Panic attacks are sudden periods of intense
fear
Fear is an intensely unpleasant emotion in response to perceiving or recognizing a danger or threat. Fear causes physiological changes that may produce behavioral reactions such as mounting an aggressive response or fleeing the threat. Fear ...
and discomfort that may include
palpitations
Palpitations are perceived abnormalities of the heartbeat characterized by awareness of cardiac muscle contractions in the chest, which is further characterized by the hard, fast and/or irregular beatings of the heart.
Symptoms include a rapi ...
, sweating,
chest pain
Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...
or chest discomfort,
shortness of breath
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing disc ...
, trembling, dizziness,
numbness
Hypoesthesia or numbness is a common side effect of various medical conditions that manifests as a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli. In everyday speech this is generally referred to as num ...
, confusion, or a feeling of impending doom or of losing control.
[ 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.] Although they can be extremely frightening and distressing, panic attacks themselves are not physically dangerous.[
The essential features of panic attacks remain unchanged, although the complicated ]DSM-IV
The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
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
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
disorders.
Panic attacks can occur due to several disorders including panic disorder
Panic disorder is a mental disorder, mental and Abnormal behavior, behavioral disease#Disorder, disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear th ...
, social anxiety disorder
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impaired ability to function in at least some aspects ...
, post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
, substance use disorder
Substance use disorder (SUD) is the persistent use of drugs (including alcohol) despite substantial harm and adverse consequences as a result of their use. Substance use disorders are characterized by an array of mental/emotional, physical, and ...
, depression, and medical problems. They can either be triggered or occur unexpectedly.[ ]Smoking
Smoking is a practice in which a substance is burned and the resulting smoke is typically breathed in to be tasted and absorbed into the bloodstream. Most commonly, the substance used is the dried leaves of the tobacco plant, which have bee ...
, caffeine
Caffeine is a central nervous system (CNS) stimulant of the methylxanthine class. It is mainly used recreationally as a cognitive enhancer, increasing alertness and attentional performance. Caffeine acts by blocking binding of adenosine t ...
, and psychological stress
In psychology, stress is a feeling of emotional strain and pressure. Stress is a type of psychological pain. Small amounts of stress may be beneficial, as it can improve athletic performance, motivation and reaction to the environment. Exces ...
increase the risk of having a panic attack.[ Before diagnosis, conditions that produce similar symptoms should be ruled out, such as ]hyperthyroidism
Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormones by the thyroid gland. Thyrotoxicosis is the condition that occurs due to excessive thyroid hormone of any cause and therefore includes hyperthyroidism ...
, hyperparathyroidism
Hyperparathyroidism is an increase in parathyroid hormone (PTH) levels in the blood. This occurs from a disorder either within the parathyroid glands (primary hyperparathyroidism) or as response to external stimuli (secondary hyperparathyroidism). ...
, heart disease
Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, hea ...
, lung disease, drug use, and dysautonomia
Dysautonomia or autonomic dysfunction is a condition in which the autonomic nervous system (ANS) does not work properly. This may affect the functioning of the heart, bladder, intestines, sweat glands, pupils, and blood vessels. Dysautonomia has m ...
.[
Treatment of panic attacks should be directed at the underlying cause.] In those with frequent attacks, counseling
Counseling is the professional guidance of the individual by utilizing psychological methods especially in collecting case history data, using various techniques of the personal interview, and testing interests and aptitudes.
This is a list of co ...
or medication
A medication (also called medicament, medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug used to diagnose, cure, treat, or prevent disease. Drug therapy (pharmacotherapy) is an important part of the medical field and re ...
s may be used. Breathing training and muscle relaxation techniques may also help. Those affected are at a higher risk of suicide
Suicide is the act of intentionally causing one's own death. Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and s ...
.[
In Europe, about 3% of the population has a panic attack in a given year while in the United States they affect about 11%.][ They are more common in females than in males.][ They often begin during ]puberty
Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a girl, the testes in a boy. ...
or early adulthood.[ Children and older people are less commonly affected.]
