Panic Disorder; Causes, Symptoms, Diagnosis, Treatment

Panic disorder is an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something really bad is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.

Types of Panic Disorder

Not only can panic attacks vary in intensity and duration, but they can also differ according to what prompted the attack. The DSM-5 lists two separate and distinct types of panic attacks

  • Expected panic attacks – These panic attacks are anticipated when one is subjected to specific cues or panic triggers. For instance, a person who has a fear of enclosed spaces (claustrophobia) may expect to have panic attacks when in an elevator or other cramped areas. A person who has a fear of flying (aerophobia) may predictably have a panic attack when boarding a plane, at the time of take-off, or at some time during the flight.
  • Unexpected Panic Attacks – These panic attacks occur suddenly without any obvious cause or indication. When an unexpected panic attack occurs, the person can be completely relaxed before symptoms develop. This type of panic attack does not accompany any conscious internal cues, such as having fearful thoughts, feelings of intense dread and anxiety, or uncomfortable physical sensations. Unexpected attacks also do not occur with external cues, such as specific phobias or being exposed to a frightening event or situation.

Causes of Panic Disorder

Panic disorder is associated with

Stressful life events – Graduating from college, getting married, having a first child, moving, and getting divorced are major life changes that can induce feelings of intense worry and apprehension.

Genetics –  Like many other mood disorders, anxiety does tend to run in families, and having a parent with panic disorder can put you at higher risk for the condition.

Symptoms of Panic Disorder

Panic attack symptoms include

Symptom inductions generally occur for one minute and may include:

Diagnosis of Panic Disorder

At the doctor’s office or emergency department, you can expect the doctor to take a thorough history and perform a thorough physical examination.

  • In particular, the doctor will be concerned with the person’s past medical history, past history of any mental illness, and any surgery the person may have had. In addition to exploring whether the person suffers from any other mental illness, the practitioner often explores whether the panic attack sufferer has a specific anxiety disorder in addition to or instead of panic disorder, like post traumatic stress disorder , phobias, obsessive compulsive disorder, or generalized anxiety disorder.
  • The doctor likely will inquire about medications the person is taking or has recently taken and in what dosage.
  • The health-care professional will usually ask about any specific life stress the person may be experiencing.
  • The doctor will inquire about whether panic or anxiety illnesses “run in the family” and about any recent use of alcohol or other drugs by the person. During the evaluation for an illness is not the time to be untruthful about drug or alcohol habits because both of these factors are critical in the evaluation.
  • Also, the doctor is likely to inquire about caffeine intake and any over-the-counter or herbal medicines taken.
  • A physical exam will generally consist of a head-to-toe check of all the vital organ systems. The doctor will listen to the heart and lungs and may perform a brief neurologic exam designed to make sure the brain is functioning properly.
  • The doctor will use his or her best judgment regarding the necessity of ordering tests. Given the nature of the symptoms in a panic attack, the person will usually receive an ECG or heart tracing.
  • Should the doctor feel concerned that the symptoms might be caused by a medical disorder, blood tests, urine tests, drug screens, and even X-rays or CT scans might be ordered.
  • If the person has a family history of seizures or symptoms that are not typical for a panic attack, a neurologist may be asked to evaluate the person. There is some overlap between the symptoms of a panic attack and what is known as “partial seizures.” Distinguishing between the two is important because the treatment for each is quite different. A neurologist, if consulted, will order an EEG(electroencephalogram) to check for seizure activity in the brain. This is a painless test but does require some time to complete (typically overnight)

