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Health Library Panic Attacks and Panic DisorderFrom Healthwise

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Panic Attacks and Panic Disorder

Topic Overview

What are panic attacks and panic disorder?

A panic attack is a sudden, intense fear or anxiety that may make you short of breath or dizzy or make your heart pound. You may feel out of control. Some people believe they are having a heart attack or are about to die. An attack usually lasts from 5 to 20 minutes but may last even longer, up to a few hours. You have the most anxiety about 10 minutes after the attack starts. If these attacks happen often, they are called a panic disorder.

Panic attacks can be scary and so bad that they get in the way of your daily activities. Treatment can help most people have fewer symptoms or even stop the attacks.

More women than men get panic attacks.

What causes panic attacks and panic disorder?

Experts aren't sure what causes panic attacks and panic disorder. But the body has a natural response when you are stressed or in danger. It speeds up your heart, makes you breathe faster, and gives you a burst of energy. This is called the fight-or-flight response. It gets you ready to either cope with or run away from danger. A panic attack occurs when this response happens when there is no danger.

Panic attacks and panic disorder may be caused by an imbalance of brain chemicals or a family history of panic disorder. They sometimes happen with no clear cause.

Panic attacks may also be brought on by:

  • A health problem such as an overactive thyroid (hyperthyroidism), or heart or breathing problems.
  • Depression or another mood disorder.
  • Alcohol abuse.
  • Using too much nicotine or too much caffeine.
  • Taking certain medicines, such as those used to treat asthma and heart problems.
  • Using illegal drugs such as marijuana or cocaine.
  • Living with high levels of stress for a long time.

You have a higher chance of getting panic disorder if you have a parent with depression or bipolar disorder.

What are the symptoms?

Symptoms of a panic attack may include:

  • A feeling of intense fear, terror, or anxiety.
  • Trouble breathing or very fast breathing.
  • Chest pain or tightness.
  • A heartbeat that races or is not regular.
  • Sweating.
  • Nausea or an upset stomach.
  • Dizziness and shaking.
  • Numbness or tingling.

Symptoms of panic disorder may include:

  • Repeated panic attacks when there is no reason for the fight-or-flight response.
  • Changing your daily activities because you worry that you will have another attack.

Some people have a fear of being in crowds, standing in line, or going into shopping malls. They are afraid of having another panic attack or of not being able to escape. This problem is called agoraphobia and can be so bad for some people that they never leave their homes.

About half of people who have panic disorder also have agoraphobia.1 People with panic disorder often have depression at the same time.

How are panic attacks and panic disorder diagnosed?

Your doctor will ask about your past health and do a physical exam. The exam may include listening to your heart, checking your blood pressure, and ordering blood tests to look for other causes of your problem. Your doctor may ask you to do some simple things that test your memory and other mental skills.

How are they treated?

Treatments for panic attacks and panic disorder include counseling and medicine. Using both will often work best. Treatment can help most people control or even stop attacks. But symptoms can come back, especially if you stop treatment too soon.1

Early treatment of panic attacks is very important. It can prevent other problems related to panic disorder. These problems include depression, anxiety disorders, and substance abuse.

Frequently Asked Questions

Learning about panic attacks and panic disorder:

Being diagnosed:

Getting treatment:

Ongoing concerns:

Cause

The exact cause of panic disorder is not clear. It is thought that panic disorder may result from an imbalance of chemicals in the brain (neurotransmitters).

Panic disorder also may be passed down through families (genetic). Children of parents who have panic disorder are up to 8 times more likely to develop panic disorder. You are also at a higher risk of developing panic disorder if you have a parent with either depression or bipolar disorder.1 Stressors (such as the sudden loss of a relationship) may trigger symptoms of panic disorder as well.

You may experience a panic attack without having panic disorder. Panic attacks may be triggered by:

  • Drinking large amounts of alcohol or abruptly stopping the use of alcohol.
  • Drinking large amounts of caffeinated beverages.
  • Chain-smoking, which causes the amount of nicotine in the blood to be very high.
  • Taking certain medicines (such as those used to treat asthma and heart conditions) or abruptly stopping certain medicines (such as those used to treat anxiety or sleep problems).
  • Using illegal drugs, such as cocaine or marijuana.
  • Having high levels of stress for a long time (chronic stress).
  • Having recently had a baby.
  • Having recently had surgery or been under general anesthesia.

