View source for Panic attack

{{Short description|Sudden periods of intense fear}}
{{Other uses}}
{{Infobox medical condition
| name = Panic attack
| image = Panic attack.svg<!--if my vector version is imperfect use the png version; Panic attact.png-->
| caption = A depiction of someone experiencing a panic attack being reassured by another person
| field = [[Psychiatry]]
| symptoms = Sudden period of intense [[fear]], [[palpitation]]s, [[sweating]], shaking, [[shortness of breath]], [[numbness]]<ref name=NIH2016/><ref name=DSM5/>
| complications = [[Self-harm]], [[suicide]],<ref name=DSM5/> [[agoraphobia]]
| onset = Over minutes<ref name=DSM5/>
| duration = Seconds to hours<ref name=Dand2013/>
| causes = [[Panic disorder]], [[social anxiety disorder]], [[post-traumatic stress disorder]], drug use, [[major depressive disorder|depression]], medical problems<ref name=DSM5/><ref name=Lancet2016/>
| risks = [[Nicotine]], [[caffeine]], [[cannabis (drug)|cannabis]], [[psychological stress]]<ref name=DSM5/>
| diagnosis = After other possible causes excluded<ref name=DSM5/>
| differential = [[Hyperthyroidism]], [[hyperparathyroidism]], [[heart disease]], [[lung disease]], drug use, [[dysautonomia]]<ref name=DSM5/>
| prevention = 
| treatment = [[Psychotherapy|Counseling]], [[medication]]s<ref name=NIH2013/>
| medication = Acute: [[Benzodiazepine]]s<ref name="Evidence-based pharmacotherapy of p">{{cite journal |last1=Batelaan |first1=Neeltje M. |last2=Van Balkom |first2=Anton J. L. M. |last3=Stein |first3=Dan J. |title=Evidence-based pharmacotherapy of panic disorder: an update |journal=The International Journal of Neuropsychopharmacology |date=April 2012 |volume=15 |issue=3 |pages=403–415 |doi=10.1017/S1461145711000800 |pmid=21733234 |doi-access=free |hdl=1871/42311 |hdl-access=free }}</ref> Preventative: [[Antidepressant]]s, [[anxiolytic]]s
| prognosis = Usually good<ref name=Ged2012/>
| frequency = 3% (EU), 11% (US)<ref name=DSM5/>
| deaths = 
| alt = 
}}
<!-- Definition and symptoms -->

'''Panic attacks''' are sudden periods of intense [[fear]] and [[Comfort|discomfort]] that may include [[palpitations]], otherwise defined as a [[Tachycardia|rapid]], [[Arrhythmia|irregular]] [[Heart rate|heartbeat]], [[Hyperhidrosis|sweating]], [[chest pain]] or discomfort, [[shortness of breath]], [[Tremor|trembling]], [[dizziness]], [[Hypoesthesia|numbness]], [[confusion]], or a [[sense of impending doom]] or loss of control.<ref name="NIH2016">{{cite web|title=Anxiety Disorders|url=https://www.nimh.nih.gov/health/topics/anxiety-disorders|website=NIMH|access-date=1 October 2016|date=March 2016|url-status=live|archive-url=https://web.archive.org/web/20160929085938/http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml|archive-date=29 September 2016}}</ref><ref name="DSM5" /><ref>{{cite journal|first1=Yu-Chi|last1=Lo|first2=Hsi-Han|last2=Chen|title=Shiau-Shian Huang Panic Disorder Correlates with the Risk for Sexual Dysfunction|journal=[[Journal of Psychiatric Practice]]|volume=26|issue=3|date=May 2020|pages=185–200|doi=10.1097/PRA.0000000000000460|pmid=32421290 |s2cid=218643956 }}</ref> Typically, 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.<ref name="Dand2013">{{cite book|last1=Bandelow|first1=Borwin|last2=Domschke|first2=Katharina|last3=Baldwin|first3=David|title=Panic Disorder and Agoraphobia|date=2013|publisher=OUP Oxford|isbn=978-0-19-100426-1|page=Chapter 1|url=https://books.google.com/books?id=T4RnAgAAQBAJ&pg=PT9|language=en|url-status=live|archive-url=https://web.archive.org/web/20161220094616/https://books.google.ca/books?id=T4RnAgAAQBAJ&pg=PT9|archive-date=20 December 2016}}</ref><ref name=":13">{{Cite web|last1=Smith|first1=Melinda|last2=Robinson|first2=Lawrence|last3=Segal|first3=Jeanne|title=Panic Attacks and Panic Disorder|url=https://www.helpguide.org/articles/anxiety/panic-attacks-and-panic-disorders.htm|access-date=6 July 2021|website=HelpGuide|language=en-US|archive-date=9 July 2021|archive-url=https://web.archive.org/web/20210709184241/https://www.helpguide.org/articles/anxiety/panic-attacks-and-panic-disorders.htm|url-status=live}}</ref> While they can be extremely distressing, panic attacks themselves are not physically dangerous.<ref name="Ged2012" /><ref>{{cite journal |date=7 June 2018 |title=International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology |journal=European Heart Journal |volume=39 |issue=22 |pages=2032–2046 |doi=10.1093/eurheartj/ehy076 |pmc=5991216 |pmid=29850871 |last16=Deshmukh |first16=Abhishek |last17=Lerman |first17=Amir |last18=Bossone |first18=Eduardo |last19=Citro |first19=Rodolfo |last20=Ueyama |first20=Takashi |last21=Corrado |first21=Domenico |last22=Kurisu |first22=Satoshi |last23=Ruschitzka |first23=Frank |last24=Winchester |first24=David |last25=Lyon |first25=Alexander R |last26=Omerovic |first26=Elmir |last27=Bax |first27=Jeroen J |last28=Meimoun |first28=Patrick |last29=Tarantini |first29=Giuseppe |last30=Rihal |first30=Charanjit |last31=Y.-Hassan |first31=Shams |last32=Migliore |first32=Federico |last33=Horowitz |first33=John D |last34=Shimokawa |first34=Hiroaki |last35=Lüscher |first35=Thomas Felix |last36=Templin |first36=Christian}}</ref>

