Panic disorder

Although panic attacks aren’t dangerous, they are extremely unpleasant and people with panic disorder can find themselves living ‘in fear of fear’. Treatment can help people with panic disorder break the cycle and recover.

Key takeaways

• Panic disorder is diagnosed when panic attacks have no clear cause or trigger. If there’s a known cause, other diagnoses, such as a phobia or social anxiety, are more appropriate

• For people with panic disorder, panic attacks often feel strongly physical, prompting fears that they are having a heart attack or other medical emergency

• Panic disorder is usually treated through medication, psychotherapy, or a combination of the two

Understanding panic disorder

Panic disorder is a relatively common anxiety disorder, affecting approximately 3.8% of women and 1.6% of men in the US each year.^[1]It typically first appears during adolescence or early adulthood.^[2]

Someone with panic disorder experiences repeated distressing panic attacks that occur unexpectedly. They also worry about having future panic attacks and how they will cope. This worry can lead them to withdraw from social relationships and struggle with everyday tasks.

How is it different from anxiety?

Panic disorder is an anxiety disorder, but it can feel very different from other anxiety disorders. People with anxiety struggle with their thoughts and feelings, experiencing worry, doubt, or feelingbeing anxious about events. This anxiety may be more persistent or specific to certain situations.

With panic disorder, sSomeone experiences intense and sudden bouts of fear and panic often without a clear cause. And, there tends to be more of awith panic disorder will usually focus more on the physical symptoms they experience. During a panic attack (especially their first panic attack), they may believe that they are having a heart attack, suffocating, or about to die.

Panic attacks are also usually much shorter in duration than anxiety. Someone may feel anxious all day, but panic attacks lasting more than about 20 minutes are relatively rare.

Causes of panic disorder

As with most mental health conditions, there is no single cause of panic disorder. It likely results from a combination of factors, including genetic, biological, and psychological.

Biological causes of panic disorder

There is a genetic component to panic disorder, and people with a close family member with the disorder are at increased risk. This is not a simple relationship, however, and researchers haven’t identified the genes involved.^[3]

There is evidence that people with panic disorder have an imbalance in some of their neurotransmitters. Several neurotransmitters have been suggested, including serotonin, dopamine, and norepinephrine. Patients with different anxiety disorders also show reductions in neuropeptide Y, which may also be the case for panic disorder.^[4]

There may be neuroanatomical causes for panic disorder as well. Fear activates the amygdala, but the prefrontal cortex (PFC), which is responsible for more rational thinking, reduces activity in the amygdala, allowing you to calm down. People with panic disorder or PTSD experience less PFC activity, keeping their amygdala active for longer.^[5]

Hormones may also play a role, especially for women. Although panic attacks are common in high-stress situations, they are rare during pregnancy and lactation, implying that hormone levels may have a protective effect.^[6]

Some researchers suggest that parts of the brainstem are more sensitive to increased levels of carbon dioxide in people with panic disorder or that there are other respiration issues. These can lead to feelings of suffocation, even at normal oxygen levels.^[7][8]

Psychological causes of panic disorder

In addition to biological predispositions, some psychological factors can increase the risk of panic disorder. People who have experienced traumatic or stressful life events, or those with other forms of anxiety, are more likely to develop panic disorder.

The way someone understands their panic attacks can also impact whether they develop panic disorder. Research suggests that people who see a panic attack as a threat or who believe they can’t cope with an attack are more likely to develop panic disorder.^[9]

Panic disorder vs panic attacks

Panic attacks are the main symptom of panic disorder, but they can happen to anyone. Experiencing one panic attack does not mean someone has panic disorder. Having panic disorder means that you have repeated, unexpected panic attacks, and you’re worried about having more.

Unexpected panic attacks are those that aren’t linked to a known trigger. For example, if you have a phobia and you have panic attacks whenever you encounter the thing you are phobic of, that is a symptom of your phobia rather than panic disorder.

Symptoms of panic disorder

Panic disorder is typically experienced as a physical condition, rather than a cognitive or psychological one. The symptoms are primarily physical.^[10]

A panic attack usually lasts 5-20 minutes, but can last up to an hour.^[11]During this time, you may experience

• Accelerated or irregular heartbeat

• Sweating

• Trembling, shivering, or shaking

• Changes in temperature (either hot flushes or chills)

• Shortness of breath or a choking sensation

• Chest pain

• Nausea

• Dizziness or feeling faint

• Numbness or pins and needles

• Ringing in your ears

• Feelings of fear or terror

A panic attack feels overwhelming while it’s happening and, although it only lasts for a short period, it’s common to feel upset or unsettled for some time afterwards.

For people with panic disorder, panic attacks will occur unexpectedly, and they worry about having another one.

Risks and complications

Panic disorder can cause additional problems. Worrying about panic attacks can make them worse. Some people with panic disorder may ineffectively try to cope with them by using alcohol or drugs, which can lead to substance use disorder. There is also a high rate of depression in people with panic disorder.^[12]

People with panic disorder often engage in “safety behaviors”, which are things they do to make themselves feel safer, such as carrying medication with them or avoiding places they fear having a panic attack. These safety behaviors often limit patients’ lives, making it harder for them to complete everyday tasks, hold down a job, or maintain social relationships.