Signs and symptoms
People with panic attacks often report a fear of dying or heart attack
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may tr ...
, flashing vision or other visual disturbances, faintness
Syncope, commonly known as fainting, or passing out, is Unconsciousness, a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery. It is caused by a decrease in blood flow to the brain ...
or nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
, numbness throughout the body, shortness of breath and hyperventilation
Hyperventilation is irregular breathing that occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood. ...
, or loss of body control. 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
The fight-or-flight or the fight-flight-or-freeze response (also called hyperarousal or the acute stress response) is a physiological reaction that occurs in response to a perceived harmful event, attack, or threat to survival. It was first des ...
", in which the hormone causing this response is released in significant amounts). This response floods the body with hormones
A hormone (from the Ancient Greek, Greek participle , "setting in motion") is a class of cell signaling, signaling molecules in multicellular organisms that are sent to distant organs by complex biological processes to regulate physiology and beh ...
, particularly epinephrine
Adrenaline, also known as epinephrine, is a hormone and medication which is involved in regulating visceral functions (e.g., respiration). It appears as a white microcrystalline granule. Adrenaline is normally produced by the adrenal glands and ...
(adrenaline), which aid it in defending against harm.[ Bourne, E. (2005). ''The Anxiety and Phobia Workbook'', 4th Edition: ]New Harbinger Press
New Harbinger Publications, Inc. is an employee-owned, Oakland-based American publisher of self-help books.
Overview
This publisher of self-help books specializes in titles that offer step-by-step procedures for dealing with phobias, anxiety, ...
.
A panic attack can result when up-regulation by the sympathetic nervous system
The sympathetic nervous system (SNS) is one of the three divisions of the autonomic nervous system, the others being the parasympathetic nervous system and the enteric nervous system. The enteric nervous system is sometimes considered part of th ...
(SNS) is not moderated by the parasympathetic nervous system
The parasympathetic nervous system (PSNS) is one of the three divisions of the autonomic nervous system, the others being the sympathetic nervous system and the enteric nervous system. The enteric nervous system is sometimes considered part of ...
(PNS). The most common symptoms include trembling
A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving neural oscillations, oscillations or twitching movements of one or more body parts. It is the most common of all involuntary movements and can affect the ...
, dyspnea (shortness of breath
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing disc ...
), heart palpitations, chest pain
Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...
(or chest tightness), hot flash
Hot flashes (also known as hot flushes) are a form of flushing, often caused by the changing hormone levels that are characteristic of menopause. They are typically experienced as a feeling of intense heat with sweating and rapid heartbeat, and ...
es, cold flashes, burning sensations (particularly in the facial or neck area), sweating
Perspiration, also known as sweating, is the production of fluids secreted by the sweat glands in the skin of mammals.
Two types of sweat glands can be found in humans: eccrine glands and apocrine glands. The eccrine sweat glands are distr ...
, nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
, dizziness
Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness.
Dizziness is a common medical c ...
(or slight vertigo), light-headedness
Lightheadedness is a common and typically unpleasant sensation of dizziness or a feeling that one may faint. The sensation of lightheadedness can be short-lived, prolonged, or, rarely, recurring. In addition to dizziness, the individual may feel ...
, heavy-headedness
Heavy-headedness is the feeling of faintness, dizziness, or feeling of floating, wooziness. Individuals may feel as though their head is heavy; also feel as though the room is moving/spinning also known as vertigo. Some causes of heavy-headedness ...
, hyperventilation
Hyperventilation is irregular breathing that occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood. ...
, paresthesia
Paresthesia is an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause. Paresthesia may be transient or chronic, and may have any of dozens of possible underlying causes. Paresthesias ar ...
s (tingling sensations), sensations of choking or smothering
Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects primarily the tissues and organs. There are many circumstances that can i ...
, difficulty moving, depersonalization and/or derealization. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety
Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
and forms a positive feedback loop.
