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Panic attacks
A depiction of someone experiencing a panic attack being reassured by another person
SpecialtyPsychiatry
SymptomsPeriods of intense fear, palpitations, sweating, shaking, shortness of breath, numbness[1][2]
ComplicationsSelf-harm, suicide,[2] agoraphobia
Usual onsetOver minutes[2]
DurationSeconds to hours[3]
CausesPanic disorder, social anxiety disorder, post-traumatic stress disorder, drug use, depression, medical problems[2][4]
Risk factorsNicotine, caffeine, cannabis, psychological stress[2]
Diagnostic methodAfter other possible causes excluded[2]
Differential diagnosisHyperthyroidism, hyperparathyroidism, heart disease, lung disease, drug use, dysautonomia[2]
TreatmentCounselling, medications[5]
MedicationAcute: Benzodiazepines[6] Preventative: Antidepressants, anxiolytics
PrognosisUsually good[7]
Frequency3% (EU), 11% (US)[2]

Panic attacks are sudden periods of intense fear and discomfort that may include palpitations, otherwise defined as a rapid, irregular heartbeat, sweating, chest pain or discomfort, shortness of breath, trembling, dizziness, numbness, confusion, or a sense of impending doom or loss of control.[1][2][8] Typically, these symptoms are the worst within ten minutes of onset and can last for roughly 30 minutes, though they can vary anywhere from seconds to hours.[3][9] While they can be extremely distressing, panic attacks themselves are not physically dangerous.[7][10]

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines them 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." These symptoms include, but are not limited to, the ones mentioned above.[11]

Panic attacks function as a marker for assessing severity, course, and comorbidity (the simultaneous presence of two or more diagnoses) of different disorders, including anxiety disorders.[12] Hence, while panic attacks cannot be applied to all disorders found in the DSM, they are a common comorbidity.[13]

Panic attacks can be caused by an identifiable source, or they may happen without any warning and without a specific, recognizable situation.[2]

Some known causes that increase the risk of having a panic attack include medical and psychiatric conditions (e.g., panic disorder, social anxiety disorder, post-traumatic stress disorder, substance use disorder, depression), substances (e.g., nicotine, caffeine), and psychological stress.[2][4]

Before making a diagnosis, physicians seek to eliminate other conditions that can produce similar symptoms, such as hyperthyroidism (an overactive thyroid), hyperparathyroidism (an overactive parathyroid), heart disease, lung disease, and dysautonomia, disease of the system that regulates the body's involuntary processes.[2][14]

Treatment of panic attacks should be directed at the underlying cause.[7] In those with frequent attacks, counseling or medications may be used, as both preventative and abortive measures, ones that stop the attack while it is happening.[5] Breathing training and muscle relaxation techniques may also be useful.[15]

Panic attacks often appear frightening to both those experiencing and those witnessing them, and often, people sometimes think they are having heart attacks due to the symptoms.[16][17] However, while they do not cause much immediate physical harm, they may be a predictive risk factor for cardiac and other illnesses.

Previous studies have suggested that those who suffer from anxiety disorders (e.g., panic disorder) are at higher risk of suicide.[18]

In Europe, approximately 3% of the population has a panic attack in a given year, while in the United States, they affect about 11%.[2] Panic attacks are more commonly diagnosed in females than males and often begin during late puberty or early adulthood.[2] Panic attacks can continue on and off for a lifetime, or appear only infrequently. Young children are less commonly affected.[2]

Signs and symptoms

[edit]

When people experience a panic attack, it usually comes on very suddenly and unexpectedly with a wide range of symptoms that tend to last, on average, a few minutes, but in infrequent cases can last for several hours.[19] Typically, the symptoms of panic attacks reach their worst intensity in the first minute, then gradually subside over the next several minutes.[20] During this time, people often feel intense fear that something catastrophic will happen despite there being no immediate danger.[1] The frequency of panic attacks varies between individuals, with some people experiencing a panic attack as frequently as every week, while others could have one panic attack per year.[21] The features that help define a panic attack are the collection of symptoms that accompany a panic attack. In panic disorder, panic attacks can occur unprompted; meaning there can be no obvious triggering event that causes the panic attack. Panic attacks can occur together with other anxiety disorders as well and can be associated with triggering events, such as someone with social anxiety disorder being in a difficult social situation, such as public speaking, with a co-occurring panic attack.[21]

Panic attacks are associated with many different symptoms, with a person experiencing at least four of the following symptoms: increased heart rate, chest pain, palpitations (i.e. feeling like one's heart is pounding out of one's chest), difficulty breathing, choking sensation, nausea, abdominal pain, dizziness, lightheadedness (i.e. one feels like passing out), numbness or tingling (also called paresthesias), derealization (i.e. feeling detached from reality, like the events occurring are not real), depersonalization (i.e. feeling disconnected from one's body or thoughts), fear of losing control, and fear of dying.[21]

These physical symptoms are typically concurrent with panic attacks in people who are prone to panicking. This results in increased anxiety and forms a positive feedback loop, meaning that the more a person with a panic attack has panic events, the more they experience feelings of "anticipatory anxiety" which serve to worsen their panic attacks.[22] Panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature.[23]

Chest pain

[edit]

People can experience a wide range of symptoms during their panic attacks; they tend to be very intense and frightening and the common symptoms of difficulty breathing and chest pain can sometimes cause people to believe they are having a heart attack, leading them to go to the emergency department.[20] Because chest pain and difficulty breathing are commonly symptoms of some sort of heart disease (such as a heart attack), there is medical importance in ruling out life-threatening reasons for their symptoms.[24] A heart attack (also called a myocardial infarction) occurs when there is a blockage in the arteries going to the heart, causing less blood to get to the heart tissue, and ultimately causing the heart tissue to die.[24] This would be evaluated in the emergency department with an electrocardiogram (i.e. a picture of the electrical activity of the heart) and by measuring a hormone called troponin, which is released from the heart tissue during times of stress on the tissue.[24]

Causes

[edit]
The Fight or Flight Response is quite different from a panic attack. Someone with panic may be phobic of riding in a bus, and might panic if they did. On the other hand, if that same bus were about to run them over, they would be more likely terrified, not panicky.

Panic attacks can be caused by a mix of factors. Biological factors that may lead to or be caused by panic attacks include psychiatric disorders such as post-traumatic stress disorder (PTSD) and obsessive–compulsive disorder (OCD), heart conditions, low blood pressure, and an overactive thyroid. Imbalance of the norepinephrine system, which is responsible for coordinating the body's fight-or-flight response, has been linked to panic attacks as well.[25]

Panic disorder tends to arise in early adulthood, though it can occur at any age. It is more commonly diagnosed in women and in individuals with above-average intelligence.[26][27] Research involving identical twins has shown that if one twin has an anxiety disorder, the other is likely to have one too.[28]

Panic attacks may also occur due to short-term stressors.[19] Major personal losses, like the end of a romantic relationship, life transitions such as jobs or moving, and other significant life changes may trigger a panic attack. Individuals who are naturally anxious, need a lot of reassurance, worry excessively about their health, have an overcautious view of the world, and have cumulative stress are more likely to experience panic attacks, which may actually cause some of those symptoms.[23][29] For adolescents, social transitions, such as changes in classes and schools, may also be a contributing factor.[30]

People often experience phobias as a direct result of panic attacks triggered by exposure to specific fears. A situation can become associated to panic if someone has had a previous reaction before in similar contexts, but more often panic is triggered by fear of entrapment in a potentially phobic environment such as a plane.

