Panic Disorder in Adults

• Accelerated heart rate or heart palpitations
• Sweating
• Trembling or shaking
• Shortness of breath or smothering sensations
• Feelings of choking
• Chest discomfort or pain
• Nausea or abdominal distress
• Dizziness, light-headedness, or faintness
• Chills or heat flashes
• Numbing or tingling sensations
• Feelings of unreality (derealization) or being detached or “out of body” (depersonalization)
• Fear of “going crazy” or losing control
• Fear of dying

Nearly a quarter of adults in the United States have had one or more panic attacks in their lifetimes.  Having panic attacks does not necessarily mean the individual has panic disorder.  To receive a diagnosis of panic disorder, a person must also experience a month or more of at least one of the following:

• Persistent worry about having another panic attack or the possible consequences of another panic attack (such as having a heart attack or losing control)
• Problematic changes in behavior related to the attacks (such as avoiding exercise or certain situations because they might trigger a panic attack)

Panic disorder is only diagnosed when at least some of the panic attacks are not expected (“out of the blue”).  If a person only has panic attacks in specific situations, like when giving a speech, panic disorder would not be diagnosed.

Panic disorder is characterized by abnormalities of brain function (including abnormal activation in the amygdala and other regions implicated in fear circuitry, such as the anterior cingulate cortex and insula), the nervous system (including the hypothalamic-pituitary-adrenal axis), and the respiratory system (including hyperventilation resulting in low levels of carbon dioxide), which are all thought to contribute to symptoms.  In addition, misinterpreting bodily sensations as dangerous and avoiding certain bodily sensations are thought to contribute to the onset and persistence of panic disorder.  Panic disorder is thought to have a genetic component, although having a genetic predisposition to panic disorder does not necessarily mean that someone will develop panic disorder.

First Line Treatments

• Cognitive-behavioral therapy consists of gradually exposing the person to feared bodily sensations while simultaneously refraining from avoidance behaviors. The person also learns to interpret bodily sensations in more accurate and less threatening ways.
• Antidepressant medications, which are thought to help by improving the amount of serotonin in the brain. Specific first-line medications for panic disorder include:
• Citalopram
• Sertraline
• Fluvoxamine
• Escitalopram
• Paroxetine
• Venlafaxine ER

For more information about drug prescribing in panic disorder, click here.

Other Treatments

In cases of nonresponse to first-line treatment, clinical research suggests that the following treatments are effective:

• Tricyclic antidepressant medications such as imipramine and clomipramine
• Alternative psychotherapeutic strategies such as cognitive therapy, applied relaxation, or psychodynamic treatment
• Augmentation strategies, such as combining SSRIs and CBT
• Self-help books based on cognitive-behavioral therapy principles
• Note: Benzodiazepine medications can be effective in reducing anxiety symptoms in the short term, but they are associated with poorer long-term outcomes.  The benefits should be weighed carefully against the potential complications of physiological and/or psychological dependence.  Benzodiazepine treatment may reduce the efficacy of cognitive-behavioral therapy for panic disorder.

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered:

• Aerobic exercise
• Alternative medications such as gabapentin