Shortness of breath
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing disc ...
and chest pain
Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...
are the predominant symptoms. Many people experiencing a panic attack incorrectly attribute them to a heart attack
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may tr ...
and thus seek treatment in an emergency room
An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of pati ...
. Because chest pain and shortness of breath are hallmark symptoms of cardiovascular illnesses, including unstable angina and myocardial infarction
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may ...
(heart attack), a diagnosis of exclusion
A diagnosis of exclusion or by exclusion (''per exclusionem'') is a diagnosis of a medical condition reached by a process of elimination, which may be necessary if presence cannot be established with complete confidence from history, examination or ...
(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 electrocardiogram and mental health assessments.
Panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature.[ They are often experienced in conjunction with anxiety disorders and other ]psychological
Psychology is the scientific study of mind and behavior. Psychology includes the study of conscious and unconscious phenomena, including feelings and thoughts. It is an academic discipline of immense scope, crossing the boundaries between t ...
conditions, although panic attacks are not generally indicative of a mental disorder
A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
.
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. 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. Various twin studies
Twin studies are studies conducted on identical or fraternal twins. They aim to reveal the importance of environmental and genetic influences for traits, phenotypes, and disorders. Twin research is considered a key tool in behavioral genetics a ...
where one identical twin has an anxiety disorder have reported a high incidence of the other twin also having an anxiety disorder diagnosis.
Biological causes may include obsessive-compulsive disorder, postural orthostatic tachycardia syndrome, post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
, hypoglycemia
Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose belo ...
, hyperthyroidism
Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormones by the thyroid gland. Thyrotoxicosis is the condition that occurs due to excessive thyroid hormone of any cause and therefore includes hyperthyroidism ...
, Wilson's disease, mitral valve prolapse
Mitral valve prolapse (MVP) is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. It is the primary form of myxomatous degeneration of the valve. There ar ...
, pheochromocytoma
Pheochromocytoma (PHEO or PCC) is a rare tumor of the adrenal medulla composed of chromaffin cells, also known as pheochromocytes. When a tumor composed of the same cells as a pheochromocytoma develops outside the adrenal gland, it is referred t ...
, and inner ear disturbances (labyrinthitis
Labyrinthitis is inflammation of the labyrinth – a maze of fluid-filled channels in the inner ear. Vestibular neuritis is inflammation of the vestibular nerve – the nerve in the inner ear that sends messages related to motion and position t ...
). Dysregulation of the norepinephrine system
A neurotransmitter is a signaling molecule secreted by a neuron to affect another cell across a synapse. The cell receiving the signal, any main body part or target cell, may be another neuron, but could also be a gland or muscle cell.
Neurotr ...
in the locus coeruleus
The locus coeruleus () (LC), also spelled locus caeruleus or locus ceruleus, is a nucleus in the pons of the brainstem involved with physiological responses to stress and panic. It is a part of the reticular activating system.
The locus coerule ...
, an area of the brain stem, has been linked to panic attacks.
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, overcautious view of the world, and cumulative stress have been correlated with panic attacks. In adolescents, social transitions may also be a cause.
People will often experience panic attacks as a direct result of exposure to an object/situation that they have a phobia
A phobia is an anxiety disorder defined by a persistent and excessive fear of an object or situation. Phobias typically result in a rapid onset of fear and are usually present for more than six months. Those affected go to great lengths to avo ...
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
Intrapersonal communication is the process by which an individual communicates within themselves, acting as both sender and receiver of messages, and encompasses the use of unspoken words to consciously engage in self-talk and inner speech.
Intr ...
("what-if" thinking), mistaken beliefs ("these symptoms are harmful and/or dangerous"), and withheld feeling
Feelings are subjective self-contained phenomenal experiences. According to the ''APA Dictionary of Psychology'', a feeling is "a self-contained phenomenal experience"; and feelings are "subjective, evaluative, and independent of the sensations ...
s.
