Panic Attacks

What is a Panic Attack?

Panic attacks are frightening but fortunately physically harmless episodes. They can occur at random or after a person is exposed to various events that may "trigger" a panic attack. They peak in intensity very rapidly and go away with or without medical help.

  • People experiencing panic attacks may fear they are dying or that they are suffocating. They may have chest pain or believe that they are having other symptoms of a heart attack. They may voice fears that they are "going crazy" and seek to remove themselves from whatever situation they may be in.
  • Some people may experience other associated physical symptoms. For example, they may begin breathing very rapidly and complain that they have palpitations, in that their "hearts are jumping around in their chest." They might experience nausea, smothering sensation, and dizziness. Then, within about an hour, the symptoms fade away.
  • A significant percentage of the population will experience at least one panic attack during their lifetimes. People who have repeated attacks require further evaluation from a mental-health professional. Panic attacks can indicate the presence of panic disorder, depression, or other forms of anxiety-based illnesses.
  • Panic attacks are a symptom of an anxiety disorder and affect a significant number of adult Americans. Other facts about panic include that many people in the United States will have full-blown panic disorder at some time in their lives, usually beginning between 15-19 years of age. Panic attacks occur suddenly and often unexpectedly, are unprovoked, and can be disabling.
  • Once someone has had a panic attack, he or she may develop irrational fears, called phobias, about the situations they are in during the attacks and begin to avoid them. That, in turn, may reach the point where the mere idea of doing things that preceded the first panic attack triggers terror or dread of future panic attacks, resulting in the individual with panic disorder being unable to drive or even step out of the house. If this occurs, the person is considered to have panic disorder with agoraphobia.
  • Panic disorder in adolescents tends to show similar symptoms as in adults. Teens tend to feel like they are not real, as if they are operating in a dreamlike state (derealization), or be frightened of going crazy or of dying.
  • The disorder in younger children is less likely to have the symptoms that involve ways of thinking (cognitive symptoms). For example, panic attacks in children may result in the child's grades declining, decreased school attendance, and avoiding that and other separations from their parents. Both children and teens with panic disorder are further at risk for developing substance abuse and depression as well as suicidal thoughts, plans, and/or actions.
Stress Pictures Slideshow: 10 Ways to Stop Stress

Panic Attacks Causes

As with most behavioral illnesses, the causes of panic attacks are many. Certainly there is evidence that the tendency to have panic attacks can sometimes be inherited. However, there is also evidence that panic may be a learned response and that the attacks can be initiated in otherwise healthy people simply given the right set of circumstances. Research into the causes of panic attacks is ongoing.

Panic disorder is a separate but related diagnosis to panic attacks. People experiencing repeated panic attacks and who meet other diagnostic criteria may be diagnosed with this illness. Panic disorder is thought to have more of an inherited component than panic attacks that are not a part of panic disorder. Certain medical conditions, like asthma and heart disease, as well as certain medications, like steroids and some asthma medications, can cause anxiety attacks as a symptom or side effect. As individuals with panic disorder are at higher risk of having a heart-valve abnormality called mitral valve prolapse (MVP), that should be evaluated by a doctor since MVP may indicate that specific precautions be taken when the person is treated for a dental problem.

Research is inconsistent as to whether nutritional deficiencies (for example, zinc or magnesium deficiency) may be risk factors for panic disorder. While food additives like aspartame, alone or in combination with food dyes, are suspected to play a role in the development of panic attacks in some people, it has not been confirmed by research so far.

Panic Attacks Symptoms

The American Psychiatric Association's official Diagnostic and Statistical Manual of Mental Disorders IV, Treatment Revision (DSM-IV-TR) defines a panic attack as a discrete period of intense fear, distress, nervousness or discomfort, in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:

