Panic Attacks and Panic Disorder
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 that they are having a heart attack or are about to die. An attack usually lasts from 5 to 20 minutes. But it 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.
Some people are more sensitive to anxiety and panic than others. Panic attacks and panic disorder may be more likely if you have 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.
- Heavy alcohol use.
- Using too much nicotine or too much caffeine.
- Taking certain medicines, such as those used to treat asthma and heart problems.
- Drug use.
- 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 isn't regular.
- 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. It can be so bad for some people that they never leave their homes.
People who have 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.
How are they treated?
Treatment for panic attacks and panic disorder includes counseling, especially cognitive-behavioral therapy (CBT). Medicines may also help. Treatment can help most people control or even stop attacks. But symptoms can come back, especially if you stop treatment too soon.
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The exact cause of panic disorder isn't clear. Some people are more sensitive to anxiety and panic than others. This may be from your family history or past experiences. You may have seen your parents or other family members experience anxiety. Or you may have experienced traumatic events in your past.
You may be very sensitive to how your body reacts to anxiety-causing experiences. You may mistake your body's reaction as harmful and begin to fear your body's reaction. This is called a cycle of panic. The same experiences that cause you panic may not cause panic in others.
You can have 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 caffeine.
- Chain-smoking. It greatly increases the amount of nicotine in the blood.
- 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 drugs.
- Having high levels of stress for a long time.
- 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:
- Thyroid problems, such as an overactive thyroid (hyperthyroidism).
- Heart problems.
- Seizure disorders, such as epilepsy.
- Respiratory problems, such as COPD.
- Stopping the use of a prescription medicine, such as a heart medicine.
- Anxiety disorders such as post-traumatic stress disorder or obsessive-compulsive disorder.
The main symptom of a panic attack is an overwhelming feeling of fear or anxiety. This feeling occurs along with physical reactions.
An attack starts suddenly and usually lasts from 5 to 20 minutes. But it 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. This can seem like one continuous attack. But if you have continuous symptoms that don't go away within an hour, you probably aren't having a panic attack. You should seek medical care right away.
Symptoms of a panic attack may include:
- Rapid breathing (hyperventilation), shortness of breath, or a feeling of choking or being smothered.
- A pounding or racing heart or an irregular heartbeat.
- Chest pain.
- Shaking, trembling, or feeling lightheaded or dizzy.
- Sweating, chills, or hot flashes.
- Nausea or an upset stomach.
- Numbness or tingling.
- Fear that you are going to die, lose control, or "go crazy."
- Feelings of being detached from yourself or from reality.
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 medical treatment right away. For more information, see the topic Chest Problems.
Panic attacks may begin without a trigger. Or they can be linked to certain situations, such as being in large crowds of people in restaurants or stadiums. Sometimes just knowing that you'll be in a certain situation can cause severe anxiety.
People who have 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 a panic attack occurs. If this pattern of avoidance and anxiety is severe, it can become agoraphobia, an intense and irrational fear of being in public places.
Isolating yourself and avoiding social situations can interfere with your ability to work. It can also harm your relationships, especially with your family members and close friends.
Symptoms in children
Panic attacks aren't 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.
- They may worry too much about monsters or about going to bed alone.
- They may refuse to go to school or become unusually upset when they are separated from a parent.
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." You may feel like 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 have physical symptoms such as shortness of breath, a pounding heart, or chest pain. It is common to think that you are having a heart attack and to seek treatment in a hospital emergency room.
The intensity of these symptoms usually peaks within 10 minutes.
For many people, the first panic attack may occur a stressful time. It may happen during a life-threatening illness or accident, the loss of a relationship, or separation from family. A woman may have her first panic attack after she gives birth.
It is also possible for a first panic attack to be caused by 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.
Common traits in panic disorder include:
- 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 trouble relating to other people in social settings because of intense feelings of anxiety.
Recurrent panic attacks can be mild to severe. They may continue for years, especially if you also have agoraphobia (avoiding places where you fear another attack will occur). You may have long periods of time without panic attacks. And you may have 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 have 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 who have panic disorder get better with treatment. They are able to get back to a normal lifestyle. But relapse can occur, especially if treatment is stopped too soon.
What Increases Your Risk
Your risk for panic attacks and panic disorder may be higher if you:
- Have a family history of panic disorder. You are also at increased risk if you have a parent with either depression or bipolar disorder.
- 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 had previous, unexpected panic attacks.
When should you call your doctor?
Call 911, or other emergency services immediately if you have symptoms of a heart attack. These may include:
- Chest pain or pressure, or a strange feeling in the chest.
- Shortness of breath.
- Nausea or vomiting.
- Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or both shoulders or arms.
- Lightheadedness or sudden weakness.
- A fast or irregular heartbeat.
After you call 911, the operator may tell you to chew 1 adult-strength or 2 to 4 low-dose aspirin. Wait for an ambulance. Do not try to drive yourself.
Call your doctor if you have:
- 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 keeps you from doing your daily activities.
- Physical symptoms now and then (such as shortness of breath and chest pain), and you aren't sure what is causing them.
It can be hard to tell the difference between the symptoms of a panic attack (such as shortness of breath and chest pain) and another serious medical problem. If you have symptoms of a panic attack, be sure to get medical care right away so that other medical conditions can be ruled out.