Panic attacks also can be caused by or linked with other medical conditions, including:

Symptoms

The main symptom of a panic attack is an overwhelming feeling of fear or anxiety, along with physical reactions. An attack starts suddenly and usually lasts from 5 to 20 minutes but may last even longer, up to a few hours. You feel most anxious about 10 minutes into the attack. It is possible to have one panic attack after another in waves for an extended period of time, and it can seem like one continuous attack. But if you have continuous symptoms that do not go away within an hour, you probably are not having a panic attack and you should seek immediate medical care.

Symptoms of a panic attack may include:

  • Rapid breathing (hyperventilation), shortness of breath, or feeling "smothered."
  • A pounding or racing heart or an irregular heartbeat.
  • Chest problems.
  • Lightheadedness.
  • Sweating.
  • A choking feeling.
  • Nausea or an upset stomach.
  • Dizziness, shaking, or trembling.
  • Numbness or tingling.
  • Chills or hot flashes.
  • Fear that you are going to die, lose control, or "go crazy."
  • Feelings of being detached from yourself or from reality.

Panic attacks can begin with a stressful event or appear without cause. They also can be associated with medicines, such as heart medicines, and medical conditions, such as an overactive thyroid (hyperthyroidism).

Panic attacks may begin without a trigger or can be linked to certain situations, such as being in large crowds of people in restaurants or stadiums. Sometimes just the anticipation of being in a certain situation can cause severe anxiety. People who experience panic attacks often learn to avoid situations that they fear will trigger a panic attack or situations where they will not be able to escape easily if an attack occurs. If this pattern of avoidance and anxiety is severe, it can become agoraphobia.

The symptoms of a panic attack can be similar to those of a heart attack. Many people seek emergency medical treatment for a panic attack for this reason. If you have chest pain and other symptoms of a heart attack, get immediate medical treatment. For more information, see the topic Chest Problems.

Panic attacks are not common in children or younger teens. But children who have panic disorder or panic attacks often have other symptoms in addition to those listed above. They may be overly afraid of common objects such as bugs or worry excessively about monsters or about going to bed alone. They also may refuse to go to school or become unusually upset when they are separated from a parent.

Not everyone who experiences panic attacks develops panic disorder. A person is diagnosed with panic disorder if he or she has at least two unexpected panic attacks along with fear or worry about having another panic attack and avoiding situations that may trigger it.

What Happens

You may be diagnosed with panic disorder after several unexpectedpanic attacks and if you continue to fear having another attack. These panic attacks can have mild to severe symptoms and usually last from 5 to 20 minutes but may last even longer, up to a few hours.

A first panic attack often starts without warning during an ordinary activity such as shopping or walking down the street. You may become confused and think you are "going crazy" or that something terrible is going to happen. You may feel a strong need to leave the area and go to a place that feels safe, such as your car or home. You may also experience physical symptoms such as shortness of breath, a pounding heart, or chest pain. The intensity of these symptoms usually peaks within 10 minutes. It is common to think you are having a heart attack and to seek treatment in a hospital emergency room.

Panic attacks may be triggered by a specific action, such as drinking too much caffeine, or by a situation, such as being in a large crowd. Panic attacks may also start suddenly without a known trigger. You may greatly fear having another panic attack (anticipatory anxiety) and avoid all social situations (agoraphobia). As many as half of people who have panic disorder also have agoraphobia.1 Isolating yourself and avoiding social situations can interfere with your ability to work and with your relationships, especially with your family members and close friends.

Other characteristics that are common in panic disorder include:

  • Fearing sleep and feeling exhausted from lack of sleep.
  • Using drugs or alcohol (to numb your fears or give you a false sense of courage to face feared situations).
  • Having depression.
  • Having irrational fears (phobias).
  • Having other anxiety disorders, such as post-traumatic stress disorder.
  • Having difficulty relating to other people in social settings because of intense feelings of anxiety.

