Panic attacks: symptoms and treatment of the most common anxiety disorder

By Cristiano Antonino On Dec 27, 2022

Panic attacks (also called panic crises) are episodes of sudden, intense fear or a rapid escalation of normally present anxiety

Panic attacks are accompanied by somatic and cognitive symptoms

E.g. palpitations, sudden sweating, trembling, choking sensation, chest pain, nausea, dizziness, fear of dying or going mad, chills or hot flashes.

Those who have experienced panic attacks describe them as a terrible experience, often sudden and unexpected, at least the first time.

It is obvious that the fear of a new attack immediately becomes strong and dominant.

The single episode then easily escalates into a full-blown panic disorder, more out of ‘fear of fear’ than anything else.

The person quickly becomes entangled in a terrible vicious circle that often leads to so-called ‘agoraphobia’

That is, anxiety about being in places or situations from which it would be difficult or embarrassing to move away, or where help might not be available, in the case of an unexpected panic attack.

With the fear of panic attacks, it therefore becomes difficult and anxiety-provoking to leave the house alone, to travel by train, bus or car, to be in a crowd or in a queue, and so on.

Avoidance of all potentially anxiety-provoking situations becomes the prevailing mode and the patient becomes a slave to panic.

He often forces all family members to adapt accordingly, to never leave him alone and to accompany him everywhere.

A sense of frustration ensues from being ‘big and fat’ but dependent on others, which can lead to secondary depression.

Characteristics of panic disorder

The essential characteristic of panic attack disorder is the presence of recurrent and unexpected attacks.

These are followed by at least one month of persistent worry of having another panic attack.

The person worries about the possible implications or consequences of the anxiety attacks and changes his or her behaviour as a result of the attacks.

He or she mainly avoids situations in which he or she fears they may occur.

The first panic attack is usually unexpected, i.e. it occurs ‘out of the blue’, so the person becomes extremely frightened and often resorts to the emergency room.

Then they can become more predictable.

Diagnosis of panic disorder

At least two unexpected panic attacks are required for diagnosis, but most individuals have many more.

Individuals with panic disorder show characteristic worries or interpretations about the implications or consequences of panic attacks.

Worry about the next attack or its implications are often associated with the development of avoidance behaviour.

These can lead to true agoraphobia, in which case Panic Disorder with Agoraphobia is diagnosed.

Attacks are usually more frequent during stressful periods.

Certain life events may in fact act as precipitating factors, although they do not necessarily indicate a panic attack.

Among the most commonly reported precipitating life events are:

marriage or cohabitation
separation
the loss or illness of a significant person
being a victim of some form of violence
financial and work problems

The first attacks usually occur in agoraphobic situations (such as driving alone or travelling on a bus in the city) and often in some stressful context.

Stressful events, agoraphobic situations, hot and humid weather conditions, and psychoactive drugs can all trigger abnormal body sensations.

These can be interpreted catastrophically, increasing the risk of developing panic attacks.

Symptoms of panic attacks

A panic attack has a sudden onset, quickly peaks (usually within 10 minutes or less) and lasts about 20 minutes (but sometimes much less or longer).

Typical symptoms of panic attacks are:

Palpitations/tachycardia (irregular, heavy beats, restlessness in the chest, feeling the pulse in the throat)
Fear of losing control or going crazy (e.g. fear of doing something embarrassing in public or fear of running away when panic strikes or of losing one’s temper)
Feelings of lurching, instability (dizziness and vertigo)
Fine or large tremors
Sweating
Feeling of suffocation
Pain or discomfort in the chest
Feelings of derealisation (perception of the outside world as strange and unreal, feelings of dizziness and detachment) and depersonalisation (altered self-perception characterised by feelings of detachment or estrangement from one’s own thought processes or body)
Chills
Hot flashes
Paresthesias (numbness or tingling sensations)
Nausea or abdominal discomfort
Feeling of asphyxiation (tightness or lump in the throat)
Intensity and pattern of panic symptoms

Not all symptoms are necessary for it to be a panic attack

There are many attacks characterised only or particularly by some of these symptoms.

The frequency and severity of symptoms vary widely over time and circumstances.

For example, some individuals present moderately frequent attacks (e.g. once a week) that occur regularly for months.

Others report short series of more frequent attacks, perhaps with less intense symptoms (e.g., daily for a week).

These are interspersed with weeks or months without attacks or with less frequent attacks (e.g., two every month) for many years.

There are also so-called paucisymptomatic attacks, very common in individuals with panic disorder, which are attacks in which only part of the panic symptoms occur, without exploding into a real attack.

Most individuals with paucisymptomatic symptoms, however, have experienced full panic attacks, with all the classic symptoms, at some time during the course of the disorder.

Concerns associated with panic attacks

During a panic attack, automatic and uncontrolled catastrophic thoughts fill the person’s mind.

The person then has difficulty thinking clearly and fears that these symptoms are truly dangerous.

