View source for Medicine:Panic attack

{{Short description|Period of intense fear}}
{{Infobox medical condition (new)
| name          = Panic attack
| image         = Panic attack.jpg
| caption       = A depiction of someone experiencing a panic attack, being reassured by another person.
| field         = [[Biology:Psychiatry|Psychiatry]]
| symptoms      = Periods of intense [[Philosophy:Fear|fear]], [[Medicine:Palpitations|palpitations]], sweating, shaking, shortness of breath, numbness<ref name=NIH2016/><ref name=DSM5/>
| complications = [[Medicine:Self-harm|Self-harm]], [[Medicine:Suicide|suicide]]<ref name=DSM5/>
| onset         = Over minutes<ref name=DSM5/>
| duration      = Seconds to hours<ref name=Dand2013/>
| causes        = [[Medicine:Panic disorder|Panic disorder]], [[Medicine:Social anxiety disorder|social anxiety disorder]], [[Medicine:Post-traumatic stress disorder|post-traumatic stress disorder]], [[Medicine:Substance use disorder|drug use]], depression, medical problems<ref name=DSM5/><ref name=Lancet2016/>
| risks         = [[Medicine:Smoking|Smoking]], [[Medicine:Psychological stress|psychological stress]]<ref name=DSM5/>
| diagnosis     = After other possible causes excluded<ref name=DSM5/>
| differential  = [[Medicine:Hyperthyroidism|Hyperthyroidism]], [[Medicine:Hyperparathyroidism|hyperparathyroidism]], heart disease, [[Medicine:Lung disease|lung disease]], drug use, [[Medicine:Dysautonomia|dysautonomia]]<ref name=DSM5/>
| prevention    = 
| treatment     = [[Medicine:Psychotherapy|Counselling]], [[Chemistry:Medication|medication]]s<ref name=NIH2013/>
| medication    = Antidepressant 
| prognosis     = Usually good<ref name=Ged2012/>
| frequency     = 3% (EU), 11% (US)<ref name=DSM5/>
| deaths        = 
| alt           = 
}}
<!-- Definition and symptoms -->
'''Panic attacks''' are sudden periods of intense [[Philosophy:Fear|fear]] and discomfort that may include [[Medicine:Palpitations|palpitations]], sweating, [[Medicine:Chest pain|chest pain]] or chest discomfort, shortness of breath, trembling, dizziness, numbness, confusion, or a feeling of impending doom or of losing control.<ref name=NIH2016>{{cite web|title=Anxiety Disorders|url=https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml|website=NIMH|access-date=1 October 2016|date=March 2016|url-status=live|archive-url=https://web.archive.org/web/20160929085938/http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml|archive-date=29 September 2016}}</ref><ref name=DSM5/><ref>{{cite journal|first1=Yu-Chi|last1=Lo|first2=Hsi-Han|last2=Chen|title=Shiau-Shian Huang Panic Disorder Correlates with the Risk for Sexual Dysfunction|journal=Journal of Psychiatric Practice|volume=26|issue=3|date=May 2020|pages=185–200|doi=10.1097/PRA.0000000000000460|pmid=32421290 |s2cid=218643956 }}</ref> Typically, symptoms reach a peak within ten minutes of onset, and last for roughly 30 minutes, but the duration can vary from seconds to hours.<ref name=Dand2013>{{cite book|last1=Bandelow|first1=Borwin|last2=Domschke|first2=Katharina|last3=Baldwin|first3=David|title=Panic Disorder and Agoraphobia|date=2013|publisher=OUP Oxford|isbn=978-0-19-100426-1|page=Chapter 1|url=https://books.google.com/books?id=T4RnAgAAQBAJ&pg=PT9|language=en|url-status=live|archive-url=https://web.archive.org/web/20161220094616/https://books.google.ca/books?id=T4RnAgAAQBAJ&pg=PT9|archive-date=20 December 2016}}</ref><ref>{{Cite web|last1=Smith|first1=Melinda|last2=Robinson|first2=Lawrence|last3=Segal|first3=Jeanne|title=Panic Attacks and Panic Disorder|url=https://www.helpguide.org/articles/anxiety/panic-attacks-and-panic-disorders.htm|access-date=2021-07-06|website=HelpGuide|language=en-US|archive-date=2021-07-09|archive-url=https://web.archive.org/web/20210709184241/https://www.helpguide.org/articles/anxiety/panic-attacks-and-panic-disorders.htm|url-status=live}}</ref> Although they can be extremely frightening and distressing, panic attacks themselves are not physically dangerous.<ref name=Ged2012/><ref>{{cite journal |last1=Ghadri |first1=Jelena-Rima |last2=Wittstein |first2=Ilan Shor |last3=Prasad |first3=Abhiram |last4=Sharkey |first4=Scott |last5=Dote |first5=Keigo |last6=Akashi |first6=Yoshihiro John |last7=Cammann |first7=Victoria Lucia |last8=Crea |first8=Filippo |last9=Galiuto |first9=Leonarda |last10=Desmet |first10=Walter |last11=Yoshida |first11=Tetsuro |last12=Manfredini |first12=Roberto |last13=Eitel |first13=Ingo |last14=Kosuge |first14=Masami |last15=Nef |first15=Holger M |last16=Deshmukh |first16=Abhishek |last17=Lerman |first17=Amir |last18=Bossone |first18=Eduardo |last19=Citro |first19=Rodolfo |last20=Ueyama |first20=Takashi |last21=Corrado |first21=Domenico |last22=Kurisu |first22=Satoshi |last23=Ruschitzka |first23=Frank |last24=Winchester |first24=David |last25=Lyon |first25=Alexander R |last26=Omerovic |first26=Elmir |last27=Bax |first27=Jeroen J |last28=Meimoun |first28=Patrick |last29=Tarantini |first29=Guiseppe |last30=Rihal |first30=Charanjit |last31=Y.-Hassan |first31=Shams |last32=Migliore |first32=Federico |last33=Horowitz |first33=John D |last34=Shimokawa |first34=Hiroaki |last35=Lüscher |first35=Thomas Felix |last36=Templin |first36=Christian |title=International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology |journal=European Heart Journal |date=7 June 2018 |volume=39 |issue=22 |pages=2032–2046 |doi=10.1093/eurheartj/ehy076 |pmid=29850871 |pmc=5991216 }}</ref>

The essential features of panic attacks remain unchanged, although the complicated DSM-IV terminology for describing different types of panic attacks (i.e., situationally bound/cued, situationally predisposed, and unexpected/uncued) is replaced with the terms unexpected and expected panic attacks. Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders, including but not limited to anxiety disorders. Hence, panic attacks can be listed as a specifier that is applicable to all DSM-5 disorders.<ref>{{Cite web |last=American Psychiatric Association |first=American Psychiatric Association |title=Changes to the DSM-V to the DSM-V-TR |url=https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf |access-date=22 March 2022 |website=Changes to the DSM V to DSM V-TR |archive-date=2 September 2018 |archive-url=https://web.archive.org/web/20180902075133/https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf |url-status=live }}</ref><!-- Cause and diagnosis -->

Panic attacks can occur due to several disorders including [[Medicine:Panic disorder|panic disorder]], [[Medicine:Social anxiety disorder|social anxiety disorder]], [[Medicine:Post-traumatic stress disorder|post-traumatic stress disorder]], [[Medicine:Substance use disorder|substance use disorder]], depression, and medical problems.<ref name=DSM5/><ref name=Lancet2016>{{cite journal |last1=Craske |first1=Michelle G |last2=Stein |first2=Murray B |title=Anxiety |journal=The Lancet |date=December 2016 |volume=388 |issue=10063 |pages=3048–3059 |doi=10.1016/S0140-6736(16)30381-6 |pmid=27349358 |s2cid=208789585 }}</ref> They can either be triggered or occur unexpectedly.<ref name=DSM5/> [[Medicine:Smoking|Smoking]], [[Biology:Caffeine|caffeine]], and [[Medicine:Psychological stress|psychological stress]] increase the risk of having a panic attack.<ref name=DSM5/> Before diagnosis, conditions that produce similar symptoms should be ruled out, such as [[Medicine:Hyperthyroidism|hyperthyroidism]], [[Medicine:Hyperparathyroidism|hyperparathyroidism]], heart disease, [[Medicine:Lung disease|lung disease]], drug use, and [[Medicine:Dysautonomia|dysautonomia]].<ref name=DSM5/><ref>{{Cite journal|last1=Stewart|first1=Julian M.|last2=Pianosi|first2=Paul|last3=Shaban|first3=Mohamed A.|last4=Terilli|first4=Courtney|last5=Svistunova|first5=Maria|last6=Visintainer|first6=Paul|last7=Medow|first7=Marvin S.|date=2018-11-01|title=Hemodynamic characteristics of postural hyperventilation: POTS with hyperventilation versus panic versus voluntary hyperventilation|journal=Journal of Applied Physiology|volume=125|issue=5|pages=1396–1403|doi=10.1152/japplphysiol.00377.2018|pmid=30138078|pmc=6442665|issn=8750-7587|doi-access=free}}</ref>