Psychoactive substances may also induce panic attacks. For example, discontinuation or reduction in the dose of a drug (drug withdrawal) without tapering can cause panic attacks. Other psychoactive substances that are commonly known to be associated with panic attacks include cannabis and nicotine.[31][32]

Panic disorder

[edit]
Main article: Panic disorder

A panic attack is an isolated episode of intense fear or discomfort that peaks within minutes.[33][5] 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 anxiety disorders in that panic attacks are often sudden and unprovoked.[34] However, panic attacks experienced by those with panic disorder may also be linked to or heightened by exposure to certain places or situations, making daily life difficult.[35]

If a person has repeated and unexpected panic attacks, this could be a potential sign of panic disorder.[5] According to the DSM-5, panic disorder can be diagnosed if a patient has not only recurrent panic attacks but also experiences at least a month of anxiety or worry about having additional attacks. This concern may lead to the person to modify their behavior to avoid situations that triggered the attack. Panic disorder can be diagnosed if the patient has another disorder at the same time (e.g., social anxiety disorder).[22]

Patients affected by panic disorder can struggle with depression and a diminished quality of life. Compared to the general population, they are also at increased risk for substance abuse and addiction.[22]

Agoraphobia

[edit]
Main articles: Agoraphobia and Hikikomori

Panic disorder frequently presents with agoraphobia, which is an anxiety disorder where the individual presents with fear of a situation from which they cannot leave or escape, especially if a panic attack occurs. People who have had a panic attack in certain situations may develop phobias of these situations and begin to take measure to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with panic disorder are unable to drive or even step out of the house, preferring the safety of remaining in a known place.[36] At this stage, the person is said to have panic disorder with agoraphobia.[37]

In Japan, people who exhibit extreme agoraphobia to the point of becoming unwilling or unable to leave their homes are referred to as Hikikomori.[38] This term is used to describe both the person and the phenomenon. According to some Japanese psychiatrists, Hikkimori can be caused by panic associated agoraphobia, or by withdrawal due to Social Anxiety. After first being defined by the Japanese Ministry of Health, Labor, and Welfare, a national research task force refined the definition as "the state of avoiding social engagement (e.g., education, employment, and friendships) with generally persistent withdrawal into one's residence for at least six months as a result of various factors."[39]

Pathophysiology

[edit]
The amygdala - the fear response system in our brain thought to be involved in the origin of panic attacks

When panic attacks occur, people experience the sudden onset of fear and anxiety in the setting of no actual perceived threat (ex. one's mind believes there is something threatening one's wellbeing, but there is nothing actual life-threatening occurring). This fear-based response leads to a release of the hormone adrenaline (also known as epinephrine), which brings about the fight-or-flight response. The human nervous state consists of the sympathetic nervous system, which is responsible for the fight-or-flight (active) response, and the parasympathetic nervous system, which is responsible for the rest-and-digest (passive) response.[40] The sympathetic nervous system prepares our body for strenuous physical activity (i.e. fight or flight) by affecting different bodily functions such as increasing heart rate, increasing breathing, sweating among others, leading to the physical symptoms that accompany a panic attack.[40] The exact mechanism behind panic attacks remains unclear; there are several different ideas for why some people experience panic attacks while others do not. The current theories include conscious or unconscious fears of entrapment, genetic susceptibility factors, the fear network model, theory of acid-base disturbances in the brain, and irregular activity of the amygdala (i.e. the part of the brain responsible for controlling emotions, such as fear, and identifying threats).[41][42][43][44]

Fear network model

[edit]

The fear network model hypothesizes that parts of our brain responsible for controlling the fear response that is created by the area of the brain where the amygdala is located (called the limbic system) is unable to control the fear sufficiently, leading to panic attacks.[44] It is thought that dysfunction of the area responsible for controlling fear could be due to stress experienced in childhood, along with a genetic component as well.[44] In summary, the fear network model states that the network in our brains responsible for responding to fear and then controlling that fear is not working properly, creating the inability for our brains to control fear that is occurring without any sort of external threat, leading to panic attacks.[44]

Acid-base disturbances theory

[edit]

This theory suggests that there is a part of the amygdala that is able to identify when the pH in our brain decreases, i.e. becomes more acidic.[41] This part of the amygdala is called the acid-sensing ion channel.[41] Since panic attacks typically occur without an obvious external trigger (meaning there is usually nothing life-threatening happening to cause a panic attack), studies have shown that panic attacks may be caused by internal triggers.[42] One such internal trigger is the amygdala sensing acidosis, which can be caused by inhaling CO2 (carbon dioxide).[41][42] In fact, one study has shown that people with a history of panic attacks had disturbances in their pH level minutes before having a panic attack.[42]

Another theory, called the false suffocation alarm theory, is associated with the idea of acid-base imbalances in the amygdala.[41][42] In this theory, inhalation of CO2 causes accumulation of acid in the blood and difficulty breathing, leading our brain to believe that we are suffocating, causing fear and panic.[41] Studies have shown that inhaling CO2 can cause fear in people who do not have any prior history of panic attacks.[41] This information has allowed scientists to suggest that panic attacks could be caused by our brain's inability to stop alarm signals that make us feel like we are suffocating.[41]

Amygdala dysfunction theory

[edit]

The amygdala in the human brain has several distinct sections that are responsible for our fear response. This theory suggests that problems in any of these brain areas or the connections between them could lead to excessive fear responses, like panic attacks. Studies have shown that in both animal and human subjects with a history of panic attacks, the amygdala is hyperactive with decreased volume when compared to the control. Another role the amygdala may play in panic attacks is decreasing its inhabitation (i.e. the amygdala not being shut down like it normally should), leading to increased levels of anxiety. A link between childhood traumatic experiences, as well as genetic abnormalities, has been found in those with a dysfunctional amygdala.[43]

Neurotransmitter imbalances

[edit]

Many neurotransmitters are affected when the body is under the increased stress and anxiety that accompany a panic attack. Some include serotonin, GABA (gamma-aminobutyric acid), dopamine, norepinephrine, and glutamate.[45]

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 selective serotonin reuptake inhibitors (SSRIs) tend to feel a reduction of anxiety when their brain has more serotonin available to use.[45]

The main inhibitory neurotransmitter in the central nervous system (CNS) is GABA. This neurotransmitter acts by inhibiting, or blocking nerve signals, which is very helpful in anxiety. In fact, medications that increase GABA activity in the brain, such as benzodiazepines and barbiturates, help with reducing anxiety almost immediately.[45]

Dopamine's role in anxiety is not well understood. Some antipsychotic medications that block dopamine production have been proven to treat anxiety. However, this may be attributed to dopamine's tendency to increase feelings of self-efficacy and confidence, which indirectly reduces anxiety. On the other hand, other medications that increase dopamine levels have also been found to improve anxiety.[45]

