Panic disorder

What is panic disorder?

Panic disorder is where you have recurring and regular panic attacks, often for no obvious reason.

Everyone experiences feelings of anxiety and panic at certain times during their lifetime. It's a perfectly natural response, particularly when you're in a dangerous or stressful situation. However, for people with panic disorder, feelings of anxiety, stress and panic occur regularly and at any time.

Anxiety

Anxiety is a feeling of unease. The feeling of unease can range from mild to severe, and can include feelings of worry and fear.

There are several different conditions that can cause severe anxiety. They include:

• phobias: an extreme or irrational fear of an animal, object, place or situation
• generalised anxiety disorder (GAD): a long-term condition that causes excessive anxiety and worry relating to a variety of situations
• post-traumatic stress disorder: a condition that has psychological and physical symptoms and is caused by very frightening or distressing events

Panic attacks

A panic attack occurs when your body experiences a rush of intense psychological (mental) and physical symptoms.

You may feel an overwhelming sense of fear, apprehension and anxiety. As well as these feelings, you may also experience physical symptoms such as:

• nausea
• sweating
• trembling
• a sensation that your heart is beating irregularly (palpitations)

The number of panic attacks you have will depend on the severity of your condition. Some people may have 1 or 2 attacks each month, while others may have several attacks a week.

Read more about the symptoms of panic disorder.

Panic attacks can be very frightening and intense, but they're not dangerous. A panic attack will not cause you any physical harm and it's unlikely that you'll be admitted to hospital if you have had a panic attack.

What to do

If you have symptoms of anxiety or panic disorder, see a doctor. A diagnosis of panic disorder will be made if you experience recurrent and unexpected panic attacks that are followed by at least 1 month of continuous worry or concern about having further attacks.

Read more about the diagnosis of panic disorder.

How common is panic disorder?

At least 1 in 10 people have occasional panic attacks, that are usually triggered by a stressful event.

Most people first develop the disorder when they're in their twenties. The condition is approximately twice as common in women as it is in men.

What causes panic disorder?

As with many mental health conditions, the exact cause of panic disorder is not fully understood. It's thought that panic disorder is probably caused by a combination of physical and psychological factors.

Read about the possible causes of panic disorder.

How is panic disorder treated?

The main aim of treatment for panic disorder is to reduce the number of panic attacks that you have and to help ease the severity of your symptoms. The 2 main types of treatment for panic disorder are psychological therapy and medication.

Find out more about the treatment of panic disorder and what you can do to help yourself during a panic attack.

Symptoms of a panic attack

The symptoms of a panic attack can be very frightening and distressing. Symptoms tend to occur very suddenly, without warning and often for no apparent reason.

As well as overwhelming feelings of anxiety, a panic attack can also cause the following symptoms:

• a sensation that your heart is beating irregularly (palpitations)
• sweating
• trembling
• hot flushes
• chills
• shortness of breath
• a choking sensation
• chest pain
• feeling sick (nausea)
• dizziness
• feeling faint
• numbness, or pins and needles
• dry mouth
• a need to go to the toilet
• ringing in your ears
• a feeling of dread, or a fear of dying
• a churning stomach
• a tingling sensation in fingers
• shivering
• shaking

The physical symptoms of a panic attack are unpleasant, and they can also be accompanied by thoughts of fear and terror. For this reason, people with panic disorder start to fear the next attack, which creates a cycle of living in ‘fear of fear’ which adds to the sense of panic.

Sometimes, the symptoms of a panic attack can be so intense it can feel like you are having a heart attack.

However, it's important to be aware that symptoms such as a racing heartbeat, or shortness of breath, will not result in you having a heart attack. Also, although a panic attack can often be frightening, it won't cause you any physical harm. People who've had panic disorder for some time usually learn to recognise this 'heart attack sensation', and become more aware of how to control their symptoms.

The symptoms of a panic attack usually peak within 10 minutes, with most attacks lasting for between 5 and 20 minutes. Some panic attacks have been reported to have lasted up to an hour. However, it's likely that the reason for this is due to one attack occurring straight after another, or high levels of anxiety being felt after the first attack.

Recurrent panic attacks

People with panic disorder have panic attacks on a recurring basis. Some people have panic attacks once or twice a month, while others have attacks several times a week.

People with panic disorder also tend to have ongoing and constant feelings of worry and anxiety. The panic attacks that are associated with panic disorder can be very unpredictable. If you have panic disorder, you may feel stressed and worried about when your next attack will be.