Although the first panic attack may occur during a routine activity, for many people it happens at the same time during their life when there is a lot of stress, such as a life-threatening illness or accident, the loss of a relationship, or separation from family. Sometimes an initial panic attack may occur after giving birth.

It is also possible for a first panic attack to occur as the result of a drug reaction or a reaction to nicotine or caffeine. But after the situation that caused the first panic attack is resolved, attacks may continue. Experts believe these stressful circumstances may start the cycle of panic attacks in people who are already prone to panic disorder.2

Recurrent panic attacks can be mild to severe and continue for years, especially if you also have agoraphobia (avoiding places where you fear another attack will occur).3 You may have long periods of time without panic attacks and other periods of time when attacks occur often.

You may need longer or different treatment if you have both panic disorder and agoraphobia. You may also experience other conditions linked with panic disorder and panic attacks such as drug or alcohol problems, depression, or other mental health disorders. You will need treatment for these conditions.

Panic disorder may last a lifetime, but its symptoms can be controlled with treatment. Most people with panic disorder get better with treatment. They are able to get back to a normal lifestyle, although relapse can occur, especially if treatment is discontinued too soon.1

What Increases Your Risk

The risk of having panic attacks and developing panic disorder may be higher if you:

  • Have a family history of panic disorder. You are 8 times more likely to develop panic disorder if a family member has been diagnosed with it. You are also at increased risk if you have a parent with either depression or bipolar disorder.1
  • Have other conditions associated with panic disorder or panic attacks, such as depression.
  • Drink alcohol, use illegal drugs, chain-smoke cigarettes, or drink large amounts of coffee or other caffeinated beverages.
  • Take medicines known to trigger panic attacks, such as those used to treat asthma or heart problems.
  • Have mitral valve prolapse, a heart condition in which one of the valves in the heart does not close as it should.
  • Have had previous, unexpected panic attacks.
  • Have experienced an episode of major depression.
  • Are a woman who has recently gone through menopause.4

When To Call a Doctor

Call your doctor if you experience:

  • Attacks of intense fear or anxiety that seem to come on without a reason.
  • A panic attack or worry that you will have another one and your worrying interferes with your ability to do your daily activities.
  • Occasional physical symptoms (such as shortness of breath and chest pain) and you are not sure what is causing them.

Watchful Waiting

It can be difficult to tell the difference between the symptoms of a panic attack (such as shortness of breath and chest pain) and the symptoms of a heart attack or another serious medical problem. If you have symptoms of a panic attack, be sure to get immediate medical care so that other medical conditions can be ruled out.

Who To See

The following health professionals can diagnose panic attacks and may work together with other health professionals to treat panic attacks and panic disorder:

Treatment for panic attacks and panic disorder may also be provided by a:

Many community mental health centers, hospital outpatient clinics, and family service agencies have treatment programs for people with panic disorder.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Panic disorder usually is diagnosed through a medical history and a physical exam. The doctor will ask you questions about your symptoms and will listen to your heart, check your blood pressure, and may order blood tests. The doctor may need to rule out other physical conditions that have symptoms similar to panic disorder, such as a heart attack, mitral valve prolapse, or hyperthyroidism.

Treatment Overview

Panic disorder can be controlled with medicines (such as antidepressants) and professional counseling (such as cognitive-behavioral therapy). Successful treatment reduces the number and frequency of panic attacks, lowers the anxiety you feel because of the fear of future attacks, and improves the quality of your life.

If your panic attacks were caused by a specific trigger, such as a medicine reaction, you may not need treatment after the trigger has been removed, which in this case would mean stopping the medicine with the help of your doctor. But sometimes panic attacks caused by outside factors can continue after the trigger has been removed and may develop into panic disorder.

Initial treatment

Initial treatment for panic disorder depends upon how bad your panic attacks are, how much fear or anxiety you feel about having another attack, and whether you have agoraphobia (avoiding situations or places that might trigger an attack) along with panic disorder.

