Harvard Health Publications

Panic Disorder

What Is It?

Panic disorder is a type of anxiety disorder. A person with panic disorder has panic attacks. These are repeated, unexpected episodes of intense fear and anxiety accompanied by physical symptoms that are similar to the body's normal response to danger.

If you are truly in danger (for example, if you are confronted by a criminal with a gun), your body readies itself for "fight or flight." Heart rate increases. Blood rushes to arm and leg muscles, causing a trembling or tingling sensation. You may sweat and become flushed. You become intensely fearful, aroused and very alert. For people having a panic attack, these changes occur even though there is no danger. At the height of a panic attack, there may be a frightening feeling that the environment has somehow become unreal or detached. The person may worry about dying, having a heart attack, losing control or "going crazy."

Some people with panic disorder have several panic attacks every day, while others go weeks or months between attacks. Since panic attacks occur without warning even during sleep people who suffer from panic disorder are usually anxious that an attack may begin at any moment. They worry not only about the psychological pain and physical discomfort of the panic attack, but also that their extreme behavior during a panic episode might embarrass them or frighten others. This unshakable fear and anticipation eventually may lead to avoiding public places where it would be difficult or embarrassing to make a sudden exit.

This fear is called agoraphobia. People who have agoraphobia may, for example, avoid attending a performance in a crowded stadium or movie theater; waiting in line at a store; traveling on a bus, train or plane; or driving on roads that have bridges or tunnels.

Although researchers do not completely understand why some people develop panic disorder, they believe that the illness involves a disturbance in brain pathways that regulate emotion. Also, it is possible that people with panic disorder may have inherited a "fight or flight" response that is either more sensitive than normal or responds more intensely than usual.

Studies of close relatives of people with panic disorder show that this disease has a genetic (inherited) basis. These relatives are four to eight times more likely to develop the illness than people with no family history of the problem. Women are two times more likely than men to have panic disorder, and about three times more likely to develop agoraphobia. On average, symptoms start at around age 25, but panic disorder and agoraphobia can affect people of all ages.

Some people with panic disorder first develop symptoms after a stressful life event, such as divorce, job loss or a death in the family. Scientists still do not understand exactly how panic attacks are triggered, but there is growing evidence that stress early in life makes a person more likely to develop panic symptoms.

People who have panic disorder have a relatively high risk for developing other types of psychiatric problems. In fact, at the time of diagnosis, more than 90% of people with panic disorder also have major depression, another anxiety disorder, a personality disorder or some form of substance abuse.

Symptoms

A panic attack is defined by having at least four of the following symptoms:

  • Palpitations, heart pounding or a rapid pulse

  • Sweating

  • Trembling or shaking

  • Breathing problems, such as shortness of breath or feeling smothered

  • Feeling of choking

  • Chest pain or chest discomfort

Panic Disorders

  • Abdominal discomfort, upset stomach or nausea

  • Feeling faint, dizzy, light-headed or unsteady on your feet

  • Feeling unreal or detached from yourself

  • Fear of losing control

  • Fear of dying

  • Numbness or tingling in arms, legs or other parts of the body

  • Chills or hot flushes

Between panic attacks, someone with panic disorder usually has persistent worries that a new attack will occur. These worries may cause the person to dramatically change his or her behavior or lifestyle to avoid the embarrassment of "losing control" while with other people.

Diagnosis

If you develop panic disorder, you may consult a primary care doctor first because the physical symptoms often make the person feel like they're having a heart attack, a stroke or a breathing problem. Many medical illnesses can cause symptoms that mimic panic attacks, including heart disease, asthma, cerebrovascular disease, epilepsy, hormone abnormalities, infections and disturbances in levels of certain blood chemicals.

Symptoms of a panic attack can also be triggered by the use of amphetamines, cocaine, marijuana, hallucinogens, alcohol and other drugs, as well as by certain prescription medications.