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.[45] On the other hand, some medications that raise overall norepinephrine levels, such as tricyclic antidepressants and serotonin–norepinephrine reuptake inhibitors (SNRIs), can be effective for treating panic attacks over the long term by reducing the sudden increases in norepinephrine that happen during a panic attack.[46]

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.[45]

Cardiac mechanism

[edit]

People who have been diagnosed with panic disorder have approximately double the risk of heart disease.[47] Panic attacks can cause chest pain by affecting blood flow in arteries of the heart. During a panic attack, the body's stress response is triggered which can cause the small vessels of the heart to tighten, leading to chest pain. The body's nervous system and rapid breathing during a panic attack can cause spasming of the arteries of the heart (also known as vasospasm). This can reduce blood flow to the heart, causing damage to heart tissue and chest pain, despite normal heart scans.[48]

In individuals with a history of coronary artery disease, panic attacks and stress can make chest pain worse by increasing the heart's need for oxygen. This occurs because increased heart rate, blood pressure, and stress responses (i.e. the sympathetic nervous system) puts more strain on the heart.[48][49][50]

Diagnosis

[edit]

According to the DSM-5, a panic attack is part of the diagnostic class of anxiety disorders.[51] 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":[51]

While some patients go to the emergency department due to their physical symptoms, there is no laboratory or imaging test used to diagnose panic attacks, it is a purely clinical diagnosis (i.e., the doctor uses their experience and expertise to diagnose panic attacks) once other more life-threatening diseases have been ruled out.[21] In the research laboratory, there are diagnostic challenge tests for panic that rely on increasing the levels of certain naturally occurring chemicals. Most commonly, blood levels of sodium lactate are increased, or patients are given air with an increased level of carbon dioxide. These tests are considered to be sensitive in panic diagnosis, and very specific. Due to the physical symptoms that occur with a panic attack, people tend go to the emergency department for further evaluation; however, those who are experiencing panic attacks that are affecting their health and wellness should be seen by a mental health professional, such as a therapist or psychiatrist.[21] Screening tools, such as the Panic Disorder Screener (PADIS), can be used to detect possible cases of panic disorder and suggest the need for a formal diagnostic assessment with a psychiatrist for further evaluation.[52]

Treatment

[edit]

Panic disorder is usually effectively managed with a variety of interventions, including pharmacological treatment with medication, and psychological therapies.[53][23] The focus on management of panic disorder involves reducing the frequency and intensity of panic attacks, reducing anticipatory anxiety and agoraphobia, and achieving full remission.[54]

Most panic attacks will resolve spontaneously within a course of 20 to 30 minutes without interference.[citation needed] However, benzodiazepines, specifically alprazolam and clonazepam, are frequently prescribed for panic disorder due to their quick onset of action and good tolerability. But because they take about 45 minutes to start working, they are not usually effective for ending a current, on-going attack. However, when clonazepam (which has a long half-life) is taken every 12 hours at a proper dose, it can prevent new panic attacks from starting.[55] Additionally, deep breathing techniques and relaxation can be used and are occasionally found to be helpful while the person is experiencing a panic attack or immediately after as a way to calm oneself.[54] Some maintaining causes include avoidance of panic-provoking situations or environments, anxious or negative self-talk ("what-if" thinking), mistaken beliefs (e.g., thinking one's symptoms are harmful or dangerous), and withheld feelings.

Cognitive behavioral therapy Clonazepam (every 12 hours)(CBT) may have the most complete and longest duration of effect, followed by specific selective serotonin reuptake inhibitors (SSRIs) and CBT. Some research suggests that CBT is more effective at gaining coping skills than at effecting true panic cessation.[56] A 2009 review found positive results from therapy and medication and a much better result when the two were combined.[57] Even though there are modern medications to make short-term benefits to the patients life, long-term medication for panic disorder is not always utilized. There is however, a method that is proven to be most effective in long-term treatment which is to combine different treatment styles. These different styles include both clonazepam or antidepressants, and CBT therapy.[9]

Lifestyle changes

[edit]

Growing research suggests that along with standardized medical treatments, lifestyle changes can help alleviate some of the most common mental health conditions.[58] Because of this, there has been a growing emphasis on the potential of lifestyle interventions and non-pharmacological methods for anxiety.[59] These lifestyle interventions include, but are not limited to, focusing on physical activity, substance avoidance, and relaxation techniques. All are helpful, but their anti-panic benefits are not clear cut.

Exercise, especially aerobic, have become an alternative method for decreasing symptoms of anxiety and panic. Other more relaxing forms, such as yoga and tai chi, have also had similar effects in improving anxiety and can also be used as adjunctive therapy. Numerous studies have determined that exercise is inversely related to anxiety symptoms, thus as physical activity increases, levels of anxiety seem to decrease. On the other hand, some people with panic disorder may be more averse to exercise. There is evidence that suggests that this effect is correlated to the release of exercise-induced endorphins and the subsequent reduction of the stress hormone, cortisol.[60] One thing to keep in mind is that with exercise, often comes increased respiration rate. This can lead to hyperventilation and hyperventilation syndrome, which mimics symptoms of a heart attack, thus inducing a panic attack,[61] so it is important to pace the exercise regimen accordingly.[62]

Substance avoidance can be important in reducing anxiety and panic symptoms, as many substances can cause, exacerbate, or mimic symptoms of panic disorder. For example, caffeine has been known to have anxiety and panic-inducing properties that can especially present in those who are more susceptible to panic attacks.[63] Anxiety and panic can also temporarily increase during withdrawal from caffeine and various other drugs and substances.[64]

Meditation may also be helpful in the treatment of panic disorder.[65] Muscle relaxation techniques are useful to some individuals as well. These can be learned using recordings, videos, or books. While muscle relaxation has proved to be less effective than cognitive behavioral therapy in controlled trials, many people still find at least temporary relief from muscle relaxation.[29]

Breathing exercises

[edit]

Irregularities in breathing, including hyperventilation and shortness of breath, are key features of anxiety and panic attacks.[66] Hyperventilation syndrome occurs when an individual experiences deep, quick-paced breathing, eventually affecting blood flow to the brain and altering conscious awareness.[66]

It has been shown that several various breathwork techniques can reduce symptoms in patients diagnosed with anxiety disorders. By managing and focusing on breathing, individuals with anxiety experience less tension and stress in their muscles, as well as a diminished stress response.[66] Breathing retraining exercise helps to rebalance the oxygen and CO2 levels in the blood, improving cerebral blood flow.[67] Capnometry, which provides exhaled CO2 levels, may help guide breathing.[68][69]

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.[70]

Although breathing into a paper bag was a common recommendation for short-term treatment of symptoms of an acute panic attack,[71] it has been criticized as inferior to measured breathing.[72][73]

Therapy

[edit]

According to the American Psychological Association, "most specialists agree that a combination of cognitive and behavioral therapies are the best treatment for panic disorder." Medication is appropriate in many cases.[74] 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. Cognitive restructuring helps people to replace those thoughts with more realistic, positive ways of viewing the attacks.[75] Avoidant behavior, such as what is seen in patients with agoraphobia, is one of the key aspects that prevent people with frequent panic attacks from functioning healthily.[29] Exposure therapy,[76] which includes repeated and prolonged confrontation with feared situations and body sensations, helps weaken anxiety responses to panic-inducing external and internal stimuli.

