Highlights
  • Panic disorder is an anxiety disorder characterized by unexpected panic attacks.
  • Most panic attack symptoms are physical, involving cardiac, respiratory, gastrointestinal, and vestibular systems.
  • Panic disorder results in more medical visits than any other anxiety disorder.
  • CBT and mindfulness interventions are the best treatments for panic disorder.

Imagine that you’re going about your morning as usual – making coffee, feeding the cat, tidying the bedroom – when your chest starts to hurt. The pain quickly mounts. Within minutes you’re drenched in sweat and you feel as if you’re suffocating. You close your eyes and try to take control, but the room begins to spin and you collapse on the bed. You’re alone and scared for your life. Are you having a heart attack? Should you call an ambulance? Are these your last moments on earth? WTF is happening?

Now imagine that these terrifying, dramatic episodes flare up again and again. You never know when they’ll happen, so you start limiting your outings. You stop exercising because a rapid heart rate makes you worry that you’re on the verge of another attack. You’re afraid that you’re going crazy. You’re afraid that the next episode will kill you. But in reality, you’re not in any physical danger. You are not going to die during these moments of intense fear. You have panic disorder. 

What Is Panic Disorder?

Panic disorder is a type of anxiety disorder characterized by unforeseen panic attacks. Panic attacks are associated with many other medical and mental health conditions, but in panic disorder (PD), they have no clear environmental trigger — at least some of the time. So a person can unexpectedly go from a calm state to a feeling of imminent doom, making the PD experience especially alarming. 

The American Psychiatric Association (APA) used to code panic disorder with agoraphobia, but in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), panic disorder and agoraphobia became distinct diagnoses. The DSM-5 also added a “panic attack specifier” to its classification system. This means that someone can be diagnosed with “major depressive disorder (MDD) with panic attacks” or post-traumatic stress disorder (PTSD) with panic attacks,” for example, but these labels differ from PD proper. 

Among the anxiety disorders, panic disorder is less common than generalized anxiety disorder (GAD), specific phobias, and social anxiety disorder, but it still affects about 2.7% of the US population (around six million adults) every year. Data from the National Comorbidity Survey Replication (NCS-R) show that panic disorder is more than twice as common in women than men. People are likely to be adults when they develop the condition, with 20-24 being the median age of onset.

How Can Panic Disorder Affect Your Quality of Life?

Panic disorder causes intense fear, both during a panic attack and while anticipating a panic attack — which could happen out of the blue, at any given moment. Panic attacks involve physical symptoms that can mimic potentially fatal medical emergencies. It’s no wonder that over a million Americans with panic disorder show up in hospital emergency departments every year, thinking that they’re having heart attacks. Among all the anxiety disorders, PD has the distinction of prompting the highest number of medical visits.  

According to the APA, about 45% of US adults with panic disorder experience serious impairment. This means that they might suffer from high levels of social, occupational, and/or physical disability. How can you cope with regular tasks when you’re always anticipating catastrophe? People with severe PD might use the healthcare system more, leading to substantial doctors’ bills and ER costs. They might also need to miss work, class, or important events due to panic attacks.

What Are the 4 Different Types of Panic Disorders?

According to diagnostic criteria in the DSM-5, there is only one panic disorder, but four subtypes are commonly reported. They’re based on the kind of somatic symptoms a person is experiencing. 

  1. Cardiac: chest pain, accelerated heart rate, palpitations (fluttering of the heart)
  2. Respiratory: shortness of breath; feelings of choking, suffocation, or smothering; hyperventilation
  3. Gastrointestinal: nausea, vomiting, diarrhea, and abdominal distress
  4. Vestibular: dizziness or faintness

Panic attack symptoms don’t have to be localized to one organ system or another. Many times all the clinical symptoms converge, amplifying a person’s sense of fear and overwhelm. 

Heart Attack vs Panic Attack

A panic attack feels incredibly dangerous – that’s why it’s called a panic attack (duh). How can people with panic disorder differentiate between their psychiatric symptoms and potentially life-threatening symptoms? Do you need a primary care doctor or a psychiatrist?  It can be extremely hard to tell. Here are the questions to ask yourself before going to the hospital:

Do you have a history of anxiety? If so, you may be experiencing a panic attack. If you go to the ER, doctors will probably administer an electrocardiogram (EKG), do bloodwork, and/or give you a chest X-ray to make sure you’re not having heart problems. If they determine that your chest pain is noncardiac, they may give you medication like benzodiazepine to calm you down in the short-term. Then, if you’re lucky, you may get a referral to a mental health professional. 

Are you having thoughts of suicide? If so, go to the ER.