Exams and Tests
You may be diagnosed with panic disorder if you have at least two unexpected panic attacks along with fear or worry about having another panic attack and avoiding situations that may trigger it.
The doctor will ask you questions about your symptoms. He or she will listen to your heart and check your blood pressure. You may get blood tests. The doctor may need to rule out other physical conditions that have symptoms similar to panic disorder, such as a heart attack or hyperthyroidism.
Successful treatment reduces how many panic attacks you have and how often you have them. It lowers the anxiety you feel because of the fear of future attacks. And it improves the quality of your life. Treatment may include:
- Professional counseling, such as cognitive-behavioral therapy. To learn more, see Other Treatment.
- Medicines, such as an antidepressant or a benzodiazepine.
- Home treatment, such as relaxation exercises.
Unfortunately, many people don't seek treatment for anxiety disorders. You may not seek treatment because you think the symptoms aren't bad enough. Or maybe you think 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.
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. In this case, that 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. They may turn into panic disorder.
Panic attacks may also start suddenly without a known trigger.
Recurring panic attacks
You may have mild to severe panic attacks off and on for years, especially if you also have agoraphobia (avoiding places where you fear another attack will occur).
Even after treatment is stopped because the attacks appear to be under control, attacks can suddenly return. Learn your early warning signs and triggers so you can seek treatment early.
If your panic attacks get too severe or happen too often, 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 harder to treat.
An important part of ongoing treatment is making sure that 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's important to continue the treatment plan.
You will be continually checked to see if you have other conditions linked with panic disorder, such as depression or problems with drugs or alcohol. These conditions will also need treatment.
Panic disorder cannot be prevented.
But you may be able to prevent or reduce the number of panic attacks with home treatment. For example, you can try relaxation exercises or limiting alcohol and caffeine.
Here are steps you can take to decrease the number of panic attacks you have. These steps can also reduce the severity of your symptoms when an attack does occur:
- Reduce anxiety. Do tension-reducing activities, and lower the amount of stress in your life.
- Do relaxation exercises. These involve 10 to 20 minutes of deep breathing and muscle relaxation each day.
- Change how you think. Changing how you think can change how you feel—and that can reduce your anxiety. Noticing negative thoughts and replacing them with helpful ones is one way to do this.
- Get regular exercise. Get your breathing and heart rate up several times a week.
- Limit alcohol and caffeine (or avoid them completely).
- Join a self-help and support group, such as one organized by the Anxiety Disorders Association of America (ADAA).
- Eat a balanced diet. This means eating fresh, healthy foods and limiting your intake of foods that are high in sugar and fat.
Support for the family
When a person has panic attacks, his or her 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 common.
Family therapy, a type of counseling that involves the entire family, may help.
For more information, see:
Medicines for panic disorder are used to control the symptoms of panic attacks, reduce their number and severity, and reduce the anxiety and fear linked with having another attack.
Your symptoms of panic disorder should start to improve within a few weeks after you start taking medicines. If improvement is not seen within 6 to 8 weeks, a higher dose or another medicine may be needed.
Some medicines used to treat panic attacks need to be continued for a year or longer and then may be decreased gradually over several weeks. 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.
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. You may need to keep taking medicines if your panic disorder is severe. Your doctor can help weigh the risks of treatment against the risk of harm to your pregnancy.
Medicines used most often to treat panic attacks include:
- Antidepressants, such as Paxil, Prozac, or Zoloft.
- Benzodiazepines, such as Ativan, Valium, or Xanax.
Medicines sometimes used to treat panic disorder include:
Medicines to treat panic disorder often may prevent another panic attack. But 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.
Cognitive-behavioral therapy focuses on changing certain thinking and behavior patterns. It has been proved effective for treating panic disorder.
Support groups and self-help
Support groups are often good places to share information, problem-solving tips, and emotions related to panic disorder.
Online discussion forums and websites may also offer information and support.
Self-help materials can help you learn to cope with panic disorder or anxiety. These include instructional videos, books, and audio materials.
Body-centered relaxation exercises can be useful for reducing anxiety and treating symptoms of stress. They include:
- Breathing exercises, such as roll breathing (a type of deep breathing).
- Progressive muscle relaxation. This reduces muscle tension by relaxing individual muscle groups.
- Massage, such as shoulder and neck massage.
- Aromatherapy. This uses the aroma-producing oils (essential oils) from plants to promote relaxation.
- Yoga,tai chi, and qi gong, and other forms of exercise and meditation. They typically require initial instruction.
Mindfulness activities are techniques that help relax the mind. They are often combined with body-centered relaxation exercises. These techniques include:
- 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.
- Guided imagery (visualization). This is 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.
Other Works Consulted
- American Psychiatric Association (2009). Practice guideline for the treatment of patients with panic disorder. Available online: http://psychiatryonline.org/guidelines.aspx.
- 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). 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.
- U.S. Department of Health and Human Services (2008). 2008 Physical Activity Guidelines for Americans (ODPHP Publication No. U0036). Washington, DC: U.S. Government Printing Office. Available online: http://www.health.gov/paguidelines/guidelines/default.aspx.
- Vannice GK (2012). Medical nutrition therapy for psychiatric conditions. In LK Mahan et al., eds., Krause's Food and the Nutrition Care Process, 13th ed., pp. 956–969. St Louis: Saunders.