Depersonalisation

During a panic attack, your symptoms can feel so intense and out of your control that you may feel detached from the situation, your body and your surroundings. It can almost feel as if you're an observer, making the situation seem very unreal.

This sense of detachment is known as depersonalisation. Being detached from the situation does not provide any relief, or make a panic attack less frightening. Instead, it often makes the experience more confusing and disorientating.

Causes of panic disorder

As with many mental health conditions, the exact cause of panic disorder is not fully understood.

It's thought that panic disorder is probably caused by a combination of physical and psychological factors. Some of these factors are outlined below.

Traumatic life experiences

A trauma, such as a bereavement, can sometimes trigger feelings of panic and anxiety. These feelings may be obvious soon after the event, or they may be triggered unexpectedly years later.

Genetic link

Having a close family member with panic disorder may increase your risk of developing the condition. However, the precise nature of the risk is not yet known.

Neurotransmitters

Neurotransmitters are chemicals that occur naturally in the brain. It's thought that if you have an imbalance of these chemicals, it may increase your risk of developing conditions such as panic disorder.

Increased sensitivity to carbon dioxide

Some experts believe that panic disorder is linked to an increased sensitivity to carbon dioxide. Experimentally breathing air with high carbon dioxide levels can bring on panic attacks, and breathing techniques can help to relieve or stop panic attacks.

Catastrophic thinking

Another theory is that people who suffer panic attacks tend to focus on minor physical symptoms and interpret them in a catastrophic way, triggering a nervous system response that causes the panic attack.

Diagnosing panic disorder

Everyone who has panic disorder will experience panic attacks.

However, not everyone who experiences panic attacks is diagnosed with panic disorder.

Panic attacks

Some people have panic attacks in response to specific situations. For example, they may have a phobia of enclosed spaces (claustrophobia) and have a panic attack when faced with an enclosed space.

Whereas most people with phobias only experience panic attacks when faced with whatever triggers their fear, the panic attacks of people with panic disorder are usually triggered without warning. For people with panic disorder, a panic attack often seems to occur for no obvious reason.

Therefore, a diagnosis of panic disorder will only be made if you experience recurrent and unexpected panic attacks and if these attacks are also followed by at least 1 month of continuous worry or concern about having further attacks.

Talk to your doctor

Your doctor will ask you to describe the symptoms you've been experiencing. They'll also ask you how often your symptoms appear, and in what situations they occur. It's very important you tell your doctor about how you've been feeling and how your symptoms have affected you.

It can sometimes be difficult to talk to someone else about your feelings, emotions and personal life. However, you should try not to feel anxious or embarrassed. Your doctor needs to gain a good understanding of your symptoms so they can make the correct diagnosis and recommend the most appropriate treatment for your individual situation.

Physical examination

Your doctor may want to carry out a physical examination to look for signs of any physical conditions that could be causing your symptoms. For example, an overactive thyroid gland can sometimes cause similar symptoms to a panic attack. By ruling out any underlying medical conditions, your doctor will be able to make the correct diagnosis.

Treatment for panic disorder

The main aim of treatment for panic disorder is to reduce the number of panic attacks you have, and to help ease the severity of your symptoms.

The 2 main types of treatment for panic disorder are:

• psychological therapy
• medication

Depending on your individual circumstances, you may require either one of these treatment types, or a combination of the two. If you're offered psychological therapy, it will probably be in the form of cognitive behavioural therapy (CBT). If this type of treatment does not work, medication may be recommended.

Before you begin any form of treatment, your doctor will discuss all of your options with you, outlining the advantages of each type of treatment, while also making you aware of any possible risks or side effects.

Different treatments will suit different people so you may need to try a variety of treatments at first. This is because no single treatment is best for everyone, and the treatment that's recommended for you will depend on your general health and the severity of your condition, as well as your personal preferences.

It's important for you to understand what your treatment will involve. If you don't understand something your doctor has told you, make sure that you ask them to explain in more detail.

Cognitive behavioural therapy

Psychological therapy has proven long-term benefits, and it's the recommended form of treatment for panic disorder. If you have psychological therapy for panic disorder, it'll usually be in the form of CBT.

CBT is thought to be one of the most effective forms of treatment for panic disorder. It's a psychological treatment and will involve you having weekly sessions where you talk to a therapist.