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.<ref>{{Cite web |last=Administration |first=Substance Abuse and Mental Health Services |date=June 2016 |title=Table 3.10, Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5 |url=https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t10/ |access-date=2024-10-29 |website=www.ncbi.nlm.nih.gov |language=en}}</ref>

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.<ref>{{Cite journal |last1=Potter |first1=Carrie M. |last2=Wong |first2=Judy |last3=Heimberg |first3=Richard G. |last4=Blanco |first4=Carlos |last5=Liu |first5=Shang-Min |last6=Wang |first6=Shuai |last7=Schneier |first7=Franklin R. |date=2014 |title=Situational panic attacks in social anxiety disorder |journal=Journal of Affective Disorders |volume=167 |pages=1–7 |doi=10.1016/j.jad.2014.05.044 |issn=1573-2517 |pmc=4119296 |pmid=25082106}}</ref> Hence, while panic attacks cannot be applied to all disorders found in the DSM, they are a common comorbidity.<ref>{{Cite web |last=American Psychiatric Association |first=American Psychiatric Association |title=Changes to the DSM-V to the DSM-V-TR |url=https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf |access-date=22 March 2022 |website=Changes to the DSM V to DSM V-TR |archive-date=2 September 2018 |archive-url=https://web.archive.org/web/20180902075133/https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf |url-status=live }}</ref><!-- Cause and diagnosis -->

Panic attacks can be caused by an identifiable source, or they may happen without any warning and without a specific, recognizable situation.<ref name="DSM5" />

Some known causes that increase the risk of having a panic attack include medical and [[Mental disorder|psychiatric conditions]] (e.g., [[panic disorder]], [[social anxiety disorder]], [[post-traumatic stress disorder]], [[substance use disorder]], [[major depressive disorder|depression]]), substances (e.g., [[nicotine]], [[caffeine]]), and [[psychological stress]].<ref name="DSM5" /><ref name="Lancet2016">{{cite journal |last1=Craske |first1=Michelle G |last2=Stein |first2=Murray B |date=December 2016 |title=Anxiety |journal=The Lancet |volume=388 |issue=10063 |pages=3048–3059 |doi=10.1016/S0140-6736(16)30381-6 |pmid=27349358 |s2cid=208789585}}</ref>

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.<ref name="DSM5" /><ref>{{Cite journal|last1=Stewart|first1=Julian M.|last2=Pianosi|first2=Paul|last3=Shaban|first3=Mohamed A.|last4=Terilli|first4=Courtney|last5=Svistunova|first5=Maria|last6=Visintainer|first6=Paul|last7=Medow|first7=Marvin S.|date=1 November 2018|title=Hemodynamic characteristics of postural hyperventilation: POTS with hyperventilation versus panic versus voluntary hyperventilation|journal=Journal of Applied Physiology|volume=125|issue=5|pages=1396–1403|doi=10.1152/japplphysiol.00377.2018|pmid=30138078|pmc=6442665|issn=8750-7587|doi-access=free}}</ref>

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

Panic attacks often appear frightening to both those experiencing and those witnessing them, and often, people sometimes think they are having [[Myocardial infarction|heart attacks]] due to the symptoms.<ref>{{Cite journal |last1=Tully |first1=Phillip J |last2=Wittert |first2=Gary A |last3=Turnbull |first3=Deborah A |last4=Beltrame |first4=John F |last5=Horowitz |first5=John D |last6=Cosh |first6=Suzanne |last7=Baumeister |first7=Harald |date=December 2015 |title=Panic disorder and incident coronary heart disease: a systematic review and meta-analysis protocol |journal=Systematic Reviews |language=en |volume=4 |issue=1 |page=33 |doi=10.1186/s13643-015-0026-2 |doi-access=free |issn=2046-4053 |pmc=4376084 |pmid=25875199}}</ref><ref>{{Cite web |title=Panic Attack vs. Heart Attack: How to Tell the Difference |url=https://www.bidmc.org/about-bidmc/wellness-insights/heart-health/2020/01/panic-attack-vs-heart-attack |archive-url=https://web.archive.org/web/20250103001504/https://www.bidmc.org/about-bidmc/wellness-insights/heart-health/2020/01/panic-attack-vs-heart-attack |archive-date=2025-01-03 |access-date=2025-05-26 |website=www.bidmc.org |language=en-us |url-status=live }}</ref> 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]].<ref>{{Cite journal |last1=Allan |first1=Nicholas P. |last2=Gorka |first2=Stephanie M. |last3=Saulnier |first3=Kevin G. |last4=Bryan |first4=Craig J. |date=2023-04-01 |title=Anxiety Sensitivity and Intolerance of Uncertainty: Transdiagnostic Risk Factors for Anxiety as Targets to Reduce Risk of Suicide |journal=Current Psychiatry Reports |language=en |volume=25 |issue=4 |pages=139–147 |doi=10.1007/s11920-023-01413-z |issn=1535-1645 |pmc=10064604 |pmid=37000403}}</ref>

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

[[File:Panic disorder svg hariadhi.svg|thumb|300x300px]]

==Signs and symptoms==
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.<ref name=":14">{{Cite web |title=Symptoms and causes - Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/panic-attacks/symptoms-causes/syc-20376021?p=1 |url-status=live |archive-url=https://web.archive.org/web/20220317204310/https://www.mayoclinic.org/diseases-conditions/panic-attacks/symptoms-causes/syc-20376021?p=1 |archive-date=17 March 2022 |access-date=17 March 2022 |website=www.mayocinic .org}}</ref> Typically, the symptoms of panic attacks reach their worst intensity in the first minute, then gradually subside over the next several minutes.<ref name=":2">{{Cite web |title=Panic Disorder {{!}} Anxiety and Depression |url=https://adaa.org/understanding-anxiety/panic-disorder |url-status=live |archive-url=https://web.archive.org/web/20230312024802/https://adaa.org/understanding-anxiety/panic-disorder |archive-date=12 March 2023 |access-date=12 March 2023 |website=adaa.org}}</ref> During this time, people often feel intense fear that something catastrophic will happen despite there being no immediate danger.<ref name="NIH2016" /> 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.<ref name=":3">{{Citation |last1=Cackovic |first1=Curt |title=Panic Disorder |date=2024 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK430973/ |access-date=2024-10-30 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=28613692 |last2=Nazir |first2=Saad |last3=Marwaha |first3=Raman}}</ref> 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.<ref name=":3" />

