Panic disorder is a type of anxiety disorder. A person with panic disorder has panic attacks, which are repeated, unexpected episodes of intense fear and anxiety along with physical symptoms linked to the body's normal response to danger. If you are truly in danger (for example, if you are confronted by a criminal with a gun), your body readies itself for "fight or flight." Your heart rate increases; blood rushes to your arm and leg muscles, causing a trembling or tingling sensation; you may sweat and become flushed; you will become intensely fearful, aroused and very alert. In people having a panic attack, however, these changes occur when there is no danger. At the height of a panic attack, people also may have a frightening feeling that the environment around them has somehow become unreal or detached, or that they are going to die, have a heart attack, lose control or "go crazy." Some people with panic disorder have several panic attacks every day, while others go weeks or months between attacks.

Since panic attacks occur without warning — even during sleep — people who suffer from panic disorder are usually anxious that an attack may begin at any moment. They worry not only about the psychological pain and physical discomfort of the panic attack, but also that their extreme behavior during a panic episode might embarrass them or frighten others. Their constant fear and anticipation eventually may lead to a fear of being in public places where it would be difficult or embarrassing to make a sudden exit. This fear is called agoraphobia. People who have agoraphobia may, for example, avoid attending a performance in a crowded stadium or movie theater; waiting in line at a store; traveling on a bus, train or plane; or driving on roads that have bridges or tunnels.

Although researchers do not completely understand why some people develop panic disorder, they believe that the illness involves a disturbance in brain pathways that regulate emotion, where chemicals called neurotransmitters are active. These chemicals (for example, norepinephrine, serotonin and gamma-aminobutyric acid) carry signals between brain cells. Researchers believe the following areas of the brain are involved in controlling your anxiety level:

• The brainstem, which controls some of the physical "fight or flight" symptoms
• The limbic system, which deals with anxiety and other emotions
• The prefrontal cortex, which instructs the body to avoid fearful situations

Also, it is possible that people with panic disorder may have inherited a "fight or flight" response that is either more sensitive than normal or that responds more intensely than usual. Studies of close relatives of people with panic disorder show that this disease has a genetic (inherited) basis. These relatives are four to eight times more likely to develop the illness than people with no family history of the problem.

In the United States, panic disorder affects an estimated 1.5% to 3.5% of people at some point during their lives. Women are two times more likely than men to have panic disorder, and about three times more likely to develop agoraphobia. On average, symptoms start at around age 25, but panic disorder and agoraphobia can affect people of all ages.

Some people with panic disorder first develop symptoms after a stressful life event, such as divorce, job loss or a death in the family. Scientists still do not understand exactly how panic attacks are triggered, but there is growing evidence that stress early in life makes a person more likely to develop panic symptoms. Also for unknown reasons, people who have panic disorder have an extraordinarily high risk of developing other types of psychiatric problems. In fact, at the time of diagnosis, more than 90% of people with panic disorder also have major depression, another anxiety disorder, a personality disorder or some form of substance abuse.

A panic attack is defined by having at least four of the following symptoms:

• Palpitations, heart pounding or a rapid pulse
• Sweating
• Trembling or shaking
• Breathing problems, especially shortness of breath or a feeling that you are being smothered
• A feeling of choking
• Chest pain or chest discomfort
• Abdominal discomfort, upset stomach or nausea
• Feeling faint, dizzy, light-headed or unsteady on your feet
• A feeling that things around you are unreal or that you are detached from yourself
• Fear that you will lose control or "go crazy"
• Fear of dying
• Numbness or tingling in your arms, legs or other parts of your body
• Chills or hot flushes

Between panic attacks, someone with panic disorder usually has persistent worries that a new attack will occur. These worries may cause the person to dramatically change his or her behavior or lifestyle to avoid the embarrassment of "losing control" or "going crazy" while with other people.

If you develop panic disorder, you may consult a primary care doctor first because the physical symptoms often feel like signs of a medical illness, such as a heart attack, a stroke or a breathing problem. Many medical illnesses can cause symptoms that mimic panic attacks, including heart disease, asthma, cerebrovascular disease, epilepsy, hormone abnormalities, infections and disturbances in levels of certain blood chemicals. Symptoms of a panic attack can also be triggered by the use of amphetamines, cocaine, marijuana, hallucinogens, alcohol and other drugs, as well as by certain prescription medications. The doctor may do tests to rule out medical problems, but the results of these tests will almost always be normal. If this is the case, the doctor may ask you questions about your family history, psychiatric history, current anxieties, recent stresses, and daily use of prescription and nonprescription drugs, including caffeine and alcohol. If your doctor suspects that the problem is panic disorder, he or she will refer you to a psychiatrist for care.