<!-- Treatment and prognosis -->
Treatment of panic attacks should be directed at the underlying cause.<ref name=Ged2012>{{cite book|last1=Geddes|first1=John|last2=Price|first2=Jonathan|last3=McKnight|first3=Rebecca|title=Psychiatry|date=2012|publisher=OUP Oxford|isbn=978-0-19-923396-0|page=298|url=https://books.google.com/books?id=F4THKWvbAPEC&pg=PA298|language=en|url-status=live|archive-url=https://web.archive.org/web/20161004230957/https://books.google.ca/books?id=F4THKWvbAPEC&pg=PA298|archive-date=4 October 2016}}</ref> In those with frequent attacks, [[Medicine:Psychotherapy|counseling]] or [[Chemistry:Medication|medication]]s may be used.<ref name="NIH2013">{{cite web |date=2022 |title=Panic Disorder: When Fear Overwhelms |url=https://www.nimh.nih.gov/health/publications/panic-disorder-when-fear-overwhelms |access-date=March 18, 2022 |website=NIMH |archive-date=March 23, 2022 |archive-url=https://web.archive.org/web/20220323233506/https://www.nimh.nih.gov/health/publications/panic-disorder-when-fear-overwhelms |url-status=live }}</ref> Breathing training and muscle relaxation techniques may also help.<ref>{{cite journal |last1=Roth |first1=Walton T. |title=Diversity of effective treatments of panic attacks: what do they have in common? |journal=Depression and Anxiety |date=January 2010 |volume=27 |issue=1 |pages=5–11 |doi=10.1002/da.20601 |pmid=20049938 |s2cid=31719106 |doi-access=free }}</ref> Those affected are at a higher risk of [[Medicine:Suicide|suicide]].<ref name=DSM5/>

<!-- Epidemiology -->
In Europe, about 3% of the population has a panic attack in a given year while in the United States they affect about 11%.<ref name=DSM5/> They are more common in females than in males.<ref name=DSM5/> They often begin during puberty or early adulthood.<ref name=DSM5/> Children and older people are less commonly affected.<ref name=DSM5>{{citation|author=American Psychiatric Association|year=2013|title=Diagnostic and Statistical Manual of Mental Disorders (5th ed.)|location=Arlington|publisher=American Psychiatric Publishing|pages=[https://archive.org/details/diagnosticstatis0005unse/page/214 214–217]|isbn=978-0-89042-555-8|url=https://archive.org/details/diagnosticstatis0005unse/page/214}}</ref>

==Signs and symptoms==

People with panic attacks often report a fear of dying or [[Medicine:Myocardial infarction|heart attack]], [[Unsolved:Photopsia|flashing vision]] or other visual disturbances, faintness or nausea, numbness throughout the body, shortness of breath and hyperventilation, or loss of body control.<ref>{{Cite web |title=Symptoms and causes - Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/panic-attacks/symptoms-causes/syc-20376021?p=1 |access-date=2022-03-17 |website=www.mayoclinic.org |archive-date=2022-03-17 |archive-url=https://web.archive.org/web/20220317204310/https://www.mayoclinic.org/diseases-conditions/panic-attacks/symptoms-causes/syc-20376021?p=1 |url-status=live }}</ref> Some people also experience tunnel vision, mostly due to blood flow leaving the head to more critical parts of the body in defense. These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the "[[Fight-or-flight response|fight-or-flight response]]", in which the hormone causing this response is released in significant amounts). This response floods the body with hormones, particularly epinephrine (adrenaline), which aid it in defending against harm.<ref name=Bourne2005>Bourne, E. (2005). ''The Anxiety and Phobia Workbook'', 4th Edition: New Harbinger Press.{{page needed|date=August 2015}}</ref>

A panic attack can result when up-regulation by the sympathetic nervous system (SNS) is not moderated by the parasympathetic nervous system (PNS). The most common symptoms include trembling, dyspnea (shortness of breath), heart palpitations, [[Medicine:Chest pain|chest pain]] (or chest tightness), hot flashes, cold flashes, burning sensations (particularly in the facial or neck area), sweating, nausea, [[Medicine:Dizziness|dizziness]] (or slight [[Medicine:Vertigo|vertigo]]), light-headedness, heavy-headedness, hyperventilation, [[Unsolved:Paresthesia|paresthesia]]s (tingling sensations), sensations of [[Medicine:Choking|choking]] or smothering, difficulty moving, [[Philosophy:Depersonalization|depersonalization]] and/or [[Philosophy:Derealization|derealization]].<ref>{{Cite web |title=Panic disorder: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/article/000924.htm |access-date=2022-03-14 |website=medlineplus.gov |language=en |archive-date=2023-06-08 |archive-url=https://web.archive.org/web/20230608055731/https://medlineplus.gov/ency/article/000924.htm |url-status=live }}</ref> These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased [[Medicine:Anxiety|anxiety]] and forms a [[Positive feedback|positive feedback]] loop.<ref>{{Cite book | title=Panic Anxiety and Its Treatments: Report of the World Psychiatric Association Presidential Educational Program Task Force | publisher=American Psychiatric Association | first1=Gerald L. | last1=Klerman | first2=Robert M. A. | last2=Hirschfeld | first3=Myrna M. | last3=Weissman | page=[https://archive.org/details/panicanxietyitst0000unse/page/44 44] | year=1993 | isbn=978-0-88048-684-2 | url=https://archive.org/details/panicanxietyitst0000unse/page/44 }}</ref><!-- Although, it must be said that the term 'positive' feedback loop is used in the sense of describing the loop itself, since multiple episodes of panic attacks are the farthest from positive many people can get.--> <!--Removed: Anxiety generated by these internal sensations activates the SNS, creating more sensations and more SNS arousal. This causes a [[Positive feedback|positive feedback]] loop that increases their anxiety and can lead to a panic attack or worsen one that has already developed.-->

Shortness of breath and [[Medicine:Chest pain|chest pain]] are the predominant symptoms. Many people experiencing a panic attack incorrectly attribute them to a heart attack and thus seek treatment in an emergency room.<ref>{{Cite web |title=Panic Disorder {{!}} Anxiety and Depression |url=https://adaa.org/understanding-anxiety/panic-disorder |access-date=2023-03-12 |website=adaa.org |archive-date=2023-03-12 |archive-url=https://web.archive.org/web/20230312024802/https://adaa.org/understanding-anxiety/panic-disorder |url-status=live }}</ref> Because chest pain and shortness of breath are hallmark symptoms of cardiovascular illnesses, including unstable angina and [[Medicine:Myocardial infarction|myocardial infarction]] (heart attack), a [[Medicine:Diagnosis of exclusion|diagnosis of exclusion]] (ruling out other conditions) must be performed before diagnosing a panic attack. It is especially important to do this for people whose mental health and heart health statuses are unknown. This can be done using an [[Biology:Electrocardiography|electrocardiogram]] and mental health assessments.

Panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature.<ref name=Bourne2005/> They are often experienced in conjunction with anxiety disorders and other psychological conditions, although panic attacks are not generally indicative of a [[Medicine:Mental disorder|mental disorder]]. <!-- Comment: Covered in Triggers section Panic attacks can be caused by very common problems such as low blood sugar [[Medicine:Hypoglycemia|hypoglycemia]], [[Medicine:Hyperthyroidism|hyperthyroidism]], or the overuse of [[Biology:Caffeine|caffeine]] or [[Chemistry:Nicotine|nicotine]].{{Fact|date=July 2007}}-->

==Causes==
There are long-term, biological, environmental, and social causes of panic attacks. In 1993, Fava et al. proposed a staging method of understanding the origins of disorders. The first stage in developing a disorder involves predisposing factors, such as genetics, personality, and a lack of well-being.<ref>{{cite journal |last1=Cosci |first1=Fiammetta |title=The psychological development of panic disorder: implications for neurobiology and treatment |journal=Revista Brasileira de Psiquiatria |date=June 2012 |volume=34 |pages=S09–S31 |doi=10.1590/s1516-44462012000500003 |pmid=22729447 |doi-access=free }}</ref> Panic disorder often occurs in early adulthood, although it may appear at any age. It occurs more frequently in women and more often in people with above-average intelligence.<ref>{{Cite web|last=Marquardt|first=David Z. Hambrick, Madeline|title=Bad News for the Highly Intelligent|url=https://www.scientificamerican.com/article/bad-news-for-the-highly-intelligent/|access-date=2021-01-26|website=Scientific American|date=March 2018 |language=en|archive-date=2021-01-27|archive-url=https://web.archive.org/web/20210127153342/https://www.scientificamerican.com/article/bad-news-for-the-highly-intelligent/|url-status=live}}</ref><ref>{{Cite journal | title=Gender Differences in Panic Disorder | url=https://www.psychiatrictimes.com/view/gender-differences-panic-disorder | access-date=2021-01-26 | journal=Psychiatric Times | series=Psychiatric Times Vol 21 No 1 | date=January 2004 | volume=21 | issue=1 | last1=Gregory a. Leskin | first1=PhD | archive-date=2021-01-23 | archive-url=https://web.archive.org/web/20210123182650/https://www.psychiatrictimes.com/view/gender-differences-panic-disorder | url-status=live }}</ref> Various twin studies where one identical twin has an anxiety disorder have reported a high incidence of the other twin also having an anxiety disorder diagnosis.<ref>{{cite journal |last1=Davies |first1=Matthew N. |last2=Verdi |first2=Serena |last3=Burri |first3=Andrea |last4=Trzaskowski |first4=Maciej |last5=Lee |first5=Minyoung |last6=Hettema |first6=John M. |last7=Jansen |first7=Rick |last8=Boomsma |first8=Dorret I. |last9=Spector |first9=Tim D. |title=Generalised Anxiety Disorder – A Twin Study of Genetic Architecture, Genome-Wide Association and Differential Gene Expression |journal=PLOS ONE |date=14 August 2015 |volume=10 |issue=8 |pages=e0134865 |doi=10.1371/journal.pone.0134865 |pmid=26274327 |pmc=4537268 |bibcode=2015PLoSO..1034865D |doi-access=free }}</ref>

Biological causes may include [[Medicine:Obsessive–compulsive disorder|obsessive-compulsive disorder]], [[Medicine:Postural orthostatic tachycardia syndrome|postural orthostatic tachycardia syndrome]], [[Medicine:Post-traumatic stress disorder|post-traumatic stress disorder]], [[Medicine:Hypoglycemia|hypoglycemia]], [[Medicine:Hyperthyroidism|hyperthyroidism]], [[Medicine:Wilson's disease|Wilson's disease]], [[Medicine:Mitral valve prolapse|mitral valve prolapse]], [[Medicine:Pheochromocytoma|pheochromocytoma]], and inner ear disturbances ([[Medicine:Labyrinthitis|labyrinthitis]]). Dysregulation of the norepinephrine system in the locus coeruleus, an area of the brain stem, has been linked to panic attacks.<ref name="Abnormal Psych">{{cite book|title=(Ab)normal Psychology|last1=Nolen-Hoeksema|first1=Susan|date=2013|publisher=McGraw Hill|isbn=978-0-07-803538-8|edition=6th}}{{page needed|date=January 2021}}</ref>

Panic attacks may also occur due to short-term stressors. Significant personal loss, including an emotional attachment to a romantic partner, life transitions, and significant life changes may all trigger a panic attack to occur. A person with an anxious temperament, excessive need for reassurance, hypochondriacal fears,<ref name="Panic disorder">{{cite journal |last1=Taylor |first1=C Barr |title=Panic disorder |journal=BMJ |date=22 April 2006 |volume=332 |issue=7547 |pages=951–955 |doi=10.1136/bmj.332.7547.951 |pmid=16627512 |pmc=1444835 }}</ref> overcautious view of the world,<ref name="Bourne2005" /> and cumulative stress have been correlated with panic attacks. In adolescents, social transitions may also be a cause.<ref>William T. O‘Donohue,· Lorraine T. Benuto, Lauren Woodward Tolle (eds, 2013). Handbook of Adolescent Health Psychology, Springer, New York. {{ISBN|978-1-4614-6632-1}}. Page 511</ref>

People will often experience panic attacks as a direct result of exposure to an object/situation that they have a [[Medicine:Phobia|phobia]] for. Panic attacks may also become situationally-bound when certain situations are associated with panic due to previously experiencing an attack in that particular situation. People may also have a cognitive or behavioral predisposition to having panic attacks in certain situations.

Some maintaining causes include avoidance of panic-provoking situations or environments, anxious/negative self-talk ("what-if" thinking), mistaken beliefs ("these symptoms are harmful and/or dangerous"), and withheld [[Philosophy:Feeling|feeling]]s.

Hyperventilation syndrome may occur when a person breathes from the chest, which can lead to over-breathing (exhaling excessive [[Chemistry:Carbon dioxide|carbon dioxide]] related to the amount of [[Chemistry:Oxygen|oxygen]] in one's bloodstream). [[Medicine:Hyperventilation syndrome|Hyperventilation syndrome]] can cause respiratory alkalosis and hypocapnia. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms, including rapid [[Medicine:Cardiac cycle|heartbeat]], [[Medicine:Dizziness|dizziness]], and lightheadedness, which can trigger panic attacks.<ref>{{cite journal |last1=Maddock |first1=Richard J. |last2=Carter |first2=Cameron S. |title=Hyperventilation-induced panic attacks in panic disorder with agoraphobia |journal=Biological Psychiatry |date=May 1991 |volume=29 |issue=9 |pages=843–854 |doi=10.1016/0006-3223(91)90051-m |pmid=1904781 |s2cid=36334143 }}</ref>

Panic attacks may also be caused by substances. Discontinuation or marked reduction in the dose of a substance such as a drug ([[Medicine:Drug withdrawal|drug withdrawal]]), for example, an antidepressant ([[Medicine:Antidepressant discontinuation syndrome|antidepressant discontinuation syndrome]]), can cause a panic attack. According to the Harvard Mental Health Letter, "the most commonly reported side effects of smoking marijuana are anxiety and panic attacks. Studies report that about 20% to 30% of recreational users experience such problems after smoking marijuana."<ref name="Harvard Mental Health Letter, 2010">{{cite web |url=http://www.health.harvard.edu/mind-and-mood/medical-marijuana-and-the-mind |title=Medical marijuana and the mind - Harvard Health |access-date=2016-08-14 |url-status=live |archive-url=https://web.archive.org/web/20160821162716/http://www.health.harvard.edu/mind-and-mood/medical-marijuana-and-the-mind |archive-date=21 August 2016 }}</ref> Cigarette smoking is another substance that has been linked to panic attacks.<ref>{{cite journal |last1=Zvolensky |first1=Michael J. |last2=Gonzalez |first2=Adam |last3=Bonn-Miller |first3=Marcel O. |last4=Bernstein |first4=Amit |last5=Goodwin |first5=Renee D. |title=Negative reinforcement/negative affect reduction cigarette smoking outcome expectancies: Incremental validity for anxiety focused on bodily sensations and panic attack symptoms among daily smokers |journal=Experimental and Clinical Psychopharmacology |date=February 2008 |volume=16 |issue=1 |pages=66–76 |doi=10.1037/1064-1297.16.1.66 |pmid=18266553 }}</ref>