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.<ref name=":3" />

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.<ref name=":4">{{Cite book | title=Panic Anxiety and Its Treatments: Report of the World Psychiatric Association Presidential Educational Program Task Force | publisher=American Psychiatric Association | first1=Gerald L. | last1=Klerman | first2=Robert M. A. | last2=Hirschfeld | first3=Myrna M. | last3=Weissman | page=[https://archive.org/details/panicanxietyitst0000unse/page/44 44] | year=1993 | isbn=978-0-88048-684-2 | url=https://archive.org/details/panicanxietyitst0000unse/page/44 }}</ref> Panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature.<ref name="Bourne2005">[[Edmund Bourne|Bourne, E.]] (2005). ''The Anxiety and Phobia Workbook'', 4th Edition: [[New Harbinger Press]].{{page needed|date=August 2015}}</ref>  <!-- Although, it must be said that the term 'positive' feedback loop is used in the sense of describing the loop itself, since multiple episodes of panic attacks are the farthest from positive many people can get.--> <!--Removed: Anxiety generated by these internal sensations activates the SNS, creating more sensations and more SNS arousal. This causes a [[positive feedback]] loop that increases their anxiety and can lead to a panic attack or worsen one that has already developed.-->

=== Chest pain ===
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.<ref name=":2" /> 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.<ref name=":5">{{Citation |last1=Ojha |first1=Niranjan |title=Myocardial Infarction |date=2024 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK537076/ |access-date=2024-10-31 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30725761 |last2=Dhamoon |first2=Amit S.}}</ref> 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.<ref name=":5" /> This would be evaluated in the emergency department with an [[Electrocardiography|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.<ref name=":5" /><!-- Comment: Covered in Triggers section Panic attacks can be caused by very common problems such as low blood sugar [[hypoglycemia]], [[hyperthyroidism]], or the overuse of [[caffeine]] or [[nicotine]].{{Fact|date=July 2007}}-->

==Causes==
[[File:The Fight or Flight Response.png|thumb|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.<ref name="Abnormal Psych">{{cite book |last1=Nolen-Hoeksema |first1=Susan |title=(Ab)normal Psychology |date=2013 |publisher=McGraw Hill |isbn=978-0-07-803538-8 |edition=6th}}{{page needed|date=January 2021}}</ref>

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.<ref>{{Cite web |last1=Marquardt |first1=Madeline |last2=Hambrick |first2=David Z. |title=Bad News for the Highly Intelligent |url=https://www.scientificamerican.com/article/bad-news-for-the-highly-intelligent/ |date=March 2018 |archive-url=https://web.archive.org/web/20210127153342/https://www.scientificamerican.com/article/bad-news-for-the-highly-intelligent/ |archive-date=27 January 2021 |url-status=live |website=Scientific American |language=en |access-date=14 June 2025}}</ref><ref>{{Cite journal | title=Gender Differences in Panic Disorder | url=https://www.psychiatrictimes.com/view/gender-differences-panic-disorder | access-date=26 January 2021 | journal=Psychiatric Times | series=Psychiatric Times Vol 21 No 1 | date=January 2004 | volume=21 | issue=1 | last1=Gregory a. Leskin | first1=PhD | archive-date=23 January 2021 | archive-url=https://web.archive.org/web/20210123182650/https://www.psychiatrictimes.com/view/gender-differences-panic-disorder | url-status=live }}</ref> Research involving identical twins has shown that if one twin has an anxiety disorder, the other is likely to have one too.<ref>{{cite journal |last1=Davies |first1=Matthew N. |last2=Verdi |first2=Serena |last3=Burri |first3=Andrea |last4=Trzaskowski |first4=Maciej |last5=Lee |first5=Minyoung |last6=Hettema |first6=John M. |last7=Jansen |first7=Rick |last8=Boomsma |first8=Dorret I. |last9=Spector |first9=Tim D. |title=Generalised Anxiety Disorder – A Twin Study of Genetic Architecture, Genome-Wide Association and Differential Gene Expression |journal=PLOS ONE |date=14 August 2015 |volume=10 |issue=8 |article-number=e0134865 |doi=10.1371/journal.pone.0134865 |pmid=26274327 |pmc=4537268 |bibcode=2015PLoSO..1034865D |doi-access=free }}</ref>

Panic attacks may also occur due to short-term stressors.<ref name=":14" /> 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.<ref name="Bourne2005" /><ref name="Panic disorder">{{cite journal |last1=Taylor |first1=C Barr |date=22 April 2006 |title=Panic disorder |journal=BMJ |volume=332 |issue=7547 |pages=951–955 |doi=10.1136/bmj.332.7547.951 |pmc=1444835 |pmid=16627512}}</ref> For adolescents, social transitions, such as changes in classes and schools, may also be a contributing factor.<ref>William T. O'Donohue,· Lorraine T. Benuto, Lauren Woodward Tolle (eds, 2013). Handbook of Adolescent Health Psychology, Springer, New York. {{ISBN|978-1-4614-6632-1}}. Page 511</ref>

