Panic Attacks

Panic attacks are frightening but fortunately physically harmless episodes. They can occur at random or after a person is exposed to various events that may "trigger" a panic attack. They peak in intensity very rapidly and go away with or without medical help.

• People experiencing panic attacks may fear they are dying, that they are suffocating, or that they are having a heart attack. They may voice fears that they are "going crazy" and seek to remove themselves from whatever situation they may be in.

• Some people may begin breathing very rapidly and complain that their "hearts are jumping around in their chest." Then, within about an hour, the symptoms fade away.

• About 5% of the population will experience panic attacks during their lifetimes. People who have repeated attacks require further evaluation from a mental health professional. Panic attacks can indicate the presence of panic disorder, depression, or other forms of anxiety-based illnesses.

As with most behavioral illnesses, the causes of panic attacks are many. Certainly there is evidence that the tendency to have panic attacks can sometimes be inherited. However, there is also evidence that panic may be a learned response and that the attacks can be initiated in otherwise healthy people simply given the right set of circumstances. Research into the causes of panic attacks is ongoing.

• Panic disorder is a separate but related diagnosis to panic attacks. People experiencing repeated panic attacks and who meet other diagnostic criteria may be diagnosed with this illness. Panic disorder is thought to be inherited for the most part.

• The American Psychiatric Association’s official Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) defines a panic attack as a discrete period of intense fear or discomfort, in which 4 (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:
  
  
  • Palpitations, pounding heart, or fast heart rate
    
    
  • Sweating
    
    
  • Trembling and shaking
    
    
  • Sensations of shortness of breath or smothering
    
    
  • Feelings 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 crazy
    
    
  • Fear of dying
    
    
  • Paresthesias (numbness or tingling sensations)
    
    
  • Chills or hot flashes

• Some of these symptoms will most likely be present in a panic attack. The attacks can be so disabling that the person is unable to express to others what is happening to them. A doctor might also note various signs of panic: The person may appear terrified or shaky or be hyperventilating (deep, rapid breathing causing dizziness).

• Recent literature suggests that men and women may experience different symptoms during an attack. Women tend to experience a predominance of respiratory symptoms compared to men.

For someone who may be experiencing their first panic attack, a call to the doctor's office or 911 is warranted. The idea is to make sure that the cause of the person’s distress is not a heart attack, asthma problem, endocrine emergency, or other dangerous medical condition.

• A medical professional is the only person who should make the diagnosis of panic attack. There is no such thing as a "wasted" visit to the doctor in this case. It is better to be told that the diagnosis is panic attack than to assume that someone is panicking and be proved wrong.

Almost everyone experiencing symptoms of a panic attack needs evaluation. Unless the person has a history of having panic attacks, is otherwise healthy, and is experiencing a typical attack, they must be evaluated promptly by a doctor. The level of evaluation depends on many factors. Err on the side of safety when deciding whether to go to a hospital's emergency department.

• Even for medical professionals, the diagnosis of panic attack is known as a diagnosis of exclusion. This simply means that before the doctor can be comfortable with the diagnosis of panic attack, all other possible causes need to be considered and ruled out.

The typical panic attack can mimic many harmful conditions. The doctor must "think of the worst" to be sure not to miss an important diagnosis. At the doctor's office or emergency department, you can expect the doctor to take a thorough history and perform a thorough physical examination.

• In particular, the doctor will be concerned with the person’s past medical history, past mental health history, and any surgery the person may have had.

• The doctor will inquire about medications the person is taking or has recently taken and in what dosage.

• The doctor will inquire about whether panic or anxiety illnesses "run in the family" and about any recent drug or alcohol use by the person. During the evaluation for an illness is not the time to be untruthful about drug or alcohol habits because both of these factors are critical in the evaluation.

• Also, the doctor is likely to inquire about caffeine intake and any over-the-counter or herbal medicines taken.

• A physical exam will generally consist of a head-to-toe check of all the vital organ systems. The doctor will listen to the heart and lungs and may perform a brief neurologic exam designed to make sure the brain is functioning properly.

• The doctor will use the best judgment regarding the necessity of ordering tests. Given the nature of the symptoms in a panic attack, the person will usually receive an ECG or heart tracing.

• Should the doctor feel concerned that the symptoms might be caused by a medical disorder, blood tests, urine tests, drug screens, and even x-rays or CT scans might be ordered.

• If the person has a family history of seizures or symptoms that are not typical for panic attack, a neurologist may be asked to evaluate the person. There is some overlap between the symptoms of panic attack and what are known as "partial seizures." Distinguishing between the two is important because the treatment for each is quite different. A neurologist, if consulted, will order an EEG (electroencephalogram) to check for seizure activity in the brain. This is a painless test but does require some time to complete (typically overnight).

|Self-Care at Home|

Taking care of panic attacks at home is possible, but be careful not to mistake another serious illness (such as a heart attack) for a panic attack. In fact, this is the dilemma that doctors face when people experiencing panic are brought to a hospital's emergency department or the clinic.

