Defining Panic 

A panic attack is defined as a period of extreme fear or discomfort that develops abruptly and reaches a peak within 10 minutes. Its symptoms include accelerated heart rate, sweating, trembling, choking sensations, hot flashes or chills, dizziness or lightheadedness, fears of losing control or going crazy, and fears of dying (APA, 2013). Sometimes panic attacks are expected, occurring in response to specific environmental triggers (such as being in a tunnel); other times, these episodes are unexpected and emerge randomly (such as when relaxing). 

The physical symptoms of a panic attack

Some of the physical manifestations of a panic attack can include dizziness, shortness of breath, sweating, trembling, feelings of faintness, chest pain, or a fear of losing control.

People with panic disorder experience recurrent (more than one) and unexpected panic attacks, along with at least one month of persistent concern about additional panic attacks, worry over the consequences of the attacks, or self-defeating changes in behavior related to the attacks (such as withdrawing from social activities out of fear of having an attack) (APA, 2013). Since panic attacks can occur unexpectedly, they can become a cause of ongoing worry and avoidance. People with panic disorder may become so afraid of having panic attacks that they experience what are known as anticipatory attacks—essentially panicking about potential panic attacks and entering a cycle of living in fear of fear.

Panic disorder is very treatable; however, left untreated, it can significantly reduce quality of life. People with untreated panic disorder are at an increased risk for specific phobias, such as agoraphobia (a fear of leaving the house), and they often suffer from one or more additional mental-health conditions, such as depression or substance abuse.

DSM-5 Diagnostic Criteria

In the DSM-5, panic attacks themselves are not mental disorders; instead, they are listed as specifiers for other mental disorders, such as anxiety disorders. Panic attacks are differentiated as being either expected or unexpected; the categories from the previous DSM-IV-TR (situationally bound/cued, situationally predisposed, or unexpected/uncued) have been removed.

In order to be diagnosed with panic disorder, a person must experience unexpected, recurrent panic attacks. These panic attacks must also be accompanied by at least one month of a significant and related behavior change in relation to the attacks, a persistent concern or fear of more attacks, or a worry about the attacks' consequences. As is the case with other anxiety disorders, the panic attacks cannot result from the physiological effects of drugs and other substances, a medical condition, or another mental disorder. While the previous version of the DSM defined panic disorder as occurring either with or without agoraphobia, the new DSM-5 lists panic disorder and agoraphobia as two distinct disorders. 

Etiology

Both genetic and environmental causes (often in combination) can cause panic disorder. Children are at a higher risk of developing panic disorder if their parents have the disorder (Biederman et al., 2001), and family and twins studies indicate that the heritability of panic disorder is around 43% (Hettema, Neale, & Kendler, 2001). The exact genes and gene functions involved in this disorder, however, are not well understood (APA, 2013). Neurobiological theories of panic disorder suggest that a region of the brain called the locus coeruleus may play a role in this disorder. Located in the brainstem, the locus coeruleus is the brain’s major source of norepinephrine, a neurotransmitter that triggers the body’s fight-or-flight response. Activation of the locus coeruleus is associated with anxiety and fear, and research with nonhuman primates has shown that stimulating the locus coeruleus either electrically or through drugs produces panic-like symptoms (Charney et al., 1990). Such findings have led to the theory that panic disorder may be caused by abnormal norepinephrine activity in the locus coeruleus (Bremner, Krystal, Southwick, & Charney, 1996).

Although the genetic link is clear, 75% of those diagnosed with panic disorder do not have a close relative with the disorder—indicating the significance of environmental factors. Major life changes (such as moving out of the family home, getting married, starting a new job, or having a baby) often precede the onset of panic disorder by contributing to stress. 

Conditioning theories of panic disorder propose that panic attacks are classical-conditioning responses to subtle bodily sensations resembling those normally occurring when one is anxious or frightened (Bouton, Mineka, & Barlow, 2001). For example, consider a child who has asthma. An acute asthma attack produces sensations, such as shortness of breath, coughing, and chest tightness, that typically elicit fear and anxiety. Later, when the child experiences subtle symptoms that resemble the frightening symptoms of earlier asthma attacks (such as shortness of breath after climbing stairs), he may become anxious, fearful, and then experience a panic attack. Similarly, cognitive theories (Clark, 1996) argue that those with panic disorder are prone to interpret ordinary bodily sensations catastrophically, and these fearful interpretations set the stage for panic attacks. 

Treatment

Although there is no known cure, panic disorder can be successfully treated in many cases using psychotherapy, medication, or a combination of both. Cognitive behavioral therapy (CBT) is the psychotherapeutic treatment of choice for panic disorder; several studies show that 85 to 90 percent of panic-disorder patients treated with CBT recover completely from their panic attacks within 12 weeks. The goal of cognitive behavioral therapy is to help a patient reorganize thinking processes and anxious thoughts regarding an experience that provokes panic. Psychotherapy can improve the effectiveness of medication, reduce the likelihood of relapse for someone who has discontinued medication, and offer help for people with panic disorder who do not respond at all to medication. Selective serotonin reuptake inhibitors (SSRIs) are first-line medication treatments for panic disorder; they are preferred over benzodiazapines due to concerns about the latter regarding tolerance, dependence, and abuse.