People 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 (drug)|cannabis]] and nicotine.<ref name="Harvard Mental Health Letter, 2010">{{cite web |title=Medical marijuana and the mind - Harvard Health |url=http://www.health.harvard.edu/mind-and-mood/medical-marijuana-and-the-mind |url-status=live |archive-url=https://web.archive.org/web/20160821162716/http://www.health.harvard.edu/mind-and-mood/medical-marijuana-and-the-mind |archive-date=21 August 2016 |access-date=14 August 2016}}</ref><ref>{{cite journal |last1=Zvolensky |first1=Michael J. |last2=Gonzalez |first2=Adam |last3=Bonn-Miller |first3=Marcel O. |last4=Bernstein |first4=Amit |last5=Goodwin |first5=Renee D. |date=February 2008 |title=Negative reinforcement/negative affect reduction cigarette smoking outcome expectancies: Incremental validity for anxiety focused on bodily sensations and panic attack symptoms among daily smokers |journal=Experimental and Clinical Psychopharmacology |volume=16 |issue=1 |pages=66–76 |doi=10.1037/1064-1297.16.1.66 |pmid=18266553}}</ref>

===Panic disorder===
{{Main|Panic disorder}}

A panic attack is an isolated episode of intense fear or discomfort that peaks within minutes.<ref>{{Cite web |title=Panic Attack and Panic Disorder: Everything You Need to Know |url=https://anxietychecklist.com/panic-attack |access-date=2025-05-26 |website=anxietychecklist.com |language=en}}</ref><ref name="NIH2013" /> 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]]s in that panic attacks are often sudden and unprovoked.<ref name="familydoctor">[http://familydoctor.org/familydoctor/en/diseases-conditions/panic-disorder.html Panic Disorder – familydoctor.org<!-- Bot generated title -->] {{webarchive|url=https://web.archive.org/web/20140203235458/http://familydoctor.org/familydoctor/en/diseases-conditions/panic-disorder.html |date=3 February 2014 }}</ref> However, panic attacks experienced by those with panic disorder may also be linked to or heightened by exposure to certain places or situations, making daily life difficult.<ref>[http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/By_Illness/Anxiety_Disorders.htm "Anxiety Disorders"] {{webarchive|url=https://web.archive.org/web/20140412144344/http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/By_Illness/Anxiety_Disorders.htm |date=12 April 2014 }}</ref>

If a person has repeated and unexpected panic attacks, this could be a potential sign of panic disorder.<ref name="NIH2013" /> 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]]).<ref name=":4" />

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]].<ref name=":4" />

===Agoraphobia===
{{Main|Agoraphobia|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 [[phobia]]s of these situations and begin to take measures 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.<ref>{{Cite journal |last1=Shin |first1=Jin |last2=Park |first2=Doo-Heum |last3=Ryu |first3=Seung-Ho |last4=Ha |first4=Jee Hyun |last5=Kim |first5=Seol Min |last6=Jeon |first6=Hong Jun |date=2020-07-24 |title=Clinical implications of agoraphobia in patients with panic disorder |journal=Medicine |language=en-US |volume=99 |issue=30 |article-number=e21414 |doi=10.1097/MD.0000000000021414|pmid=32791758 |pmc=7387026 }}</ref> At this stage, the person is said to have panic disorder with agoraphobia.<ref>{{Cite journal |last1=Perugi |first1=Giulio |last2=Frare |first2=Franco |last3=Toni |first3=Cristina |date=2007 |title=Diagnosis and treatment of agoraphobia with panic disorder |journal=CNS Drugs |volume=21 |issue=9 |pages=741–764 |doi=10.2165/00023210-200721090-00004 |issn=1172-7047 |pmid=17696574 |s2cid=43437233 }}</ref>

In Japan, people who exhibit extreme agoraphobia to the point of becoming unwilling or unable to leave their homes are referred to as ''[[hikikomori]]''.<ref>{{Cite journal|last1=Bowker|first1=Julie C.|last2=Bowker|first2=Matthew H.|last3=Santo|first3=Jonathan B.|last4=Ojo|first4=Adesola Adebusola|last5=Etkin|first5=Rebecca G.|last6=Raja|first6=Radhi|date=3 September 2019|title=Severe Social Withdrawal: Cultural Variation in Past Hikikomori Experiences of University Students in Nigeria, Singapore, and the United States|journal=The Journal of Genetic Psychology|volume=180|issue=4–5|pages=217–230|doi=10.1080/00221325.2019.1633618|issn=0022-1325|pmid=31305235|s2cid=196616453}}</ref> This term is used to describe both the person and the phenomenon. According to some Japanese psychiatrists, hikikomori 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."<ref>{{Cite journal |last1=Teo |first1=Alan R. |last2=Gaw |first2=Albert C. |date=June 2010 |title=Hikikomori, a Japanese Culture-Bound Syndrome of Social Withdrawal?: A Proposal for DSM-5 |journal=Journal of Nervous & Mental Disease |language=en |volume=198 |issue=6 |pages=444–449 |doi=10.1097/NMD.0b013e3181e086b1 |issn=0022-3018 |pmc=4912003 |pmid=20531124}}</ref>

==Pathophysiology==
[[File:The Amygdala - Psych 1010.jpg|thumb|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.<ref name=":6">{{Citation |last1=Alshak |first1=Mark N. |title=Neuroanatomy, Sympathetic Nervous System |date=2024 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK542195/ |access-date=2024-11-04 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=31194352 |last2=Das |first2=Joe M.}}</ref> 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.<ref name=":6" /> 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).<ref name=":7">{{cite journal |last1=Maren |first1=Stephen |date=November 2009 |title=An Acid-Sensing Channel Sows Fear and Panic |journal=Cell |volume=139 |issue=5 |pages=867–869 |doi=10.1016/j.cell.2009.11.008 |pmid=19945375 |s2cid=18322284 |hdl-access=free |hdl=2027.42/83231}}</ref><ref name=":11">{{Cite journal |last1=Vollmer |first1=L L |last2=Strawn |first2=J R |last3=Sah |first3=R |date=2015-05-26 |title=Acid–base dysregulation and chemosensory mechanisms in panic disorder: a translational update |journal=Translational Psychiatry |language=en |volume=5 |issue=5 |pages=e572 |doi=10.1038/tp.2015.67 |issn=2158-3188 |pmc=4471296 |pmid=26080089}}</ref><ref name=":12">{{Cite journal |last1=Kim |first1=Jieun E |last2=Dager |first2=Stephen R |last3=Lyoo |first3=In Kyoon |date=December 2012 |title=The role of the amygdala in the pathophysiology of panic disorder: evidence from neuroimaging studies |journal=Biology of Mood & Anxiety Disorders |language=en |volume=2 |issue=1 |page=20 |doi=10.1186/2045-5380-2-20 |doi-access=free |issn=2045-5380 |pmc=3598964 |pmid=23168129}}</ref><ref name=":9">{{Cite journal |last=Lai |first=Chien-Han |date=2019-01-25 |title=Fear Network Model in Panic Disorder: The Past and the Future |journal=Psychiatry Investigation |language=en |volume=16 |issue=1 |pages=16–26 |doi=10.30773/pi.2018.05.04.2 |issn=1738-3684 |pmc=6354036 |pmid=30176707}}</ref>

