Panic Disorder

Does this sound like you?

Descriptions of Panic Disorder from Patients' Perspectives

“My first panic attack occurred during a hectic time at work. I was under a lot of pressure to meet deadlines on a few projects. I was at my desk working as usual when I suddenly felt like I couldn't catch my breath. This feeling was totally out of the blue. I felt like I was going to suffocate and like I was gasping for air. I felt like I was losing control of my body and had this terrifying feeling of being disconnected from reality. The symptoms seemed to go on forever. In between attacks, I fear having another attack and I notice that I'm avoiding situations where I think I might be more likely to panic or where I wouldn't be able to get help from others if I did panic. I notice that this is the first thing that crosses my mind when I'm invited somewhere - I evaluate how this situation may affect having or coping with a panic attack. At first, there were only a few places and activities that I avoided, but the list keeps growing…“.

“I'm an actor and my first panic attack occurred after one of many auditions. I wasn't particularly nervous or anxious before the audition and it went fine. But, as I was walking down the street after it, I felt like my heart began to pound really hard. I wondered if something was wrong with me. I started to get really searing pains in my chest. I grabbed my chest and sat down on the curb. People asked me if I was ok. I was sure I was having a heart attack. I went to the doctor and he said I was fine, but the problem didn't stop and in the next few weeks I had a few more attacks like this and I went to the ER. They kept saying I was fine, but how could that be? I felt like maybe they weren't catching it when the problem was happening, so they just didn't know I was having a heart attack. Now, I'm sure that something is wrong with my heart even though they say that it's fine. So, I'm really careful with what I do. I don't exercise anymore or exert myself because I don't want to put a strain on my heart.“

“I've avoided driving now for several years. A few years back I began having panic attacks in the car. My heart was pounding and my chest was aching, but the thing that scared me most was the feeling that I couldn't concentrate, my mind was racing. I felt like I was losing control of my ability to think and going crazy. I gripped the steering wheel really tight and somehow didn't get into an accident. I pulled over to the shoulder until I felt better. At first, I just started planning my driving ahead of time, and wouldn't travel to a place where I didn't know the route well or where I knew there would not be a shoulder, so that I could pull off if I began to lose control again. Eventually the planning became too much and I just stopped driving on freeways. Now, it has gotten to the point where I pretty much avoid driving altogether. It's a real hassle - to me and my family, but I can't take a chance of having another one of those attacks again.“

Panic Disorder - Prevalence Rates and Course of the Disorder

Panic disorder affects approximately 2.4 million adults in the United States. It usually develops during late adolescence or early adulthood. Panic attacks can occur in any place and at any time. Some people even suffer from nocturnal panic attacks - in other words, they are jolted out of sleep in the middle of a panic attack. Most attacks peak (or reach their worst point) in about 10 minutes, but residual symptoms can last for much longer.

Occasionally, some people experience only a few isolated panic attacks during their lives that never manifest themselves as panic disorder; in other words, they do not have repeated panics or live in fear of having another panic attack. In fact, 14% of people report experiencing an unexpected panic attack within the past year. However, once someone has developed fear of having another panic attack or begins changing their lives or their routines in any way (out of fear of panic), panic disorder usually becomes a more chronic problem.

Left untreated, panic disorder tends to become worse over time. More and more situations and activities are avoided over time (agoraphobia increases) and it is not uncommon for many important life decisions to be dictated by the fear of panic (e.g., whether or not to take a trip where you would need to get on a plane, whether or not to accept a promotion where speaking in front of others is necessary). Sometimes, people become so controlled by their fear of panic that they become completely housebound.

What are the Causes of Panic Disorder?

This is still somewhat unclear. However, the current research seems to indicate that people who are vulnerable to developing panic disorder tend to have an over-reactive autonomic nervous system -- the system that controls the fight/flight response that is part of panic (for more information, see Anxiety/Fear and your Body section on this website). It is believed that for many of the anxiety disorders, people are not genetically predisposed to developing a specific anxiety disorder - however, panic has a slightly stronger heritability. Onset of panic attacks usually surrounds stressful life events - this includes both bad stresses (e.g., having a heavy workload at school, getting laid off from work) and good stresses (e.g., getting married).

So, frequently, an over-responsive flight/flight system is unexpectedly set into motion under a time of high stress. This first panic attack tends to be very terrifying for most people and they might then begin to fear the panic attacks themselves. This is what differentiates panic disorder from the other anxiety disorders (where you might also have a panic attack). People with panic disorder begin to fear their own bodily sensations (“fear of fear“) because these are used as cues that another terrifying panic attack may be starting again. Thus, panic is viewed as a phobia of one's own bodily sensations. This differs from other phobias where the feared object can be more easily avoided. For example, if someone has a phobic fear of dogs, then they can run away when they see a dog and feel okay. If someone has a phobia of their own physical sensations, when they begin to notice a sensation that has been linked with panic (e.g., increased heart rate), they become afraid. Naturally, our flight/flight response is then designed to actually increase physical arousal - which is the very thing that people with panic fear. These internal sensations are also less predictable and controllable than other phobic stimuli - making them even more terrifying.

Although people with panic are very sensitive of these internal cues, these are often not consciously processed. For example, just as a person might discover that somehow they drove from one place to another without really thinking about it, this is what also happens when people are processing their bodily sensations. However, because people are aware of their bodily sensations but not explicitly thinking about them, this often accounts for why panic attacks frequently seem to “come out of the blue“. Agoraphobia develops as more and more situations that appear to trigger or affect panic are avoided (e.g., malls, driving, beaches).