  • Palpitations, pounding heart, or fast heart rate
  • Sweating
  • Trembling and shaking
  • Sensations of shortness of breath or smothering
  • Feelings of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, or faint
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  • Fear of losing control or going crazy
  • Fear of dying
  • Paresthesias (numbness or tingling sensations)
  • Chills or hot flashes
  • Some of these symptoms will most likely be present in a panic attack. The attacks can be so disabling that the person is unable to express to others what is happening to them. A doctor might also note various signs of panic: The person may appear to be very afraid or shaky or be hyperventilating (deep, rapid breathing that causes dizziness). Anxiety attacks that take place while sleeping, also called nocturnal panic attacks, occur less often than do panic attacks during the daytime, but affect a large percentage of people who suffer from daytime panic attacks. Individuals with nocturnal panic attacks tend to have more respiratory symptoms associated with panic and have more symptoms of depression and of other psychiatric disorders compared to people who do not have panic attacks at night. Nocturnal panic attacks tend to result in sufferers waking suddenly from sleep in a state of sudden fright or dread for no known reason. As opposed to people with sleep apnea and other sleep disorders, sufferers of nocturnal panic can have all the other symptoms of a panic attack. Although nocturnal panic attacks usually last no more than 10 minutes, it can take much longer for the person to fully recover from the episode.
  • Recent literature suggests that men and women may experience different symptoms during an attack. Women tend to experience a predominance of respiratory symptoms compared to men.
Stress Pictures Slideshow: 10 Ways to Stop Stress

When to Seek Medical Care

For someone who may be experiencing their first panic attack, a call to the doctor's office or 911 is warranted. The idea is to make sure that the cause of the person's distress is not a heart attack, asthma problem, endocrine emergency, or other dangerous medical condition.

  • A medical professional is the only person who should make the diagnosis of panic attack. There is no such thing as a "wasted" visit to the doctor in this case. It is better to be told that the diagnosis is panic attack than to assume that someone is panicking and be proved wrong.

Almost everyone experiencing symptoms of a panic attack needs evaluation. Unless the person has a history of having panic attacks, is otherwise healthy, and is experiencing a typical attack, they must be evaluated promptly by a doctor. The level of evaluation depends on many factors. Err on the side of safety when deciding whether to go to a hospital's emergency department.

  • Even for medical professionals, the diagnosis of a panic attack is known as a diagnosis of exclusion. This simply means that before the doctor can be comfortable with the diagnosis of panic attack, all other possible causes of the symptoms need to be considered and ruled out.

Panic Attacks Diagnosis

The typical panic attack can mimic many harmful conditions. The doctor must "think of the worst" to be sure not to miss a diagnosis with a potentially more medically serious outcome. 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 (PTSD), 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 panic attack, a neurologist may be asked to evaluate the person. There is some overlap between the symptoms of panic attack and what are 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).
Stress Pictures Slideshow: 10 Ways to Stop Stress

Panic Attack Home Remedies

Taking care of panic attacks at home is possible, but be careful not to mistake another serious illness (such as a heart attack) for a panic attack. In fact, this is the dilemma that doctors face when people experiencing panic are brought to a hospital's emergency department or the clinic.

  • There are things that people with panic disorder can do to assist with their own recovery. Since substances like caffeine, alcohol, and illicit drugs can worsen panic attacks, those things should be avoided. Other tips for managing panic attacks include engaging in aerobic exercise and stress-management techniques like deep breathing and yoga on a regular basis, since these activities have also been found to help decrease panic attacks.
  • Although many people breathe into a paper bag in an attempt to alleviate the hyperventilation that can be associated with panic, the benefit received may be the result of the individual thinking it will help (a placebo effect). Unfortunately, breathing into a paper bag while having trouble breathing can worsen symptoms when the hyperventilation is caused by a condition associated with oxygen deprivation, like an asthma attack or a heart attack.
  • If a person has been diagnosed with panic attacks in the past and is familiar with the signs and symptoms, the following techniques may help the person stop the attack. You may also try these tips for overcoming the symptoms of a panic attack.
  • First, relax your shoulders and become conscious of any tension that you may be feeling in your muscles.
  • Then, with gentle reassurance, progressively tense and relax all the large muscle groups. Tighten your left leg while taking a deep breath in, for example, hold it, then release the leg muscles and the breath. Move on to the other leg. Move up the body, one muscle group at a time.
  • Slow down your breathing. This may best be done by blowing out every breath through pursed lips as if blowing out a candle. Also, place your hands on your stomach to feel the rapidity of your breathing. This may allow you to further control your symptoms.
  • Tell yourself (or someone else if you are trying this technique with someone) that you are not "going crazy." If you are concerned about not being able to breathe, remember that if you are able to talk, you are able to breathe.
  • If a person is diagnosed with any medical illness, especially heart disease, home treatment is not appropriate. Even if the person has a history of panic attacks, home care is not appropriate if there is any new or otherwise worrisome symptom.