A common denominator of current psychiatric approaches to panic disorder is that no real danger exists, and the person's anxiety is inappropriate.<ref>{{cite journal |last1=Gorman |first1=JM |last2=Kent |first2=JM |last3=Sullivan |first3=GM |last4=Coplan |first4=JD |title=Neuroanatomical hypothesis of panic disorder, revised |journal=The American Journal of Psychiatry |date=April 2000 |volume=157 |issue=4 |pages=493–505 |doi=10.1176/appi.ajp.157.4.493 |pmid=10739407}}</ref>

===Panic disorder===
{{Main|Medicine:Panic disorder}}

People who have repeated, persistent attacks or feel severe anxiety about having another attack are said to have panic disorder. Panic disorder is strikingly different from other types of [[Medicine:Anxiety disorder|anxiety disorder]]s in that panic attacks are often sudden and unprovoked.<ref name="familydoctor">[http://familydoctor.org/familydoctor/en/diseases-conditions/panic-disorder.html Panic Disorder – familydoctor.org<!-- Bot generated title -->] {{webarchive|url=https://web.archive.org/web/20140203235458/http://familydoctor.org/familydoctor/en/diseases-conditions/panic-disorder.html |date=3 February 2014 }}</ref> However, panic attacks experienced by those with panic disorder may also be linked to or heightened by certain places or situations, making daily life difficult.<ref>[http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/By_Illness/Anxiety_Disorders.htm "Anxiety Disorders"] {{webarchive|url=https://web.archive.org/web/20140412144344/http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/By_Illness/Anxiety_Disorders.htm |date=12 April 2014 }}</ref>

===Agoraphobia===
[[Medicine:Agoraphobia|Agoraphobia]] is an [[Medicine:Anxiety disorder|anxiety disorder]] that primarily consists of the fear of experiencing a difficult or embarrassing situation from which the affected cannot escape. Panic attacks are commonly linked to agoraphobia.<ref>{{cite journal |last1=Inglis |first1=Sally C |last2=Clark |first2=Robyn A |last3=Dierckx |first3=Riet |last4=Prieto-Merino |first4=David |last5=Cleland |first5=John GF |title=Structured telephone support or non-invasive telemonitoring for patients with heart failure |journal=Cochrane Database of Systematic Reviews |date=31 October 2015 |volume=2015 |issue=10 |pages=CD007228 |doi=10.1002/14651858.CD007228.pub3|pmc=8482064 |pmid=26517969 |hdl=2328/35732 |hdl-access=free }}</ref> People with severe agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place".<ref>{{Cite web |url=http://www.mayoclinic.com/health/agoraphobia/DS00894 |title=Agoraphobia |publisher=MayoClinic.com |date=21 April 2011 |access-date=2012-06-15 |url-status=live |archive-url=https://web.archive.org/web/20120624042624/http://www.mayoclinic.com/health/agoraphobia/DS00894 |archive-date=24 June 2012 }}</ref> The word "agoraphobia" comes from the [[Social:Greek language|Greek]] words [[Social:Agora|agora]] (αγορά) and [[Medicine:Phobia|Phobos]] (φόβος), the term "agora" referring to the city centre in an ancient Greek city. In Japan, people who exhibit extreme agoraphobia to the point of becoming unwilling or unable to leave their homes are referred to as ''Hikikomori''.<ref>{{Cite journal|last1=Bowker|first1=Julie C.|last2=Bowker|first2=Matthew H.|last3=Santo|first3=Jonathan B.|last4=Ojo|first4=Adesola Adebusola|last5=Etkin|first5=Rebecca G.|last6=Raja|first6=Radhi|date=2019-09-03|title=Severe Social Withdrawal: Cultural Variation in Past Hikikomori Experiences of University Students in Nigeria, Singapore, and the United States|url=https://doi.org/10.1080/00221325.2019.1633618|journal=The Journal of Genetic Psychology|volume=180|issue=4–5|pages=217–230|doi=10.1080/00221325.2019.1633618|issn=0022-1325|pmid=31305235|s2cid=196616453}}</ref> The phenomena in general is known by the same name, and it is estimated that roughly half a million Japanese youths are ''Hikikomori''.<ref>{{Cite web|author=Emiko Jozuka|date=2016-09-12|title=Why won't 541,000 young Japanese leave the house?|url=https://www.cnn.com/2016/09/11/asia/japanese-millennials-hikikomori-social-recluse/index.html|access-date=2021-01-26|website=CNN Digital|language=en|archive-date=2021-03-06|archive-url=https://web.archive.org/web/20210306183040/https://www.cnn.com/2016/09/11/asia/japanese-millennials-hikikomori-social-recluse/index.html|url-status=live}}</ref>

People who have had a panic attack in certain situations may develop [[Medicine:Phobia|phobia]]s of these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with [[Medicine:Panic disorder|panic disorder]] are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with [[Medicine:Agoraphobia|agoraphobia]].<ref>{{Cite journal|last1=Perugi|first1=Giulio|last2=Frare|first2=Franco|last3=Toni|first3=Cristina|date=2007|title=Diagnosis and treatment of agoraphobia with panic disorder|url=https://pubmed.ncbi.nlm.nih.gov/17696574/|journal=CNS Drugs|volume=21|issue=9|pages=741–764|doi=10.2165/00023210-200721090-00004|issn=1172-7047|pmid=17696574|s2cid=43437233|access-date=2021-02-03|archive-date=2021-02-24|archive-url=https://web.archive.org/web/20210224161207/https://pubmed.ncbi.nlm.nih.gov/17696574/|url-status=live}}</ref>

===Experimentally induced===
Panic attack symptoms can be experimentally induced in the laboratory by various means. Among them, for research purposes, by administering a [[Medicine:Bolus|bolus]] injection of the [[Biology:Neuropeptide|neuropeptide]] cholecystokinin-tetrapeptide ([[Chemistry:CCK-4|CCK-4]]).<ref name="Experimental panik 1">{{cite journal |last1=Leicht |first1=Gregor |last2=Mulert |first2=Christoph |last3=Eser |first3=Daniela |last4=Sämann |first4=Philipp G. |last5=Ertl |first5=Matthias |last6=Laenger |first6=Anna |last7=Karch |first7=Susanne |last8=Pogarell |first8=Oliver |last9=Meindl |first9=Thomas |last10=Czisch |first10=Michael |last11=Rupprecht |first11=Rainer |title=Benzodiazepines Counteract Rostral Anterior Cingulate Cortex Activation Induced by Cholecystokinin-Tetrapeptide in Humans |journal=Biological Psychiatry |volume=73 |issue=4 |pages=337–44 |year=2013 |pmid=23059050 |doi=10.1016/j.biopsych.2012.09.004 |s2cid=23586549 }}</ref> Various animal models of panic attacks have been experimentally studied.<ref name="Exp panic 2">{{cite journal |last1=Moreira |first1=Fabrício A. |last2=Gobira |first2=Pedro H. |last3=Viana |first3=Thércia G. |last4=Vicente |first4=Maria A. |last5=Zangrossi |first5=Hélio |last6=Graeff |first6=Frederico G. |title=Modeling panic disorder in rodents |journal=Cell and Tissue Research |volume=354 |issue=1 |pages=119–25 |year=2013 |pmid=23584609 |doi=10.1007/s00441-013-1610-1 |s2cid=14699738 }}</ref>

===Neurotransmitter imbalances===
Many [[Biology:Neurotransmitter|neurotransmitter]]s are affected when the body is under the increased [[Medicine:Stress|stress]] and [[Medicine:Anxiety|anxiety]] that accompany a panic attack. Some include [[Chemistry:Serotonin|serotonin]], GABA (gamma-aminobutyric acid), [[Biology:Dopamine|dopamine]], [[Biology:Norepinephrine|norepinephrine]], and glutamate. More research into how these neurotransmitters interact with one another during a panic attack is needed to make any solid conclusions, however.