=== Fear network model ===
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.<ref name=":9" /> 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.<ref name=":9" /> 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.<ref name=":9" />

=== Acid-base disturbances theory ===
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.<ref name=":7" /> This part of the amygdala is called the acid-sensing ion channel.<ref name=":7" /> 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.<ref name=":11" /> One such internal trigger is the amygdala sensing acidosis, which can be caused by inhaling CO<sub>2</sub> (carbon dioxide).<ref name=":7" /><ref name=":11" /> 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.<ref name=":11" />

Another theory, called the false suffocation alarm theory, is associated with the idea of acid-base imbalances in the amygdala.<ref name=":7" /><ref name=":11" /> In this theory, inhalation of CO<sub>2</sub> causes accumulation of acid in the blood and difficulty breathing, leading our brain to believe that we are suffocating, causing fear and panic.<ref name=":7" /> Studies have shown that inhaling CO<sub>2</sub> can cause fear in people who do not have any prior history of panic attacks.<ref name=":7" /> 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.<ref name=":7" />

=== Amygdala dysfunction theory ===
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.<ref name=":12" />

===Neurotransmitter imbalances===
Many [[neurotransmitter]]s are affected when the body is under the increased [[stress (biology)|stress]] and [[anxiety]] that accompany a panic attack. Some include [[serotonin]], [[GABA]] (gamma-aminobutyric acid), [[dopamine]], [[norepinephrine]], and [[glutamate]].<ref name="By2013" />

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 inhibitor|selective serotonin reuptake inhibitors]] (SSRIs) tend to feel a reduction of anxiety when their brain has more serotonin available to use.<ref name="By2013">{{cite journal |last1=Bystritsky |first1=Alexander |last2=Khalsa |first2=Sahib S. |last3=Cameron |first3=Michael E. |last4=Schiffman |first4=Jason |date=2013 |title=Current Diagnosis and Treatment of Anxiety Disorders |journal=Pharmacy and Therapeutics |volume=38 |issue=1 |pages=30–57 |pmc=3628173 |pmid=23599668}}</ref>

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 [[benzodiazepine]]s and [[barbiturate]]s, help with reducing anxiety almost immediately.<ref name="By2013" />

Dopamine's role in anxiety is not well understood. Some [[antipsychotic medication]]s 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.<ref name="By2013" />

Many physical symptoms of anxiety, such as rapid heart rate and hand tremors, are regulated by norepinephrine. Drugs that counteract norepinephrine's effect may be effective in reducing the physical symptoms of a panic attack.<ref name="By2013" /> On the other hand, some medications that raise overall norepinephrine levels, such as [[Tricyclic antidepressant|tricyclic antidepressants]] and [[Serotonin–norepinephrine reuptake inhibitor|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.<ref>{{cite journal |last1=Montoya |first1=Alonso |last2=Bruins |first2=Robert |last3=Katzman |first3=Martin A |last4=Blier |first4=Pierre |date=1 March 2016 |title=The noradrenergic paradox: implications in the management of depression and anxiety |journal=Neuropsychiatric Disease and Treatment |volume=12 |pages=541–557 |doi=10.2147/NDT.S91311 |pmc=4780187 |pmid=27042068 |doi-access=free}}</ref>

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

=== Cardiac mechanism ===
People who have been diagnosed with panic disorder have approximately double the risk of heart disease.<ref name="pmid24923348">{{cite journal |last1=Soares-Filho |first1=Gastao L. F. |last2=Arias-Carrion |first2=Oscar |last3=Santulli |first3=Gaetano |last4=Silva |first4=Adriana C. |last5=Machado |first5=Sergio |last6=Nardi |first6=Alexandre M. Valenca and Antonio E. |last7=Nardi |first7=AE |date=31 July 2014 |title=Chest Pain, Panic Disorder and Coronary Artery Disease: A Systematic Review |journal=CNS & Neurological Disorders Drug Targets |volume=13 |issue=6 |pages=992–1001 |doi=10.2174/1871527313666140612141500 |pmid=24923348}}</ref>  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.<ref name=":1">{{Cite journal |last1=Huffman |first1=Jeff C. |last2=Pollack |first2=Mark H. |last3=Stern |first3=Theodore A. |date=2002-04-01 |title=Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management |url=https://www.psychiatrist.com/pcc/panic-disorder-chest-pain-mechanisms-morbidity-management |journal=The Primary Care Companion for CNS Disorders |volume=4 |issue=2 |pages=54–62 |doi=10.4088/PCC.v04n0203 |issn=2155-7780 |pmc=181226 |pmid=15014745}}</ref>

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.<ref name=":1" /><ref>{{Cite journal |last1=Soares-Filho |first1=Gastão Luiz |last2=Mesquita |first2=Claudio |last3=Mesquita |first3=Evandro |last4=Arias-Carrión |first4=Oscar |last5=Machado |first5=Sergio |last6=González |first6=Manuel |last7=Valença |first7=Alexandre |last8=Nardi |first8=Antonio |date=2012 |title=Panic attack triggering myocardial ischemia documented by myocardial perfusion imaging study. A case report |journal=International Archives of Medicine |language=en |volume=5 |issue=1 |page=24 |doi=10.1186/1755-7682-5-24 |doi-access=free |issn=1755-7682 |pmc=3502479 |pmid=22999016}}</ref><ref>{{Cite web |title=Elevated troponin linked to mental stress ischemia in heart disease patients |url=https://www.sciencedaily.com/releases/2016/04/160403195916.htm |access-date=2024-04-16 |website=ScienceDaily |language=en}}</ref>

