Panic Attacks and Panic Disorder
Symptoms, Causes, and Treatment
A panic attack is a sudden surge of overwhelming anxiety and fear. Your heart pounds and you can’t breathe. You may even feel like you’re dying or going crazy. Left untreated, panic attacks can lead to panic disorder and other problems. They may even cause you to withdraw from normal activities. But panic attacks can be cured and the sooner you seek help, the better. With treatment, you can reduce or eliminate the symptoms of panic and regain control of your life.
Paula had her first panic attack 6 months ago. She was in her office preparing for an important work presentation when, suddenly, she felt an intense wave of fear. Then the room started spinning and she felt like she was going to throw up. Her whole body was shaking, she couldn’t catch her breath, and her heart was pounding out of her chest. She gripped her desk until the episode passed, but it left her deeply shaken.
Paula had her next panic attack three weeks later, and since then, they’ve been occurring with increasing frequency. She never knows when or where she’ll suffer an attack, but she’s afraid of having one in public. Consequently, she’s been staying home after work, rather than going out with friends. She also refuses to ride the elevator up to her 12th floor office out of fear of being trapped if she has another panic attack.
In many cases, panic attacks strike out of the blue, without any warning. Often, there is no clear reason for the attack. They may even occur when you’re relaxed or asleep.
A panic attack may be a one-time occurrence, but many people experience repeat episodes. Recurrent panic attacks are often triggered by a specific situation, such as crossing a bridge or speaking in public—especially if that situation has caused a panic attack before. Usually, the panic-inducing situation is one in which you feel endangered and unable to escape.
You may experience one or more panic attacks, yet be otherwise perfectly happy and healthy. Or your panic attacks may occur as part of another disorder, such as panic disorder, social phobia, or depression. Regardless of the cause, panic attacks are treatable. There are many effective treatments and coping strategies you can use to deal with the symptoms.
Panic attacks often strike when you’re away from home, but they can happen anywhere and at any time. You may have one while you’re in a store shopping, walking down the street, driving in your car, or sitting on the couch at home.
The signs and symptoms of a panic attack develop abruptly and usually reach their peak within 10 minutes. Most panic attacks end within 20 to 30 minutes, and they rarely last more than an hour.
A full-blown panic attack includes a combination of the following signs and symptoms:
Is it a heart attack or a panic attack?
Most of the symptoms of a panic attack are physical, and many times these symptoms are so severe that people think they’re having a heart attack. In fact, many people suffering from panic attacks make repeated trips to the doctor or the emergency room in an attempt to get treatment for what they believe is a life-threatening medical problem. While it’s important to rule out possible medical causes of symptoms such as chest pain, heart palpitations, or difficulty breathing, it’s often panic that is overlooked as a potential cause—not the other way around.
Many people experience panic attacks without further episodes or complications. There is little reason to worry if you’ve had just one or two panic attacks. However, some people who’ve experienced panic attacks go on to develop panic disorder. Panic disorder is characterized by repeated panic attacks, combined with major changes in behavior or persistent anxiety over having further attacks.
Signs and symptoms of panic disorder
You may be suffering from panic disorder if you:
- Experience frequent, unexpected panic attacks that aren’t tied to a specific situation
- Worry a lot about having another panic attack
- Are behaving differently because of the panic attacks, such as avoiding places where you’ve previously panicked
While a single panic attack may only last a few minutes, the effects of the experience can leave a lasting imprint. If you have panic disorder, the recurrent panic attacks take an emotional toll. The memory of the intense fear and terror that you felt during the attacks can negatively impact your self-confidence and cause serious disruption to your everyday life. Eventually, this leads to the following panic disorder symptoms:
- Anticipatory anxiety – Instead of feeling relaxed and like yourself in between panic attacks, you feel anxious and tense. This anxiety stems from a fear of having future panic attacks. This “fear of fear” is present most of the time, and can be extremely disabling.
- Phobic avoidance – You begin to avoid certain situations or environments. This avoidance may be based on the belief that the situation you’re avoiding caused a previous panic attack. Or you may avoid places where escape would be difficult or help would be unavailable if you had a panic attack. Taken to its extreme, phobic avoidance becomes agoraphobia.
