation should be performed to ensure that no underlying medical condition is the cause of the symptoms. This evaluation may include blood tests (e.g., thyroid tests), urine tests (for drugs and alcohol), electrocardiograms (EKG) and a physical examination.

What are some problems that people with panic disorder experience?

Many people with panic disorder “fear the fear,” or worry about when the next attack is coming. The fear of more panic attacks can lead to a very limited life and, in some people, can cause agoraphobia, an intense fear of feeling trapped in a public place. People with panic disorder may avoid the places they used to go to or stop doing the things that they think trigger their panic attacks. This can cause significant occupational and social problems if a person feels uncomfortable going to work, school, family gatherings or other events.

Similar to people with other anxiety disorders, people with panic disorder are at increased risk of developing other mental illnesses. Many people feel sad or depressed about how panic attacks have affected their lives, and up to half of the people with panic disorder may eventually be diagnosed with depression. Alcohol and drug abuse can also be a serious problem for some people with panic disorder, both as a trigger for panic attacks and as a type of self-medication that can quickly get out of control. Panic disorder, particularly if untreated, can raise the risk of suicidal thoughts or acts.

Even people without the added difficulties of depression and substance abuse may feel very scared and ashamed of their panic attacks. The associated secretiveness and feelings of shame or low self-esteem that occur with this illness can cause some people to isolate themselves from their friends and family. Other people are unwilling to go anywhere or do anything outside their homes without the help of others they trust. This can be very concerning or confusing for loved ones who are trying to help. Therefore, it is recommended that friends and family of people with panic attacks encourage their loved one to seek treatment for their illness.

What causes panic disorder?

Panic attacks occur frequently, and approximately one in 20 Americans will be diagnosed and treated for panic disorder each year. Panic disorder is more common in females than males (2-to-1 ratio). Scientists have not isolated a single gene in studying panic attacks, but it is generally thought that there is a genetic component to panic disorder. This means that people who have a parent with panic disorder are more likely to develop the disorder themselves. Scientific studies have shown that areas of the brain function differently in people with panic disorder. Inappropriate activation of a region of the brain called the amygdala—which is involved in the fight-or-flight response—has been associated with panic disorder in research studies. However, brain imaging is not a practical clinical tool to make a diagnosis.

People who experience high levels of stress in their lives are also at increased risk of developing panic disorder. For example, people who have been physically or sexually abused, people with severe medical illnesses (e.g., asthma or heart disease) and people who abuse drugs and alcohol are at increased risk of developing panic disorder.

Is panic disorder treatable?

Panic disorder is generally very responsive to treatment. People who are able to remain in treatment can expect to have less severe and less frequent panic attacks as well as anxiety in between these events. Complete recovery is a reasonable goal for many people, although a significant percentage of individuals will experience further episodes later in life. This suggests that ongoing treatment may be indicated in certain situations.

Recovery from panic disorder can be achieved either by taking medications or by a form of cognitive behavioral therapy (CBT) that is specific for panic disorder. Studies suggest that medication and CBT are about equally effective, and the decision about which treatment to choose depends largely on the preference of the individual seeking treatment. There is also evidence that the combination of CBT and medication may offer some benefits over either one alone. Some medication treatments probably work a bit faster but are likely to have increased adverse side effects than CBT. Also, when successful treatment is finished, people who have had CBT tend to remain without symptoms for longer than people who have taken medications.

CBT involves exploring the connection between thoughts, feelings and behaviors. People will learn to understand the links between their bodily sensations and their emotions and how their subjective fears can increase the symptoms of panic attacks. For some people, understanding the brain’s connection between fear and the physical symptoms of a panic attack can be extraordinarily helpful in decreasing symptoms. For other people, exposure therapy is useful in learning how to experience the symptoms of a panic attack without “losing control.” By simulating the symptoms of a panic attack in a controlled environment, some people can learn to control their fear of future panic attacks and decrease the severity of their symptoms. Family members and friends can help a great deal in this process when they are supportive and encouraging.

Medications are most effective when they are used as part of an overall treatment plan that includes supportive therapy. Antidepressants and antianxiety medications are the most frequently used medications for this disorder. Medications called selective serotonin reuptake inhibitors (SSRIs) are commonly used. These include paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro). A serotonin norrepinephrine reuptake inhibitor (SNRI), venlafaxine (Effexor), also has FDA approval for panic disorder. These medications can successfully control the symptoms of panic attacks but may take up to two or three months to achieve their full effect. Another commonly used class of medications is benzodiazapines which includes lorazepam (Ativan), clonazepam (Klonopin) and alprazolam (Xanax). These medications can be highly effective in the short-term but are usually not indicated for the long-term treatment of panic disorder. The most appropriate medication for each individual will depend on a number of factors and should be discussed with one’s doctor. Furthermore, a person should also discuss with the doctor whether or not any medication prescribed is approved by the United States Food and Drug Administration (US-FDA) for the treatment of panic disorder, or whether the doctor feels “off label” use is indicated. If the latter is the case, ask your doctor about the reasoning behind this.

Healthy living practices can also help people to overcome panic disorder. Aerobic exercise, a proper and balanced diet and decreased use of caffeine and alcohol are all very important in decreasing symptoms. For many people, learning how to reduce stress through meditation and mindfulness are also very useful.

Peer support is a vital part of overcoming panic disorder. Family and friends can play a critical role in the treatment process and should be informed of the treatment plan and of the ways that they can be most helpful.

Reviewed by Ken Duckworth, M.D., and Jacob L. Freedman, M.D., February 2013

The authors would like to thank Jack Gorman, M.D., who was responsible for a previous version of this content.