==Diagnosis==
According to the [[DSM-5]], a panic attack is part of the diagnostic class of [[anxiety disorder]]s.<ref name=":0">{{Cite web |last=Rockville (MD) |first=Substance Abuse and Mental Health Services Administration. |date=June 2016 |title=Table 3.10, Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5 |url=https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t10/ |access-date=14 March 2023 |website=www.ncbi.nlm.nih.gov |language=en |archive-date=7 March 2023 |archive-url=https://web.archive.org/web/20230307001612/https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t10/ |url-status=live }}</ref> DSM-5 criteria for a panic attack is defined as "''an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of the following symptoms occur":<ref name=":0" />'' 
{{Col-begin}}
{{Col-2}}
*Palpitations, 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 heat sensations
{{Col-end}}
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.<ref name=":3" /> 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]].<ref name=":3" /> 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.<ref>{{Cite web |title=Panic Disorder Screener (PADIS) |url=https://nceph.anu.edu.au/research/tools-resources/panic-disorder-screener-padis |access-date=2024-10-30 |website=ANU National Centre for Epidemiology and Population Health |language=en}}</ref>

==Treatment==
Panic disorder is usually effectively managed with a variety of interventions, including pharmacological treatment with medication, and psychological therapies.<ref>{{Cite web |title=Panic disorder: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/article/000924.htm |access-date=12 March 2023 |website=medlineplus.gov |language=en |archive-date=8 June 2023 |archive-url=https://web.archive.org/web/20230608055731/https://medlineplus.gov/ency/article/000924.htm |url-status=live }}</ref><ref name=Bourne2005/> 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.<ref name=":8">{{Cite journal |last1=Manjunatha |first1=Narayana |last2=Ram |first2=Dushad |date=March 2022 |title=Panic disorder in general medical practice- A narrative review |journal=Journal of Family Medicine and Primary Care |language=en-US |volume=11 |issue=3 |pages=861–869 |doi=10.4103/jfmpc.jfmpc_888_21 |doi-access=free |pmid=35495823 |pmc=9051703 |issn=2249-4863}}</ref>

Most panic attacks will resolve spontaneously within a course of 20 to 30 minutes without interference.{{cn|date=November 2024}} However, [[Benzodiazepine|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.<ref>{{Cite journal |last1=Susman |first1=Jeffrey |last2=Klee |first2=Brian |date=2005-02-15 |title=The Role of High-Potency Benzodiazepines in the Treatment of Panic Disorder |url=https://www.psychiatrist.com/pcc/role-high-potency-benzodiazepines-treatment-panic |journal=The Primary Care Companion for CNS Disorders |volume=7 |issue=1 |pages=5–11 |doi=10.4088/PCC.v07n0101 |issn=2155-7780 |pmc=1076453 |pmid=15841187}}</ref> 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.<ref name=":8" /> 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 [[feeling]]s.

[[Cognitive behavioral therapy]] (CBT) and Clonazepam (every 12 hours) may have the most complete and longest duration of effect, followed by specific [[selective serotonin reuptake inhibitor]]s (SSRIs) and CBT. Some research suggests that CBT is more effective at gaining coping skills than at effecting true panic cessation.<ref>{{cite book |title=Generalised anxiety disorder and panic disorder in adults: management |date=26 July 2019 |publisher=[[National Institute for Health and Care Excellence]] |series=Clinical Guideline 113 |url=https://www.nice.org.uk/guidance/cg113 |isbn=978-1-4731-2854-5 |access-date=8 January 2021 |archive-date=22 November 2018 |archive-url=https://web.archive.org/web/20181122005818/https://www.nice.org.uk/guidance/cg113 |url-status=live }}</ref> A 2009 review found positive results from therapy and medication and a much better result when the two were combined.<ref name="pmid17654408">{{cite journal |last1=Bandelow |first1=Borwin |last2=Seidler-Brandler |first2=Ulrich |last3=Becker |first3=Andreas |last4=Wedekind |first4=Dirk |last5=Rüther |first5=Eckart |title=Meta-analysis of randomized controlled comparisons of psychopharmacological and psychological treatments for anxiety disorders |journal=The World Journal of Biological Psychiatry |date=January 2007 |volume=8 |issue=3 |pages=175–187 |doi=10.1080/15622970601110273 |pmid=17654408 |s2cid=8504020 }}</ref> 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.<ref name=":13" />

===Lifestyle changes===
Growing research suggests that along with standardized medical treatments, lifestyle changes can help alleviate some of the most common mental health conditions.<ref>{{Cite journal |last1=Correll |first1=Terry |last2=Gentile |first2=July |last3=Correll |first3=Andrew |date=September 1, 2023 |title=Healthy Lifestyle Interventions Augmenting Psychotherapy in Anxiety and PTSD |journal=Innovations in Clinical Neuroscience |volume=20 |issue=7–9 |pages=18–26 |pmid=37817811 |pmc=10561983 }}</ref> Because of this, there has been a growing emphasis on the potential of lifestyle interventions and non-pharmacological methods for anxiety.<ref>{{Cite journal |last1=Chong |first1=Terence W. H. |last2=Curran |first2=Eleanor |last3=Southam |first3=Jenny |last4=Bryant |first4=Christina |last5=Cox |first5=Kay L |last6=Ellis |first6=Kathryn A. |last7=Anstey |first7=Kaarin J. |last8=Goh |first8=Anita |last9=Lautenschlager |first9=Nicola T |date=2023-12-01 |title=The potential of physical activity and technology interventions to reduce anxiety in older adults |url=https://www.sciencedirect.com/science/article/pii/S2666915323001713 |journal=Journal of Affective Disorders Reports |volume=14 |article-number=100633 |doi=10.1016/j.jadr.2023.100633 |issn=2666-9153|hdl=1959.4/unsworks_84293 |hdl-access=free }}</ref> 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]].<ref>{{cite web |date=17 July 2013 |title=3 Tips for Using Exercise to Shrink Anxiety |url=http://psychcentral.com/blog/archives/2013/07/17/3-tips-for-using-exercise-to-shrink-anxiety/ |url-status=live |archive-url=https://web.archive.org/web/20150420020719/http://psychcentral.com/blog/archives/2013/07/17/3-tips-for-using-exercise-to-shrink-anxiety/ |archive-date=20 April 2015 |access-date=14 April 2015}}{{full citation needed|date=August 2015}}</ref> 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,<ref>{{MedlinePlusEncyclopedia|003071|Hyperventilation}}</ref>  so it is important to pace the exercise regimen accordingly.<ref>{{cite web |title=Cardio Exercise for Beginners |url=http://www.livestrong.com/article/103790-cardio-exercise-beginners |url-status=live |archive-url=https://web.archive.org/web/20150423164013/http://www.livestrong.com/article/103790-cardio-exercise-beginners/ |archive-date=23 April 2015 |access-date=14 April 2015}}{{full citation needed|date=August 2015}}</ref>

