What are the typical symptoms of panic attacks and the recommended acute and long‑term management?

Panic Attack Symptoms and Management

Core Symptoms of Panic Attacks

A panic attack is a discrete period of intense fear or discomfort that develops abruptly and reaches a peak within 10 minutes, characterized by at least four of the following symptoms: 1, 2

Physical/Autonomic Symptoms

• Palpitations, pounding heart, or accelerated heart rate 1, 2
• Sweating 1, 2
• Trembling or shaking 1, 2
• Shortness of breath or sensations of smothering 1, 2
• Feeling of choking 1, 2
• Chest pain or discomfort 1, 2
• Nausea or abdominal distress 1, 2
• Dizziness, unsteadiness, lightheadedness, or faintness 1, 2
• Chills or hot flushes 1, 2
• Paresthesias (numbness or tingling sensations) 1, 2

Psychological Symptoms

• Depersonalization (feeling detached from oneself) or derealization (sensation that the world is unreal) 1, 2
• Fear of losing control or going crazy 1, 2
• Fear of dying 1, 2

Cultural Variations in Symptom Presentation

Clinicians should recognize that panic attack symptoms vary across cultural groups, which may affect diagnosis if relying solely on DSM criteria 3:

• Additional symptoms reported in certain populations include tinnitus, neck soreness, headache, and uncontrollable screaming or crying 3
• Feelings of heat in specific body parts (head, chest, neck) are common across several cultural groups but not well captured by the phrase "hot flushes" 3
• Higher rates of specific symptoms occur in different populations: paresthesias in African Americans, trembling in Caribbean Latinos, dizziness in Asian groups, and fear of dying in Arabs and African Americans 3

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Acute Management of Panic Attacks

Immediate Assessment: Rule Out Medical Emergencies

Before treating as panic, rule out acute coronary syndrome in patients with chest pain, especially those over 30 years old or with cardiac risk factors 4:

• Key features distinguishing panic from cardiac causes: trembling, dizziness, derealization, paresthesias, chills/hot flushes, and abrupt onset peaking within minutes 4
• Pain affected by palpation, breathing, turning, twisting, or bending, or pain from multiple sites argues against angina 4

First-Line Acute Interventions

Apply psychological first aid principles including relaxation techniques and reassurance that symptoms are not life-threatening 4:

Environmental Management

• Place the patient in a private room when possible to minimize anxiety-provoking stimuli 4
• Position comfortably in a seated position with upper body elevated 4

Breathing Control Techniques

• Guide the patient to take slow, deep breaths through the nose, hold briefly, and exhale slowly through pursed lips to interrupt catastrophic thinking 4
• Encourage the "coachman's seat" position to optimize breathing 4
• Avoid rebreathing from a paper bag as it may cause hypoxemia 4

Physical Interventions

• Apply cooling to the face (cold compress or cool air) to reduce physiological arousal 4
• Use small ventilators to help with breathlessness 4

What NOT to Do

Do not provide psychological debriefing (formal structured interventions where patients are asked to ventilate emotions and relive the trauma), as this may worsen outcomes 4

Oxygen Therapy Considerations

• Patients with pure hyperventilation due to panic attacks are unlikely to require oxygen therapy 4
• Provide oxygen only if the patient is actually hypoxemic (oxygen saturation <90%) 4

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Post-Attack Management and Prevention

Patient Education and Action Planning

Develop a written action plan for managing future episodes, teaching patients to recognize early warning signs (racing heart, tight chest, sense of impending doom) so they can implement coping strategies before symptoms escalate 4:

Sensory Grounding Techniques

• Teach patients to notice environmental details (colors, textures, sounds) 4
• Implement cognitive distractions (word games, counting backwards) 4
• Use sensory-based distractors (flicking rubber band on wrist) 4

Screening for Comorbidities

Screen for depression, as it occurs commonly with panic disorder and untreated depression can influence clinical outcomes and end-of-life preferences 4:

• Twenty percent of subjects with panic disorder and 12 percent with panic attacks have made suicide attempts 5
• The adjusted odds ratio for suicide attempts in panic disorder is 2.62 compared to other psychiatric disorders, and 17.99 compared to those with no psychiatric disorder 5

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Long-Term Management

Psychotherapy: First-Line Treatment

Cognitive-behavioral therapy (CBT) specifically designed for panic disorder is the psychological treatment of choice 6:

CBT Structure and Components

• Provide approximately 12-14 individual sessions of 60-90 minutes each, conducted over 3-4 months 6
• Include psychoeducation about panic and anxiety, diaphragmatic breathing techniques, cognitive restructuring, interoceptive exposure, and in vivo exposure to feared situations 7, 6
• Individual CBT is prioritized over group therapy due to superior clinical and economic effectiveness 6
• CBT has demonstrated large effect sizes for generalized anxiety disorder (Hedges g = 1.01) 6

Cultural Adaptations

• Incorporate mindfulness techniques for Asian Americans 7
• Address culturally specific manifestations of panic for Hispanic/Latino patients 7
• Emphasize in vivo exposure for African Americans 7
• Consider group therapy for patients with interdependent self-construal, common in Asian American populations 7

Pharmacological Management

For panic disorder with or without agoraphobia, SSRIs are the treatment of choice due to their established efficacy, favorable safety profile, and effectiveness for both panic attacks and anticipatory anxiety/avoidance behavior 6, 1:

SSRI Treatment Parameters

• Expect statistically significant improvement beginning at week 2, clinically significant improvement by week 6, and maximum therapeutic benefit by week 12 or later 6
• Among SSRIs, paroxetine and fluoxetine have stronger evidence of efficacy than sertraline 1
• Continue treatment for at least 9-12 months after recovery to prevent relapse 7

Medication Ranking by Efficacy

Based on network meta-analysis, the most effective medications for response are: 1

• Diazepam, alprazolam, and clonazepam (benzodiazepines) ranked highest 1
• Paroxetine, venlafaxine, clomipramine, fluoxetine, and adinazolam also showed strong effects 1

Medication Ranking by Tolerability

Alprazolam and diazepam were associated with lower dropout rates compared to placebo and ranked as most tolerated 1:

• Benzodiazepines as a class were the only medications associated with lower dropout compared to placebo 1

Medications to Avoid

• Avoid tricyclic antidepressants due to unfavorable risk-benefit profile, particularly cardiac toxicity 6
• Consider monoamine oxidase inhibitors only as third-line treatment due to drug interactions, dietary restrictions, and side effects 6

Benzodiazepine Use: Important Caveats

Reserve benzodiazepines like clonazepam for short-term use only (4 to 10 weeks) due to risks of dependence, tolerance, and withdrawal symptoms 6:

• When discontinuing, reduce dosage gradually by 25% every two weeks to minimize withdrawal symptoms 6
• Do not use benzodiazepines as sole first-line treatment due to risk of dependence 7

Combination Therapy

The combination of CBT with SSRIs provides superior results compared to either treatment alone for patients with moderate to severe panic disorder 6

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Common Pitfalls to Avoid

• Failing to differentiate panic disorder from medical conditions with similar presentations, particularly acute coronary syndrome 7
• Stopping medication treatment too early, before 9-12 months after recovery 7
• Using benzodiazepines as sole first-line treatment 7
• Overlooking cultural factors that may influence symptom presentation and treatment response 7
• Implementing psychological debriefing, which may worsen outcomes 4