• If a person has been diagnosed with panic attacks in the past and is familiar with the signs and symptoms, the following techniques may help the person stop the attack. You may also try this for yourself if you are experiencing the symptoms of a panic attack.

• First, relax your shoulders and become conscious of any tension that you may be feeling in your muscles.

• Then, with gentle reassurance, progressively tense and relax all the large muscle groups. Tighten your left leg with a deep breath in, for example, hold it, then release the leg muscles and the breath. Move on to the other leg. Move up the body, one muscle group at a time.

• Slow down your breathing. This may best be done blowing out every breath through pursed lips as if blowing out a candle. Also, place your hands on your stomach to feel the rapidity of your breathing. This may allow you to further control your symptoms.

• Tell yourself (or someone else if you are trying this technique with someone) that you are not "going crazy." If you are concerned about not being able to breathe, remember that if you are able to talk, you are able to breathe.

• If a person is diagnosed with any medical illness, especially heart disease, home treatment is not appropriate. Even if the person has a history of panic attacks, home care is not appropriate if there is any new or worrisome symptom.

|Medical Treatment|

Generally, panic attacks are treated with reassurance and relaxation techniques. By definition, panic attacks last less than an hour, so many times a person already feels much better by the time he or she makes it to the doctor's office. Nevertheless, because the diagnosis is made by excluding more dangerous causes, people may be given medications during their attack.

• If the doctor is suspicious of a cardiac (heart) cause, then the person may be given aspirin and various blood pressure medicines. An IV line may be started and fluids given. Some doctors will prescribe various antianxiety medicines such as diazepam (Valium) or lorazepam (Ativan) during the evaluation.

• Once the diagnosis of panic attack is made, however, the person may be surprised that no medicines are prescribed. Before medications are started, the person requires further evaluation by a mental health professional to check for the presence of other disorders. These may include anxiety disorders, depression, or panic disorder (a different diagnosis than panic attack).
  
  
• If medications are prescribed, several options are available. Selective serotonin reuptake inhibitors (SSRIs) such as sertraline (Zoloft), fluoxetine (Prozac), paroxetine (Paxil), and fluvoxamine (Luvox) are often the first choice. Clinical trials have shown SSRIs reduce the frequency of panic attack up to 75-85%. SSRIs must be taken 3-6 weeks before they are effective in reducing panic attacks and are taken once daily.
  
  
• Other choices of drug treatment include benzodiazepines such as alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), or diazepam (Valium). They effectively decrease panic attacks by up to 70-75% almost immediately; however, they must be up to 4 times per day. Additional drawbacks include sedation, memory loss, and after several weeks, tolerance to their effects and withdrawal symptoms may occur.
  
  
• Tricyclic antidepressants such as imipramine (Tofranil) and MAO inhibitors such as phenelzine (Nardil) have also been used, but many individuals experience side effects that are difficult to tolerate.

|Follow-up|

After a person is diagnosed with "panic attack," he or she will be given follow-up instructions depending on the entire picture of the illness obtained by the evaluating doctor. Most people are referred for immediate follow–up. Others may be given instructions that follow-up is not needed unless the symptoms return.

|Prevention|

For those people whose panic attacks are brought about by known stimuli, obviously the idea is to avoid those stimuli. Behavioral therapy is an important part of treatment, and people who have panic attacks may "practice" being in their trigger situations (such as riding an elevator or flying in an airplane) as part of their treatment. For those who go on to be diagnosed with panic disorder or other forms of anxiety, taking the prescribed medications is the key to prevention. Behavioral therapy may also be recommended.

|Outlook|

The prognosis for people who suffer a panic attack is troubling. Some people have 1 attack and are never bothered again. Yet, two-thirds of people experiencing a panic attack go on to be diagnosed with panic disorder. Also, half of those who go through a panic attack will develop clinical depression within the following year. Occasionally, a person will, after a long evaluation, be diagnosed with a medical condition that causes panic symptoms.

• Seek medical follow-up. For those who are diagnosed with panic disorder, depression, or another form of anxiety disorder, the news is encouraging. These disorders are usually well controlled with medications. However, many people suffer the effects of these illnesses for years before coming to a doctor for evaluation. These conditions can be extremely disabling, so follow up after the initial visit to the doctor is crucial so that diagnosis and treatment can continue.

• People who experience panic attacks are not "faking it." They have a real illness. It is important to gain knowledge about the diagnosis to understand and prevent future attacks. As a person comes to recognize the symptoms of panic attack and complies with whatever treatment is eventually recommended, the person can hope to end the panic attacks.

• Also, recent research indicates that adolescents who experience panic attacks are at increased risk for having thoughts about suicide and even for attempting suicide. This underscores the need to receive a thorough evaluation by a doctor.

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Author: John Shields, MD, Staff Physician, Department of Emergency Medicine, Denver Health Medical Center.

Coauthor(s): Erik D Barton, MD, MS, Associate Director, Assistant Professor, Department of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; James Quinn, MD, Director of Research Department of Medicine, Division of Emergency Medicine University of California at San Francisco Medical Center.