In general, initial treatment includes:

Your symptoms of panic disorder may start to improve within a few weeks after beginning medicines. If improvement is not seen within 6 to 8 weeks, a higher dose or another medicine may be needed.5

Click here to view a Decision Point.Panic Disorder: Should I Take Medicine?

Ongoing treatment

Treatment for recurring or ongoing panic disorder usually consists of continuing or changing initial measures, which include professional counseling and medicines.

During initial treatment, a short-term medicine such as a benzodiazepine may be prescribed to help you deal with immediate symptoms. The short-term medicine will likely need to be tapered off and stopped after long-term medicines begin working and your symptoms improve.

You will be continually assessed to determine whether you have developed any other conditions linked with panic disorder, such as depression or problems with drugs or alcohol. These additional conditions will also need treatment.

An important part of ongoing treatment is making sure you are taking your medicine as prescribed. Often people who feel better after using medicine for a period of time may believe they are "cured" and no longer need treatment. But when medicine is stopped, symptoms usually return. So it is important that you continue the treatment plan.

Recurrent panic attacks can be mild to severe and continue for years, especially if you also have agoraphobia (avoiding places where you fear another attack will occur).3 You may have long periods without panic attacks or times when attacks occur frequently. Even after treatment is stopped because the attacks appear to be under control, attacks can suddenly return. Learn to identify your early warning signs and triggers so you can seek treatment early.

Treatment if the condition gets worse

If your panic attacks become severe or continually recur, you may need to be hospitalized until they are under control. You also may need a brief hospital stay if you have panic attacks along with another health condition, such as agoraphobia or depression. Panic attacks combined with these conditions can be more difficult to treat.

If you are taking medicines that do not seem to be helping, your doctor may prescribe a different medicine or a combination of medicines.

If medicine is currently your only treatment, counseling may be added to your treatment. Counseling may include cognitive-behavioral therapy, which focuses on modifying certain thinking and behavior patterns, or exposure therapy, which focuses on confronting a feared object or situation. If you are in counseling, but it does not seem to be working, more intensive, more frequent, or a different type of counseling may be added to your treatment.

If counseling is currently your only treatment, medicines may be added.

What To Think About

Although medicines to treat panic disorder often may prevent another panic attack, they may not take away the fear of having another attack. Counseling can help you handle this fear. The fear of having an attack may actually bring on another attack.

It can take up to several weeks or longer before a medicine becomes fully effective. You may need to try several medicines or combinations before you find the one that works best for you.

People who have panic disorder may be at an increased risk for suicide if they also have depression or another mood or personality disorder. These conditions can also have a significant impact on social functioning and quality of life. Diagnosis and treatment of conditions that occur along with panic disorder are essential.

Unfortunately, many people don't seek treatment for anxiety disorders. You may not seek treatment because you think the symptoms are not bad enough or that you can work things out on your own. But getting treatment is important.

If you need help deciding whether to see your doctor, see some reasons why people don't get help and how to overcome them.

Prevention

Although panic disorder cannot be prevented, you may be able to prevent or reduce the number of additional panic attacks with proper treatment. Simply avoiding certain situations or places does not guarantee that a panic attack will not occur under new circumstances. In fact, avoiding situations and places where panic attacks have occurred often increases your level of anxiety.

You may be able to reduce the severity of future attacks if you follow home treatment practices such as:

  • Reducing anxiety and limiting triggers like caffeine and alcohol.
  • Continuing medical treatment and counseling, such as exposure therapy.
  • Calling your doctor if symptoms recur or get worse.

Home Treatment

You may be able to decrease the number of panic attacks due to panic disorder and reduce the severity of your symptoms when an attack does occur by:

Support for family members

When a person has panic attacks, that person's entire family is affected. If someone in your family has panic attacks, you may feel frustrated, overworked (because you have to take over his or her responsibilities), or socially isolated because the person restricts family activities. These feelings are normal. Family therapy, a type of counseling that involves the entire family, may be helpful for all family members. For more information, see:

Helping a Person Who Is Having a Panic Attack

Medications

Medicines for panic disorder are often used to control the symptoms of panic attacks, reduce their number and severity, and reduce the anxiety and fear linked with having another attack. Medicines work best if they are used along with counseling and home treatment, such as relaxation exercises.

