Panic disorder is a type of anxiety disorder in which someone has repeated attacks of intense fear that something bad will occur when not expected. The person lives in fear that another attack will occur.

See also: Generalized anxiety disorder

Panic attacks

The exact cause of panic disorders is unknown. Genetics may play a role. Studies suggest that if one identical twin has panic disorder, the other twin will also develop the condition 40% of the time. However, panic disorder often occurs when there is no family history.

Panic disorder is twice as common in women as in men. Symptoms usually begin before age 25, but may occur in the mid 30s. Although panic disorder may occur in children, it is often not diagnosed until they are older.

Before a diagnosis of panic disorder is made, people with this condition often have had visits to emergency rooms and health care providers for symptoms related to possible heart attack or other physical symptoms.

A panic attack begins suddenly, and most often peaks within 10 - 20 minutes. Some symptoms may linger for 1 or more hours afterwards. During a panic attack, the person believes he or she is "going crazy," having a heart attack, or about to die.

Panic attacks cannot be predicted. At least in the early stages of the disorder, there is no cue or trigger that starts the attack. Recalling a past attack may trigger panic attacks. How often and in what pattern they occur can vary.

Panic attacks may include anxiety about being in a situation where an escape may be difficult (such as being in a crowd or traveling in a car or bus).

A person with panic disorder often lives in fear of another attack, and may be afraid to be alone or far from medical help.

With panic disorder, at least four of the following symptoms occur during an attack:

• Chest pain or discomfort
• Dizziness or faintness
• Fear of dying
• Fear of losing control or impending doom
• Feeling of choking
• Feelings of detachment
• Feelings of unreality
• Nausea or upset stomach
• Numbness or tingling in the hands, feet, or face
• Palpitations, fast heart rate, or pounding heart
• Sensation of shortness of breath or smothering
• Sweating, chills, or hot flashes
• Trembling or shaking

Panic attacks may change behavior and function at home, school, or work. People with the disorder often worry about the effects of their panic attacks.

People with panic disorder may have symptoms of:

• Alcoholism
• Depression
• Drug abuse

A health care provider will perform a physical examination, including blood tests and a psychiatric evaluation. Medical disorders must be ruled out before panic disorder can be diagnosed.

Disorders related to substance abuse should also be considered, because some can mimic panic attacks. Substance abuse also can occur when people who have panic attacks try to cope with their fear by using alcohol or illegal drugs.

Cardiovascular, endocrine, respiratory, and nervous system (neurologic) disorders can be present at the same time as panic disorders. Specific tests will vary from person to person depending on the symptoms.

Many people with panic disorder first seek treatment in the emergency room, because the panic attack feels like a heart attack.

The goal of treatment is to help you function well during everyday life. Cognitive-behavioral therapy (CBT) and medications are the mainstays of treatment.

Medications are an important part of treatment. Once you start taking them, do not suddenly stop without talking with your health care provider.

Medications that may be used include:

• Antidepressants called SSRIs (selective serotonin reuptake inhibitors) are the most commonly used medications for panic disorder. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) and other antidepressants.
• If SSRIs or SNRIs do not help, benzodiazepines may be used. They include alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan). However, people can become dependant on or addicted to drugs in this class of medications. Ideally, these drugs should be used only on a temporary basis.
• Other antidepressants and some anti-seizure drugs may be used for severe cases.
• Monoamine oxidase inhibitors (MAOIs), such as phenelzine (Nardil), tranylcypramine (Parnate), and isocarboxazid (Marplan), are only used when the other drugs do not work. Although they can be very helpful for treating panic disorders, MAOIs have serious side effects and can interact with other drugs and foods.

Cognitive-behavioral therapies should be used together with drug therapy. Ten to 20 visits with a mental health professional should take place over a number of weeks. Common parts of this therapy include:

• Gaining understanding of and control over distorted views of life stressors, such as other people's behavior or life events.
• Learning to recognize and replace panic-causing thoughts to decrease the sense of helplessness.
• Learning stress management and relaxation techniques to help when symptoms occur.
• Practicing systematic desensitization and exposure therapy, in which you are asked to relax, then imagine the things that cause the anxiety, working from the least fearful to the most fearful. Gradual exposure to the real-life situation also has been used with success to help people overcome their fears.

Behavioral treatment appears to have long-lasting benefits.

Regular exercise, adequate sleep, and regularly scheduled meals may help reduce the frequency of the attacks. Reduce or avoid the use of caffeine, some over-the-counter cold medicines, and other stimulants, because they may make symptoms worse.

Panic disorders may be long-lasting and difficult to treat. Some people with this disorder may not be cured with treatment. However, most people can expect rapid improvement with drug and behavioral therapies.

Substance abuse can occur when people who have panic attacks try to cope with their fear by using alcohol or illegal drugs.

People with panic disorder are more likely to be unemployed, less productive at work, and to have difficult personal relationships, including marital problems. Work, social, and family function are all disrupted.

