What is a panic attack

A panic attack is a brief period of extreme distress, anxiety, or fear that begins suddenly and is accompanied by physical and/or emotional symptoms when there is no real danger or apparent cause ¹. Panic attacks can be very frightening. When panic attacks occur, you might think you’re losing control, having a heart attack or even dying ².

Panic attacks typically begin suddenly, without warning. They can strike at any time — when you’re driving a car, at the mall, sound asleep or in the middle of a business meeting.

• A panic attack goes away in 10 or 15 minutes.

A panic attack is when all of a sudden you get very scared and anxious. You might also have chest pain and choking and feel sick to your stomach, dizzy, and short of breath.

Many people have just one or two panic attacks in their lifetimes, and the problem goes away, perhaps when a stressful situation ends. But if you’ve had recurrent, unexpected panic attacks and spent long periods in constant fear of another attack, you may have a condition called panic disorder.

Although panic attacks themselves aren’t life-threatening, they can be frightening and significantly affect your quality of life. But treatment can be very effective.

• Panic attacks may be triggered by something scary, like seeing a snake, or they may just come on their own
• During a panic attack, you may think you’re having a serious medical problem, like a heart attack or stroke
• Although panic attacks are uncomfortable and scary, they aren’t dangerous
• Panic attacks are common, occurring in at least 11% of adults each year. Most people recover from panic attacks without treatment, but a few develop panic disorder.

Panic attacks may occur in any anxiety disorder, usually in response to a specific situation tied to the main characteristic of the disorder. For example, a person with a phobia of snakes may panic when encountering a snake. Such attacks are called expected attacks. However, such situational panic attacks differ from the spontaneous, unexpected ones that often occur in panic disorder. These attacks occur without any apparent cause.

Panic disorder is occurrence of repeated panic attacks typically accompanied by fears about future attacks or changes in behavior to avoid situations that might predispose to attacks. Diagnosis is clinical. Isolated panic attacks may not require treatment. Panic disorder is treated with drug therapy, psychotherapy (eg, exposure therapy, cognitive-behavioral therapy), or both.

Panic disorder is when you keep having panic attacks and also:

• Worry a lot about having more attacks
• Worry that you’re going crazy or going to lose control of yourself
• Avoid going places or doing your usual activities because you think you might have an attack

Panic disorder is present in 2 to 3% of the population during any 12-month period. Women are about 2 times more likely than men to have panic disorder. Panic disorder usually begins in late adolescence or early adulthood.

When to see a doctor

If you have panic attack symptoms, seek medical help as soon as possible. Panic attacks, while intensely uncomfortable, are not dangerous. But panic attacks are hard to manage on your own, and they may get worse without treatment.

Because panic attack symptoms can also resemble other serious health problems, such as a heart attack, it’s important to get evaluated by your health care provider if you aren’t sure what’s causing your symptoms.

What causes panic attacks ?

Panic attacks sometimes happen for no apparent reason. Also, doctors aren’t sure why some people get panic attacks when something scary happens and some people don’t.

It’s not known what causes panic attacks or panic disorder, but these factors may play a role:

• Genetics
• Major stress
• Temperament that is more sensitive to stress or prone to negative emotions
• Certain changes in the way parts of your brain function
• Panic attacks can be triggered by something you’re scared of. For example, if you’re afraid of snakes, you might have a panic attack when you see a snake.

Panic attacks may start off by coming on suddenly and without warning, but over time, they’re usually triggered by certain situations.

Some research suggests that your body’s natural fight-or-flight response to danger is involved in panic attacks. For example, if a grizzly bear came after you, your body would react instinctively. Your heart rate and breathing would speed up as your body prepared itself for a life-threatening situation. Many of the same reactions occur in a panic attack. But it’s not known why a panic attack occurs when there’s no obvious danger present.

One of the worst things about panic attacks is the intense fear that you’ll have another one. You may fear having a panic attack so much that you avoid situations where they may occur.

Risk factors for panic attack

Symptoms of panic disorder often start in the late teens or early adulthood and affect more women than men.

Factors that may increase the risk of developing panic attacks or panic disorder include:

• Family history of panic attacks or panic disorder
• Major life stress, such as the death or serious illness of a loved one
• A traumatic event, such as sexual assault or a serious accident
• Major changes in your life, such as a divorce or the addition of a baby
• Smoking or excessive caffeine intake
• History of childhood physical or sexual abuse

Complications of panic attacks

Left untreated, panic attacks and panic disorder can affect almost every area of your life. You may be so afraid of having more panic attacks that you live in a constant state of fear, ruining your quality of life.

