Panic disorder (panic attacks)

Causes and Risk Factors

The exact cause of panic disorder is unknown, but likely involves a combination of factors (1, 3):

• Genetics: Panic disorder tends to run in families, suggesting a genetic predisposition.
• Neurobiology: Dysregulation in brain circuits and neurotransmitter systems involved in fear and anxiety responses (e.g., involving the amygdala, serotonin, norepinephrine, GABA) is implicated.
• Temperament: Individuals with higher neuroticism or anxiety sensitivity may be more prone.
• Stressful Life Events: Major stressors (e.g., loss, trauma, significant life changes) can sometimes precede the onset or trigger attacks, although often attacks appear unexpectedly.
• Other Factors: Certain medical conditions or substance use/withdrawal can sometimes trigger panic-like symptoms.

Panic disorder typically begins in late adolescence or early adulthood (often in the twenties) and affects women about twice as often as men (1). No significant differences across ethnic or socioeconomic groups have been consistently found.

 

Diagnosis

Diagnosis is made by a qualified healthcare or mental health professional based on (1, 2):

• Detailed clinical interview about symptoms, frequency, triggers (or lack thereof), worry, avoidance behaviors, and impact on life.
• Assessment against DSM-5 (or ICD) criteria for Panic Disorder.
• Ruling out other medical conditions that can cause similar symptoms (e.g., thyroid disorders, cardiac arrhythmias, respiratory conditions, neurological disorders, substance withdrawal). This often involves a physical examination and may include laboratory tests or ECG.
• Differentiating from other anxiety disorders or mental health conditions.

Treatment Options

Panic disorder is highly treatable. Effective treatments typically involve psychotherapy, medication, or a combination (1, 3, 4).

Psychotherapy (CBT)

Cognitive Behavioral Therapy (CBT) is considered a first-line, highly effective treatment for panic disorder (1, 4). Key components often include:

1. Psychoeducation (Learning): Understanding panic attacks, the disorder, the "fight or flight" response, and the treatment rationale.
2. Self-Monitoring: Keeping diaries to track panic attacks, symptoms, triggers (if any), and associated thoughts/behaviors.
3. Breathing Retraining: Learning diaphragmatic breathing techniques to manage hyperventilation and reduce physical symptoms during anxiety or an attack.
4. Cognitive Restructuring (Rethinking): Identifying and challenging catastrophic misinterpretations of physical sensations (e.g., realizing palpitations are not a heart attack) and replacing fearful thoughts with more realistic ones.
5. Exposure Therapy: Gradually and systematically exposing the individual to feared physical sensations (interoceptive exposure) and avoided situations (in vivo exposure) to reduce fear and avoidance behaviors through habituation and learning.

Medications

Medications can also be effective, particularly for reducing the frequency and severity of attacks (1, 4):

• Selective Serotonin Reuptake Inhibitors (SSRIs) & Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): These antidepressants are generally considered first-line medications due to their effectiveness and safety profile. Examples include fluoxetine, sertraline, paroxetine, escitalopram, venlafaxine. They usually require several weeks to take full effect.
• Benzodiazepines: (e.g., alprazolam, clonazepam, lorazepam). These anti-anxiety medications work quickly to relieve panic symptoms but are generally recommended for short-term use or as needed due to risks of tolerance, dependence, withdrawal symptoms, and cognitive side effects (1, 4).
• Tricyclic Antidepressants (TCAs): Older antidepressants, sometimes used if SSRIs/SNRIs are ineffective, but often have more side effects.
• Anti-seizure Medications: Some may be used off-label in specific cases, but are not standard first-line treatments.

Treatment choice depends on symptom severity, patient preference, medical history, and response to previous treatments. Combining CBT and medication is often very effective (4).

With appropriate treatment, many individuals with panic disorder experience significant improvement or full recovery and can return to normal activities (1, 3).

Differential Diagnosis

It's crucial to differentiate panic attacks/disorder from other conditions:

Condition	Key Differentiating Features
Medical Conditions	Cardiac (arrhythmias, angina, MI), Pulmonary (asthma, COPD, PE), Endocrine (hyperthyroidism, hypoglycemia, pheochromocytoma), Neurologic (seizures, vestibular disorders), Anemia. Requires medical workup (ECG, labs, etc.). Symptoms may be more persistent or directly related to exertion/specific triggers.
Substance Use/Withdrawal	Stimulant intoxication (cocaine, amphetamines), caffeine excess, alcohol or benzodiazepine withdrawal can mimic panic attacks. History is key.
Other Anxiety Disorders	Panic attacks can occur in other disorders (Social Anxiety, PTSD, Specific Phobia), but in Panic Disorder, at least some attacks are *unexpected*, and the primary fear is often about the attacks themselves. Generalized Anxiety Disorder involves persistent worry, not discrete attacks.
Somatic Symptom Disorder	Focus is on the physical symptoms themselves and excessive thoughts/feelings/behaviors related to them, less emphasis on discrete attacks of fear.

References

1. National Institute of Mental Health (NIMH). Panic Disorder: When Fear Overwhelms. Updated April 2022. Available from: https://www.nimh.nih.gov/health/publications/panic-disorder-when-fear-overwhelms
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision (DSM-5-TR). American Psychiatric Publishing; 2022.
3. Bystritsky A, Khalsa SS, Cameron ME, Schiffman J. Current diagnosis and treatment of anxiety disorders. P T. 2013;38(1):30-57.
4. Roy-Byrne PP, Craske MG, Stein MB. Panic disorder. Lancet. 2006;368(9540):1023-1032. doi:10.1016/S0140-6736(06)69418-X