A person with panic disorder experiences sudden and repeated episodes of intense fear accompanied by physical symptoms such as chest pain, heart palpitations, breathlessness, vertigo or abdominal distress. Because these symptoms are so similar to those of a heart attack or other life-threatening medical conditions, panic disorder may not be diagnosed until extensive and expensive medical tests have ruled out other serious illnesses.
Even between panic attacks, it is common for sufferers to be extremely anxious. These people often develop phobias about places such as shopping malls—where previous episodes have occurred. They also develop fears about experiences that have set off an attack, such as an airplane flight. As panic attacks become more frequent, the person may begin to shun situations that might trigger another episode. This avoidance may lead to agoraphobia, the inability to leave familiar, safe surroundings because of intense fear and anxiety.
Approximately 2.4 million Americans, or 1.7 percent of the population between the ages of 18 and 54, suffer from panic disorder each year. Women are twice as likely as men to develop the disorder and in about half of all cases, it strikes before age 25.
To be formally diagnosed with panic disorder, a patient must have experienced either four panic attacks in four weeks, or one or more attacks followed by at least a month of continual anxiety about having another episode. During one of these attacks, at least four of these symptoms must peak within 10 minutes.
Palpitations, pounding heart, or accelerated heart rate
Trembling or shaking
Shortness of breath or a sensation of smothering
A choking feeling
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Feeling detached from oneself
Fear of losing control or of going crazy
Fear of dying
Numbness or tingling sensation
Chills or hot flashes
Heredity, other biological factors, stressful events, and thinking that magnifies normal reactions play a role in the onset of panic disorder. Although the precise causes are still unknown, they are the subject of many scientific studies.
Researchers have conducted both animal and human studies to pinpoint the particular parts of the brain that are involved in anxiety and fear. Because fear evolved to deal with danger, it sets off an immediate protective response without conscious thought. This fear response is believed to be coordinated by the amygdala, a structure deep inside the brain. Although relatively small, the amygdala is quite complex, and recent studies suggest that anxiety disorders may be associated with abnormal activity in the amygdala.
Panic disorder is treated with medications and cognitive-behavioral therapy, psychotherapy that teaches patients to view their attacks in a different way and demonstrates how to reduce anxiety. Appropriate treatment by an experienced professional can reduce or prevent panic attacks in 70 to 90 percent of people with the disorder. Most patients show significant progress after just a few weeks of therapy. Relapses may occur, but they can be treated effectively.
Several medications initially approved to treat depression have been found to be effective for relieving panic disorder. These antidepressants must be taken for several weeks before symptoms begin to disappear. Patients must not get discouraged or stop taking their medications, which need time to work.
Among the latest antidepressants are the selective serotonin reuptake inhibitors, or SSRIs. These work in the brain on a chemical messenger called serotonin. SSRIs tend to have fewer side effects than the earlier generation of antidepressants. Patients may be slightly nauseated or jittery when they first take SSRIs, but in time that feeling goes away. Sexual dysfunction may be a side effect of these antidepressants, but an adjustment in dosage or a switch to another SSRI may correct the problem. Patients should discuss all side effects with their doctor so that any needed changes in medication can be made.
SSRIs commonly prescribed for panic disorder in combination with obsessive-compulsive disorder, social phobia, or depression include fluoxetine, sertraline, fluvoxamine, paroxetine and citalopram. An initial low dose of these medications is gradually increased until it reaches a therapeutic level.
The antidepressants known as tricyclics are also taken at low doses, and are slowly increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating panic disorders. They are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics can have side effects such as dizziness, drowsiness, dry mouth, and weight gain. If these problems persist, the patient may request a change in dosage or a switch in medications.
The oldest generation of antidepressant medications is the monoamine oxidase inhibitors, or MAOIs. Phenelzine, the most commonly prescribed MAOI, is helpful for patients with panic disorder. People who take MAOIs must watch their diet because these antidepressants can interact with some foods and beverages, including cheese and red wine, which contain a chemical called tyramine. MAOIs also interact with certain other medications, including SSRIs. These different interactions can cause a dangerous rise in blood pressure and other life-threatening reactions.
The group of anti-anxiety medications known as benzodiazepines, including alprazolam and lorazepam, may be prescribed for patients with panic disorder. These drugs alleviate symptoms quickly and have few side effects other than drowsiness, but because people can develop a tolerance to them—and would have to increase the dosage to keep getting the same effect—they are generally prescribed only for short time periods. Because of dependency issues, they are not recommended for patients who have abused drugs or alcohol. Reducing the dosage gradually should prevent possible withdrawal symptoms in patients going off benzodiazepines, but their anxiety may return once they stop taking the medication.
Cognitive-Behavioral and Behavioral Therapy
One form of psychotherapy that has been shown to be effective in treating several anxiety disorders, including panic, is cognitive-behavioral therapy (CBT). A major goal of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that trigger panic. It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her attacks are not really heart problems as previously feared; the tendency to put the worst possible interpretation on physical symptoms can be overcome.
The behavioral component of CBT seeks to change people’s reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. The therapist helps the patient to cope with the resultant anxiety. Eventually, after this exercise has been repeated a number of times, anxiety will diminish. If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.
To be effective, CBT or behavioral therapy must be directed at the person’s specific anxieties and it is necessary to tailor it to the person’s particular concerns. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign “homework”—specific problems that the patient will need to work on between sessions.
CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder.
Medication may be combined with psychotherapy, and for many people this is the best approach to treatment. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn’t work, the odds are that another one will, so don’t give up.
If you have recovered from an anxiety disorder, and at a later date it recurs, don’t consider yourself a “treatment failure.” Recurrences can be treated effectively, just like an initial episode. In fact, the skills you learned in dealing with the initial episode can be helpful in coping with a setback.
National Institutes of Health – National Library of Medicine
National Institute of Mental Health
US Department of Health and Human Services
Last Reviewed: 5 Jul 2006
Last Reviewed By: Psychology Today Staff