Psychiatry · Anxiety Disorders
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Panic disorder is recurrent unexpected panic attacks, more common in women, with no specific trigger and often agoraphobia.
A panic attack is sudden intense fear with >=4 autonomic symptoms (palpitations, dyspnea, chest pain, dizziness, paresthesias) that peaks within minutes and lasts <30 minutes.
Diagnosis requires recurrent attacks plus >=1 month of worry about future attacks or maladaptive avoidance.
SSRIs (fluoxetine, paroxetine, sertraline) are first-line for panic disorder.
A benzodiazepine such as alprazolam aborts an acute attack or bridges until the SSRI works, but must be tapered off due to abuse potential.
Cognitive-behavioral therapy with interoceptive exposure is highly effective alongside medication.
Always exclude hyperthyroidism, cardiac disease, hypoglycemia, pheochromocytoma, and stimulant use before diagnosing panic disorder.
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A 28-year-old woman has had recurrent episodes over 3 months of sudden palpitations, chest tightness, shortness of breath, dizziness, and a fear of dying that peak within minutes and resolve in under half an hour. She now avoids crowded stores for fear of having another episode. ECG, troponin, TSH, and a fasting glucose are all normal. She worries constantly about when the next attack will strike.
Which of the following is the most appropriate first-line long-term treatment?
An SSRI (e.g., sertraline, paroxetine, or fluoxetine).
Recurrent unexpected panic attacks with at least 1 month of anticipatory worry and avoidance, after excluding cardiac, thyroid, and metabolic causes, define panic disorder. SSRIs are first-line maintenance therapy, often combined with CBT; benzodiazepines are reserved for acute attacks and tapered off due to abuse potential.
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Etiology / Epidemiology
Recurrent unexpected panic attacks, more common in women, usually with no specific stressor; often with agoraphobia.
Clinical Manifestations
Sudden intense fear with >=4 autonomic symptoms (palpitations, dyspnea, chest pain, dizziness, paresthesias) peaking and resolving within minutes.
Diagnosis
Clinical, recurrent attacks plus >=1 month of worry about future attacks; exclude thyroid, cardiac disease, and hypoglycemia.
Treatment
SSRIs are first-line for panic disorder; benzodiazepines (alprazolam) abort an acute attack but are tapered off.
Prognosis
Chronic but responsive to SSRIs plus CBT.
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Epidemiology & Etiology
Panic disorder consists of recurrent, unexpected panic attacks and is typically seen in women; attacks can occur at any time and usually have no specific identifiable stressor. It frequently coexists with agoraphobia (fear of places where escape feels difficult). Because the somatic symptoms mimic medical emergencies, it is essential to exclude organic mimics, thyroid disease, cardiac disease, and hypoglycemia, and substance effects before settling on the diagnosis.
Pertinent Anatomy
Panic attacks are thought to originate in a hypersensitive brainstem-amygdala "fear network," with the locus coeruleus (the principal noradrenergic nucleus) driving the surge of autonomic arousal. Heightened amygdala reactivity and deficient prefrontal/GABA-ergic inhibition lower the threshold for false suffocation/danger alarms, while abnormal serotonergic modulation underlies the response to SSRIs.
Pathophysiology
A panic attack represents an abrupt, paroxysmal discharge of the central autonomic/fear circuit, an exaggerated locus coeruleus noradrenergic surge with amygdala activation, producing intense sympathetic symptoms that peak within minutes. Carbon dioxide hypersensitivity and a "false suffocation alarm" plus hyperventilation contribute to dizziness and paresthesias. Deficient serotonergic and GABAergic inhibitory tone perpetuates the recurrence of attacks and the anticipatory anxiety that defines the disorder.
Clinical Manifestations
A panic attack is an episode of intense anxiety with feelings of dread and impending doom accompanied by at least 4 autonomic symptoms: diaphoresis, trembling, chest pain, fear of dying, chills, palpitations, shortness of breath, nausea, dizziness, dissociation, or paresthesias. Attacks typically peak quickly and last less than 30 minutes. Panic disorder requires recurrent attacks plus at least 1 month of persistent worry about future attacks and/or maladaptive avoidance behavior, frequently with agoraphobia.
Diagnosis
Panic disorder is a clinical diagnosis: recurrent unexpected panic attacks plus >=1 month of worry about additional attacks or maladaptive avoidance. A useful exam pearl distinguishes the scenario, a patient actively presenting with autonomic hyperactivity is having a panic attack (treat acutely with a benzodiazepine), whereas a patient recounting a history of repeated attacks has panic disorder (treat with an SSRI). Always exclude hyperthyroidism, cardiac disease, hypoglycemia, and stimulant/substance use.
Treatment
SSRIs (fluoxetine, paroxetine, sertraline) are first-line for panic disorder. A benzodiazepine such as alprazolam may be co-started to control symptoms while the SSRI takes effect, then tapered and discontinued because of abuse potential; for a single acute panic attack, a benzodiazepine alone is appropriate. Cognitive-behavioral therapy with interoceptive exposure is highly effective and is used alongside medication rather than as sole therapy in most patients.
Prognosis
Panic disorder tends to be chronic with a fluctuating course, but it responds well to combined SSRI therapy and CBT, and most patients improve substantially. Comorbid agoraphobia, depression, or substance use worsens prognosis and should be treated. Early effective treatment reduces the development of avoidance behavior and disability.
Differential Diagnosis
Generalized Anxiety Disorder: chronic, pervasive worry lasting >=6 months without discrete attacks of autonomic hyperactivity.
Hyperthyroidism: palpitations, tremor, heat intolerance, and weight loss with suppressed TSH; must be excluded before diagnosing panic disorder.
Acute Coronary Syndrome / Cardiac disease: chest pain with ECG changes and troponin elevation; can mimic a panic attack and must be ruled out, especially with risk factors.
Pheochromocytoma: episodic palpitations, headache, and sweating with paroxysmal hypertension and elevated catecholamines/metanephrines.
Stimulant intoxication / Substance use: cocaine, amphetamines, or caffeine reproduce panic symptoms; clarified by history and urine drug screen.