Panic Attacks

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A panic attack is a discrete period of intense fear or discomfort that is associated with numerous somatic and cognitive symptoms (DSM-IV). These symptoms include palpitations, sweating, trembling, shortness of breath, sensations of choking or smothering, chest pain, nausea or gastrointestinal distress, dizziness or light headedness, tingling sensations, and chills or blushing and “hot flashes.”

The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes. Most people report a fear of dying, “going crazy,” or losing control of emotions or behavior.

The experiences generally provoke a strong urge to escape or flee the place where the attack begins and, when associated with chest pain or shortness of breath, frequently results in seeking aid from a hospital emergency room or other type of urgent assistance.

Yet an attack rarely lasts longer than 30 minutes. Current diagnostic practice specifies that a panic attack must be characterized by at least four of the associated somatic and cognitive symptoms described above. The panic attack is dis- tinguished from other forms of anxiety by its intensity and its sudden, episodic nature. Panic attacks may be further characterized by the relationship between the onset of the attack and the presence or absence of situational factors. For example, a panic attack may be described as unexpected, situationally bound, or situationally predisposed (usually, but not invariably occurring in a particular situation). There are also attenuated or “limited symptom” forms of panic attacks.

      Panic attacks are not always indicative of a mental disorder, and up to 10 percent of otherwise healthy people experience an isolated panic attack per year (Barlow, 1988; Klerman et al., 1991). Panic attacks also are not limited to panic disorder. They commonly occur in the course of social phobia, generalized anxiety disorder, and major depressive disorder (DSM-IV).


      Panic disorder is diagnosed when a person has experienced at least two unexpected panic attacks and develops persistent concern or worry about having further attacks or changes his or her behavior to avoid or minimize such attacks. Whereas the number and severity of the attacks varies widely, the concern and avoidance behavior are essential features. The diagnosis is inapplicable when the attacks are presumed to be caused by a drug or medication or a general medical disorder, such as hyperthyroidism.


      Lifetime rates of panic disorder of 2 to 4 percent and 1-year rates of about 2 percent are documented consistently in epidemiological studies (Kessler et al., 1994; Weissman et al., 1997) (Table 4-1). Panic disorder is frequently complicated by major depressive disorder (50 to 65 percent lifetime comorbidity rates) and alcoholism and substance abuse disorders (20 to 30 percent comorbidity) (Keller & Hanks, 1994; Magee et al., 1996; Liebowitz, 1997).

Panic disorder is also concomitantly diagnosed, or co-occurs, with other specific anxiety disorders, including social phobia (up to 30 percent), generalized anxiety disorder (up to 25 percent), specific phobia (up to 20 percent), and obsessive-compulsive disorder (up to 10 percent) (DSM-IV). As discussed subsequently, approximately one-half of people with panic disorder at some point develop such severe avoidance as to warrant a separate description, panic disorder with agoraphobia.

      Panic disorder is about twice as common among women as men (American Psychiatric Association, 1998). Age of onset is most common between late adolescence and mid-adult life, with onset relatively uncommon past age 50. There is developmental continuity between the anxiety syndromes of youth, such as separation anxiety disorder. Typically, an early age of onset of panic disorder carries greater risks of comorbidity, chronicity, and impairment.  Panic disorder is a familial condition and can be distinguished from depressive disorders by family studies (Rush et al., 1998).