What are the symptoms of Panic Disorder?

Panic attacks are defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as: A discrete period of intense fear or discomfort, that usually comes on suddenly and unexpectedly. They usually peak within 10 minutes. Several of the following physical symptoms and fears are often experienced:

  • racing heart
  • sweating
  • trembling or shaking
  • sensations of shortness of breath or smothering
  • choking feelings
  • chest pain or discomfort
  • nausea or abdominal distress
  • feeling dizzy or lightheaded
  • feelings of unreality
  • feelings of being detached from oneself
  • numbness or tingling
  • chills or hot flashes
  • fear of losing control
  • fear of going crazy
  • fear of dying
  • Many people genuinely believe that these attacks mean that they are losing their mind, they are dying, or having a heart attack. It is not uncommon for people to have had visits to their primary care doctor or to the emergency room due to these symptoms.

    For individuals with panic disorder, they have recurrent, unexpected panic attacks (as defined above) and frequently:

  • fear having another attack
  • worry a lot about the consequences of their panic attacks (e.g., what if I'm going crazy, what if I lose control one of these times, what if the next time I really do have a heart attack?)
  • change their behavior due to the attacks or out of fear of triggering another attack
  • For people with panic disorder, their initial panic attacks are “out of the blue". However, many people find that, over time, certain situations or activities are more likely to trigger a panic attack. Thus, many people eventually begin restricting their behaviors because they fear that they may have a panic attack if they go to certain places or engage in particular activities. The avoidance is usually even more pronounced if these situations are not only a place that may trigger a panic attack, but also are places/situations where escape may not be easy, help may not be readily available, or if panic in that situation may be particularly embarrassing.

    Over time, people with panic often begin to fear certain situations - thinking that these situations might be likely to trigger a panic attack or they don't know how they would cope if a panic attack occurred in that type of situation. When a person begins to avoid situations or endure situations with an extreme level of discomfort, this is called agoraphobia. Common agoraphobic situations are:

  • being in crowds
  • being outside of the home alone
  • being on a bridge or in a tunnel
  • being in a wide, open place
  • being on a bridge or in a tunnel
  • In addition, activities that trigger physical sensations may also be avoided such as:

  • exercise
  • saunas
  • tying scarves around the neck
  • drinking caffeine
  • If an individual needs to enter a feared situation, usually they do something that helps to make them feel safer there - for example, insist that someone they trust accompanies them or bringing things with them that help them feel safe (e.g., anxiety medications, cell phone, water bottle, etc.).

    It is important to note that panic attacks may occur in any of the anxiety disorders. You may need professional help to determine if you have panic disorder or panic attacks in the context of another anxiety disorder.

    Treatment for Panic Disorder

    The good news is that panic disorder is very treatable. The two treatments that have been proven by research to be effective for panic disorder and agoraphobia are medication and therapy - specifically, Cognitive-Behavioral Therapy (CBT). The types of medications that have been studied for the treatment of panic disorder are: the selective serotonin reuptake inhibitors (SSRIs; Prozac, Paxil, etc.), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and benzodiazepines. Although medications are often quite effective, it is not uncommon for panic attacks to resume once the medication is no longer taken. CBT is often implemented to minimize relapse if the patient decides to go off of medication. Medication and CBT can be combined, but it is often helpful if patients keep their medication regimen stable while engaging in CBT - especially if benzodiazepines are being taken.

    The first step in Cognitive-Behavior Therapy (CBT) is education about panic and anxiety; this information is presented, in large part, to correct the misinterpretations of certain bodily sensations as scary or dangerous. Although many of the symptoms may not feel very good, they are actually linked to the fight/flight system that is designed to protect you during times of actual threat. This step is commonly referred to as “cognitive restructuring“ - where individuals learn how to more realistically appraise what is happening in panic and how not to interpret the sensations that they are feeling as being dangerous (e.g., “this feeling means I'm having a heart attack“). In addition, patients are also taught how to catch the common thinking errors that are very common in panic - overestimating the probability of the feared outcome (e.g., “if this feeling happens again, I will crash the car“) and catastrophizing (e.g., “if I fainted during the business meeting, I would never be able to show my face there again“).

    In addition, patients are also taught how to breathe correctly; this step is often referred to as “breathing retraining“. This step is taught because the symptoms of hyperventilation often play a role in many panic attacks.

    Patients are also guided through interoceptive exposures. This is a fancy term for evaluating what kinds of bodily sensations are feared (or are triggering the panic attacks), and then confronting these sensations in a structured way to learn that they are not really as dangerous as initially perceived. Typically, the types of sensations that are feared are placed on a hierarchy from the least to the most frightening. Then, the sensations are confronted, usually beginning with the least fear provoking sensations.

    Finally, for those with agoraphobia, “in vivo“ exposures are also implemented. This involves entering the situations that have been currently avoided (or otherwise endured only when absolutely necessary with extreme distress) due to fear of panic. Like interoceptive exposures, the types of situations are placed on a hierarchy and the least anxiety provoking items are confronted first. Usually, even within one specific situation, there are things that can make that situation easier and harder (e.g., having a companion available, close to home, etc.). These factors that affect the difficulty of the situation are also taken into account when designing exposure assignments. Generally, treatment for panic takes longer if there are many agoraphobic situations. It is important to note that although initial exposures are usually conducted with the psychologist, patients are asked to practice what has been worked on in session at home as well.

    If you are interested in learning more about anxiety disorders and their treatment, and you live in the Los Angeles area, contact Dr. Nelson at (310) 963-4891 or e-mail her at