Panic disorder
Panic disorder is an anxiety disorder defined by recurrent, unexpected panic attacks, discrete surges of fear that peak within 10 minutes with 4 or more characteristic symptoms, followed by at least 1 month of persistent worry about further attacks, worry about their consequences, or a maladaptive behavior change. Medical mimics such as acute coronary syndrome, pulmonary embolism, arrhythmia, hyperthyroidism, pheochromocytoma, and hypoglycemia must be excluded first. First-line treatment is a selective serotonin reuptake inhibitor such as sertraline, started low and titrated slowly, combined with cognitive behavioral therapy; benzodiazepines are reserved for short-term acute control.
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What this article covers
- Overview
Definition: panic disorder is an anxiety disorder defined by recurrent, unexpected panic attacks, discrete surges of intense fear or discomfort that peak within 10 minutes, plus at least 1 month of…
- Epidemiology
Sex and prevalence: more common in women, with a prevalence of 2% to 3%, versus 0.5% to 1.5% in men.
- Risk factors
Family history and childhood separation anxiety: first- and second-degree relatives of an affected person carry greater risk, and 20% to 50% of patients report childhood separation anxiety.
- Pathophysiology
Strong genetic loading: panic disorder shows a strong genetic component, consistent with its higher prevalence among first- and second-degree relatives.
- Clinical features
Panic attack definition: a discrete period of intense fear or discomfort that develops abruptly and peaks within 10 minutes, with 4 or more of the following: palpitations or tachycardia, diaphoresis…
- Differential diagnosis
Agoraphobia: fear and avoidance of 2 or more situations from which escape may be unavailable drives the presentation, and it stands even without a personal history of panic attacks, unlike panic…
- Diagnosis
Diagnostic basis: the diagnosis is clinical, confirmed when recurrent, unexpected panic attacks (4 or more defining symptoms peaking within 10 minutes) are followed by at least 1 month of persistent…
- Management
First, treat the acute attack symptomatically: coach the patient through the attack with reassurance and reserve a benzodiazepine for short-term, acute symptom control rather than routine first-line therapy.
- Complications
Suicide risk: panic disorder carries an elevated risk of suicide.
- Prognosis
Combined treatment gives the best outcome: CBT paired with an SSRI or SNRI produces higher rates of response and more sustained effects than either placebo or pharmacotherapy alone.
- Prevention
Ask about family history: given the strong genetic component, screen for family history when evaluating unexplained anxiety or new physical symptoms.
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Related articles
- Agoraphobia
Agoraphobia is marked fear, anxiety, or avoidance of two or more situations, such as public transportation, open or closed spaces, lines or crowds, or being outside the home alone, driven by the concern that escape or help may be unavailable, present for 6 months or more and now diagnosed independently of panic disorder even though the two frequently coexist. First-line treatment is exposure-based cognitive behavioral therapy, with an SSRI as the pharmacologic adjunct.
- Generalized anxiety disorder
Generalized anxiety disorder is excessive, hard-to-control worry about multiple life domains occurring more days than not for at least 6 months, with at least 3 of 6 associated physical symptoms and functional impairment. Screen with the GAD-7 after excluding hyperthyroidism and substance use, then treat first-line with cognitive behavioral therapy and/or an SSRI or SNRI such as escitalopram or venlafaxine extended-release, reserving benzodiazepines for short-term severe symptom control only.
- Social anxiety disorder
Social anxiety disorder is marked, persistent fear of scrutiny or embarrassment in social or performance situations lasting at least 6 months with significant functional impairment. Generalized social anxiety disorder is treated with cognitive behavioral therapy (CBT) plus an SSRI such as sertraline, while the performance-only subtype is treated with a PRN beta blocker such as propranolol taken before the anticipated situation.
- Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is defined by ego-dystonic obsessions and/or compulsions that are time-consuming or cause significant distress and functional impairment, distinguishing it from the ego-syntonic perfectionism of obsessive-compulsive personality disorder. Diagnosis is clinical. First-line treatment combines cognitive behavioral therapy using exposure and response prevention with a high-dose selective serotonin reuptake inhibitor, with clomipramine as an effective second-line tricyclic and an OCD trial that can take up to 10 weeks to judge full response.
- Post-traumatic stress disorder
Posttraumatic stress disorder follows exposure to actual or threatened death, serious injury, or sexual violence, producing intrusive re-experiencing, avoidance, negative alterations in cognition and mood, and hyperarousal that persist beyond 1 month with significant distress or impairment. First-line treatment is trauma-focused cognitive behavioral therapy combined with an SSRI or SNRI, with prazosin added for persistent nightmares.
- Illness anxiety disorder
Illness anxiety disorder, formerly hypochondriasis, is a preoccupation with having or acquiring a serious illness that persists for 6 months or longer with minimal or absent somatic symptoms despite reassurance. Diagnosis is clinical; first-line management is a single primary physician with regularly scheduled visits, limited testing, and cognitive behavioral therapy, reserving antidepressant pharmacotherapy for comorbid anxiety or depression.
- Major depressive disorder
Major depressive disorder is a mood disorder defined by 5 or more of 9 major depressive episode symptoms, including depressed mood or anhedonia, present nearly every day for at least 2 weeks and causing significant functional impairment. Diagnosis is clinical, screened with the Patient Health Questionnaire. First-line treatment is cognitive behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) such as sertraline, or both, escalating to augmentation, esketamine, or electroconvulsive therapy for refractory or acutely suicidal presentations.