For example, the therapist may talk to you about the way you react when you have a panic attack, and what you think about when you're having an attack.

Once you and your therapist have identified any negative thoughts and beliefs, you can work on replacing them with more realistic and balanced ones. Your therapist can also teach you ways of changing your behaviour, which should make it easier for you to deal with future panic attacks. For example, they may be able to show you breathing techniques that can be used to help keep you calm during the stress of a panic attack.

During your course of CBT, you should visit your doctor regularly so that they can assess your progress and see how you are doing.

Support groups

Support groups will be able to provide you with useful information and advice about how to effectively manage your panic disorder, and they're also a good way of meeting other people who have similar experiences of the condition.

Panic attacks can sometimes be frightening and isolating, so it can be helpful to know that other people are experiencing the same feelings and emotions as you.

Support groups often involve face-to-face meetings where you can talk about your problems and difficulties with others. Many support groups can also provide support and guidance over the telephone or in writing. Ask your doctor about support groups for panic disorder in your local area.

Antidepressants

Antidepressants are often associated with depression, but they can also be used to treat a number of other psychological conditions.

Antidepressants can take between 2 to 4 weeks before they become effective. It's therefore important that you continue to take antidepressant medication, even if you feel that it is not working. You should only ever stop taking prescribed medication if your doctor specifically advises you to do so.

The types of antidepressants that are recommended to treat panic disorder are:

• selective serotonin reuptake inhibitors (SSRIs)
• tricyclic antidepressants

When starting a new type of medication, it's important that you're regularly assessed by your doctor at 2, 4, 6 and 12-week intervals. This gives you the opportunity to discuss any issues you have with your medication and enables your doctor to assess which treatment is most effective and whether you want to consider trying a different type of medication.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that work by increasing the level of a chemical in your brain called serotonin.

SSRIs are the most commonly prescribed form of antidepressant for the treatment of panic disorder. They're usually started at a low dose before gradually being increased as your body adjusts to the medicine.

Common side effects of SSRIs include:

• nausea
• headaches
• low sex drive
• blurred vision
• diarrhoea or constipation
• dizziness
• dry mouth
• loss of appetite
• sweating
• feeling agitated
• insomnia (being unable to sleep)
• abdominal pain

When you first start taking SSRIs, your feelings of anxiety and panic may seem to get worse. In the majority of cases, this is only temporary and you'll usually find your symptoms start to return to normal levels within a few days of taking the medicine.

However, you should speak to your doctor if you feel your symptoms have got worse and that they're not showing signs of returning to normal levels after a few days.

After you start to take a SSRI, you should visit your doctor after two, four, six, and 12 weeks so that they can check on your progress and see whether you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it is important that your progress is carefully monitored.

If your doctor feels it's necessary, you may require regular blood tests, or blood pressure checks, or they may prescribe an alternative SSRI for you to see if it has any effect.

The length of time you'll have to take an SSRI for will vary depending on how well you respond to the treatment. Even if you feel your panic disorder has been successfully treated, it's likely you'll need to keep taking the medication for at least 6 to 12 months.

If you stop taking your SSRI medication before this time, the risk of your symptoms recurring once you stop taking the medication may be increased. Some people may have to take SSRIs for longer than 6 to 12 months.

When you and your doctor decide that it's appropriate for you to stop taking SSRIs, you'll gradually be weaned off them by slowly reducing your dosage. As with antidepressants, you should never stop taking your medication unless your doctor specifically advises you to.

Stopping your medication straight away without being weaned off, or without seeking advice from your doctor, may result in withdrawal symptoms such as:

• dizziness
• numbness and tingling
• nausea and vomiting
• headache
• anxiety
• sleep disturbances
• sweating

These symptoms can also occur if you miss a dose of medication, or if your dose is reduced. The symptoms are usually mild, but they can be severe if the medication is stopped suddenly.

For some people, this means having to take SSRIs on a long-term basis. For others, a course of cognitive behavioural therapy can help to reduce the risk of their symptoms recurring.

Contact your doctor if your side effects become troublesome and don't ease.

Tricyclic antidepressants

If SSRIs don't help to improve your symptoms after a 12-week course, or if they're not suitable, your doctor may try prescribing a different type of antidepressant.

Tricyclic antidepressants work in a similar way to SSRIs. They regulate the levels of certain chemicals in your brain (noradrenaline and serotonin), which has a positive effect on your feelings and mood.