Complications that panic attacks may cause or be linked to include:

• Development of specific phobias, such as fear of driving or leaving your home
• Frequent medical care for health concerns and other medical conditions
• Avoidance of social situations
• Problems at work or school
• Depression, anxiety disorder and other psychiatric disorders
• Increased risk of suicide or suicidal thoughts
• Alcohol or other substance misuse
• Financial problems

For some people, panic disorder may include agoraphobia — avoiding places or situations that cause you anxiety because you fear not being able to escape or get help if you have a panic attack. Or you may become reliant on others to be with you in order to leave your home.

How can you prevent having a panic attack ?

There’s no sure way to prevent panic attacks or panic disorder. However, these recommendations may help.

• Get treatment for panic attacks as soon as possible to help stop them from getting worse or becoming more frequent.
• Stick with your treatment plan to help prevent relapses or worsening of panic attack symptoms.
• Get regular physical activity, which may play a role in protecting against anxiety.
• Not drinking alcohol
• Eating at regular times
• Getting enough sleep
• Reducing or avoiding caffeine, certain cold medicines, and stimulant.
• Avoid illicit drugs like cocaine and speed

What are the symptoms of a panic attack

Panic attacks have many variations, but symptoms usually peak within minutes. You may feel fatigued and worn out after a panic attack subsides.

The main symptom of a panic attack:

A panic attack involves the sudden appearance of intense fear or discomfort

Plus at least four of the following physical and emotional symptoms:

• Chest pain or discomfort
• A sensation of choking
• Dizziness, unsteadiness, or faintness
• Fear of dying
• Fear of going crazy or of losing control
• Feelings of unreality, strangeness, or detachment from the environment
• Flushes or chills
• Nausea, stomachache, or diarrhea
• Numbness or tingling sensations
• Palpitations or an accelerated heart rate
• Shortness of breath or a sense of being smothered
• Sweating
• Trembling or shaking.

Many people with panic disorder also have symptoms of depression.

Symptoms usually peak within 10 minutes and disappear within minutes, leaving little for a doctor to observe except the person’s fear of another terrifying attack. Because panic attacks sometimes are unexpected or occur for no apparent reason, especially when people experience them as part of panic disorder, people who have them frequently anticipate and worry about another attack—a condition called anticipatory anxiety—and try to avoid situations that they associate with previous panic attacks.

Because symptoms of a panic attack involve many vital organs, people often worry that they have a dangerous medical problem involving the heart, lungs, or brain. Thus, they may repeatedly visit their family doctor or a hospital emergency department. If the correct diagnosis of panic attack is not made, they may have the additional worry that a serious medical problem has been overlooked. Although panic attacks are uncomfortable—at times extremely so—they are not dangerous.

The frequency of attacks can vary greatly. Some people have weekly or even daily attacks that occur for months, whereas others have several daily attacks followed by weeks or months without attacks.

What to do during a panic attack

During a panic attack you need to tell yourself that you are having a panic attack and that it’s not serious and you’re not going to die.

• However, heart disease in women is often mistaken for panic attack with shortness of breath, anxiety, palpitations and indigestion. When in doubt about symptoms, call your local emergency number and seek medical attention without delay to rule out heart disease.

Diagnosis of a panic attack

Your doctor or other health care provider must determine if you have panic attacks, panic disorder or another condition, such as heart or thyroid problems, that resembles panic symptoms.

• A doctor’s evaluation, based on specific criteria
• A complete physical exam
• Blood tests to check your thyroid and other possible conditions and tests on your heart, such as an electrocardiogram (ECG or EKG)
• A psychological evaluation to talk about your symptoms, stressful situations, fears or concerns, relationship problems, and other issues affecting your life

Because serious physical disorders often cause some of the same physical and emotional symptoms as panic attacks, doctors first make sure people do not have a physical disorder.

Panic disorder is diagnosed when people have repeated unprovoked and unexpected panic attacks plus at least one of the following for at least 1 month:

• Persistent worry that they will have more panic attacks or worry about the consequences of the attack (for example, that they will lose control or go crazy)
• Changes in behavior due to the panic attacks (for example, avoiding situations that may cause an attack)

Once doctors are confident that a person’s symptoms are caused by a panic disorder, they try to avoid doing extensive tests when future panic attacks occur unless the person’s symptoms or physical examination results suggest a new problem.