Agoraphobia is when the fear of future panic attacks causes someone to avoid situations or places that are thought to cause the attacks. This can lead a person to place severe restrictions on where they go or who they are around. See: Panic disorder with agoraphobia

Dependence on anti-anxiety medications is a possible complication of treatment. Dependence involves needing a medication to be able to function and to avoid withdrawal symptoms. It is not the same as addiction.

Call for an appointment with your health care provider if panic attacks are interfering with your work, relationships, or self-esteem.

If you get panic attacks, avoid the following:

• Alcohol
• Stimulants such as caffeine and cocaine

These substances may trigger or worsen the symptoms.

Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69:621-632.

Taylor CT, Pollack MH, LeBeau RT, Simon NM. Anxiety disorders: Panic, social anxiety, and generalized anxiety. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 32.

Pollack MH, Kinrys G, Delong H, Vasconcelos e Sa D, Simon NM. The pharmacotherapy of anxiety disorders. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 41.

Panic disorder with agoraphobia is an anxiety disorder in which there are repeated attacks of intense fear and anxiety, and a fear of being in places where escape might be difficult, or where help might not be available.

Agoraphobia usually involves fear of crowds, bridges, or of being outside alone.

This article discusses panic disorder with agoraphobia. For information on panic disorder itself, see also: Panic disorder

Agoraphobia; Anxiety disorder- agoraphobia

The exact causes of panic disorder and agoraphobia are unknown. Because panic attacks often occur in areas or situations where they have happened in the past, panic may be a learned behavior. Agoraphobia sometimes occurs when a person has had a panic attack and begins to fear situations that might lead to another panic attack.

Anyone can develop a panic disorder, but it usually starts around age 25. Panic disorder is more common in women than men.

Panic attacks involve short periods of intense anxiety symptoms, which peak within 10 minutes. Panic attack symptoms can include:

• Chest pain or discomfort
• Choking
• Dizziness or faintness
• Fear of being out of control
• Fear of dying
• Fear of "going crazy"
• Hot flashes or chills
• Nausea or other stomach distress
• Numbness or tingling
• Racing heart
• Shortness of breath
• Sweating
• Trembling

Agoraphobia is considered to be present when places or situations are being avoided. People with agoraphobia generally do not feel safe in public places. Their fear is worse when the place is crowded. Symptoms of agoraphobia include:

• Becoming housebound for prolonged periods of time
• Dependence on others
• Fear of being alone
• Fear of being in places where escape might be difficult
• Fear of losing control in a public place
• Feelings of detachment or estrangement from others
• Feelings of helplessness
• Feeling that the body is unreal
• Feeling that the environment is unreal
• Unusual temper or agitation

People who first experience panic sometimes fear they have a serious illness, or are even dying. Often, people will go to an emergency room or other urgent care center because they think they are having a heart attack.

A physical examination and psychological evaluation can help diagnose panic disorder. It is important to rule out any medical disorders, such as problems involving the heart, hormones, breathing, nervous system, and substance abuse. Which tests are done to rule out these conditions depends on the symptoms.

The goal of treatment is to help you feel and function better. The success of treatment usually depends in part on how severe the agoraphobia is.

The standard treatment approach combines cognitive-behavioral therapy (CBT) with an antidepressant medication.

• Selective serotonin reuptake inhibitors (SSRIs) are usually the first choice of antidepressant.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) are another choice. Other antidepressants and some anti-seizure drugs may be used for more severe cases.
• Other anti-anxiety medications may also be prescribed. For example, your health care provider may recommend benzodiazepines when antidepressants don't help or before they take effect.

CBT involves 10 to 20 visits with a mental health professional over a number of weeks. CBT helps you change the thoughts that cause your condition. It may involve:

• Gaining understanding and control of distorted feelings or views of stressful events or situations
• Learning to recognize and replace panic-causing thoughts
• Learning stress management and relaxation techniques
• Systematic desensitization and exposure therapy, in which you are asked to relax, then imagine the things that cause the anxiety, working from the least fearful to the most fearful.

Gradually exposing the patient to the real-life situation that causes the fear has also helped some people overcome their fears.

A healthy lifestyle that includes exercise, enough rest, and good nutrition can also help be helpful.

Most patients can get better with medications or behavioral therapy. However, without early and effective help, the disorder may become more difficult to treat.

• Some people may abuse alcohol or other drugs while trying to self-medicate.
• Some people may be unable to function at work or in social situations.
• Some people may feel isolated, lonely, depressed, or suicidal.

Call for an appointment with your health care provider if you have symptoms of panic attacks or agoraphobia.

Early treatment of panic disorder can often prevent agoraphobia.

Taylor CT, Pollack MH, LeBeau RT, Simon NM. Anxiety disorders: panic, social anxiety, and generalized anxiety. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 32.

You may panic now, if you wish.

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