Hyperventilation syndrome may occur when a person breathes from the chest, which can lead to over-breathing (exhaling excessive carbon dioxide
Carbon dioxide (chemical formula ) is a chemical compound made up of molecules that each have one carbon atom covalently double bonded to two oxygen atoms. It is found in the gas state at room temperature. In the air, carbon dioxide is transpar ...
related to the amount of oxygen
Oxygen is the chemical element with the symbol O and atomic number 8. It is a member of the chalcogen group in the periodic table, a highly reactive nonmetal, and an oxidizing agent that readily forms oxides with most elements as wel ...
in one's bloodstream). Hyperventilation syndrome
Hyperventilation syndrome (HVS), also known as chronic hyperventilation syndrome (CHVS), dysfunctional breathing hyperventilation syndrome, cryptotetany, spasmophilia, latent tetany, and central neuronal hyper excitability syndrome (NHS), is a re ...
can cause respiratory alkalosis and hypocapnia. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms, including rapid heartbeat
A heartbeat is one cardiac cycle of the heart.
Heartbeat, heart beat, heartbeats, and heart beats may refer to:
Computing
*Heartbeat (computing), a periodic signal to indicate normal operation or to synchronize parts of a system
*Heartbeat, clus ...
, dizziness
Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness.
Dizziness is a common medical c ...
, and lightheadedness, which can trigger panic attacks.
Panic attacks may also be caused by substances. Discontinuation or marked reduction in the dose of a substance such as a drug (drug withdrawal
Drug withdrawal, drug withdrawal syndrome, or substance withdrawal syndrome, is the group of symptoms that occur upon the abrupt discontinuation or decrease in the intake of pharmaceutical or recreational drugs.
In order for the symptoms of with ...
), for example, an antidepressant ( 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." Cigarette smoking is another substance that has been linked to panic attacks.
A common denominator of current psychiatric approaches to panic disorder is that no real danger exists, and the person's anxiety is inappropriate.
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 anxiety disorder
Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired. Anxiety may cause physi ...
s in that panic attacks are often sudden and unprovoked.[Panic Disorder – familydoctor.org](_blank)
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.
Agoraphobia
Agoraphobia
Agoraphobia is a mental and behavioral disorder, specifically an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. These situations can in ...
is an anxiety disorder
Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired. Anxiety may cause physi ...
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. People with severe agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place". The word "agoraphobia" comes from the Greek words agora
The agora (; grc, ἀγορά, romanized: ', meaning "market" in Modern Greek) was a central public space in ancient Greek city-states. It is the best representation of a city-state's response to accommodate the social and political order of t ...
(αγορά) and 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
, also known as acute social withdrawal, is total withdrawal from society and seeking extreme degrees of social isolation and confinement. ''Hikikomori'' refers to both the phenomenon in general and the recluses themselves. ''Hikikomori'' ha ...
''. The phenomena in general is known by the same name, and it is estimated that roughly half a million Japanese youths are ''Hikikomori''.
People who have had a panic attack in certain situations may develop phobia
A phobia is an anxiety disorder defined by a persistent and excessive fear of an object or situation. Phobias typically result in a rapid onset of fear and are usually present for more than six months. Those affected go to great lengths to avo ...
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 panic disorder
Panic disorder is a mental disorder, mental and Abnormal behavior, behavioral disease#Disorder, disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear th ...
are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia
Agoraphobia is a mental and behavioral disorder, specifically an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. These situations can in ...
.
Experimentally induced
Panic attack symptoms can be experimentally induced in the laboratory by various means. Among them, for research purposes, by administering a bolus
Bolus may refer to:
Geography
* Bolus, Iran, a village in Ardabil Province, Iran
* Bolus, or Baulus, an Anatolian village on the site of ancient Berissa
Medicine
* Bolus (digestion), a ball-shaped mass moving through the digestive tract
* Bolus ...
injection of the neuropeptide
Neuropeptides are chemical messengers made up of small chains of amino acids that are synthesized and released by neurons. Neuropeptides typically bind to G protein-coupled receptors (GPCRs) to modulate neural activity and other tissues like the ...
cholecystokinin-tetrapeptide ( CCK-4). Various animal models of panic attacks have been experimentally studied.
