Definition and Overview
Panic disorder is characterized by recurrent unexpected panic attacks -- abrupt surges of intense fear peaking within minutes, accompanied by physical and cognitive symptoms -- followed by persistent worry about future attacks or maladaptive behavioral changes [1].
Lifetime prevalence is 2-5%, typically beginning in young adulthood (late teens to mid-30s). Women are affected twice as often as men [1].
Pathophysiology
The locus coeruleus-norepinephrine system hyperactivation triggers the acute "fight-or-flight" response. Amygdala hyperexcitability and impaired prefrontal cortex regulation create a low threshold for fear circuitry activation [2].
Autonomic dysregulation: reduced HRV, blunted baroreflex sensitivity, and heightened interoceptive awareness (excessive monitoring of bodily sensations) contribute to both attacks and anticipatory anxiety [3].
Symptoms of a Panic Attack
DSM-5 requires 4 or more of the following reaching peak intensity within minutes [1]:
- Palpitations or accelerated heart rate
- Sweating
- Trembling or shaking
- Shortness of breath or smothering sensation
- Chest pain or discomfort
- Nausea or abdominal distress
- Dizziness, lightheadedness, or faintness
- Chills or heat sensations
- Paresthesias (numbness or tingling)
- Derealization or depersonalization
- Fear of losing control or "going crazy"
- Fear of dying
Diagnosis
Clinical diagnosis using DSM-5 criteria. Cardiac evaluation (ECG, echocardiogram) is often necessary to differentiate from cardiac arrhythmias. Thyroid function tests, and when indicated, pheochromocytoma screening [4].
Panic Disorder Severity Scale (PDSS) quantifies attack frequency and severity.
Treatment
Psychotherapy
CBT with interoceptive exposure is the first-line psychological treatment. Interoceptive exposure deliberately induces panic-like sensations (hyperventilation, spinning) to reduce fear of bodily sensations [5].
Pharmacotherapy
SSRIs (escitalopram 10-20 mg, sertraline 50-200 mg) are first-line medications. SNRIs (venlafaxine) are second-line. Initial worsening of anxiety may occur in the first 1-2 weeks; start at low doses.
Benzodiazepines (alprazolam, clonazepam) provide rapid relief but risk dependence; use only short-term or as bridge therapy while SSRIs take effect.
Differentiating from Heart Disease
Panic attacks mimic cardiac events with chest pain and palpitations. Key differences: panic attacks peak rapidly (minutes), resolve within 20-30 minutes, occur in younger patients, and ECG is normal. However, cardiac evaluation should be performed when chest pain is a prominent symptom, especially in patients with cardiovascular risk factors.