Agoraphobia was traditionally thought to involve a fear of public places and open spaces. However, it is now believed that agoraphobia develops as a complication of panic attacks. With agoraphobia, you’re afraid of having a panic attack in a situation where escape would be difficult or embarrassing. You may also be afraid of having a panic attack where you wouldn’t be able to get help.
Because of these fears, you start avoiding more and more situations. For example, you might begin to avoid crowded places such as shopping malls or sports arenas. You might also avoid cars, airplanes, subways, and other forms of travel. In more severe cases, you might only feel safe at home.
Situations or activities you may avoid if you have agoraphobia:
- Being far away from home
- Going anywhere without the company of a "safe" person
- Physical exertion (because of the belief that it could trigger a panic attack)
- Going to places where escape is not readily available (e.g. restaurants, theaters, stores, public transportation)
- Places where it would be embarrassing to have a panic attack, such as a social gathering
- Eating or drinking anything that could possibly provoke panic (such as alcohol, caffeine, or certain foods or medications)
Adapted from: American Academy of Family Physicians
Although agoraphobia can develop at any point, it usually appears within a year of your first recurrent panic attacks.
Although the exact causes of panic attacks and panic disorder are unclear, the tendency to have panic attacks runs in families. There also appears to be a connection with major life transitions such as graduating from college and entering the workplace, getting married, and having a baby. Severe stress, such as the death of a loved one, divorce, or job loss can also trigger a panic attack.
Panic attacks can also be caused by medical conditions and other physical causes. If you’re suffering from symptoms of panic, it’s important to see a doctor to rule out the following possibilities:
- Mitral valve prolapse, a minor cardiac problem that occurs when one of the heart’s valves doesn't close correctly.
- Hyperthyroidism (overactive thyroid gland)
- Hypoglycemia (low blood sugar)
- Stimulant use (amphetamines, cocaine, caffeine)
- Medication withdrawal
Panic attacks and panic disorder are treatable conditions. They can usually be treated successfully with self-help strategies or a series of therapy sessions.
Cognitive Behavioral Therapy
Cognitive behavioral therapy is generally viewed as the most effective form of treatment for panic attacks, panic disorder, and agoraphobia. Cognitive behavioral therapy focuses on the thinking patterns and behaviors that are sustaining or triggering the panic attacks. It helps you look at your fears in a more realistic light.
For example, if you had a panic attack while driving, what is the worst thing that would really happen? While you might have to pull over to the side of the road, you are not likely to crash your car or have a heart attack. Once you learn that nothing truly disastrous is going to happen, the experience of panic becomes less terrifying.
Exposure therapy for panic attacks and panic disorder
In exposure therapy for panic disorder, you are exposed to the physical sensations of panic in a safe and controlled environment, giving you the opportunity to learn healthier ways of coping. You may be asked to hyperventilate, shake your head from side to side, or hold your breath. These different exercises cause sensations similar to the symptoms of panic. With each exposure, you become less afraid of these internal bodily sensations and feel a greater sense of control over your panic.
If you have agoraphobia, exposure to the situations you fear and avoid is also included in treatment. As in exposure therapy for specific phobias, you face the feared situation until the panic begins to go away. Through this experience, you learn that the situation isn’t harmful and that you have control over your emotions.
Medication can be used to temporarily control or reduce some of the symptoms of panic disorder. However, it doesn't treat or resolve the problem. Medication can be useful in severe cases, but it should not be the only treatment pursued. Medication is most effective when combined with other treatments, such as therapy and lifestyle changes, that address the underlying causes of panic disorder.
The medications used for panic attacks and panic disorder include:
- Antidepressants. It takes several weeks before they begin to work, so you have to take them continuously, not just during a panic attack.
- Benzodiazepines. These are anti-anxiety drugs that act very quickly (usually within 30 minutes to an hour). Taking them during a panic attack provides rapid relief of symptoms. However, benzodiazepines are highly addictive and have serious withdrawal symptoms, so they should be used with caution.