Your psychiatrist will do a full psychiatric evaluation that includes:

• Asking questions about the thoughts, feelings and physical symptoms that you experience during a panic attack
• Asking about your thoughts, feelings and behaviors between attacks
• Checking for symptoms of other forms of psychiatric illness

Your psychiatrist may request blood tests or refer you to another medical specialist if he or she is concerned that a medical illness is causing your symptoms.

Panic disorder usually is a long-lasting condition, but it is very treatable. With proper care, many people find long-term relief from their symptoms.

There is no way to prevent panic disorder. However, if you have been diagnosed with panic disorder, you may be able to prevent panic attacks by cutting down on caffeine, alcohol or other substances that might be triggering your symptoms. Your doctor can help you figure this out. Once a diagnosis is made, treatment often eliminates panic attacks or makes them less intense.

If you have panic attacks, there are several treatment options. Your doctor may try one or more of the following:

• Benzodiazepines — These medications include clonazepam (Klonopin), lorazepam (Ativan), diazepam (Valium) and alprazolam (Xanax). They are very safe and often bring quick relief from the intense fear and anxiety that accompany panic attacks. They may be used particularly during the first weeks of treatment while you are waiting for other medications, such as antidepressants, to start working. In some people, the medication may become less effective because the body becomes accustomed to it. This is called tolerance. There is some risk of dependency and addiction with these drugs, but concerns about this are probably overemphasized. If you have panic disorder, the advantages of relief often outweigh the risk of addiction. If you need to stop taking these drugs, it needs to be done gradually under a doctor's direction, because withdrawal reactions can occur.



• Antidepressants — These are the main treatment for panic attacks, especially when panic attacks keep occurring or when the person also has depression. The antidepressants most used to treat panic attacks are the popular selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa). Tricyclic antidepressants, such as nortriptyline (Aventyl, Pamelor) and imipramine (Tofranil), are a good choice as is the newer antidepressant venlafaxine (Effexor). Another class of antidepressants, called monoamine oxidase inhibitors, are a bit more difficult to take because they require you to be on a special diet. However, they have been effective when other medications have not. All antidepressants take several weeks to start working so a benzodiazepine often is prescribed to give relief during that time.



• Cognitive therapy — This nondrug therapy involves teaching the patient that a panic attack will stop and is not life threatening, and to learn the triggers of attacks and how to manage them.



• Behavior therapies — These treatments include in vivo exposure, a form of behavior therapy that gradually exposes the patient to fear-provoking situations; respiratory training, a technique that focuses on breath control as a way of fighting panic; and applied relaxation, a method that teaches the patient to control his or her anxiety level by using muscle control and imagination.

For many patients, the most effective approach is a combination of one or more medications, plus some form of cognitive or behavior therapy.

If you have symptoms of a panic attack, and you have never been diagnosed with panic disorder, seek medical help immediately. Remember, symptoms of a panic attack can mimic those of many life-threatening medical illnesses. For this reason, a doctor should determine the cause of your problem.

Panic attacks are so uncomfortable, you are likely to be eager to get help as quickly as you can. When you see your doctor, describe your attacks in as much detail as possible. The list of symptoms above may help you to organize your description.

With appropriate treatment, the prognosis is good. Between 30% and 40% of patients become symptom-free for extended periods, while another 50% continue to experience only mild symptoms that do not significantly affect daily life. Only 10% to 20% of patients do not improve.

American Psychiatric Association
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E-Mail: apa@psych.org
http://www.psych.org/

National Institute of Mental Health
Office of Communications
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Phone: (301) 443-4513
Toll-Free: (866) 615-6464
TTY: (301) 443-8431
Fax: (301) 443-4279
E-Mail: nimhinfo@nih.gov
http://www.nimh.nih.gov/

Anxiety Disorders Association of America
8730 Georgia Ave.
Suite 600
Silver Spring, MD 20910
Phone: (240) 485-1001
Fax: (240) 485-1035
http://www.adaa.org/