People with panic disorder have higher rates of cardiovascular disease, respiratory issues, and gastrointestinal problems. They also have a higher risk of suicidal ideation and suicide attempts, although this may be due to other mental health issues that commonly co-occur with panic disorder.^[13]

Prevention

It’s hard to know whether someone is at risk of panic disorder, so it’s rarely something you can prevent. A healthy lifestyle that includes regular movement and good sleep hygiene can help reduce the risks of most anxiety disorders, and is helpful in people at risk of panic disorder.

People who are comfortable with risk or who can tolerate uncomfortable or difficult emotions may find it easier to cope with panic attacks, so mindfulness practice and meditation may have a protective effect.

Similarly, those who know what a panic attack is will find it easier to recognize what is happening and avoid the vicious cycle.

Treatment for panic disorder

Treatment for panic disorder isn’t always just about trying to reduce the symptoms of panic attacks. To be symptom-free of the disorder and the fear it brings, patients need to break the vicious cycle that panic disorder creates.

Medication

Medication is often used to treat the symptoms of panic disorder, as well as to address other anxiety or mood disorders you may be suffering from at the same time.

The most common medication offered to people with panic disorder is an antidepressant. Usually, this will be a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI).^[14]These are usually prescribed for at least 6 months, and often longer.

If the panic attacks are particularly severe, a doctor may prescribe a beta-blocker, such as propranolol, to reduce some of the symptoms. These can be taken either at the start of the day or if you are likely to experience a panic attack soon. Although these work quickly (sometimes within an hour), a panic attack will usually be over before you feel the benefits.^[11]

Medications to relieve panic attacks can become an unhelpful safety behavior, leading you to believe that you can only cope with the attacks because of the medication. As a result, doctors may be reluctant to prescribe beta-blockers or other anti-anxiety medications like benzodiazepines for panic disorder.

Benzodiazepines can also be used to help reduce anxiety, but patients using them can become dependent and need increasing dosages to have the same effect. Doctors will usually only prescribe them for short periods to minimize this risk.^[15]

Psychotherapy

There is strong evidence for the use of cognitive behavioral therapy (CBT) in the treatment of panic disorder.^[16]CBT works to challenge false and unhelpful beliefs you may have about your panic attacks, reducing the fear you experience, and allowing you to learn that you are safe.

Exposure therapy is a kind of CBT that is commonly used for people with panic disorder. This encourages you to face your fears, for example, by going to places you think you might have a panic attack or reducing your safety behaviors.^[17]This is done slowly and carefully, with plenty of support, to ensure that your exposure doesn’t leave you feeling more afraid than before.

In many conditions, including other anxiety disorders, CBT is regularly combined with medication. For patients with panic disorder, some studies have found that CBT is more effective when used alone than when used in conjunction with medication.^[4]For patients whose fears are too severe to allow them to access CBT, however, medication may still be necessary. The best treatment approach for you will depend on your medical history, symptom intensity, frequency, and duration, as well as your needs and goals.

Alternative treatments for panic disorder

New treatments are being investigated for panic disorder, but none currently have strong evidence for their effectiveness.

Repetitive transcranial magnetic stimulation (rTMS) uses magnets to briefly disrupt brain activity and may be used as a treatment in the future, but the current evidence is insufficient.^[18]

Similarly, there is little support for the role of medical cannabis, ketamine, or supplements in helping patients with panic disorder. More research would be needed before these could be offered as a treatment.^[19]

Self-management for panic disorder

Many people with panic disorder choose to self-manage their condition, and this is possible if symptoms are mild or moderate.

With self-management, you are trying to both deal with panic attacks when they happen and ensure that you can live a fulfilling life, free from the fear that an attack may happen.

During panic attacks

Here are some strategies that can help during a panic attack

• Focus on your breathing, trying to keep it as slow and deep as possible, with your exhale being longer than your inhale

• Remind yourself that your panic attack will end and that you are not in danger

• Acknowledge that your attacks are horrible. Try to see them as something to cope with, rather than trying to fight them

• Consider trying to distract yourself. If possible, ask someone you trust to talk to you about something unrelated

• Practice grounding techniques, such as focusing on things you can see, feel, hear, smell, and touch, like with the 5-4-3-2-1 grounding exercise

Outside of panic attacks

Consider finding a local support group. Talking to others with a similar experience can help you notice common patterns or find new ways of coping.

Try to minimize or challenge your safety behaviors, but take it slowly. Challenging yourself to go without a safety behavior (such as going to a new place without taking a friend, or not taking anxiety medication when you have a panic attack) while using effective coping strategies can increase your confidence that you can cope. Removing all safety behaviors or pushing yourself too far can be counterproductive, however. Work in small, manageable increments and focus on your success. A licensed mental health provider can help you develop a plan that is tailored to your needs.

If you notice that your symptoms are starting to prevent you from taking part in activities or performing everyday tasks, it might be time to consider seeking help beyond self-management.

Final thoughts

Panic disorder is a difficult condition to live with, but effective treatments are available. Speak to your doctor or other healthcare professional if you’re worried about panic disorder.