In deeper-level psychoanalytic approaches, in particular object relations theory, panic attacks are frequently associated with splitting (psychology), paranoid-schizoid and depressive positions, and paranoid anxiety. They are often found to be comorbid with borderline personality disorder and child sexual abuse.[77]

There was a meta-analysis of the comorbidity of panic disorders and agoraphobia that used exposure therapy to treat hundreds of patients over a period of time.[78] A result was that thirty-two percent of patients had a panic episode after treatment. They concluded that the use of exposure therapy has some efficacy for a client who is living with a panic disorder and agoraphobia.[78]

Medication

[edit]

Medication options for panic attacks typically include benzodiazepines (clonazepam and alprazolam) and antidepressants. Benzodiazepines are being prescribed less often because excess concern about such potential side effects such as dependence, fatigue, slurred speech, and memory loss.[6] Antidepressant treatments for panic attacks include selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs).[79]

SSRIs in particular tend to be the first drug treatment used to treat panic attacks. SSRIs and tricyclic antidepressants appear similar for short-term efficacy.[79]

SSRIs carry a relatively low risk since they are not associated with much tolerance or dependence, and have a more tolerable side effect profile. TCAs are similar to SSRIs in their many advantages, and may be more effecive, but they do come with more common side effects such as weight gain and cognitive disturbances. MAOIs are generally suggested for patients who have not responded to other forms of treatment.[80]

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 discontinue these drugs gradually while undergoing therapy.[29] While drug treatment seems promising for children and adolescents, they are at an increased risk of suicidal thoughts while taking these medications and their well-being should be monitored closely.[80]

Prognosis

[edit]

Panic attacks, while unpleasant, are not life-threatening. However, recurrent panic attacks can significantly affect one's mental health if people experiencing them do not seek or benefit from treatment. Sometimes, panic attacks can develop into phobias or panic disorder if untreated. However, when treated, people can do very well, with symptoms decreasing or fully disappearing within several weeks to months.[81]

Epidemiology

[edit]

In Europe, about 3% of the population has a panic attack in a given year. In the United States, they affect about 11%.[2] Panic attacks are more common in females than in males.[2] They often begin during puberty or early adulthood.[2] Children and older people are less commonly affected.[2] Results from twin and family studies have concluded that disorders, such as panic disorder, have a genetic component and are inherited or passed down through genes.[82]

See also

[edit]

References

[edit]
[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Panic attack

View on Grokipedia
from Grokipedia
A panic attack is a sudden episode of intense or discomfort that reaches a peak within minutes, during which at least four of the following symptoms occur: or accelerated , sweating, trembling or shaking, sensations of or smothering, feelings of , or discomfort, or abdominal distress, feeling dizzy or faint, chills or heat sensations, paresthesias (numbness or tingling), (feelings of unreality) or depersonalization (being detached from oneself), fear of losing control or "going crazy," and fear of dying. These episodes are not triggered by real danger and typically last from a few minutes to half an hour, though the they provoke can linger. While panic attacks are not life-threatening, they can mimic serious medical conditions like heart attacks, leading individuals to seek emergency care. Panic attacks can occur in isolation or as part of various conditions, most notably panic disorder, which is defined by recurrent, unexpected attacks followed by at least one month of persistent about additional attacks or significant maladaptive changes in behavior related to the attacks. In the general population, lifetime of panic attacks is estimated at 13.2%, with a projected risk of 23% by age 75, making them a relatively common experience. By contrast, panic disorder has a lifetime of 4.7% and a past-year of about 2.7% among U.S. adults (as of 2001-2003 data), with past-year rates higher among females (3.8%) than males (1.6%). Isolated panic attacks may also arise in other anxiety disorders, such as or specific phobias, or in response to substance use, medical conditions, or major stressors. The underlying causes of panic attacks are multifaceted and not fully understood, but they are thought to involve a dysregulated response in the , particularly in the and related neural circuits, combined with genetic predispositions. Major life stressors, such as trauma, loss, or significant changes, can trigger or exacerbate attacks, while biological factors like alterations in systems (e.g., serotonin and norepinephrine) play a role. Risk factors include a family history of , female sex (women are twice as likely to experience them), onset typically in late adolescence or early adulthood, excessive or use, and certain personality traits like heightened sensitivity to bodily sensations. Untreated recurrent attacks can lead to complications such as (avoidance of situations where escape might be difficult), depression, substance misuse, or chronic avoidance behaviors that impair daily functioning.

Signs and Symptoms

Physical Symptoms

Panic attacks are characterized by a sudden onset of intense physical symptoms that typically peak within minutes and last from 5 to 30 minutes, though some residual effects may persist longer. These episodes arise abruptly, often without an apparent trigger, and involve activation of the body's , leading to a cluster of autonomic manifestations. Common physical symptoms include , pounding heart, or accelerated ; sweating; trembling or shaking; sensations of or smothering; feelings of or throat tightness; or discomfort; or abdominal distress; extreme fatigue or exhaustion; feeling dizzy, unsteady, lightheaded, or faint; chills or heat sensations or hot flushes; and paresthesias, such as numbness or tingling sensations. These symptoms can occur in various combinations, with at least four typically required for a full panic attack episode. Trembling or shaking often manifests prominently in the hands. In cases involving significant hyperventilation, carpopedal spasms may occur, leading to involuntary cramps, contractions, or fist-like clenching of the hands and feet due to respiratory alkalosis and reduced ionized calcium levels. The combination of sudden overwhelming fatigue, nausea, and intense anxiety or fear is commonly associated with panic attacks. Panic attacks can onset suddenly and include intense anxiety or fear, nausea, and feelings of extreme fatigue or exhaustion. These symptoms can also occur in other conditions such as hypoglycemia, dehydration, or more serious issues like heart problems or adrenal insufficiency, but panic attacks are a frequent cause. Seek medical attention if symptoms are severe or recurrent. Chest pain or discomfort during a panic attack is often described as a sharp, stabbing, pressure-like, or tightness sensation in the chest. This discomfort can arise not only during acute episodes but also when thinking about stressful situations, as cognitive triggers alone can activate the body's fight-or-flight response, releasing stress hormones such as adrenaline and cortisol. This leads to muscle tension in the chest (particularly the intercostal muscles), hyperventilation, increased heart rate, and sensations of tightness, sharpness, stabbing, or pressure—even without an external physical threat. This discomfort can radiate to the arms (including the left arm), neck, or jaw and closely mimic the discomfort of a heart attack, though it does not involve actual cardiac damage or ischemia in most cases. However, chest pain can also indicate serious heart issues, so seek immediate medical evaluation to rule out cardiac causes. Some individuals also report a peculiar "leaking" sensation in the chest, as if fluid, air, or something is escaping or flowing inside. This description is frequently shared in online communities such as Reddit's r/Anxiety and r/PanicAttack, where it is characterized as an unsettling yet harmless symptom often attributed to adrenaline surges or heightened body awareness. Community members commonly recommend breathing exercises or seeking professional help if the sensation persists. This symptom contributes significantly to the distress, as individuals may seek emergency medical care fearing a cardiovascular event. Paresthesias and dizziness represent key sensory disturbances, where individuals experience abnormal tingling or numbness in the extremities, often including the left arm and accompanying hyperventilation-induced changes in blood chemistry such as low CO2 levels. or smothering sensations can feel profoundly threatening, exacerbating the overall intensity. Such physical manifestations may subsequently foster avoidance behaviors to prevent recurrence in perceived high-risk situations.