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.<ref>{{Cite journal |last1=Klevebrant |first1=Lisa |last2=Frick |first2=Andreas |date=2022 |title=Effects of caffeine on anxiety and panic attacks in patients with panic disorder: A systematic review and meta-analysis |journal=General Hospital Psychiatry |volume=74 |pages=22–31 |doi=10.1016/j.genhosppsych.2021.11.005 |issn=1873-7714 |pmid=34871964}}</ref>  Anxiety and panic can also temporarily increase during [[Drug withdrawal|withdrawal]] from caffeine and various other drugs and substances.<ref>American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev., p. 479). Washington, D.C.: American Psychiatric Association.{{page needed|date=January 2021}}</ref>

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

===Breathing exercises===
Irregularities in breathing, including [[Hyperventilation syndrome|hyperventilation]] and [[shortness of breath]], are key features of anxiety and panic attacks.<ref name=":10">{{Cite journal |last1=Banushi |first1=Blerida |last2=Brendle |first2=Madeline |last3=Ragnhildstveit |first3=Anya |last4=Murphy |first4=Tara |last5=Moore |first5=Claire |last6=Egberts |first6=Johannes |last7=Robison |first7=Reid |date=2023-02-02 |title=Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review |journal=Brain Sciences |language=en |volume=13 |issue=2 |page=256 |doi=10.3390/brainsci13020256 |doi-access=free |issn=2076-3425 |pmc=9954474 |pmid=36831799}}</ref> [[Hyperventilation syndrome]] occurs when an individual experiences deep, quick-paced breathing, eventually affecting blood flow to the brain and altering conscious awareness.<ref name=":10" />

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.<ref name=":10" /> Breathing retraining exercise helps to rebalance the oxygen and CO<sub>2</sub> levels in the blood, improving cerebral blood flow.<ref>{{Cite web |url=http://emedicine.medscape.com/article/807277-overview#a6 |title=Hyperventilation Syndrome  |date=28 November 2016 |access-date=18 September 2017 |url-status=live |archive-url=https://web.archive.org/web/20170713055956/http://emedicine.medscape.com/article/807277-overview |archive-date=13 July 2017 }}</ref> [[Capnometry]], which provides exhaled CO<sub>2</sub> levels, may help guide breathing.<ref>{{Cite web |last=Craske |first=Michelle |date=30 September 2011 |title=Psychotherapy for panic disorder |url=http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?10/7/10353/ |archive-url=https://web.archive.org/web/20171014035243/http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?10%2F7%2F10353%2F |archive-date=14 October 2017 |access-date=29 April 2020}}</ref><ref>{{cite journal |last1=Meuret |first1=Alicia E. |last2=Ritz |first2=Thomas |date=October 2010 |title=Hyperventilation in panic disorder and asthma: Empirical evidence and clinical strategies |journal=International Journal of Psychophysiology |volume=78 |issue=1 |pages=68–79 |doi=10.1016/j.ijpsycho.2010.05.006 |pmc=2937087 |pmid=20685222}}</ref>

[[David D. Burns]] recommends breathing exercises for those with anxiety. One such breathing exercise is a 5-2-5 count. Using the stomach (or diaphragm)—and not the chest—inhale (feel the stomach come out, as opposed to the chest expanding) for 5 seconds. As the maximal point at inhalation is reached, hold the breath for 2 seconds. Then slowly exhale, over 5 seconds. Repeat this cycle twice and then breathe 'normally' for 5 cycles (1 cycle = 1 inhale + 1 exhale). The point is to focus on breathing and relax the heart rate.<ref>{{Cite journal |last1=Bhagat |first1=Vidya |last2=Haque |first2=Mainul |last3=Jaalam |first3=Kamarudin |title=Breathing Exercise – A Commanding Tool for Self-help Management during Panic attacks|url=https://www.researchgate.net/publication/323111032 |date=2017 |journal=Research Journal of Pharmacy and Technology |volume=10 |issue=12 |pages=4471–4473 |access-date=14 June 2025}}</ref>