An increase of serotonin in certain pathways of the brain seems to be correlated with reduced anxiety. More evidence that suggests serotonin plays a role in anxiety is that people who take SSRIs tend to feel a reduction of anxiety when their brain has more serotonin available to use.<ref name=By2013>{{cite journal |last1=Bystritsky |first1=Alexander |last2=Khalsa |first2=Sahib S. |last3=Cameron |first3=Michael E. |last4=Schiffman |first4=Jason |title=Current Diagnosis and Treatment of Anxiety Disorders |journal=Pharmacy and Therapeutics |date=2013 |volume=38 |issue=1 |pages=30–57 |pmid=23599668 |pmc=3628173 }}</ref>

The main inhibitory neurotransmitter in the [[Biology:Central nervous system|central nervous system]] (CNS) is GABA. Most of the pathways that use GABA tend to reduce anxiety immediately.<ref name=By2013/>

Dopamine's role in anxiety is not well understood. Some antipsychotic medications that affect dopamine production have been proven to treat anxiety. However, this may be attributed to dopamine's tendency to increase feelings of [[Philosophy:Self-efficacy|self-efficacy]] and confidence, which indirectly reduces anxiety.<ref name=By2013/>

Many physical symptoms of anxiety, such as rapid heart rate and hand tremors, are regulated by norepinephrine. Drugs that counteract norepinephrine's effect may be effective in reducing the physical symptoms of a panic attack.<ref name=By2013/> Nevertheless, some drugs that increase 'background' norepinephrine levels such as tricyclics and SNRIs are effective for the long-term treatment of panic attacks, possibly by blunting the norepinephrine spikes associated with panic attacks.<ref>{{cite journal |last1=Montoya |first1=Alonso |last2=Bruins |first2=Robert |last3=Katzman |first3=Martin A |last4=Blier |first4=Pierre |title=The noradrenergic paradox: implications in the management of depression and anxiety |journal=Neuropsychiatric Disease and Treatment |date=1 March 2016 |volume=12 |pages=541–557 |doi=10.2147/NDT.S91311 |pmid=27042068 |pmc=4780187 |doi-access=free }}</ref>

Because glutamate is the primary excitatory neurotransmitter involved in the central nervous system (CNS), it can be found in almost every neural pathway in the body. Glutamate is likely involved in conditioning, which is the process by which certain fears are formed, and extinction, which is the elimination of those fears.<ref name=By2013/>

==Pathophysiology==
The symptoms of a panic attack may cause the person to feel that their body is failing. The symptoms can be understood as follows. First, there is frequently the sudden onset of fear with little provoking stimulus. This leads to a release of [[Biology:Adrenaline|adrenaline]] (epinephrine) which brings about the [[Fight-or-flight response|fight-or-flight response]] when the body prepares for strenuous physical activity. This leads to an increased heart rate ([[Medicine:Tachycardia|tachycardia]]), rapid breathing (hyperventilation) which may be perceived as shortness of breath (dyspnea), and sweating. Because strenuous activity rarely ensues, the hyperventilation leads to a drop in [[Chemistry:Carbon dioxide|carbon dioxide]] levels in the [[Medicine:Lung|lung]]s and then in the [[Biology:Blood|blood]]. This leads to shifts in blood [[Chemistry:PH|pH]] (respiratory alkalosis or hypocapnia), causing compensatory metabolic acidosis activating chemosensing mechanisms that translate this [[Chemistry:PH|pH]] shift into autonomic and respiratory responses.<ref>{{cite journal |last1=Vollmer |first1=L L |last2=Strawn |first2=J R |last3=Sah |first3=R |title=Acid–base dysregulation and chemosensory mechanisms in panic disorder: a translational update |journal=Translational Psychiatry |date=May 2015 |volume=5 |issue=5 |pages=e572 |doi=10.1038/tp.2015.67 |pmid=26080089 |pmc=4471296 }}</ref><ref>{{cite journal |last1=Ueda |first1=Y. |last2=Aizawa |first2=M. |last3=Takahashi |first3=A. |last4=Fujii |first4=M. |last5=Isaka |first5=Y. |title=Exaggerated compensatory response to acute respiratory alkalosis in panic disorder is induced by increased lactic acid production |journal=Nephrology Dialysis Transplantation |date=8 October 2008 |volume=24 |issue=3 |pages=825–828 |doi=10.1093/ndt/gfn585 |pmid=18940883 |doi-access=free }}</ref>

Moreover, this hypocapnia and release of [[Biology:Adrenaline|adrenaline]] during a panic attack cause [[Chemistry:Vasoconstriction|vasoconstriction]] resulting in slightly less blood flow to the head which causes [[Medicine:Dizziness|dizziness]] and lightheadedness.<ref>{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK53082/|title=Control of Cerebral Blood Flow|last=Cipolla|first=Marilyn J.|date=2009|publisher=Morgan & Claypool Life Sciences|language=en|access-date=2017-10-04|archive-date=2020-09-28|archive-url=https://web.archive.org/web/20200928121535/https://www.ncbi.nlm.nih.gov/books/NBK53082/|url-status=live}}</ref><ref>{{Cite book|url=https://books.google.com/books?id=JWNBDAAAQBAJ&q=vasoconstriction+panic+attack+Co2&pg=PA189|title=Panic Disorder: Neurobiological and Treatment Aspects|last1=Nardi|first1=Antonio Egidio|last2=Freire|first2=Rafael Christophe R.|date=2016-05-25|publisher=Springer|isbn=978-3-319-12538-1|language=en|access-date=2020-10-27|archive-date=2023-12-30|archive-url=https://web.archive.org/web/20231230124637/https://books.google.com/books?id=JWNBDAAAQBAJ&q=vasoconstriction+panic+attack+Co2&pg=PA189#v=snippet&q=vasoconstriction%20panic%20attack%20Co2&f=false|url-status=live}}</ref> A panic attack can cause blood sugar to be drawn away from the [[Biology:Human brain|brain]] and toward the major muscles. [[Biology:Neuroimaging|Neuroimaging]] suggests heightened activity in the [[Medicine:Amygdala|amygdala]], [[Biology:Thalamus|thalamus]], [[Biology:Hypothalamus|hypothalamus]], and [[Biology:Brainstem|brainstem]] regions including the periaqueductal gray, parabrachial nucleus, and Locus coeruleus.<ref>{{cite journal |last1=Shin |first1=Lisa M |last2=Liberzon |first2=Israel |title=The Neurocircuitry of Fear, Stress, and Anxiety Disorders |journal=Neuropsychopharmacology |date=January 2010 |volume=35 |issue=1 |pages=169–191 |doi=10.1038/npp.2009.83 |pmid=19625997 |pmc=3055419 }}</ref> In particular, the [[Medicine:Amygdala|amygdala]] has been suggested to have a critical role.<ref>{{cite journal |last1=Maren |first1=Stephen |title=An Acid-Sensing Channel Sows Fear and Panic |journal=Cell |date=November 2009 |volume=139 |issue=5 |pages=867–869 |doi=10.1016/j.cell.2009.11.008 |pmid=19945375 |hdl=2027.42/83231 |s2cid=18322284 |hdl-access=free }}</ref> The combination of increased activity in the [[Medicine:Amygdala|amygdala]] (fear center) and [[Biology:Brainstem|brainstem]] along with decreased blood flow and blood sugar in the brain can lead to decreased activity in the [[Biology:Prefrontal cortex|prefrontal cortex]] (PFC) region of the brain.<ref>{{Cite book|url=https://books.google.com/books?id=EhCDCwAAQBAJ&q=A+panic+attack+can+cause+blood+sugar+to+be+drawn+away+from+the+brain+and+toward+the+major+muscles.&pg=PA273|title=A Guide to the Standard EMDR Therapy Protocols for Clinicians, Supervisors, and Consultants, Second Edition|last=PhD|first=Andrew M. Leeds|date=2016-02-03|publisher=Springer Publishing Company|isbn=978-0-8261-3117-1|language=en|access-date=2020-10-27|archive-date=2023-12-30|archive-url=https://web.archive.org/web/20231230124605/https://books.google.com/books?id=EhCDCwAAQBAJ&q=A+panic+attack+can+cause+blood+sugar+to+be+drawn+away+from+the+brain+and+toward+the+major+muscles.&pg=PA273#v=snippet&q=A%20panic%20attack%20can%20cause%20blood%20sugar%20to%20be%20drawn%20away%20from%20the%20brain%20and%20toward%20the%20major%20muscles.&f=false|url-status=live}}</ref> There is evidence that having an anxiety disorder increases the risk of cardiovascular disease (CVD).<ref name=pmid25071612>{{cite journal |last1=Chalmers |first1=John A. |last2=Quintana |first2=Daniel S. |last3=Abbott |first3=Maree J.-Anne |last4=Kemp |first4=Andrew H. |title=Anxiety Disorders are Associated with Reduced Heart Rate Variability: A Meta-Analysis |journal=Frontiers in Psychiatry |date=11 July 2014 |volume=5 |page=80 |doi=10.3389/fpsyt.2014.00080 |pmid=25071612 |pmc=4092363 |doi-access=free }}</ref> Those affected also have a reduction in heart rate variability.<ref name=pmid25071612/>