Medication Choices

Medicines used most often to treat panic attacks include the following:3

Medicines sometimes used to treat panic disorder include the following:

What To Think About

Panic disorder is best treated with both medicines and counseling such as cognitive-behavioral therapy, which focuses on modifying certain thinking and behavior patterns.

Your symptoms of panic disorder should start to improve within a few weeks after beginning medicines. If improvement is not seen within 6 to 8 weeks, a higher dose or another medicine may be needed.

Most medicines used to treat panic attacks need to be continued for a year or longer and then may be decreased gradually over several weeks.1 If you have panic attacks again while medicines are being stopped, the medicines may be continued for at least a few months more. Some people may need to stay on medicines for a long time to keep symptoms under control.

You may also need to be reevaluated for other conditions linked with panic disorder, such as depression or substance abuse. Having one of these conditions makes treatment more difficult.1

Taking medicines for panic disorder during pregnancy may increase the risk of birth defects. If you are pregnant, or thinking of becoming pregnant, talk to your doctor. Medicines may need to be continued if your panic disorder is severe. Your doctor can help weigh the risks of treatment against the risk of harm to your pregnancy.

Surgery

There is no surgical treatment for panic disorder at this time.

Other Treatment

Other treatments for panic disorder include:

  • Counseling. Cognitive-behavioral therapy is most effective in treating panic disorder. Other types of counseling you might choose to seek include:
    • Exposure therapy, a type of cognitive-behavioral counseling.
    • Family therapy, which can help those who care about you learn about panic disorder and help you maintain good relationships.
  • Self-help materials, such as instructional videos, books, and audio materials, that can help you learn to cope with panic disorder or anxiety.
  • Support groups. Support groups are often good places to share information, problem-solving tips, and emotions related to panic disorder.
  • Online discussion forums and Web sites.

Body-centered relaxation exercises can be useful for reducing anxiety and treating symptoms of stress. They include:

Mindfulness activities help relax the mind and are often combined with body-centered relaxation exercises. These include:

  • Autogenic training, which is used to return the body to a normal state after a stress response.
  • Self-hypnosis, which can open the mind to suggestions that can relieve stress or change the way you respond to stressful situations.
  • Meditation, where you focus your attention on the things that are happening right now in the present moment. One way to do this is by paying attention to your breathing. For information, see:
    Click here to view an Actionset.Stress Management: Doing Meditation.
  • Guided imagery (visualization), a method of using your imagination to help you relax and release tension caused by stress. Your body responds to the images in your mind. To try guided imagery, see:
    Click here to view an Actionset.Stress Management: Doing Guided Imagery to Relax.
  • Music therapy, which can relax your body, improve your mood, and change the pace of your day.
  • Humor therapy, which is becoming widely accepted as a tool for reducing stress and boosting the body's immune system.

Other Places To Get Help

Organizations

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

The Anxiety Disorders Association of America (ADAA) works to improve the lives of people who have anxiety disorders. Members of the association are not only people who have or are interested in anxiety disorders but also health professionals who do research and treat people who have anxiety disorders.


Healthy Minds. Healthy Lives.American Psychiatric Association
1000
Wilson Boulevard
1825
Arlington, VA 22209
Phone: 1-888-35-PSYCH
Email: apa@psych.org
Web Address: www.healthyminds.org
 

This online resource is provided by the American Psychiatric Association for anyone seeking mental health information. It includes information on many common mental health concerns, including warning signs of mental disorders, treatment options, and preventive measures.


Mental Health America
2000 North Beauregard Street, 6th Floor
Alexandria, VA  22311
Phone: 1-800-969-NMHA (1-800-969-6642) referral service for help with depression
(703) 684-7722
Fax: (703) 684-5968
TDD: 1-800-433-5959
Web Address: www.mentalhealthamerica.net
 

Mental Health America (formerly known as the National Mental Health Association) is a nonprofit agency devoted to helping people of all ages live mentally healthier lives. Its Web site has information about mental health conditions. It also addresses issues such as grief, stress, bullying, and more. It includes a confidential depression screening test for anyone who would like to take it. The short test may help you decide whether your symptoms are related to depression.


