Frequency of panic attacks may vary considerably in panic disorder, with some individuals reporting brief clusters of several panic episodes in a short period of time, weekly panic attacks, or periodic attacks over the course of several months.
Higher risk among first-degree relatives; onset of attacks triggered by stress; often comorbid with other anxiety, mood, and substance-use disorders.
Assessment is made through ruling out organic causes; self-report; clinical interview; and behavioural observation.
Self-help, cognitive behavioural therapy, selective serotonin-reuptake inhibitors and serotonin-noradrenaline reuptake inhibitors are first-line treatments.
Long-term management includes relapse prevention after treatment discontinuation.
Panic disorder is characterised by recurring unexpected panic attacks over a 1-month period. People with panic disorder are persistently concerned about having another panic attack, and/or about the consequences of this (e.g., having a heart attack or losing control). People with panic disorder may also change their behaviour in an attempt to avoid having more panic attacks (e.g., avoiding situations that may trigger the panic sensations; engaging in various safety-related behaviours). Panic attacks involve the sudden onset of intense physical and cognitive symptoms of anxiety that may be triggered by specific cues or occur unexpectedly. For a diagnosis of panic disorder, panic attacks must be recurrent; note that non-recurrent panic attacks are relatively common in the general population. In panic disorder, frequency of attacks may vary widely, with some individuals reporting brief clusters of several panic episodes in a short period of time, weekly panic attacks, or periodic attacks over the course of several months. Regardless of frequency, the person remains persistently concerned or anxious about the possibility of another attack.
History and exam
Key diagnostic factors
- presence of risk factors
- unexpected onset
- apprehension and worry
- behavioural avoidance
- positive PRIME-MD panic screen
- Panic Disorder Severity Scale (PDSS)
- GAD-7 cute score ≥10
Other diagnostic factors
- palpitations; chest pain and discomfort
- nausea and abdominal pain
- perceptual abnormality
- respiratory symptoms
- reliance on safety cues
- muscle shaking
- chills or hot flushes
- history in first-degree relatives
- age 18 to 39 years
- female sex
- white and Native American ethnicity
- major life events
- comorbid disorders
- psychological factors
- asthma and respiratory variability
- cigarette smoking
- caffeine use
1st investigations to order
- clinical assessment
Investigations to consider
- blood glucose
- thyroid function tests
- metabolic panel
- toxicology screen
acute panic attack
panic attacks without panic disorder
Craig N. Sawchuk, PhD
Department of Psychiatry and Psychology
CNS declares that he has no competing interests.
Jason P. Veitengruber, MD
Department of Psychiatry and Behavioral Sciences
University of Washington School of Medicine
JPV declares that he has no competing interests.
Tanveer A. Padder, MD
Department of Psychiatry
Trinity School of Medicine
TAP declares that he has no competing interests.
Paul Blenkiron, BM BCh, MA
Leeds and York Partnership NHS Foundation Trust
Bootham Park Hospital
PB declares that he has no competing interests.
Philip J. Cowen, MD, FRCPsych, FMedSci
Professor of Psychopharmacology
PJC declares that he has no competing interests.
Toshiaki A. Furukawa, MD, PhD
Professor and Chair
Department of Psychiatry and Cognitive-Behavioral Medicine
Graduate School of Medical Sciences
Nagoya City University
TAF has received research funds and speaking fees from Astellas, Dai-Nippon, Sumitomo, Eli Lilly, GlaxoSmithKline, Janssen, Meiji, Otsuka, Schering-Plough, and Yoshitomi. He was on a research advisory board for Meiji and Mochida, and is currently on research advisory boards for Sekisui chemicals and Takeda Science Foundation. He has received royalties from Igaku-Shion and Seiwa-Shoten Publishers. The Japanese Ministry of Education, Science, and Technology and the Japanese Ministry of Health, Labor, and Welfare have also funded his research.
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