=== Cardiovascular disease ===
People who have been diagnosed with panic disorder have approximately double the risk of coronary heart disease.<ref name=pmid24923348>{{cite journal |last1=Soares-Filho |first1=Gastao L. F. |last2=Arias-Carrion |first2=Oscar |last3=Santulli |first3=Gaetano |last4=Silva |first4=Adriana C. |last5=Machado |first5=Sergio |last6=Nardi |first6=Alexandre M. Valenca and Antonio E. |last7=Nardi |first7=AE |title=Chest Pain, Panic Disorder and Coronary Artery Disease: A Systematic Review |journal=CNS & Neurological Disorders Drug Targets |date=31 July 2014 |volume=13 |issue=6 |pages=992–1001 |doi=10.2174/1871527313666140612141500 |pmid=24923348 }}</ref> Certain stress responses to depression also have been shown to increase the risk and those diagnosed with both depression and panic disorder are nearly three times more at risk.<ref name=pmid24923348/>

==Diagnosis==
According to the DSM-5 a panic attack is part of the diagnostic class of [[Medicine:Anxiety disorder|anxiety disorders]].  It is not considered a specific disorder on its own, with the symptoms of a panic attack regarded as characteristics of another disorder during which the panic attack occurs. <ref name=":0">{{Cite web |last=Rockville (MD) |first=Substance Abuse and Mental Health Services Administration. |date=June 2016 |title=Table 3.10, Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5 |url=https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t10/ |access-date=2023-03-14 |website=www.ncbi.nlm.nih.gov |language=en |archive-date=2023-03-07 |archive-url=https://web.archive.org/web/20230307001612/https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t10/ |url-status=live }}</ref>   DSM-5 criteria for a panic attack is defined as "''an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of the following symptoms occur": <ref name=":0" />'' 
{{Col-begin}}
{{Col-2}}
*Palpitations, and/or accelerated heart rate
*Sweating
*Trembling or shaking
*Sensations of shortness of breath or being smothered
*Feeling of choking
*Chest pain or discomfort
*Nausea or abdominal distress
{{Col-2}}
*Feeling dizzy, unsteady, lightheaded, or faint
*Derealization (feelings of unreality) or depersonalization (being detached from oneself)
*Fear of losing control or going insane
*Sense of impending doom
*Paresthesias (numbness or tingling sensations)
*Chills or heat sensations
{{Col-end}}<ref name=":0" />
In DSM-5, culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Some or all of these symptoms can be found in the presence of a [[Medicine:Pheochromocytoma|pheochromocytoma]].

Screening tools such as the Panic Disorder Severity Scale can be used to detect possible cases of disorder and suggest the need for a formal diagnostic assessment.<ref>{{cite journal |last1=Houck |first1=P. R. |last2=Spiegel |first2=D. A. |last3=Shear |first3=M. K. |last4=Rucci |first4=P. |year=2002 |title=Reliability of the self-report version of the Panic Disorder Severity Scale |journal=Depression and Anxiety |volume=15 |issue=4 |pages=183–185 |doi=10.1002/da.10049 |pmid=12112724|s2cid=25176812 }}</ref><ref>{{cite journal |last1=Shear |first1=M. K. |last2=Rucci |first2=P. |last3=Williams |first3=J. |last4=Frank |first4=E. |last5=Grochocinski |first5=V. |last6=Vander Bilt |first6=J. |last7=Houck |first7=P. |last8=Wang |first8=T. |year=2001 |title=Reliability and validity of the Panic Disorder Severity Scale: Replication and extension |journal=Journal of Psychiatric Research |volume=35 |issue=5 |pages=293–296 |doi=10.1016/S0022-3956(01)00028-0 |pmid=11591432 }}</ref>

==Treatment==
Panic disorder is usually effectively treated with a variety of interventions, including psychological therapies and medication.<ref>{{Cite web |title=Panic disorder: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/article/000924.htm |access-date=2023-03-12 |website=medlineplus.gov |language=en |archive-date=2023-06-08 |archive-url=https://web.archive.org/web/20230608055731/https://medlineplus.gov/ency/article/000924.htm |url-status=live }}</ref><ref name=Bourne2005/> [[Medicine:Cognitive behavioral therapy|Cognitive-behavioral therapy]] has the most complete and longest duration of effect, followed by specific [[Chemistry:Selective serotonin reuptake inhibitor|selective serotonin reuptake inhibitor]]s.<ref>{{cite book |title=Generalised anxiety disorder and panic disorder in adults: management |date=26 July 2019 |publisher=[[Organization:National Institute for Health and Care Excellence|National Institute for Health and Care Excellence]] |series=Clinical Guideline 113 |url=https://www.nice.org.uk/guidance/cg113 |isbn=978-1-4731-2854-5 |access-date=8 January 2021 |archive-date=22 November 2018 |archive-url=https://web.archive.org/web/20181122005818/https://www.nice.org.uk/guidance/cg113 |url-status=live }}</ref> A 2009 review found positive results from therapy and medication and a much better result when the two were combined.<ref name=pmid17654408>{{cite journal |last1=Bandelow |first1=Borwin |last2=Seidler-Brandler |first2=Ulrich |last3=Becker |first3=Andreas |last4=Wedekind |first4=Dirk |last5=Rüther |first5=Eckart |title=Meta-analysis of randomized controlled comparisons of psychopharmacological and psychological treatments for anxiety disorders |journal=The World Journal of Biological Psychiatry |date=January 2007 |volume=8 |issue=3 |pages=175–187 |doi=10.1080/15622970601110273 |pmid=17654408 |s2cid=8504020 }}</ref>

===Lifestyle changes===
[[Biology:Caffeine|Caffeine]] may cause or exacerbate panic anxiety. Anxiety can temporarily increase during withdrawal from caffeine and various other drugs.<ref>American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev., p. 479). Washington, D.C.: American Psychiatric Association.{{page needed|date=January 2021}}</ref>

Increased and regimented aerobic exercise such as running has been shown to have a positive effect on combating panic anxiety. There is evidence that suggests that this effect is correlated to the release of exercise-induced [[Biology:Endorphins|endorphins]] and the subsequent reduction of the stress hormone [[Chemistry:Cortisol|cortisol]].<ref>{{cite web |url=http://psychcentral.com/blog/archives/2013/07/17/3-tips-for-using-exercise-to-shrink-anxiety/ |title=3 Tips for Using Exercise to Shrink Anxiety |access-date=2015-04-14 |url-status=live |archive-url=https://web.archive.org/web/20150420020719/http://psychcentral.com/blog/archives/2013/07/17/3-tips-for-using-exercise-to-shrink-anxiety/ |archive-date=20 April 2015 |date=2013-07-17 }}{{full citation needed|date=August 2015}}</ref>

There remains a chance of panic symptoms becoming triggered or being made worse due to increased respiration rate that occurs during aerobic exercise. This increased respiration rate can lead to hyperventilation and [[Medicine:Hyperventilation syndrome|hyperventilation syndrome]], which mimics symptoms of a heart attack, thus inducing a panic attack.<ref>{{MedlinePlusEncyclopedia|003071|Hyperventilation}}</ref> The benefits of incorporating an exercise regimen have shown the best results when paced accordingly.<ref>{{cite web |url=http://www.livestrong.com/article/103790-cardio-exercise-beginners |title=Cardio Exercise for Beginners |access-date=2015-04-14 |url-status=live |archive-url=https://web.archive.org/web/20150423164013/http://www.livestrong.com/article/103790-cardio-exercise-beginners/ |archive-date=23 April 2015 }}{{full citation needed|date=August 2015}}</ref>