Some fear that the attacks indicate the presence of an undiagnosed, life-threatening illness (e.g. heart disease, epilepsy).

Despite repeated medical examinations and reassurance, they may remain fearful and convinced that they are physically vulnerable.

Others fear that panic attack symptoms indicate that they are ‘going crazy’ or losing control, or that they are emotionally weak and unstable.

Treatment of panic disorder and panic attacks

Psychotherapy for panic attacks

In the treatment of panic attacks with or without agoraphobia and anxiety disorders in general, the form of psychotherapy that scientific research has shown to be most effective is ‘cognitive-behavioural’ psychotherapy.

This is a relatively short psychotherapy, usually weekly, in which the patient plays an active role in solving his or her problem.

Together with the therapist, he or she focuses on learning ways of thinking and behaving that are more functional for the treatment of panic attacks.

This is with the aim of breaking the vicious circles of the disorder.

For panic and agoraphobia, treatment based on cognitive behavioural therapy is highly recommended and the first choice.

Basically, it is contraindicated to rely on medication or other forms of psychotherapy without undertaking this form of treatment.

In fact, the entire scientific community has proven it to be the most effective for the treatment of panic disorder.

Fundamental steps in psychotherapy

Cognitive techniques

In therapy, verbal strategies are used to modify automatic catastrophic thoughts (e.g. I will have a heart attack, I will faint, etc.).

This causes the person to learn over time not to be afraid of the physical sensations of anxiety.

By not being afraid of them, by learning to live with them simply by waiting for them to pass, one avoids the escalation of anxiety that leads to panic.

Behavioural techniques

Verbal strategies are combined with techniques aimed at modifying the problematic behaviour that maintains the disorder.

Firstly, the tendency to avoid fearful situations (i.e. those from which there is no immediate escape) must be gradually counteracted.

It is also necessary to help the subject expose himself to the physical sensations that alarm him (e.g. tachycardia) through in-session exercises and the resumption of activities that are avoided.

For example, one accompanies the patient on a path where having coffee, running up stairs, playing sports, etc., must become part of his life again.

Finally, so-called ‘protective behaviours’, which give illusory security, must be gradually abandoned.

First and foremost, being accompanied by others, but also taking along the drops of anti-anxiety medication, the water bottle or the mobile phone.

Experiential techniques

Finally, relaxation techniques and especially strategies that increase the subject’s ability to accept negative emotions can be useful.

In particular mindfulness meditation and experiential techniques typical of Acceptance and Commitment Therapy (ACT).

Further interventions

First of all, it is necessary to regain the freedom to move independently and gain a sense of mastery over the panic phenomenon.

Then therapy can proceed by working on the historical elements that have made the subject vulnerable.

Reconstruction of life history, significant ties, emotional and social relationships are therefore important.

Possible traumas are examined, including the first experience of a panic attack.

Techniques to emotionally process them, such as EMDR, may be employed.

Medication for panic attacks

The pharmacological treatment of panic and agoraphobia, although often inadvisable (at least as the only treatment), is basically based on two classes of drugs: benzodiazepines and antidepressants, often used in combination.

In mild forms, the prescription of benzodiazepines alone may be sufficient as a temporary cure, but hardly resolving.

The most commonly used molecules are alprazolam, etizolam, clonazepam and lorazepam.

These drugs, however, in the case of panic attacks and agoraphobia, risk being highly addictive and maintaining the disorder.

This is especially so if cognitive behavioural psychotherapy is not carried out in parallel.

Of the antidepressants, tricyclics – TCAs – (e.g. chlorimipramine, imipramine, desimipramine) have proved effective in treating panic attacks and agoraphobia, the monoamine oxidase inhibitors (MAOIs) and especially the selective serotonin reuptake inhibitors – SSRIs – (e.g. citalopram, escitalopram, paroxetine, fluoxetine, fluvoxamine, sertraline), which are widely used today.

The latter class of drugs is more manageable and has fewer side effects than the previous ones.

In cases of panic attacks and agoraphobia that do not respond to treatment with SSRIs, TCAs can be used, although many clinicians use these molecules as first-line therapy.

MAOIs, although very effective drugs, have all but fallen into disuse due to the serious side effects that can occur if certain molecules are combined or prescribed dietary restrictions are not adhered to.

Resources on panic disorder and panic attacks

BIBLIOGRAPHY

Andrisano, C., Chiesa, A., & Serretti, A. (2013). Newer antidepressants and panic disorder: A meta-analysis. International Clinical Psychopharmacology, 28, 33-45.

Faretta, E. (2018). EMDR and panic disorder. From integrated theories to the intervention model in practice. Milan: Edra.

Gallagher, M. W. et al. (2013). Mechanisms of change in cognitive behavioral therapy for panic disorder: The unique effects of self-efficacy and anxiety sensitivity. Behaviour Research and Therapy, 51, 767-777.

Rovetto, F. (2003). Panic. Origins, dynamics, therapies. Milan: McGraw Hill

Taylor, S. (2006). Panic disorders. Monduzzi