Panic Attacks Medical Treatment

Generally, panic attacks are treated with reassurance and relaxation techniques. By definition, panic attacks last less than an hour, so many times a person already feels much better by the time he or she makes it to the doctor's office. Nevertheless, because the diagnosis is made by excluding more dangerous causes, people may be given medications during their attack.

  • If the doctor is suspicious of a cardiac (heart) cause, then the person might be given aspirin and various blood pressure medicines. An IV line may be started and fluids given. Some doctors will prescribe various antianxiety medicines such as diazepam (Valium) or lorazepam (Ativan) during the evaluation.
  • Once the diagnosis of panic attack is made, however, the person may be surprised that no medicines are prescribed. Before medications are started, the person requires further evaluation by a mental-health professional to check for the presence of other mental-health disorders. These may include anxiety disorders, depression, or panic disorder (a different diagnosis than panic attack).
  • If medications are prescribed, several options are available. Selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SSNRIs), and the benzodiazepine families of medications are considered to be effective treatment of panic disorder. SSRIs include sertraline (Zoloft), fluoxetine (Prozac), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and fluvoxamine (Luvox). SSNRIs include duloxetine (Cymbalta) and venlafaxine (Effexor). Clinical trials have shown SSRIs reduce the frequency of panic attack up to 75%-85%. SSRIs must be taken three to six weeks before they are effective in reducing panic attacks and are taken once daily.
  • Beta-blocker medications like propranolol are sometimes used to treat the physical symptoms associated with panic.
  • Benzodiazepines are often used to provide short-term relief of panic symptoms. Clonazepam (Klonopin) and lorazepam (Ativan) are examples of this group of medications. Although another benzodiazepine, alprazolam (Xanax), is often used to treat panic attacks, the short period of time that it works can cause the panic sufferer to have to take it multiple times each day. Benzodiazepines tend to be effective in decreasing panic attacks by up to 70%-75% almost immediately; however, this class of medications has a strong addiction potential and should be used with caution. Additional drawbacks include sedation, memory loss, and after several weeks, tolerance to their effects and withdrawal symptoms may occur.
  • Tricyclic antidepressants such as imipramine (Tofranil) and MAO inhibitors such as phenelzine (Nardil) have also been used in the past, but is rarely prescribed currently.
  • The person being treated will be closely monitored for the possibility of side effects that can range from minor to severe and can sometimes even be life-threatening. Because of the possible risks to the fetus of a mother being treated with medications for panic attacks, psychotherapy continues to be the treatment of first choice when treatment of this symptom is given during pregnancy.
  • Psychotherapy is at least as important as medication treatment of panic disorder. In fact, research shows that psychotherapy alone or the combination of medication and psychotherapy treatment are more effective than medications alone in overcoming panic attacks. To address anxiety, cognitive behavioral therapy is widely accepted as an effective form of psychotherapy. This form of therapy seeks to help those with panic disorder identify and decrease the self-defeating thoughts and behaviors that reinforce panic symptoms. Behavioral techniques that are often used to decrease anxiety include relaxation and gradually increasing the panic sufferer's exposure to situations that may have previously caused anxiety. Helping the anxiety sufferer understand the emotional issues that may have contributed to developing symptoms is called panic-focused psychodynamic psychotherapy and has also been found to be effective.
  • Often, a combination of psychotherapy and medications produces good results. Improvement is usually noticed by about three months. Thus, appropriate treatment for panic disorder can prevent panic attacks or at least substantially reduce their severity and frequency, bringing significant relief to up to 90% of people with panic disorder.

