Panic disorder

• Alternative Names

  Panic attacks

• Causes, incidence, and risk factors

  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 in family members who are not blood relatives.

  Panic disorder is twice as common in women as in men.

  Symptoms usually begin before age 25. Although panic disorder may occur in children, it is often not diagnosed until they are older. People with this condition often have medical tests and exams for symptoms related to heart attack or other conditions before a diagnosis of panic disorder is made.

• Symptoms

  With panic disorder, at least four of the following symptoms suddenly occur within 10 minutes. Attacks may be followed by at least 1 month of persistent fear of having another attack.

  • Chest pain or discomfort
  • Dizziness or faintness
  • Fear of dying
  • Fear of losing control
  • Feeling of choking
  • Feelings of detachment
  • Feelings of unreality
  • Nausea or upset stomach
  • Numbness or tingling
  • Palpitations or pounding heart
  • Sensation of shortness of breath
  • Sweating, chills, or hot flashes
  • Trembling or shaking

  There are often extreme changes in behavior at home, school, work, or with family. People with the disorder often worry about the significance of their panic attacks. They may think they are "going crazy" or having a heart attack.

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

• Signs and tests

  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.

• Treatment

  Anti-anxiety medications, antidepressants, and cognitive behavioral therapy (working with a therapist) have been successfully used to treat panic disorders.

  Medications act on the central nervous system to reduce anxiety and related symptoms.

  Benzodiazepines are a commonly used class of anti-anxiety medications. They include alprazolam (Xanax). However, people can become dependent on or addicted to drugs in this class of medications. Ideally, these drugs are used only on a temporary basis.

  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). If SSRIs do not help, longer term use of benzodiazepines may be considered if you do not have a history of drug dependence and tolerance.

  Monoamine oxidase inhibitors (MAOIs), such as phenelzine (Nardil), tranylcypramine (Parnate), and isocarboxazid (Marplan), are only used when none of the other drugs work. MAOIs are the most effective medications for panic disorder, but they have serious side effects and they can interact with other drugs and foods. They should only be prescribed by a psychiatrist who is experienced in their use.

  Behavioral therapies should be used together with drug therapy. These include:

  • Cognitive-behavioral therapy
  • Cognitive restructuring (learning to recognize and replace panic-causing thoughts)
  • Exposure
  • Pleasant mental imagery
  • Relaxation techniques

  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 and other stimulants.

• Expectations (prognosis)

  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.

• Complications

  Possible complications of this condition include:

  • Avoiding situations or places that might bring on an attack
  • Other anxiety and mood disorders

  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, which involves the uncontrolled use of a substance despite negative results. Dependence and addiction often occur together, but dependence itself is not always a problem.

• Calling your health care provider

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

• Prevention

  If you get panic attacks, avoid the following:

  • Alcohol
  • Stimulants such as caffeine and cocaine

  These substances may trigger or worsen the symptoms.

• References

  Fava GA, Rafanelli C, Grandi S, et. al. Long-term outcome of panic disorder with agoraphobia treated by exposure. Psychol Med. 2001;31(5):891-898.

  Katon WJ. Clinical practice: panic disorder. N Engl J Med. 2006;354(22):2360-2367.

  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.

  Smoller JW, Pollack MH, Wassertheil-Smoller S, et al. Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women's Health Initiative Observational Study. Arch Gen Psychiatry. 2007;64(10):1153-1160.

Review Date: 1/15/2009

Reviewed By: Christos Ballas, MD. Attending Psychiatrist, Hospital of the University of Pennsylvania, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.