Treatment of Panic Disorder

  • Psychotherapy – All the effective psychotherapies for PTSD focus on the traumatic experience – or experiences – rather than your past life. You cannot change or forget what has happened. You can learn to think differently about it, about the world, and about your life.
  • EMDR (Eye Movement Desensitisation & Reprocessing) – This is a technique which uses eye movements to help the brain to process flashbacks and to make sense of the traumatic experience.  It may sound odd, but it has been shown to work.
  • Group therapy – This involves meeting with a group of other people who have been through the same, or a similar traumatic event. It can be easier to talk about what happened if you are with other people who have been through a similar experience.
  • Exposure therapy for panic disorder –  allows you to experience the physical sensations of panic in a safe and controlled environment, giving you the opportunity to learn healthier ways of coping. You may be asked to hyperventilate, shake your head from side to side, or hold your breath. These different exercises cause sensations similar to the symptoms of panic. With each exposure, you become less afraid of these internal bodily sensations and feel a greater sense of control over your panic.
  • Exposure therapy for panic disorder with agoraphobia –  includes exposure to the situations you fear and avoid is also included in treatment. As in exposure therapy for specific phobias, you face the feared situation until the panic begins to go away. Through this experience, you learn that the situation isn’t harmful and that you have control over your emotions.
  • Medication – SSRI antidepressant tablets may help to reduce the strength of PTSD symptoms and relieve any depression that is also present. They will need to be prescribed by a doctor.
  • Antidepressants – Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may have some benefit for panic disorder symptoms. Tricyclic antidepressants are equally effective but are less well tolerated. Evidence provides support for a small or modest improvement with sertraline, fluoxetine, paroxetine, and venlafaxine. Thus, these four medications are considered to be first-line medications for panic disorder.
  • Anti-anxiety medications – These drugs can relieve severe anxiety and related problems. Some anti-anxiety medications have the potential for abuse, so they are generally used only for a short time.
  • Prazosin  – If symptoms include insomnia with recurrent nightmares, a drug called prazosin (Minipress) may help. Although not specifically FDA approved for panic disorder treatment, prazosin may reduce or suppress nightmares in many people with panic disorder
  • Benzodiazepines – Benzodiazepines are not recommended for the treatment of panic disorder due to a lack of evidence of benefit and risk of worsening panic disorder symptoms. Some authors believe that the use of benzodiazepines is contraindicated for acute stress, as this group of drugs promotes dissociation and ulterior revivals. Nevertheless, some use benzodiazepines with caution for short-term anxiety and insomnia. While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of panic disorder.
  • Glucocorticoids – Glucocorticoids may be useful for short-term therapy to protect against neurodegeneration caused by the extended stress response that characterizes panic disorder but long-term use may actually promote neurodegeneration.
  • Exercise, sport and physical activity – Physical activity can influence people’s psychological and physical health. The U.S. National Center for panic disorder recommends moderate exercise as a way to distract from disturbing emotions, build self-esteem and increase feelings of being in control again. They recommend a discussion with a doctor before starting an exercise program.
  • Cognitive Processing Therapy (CPT)  – where you learn skills to understand how trauma changed your thoughts and feelings. Changing how you think about the trauma can change how you feel.
  • Prolonged Exposure (PE) – where you talk about your trauma repeatedly until memories are no longer upsetting. This will help you get more control over your thoughts and feelings about the trauma. You also go to places or do things that are safe, but that you have been staying away from because they remind you of the trauma.
  • Eye Movement Desensitization and Reprocessing (EMDR)  – which involves focusing on sounds or hand movements while you talk about the trauma. This helps your brain work through traumatic memories.
  • Body-focused therapies – These don’t help PTSD directly, but can help to control your distress and hyperarousal, the feeling of being ‘on guard’ all the time. These include physiotherapy and osteopathy, but also complementary therapies such as massage, acupuncture, reflexology, yoga, meditation and tai chi. They can help you to develop ways of relaxing and managing stress.
  • Interoceptive techniques  – Interoceptive exposure is sometimes used for panic disorder. People’s interoceptive triggers of anxiety are evaluated one-by-one before conducting interoceptive exposures, such as addressing palpitation sensitivity via light exercise. Though this practice is used in 12-20% of cases
  • Self-help tips for panic attacks – No matter how powerless or out of control you may feel about your panic attacks, it’s important to know that there are many things you can do to help yourself. The following self-help techniques can make a big difference to helping you overcome panic:
  • Learn about panic and anxiety – Simply knowing more about panic can go a long way towards relieving your distress. Read up on anxiety, panic disorder, and the fight-or-flight response experienced during a panic attack. You’ll learn that the sensations and feelings you have when you panic are normal and that you aren’t going crazy.
  • Avoid smoking, alcohol, and caffeine  –  These can all provoke panic attacks in people who are susceptible. If you need help to kick the cigarette habit, see How to Quit Smoking. Also, be careful with medications that contain stimulants, such as diet pills and non-drowsy cold medications.
  • Learn how to control your breathing  –  Hyperventilation brings on many sensations (such as lightheadedness and tightness of the chest) that occur during a panic attack. Deep breathing, on the other hand, can relieve the symptoms of panic. By learning to control your breathing, you can calm yourself down when you begin to feel anxious. And if you know how to control your breathing, you’re also less likely to create the very sensations that you’re afraid of.
  • Practice relaxation techniques – When practiced regularly, activities such as yoga, meditation, and progressive muscle relaxation strengthen the body’s relaxation response—the opposite of the stress response involved in anxiety and panic. And not only do these relaxation practices promote relaxation, but they also increase feelings of joy and equanimity.
  • Connect face-to-face with family and friends –  Symptoms of anxiety can become worse when you feel isolated, so reach out to people who care about you on a regular basis. If you feel that you don’t have anyone to turn to, explore ways to meet new people and build supportive friendships.
  • Exercise regularly –  Exercise is a natural anxiety reliever so try to get moving for at least 30 minutes on most days (three 10-minute sessions is just as good). Rhythmic aerobic exercise that requires moving both your arms and legs—like walking, running, swimming, or dancing—can be especially effective.
  • Get enough restful sleep – Insufficient or poor quality sleep can make anxiety worse, so try to get seven to nine hours of restful sleep a night. If sleeping well is a problem for you, these tips to getting a good night’s sleep can help.


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Panic Disorder

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