What is a panic attack, its symptoms, diagnosis, and treatment options?

Panic Attack: Definition, Symptoms, Diagnosis, and Treatment

A panic attack is characterized by a sudden onset of intense fear or discomfort that reaches its peak within 10 minutes, accompanied by at least 4 of 13 specific physical and cognitive symptoms, including palpitations, sweating, trembling, shortness of breath, and fear of dying 1. Cognitive-behavioral therapy is the first-line treatment for panic attacks and panic disorder, with selective serotonin reuptake inhibitors (SSRIs) recommended as the first pharmacological option when medication is needed.

What is a Panic Attack?

Panic attacks are discrete periods of intense fear or anxiety with:

• Rapid onset (typically reaching peak intensity within 10 minutes)
• Limited duration (usually subsiding within 30 minutes)
• Significant autonomic nervous system activation
• Physical and cognitive manifestations

Panic attacks can occur:

• Unexpectedly (without an obvious trigger)
• In response to specific situations
• During sleep (affecting up to 71% of patients with panic disorder) 2

Symptoms of Panic Attacks

A panic attack is diagnosed by the presence of at least 4 of these 13 symptoms:

1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
10. Fear of losing control
11. Fear of dying
12. Paresthesias (numbness or tingling sensations)
13. Chills or hot flushes 1, 3

Cultural Variations in Symptom Presentation

Different cultural groups may emphasize diverse symptoms during panic attacks:

• Dizziness is more commonly reported in several Asian groups
• Visual disturbances may be more prominent in certain cultural contexts or syndromes, such as:
  • Khyâl (wind) attacks in Cambodians
  • Trung gió attacks in Vietnamese
  • Ataque de nervios in Latin Americans 1

Diagnosing Panic Attacks and Panic Disorder

Diagnostic Criteria

Panic attacks themselves are not a disorder but a symptom that can occur in various anxiety disorders. Panic disorder is diagnosed when:

1. The person experiences recurrent unexpected panic attacks
2. At least one attack has been followed by one month or more of:
   • Persistent concern about having additional attacks
   • Worry about the implications or consequences of the attacks
   • Significant change in behavior related to the attacks 4, 3

Diagnostic Process

1. Clinical interview: Systematic assessment of symptoms, frequency, duration, and impact on functioning
2. Screening tools: The American Psychiatric Association's Level 1 Cross-Cutting Symptom Measures can help identify anxiety symptoms 4
3. Rule out medical causes: Medical conditions that can mimic panic symptoms must be excluded, particularly cardiac conditions 1
4. Assess for comorbidities: Depression, substance use disorders, and other anxiety disorders frequently co-occur with panic disorder 5, 6

Treatment Approaches

Psychological Interventions

Cognitive-behavioral therapy (CBT) is the first-line treatment for panic attacks and panic disorder:

• Helps patients identify and challenge catastrophic misinterpretations of bodily sensations
• Includes exposure to feared sensations and situations
• Teaches coping skills and relaxation techniques 1

Pharmacological Treatment

When medication is indicated:

1. First-line: Selective Serotonin Reuptake Inhibitors (SSRIs)

   • Paroxetine and fluoxetine show stronger evidence of efficacy than sertraline 7
   • FDA-approved for panic disorder: sertraline, fluoxetine 3, 8
   • Better tolerated than older medications
   • Effective for comorbid conditions

2. Second-line: Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

   • Venlafaxine has demonstrated efficacy 7

3. Third-line: Tricyclic Antidepressants (TCAs)

   • Clomipramine and imipramine show good efficacy
   • More side effects than SSRIs/SNRIs

4. Benzodiazepines:

   • Alprazolam, diazepam, and clonazepam show strong efficacy and are ranked highest for effectiveness 7
   • Associated with lower dropout rates compared to antidepressants
   • Concerns about dependence and withdrawal limit long-term use
   • Best reserved for short-term use or treatment-resistant cases

Treatment Selection Considerations

1. Severity of symptoms: More severe symptoms may warrant combination therapy
2. Comorbid conditions: Select medications that address both panic and comorbid disorders
3. Prior treatment response: Consider what has worked previously
4. Side effect profile: Choose medications with tolerable side effects
5. Patient preference: Involve patients in treatment decisions

Complications and Prognosis

If left untreated, panic attacks can lead to:

• Development of panic disorder
• Agoraphobia (fear and avoidance of places where escape might be difficult)
• Alcohol or substance abuse
• Depression
• Increased risk of suicide 1

Early recognition and treatment significantly improve outcomes and prevent these complications.

Common Pitfalls in Management

1. Misdiagnosis: Mistaking panic symptoms for cardiac or neurological conditions, leading to unnecessary medical testing
2. Undertreatment: Not providing adequate duration or dosage of medication
3. Overreliance on benzodiazepines: Despite their efficacy, long-term use can lead to dependence
4. Neglecting psychological treatment: Medication alone is often insufficient for complete remission
5. Failing to address comorbidities: Untreated depression or substance use can undermine panic treatment

By recognizing these common pitfalls and implementing evidence-based treatments, clinicians can effectively manage panic attacks and improve patients' quality of life.