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Panic Disorder

BASICS

  • Definition: Multiple panic attacks (at least 2 untriggered) with ≥1 month of persistent worry about future attacks and/or maladaptive behavior (e.g., avoidance).
  • Panic Attack: Sudden, brief episode of intense fear with sympathetic hyperarousal.
  • Onset: Median age 24 years; more common in women (2:1).
  • Lifetime Prevalence: 4.7%

ETIOLOGY & PATHOPHYSIOLOGY

  • Anxiety about anxiety: Resistance to adrenaline surge worsens symptoms.
  • Genetics: Increased incidence in families.
  • Precipitating Factors: Stressful life events, trauma, substance abuse, comorbid psychiatric disorders.
  • Associated Conditions: PTSD, depression, social phobia, OCD, asthma, migraine, MVP, IBS, hypertension, fibromyalgia.

RISK FACTORS

  • History of abuse (sexual, physical)
  • Family history of panic disorder
  • Substance use, smoking
  • Comorbid mental health conditions

PREVENTION

  • Healthy lifestyle: Diet, exercise, mindfulness/stress reduction.
  • Screening: USPSTF recommends anxiety screening in children (8–18), draft guidance for adults ≤64 years.

DIAGNOSIS

Panic Attack:

  • Abrupt intense fear/discomfort, peak in minutes, ≥4 symptoms:
  • Palpitations, sweating, trembling, SOB, choking sensation, chest pain, nausea, dizziness, derealization/depersonalization, fear of losing control/dying, paresthesias, chills/hot flashes.

Panic Disorder:

  • ≥2 unexpected attacks, not explained by other conditions/substances
  • ≥1 month of persistent worry or behavioral change

History & Exam

  • Careful, nonjudgmental interview for stress, avoidance, substance use, triggers.
  • Physical: May have tachycardia, hyperventilation, diaphoresis.
  • Rule out thyroid/cardiac/lung issues.

Differential Diagnosis

  • Medical: MI, arrhythmia, asthma, thyroid, hypoglycemia, neurologic (TIA, seizure), pheochromocytoma
  • Medications: Withdrawal, stimulant/antidepressant side effects
  • Psychiatric: PTSD, social phobia, GAD, OCD, mood disorders

Workup

  • Labs/tests only to rule out medical mimics (ECG, TSH, CBC, metabolic panel, glucose if diabetic)
  • Panic Disorder Severity Scale (PDSS), PHQ-PD for monitoring

TREATMENT

General Measures

  • Patient Education: Use HR BET mnemonic:
  • Harmless: Symptoms are not dangerous (explain hyperventilation effects)
  • Resistance: Resisting panic increases duration
  • Breathing: Teach mindful diaphragmatic breathing
  • Energy: Reframe adrenaline as “energy burst”
  • Thoughts: Notice and dispute irrational beliefs

Psychotherapy

  • First-line: CBT, mindfulness-based therapy, exposure therapy
  • Best: Combination of medication + psychotherapy
  • Other: Aerobic exercise, yoga, tai chi, mindfulness apps

Medications

  • First-line: SSRIs/SNRIs
  • Start low, titrate slowly (e.g., fluoxetine 5–10 mg, sertraline 25 mg, escitalopram 5 mg, venlafaxine XR 37.5 mg)
  • Warn about initial nausea, possible suicidality in young patients
  • Continue ≥1 year after remission, taper gradually
  • Second-line:
  • Mirtazapine (15–30 mg QHS, helpful for insomnia/weight loss)
  • TCAs (e.g., imipramine), less used due to side effects, cardiac risk—screen ECG >40y
  • MAOIs (rare; diet/drug restrictions)
  • Benzodiazepines: Avoid or limit to short-term/severe crisis. Use lowest dose (clonazepam, alprazolam). Risk: dependence, falls, overdose (esp. with opioids).

Complementary & Alternative

  • Limited evidence: omega-3 fatty acids (2g/day, EPA <60%), avoid kava kava

ISSUES FOR REFERRAL

  • Refer for CBT/mindfulness/exposure therapy
  • Psychiatrist referral for comorbid bipolar, BPD, schizophrenia, suicidality, substance abuse, or treatment-resistant cases

ADMISSION/INPATIENT

  • Admit for concrete suicidal ideation

ONGOING CARE & FOLLOW-UP

  • Monitor for response, suicidality (esp. <24y), side effects
  • Antidepressant effect: may take 4–6 weeks
  • Continue whole-food, plant-based diet, limit caffeine

PATIENT EDUCATION

PROGNOSIS

  • Remission: 64.5% (avg. 5.7 months), 21.4% relapse after remission
  • Better prognosis: Female, low stress, low attack frequency

COMPLICATIONS

  • Iatrogenic: Benzodiazepine dependence, mania in bipolar from unopposed antidepressant
  • Increased risk of suicide (esp. with comorbid depression)

ICD-10 Code

  • F41.0 Panic disorder [episodic paroxysmal anxiety]

CLINICAL PEARLS

  • First-line: SSRIs/SNRIs + CBT
  • Always assess suicidality
  • Benzodiazepines: avoid long-term use
  • Consider medical/medication mimics in late-onset panic (>40y)