National Alliance on Mental Illness (NAMI)
3803 North Fairfax Drive
Suite 100
Arlington, VA  22203
Phone: 1-800-950-NAMI (1-800-950-6264) hotline for help with depression
(703) 524-7600
Fax: (703) 524-9094
Email: info@nami.org
Web Address: www.nami.org
 

The National Alliance on Mental Illness is a national self-help and family advocacy organization dedicated solely to improving the lives of people who have severe mental illnesses such as schizophrenia, bipolar disorder (manic depression), major depression, obsessive-compulsive disorder, and panic disorder. NAMI focuses on support, education, advocacy, and research. The mission of the organization is to "eradicate mental illness and improve the quality of life of those affected by these diseases."


National Institute of Mental Health (NIMH)
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD  20892-9663
Phone: 1-866-615-6464 toll-free
(301) 443-4513
Fax: (301) 443-4279
TDD: 1-866-415-8051 toll-free
Email: nimhinfo@nih.gov
Web Address: www.nimh.nih.gov
 

The National Institute of Mental Health (NIMH) provides information to help people better understand mental health, mental disorders, and behavioral problems. NIMH does not provide referrals to mental health professionals or treatment for mental health problems.


References

Citations

  1. American Psychiatric Association (2009). Practice guideline for the treatment of patients with panic disorder. Available online: http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=PanicDisorder_2e_PracticeGuideline.
  2. Hollander E, Simeon D (2008). Anxiety disorders. In RE Hales et al., eds., American Psychiatric Publishing Textbook of Psychiatry, 5th ed., pp. 505–529. Washington, DC: American Psychiatric Publishing.
  3. Kumar S, Malone D (2008). Panic disorder, search date June 2007. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.
  4. Smoller JW, et al. (2003). Prevalence and correlates of panic attacks in postmenopausal women: Results from an ancillary study to the Women’s Health Initiative. Archives of Internal Medicine, 163(17): 2041–2050.
  5. Nicholas LM, et al. (2004). Panic disorder. In JE Tintinalli et al., eds., Emergency Medicine: A Comprehensive Study Guide, 6th ed., pp. 1826–1830. New York: McGraw-Hill.

Other Works Consulted

  • Campbell-Sills L, Stein MB (2006). Guideline Watch: Practice Guideline for the Treatment of Patients With Panic Disorder. Arlington, VA: American Psychological Association. Available online: http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=Panic.watch.
  • Huppert JC, et al. (2009). Anxiety disorders: Cognitive-behavioral therapy. In BJ Sadock et al., eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9th ed., vol. 1, pp. 1915–1926. Philadelphia: Lippincott Williams and Wilkins.
  • McClure-Tone EB, Pine DS (2009). Panic disorder and agoraphobia section of Clinical features of the anxiety disorders. In BJ Sadock et al., eds., Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed., vol. 1, pp. 1844–1856. Philadelphia: Lippincott Williams and Wilkins.
  • Ravindran LN, Stein MB (2009). Anxiety disorders: Somatic treatment. In BJ Sadock et al., eds., Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed., vol. 1, pp. 1906–1914. Philadelphia: Lippincott Williams and Wilkins.
  • Sadock BJ, et al. (2007). Panic disorder and agoraphobia. In Kaplan and Sadock's Synopsis of Psychiatry, Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 587-597. Philadelphia: Lippincott Williams and Wilkins.

Credits

ByHealthwise Staff
Primary Medical ReviewerKathleen Romito, MD - Family Medicine
Specialist Medical ReviewerLisa S. Weinstock, MD - Psychiatry
Last RevisedSeptember 15, 2010

Last Revised: September 15, 2010

Author: Healthwise Staff

Medical Review: Kathleen Romito, MD - Family Medicine & Lisa S. Weinstock, MD - Psychiatry

This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. How this information was developed to help you make better health decisions.

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