Neurotransmitter imbalances
Many neurotransmitter
A neurotransmitter is a signaling molecule secreted by a neuron to affect another cell across a synapse. The cell receiving the signal, any main body part or target cell, may be another neuron, but could also be a gland or muscle cell.
Neuro ...
s are affected when the body is under the increased stress and anxiety
Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
that accompany a panic attack. Some include serotonin
Serotonin () or 5-hydroxytryptamine (5-HT) is a monoamine neurotransmitter. Its biological function is complex and multifaceted, modulating mood, cognition, reward, learning, memory, and numerous physiological processes such as vomiting and vas ...
, GABA (gamma-aminobutyric acid), dopamine
Dopamine (DA, a contraction of 3,4-dihydroxyphenethylamine) is a neuromodulatory molecule that plays several important roles in cells. It is an organic compound, organic chemical of the catecholamine and phenethylamine families. Dopamine const ...
, norepinephrine
Norepinephrine (NE), also called noradrenaline (NA) or noradrenalin, is an organic chemical in the catecholamine family that functions in the brain and body as both a hormone and neurotransmitter. The name "noradrenaline" (from Latin '' ad'', ...
, and glutamate
Glutamic acid (symbol Glu or E; the ionic form is known as glutamate) is an α-amino acid that is used by almost all living beings in the biosynthesis of proteins. It is a non-essential nutrient for humans, meaning that the human body can syn ...
. 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.
The main inhibitory neurotransmitter in the central nervous system
The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain and spinal cord. The CNS is so named because the brain integrates the received information and coordinates and influences the activity of all par ...
(CNS) is GABA. Most of the pathways that use GABA tend to reduce anxiety immediately.[
Dopamine's role in anxiety is not well understood. Some ]antipsychotic medication
Antipsychotics, also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia but also in a range of oth ...
s that affect dopamine production have been proven to treat anxiety. However, this may be attributed to dopamine's tendency to increase feelings of self-efficacy
In psychology, self-efficacy is an individual's belief in their capacity to act in the ways necessary to reach specific goals. The concept was originally proposed by the psychologist Albert Bandura.
Self-efficacy affects every area of human endea ...
and confidence, which indirectly reduces anxiety.[
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.][ 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.
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.][
]
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 adrenaline (epinephrine) which brings about the fight-or-flight response
The fight-or-flight or the fight-flight-or-freeze response (also called hyperarousal or the acute stress response) is a physiological reaction that occurs in response to a perceived harmful event, attack, or threat to survival. It was first des ...
when the body prepares for strenuous physical activity. This leads to an increased heart rate (tachycardia
Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal (su ...
), rapid breathing (hyperventilation
Hyperventilation is irregular breathing that occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood. ...
) which may be perceived as shortness of breath ( dyspnea), and sweating. Because strenuous activity rarely ensues, the hyperventilation
Hyperventilation is irregular breathing that occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood. ...
leads to a drop in carbon dioxide
Carbon dioxide (chemical formula ) is a chemical compound made up of molecules that each have one carbon atom covalently double bonded to two oxygen atoms. It is found in the gas state at room temperature. In the air, carbon dioxide is transpar ...
levels in the lung
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
s and then in the blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...
. This leads to shifts in blood pH ( respiratory alkalosis or hypocapnia), causing compensatory metabolic acidosis
Metabolic acidosis is a serious electrolyte disorder characterized by an imbalance in the body's acid-base balance. Metabolic acidosis has three main root causes: increased acid production, loss of bicarbonate, and a reduced ability of the kidneys ...
activating chemosensing
A chemoreceptor, also known as chemosensor, is a specialized sensory receptor which transduces a chemical substance (endogenous or induced) to generate a biological signal. This signal may be in the form of an action potential, if the chemorecept ...
mechanisms that translate this pH shift into autonomic and respiratory responses.