Psychological Symptoms

Psychological symptoms during a panic attack primarily involve overwhelming emotional and cognitive experiences that intensify the sense of danger and helplessness. Individuals often report an intense, sudden fear of dying, going crazy, or losing control, as well as (feelings of unreality) or depersonalization (being detached from oneself), which can feel utterly convincing despite the absence of real threat. These fears arise abruptly and peak within minutes, contributing to a profound sense of terror that distinguishes panic attacks from general anxiety. A hallmark psychological feature is the feeling of or terror, where the person perceives an immediate catastrophe as inevitable, even in safe environments. This sensation amplifies the distress, making everyday situations feel life-threatening and prompting desperate urges to escape. Cognitive distortions, such as catastrophic thinking, further exacerbate these symptoms; for instance, benign physical sensations like heart may be misinterpreted as signs of a heart attack, fueling a cycle of escalating . According to the of panic, this misinterpretation of bodily cues as disastrous is central to the onset and maintenance of attacks. Beyond the acute episode, individuals commonly experience persistent anxiety about future panic attacks or avoidance of situations perceived as risky, which can lead to significant restrictions. This anticipatory reinforces the response, creating a feedback loop that heightens vulnerability to subsequent episodes. Such psychological elements underscore the subjective mental anguish of panic, often overlapping briefly with physical symptoms to heighten misperceptions of danger.

Risk Factors and Triggers

Genetic and Biological Risk Factors

Twin studies have consistently estimated the heritability of to be between 30% and 40%, indicating a moderate genetic contribution to vulnerability. This genetic influence is supported by patterns, where first-degree relatives of individuals with exhibit a significantly elevated risk, with morbidity rates up to 17.3% compared to general estimates. Candidate studies have investigated variations in genes involved in regulation and stress response, such as catechol-O-methyltransferase (COMT), serotonin transporter (SLC6A4), and brain-derived neurotrophic factor (BDNF), but associations have been inconsistent and not replicated in large-scale genome-wide association studies (GWAS). Recent GWAS from 2023 to 2025 have advanced understanding by identifying polygenic risk scores (PRS) for , aggregating multiple common variants to predict susceptibility with improved precision across ancestries. These PRS demonstrate modest predictive utility and highlight shared genetic architecture with other anxiety disorders. Beyond , inherent biological factors heighten risk. Hormonal influences, particularly fluctuations, contribute to the higher prevalence of in females, as modulates serotonin and GABA systems, with vulnerability peaking during periods like perimenopause or postpartum. Early life adversity, such as or maltreatment, alters the hypothalamic-pituitary-adrenal (HPA) axis, leading to dysregulated stress responses that increase lifetime risk for . Furthermore, obesity is associated with an increased risk of panic disorder and anxiety disorders, with studies indicating approximately a 25% higher odds among obese individuals.

Environmental and Psychological Triggers

Psychological triggers for panic attacks often involve , which can exacerbate vulnerability to sudden episodes by heightening physiological arousal and sensitivity to bodily sensations. Stressful life events, such as major changes or ongoing pressures, have been linked to the onset of panic attacks in individuals predisposed to . A history of trauma, including physical or , increases the risk of developing panic attacks, with significant overlap observed between and (PTSD), where trauma-related cues can precipitate panic symptoms. Cognitive biases toward threat perception play a key role in psychological triggering, as individuals with tend to interpret ambiguous or benign bodily sensations—such as a racing heart—as signs of imminent danger, thereby amplifying anxiety into a full attack. These biases, including heightened attentional focus on potential threats, contribute to a cycle where perceived danger reinforces responses. Environmental factors frequently act as precipitants, with stimulants like capable of inducing panic attacks, particularly in those with , by mimicking or intensifying anxiety-related symptoms such as . Similarly, interacts with panic vulnerability to heighten post-withdrawal panic symptoms, while withdrawal from substances like alcohol or can manifest as acute anxiety episodes resembling panic attacks. Exposure to graphic, disturbing, or upsetting images or videos on social media platforms, such as TikTok, can serve as an environmental or psychological trigger for acute anxiety responses or panic attacks, commonly resulting in symptoms such as chest tightness, intense fear, and anxiety. Hyperventilation, often arising in anxiety-provoking situations, can trigger by altering blood chemistry and producing sensations of or that are misinterpreted as catastrophic. Phobias may also lead to attacks; for instance, fear of specific situations can escalate into , and recurrent attacks frequently contribute to the development of , where individuals avoid places perceived as escape-proof due to fear of entrapment during an episode. In the context of , recurrent panic attacks define the condition, with at least one month of persistent concern about additional attacks or behavioral changes to avoid them; initial attacks are often spontaneous and without identifiable triggers, though subsequent ones may become associated with specific situations. Situational triggers can vary culturally; for example, in , the phenomenon of —prolonged social withdrawal—often involves anxiety disorders, where pressures from academic or societal expectations trigger panic attacks leading to isolation as a coping mechanism.

Pathophysiology

Central Nervous System Involvement

Panic attacks involve significant hyperactivity in the , a key brain structure functioning as the primary fear center, which initiates the by rapidly processing perceived threats and amplifying emotional distress. This heightened amygdala activity is consistently observed in studies of individuals with , where it correlates with the intensity of anxiety symptoms during threat exposure. The network model provides a framework for understanding panic attacks as disruptions within an interconnected that includes the , , hippocampus, and insula. In this model, the modulates responses by exerting inhibitory control over the , while the hippocampus integrates contextual memories of prior attacks to heighten anticipatory anxiety, and the insula facilitates the interoceptive awareness of bodily sensations interpreted as . Dysfunctions in these interactions lead to exaggerated processing and impaired regulation characteristic of panic episodes. Neuroimaging evidence from (fMRI) studies demonstrates heightened disruptions in -prefrontal cortex connectivity during emotional processing in , reflecting impaired top-down regulation of signals. These connectivity alterations are associated with increased reactivity to neutral or ambiguous stimuli, contributing to the misinterpretation of benign cues as dangerous. Such findings underscore the role of aberrant circuitry in sustaining the cycle of panic vulnerability. Recent developments from 2023 to 2025, including advanced fMRI and (EEG) research, have captured real-time brain changes during induced or spontaneous panic attacks, revealing dynamic hyperactivity in the network that supports theories of underlying neural dysfunction. For instance, resting-state fMRI studies have identified abnormal functional connectivity patterns in patients, particularly involving the and prefrontal regions, which persist even outside acute episodes. EEG analyses during anxiety provocation tasks further highlight altered oscillatory activity in these circuits, providing temporal insights into the rapid onset of panic-related neural shifts. This activation ultimately drives the autonomic seen in peripheral symptoms like .