Criteria for diagnosis of panic disorder

Not everyone who has panic attacks has a panic disorder. For a diagnosis of panic disorder, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists these points:

• You have frequent, unexpected panic attacks.
• At least one of your attacks has been followed by one month or more of ongoing worry about having another attack; continued fear of the consequences of an attack, such as losing control, having a heart attack or “going crazy”; or significantly changing your behavior, such as avoiding situations that you think may trigger a panic attack.
• Your panic attacks aren’t caused by drugs or other substance use, a medical condition, or another mental health condition, such as social phobia or obsessive compulsive disorder.

If you have panic attacks but not a diagnosed panic disorder, you can still benefit from treatment. If panic attacks aren’t treated, they can get worse and develop into panic disorder or phobias.

Panic attack treatment

Some people recover without treatment, particularly if they continue to confront situations in which attacks have occurred. For others, especially without treatment, panic disorder follows a chronic waxing and waning course.

Treatment can help reduce the intensity and frequency of your panic attacks and improve your function in daily life. The main treatment options are psychotherapy and medications. One or both types of treatment may be recommended, depending on your preference, your history, the severity of your panic disorder and whether you have access to therapists who have special training in panic disorders.

• Treatment usually helps control symptoms.

Treatment for panic attacks and panic disorder may include:

• Therapy, such as exposure therapy, cognitive-behavioral therapy, or supportive psychotherapy
• Often antidepressants, benzodiazepines, or both
• Often nondrug measures (eg, exposure therapy, cognitive-behavioral therapy)

If avoidance behaviors have not developed, reassurance, education about anxiety, and encouragement to continue to return to and remain in places where panic attacks have occurred may be all that is needed. However, with a long-standing disorder that involves frequent attacks and avoidance behaviors, treatment is likely to require drug therapy combined with more intensive psychotherapy.

Exposure therapy

Exposure therapy, in which patients confront their fears, helps diminish the fear and complications caused by fearful avoidance. For example, patients who fear that they will faint during a panic attack are asked to spin in a chair or to hyperventilate until they feel dizzy or faint, thereby learning that they will not faint during an attack.

Exposure therapy helps lessen the fear by:

• Exposing you gradually and repeatedly to whatever triggers your attacks until you’re comfortable with it
• If you’re afraid of fainting, helping you practice the feeling of faintness caused by breathing quickly so that you know you won’t actually faint during a panic attack.

Typically, doctors begin with the lowest level of exposure that people can easily tolerate. For example, people may be asked to look at the feared object from a distance or perhaps only a picture of the object. Doctors then instruct people to reassure themselves that the remote object is unlikely to harm them. If their heart starts to race or they feel short of breath, they are instructed to respond with slow, deep breaths or to do other relaxation exercises (such as picturing a peaceful scene).

When people feel comfortable at one level of exposure, they are gradually exposed to closer contact with the situation or object—but just to the point that symptoms become uncomfortable. Then, they are instructed to again reassure themselves that harm is unlikely and to repeat the relaxation exercises. People are exposed to closer and closer contact until they can tolerate normal interaction with the situation or object.

Sometimes only a few sessions of exposure are needed.

Two variants of exposure therapy are flooding and graduated exposure.

• Flooding exposes people to the anxiety-producing stimulus for as long as 1 or 2 hours.
• Graduated exposure gives people a greater degree of control over the length and frequency of exposures.

Cognitive-behavioral therapy

Cognitive-behavioral therapy involves teaching patients to recognize and control their distorted thinking and false beliefs and to modify their behavior so that it is more adaptive. For example, if patients describe acceleration of their heart rate or shortness of breath in certain situations or places and fear that they are having a heart attack, they are taught the following:

• Not to avoid situations that cause panic attacks
• To recognize when your fears aren’t real
• To understand that their worries are unfounded
• To respond instead with slow, controlled breathing or other relaxation techniques.

Supportive psychotherapy

Supportive psychotherapy includes education and counseling to give you:

• General information about the disorder and its treatment
• Realistic hope for improvement
• Support that comes from a trusting relationship with a doctor.

Medications for panic attack

Many drugs can prevent or greatly reduce anticipatory anxiety, phobic avoidance, and the number and intensity of panic attacks:

• Antidepressants: The different classes—Selective serotonin re‐uptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin modulators, tricyclics (TCAs), and monoamine oxidase inhibitors (MAOIs)—are similarly effective. However, SSRIs and SNRIs offer a potential advantage of fewer adverse effects in comparison with other antidepressants.
• Benzodiazepines: These anxiolytics— work more rapidly than antidepressants but are more likely to cause physical dependence and such adverse effects as somnolence, ataxia, and memory problems. For some patients, long-term use of benzodiazepines is the only effective treatment.
• Antidepressants plus benzodiazepines: These drugs are sometimes used in combination initially; the benzodiazepine is slowly tapered after the antidepressant becomes effective (although some patients respond only to the combination treatment).