Moreover, this hypocapnia and release of adrenaline during a panic attack cause vasoconstriction
Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, in particular the large arteries and small arterioles. The process is the opposite of vasodilation, the widening of blood vessel ...
resulting in slightly less blood flow to the head which causes dizziness
Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness.
Dizziness is a common medical c ...
and lightheadedness. A panic attack can cause blood sugar
Glycaemia, also known as blood sugar level, blood sugar concentration, or blood glucose level is the measure of glucose concentrated in the blood of humans or other animals. Approximately 4 grams of glucose, a simple sugar, is present in the blo ...
to be drawn away from the brain
A brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as vision. It is the most complex organ in a v ...
and toward the major muscles. Neuroimaging
Neuroimaging is the use of quantitative (computational) techniques to study the structure and function of the central nervous system, developed as an objective way of scientifically studying the healthy human brain in a non-invasive manner. Incre ...
suggests heightened activity in the amygdala
The amygdala (; plural: amygdalae or amygdalas; also '; Latin from Greek, , ', 'almond', 'tonsil') is one of two almond-shaped clusters of nuclei located deep and medially within the temporal lobes of the brain's cerebrum in complex verteb ...
, thalamus
The thalamus (from Greek θάλαμος, "chamber") is a large mass of gray matter located in the dorsal part of the diencephalon (a division of the forebrain). Nerve fibers project out of the thalamus to the cerebral cortex in all directions, ...
, hypothalamus
The hypothalamus () is a part of the brain that contains a number of small nuclei with a variety of functions. One of the most important functions is to link the nervous system to the endocrine system via the pituitary gland. The hypothalamu ...
, and brainstem
The brainstem (or brain stem) is the posterior stalk-like part of the brain that connects the cerebrum with the spinal cord. In the human brain the brainstem is composed of the midbrain, the pons, and the medulla oblongata. The midbrain is cont ...
regions including the periaqueductal gray, parabrachial nucleus
The parabrachial nuclei, also known as the parabrachial complex, are a group of nuclei in the dorsolateral pons that surrounds the superior cerebellar peduncle as it enters the brainstem from the cerebellum. They are named from the Latin term for ...
, and Locus coeruleus
The locus coeruleus () (LC), also spelled locus caeruleus or locus ceruleus, is a nucleus in the pons of the brainstem involved with physiological responses to stress and panic. It is a part of the reticular activating system.
The locus coerule ...
. In particular, the amygdala
The amygdala (; plural: amygdalae or amygdalas; also '; Latin from Greek, , ', 'almond', 'tonsil') is one of two almond-shaped clusters of nuclei located deep and medially within the temporal lobes of the brain's cerebrum in complex verteb ...
has been suggested to have a critical role. The combination of increased activity in the amygdala
The amygdala (; plural: amygdalae or amygdalas; also '; Latin from Greek, , ', 'almond', 'tonsil') is one of two almond-shaped clusters of nuclei located deep and medially within the temporal lobes of the brain's cerebrum in complex verteb ...
(fear center) and brainstem
The brainstem (or brain stem) is the posterior stalk-like part of the brain that connects the cerebrum with the spinal cord. In the human brain the brainstem is composed of the midbrain, the pons, and the medulla oblongata. The midbrain is cont ...
along with decreased blood flow and blood sugar in the brain can lead to decreased activity in the prefrontal cortex
In mammalian brain anatomy, the prefrontal cortex (PFC) covers the front part of the frontal lobe of the cerebral cortex. The PFC contains the Brodmann areas BA8, BA9, BA10, BA11, BA12, BA13, BA14, BA24, BA25, BA32, BA44, BA45, BA46, ...
(PFC) region of the brain. There is evidence that having an anxiety disorder increases the risk of cardiovascular disease (CVD). Those affected also have a reduction in heart rate variability.[
]
Cardiovascular disease
People who have been diagnosed with panic disorder have approximately double the risk of coronary heart disease. 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.[
]
Diagnosis
DSM-5
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
diagnostic criteria for a panic attack include a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within minutes:
*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
*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 hot flashes
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 pheochromocytoma
Pheochromocytoma (PHEO or PCC) is a rare tumor of the adrenal medulla composed of chromaffin cells, also known as pheochromocytes. When a tumor composed of the same cells as a pheochromocytoma develops outside the adrenal gland, it is referred t ...