Peripheral and Biochemical Mechanisms

Peripheral and biochemical mechanisms in panic attacks involve dysregulation in systems, acid-base balance, autonomic cardiac responses, and emerging influences from the gut microbiome, all contributing to the somatic manifestations of the disorder. imbalances play a central role in sustaining the heightened during panic attacks. Excess noradrenaline (norepinephrine) release is implicated in the , with polymorphisms in the gene (SLC6A2), such as rs2242446 and rs11076111, associated with increased risk for through altered reactivity. Serotonin dysregulation, including potential deficiencies or excesses, further exacerbates symptoms, as evidenced by variations in the 5-HTR1A gene (rs6295) that correlate with higher panic severity scores in affected individuals. These peripheral neurochemical shifts amplify sympathetic activation, leading to physical sensations of anxiety without primary cardiac . The acid-base disturbance theory highlights how during panic attacks induces , a key biochemical trigger for certain symptoms. reduces arterial partial pressure of (PaCO₂) below 35 mmHg, decreasing levels and elevating blood pH, which disrupts balances like calcium. This causes paresthesias through altered nerve excitability, can lead to carpopedal spasms—manifesting as muscle cramps or involuntary contractions in the hands and feet (sometimes perceived as fist clenching)—due to increased neuromuscular irritability from reduced ionized calcium, and cerebral , while the resulting impairs cerebral blood flow, contributing to and . In patients, this response is often exaggerated, perpetuating the cycle of fear and . Cardiac mechanisms involve autonomic imbalances, particularly vagal withdrawal and sympathetic surges, that produce mimicking heart disease. During stressors like lactate infusion, patients with show exaggerated cardiac vagal withdrawal, reducing parasympathetic modulation and increasing in the high-frequency band. Concurrently, sympathetic dominance elevates the low-frequency to high-frequency ratio, driving and perceived chest discomfort through norepinephrine release, yet without underlying structural heart issues. This peripheral surge underscores the disorder's somatic intensity. Recent research from 2023 to 2025 has illuminated the gut-brain axis and microbiome's role in biochemical triggers for attacks. A 2025 case-control study found lower microbial richness in acute patients, with enrichment of gnavus linked to and imbalances via altered metabolic pathways like . These changes influence the gut-brain axis through immune signaling, potentially sensitizing peripheral systems to stress and precipitating episodes. Such findings suggest bidirectional biochemical interactions beyond central neural pathways.

Diagnosis

Criteria for Diagnosis

The diagnosis of a panic attack is primarily guided by criteria outlined in major psychiatric classification systems, such as the and the . In the , a panic attack is defined as an abrupt surge of intense or intense discomfort that reaches a peak within minutes, accompanied by four or more of the following 13 symptoms: , pounding heart, or accelerated ; sweating; trembling or shaking; sensations of or smothering; feelings of ; or discomfort; or abdominal distress; feeling dizzy, unsteady, light-headed, or faint; chills or heat sensations; paresthesias (numbness or tingling sensations); (feelings of unreality) or depersonalization (being detached from oneself); fear of losing control or "going crazy"; and fear of dying. These symptoms must occur concurrently and not be attributable to the physiological effects of a substance (e.g., drug abuse or medication) or another medical condition (e.g., or cardiac ). Limited-symptom panic attacks, involving fewer than four symptoms, are acknowledged but do not meet the full criteria for a standard panic attack . The aligns closely with the in defining a panic attack as a discrete of intense or discomfort that develops abruptly, reaches a peak within minutes, and includes several of the same physical and cognitive symptoms listed above. Unlike standalone diagnoses, panic attacks in often serve as a specifier for other disorders (e.g., in PTSD or ) and must not be better explained by substance use, medication effects, or a condition. This emphasis on acute or discomfort with associated symptoms provides a flexible yet standardized framework. Panic attacks typically last from several minutes to less than an hour, though some may persist for hours in rare cases, with the core symptoms peaking rapidly (usually within 10 minutes). For diagnostic purposes, especially in the context of , attacks must be recurrent and unexpected, occurring without an identifiable trigger, and the diagnosis requires exclusion of physiological causes through clinical . Historically, the criteria evolved from DSM-IV to with key refinements: the unlinking of from as separate diagnoses, the introduction of the panic attack specifier applicable across other mental disorders to capture its transdiagnostic nature, and greater recognition of limited-symptom variants while maintaining the four-symptom threshold for full attacks. These changes aimed to improve diagnostic precision and clinical utility by emphasizing the episodic, fear-based core of panic attacks over rigid syndromal boundaries.

Differential Diagnosis and Assessment Tools

Differentiating panic attacks from other medical conditions is essential, as symptoms such as , , and can overlap with various physical disorders. Common differentials include cardiac conditions like or , which may present with similar and chest discomfort; respiratory issues such as or , mimicking dyspnea; thyroid disorders like , causing and anxiety-like symptoms; and or withdrawal, which can trigger acute episodes of fear and physiological arousal. This overlap underscores the need for thorough evaluation to rule out life-threatening causes before attributing symptoms to . Assessment begins with a detailed clinical history to identify patterns of attacks, triggers, and associated fears, which helps distinguish from other anxiety disorders or situational stressors. Structured tools enhance diagnostic precision: the Severity Scale (PDSS), a 7-item self-report measure scoring symptom frequency, distress, and avoidance on a 0-4 scale (total 0-28), quantifies severity and tracks treatment response. The Anxiety Disorders Interview Schedule (ADIS), a semi-structured diagnostic , systematically assesses anxiety symptoms and comorbidities to confirm while excluding mimics like specific phobias. Physical examination and targeted tests are critical to exclude organic causes. A comprehensive physical exam evaluates vital signs and neurological status, while electrocardiography (ECG) rules out cardiac arrhythmias or ischemia in patients with chest pain or palpitations. Blood tests, including thyroid function assays and metabolic panels, identify endocrine or electrolyte imbalances that could precipitate similar symptoms. Recent advancements from 2023 to 2025 have integrated for real-time monitoring of panic attack frequency and precursors, using sensors to track , skin conductance, and activity levels via devices like smartwatches. These tools enable predictive algorithms to forecast attacks, facilitating early intervention and personalized management.