Meditation may also be helpful in the treatment of [[Medicine:Panic disorder|panic disorder]]s.<ref>{{cite journal |last1=Kabat-Zinn |first1=J |last2=Massion |first2=AO |last3=Kristeller |first3=J |last4=Peterson |first4=LG |last5=Fletcher |first5=KE |last6=Pbert |first6=L |last7=Lenderking |first7=WR |last8=Santorelli |first8=SF |date=July 1992 |title=Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders |journal=American Journal of Psychiatry |volume=149 |issue=7 |pages=936–943 |citeseerx=10.1.1.474.4968 |doi=10.1176/ajp.149.7.936 |pmid=1609875}}</ref>

Muscle relaxation techniques are useful to some individuals. These can be learned using recordings, videos, or books. While muscle relaxation has proved to be less effective than cognitive-behavioral therapies in controlled trials, many people still find at least temporary relief from muscle relaxation.<ref name="Panic disorder"/>

===Breathing exercises===
In the great majority of cases, [[Medicine:Hyperventilation syndrome|hyperventilation]] is involved, exacerbating the effects of the panic attack. Breathing retraining exercise helps to rebalance the oxygen and CO<sub>2</sub> levels in the blood.<ref>{{Cite web |url=http://emedicine.medscape.com/article/807277-overview#a6 |title=Hyperventilation Syndrome  |date=28 November 2016 |access-date=2017-09-18 |url-status=live |archive-url=https://web.archive.org/web/20170713055956/http://emedicine.medscape.com/article/807277-overview |archive-date=13 July 2017 }}</ref>

David D. Burns recommends breathing exercises for those with anxiety. One such breathing exercise is a 5-2-5 count. Using the stomach (or diaphragm)—and not the chest—inhale (feel the stomach come out, as opposed to the chest expanding) for 5 seconds. As the maximal point at inhalation is reached, hold the breath for 2 seconds. Then slowly exhale, over 5 seconds. Repeat this cycle twice and then breathe 'normally' for 5 cycles (1 cycle = 1 inhale + 1 exhale). The point is to focus on breathing and relax the heart rate. Regular [[Biology:Diaphragmatic breathing|diaphragmatic breathing]] may be achieved by extending the out-breath by counting or humming.<ref>{{Cite journal|last1=Bhagat|first1=Vidya|last2=Haque2|first2=Mainul|last3=Jaalam3|first3=Kamarudin|date=2017|title=Breathing Exercise - A Commanding Tool for Self-help Management during Panic attacks|url=https://www.researchgate.net/publication/323111032|journal=Research Journal of Pharmacy and Technology, 10(12), 4471-4473.|volume=10|issue=12|pages=4471–4473|via=}}</ref>

Although breathing into a paper bag was a common recommendation for short-term treatment of symptoms of an acute panic attack,<ref>[http://www.netdoctor.co.uk/ate/mentalhealth/205625.html Breathing in and out of a paper bag] {{webarchive|url=https://web.archive.org/web/20071021032153/http://www.netdoctor.co.uk/ate/mentalhealth/205625.html |date=21 October 2007 }}</ref> it has been criticized as inferior to measured breathing, potentially worsening the panic attack and possibly reducing needed blood oxygen.<ref>{{cite book |last1=Bergeron |first1=J. David |last2=Le Baudour |first2=Chris |title=First Responder |edition=8 |year=2009 |publisher=Pearson Prentice Hall |location=New Jersey |isbn=978-0-13-614059-7 |page=262 |chapter=Chapter 9: Caring for Medical Emergencies |quote= Do not use a paper bag in an attempt to treat hyperventilation. These patients can often be cared for with low-flow oxygen and lots of reassurance}}</ref><ref name=paperbaghazard>[http://firstaid.about.com/od/shortnessofbreat1/f/07_paper_bags.htm Hyperventilation Syndrome – Can I treat hyperventilation syndrome by breathing into a paper bag?] {{webarchive|url=https://web.archive.org/web/20130120102140/http://firstaid.about.com/od/shortnessofbreat1/f/07_paper_bags.htm |date=20 January 2013 }}</ref> While the paper bag technique increases needed [[Chemistry:Carbon dioxide|carbon dioxide]] and so reduces symptoms, it may excessively lower [[Chemistry:Oxygen|oxygen]] levels in the bloodstream.

Capnometry, which provides exhaled CO<sub>2</sub> levels, may help guide breathing.<ref>{{Cite web|url=http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?10/7/10353/|title=Psychotherapy for panic disorder|last=Craske|first=Michelle|date=30 September 2011|access-date=29 April 2020|archive-url=https://web.archive.org/web/20171014035243/http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?10%2F7%2F10353%2F|archive-date=14 October 2017|url-status=dead}}</ref><ref>{{cite journal |last1=Meuret |first1=Alicia E. |last2=Ritz |first2=Thomas |title=Hyperventilation in panic disorder and asthma: Empirical evidence and clinical strategies |journal=International Journal of Psychophysiology |date=October 2010 |volume=78 |issue=1 |pages=68–79 |doi=10.1016/j.ijpsycho.2010.05.006 |pmid=20685222 |pmc=2937087 }}</ref>

===Therapy===
According to the American Psychological Association, "most specialists agree that a [[Medicine:Cognitive behavioral therapy|combination of cognitive and behavioral therapies]] are the best treatment for panic disorder. Medication might also be appropriate in some cases."<ref>{{cite web |title=Answers to Your Questions About Panic Disorder |url=https://www.apa.org/topics/anxiety/panic-disorder |website=American Psychological Association |year=2008 |access-date=2021-01-08 |archive-date=2021-01-10 |archive-url=https://web.archive.org/web/20210110071101/https://www.apa.org/topics/anxiety/panic-disorder |url-status=live }}</ref> The first part of therapy is largely informational; many people are greatly helped by simply understanding exactly what panic disorder is and how many others experience it. Many people with panic disorder are worried that their panic attacks mean they are "going crazy" or that the panic might induce a heart attack. [[Medicine:Cognitive restructuring|Cognitive restructuring]] helps people to replace those thoughts with more realistic, positive ways of viewing the attacks.<ref name="Cognitive Restructuring Ability">{{Cite web|url=http://www.cehd.umn.edu/rationalnumberproject/89_2.html|title=Cognitive Restructuring Ability, Teacher Guidance and Perceptual Distracter Tasks: An Aptitude Treatment Interaction Study|last=Cramer, K., Post, T., & Behr, M.|date=January 1989|access-date=2010-11-19|url-status=live|archive-url=https://web.archive.org/web/20101222180132/http://www.cehd.umn.edu/rationalnumberproject/89_2.html|archive-date=22 December 2010}}</ref> Avoidant behavior is one of the key aspects that prevent people with frequent panic attacks from functioning healthily.<ref name="Panic disorder"/> Exposure therapy,<ref>{{Cite book|title = Exposure Therapy for Anxiety: Principles and Practice|url = https://books.google.com/books?id=7RAsnO1vU0UC|publisher = Guilford Press|date = 17 December 2012|isbn = 978-1-4625-0969-0|first1 = Jonathan S.|last1 = Abramowitz|first2 = Brett J.|last2 = Deacon|first3 = Stephen P. H.|last3 = Whiteside|url-status = live|archive-url = https://web.archive.org/web/20160520171142/https://books.google.com/books?id=7RAsnO1vU0UC|archive-date = 20 May 2016}}</ref> which includes repeated and prolonged confrontation with feared situations and body sensations, helps weaken anxiety responses to panic-inducing external and internal stimuli and reinforce realistic ways of viewing panic symptoms.