.
Screening tools such as the Panic Disorder Severity Scale
The Panic Disorder Severity Scale (PDSS) is a questionnaire developed for measuring the severity of panic disorder. The clinician-administered PDSS is intended to assess severity and considered a reliable tool for monitoring of treatment outcome. S ...
can be used to detect possible cases of disorder and suggest the need for a formal diagnostic assessment.
Treatment
Panic disorder is usually effectively treated with a variety of interventions, including psychological therapies and medication.[ Cognitive-behavioral therapy has the most complete and longest duration of effect, followed by specific selective serotonin reuptake inhibitors. A 2009 review found positive results from therapy and medication and a much better result when the two were combined.]
Lifestyle changes
Caffeine
Caffeine is a central nervous system (CNS) stimulant of the methylxanthine class. It is mainly used recreationally as a cognitive enhancer, increasing alertness and attentional performance. Caffeine acts by blocking binding of adenosine t ...
may cause or exacerbate panic anxiety. Anxiety can temporarily increase during withdrawal from caffeine and various other drugs.
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 endorphins
Endorphins (contracted from endogenous morphine) are chemical signals in the brain that block the perception of pain and increase feelings of wellbeing. They are produced and stored in an area of the brain known as the pituitary gland.
Hist ...
and the subsequent reduction of the stress hormone cortisol
Cortisol is a steroid hormone, in the glucocorticoid class of hormones. When used as a medication, it is known as hydrocortisone.
It is produced in many animals, mainly by the ''zona fasciculata'' of the adrenal cortex in the adrenal gland ...
.
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 hyperventilation syndrome
Hyperventilation syndrome (HVS), also known as chronic hyperventilation syndrome (CHVS), dysfunctional breathing hyperventilation syndrome, cryptotetany, spasmophilia, latent tetany, and central neuronal hyper excitability syndrome (NHS), is a re ...
, which mimics symptoms of a heart attack, thus inducing a panic attack. The benefits of incorporating an exercise regimen have shown the best results when paced accordingly.
Meditation may also be helpful in the treatment of panic disorder
Panic disorder is a mental disorder, mental and Abnormal behavior, behavioral disease#Disorder, disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear th ...
s.
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.
Breathing exercises
In the great majority of cases, hyperventilation
Hyperventilation is irregular breathing that occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood. ...
is involved, exacerbating the effects of the panic attack. Breathing retraining exercise helps to rebalance the oxygen and CO2 levels in the blood.
David D. Burns
David D. Burns (born September 19, 1942) is an American psychiatrist and adjunct professor emeritus in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine and the author of bestselling books such as ...
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 diaphragmatic breathing
Diaphragmatic breathing, abdominal breathing, belly breathing, or deep breathing, is breathing that is done by contracting the diaphragm, a muscle located horizontally between the thoracic cavity and abdominal cavity. Air enters the lungs as the ...
may be achieved by extending the out-breath by counting or humming.
Although breathing into a paper bag was a common recommendation for short-term treatment of symptoms of an acute panic attack, it has been criticized as inferior to measured breathing, potentially worsening the panic attack and possibly reducing needed blood oxygen.[Hyperventilation Syndrome – Can I treat hyperventilation syndrome by breathing into a paper bag?]
While the paper bag technique increases needed carbon dioxide
Carbon dioxide (chemical formula ) is a chemical compound made up of molecules that each have one carbon atom covalently double bonded to two oxygen atoms. It is found in the gas state at room temperature. In the air, carbon dioxide is transpar ...
and so reduces symptoms, it may excessively lower oxygen
Oxygen is the chemical element with the symbol O and atomic number 8. It is a member of the chalcogen group in the periodic table, a highly reactive nonmetal, and an oxidizing agent that readily forms oxides with most elements as wel ...
levels in the bloodstream.