Follow-up for Panic Attacks

After a person is diagnosed with panic attack, he or she will be given follow-up instructions depending on the entire picture of the illness obtained by the evaluating doctor. Most people are referred for immediate follow-up. Others may be given instructions that follow-up is not needed unless the symptoms return.

Panic Attacks Prevention

For those people whose panic attacks are brought about by known stimuli, the primary way to prevent panic attacks is to avoid those stimuli as long as the avoidance does not get in the way of the person's ability to interact with others or otherwise function. Behavioral therapy is an important part of treatment, and people who have panic attacks may "practice" being in their trigger situations (such as riding an elevator or flying in an airplane) as part of their treatment. For those who go on to be diagnosed with panic disorder or other forms of anxiety, taking the prescribed medications is the key to prevention. Behavioral therapy may also be recommended.

Panic Attacks Prognosis

The prognosis for people who suffer a panic attack is overall, good. Some people have a single attack and are never bothered again. Yet, two-thirds of people experiencing a panic attack go on to be diagnosed with panic disorder. Also, half of those who go through a panic attack might develop clinical depression within the following year, if not treated promptly. Occasionally, a person will, after a long evaluation, be diagnosed with a medical condition that causes panic symptoms.

  • Seek medical follow-up. For those who are diagnosed with panic disorder, depression, or another form of anxiety disorder, the news is encouraging when treatment is received. These disorders are usually well controlled with medications. However, many people suffer the effects of these illnesses for years before coming to a doctor for evaluation. These conditions can be extremely disabling, so follow-up after the initial visit to the doctor is crucial so that diagnosis and treatment can continue.
  • People who experience panic attacks are not "faking it." They have a real illness. It is important to gain knowledge about the diagnosis to understand and prevent future attacks. As a person comes to recognize the symptoms of panic attack and complies with whatever treatment is eventually recommended, the person can hope to end the panic attacks.
  • Also, recent research indicates that adolescents who experience panic attacks are at increased risk for having thoughts about suicide and even for attempting suicide. This underscores the need to receive a thorough evaluation by a doctor.

Medically reviewed by Marina Katz, MD; American Board of Psychiatry & Neurology

REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Treatment Revision. 4th ed. Washington, D.C.: American Psychiatric Association, 2000.

American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Panic Disorder. 2nd ed. Arlington: American Psychiatric Association, 2009.

David, J.E., S.H. Yale, and H.J. Vidaillet. "Hyperventilation-Induced Syncope: No Need to Panic." Clinical Medicine and Research 1.2 (2003): 137-139.

Deshmukh, V., B. Toelle, T. Usherwood, B. O'Grady, and C. Jenkins. "Anxiety, Panic and Adult Asthma: A Cognitive-Behavioral Perspective." Respiratory Medicine 101.2 (2009): 194-202.

Kessler, R.C., W. Tat-Chiu, R. Jin, A. Meron-Ruscio, et al. "The Epidemiology of Panic Attacks, Panic Disorder and Agoraphobia in the National Comorbidity Survey Replication." Archives of General Psychiatry 63 (2006): 415-424.

Madaan, V. "Assessment of Panic Disorder Across the Life Span." Focus 6 Fall 2008: 438-444.

Sarisoy, G., O. Boke, A.C. Arik, and A.R. Sahin. "Panic Disorder With Nocturnal Panic Attacks: Symptoms and Comorbidities." European Psychiatry 23.3 Apr. 2008 April: 195-200.

Stores, G. "Clinical Diagnosis and Misdiagnosis of Sleep Disorders." Journal of Neurological Neurosurgical Psychiatry 78 (2007): 1293-1297.

Watters, K., G. Rait, I. Peterson, et al. "Panic Disorder and the Risk of New Onset Coronary Heart Disease, Acute Myocardial Infarction and Cardiac Mortality: Cohort Study Using the General Practice Research Database." European Heart Journal 29.24 (2010): 2981-2988.

Patient Comments & Reviews

The eMedicineHealth doctors ask about Panic Attacks:

Panic Attack - Symptoms

What are your panic attack symptoms?

Panic Attacks - Effective Treatments

What kinds of treatments have been effective for your panic attacks?

Health Solutions From Our Sponsors