Management and Treatment

Psychological Interventions

Psychological interventions for panic attacks primarily involve evidence-based talk therapies that target maladaptive thoughts, behaviors, and emotional responses associated with panic symptoms. stands as the cornerstone treatment, emphasizing the identification and modification of cognitive distortions—such as catastrophic interpretations of bodily sensations—and behavioral avoidance patterns that perpetuate fear of future attacks. A key component is , which systematically desensitizes individuals to panic-provoking stimuli through interoceptive exercises (e.g., hyperventilation to mimic symptoms) and situational exposures, reducing the anticipated fear and frequency of attacks. Meta-analyses indicate that CBT yields response rates of approximately 77%, with many patients experiencing 70-90% reductions in panic attack frequency and severity compared to control conditions. Other established therapies include , which promotes psychological flexibility by encouraging acceptance of panic sensations rather than avoidance, while aligning actions with personal values to diminish the impact of attacks. ACT demonstrates efficacy comparable to CBT for anxiety disorders, including panic, with moderate effect sizes in reducing symptoms relative to waitlist controls. Similarly, mindfulness-based stress reduction (MBSR) fosters non-judgmental awareness of bodily experiences, helping individuals observe panic symptoms without escalation; randomized trials show it effectively lowers anxiety and panic frequency, with sustained benefits over inactive controls. For acute panic attacks, mindfulness meditation can be applied briefly to interrupt escalating symptoms by focusing on the present moment and sensations, as supported by evidence from relaxation technique reviews. These interventions are typically delivered in 12-16 weekly sessions, lasting 45-60 minutes each, and can be conducted individually for personalized focus or in groups to enhance and cost-effectiveness, with no significant efficacy differences between formats. Recent advancements from 2023-2025 include (VR)-assisted integrated into CBT, which simulates panic triggers in a controlled environment; clinical trials report promising reductions in symptoms and improved executive function, comparable to traditional exposure. Additionally, intensive formats of CBT, such as the 4-day treatment, have demonstrated long-term efficacy in reducing panic symptoms, with outcomes sustained at follow-up as of 2025.

Pharmacological Treatments

Pharmacological treatments for panic attacks primarily target the underlying mechanisms of , addressing both acute episodes and long-term prevention of recurrence. These interventions focus on modulating systems, particularly serotonin and norepinephrine, to reduce the frequency, intensity, and anticipatory anxiety associated with attacks. Guidelines from major psychiatric organizations recommend antidepressants as the cornerstone of due to their efficacy in sustained symptom control, while short-acting agents are reserved for immediate relief. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are considered first-line treatments for , with sertraline and among the most commonly prescribed. These medications typically require 4-6 weeks to achieve full therapeutic effect, as they gradually enhance serotonin and norepinephrine availability in the , leading to stabilization of mood and anxiety regulation. Clinical trials demonstrate that SSRIs and SNRIs reduce the frequency of panic attacks by 50-70% in responsive patients, alongside improvements in overall symptom severity and . Benzodiazepines, such as , provide rapid relief for acute panic attacks by enhancing gamma-aminobutyric acid (GABA) activity, which dampens excessive neural excitability and interrupts the escalation of symptoms within minutes. They are particularly useful for episodes or during the initial weeks of SSRI/SNRI when anxiety may temporarily worsen. However, due to the high risk of tolerance, dependence, and withdrawal, benzodiazepines are recommended for short-term use only, typically not exceeding 4-8 weeks, and are tapered as antidepressants take effect. Other pharmacological options include beta-blockers like for managing prominent somatic symptoms, such as and tremors, by blocking adrenergic effects during attacks; these are often used off-label in situational contexts but lack robust evidence for core panic prevention. Anticonvulsants, including , may serve as adjunctive therapies in refractory cases, potentially stabilizing neural hyperexcitability through GABA modulation, though their role remains supportive rather than primary. Recent research from 2023-2025 has explored derivatives, such as , for rapid anxiety relief in treatment-resistant cases, showing potential to alleviate acute symptoms within hours via pathways that promote . Administered intranasally under supervision, has demonstrated preliminary efficacy in reducing anxiety severity in comorbid conditions like depression with anxious distress, though larger trials specific to are ongoing. Combining pharmacological treatments with psychological interventions often yields superior outcomes in reducing relapse rates compared to medication alone.

Complementary and Lifestyle Approaches

Breathing exercises, such as , involve deep inhalation through the nose to expand the abdomen while keeping the chest relatively still, followed by slow exhalation, which helps counteract during attacks by promoting parasympathetic and reducing physiological . For acute anxiety attacks, deep or abdominal breathing can quickly calm symptoms by regulating the autonomic nervous system. Studies have shown that regular practice of slow significantly reduces anxiety symptoms in individuals with , including decreased frequency of attacks and improved measures. The 4-7-8 technique, developed by , entails inhaling for 4 seconds, holding for 7 seconds, and exhaling for 8 seconds, typically repeated for four cycles, and has demonstrated effectiveness in lowering state and trait anxiety levels, particularly in clinical settings like post-surgical recovery. Similarly, box breathing (also known as square breathing) involves inhaling for 4 seconds, holding for 4 seconds, exhaling for 4 seconds, and holding again for 4 seconds; this technique promotes relaxation, activates the parasympathetic nervous system, and reduces acute anxiety symptoms. Progressive muscle relaxation is another technique useful for acute panic management, involving the systematic tensing and releasing of muscle groups to reduce physical tension and interrupt anxiety escalation, with evidence from clinical studies showing increased relaxation states. Distraction methods, such as the 5-4-3-2-1 grounding technique (identifying 5 things you can see, 4 you can touch, 3 you can hear, 2 you can smell, and 1 you can taste), stepping away from the triggering content and taking a physical break (e.g., walking outside), talking to a trusted friend or family member, or engaging in a positive distracting activity, can redirect attention away from panic symptoms during acute episodes, supported by self-help strategies for anxiety control. It is recommended to avoid re-exposure to similar upsetting content. Stimulating the vagus nerve by splashing cold water on the face, known as the cold face test, activates parasympathetic responses to reduce acute stress and panic symptoms, as demonstrated in experimental studies on psychosocial stress reduction. Physical activation techniques, such as walking quickly, climbing or descending stairs, or performing push-ups, can help discharge the adrenaline generated during a panic attack, thereby signaling to the body that the danger has passed by completing the fight-or-flight response through release of pent-up energy. These methods de-escalate symptoms by allowing the body to utilize the surge of adrenaline through vigorous activity. If symptoms such as chest tightness are severe, persistent, or accompanied by additional signs like dizziness, sweating, or pain radiating to the arm, individuals should seek emergency medical care immediately to rule out serious conditions such as a heart attack, as only medical evaluation can differentiate these from panic symptoms. For ongoing or recurrent distress, consulting a mental health professional or contacting a crisis helpline (such as 988 in the United States) is advised. Lifestyle modifications play a key role in managing panic attack severity by addressing modifiable risk factors. Regular , such as running or for 30-45 minutes three times weekly, has been associated with substantial symptom reduction in randomized controlled trials, with one study reporting up to 50% decreases in scores among participants with anxiety disorders, including . Specifically, endurance exercise at moderate intensity three times per week has been shown in systematic reviews to significantly reduce the frequency of panic attacks. Avoiding is recommended, as doses equivalent to 400-750 mg—roughly 4-7 cups of —induce panic attacks in over 50% of patients compared to fewer than 2% of healthy controls, suggesting that limiting intake can prevent exacerbation. Implementing practices, including consistent bedtime routines and minimizing screen time before bed, leads to medium-sized reductions in anxiety symptoms (Hedges' g = -0.51), as evidenced by meta-analyses of interventions that improve . Additionally, for individuals following vegan diets, it is advisable to rule out and correct deficiencies in iron, vitamin B12, and vitamin B6, as these can exacerbate panic tendencies, supported by studies linking such deficiencies, which are more common in vegans, to increased anxiety and panic symptoms. Complementary therapies offer additional support for panic attack management. Yoga, incorporating postures, breathing, and , exhibits a small-to-moderate effect on reducing anxiety symptoms (standardized mean difference = -0.43 versus no treatment), with benefits most pronounced in individuals with elevated but undiagnosed anxiety. Acupuncture, involving needle insertion at specific points to modulate autonomic responses, shows superior efficacy over controls in alleviating symptoms (standardized mean difference = -0.41), with good tolerability and minimal side effects like transient needle pain. Heart rate variability (HRV) biofeedback training shows promising results for reducing symptoms, though with somewhat weaker evidence compared to established treatments; meta-analyses indicate large reductions in self-reported stress and anxiety. Mindfulness training, such as mindfulness-based stress reduction (MBSR), also shows promising but somewhat weaker evidence for reducing panic symptoms compared to established psychological interventions. Digital therapeutics, including mobile apps providing guided interventions, represent an emerging self-help option. Apps delivering components like mood tracking, educational modules, and breathing exercises have achieved 42.5% reductions in Severity Scale scores over four weeks in randomized trials, outperforming waitlist controls. Real-world data from 2022 onward indicate that capnometry-guided respiratory apps yield approximately 50% symptom improvement in patients, with high adherence rates exceeding 70%.