Capnometry
Capnography is the monitoring of the concentration or partial pressure of carbon dioxide () in the respiratory gases. Its main development has been as a monitoring tool for use during anesthesia and intensive care. It is usually presented as a g ...
, which provides exhaled CO2 levels, may help guide breathing.
Therapy
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 might also be appropriate in some cases." 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. Avoidant behavior is one of the key aspects that prevent people with frequent panic attacks from functioning healthily. Exposure therapy, 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 object relations theory
Object relations theory is a school of thought in psychoanalytic theory centered around theories of stages of ego development. Its concerns include the relation of the psyche to others in childhood and the exploration of relationships between ...
, panic attacks are frequently associated with splitting (psychology), paranoid-schizoid and depressive positions, and paranoid anxiety Paranoid anxiety is a term used in object relations theory, particularity in discussions about the Paranoid-schizoid and depressive positions. The term was frequently used by Melanie Klein, especially to refer to a pre-depressive and persecutory sen ...
. They are often found to be comorbid with borderline personality disorder
Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
and child sexual abuse. Paranoid anxiety may reach the level of a persecutory anxiety state.
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. 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.[
The efficacy of group therapy treatment over conventional individual therapy for people with panic disorder with or without agoraphobia appears similar.]
Medication
Medication options for panic attacks typically include benzodiazepine
Benzodiazepines (BZD, BDZ, BZs), sometimes called "benzos", are a class of depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat conditions such as anxiety disorders, ...
s and antidepressants. Benzodiazepines are being prescribed less often because of their potential side effects, such as dependence, fatigue, slurred speech, and memory loss. Antidepressant treatments for panic attacks include selective serotonin reuptake inhibitors (SSRIs
Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions.
SSRIs increase the extracellul ...
), serotonin noradrenaline reuptake inhibitors ( SNRIs), tricyclic antidepressant
Tricyclic antidepressants (TCAs) are a class of medications that are used primarily as antidepressants, which is important for the management of depression. They are second-line drugs next to SSRIs. TCAs were discovered in the early 1950s and wer ...
s (TCAs), and MAO inhibitor
Monoamine oxidase inhibitors (MAOIs) are a class of drugs that inhibit the activity of one or both monoamine oxidase enzymes: monoamine oxidase A (MAO-A) and monoamine oxidase B (MAO-B). They are best known as effective antidepressants, espec ...
s (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.
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.
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. 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.[
]
Prognosis
Roughly one-third are treatment-resistant. These people continue to have panic attacks and various other panic disorder symptoms after receiving treatment.[
Many people being treated for panic attacks begin to experience ]limited symptom attack
A limited symptom attack (LSA), also referred to as a limited symptom panic attack (LPA), is a milder, less comprehensive form of panic attack, with fewer than four panic related symptoms being experienced (APA 1994). For example, a sudden episode ...
s. These panic attacks are less comprehensive, with fewer than four bodily symptoms being experienced.[
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.][
]
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%.[ They are more common in females than in males.][ They often begin during ]puberty
Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a girl, the testes in a boy. ...
or early adulthood.[ Children and older people are less commonly affected.] 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
MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online) is a bibliographic database of life sciences and biomedical information. It includes bibliographic information for articles from academic journals covering medic ...
to accumulate their data. 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%.[
]
See also
* Hysteria
Hysteria is a term used colloquially to mean ungovernable emotional excess and can refer to a temporary state of mind or emotion. In the nineteenth century, hysteria was considered a diagnosable physical illness in women. It is assumed that ...
* Nervous breakdown
* Panic
Panic is a sudden sensation of fear, which is so strong as to dominate or prevent reason and logical thinking, replacing it with overwhelming feelings of anxiety and frantic agitation consistent with an animalistic fight-or-flight reactio ...
References
External links
*
{{DEFAULTSORT:Panic Attack
Anxiety
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