Is this a brand new experience? You’re anxious and hyperventilating, and you think you must be having a panic attack. But you’ve never had one before. In this scenario, it’s probably wise to play it safe and seek immediate medical attention. Heart attacks, blood clots in the lungs, and collapsed lungs can all cause symptoms that resemble those of panic attacks. 

What Are the Signs of Panic Disorder?

To be diagnosed with panic disorder (300.01 (F41.0)) within the clinical guidelines of the DSM-5, you must meet the following criteria:

1. You experience recurrent, unexpected panic attacks (abrupt and dramatic feelings of fear that peak within minutes). You might feel calm or anxious before one of these episodes. They might even wake you up from a dead sleep (nocturnal panic attack). And these attacks must include at least four of the following 13 symptoms of panic disorder:

  • Palpitations or quickened heartbeat
  • Abnormal sweating
  • Trembling or shaking
  • Shortness of breath or a feeling of suffocation
  • Choking sensation
  • Chest pain 
  • Stomach distress
  • Feeling faint or unsteady
  • “Heat sensations” or chills
  • Numbness or tingling (aka paresthesias)
  • Feelings of being detached from reality (derealization) or yourself (depersonalization) 
  • Fear of loss of sanity or control
  • Mortal fear

2. For at least a month following an attack, you’ve significantly changed your behavior or have been persistently worried about having another episode (i.e., you live in fear of losing control).

3. You’re not having panic attacks due to a medical condition or a substance. 

4. Your panic attacks aren’t rooted in another mental disorder such as separation anxiety, social anxiety, or obsessive-compulsive disorder (OCD). 

Is There a Difference Between Anxiety and Panic Disorder?

Panic disorder is classified as an anxiety disorder, but it tends to have a more pronounced kind of physical involvement than simple anxiety. Someone with anxiety has irrational fears of some future threat to their safety. Their muscles might tense up as they prepare to avoid what they fear. But someone in the midst of a full-fledged panic attack is having a distinct, heightened fear response throughout their nervous system. They tend to feel that they are in immediate danger and their threatened body is firing on all cylinders.  

What Causes Panic Disorder?

There is no single cause for panic disorder, nor is there a distinct biomarker in the brain that points to PD. But psychiatrists generally cite four risk factors for developing the condition:

Temperament: Neuroticism (a “big 5” personality trait), anxiety sensitivity, a history of “fearful spells.”

Environment: Interpersonal stressors, traumatic experience, childhood abuse, smoking. Some experts have even proposed a new subtype of panic disorder caused by the Covid-19 pandemic: Covid-associated panic disorder.

Genes: Research is ongoing, but multiple genes have been implicated in panic disorder. Also, the children of parents with anxiety or mood disorders have an increased risk of PD. 

Neurobiology: Some people with panic disorder have hypersensitive carbon dioxide detectors in their brains. Neuroscientists are also looking closely at the brain’s ”fear network,” which involves the amygdala and related structures.

But it cannot be overemphasized that various medical conditions and substances can also cause anxiety, so medical professionals need to ask the right questions, especially if someone doesn’t have a personal or family history of anxiety. The following medical conditions can also be comorbid with panic disorder, however, so it might be difficult to unravel cause and effect. 

  • Heart disease
  • Cardiac arrhythmias*
  • Supraventricular tachycardia*
  • Hyperthyroidism*
  • Hyperparathyroidism*
  • Pheochromocytoma*
  • Asthma*
  • Chronic obstructive pulmonary disease (COPD)*
  • Irritable bowel syndrome (IBS)
  • Drug misuse
  • Withdrawal from alcohol or certain medications
  • Chronic pain
  • Vestibular dysfunctions*
  • Seizure disorders*

Examples of prescription drugs known to induce anxiety include corticosteroids, asthma medications, medications containing caffeine, stimulants used to treat attention deficit/hyperactivity disorder (ADHD), Parkinson’s medications, seizure drugs, and thyroid medications. 

*Can cause panic attacks.

Best Panic Disorder Treatments

If you visit the ER for a panic attack, you will probably be given medication to calm you in the moment. The most common PD meds prescribed in emergency departments are anxiolytics and benzodiazepines. These are both short-term solutions to a chronic mental health condition, and they may carry a risk of addiction and/or overdose. Antidepressants like SSRIs can also be prescribed for panic disorder, though they don’t provide immediate relief.

Behavioral interventions have been proven more effective than medications in improving anxiety symptoms and preventing recurrence of panic attacks. Currently, the best treatments for panic disorder are cognitive behavioral therapy (CBT) and mindfulness interventions.