A doctor may do tests to rule out medical problems, but the results of these tests will usually be normal. The doctor may then ask you questions about your family history; psychiatric history; current anxieties; recent stresses; and daily use of prescription and nonprescription drugs, including caffeine and alcohol. If your doctor suspects that the problem is panic disorder, he or she will refer you to a mental health professional for care.

A mental health professional will do a full evaluation that includes:

  • Questions about thoughts, feelings and physical symptoms during a panic attack

  • Asking about thoughts, feelings and behaviors between attacks

  • Checking for symptoms of other forms of psychiatric illness

Expected Duration

Panic disorder can be long-lasting, especially if it is not treated. Fortunately, it is a very treatable illness. With proper care, many people find long-term relief from their symptoms.

Prevention

There is no way to prevent panic disorder. However, if you have been diagnosed with panic disorder, you may be able to prevent panic attacks by cutting down on caffeine, alcohol or other substances that might be triggering your symptoms. Once a diagnosis is made, treatment often eliminates panic attacks or makes them less intense.

Treatment

If you have panic attacks, there are several treatment options both medications and psychotherapy.

  • Antidepressants – Though they are known as depression treatments, these drugs are very effective for panic disorder. These medications may be effective because of their effect on serotonin, one of the chemical messengers involved in the brain's anxiety response. The popular selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (Paxil) are commonly used. Also, the older tricyclic antidepressants, such as nortriptyline (Aventyl, Pamelor) and imipramine (Tofranil) are effective, as are some newer antidepressants.

    All antidepressants take several weeks to start working. As a result, your doctor may also prescribe a faster-acting benzodiazepine to give relief sooner.

  • Benzodiazepines – This group of drugs affects another chemical messenger at work in the brain's fear response system gamma aminobutyric acid (GABA). Examples of benzodiazepines are clonazepam (Klonopin), lorazepam (Ativan), diazepam (Valium) and alprazolam (Xanax). They are safe when used as directed and often bring quick relief from panic symptoms.

    These drugs are often prescribed for a relatively short time because the body can become accustomed to the drug's effect. That is, benzodiazepines may provide less relief as time goes on. And withdrawal reactions can occur if you stop the drug suddenly. Discontinuing a benzodiazepine should be done gradually under a doctor's direction.

    Nonetheless, they are important tools for the short run, so your doctor may recommend them to you for the first weeks of treatment while you're waiting for the positive effects of an antidepressant medication to take hold.

  • Cognitive therapy – This nondrug therapy is designed to help a person with panic attacks recognize the unreasonableness of the fears that cause panic. The therapist sometimes teaches specialized techniques that can help to manage the attacks.

  • Behavior therapies – These treatments include in vivo exposure, a form of behavior therapy that gradually exposes the person to fear-provoking situations; respiratory training, a technique that focuses on breath control as a way of fighting panic; and applied relaxation, a method that teaches the patient to control his or her anxiety level by using muscle control and imagination.

For many patients, the most effective approach is a combination of one or more medications, plus some form of cognitive or behavior therapy.

When To Call a Professional

If you have symptoms of a panic attack, and you have never been diagnosed with panic disorder, seek medical help immediately. Remember, symptoms of a panic attack can mimic those of many life-threatening medical illnesses. For this reason, a doctor should evaluate your problem comprehensively.

Prognosis

With appropriate treatment, the prognosis is good. Between 30% and 40% of patients become symptom-free for extended periods, while another 50% continue to experience only mild symptoms that do not significantly affect daily life.

External resources

American Psychiatric Association
1000 Wilson Blvd.
Suite 1825
Arlington, VA 22209-3901
Toll-Free: 1-888-357-77924
http://www.psych.org/

National Institute of Mental Health
Office of Communications
6001 Executive Blvd.
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Toll-Free: 1-866-615-6464
TTY: 1-866-415-8051
http://www.nimh.nih.gov/

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


Disclaimer: This content should not be considered complete and should not be used in place of a call or visit to a health professional. Use of this content is subject to specific Terms of Use & Medical Disclaimers.

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