When it comes to panic attacks, professional treatment and therapy can make a big difference. But there are many things you can do to help yourself, too:
- Learn about panic. Simply knowing more about panic can go a long way towards relieving your distress. So read up on anxiety, panic disorder, and the fight-or-flight response experienced during a panic attack. You’ll learn that the sensations and feelings you have when you panic are normal and that you aren’t going crazy.
- Avoid smoking and caffeine. Smoking and caffeine can provoke panic attacks in people who are susceptible. As a result, it’s wise to avoid cigarettes, coffee, and other caffeinated beverages. Also be careful with medications that contain stimulants, such as diet pills and non-drowsy cold medications.
- Learn how to control your breathing. Hyperventilation brings on many sensations (such as lightheadedness and tightness of the chest) that occur during a panic attack. Deep breathing, on the other hand, can relieve the symptoms of panic. By learning to control your breathing, you develop a coping skill that you can use to calm yourself down when you begin to feel anxious. If you know how to control your breathing, you are also less likely to create the very sensations that you are afraid of.
- Practice relaxation techniques. When practiced regularly, activities such as yoga, meditation, and progressive muscle relaxation strengthen the body’s relaxation response—the opposite of the stress response involved in anxiety and panic. And not only do these relaxation practices promote relaxation, but they also increase feelings of joy and equanimity. So make time for them in your daily routine.
More help for panic attacks and panic disorders
- How to Stop Worrying: Self-Help Strategies for Anxiety Relief
- Stress Relief in the Moment: Using Your Senses to Quickly Change Your Response to Stress
- Anxiety Medication: What You Need to Know About Anti-Anxiety Drugs
- Benefits of Mindfulness: Practices for Improving Emotional and Physical Well-Being
Overcoming panic: Exploring effective therapies. If you’re suffering from panic disorder, therapy can teach you how to prevent and cope with panic attacks. Even a short course of treatment can help! Many people experience a drastic reduction in symptoms within eight to ten treatment sessions. Read Therapy for Anxiety Disorders
Resources and references
Signs and symptoms of panic attacks and panic disorder
When Fear Overwhelms: Panic Disorder – Provides an overview of panic disorder, including the symptoms, causes, and treatment. Includes information on how to manage a panic attack. (National Institute of Mental Health)
Answers to Your Questions About Panic Disorder – Covers the signs and symptoms of panic attacks, the causes of panic disorder, and the effective treatments. (American Psychological Association)
Understanding Panic Disorder and Agoraphobia – Question and answer information sheet on the symptoms, causes, and treatment of panic disorder. (American Academy of Family Physicians)
Screening for Panic Disorder – Online self-test helps you determine if you’re experiencing the signs and symptoms of panic disorder. (Anxiety Disorders Association of America)
Treatment and support for panic attacks and panic disorder
The Panic Center – Online resource center offers free, personalized tools for people struggling with panic attacks. Includes an interactive 12-session cognitive behavioral therapy course, an online support group, and a confidential assessment of your symptoms. (The Panic Center)
Anxiety UK – UK charity for suffers and ex-sufferers of anxiety disorders, including panic disorder. Includes self-help information packs, therapy tapes, and online and phone counseling. (Anxiety UK)
Self-help tips for panic attacks and panic disorder
Panic Stations: Coping with Panic Attacks – Self-help series of workbooks offers strategies, exercises, and activities that teach you how to manage panic attacks. (Centre for Clinical Interventions)
Mastering Panic – Offers step-by-step, self-help tips for overcoming panic attacks and panic disorder. The tips are based on cognitive behavioral therapy. (Agoraphobia and Panic Disorder Foundation)
Self-Help for Panic Attacks – Use the left-hand menu on this website to navigate through a wealth of self-help tips for coping with and reducing panic attacks. (Anxieties.com)
Overcoming Agoraphobia – Describes helpful cognitive techniques for overcoming agoraphobia, how to create “safe bases” outside the home, and what to do if you have a panic attack. (Agoraphobia and Panic Disorder Foundation)