Panic Disorder & Panic Attacks

Overview

Panic disorder is an anxiety disorder characterized by recurrent, unexpected panic attacks — sudden surges of intense fear or discomfort that peak within minutes and are accompanied by distressing physical and cognitive symptoms.[1]

A panic attack itself is not a mental disorder; it's an acute fear response that can occur in the context of any anxiety disorder or even without one. Panic disorder is diagnosed when a person experiences recurrent unexpected panic attacks and develops persistent concern about having more attacks or changes their behavior to avoid them.

Approximately 6 million adults in the United States (2.7%) are affected by panic disorder in any given year, with women roughly twice as likely as men to develop the condition.[2] Panic disorder typically emerges in late adolescence or early adulthood, with the median age of onset around 24 years. While individual panic attacks are common — up to 28% of adults experience at least one in their lifetime — only a fraction develop the full disorder.[3]

Symptoms

A panic attack involves the abrupt onset of at least four of the following symptoms, which typically peak within 10 minutes:[1]

• Pounding or racing heart (palpitations)
• Sweating
• Trembling or shaking
• Shortness of breath or feeling of smothering
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness, lightheadedness, or feeling faint
• Chills or hot flashes
• Numbness or tingling (paresthesias)
• Derealization (feeling of unreality) or depersonalization (feeling detached from oneself)
• Fear of losing control or "going crazy"
• Fear of dying

The Agoraphobia Connection

About one-third of people with panic disorder develop agoraphobia — an intense fear and avoidance of situations where escape might be difficult or help unavailable during a panic attack.[4] Common avoidance situations include:

• Public transportation (buses, trains, planes)
• Open spaces (parking lots, bridges, markets)
• Enclosed spaces (shops, theaters, elevators)
• Crowds or standing in line
• Being outside the home alone

Agoraphobia can become severely debilitating, with some individuals becoming homebound. Early treatment of panic disorder is crucial to preventing the development of agoraphobia.

Causes & Risk Factors

The exact cause of panic disorder is not fully understood, but research points to a combination of biological, psychological, and environmental factors.[5]

Biological Factors

• Genetics — First-degree relatives of people with panic disorder are 4-8 times more likely to develop the condition. Twin studies estimate heritability at 30-40%.
• Neurochemistry — Dysregulation of serotonin, norepinephrine, and GABA systems; increased sensitivity of the brain's "suffocation alarm" (carbon dioxide hypersensitivity).
• Brain structure — Hyperactivity in the amygdala and dysfunction in the prefrontal cortex, which normally modulates fear responses.

Psychological Factors

• Anxiety sensitivity — tendency to interpret bodily sensations as dangerous ("My heart is racing — I must be dying")
• Catastrophic misinterpretation — viewing normal physical sensations as signs of imminent catastrophe
• Interoceptive conditioning — internal bodily cues become associated with panic, triggering further attacks

Environmental Triggers

• Major life stressors (bereavement, job loss, relationship breakdown)
• History of childhood abuse or traumatic experiences
• Excessive caffeine or stimulant use
• Abrupt discontinuation of certain medications or substances

Diagnosis

Diagnosis of panic disorder requires:[1]

• Recurrent unexpected panic attacks — at least some attacks occur "out of the blue" without an obvious trigger
• At least one month of one or more of:
  • Persistent worry about having additional attacks
  • Worry about the implications of the attacks (e.g., losing control, having a heart attack)
  • Significant behavioral change related to the attacks (e.g., avoidance)
• Symptoms not attributable to substances or another medical condition

A thorough medical evaluation is essential to rule out conditions that can mimic panic attacks, including hyperthyroidism, cardiac arrhythmias, pheochromocytoma, and mitral valve prolapse.

Treatment Options

Panic disorder responds well to treatment, with most patients experiencing significant improvement. The two primary evidence-based approaches are psychotherapy and medication.[6]

Cognitive Behavioral Therapy (CBT)

CBT is the most extensively studied and effective psychotherapy for panic disorder. It typically involves 12-16 sessions and includes:

• Psychoeducation — understanding the fight-or-flight response and why panic attacks, while terrifying, are not dangerous
• Cognitive restructuring — identifying and challenging catastrophic thoughts about bodily sensations
• Interoceptive exposure — deliberately inducing feared bodily sensations (e.g., spinning in a chair, breathing through a straw) to reduce fear of them
• In vivo exposure — gradually confronting avoided situations, especially if agoraphobia is present

CBT produces panic-free outcomes in 70-90% of patients, with benefits maintained at long-term follow-up.[6]

Medication

• SSRIs (sertraline, fluoxetine, paroxetine) — first-line medication with strong evidence base. Full effect typically takes 4-6 weeks.
• SNRIs (venlafaxine) — effective alternative, particularly when depression co-occurs.
• Benzodiazepines (alprazolam, clonazepam) — rapid onset but significant dependence risk. Reserved for short-term or acute use.
• Tricyclic antidepressants (imipramine, clomipramine) — effective but more side effects than SSRIs.

Self-Help Strategies

During a Panic Attack

• Remind yourself it will pass — panic attacks peak within 10 minutes and typically resolve within 20-30 minutes
• Slow breathing — inhale for 4 counts, hold for 4, exhale for 6. This counteracts hyperventilation.
• Ground yourself — the 5-4-3-2-1 technique: name 5 things you see, 4 you can touch, 3 you hear, 2 you smell, 1 you taste
• Stay where you are if possible — fleeing reinforces the idea that the situation is dangerous

Long-Term Management

• Regular aerobic exercise — reduces overall anxiety and panic frequency[7]
• Caffeine elimination — caffeine can directly trigger panic attacks in susceptible individuals
• Sleep consistency — sleep deprivation lowers the panic threshold
• Mindfulness practice — reduces anticipatory anxiety and improves interoceptive awareness
• Avoid "safety behaviors" — carrying medication "just in case," needing a companion, sitting near exits — these maintain the anxiety cycle

When to Seek Help

Seek professional help if:

• You've had multiple panic attacks and worry about having more
• You're avoiding places or situations because of fear of panicking
• Panic attacks are affecting your work, relationships, or daily activities
• You're using alcohol or substances to cope with the fear
• You can't distinguish panic attacks from a medical emergency

With appropriate treatment, the prognosis for panic disorder is excellent. CBT and medication — alone or in combination — help the vast majority of patients achieve significant and lasting improvement.