Benzodiazepines. These sedatives are central nervous system depressants. Benzodiazepines work faster than antidepressants but can cause drug dependence and are probably more likely to cause sleepiness, impaired coordination, memory problems, and slowed reaction time. Benzodiazepines may be habit-forming, causing mental or physical dependence, especially when taken for a long time or in high doses. Benzodiazepines approved by the FDA for the treatment of panic disorder include alprazolam (Xanax) and clonazepam (Klonopin). If you seek care in an emergency room for a panic attack, you may be given a benzodiazepine to help stop the attack. Benzodiazepines are generally used only on a short-term basis. Because they can be habit-forming, these medications aren’t a good choice if you’ve had problems with alcohol or drug abuse. They can also interact with other medications, causing dangerous side effects.

Selective serotonin re‐uptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are the preferred drugs because they are as effective as the other drugs but usually have fewer side effects. For example, they are much less likely to cause sleepiness, and they do not cause drug dependence, although if stopped abruptly most SSRIs and SNRIs can cause uncomfortable withdrawal symptoms that can last a week or more.

• Selective serotonin re‐uptake inhibitors (SSRIs) approved by the Food and Drug Administration (FDA) for the treatment of panic disorder include fluoxetine (Prozac), paroxetine (Paxil, Pexeva) and sertraline (Zoloft).
• The serotonin-norepinephrine reuptake inhibitor (SNRI) drug called venlafaxine hydrochloride (Effexor XR) is FDA approved for the treatment of panic disorder.

If one medication doesn’t work well for you, your doctor may recommend switching to another or combining certain medications to boost effectiveness. Keep in mind that it can take several weeks after first starting a medication to notice an improvement in symptoms.

All medications have a risk of side effects, and some may not be recommended in certain situations, such as pregnancy. Talk with your doctor about possible side effects and risks.

Initially, people may be given a benzodiazepine and an antidepressant. When the antidepressant starts working, the dose of benzodiazepine is decreased, then stopped. However, for some people, a benzodiazepine is the only effective long-term treatment.

When a drug is effective, it prevents or greatly reduces the number of panic attacks. It can also help people worry less about future attacks and stop avoiding situations that cause panic attacks. A drug may have to be taken for a long time because panic attacks often return once the drug is stopped.

 

Alternative medicine

An oral supplement called inositol, which influences the action of serotonin, possibly may reduce the frequency and severity of panic attacks. However, more research is needed.

Talk with your doctor before trying any supplements. These products can cause side effects and may interact with other medications. Your doctor can help determine if they’re safe for you.

Home remedies for panic attack

While panic attacks and panic disorder benefit from professional treatment, you can also help manage symptoms on your own. Some lifestyle and self-care steps you can take include:

• Stick to your treatment plan. Facing your fears can be difficult, but treatment can help you feel like you’re not a hostage in your own home.
• Join a support group. Joining a group for people with panic attacks or anxiety disorders can connect you with others facing the same problems.
• Avoid caffeine, alcohol, smoking and recreational drugs. All of these can trigger or worsen panic attacks.
• Practice stress management and relaxation techniques. For example, yoga, deep breathing and progressive muscle relaxation — tensing one muscle at a time, and then completely releasing the tension until every muscle in the body is relaxed — also may be helpful.
• Get physically active. Aerobic activity may have a calming effect on your mood.
• Get sufficient sleep. Get enough sleep so that you don’t feel drowsy during the day.

Support Groups

You can ease the stress of having panic disorder by joining a support group. Sharing with others who have common experiences and problems can help you not feel alone.

Support groups are usually not a good substitute for talk therapy or taking medicine, but can be a helpful addition.

Resources for more information include:

• Anxiety and Depression Association of America: www.adaa.org
• National Institute of Mental Health: www.nimh.nih.gov/health/publications/panic-disorder-when-fear-overwhelms/index.shtml

References

1. Panic Attacks and Panic Disorder. Merck Manual. https://www.merckmanuals.com/home/mental-health-disorders/anxiety-and-stress-related-disorders/panic-attacks-and-panic-disorder
2. Panic attacks and panic disorder. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/panic-attacks/basics/definition/con-20020825