In deeper-level psychoanalytic approaches, in particular [[Philosophy:Object relations theory|object relations theory]], panic attacks are frequently associated with [[Philosophy:Splitting (psychology)|splitting (psychology)]], paranoid-schizoid and depressive positions, and [[Social:Paranoid anxiety|paranoid anxiety]]. They are often found to be comorbid with [[Medicine:Borderline personality disorder|borderline personality disorder]] and [[Medicine:Child sexual abuse|child sexual abuse]]. Paranoid anxiety may reach the level of a persecutory anxiety state.<ref>{{cite book|last=Waska|first=Robert|title=Treating Severe Depressive and Persecutory Anxiety States: To Transform the Unbearable|year=2010|publisher=Karnac Books|isbn=978-1855757202}}{{page needed|date=January 2021}}</ref>

There was a meta-analysis of the comorbidity of panic disorders and agoraphobia. It used exposure therapy to treat patients over a period. Hundreds of patients were used in these studies and they all met the DSM-IV criteria for both of these disorders.<ref name=pmid11459386>{{cite journal |last1=Fava |first1=G. A. |last2=Rafanelli |first2=C. |last3=Grandi |first3=S. |last4=Conti |first4=S. |last5=Ruini |first5=C. |last6=Mangelli |first6=L. |last7=Belluardo |first7=P. |title=Long-term outcome of panic disorder with agoraphobia treated by exposure |journal=Psychological Medicine |date=July 2001 |volume=31 |issue=5 |pages=891–898 |doi=10.1017/s0033291701003592 |pmid=11459386 |s2cid=5652068 }}</ref> A result was that thirty-two percent of patients had a panic episode after treatment. They concluded that the use of exposure therapy has lasting efficacy for a client who is living with a panic disorder and agoraphobia.<ref name=pmid11459386/>

The efficacy of group therapy treatment over conventional individual therapy for people with panic disorder with or without agoraphobia appears similar.<ref name="Schwartze et al 2017">{{cite journal |last1=Schwartze |first1=Dominique |last2=Barkowski |first2=Sarah |last3=Strauss |first3=Bernhard |last4=Burlingame |first4=Gary M. |last5=Barth |first5=Jürgen |last6=Rosendahl |first6=Jenny |title=Efficacy of group psychotherapy for panic disorder: Meta-analysis of randomized, controlled trials |journal=Group Dynamics: Theory, Research, and Practice |date=June 2017 |volume=21 |issue=2 |pages=77–93 |doi=10.1037/gdn0000064 |s2cid=152168481 }}</ref>

=== Medication ===
Medication options for panic attacks typically include [[Chemistry:Benzodiazepine|benzodiazepine]]s and antidepressants. Benzodiazepines are being prescribed less often because of their potential side effects, such as dependence, fatigue, slurred speech, and memory loss.<ref>{{cite journal |last1=Batelaan |first1=Neeltje M. |last2=Van Balkom |first2=Anton J. L. M. |last3=Stein |first3=Dan J. |title=Evidence-based pharmacotherapy of panic disorder: an update |journal=The International Journal of Neuropsychopharmacology |date=April 2012 |volume=15 |issue=3 |pages=403–415 |doi=10.1017/S1461145711000800 |pmid=21733234 |doi-access=free |hdl=1871/42311 |hdl-access=free }}</ref> Antidepressant treatments for panic attacks include selective serotonin reuptake inhibitors ([[Chemistry:Selective serotonin reuptake inhibitor|SSRIs]]), serotonin noradrenaline reuptake inhibitors ([[Chemistry:Serotonin–norepinephrine reuptake inhibitor|SNRIs]]), [[Chemistry:Tricyclic antidepressant|tricyclic antidepressant]]s (TCAs), and MAO inhibitors (MAOIs). SSRIs in particular tend to be the first drug treatment used to treat panic attacks. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants appear similar for short-term efficacy.<ref name=pmid12197851>{{cite journal |last1=Bakker |first1=A. |last2=Van Balkom |first2=A. J. L. M. |last3=Spinhoven |first3=P. |title=SSRIs vs. TCAs in the treatment of panic disorder: a meta-analysis |journal=Acta Psychiatrica Scandinavica |date=2002 |volume=106 |issue=3 |pages=163–167 |doi=10.1034/j.1600-0447.2002.02255.x |pmid=12197851 |s2cid=26184300 }}</ref>

SSRIs carry a relatively low risk since they are not associated with much tolerance or dependence, and are difficult to overdose with. TCAs are similar to SSRIs in their many advantages but come with more common side effects such as weight gain and cognitive disturbances. They are also easier to overdose on. MAOIs are generally suggested for patients who have not responded to other forms of treatment.<ref name=pmid18728820>{{cite journal |last1=Marchesi |first1=Carlo |title=Pharmacological management of panic disorder |journal=Neuropsychiatric Disease and Treatment |date=March 2008 |volume=4 |issue=1 |pages=93–106 |doi=10.2147/ndt.s1557 |pmid=18728820 |pmc=2515914 |doi-access=free }}</ref>

While the use of drugs in treating panic attacks can be very successful, it is generally recommended that people also be in some form of therapy, such as cognitive-behavioral therapy. Drug treatments are usually used throughout the duration of panic attack symptoms and discontinued after the patient has been free of symptoms for at least six months. It is usually safest to withdraw from these drugs gradually while undergoing therapy.<ref name="Panic disorder"/> While drug treatment seems promising for children and adolescents, they are at an increased risk of suicide while taking these medications and their well-being should be monitored closely.<ref name=pmid18728820/>

==Prognosis==
Roughly one-third are treatment-resistant.<ref name=pmid26635099>{{cite journal |last1=Freire |first1=Rafael C. |last2=Zugliani |first2=Morena M. |last3=Garcia |first3=Rafael F. |last4=Nardi |first4=Antonio E. |title=Treatment–resistant panic disorder: a systematic review |journal=Expert Opinion on Pharmacotherapy |date=22 January 2016 |volume=17 |issue=2 |pages=159–168 |doi=10.1517/14656566.2016.1109628 |pmid=26635099 |s2cid=9242842 }}</ref> These people continue to have panic attacks and various other panic disorder symptoms after receiving treatment.<ref name=pmid26635099/>

Many people being treated for panic attacks begin to experience [[Medicine:Limited symptom attack|limited symptom attack]]s. These panic attacks are less comprehensive, with fewer than four bodily symptoms being experienced.<ref name=Bourne2005/>

It is not unusual to experience only one or two symptoms at a time, such as vibrations in their legs, shortness of breath, or an intense wave of heat traveling up their bodies, which is not similar to hot flashes due to estrogen shortage. Some symptoms, such as vibrations in the legs, are sufficiently different from any normal sensation that they indicate a panic disorder. Other symptoms on the list can occur in people who may or may not have panic disorder. Panic disorder does not require four or more symptoms to all be present at the same time. Causeless panic and racing heartbeat are sufficient to indicate a panic attack.<ref name=Bourne2005/>

==Epidemiology==
In Europe, about 3% of the population has a panic attack in a given year while in the United States they affect about 11%.<ref name=DSM5/> They are more common in females than in males.<ref name=DSM5/> They often begin during puberty or early adulthood.<ref name=DSM5/> Children and older people are less commonly affected.<ref name="DSM5"/> A meta-analysis was conducted on data collected about twin studies and family studies on the link between genes and panic disorder. The researchers also examined the possibility of a link to phobias, obsessive-compulsive disorder (OCD), and generalized anxiety disorder. The researchers used a database called [[MEDLINE]] to accumulate their data.<ref name=pmid11578982>{{cite journal |last1=Hettema |first1=John M. |last2=Neale |first2=Michael C. |last3=Kendler |first3=Kenneth S. |title=A Review and Meta-Analysis of the Genetic Epidemiology of Anxiety Disorders |journal=American Journal of Psychiatry |date=October 2001 |volume=158 |issue=10 |pages=1568–1578 |doi=10.1176/appi.ajp.158.10.1568 |pmid=11578982 |s2cid=7865025 }}</ref> The results concluded that the aforementioned disorders have a genetic component and are inherited or passed down through genes. For the non-phobias, the likelihood of inheriting is 30–40%, and for the phobias, it was 50–60%.<ref name=pmid11578982/>

==See also==
* Hysteria
* Nervous breakdown
* Panic

==References==
{{Reflist}}

== External links ==
* {{curlie|Health/Mental_Health/Disorders/Anxiety/Panic}}

{{Medical resources
| DiseasesDB=30913
|  ICD10 = {{ICD10|F|41|0|f|40}}
|  ICD9 = {{ICD9|300.01}}
|  ICDO =
|  OMIM =
|  MedlinePlus =
|  eMedicineSubj =
|  eMedicineTopic =
|  MeshID = D016584
}}

{{DEFAULTSORT:Panic Attack}}
[[Category:Anxiety]]
[[Category:Wikipedia medicine articles ready to translate]]

{{Sourceattribution|Panic attack}}