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

===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 is appropriate in many cases.<ref>{{cite web |title=Answers to Your Questions About Panic Disorder |url=https://www.apa.org/topics/anxiety/panic-disorder |website=American Psychological Association |year=2008 |access-date=8 January 2021 |archive-date=10 January 2021 |archive-url=https://web.archive.org/web/20210110071101/https://www.apa.org/topics/anxiety/panic-disorder |url-status=live }}</ref> The first part of therapy is largely informational; many people are greatly helped by simply understanding exactly what panic disorder is and how many others experience it. Many people with panic disorder are worried that their panic attacks mean they are "going crazy" or that the panic might induce a heart attack. [[Cognitive restructuring]] helps people to replace those thoughts with more realistic, positive ways of viewing the attacks.<ref name="Cognitive Restructuring Ability">{{Cite web |last1=Cramer |first1=Kathleen A. |last2=Post |first2=Thomas R. |last3=Behr |first3=Merlyn J. |title=Cognitive Restructuring Ability, Teacher Guidance and Perceptual Distracter Tasks: An Aptitude Treatment Interaction Study |url=http://www.cehd.umn.edu/rationalnumberproject/89_2.html |date=January 1989 |archive-url=https://web.archive.org/web/20101222180132/http://www.cehd.umn.edu/rationalnumberproject/89_2.html |archive-date=22 December 2010 |access-date=14 June 2025}}</ref> 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.<ref name="Panic disorder"/> Exposure therapy,<ref>{{Cite book|title = Exposure Therapy for Anxiety: Principles and Practice|url = https://books.google.com/books?id=7RAsnO1vU0UC|publisher = Guilford Press|date = 17 December 2012|isbn = 978-1-4625-0969-0|first1 = Jonathan S.|last1 = Abramowitz|first2 = Brett J.|last2 = Deacon|first3 = Stephen P. H.|last3 = Whiteside|url-status = live|archive-url = https://web.archive.org/web/20160520171142/https://books.google.com/books?id=7RAsnO1vU0UC|archive-date = 20 May 2016}}</ref> which includes repeated and prolonged confrontation with feared situations and body sensations, helps weaken anxiety responses to panic-inducing external and internal stimuli.

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]].<ref>{{cite book|last=Waska|first=Robert|title=Treating Severe Depressive and Persecutory Anxiety States: To Transform the Unbearable|year=2010|publisher=Karnac Books|isbn=978-1-85575-720-2}}{{page needed|date=January 2021}}</ref>

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.<ref name=pmid11459386>{{cite journal |last1=Fava |first1=G. A. |last2=Rafanelli |first2=C. |last3=Grandi |first3=S. |last4=Conti |first4=S. |last5=Ruini |first5=C. |last6=Mangelli |first6=L. |last7=Belluardo |first7=P. |title=Long-term outcome of panic disorder with agoraphobia treated by exposure |journal=Psychological Medicine |date=July 2001 |volume=31 |issue=5 |pages=891–898 |doi=10.1017/s0033291701003592 |pmid=11459386 |s2cid=5652068 }}</ref> A result was that thirty-two percent of patients had a panic episode after treatment. They concluded that the use of exposure therapy has some efficacy for a client who is living with a panic disorder and agoraphobia.<ref name=pmid11459386/>

=== Medication ===
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 [[Benzodiazepine dependence|dependence]], fatigue, slurred speech, and memory loss.<ref name="Evidence-based pharmacotherapy of p">{{cite journal |last1=Batelaan |first1=Neeltje M. |last2=Van Balkom |first2=Anton J. L. M. |last3=Stein |first3=Dan J. |title=Evidence-based pharmacotherapy of panic disorder: an update |journal=The International Journal of Neuropsychopharmacology |date=April 2012 |volume=15 |issue=3 |pages=403–415 |doi=10.1017/S1461145711000800 |pmid=21733234 |doi-access=free |hdl=1871/42311 |hdl-access=free }}</ref> Antidepressant treatments for panic attacks include selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and [[MAO inhibitor|monoamine oxidase inhibitor]]s (MAOIs).<ref name="pmid12197851" /> 

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.<ref name="pmid12197851">{{cite journal |last1=Bakker |first1=A. |last2=Van Balkom |first2=A. J. L. M. |last3=Spinhoven |first3=P. |title=SSRIs vs. TCAs in the treatment of panic disorder: a meta-analysis |journal=Acta Psychiatrica Scandinavica |date=2002 |volume=106 |issue=3 |pages=163–167 |doi=10.1034/j.1600-0447.2002.02255.x |pmid=12197851 |s2cid=26184300 }}</ref>

SSRIs carry a relatively low risk since they are not associated with much [[Drug tolerance|tolerance]] or [[Substance dependence|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.<ref name="pmid18728820">{{cite journal |last1=Marchesi |first1=Carlo |title=Pharmacological management of panic disorder |journal=Neuropsychiatric Disease and Treatment |date=March 2008 |volume=4 |issue=1 |pages=93–106 |doi=10.2147/ndt.s1557 |pmid=18728820 |pmc=2515914 |doi-access=free }}</ref>

While the use of drugs in treating panic attacks can be very successful, it is generally recommended that people also be in some form of therapy, such as cognitive behavioral therapy. Drug treatments are usually used throughout the duration of panic attack symptoms and discontinued after the patient has been free of symptoms for at least six months. It is usually safest to discontinue these drugs [[Tapering (medicine)|gradually]] while undergoing therapy.<ref name="Panic disorder"/> 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.<ref name=pmid18728820/>

==Prognosis==
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 [[Phobia|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.<ref>{{Cite web |title=Panic attacks and panic disorder - Diagnosis and treatment - Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/panic-attacks/diagnosis-treatment/drc-20376027#:~:text=Successful%20treatment%20can%20also%20help,go%20away%20within%20several%20months. |access-date=2024-11-14 |website=www.mayoclinic.org}}</ref>

==Epidemiology==
In Europe, about 3% of the population has a panic attack in a given year. In the United States, they affect about 11%.<ref name=DSM5/> Panic attacks are more common in females than in males.<ref name=DSM5/> They often begin during [[puberty]] or early adulthood.<ref name=DSM5/> Children and older people are less commonly affected.<ref name="DSM5"/>  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.<ref name="pmid11578982">{{cite journal |last1=Hettema |first1=John M. |last2=Neale |first2=Michael C. |last3=Kendler |first3=Kenneth S. |date=October 2001 |title=A Review and Meta-Analysis of the Genetic Epidemiology of Anxiety Disorders |journal=American Journal of Psychiatry |volume=158 |issue=10 |pages=1568–1578 |doi=10.1176/appi.ajp.158.10.1568 |pmid=11578982 |s2cid=7865025}}</ref>

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

==References==
{{Reflist}}

== External links ==

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

{{DEFAULTSORT:Panic Attack}}
[[Category:Anxiety]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Wikipedia neurology articles ready to translate]]
[[Category:Symptoms or signs involving appearance or behaviour]]