Prognosis and Complications

Prognosis

Panic attacks are typically self-limiting events that resolve spontaneously within minutes to an hour without medical intervention, though the associated fear and distress may linger briefly. In the short term, the majority of individuals experience isolated episodes and recover fully without progression, but approximately 10-20% of those with untreated panic attacks go on to develop recurrent attacks meeting criteria for . Over the long term, prognosis improves significantly with appropriate treatment, where or leads to remission in about 70-80% of cases, often with sustained benefits and low relapse rates upon completion. Without treatment, however, 30-50% of individuals may experience chronic anxiety symptoms, including persistent about future attacks and functional impairment. Key factors influencing include early intervention, which enhances recovery likelihood by addressing symptoms before they entrench; the absence of co-occurring conditions, which otherwise complicates resolution; and consistent adherence to recommended therapies. Recent longitudinal studies from 2023 to 2025 highlight improved outcomes through integrated care models, such as combined psychological and technological interventions, achieving remission rates up to 82% at 12-month follow-up with reduced . These approaches demonstrate that holistic, multidisciplinary strategies can optimize long-term trajectories beyond traditional methods. Complications, such as those arising from untreated progression, may further adversely affect overall outlook.

Complications and Comorbidities

Panic attacks and panic disorder are associated with an increased risk of suicidal ideation, particularly in individuals presenting with unexplained chest pain in emergency settings, where panic symptoms can exacerbate distress and lead to heightened suicidality. Substance use disorders frequently co-occur with panic disorder, with prevalence rates of 33% to 45% for comorbid substance abuse among those with anxiety disorders, often as a form of self-medication that perpetuates the cycle of symptoms. Additionally, panic attacks commonly result in frequent emergency room visits, as their symptoms—such as chest pain, palpitations, and shortness of breath—are frequently misdiagnosed as cardiac events like heart attacks. Comorbidities with panic disorder are prevalent and multifaceted. Approximately 50% of individuals with panic disorder experience a major depressive episode at some point, contributing to greater symptom severity and functional impairment. The disorder also shows significant overlap with posttraumatic stress disorder (PTSD), where shared mechanisms like hyperarousal amplify cardiovascular risks through chronic sympathetic nervous system activation. Obsessive-compulsive disorder (OCD) co-occurs in a notable subset of cases, often complicating treatment due to overlapping intrusive thoughts and avoidance behaviors. Repeated sympathetic activation during panic attacks imposes cardiovascular strain, increasing the likelihood of conditions such as hypertension and coronary artery disease over time. A key long-term complication is the development of , which arises in approximately 50% of cases as individuals avoid situations perceived as triggers for attacks, leading to progressive isolation and reduced . Recent studies from 2023 to 2025 have highlighted links between chronic anxiety, including , and elevated risk, with chronic anxiety associated with a 2.8-fold increase in all-cause incidence due to sustained stress-induced and hippocampal damage.

Epidemiology and Prevention

Epidemiology

Panic attacks are a common phenomenon, with a global lifetime of approximately 13.2% across 28 countries surveyed in the World Mental Health (WMH) initiative. The projected lifetime morbid risk at age 75 is 23.0%. , lifetime prevalence is notably higher at 27.3%, while rates in European countries vary but are generally lower, ranging from 10% to 20% depending on the specific nation and . The 12-month prevalence worldwide stands at about 4.9%. Demographically, panic attacks typically onset in late or early adulthood, with the average age of first occurrence around 20-22 years for both genders. There is a consistent 2:1 female-to-male in , observed across global datasets, though this disparity may narrow with age. is elevated in urban environments compared to rural areas, linked to factors such as higher and economic pressures in developed regions. Certain populations exhibit substantially higher rates; for instance, up to 35% of individuals with (PTSD) experience panic attacks in the past year, contributing to increased disability.

Prevention Strategies

Individual-level prevention of panic attacks emphasizes proactive strategies to build resilience and mitigate risk factors. Stress management training, such as breathing exercises, , and , has been shown to reduce the frequency and intensity of panic attacks by enhancing coping skills and lowering physiological . Early screening in high-risk groups, including those with a family history of , is recommended due to established genetic influences, with family studies indicating a significantly elevated risk among first-degree relatives, allowing for timely interventions to prevent onset. Avoiding triggers like stimulants, particularly , is a key measure, as meta-analyses confirm that caffeine intake elevates anxiety risk and can induce panic attacks in susceptible individuals. Public health approaches focus on broad interventions to foster environments that minimize panic attack incidence. School-based anxiety education programs, often incorporating cognitive-behavioral techniques, demonstrate small but significant effects in reducing anxiety symptoms, including those related to panic, with benefits persisting up to 12 months post-intervention. Workplace wellness initiatives, such as flexible scheduling, stress reduction workshops, and access to resources, improve employee and resilience, thereby lowering the risk of anxiety disorders like panic through decreased burnout and enhanced support systems. Cultural considerations are essential for effective prevention, as expressions and reporting of panic symptoms vary across groups, often leading to underdiagnosis in non-Western contexts. Tailored interventions, such as culturally adapted cognitive-behavioral programs that integrate community values and language-specific coping mechanisms, yield improved outcomes in reducing anxiety symptoms among diverse ethnic populations compared to non-adapted approaches. Community-based support in non-Western settings, including aligned with local traditions, addresses underreporting by building trust and accessibility, promoting early help-seeking and stigma reduction. Emerging strategies from 2023 to 2025 leverage technology and policy to enhance prevention. AI-driven early detection apps, utilizing to analyze user inputs like mood patterns and physiological , enable proactive screening for anxiety escalation, including risk, with scoping reviews highlighting their role in pre-treatment identification phases. Policy advocacy for expanded access, through initiatives like integrated care models and reduced barriers to services, supports population-level prevention by ensuring equitable resources, as evidenced by efforts to close coverage gaps in behavioral health.

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