The 2 tricyclic antidepressants that are often prescribed to treat panic disorder are:

• imipramine
• clomipramine

Tricyclic antidepressants are not addictive.

SSRIs are usually prescribed before tricyclic antidepressants because they have fewer side effects. However, common side effects of tricyclic antidepressants include:

• constipation
• difficulty urinating
• blurred vision
• dry mouth
• weight gain or weight loss
• drowsiness
• sweating
• lightheadedness
• skin rash

The side effects should ease after 7 to 10 days as your body begins to get used to the medication. However, contact your doctor if they become troublesome and don't ease.

Referral

If CBT, medication, or attending a support group do not help to improve your symptoms of panic disorder, you may be referred to a mental health specialist.

A mental health specialist will carry out an overall reassessment of your condition. They'll ask you about your previous treatment and how effective you found it. They may also ask you about things in your life that may be affecting your condition, or how much support you get from family and friends.

The specialist will be able to devise a treatment plan for you, which will aim to effectively treat your symptoms.

The type of mental health specialist that you'll be referred to will depend on your individual situation. For example, you may be referred to:

• a psychiatrist – a trained medical doctor who specialises in mental health; a psychiatrist is one of the only mental health specialists able to prescribe medication
• clinical psychologists – are trained in the scientific study of human behaviour and mental processes, and focus solely on the assessment and treatment of mental health conditions; a clinical psychologist will help you find ways of effectively managing your anxiety and your panic attacks

Self-help for panic disorder

There are several self-help techniques you can use to help treat the symptoms of panic disorder yourself.

Stay where you are

If possible, you should stay where you are during a panic attack. The panic attack could last up to an hour, so you may need to pull over and park where it's safe to do so if you are driving. Don't rush to a place of safety.

Focus

During a panic attack, remind yourself that the frightening thoughts and sensations are a sign of panic and will eventually pass. During a panic attack, it's important for you to focus on something that's non-threatening and visible, such as the time passing on your watch, or items in a supermarket.

Slow deep breathing

While you're having a panic attack, try to focus on your breathing. Your feelings of panic and anxiety can get worse if you breathe too quickly. Try to focus on slow deep breathing while counting slowly to 3 on each breath in and out.

Challenge your fear

During a panic attack, try to notice what it is you fear and challenge it. You can do this by constantly reminding yourself that what you fear isn't real and that it'll pass in a few minutes.

Creative visualisation

During a panic attack, lots of things can go through your mind. Some people think about disaster, or even death. Instead of letting your imagination focus on these negative thoughts, try to concentrate on positive images.

Think of a place or a situation that makes you feel peaceful, relaxed or at ease. Once you have this image in your mind, try to focus your attention on it. It should help to distract you from the situation, and may help ease your symptoms.

Thinking positively can be challenging, particularly if you've been thinking negatively over a long period of time. Creative visualisation is a technique that will need practice, but you may gradually notice positive changes in the way you think about yourself and others.

Do not fight an attack

Fighting a panic attack can often make the experience worse. Trying to resist the attack and finding that you're unable to can increase your sense of anxiety and panic.

Instead, during a panic attack, reassure yourself by accepting that although it may seem embarrassing, and your symptoms may be difficult to deal with, your attack is not life-threatening. Focus on the fact that your attack will have an end and try your best to let it pass.

Relaxation

If you have panic disorder, you may feel constantly stressed and anxious, particularly about when your next panic attack may be. Learning to relax can help to relieve some of this stress and tension, and may also help you to deal more effectively with your panic attacks when they occur.

Some people find that complementary therapies, such as massage and aromatherapy, help them relax. Others find activities such as yoga, or pilates, helpful. You can also practise breathing and relaxation techniques, which you can use during a panic attack to help ease your symptoms.

Exercise

Regular exercise, particularly aerobic exercise, will help you combat stress and release tension. It can also encourage your brain to release the chemical serotonin, which can help to improve your mood.

You should be aiming to do a minimum of 30 minutes of vigorous exercise, at least 5 days a week. Vigorous exercise should make you feel out of breath and tired, although not to the point where it's unbearable. Going for a brisk walk, or walking uphill, are both examples of vigorous exercise.

However, if you haven't exercised before, or for a long time, you should visit your doctor for a fitness assessment before starting a new exercise programme.

Diet

Unstable levels of blood sugar can contribute to the symptoms of a panic attack. Therefore, you should maintain a healthy, balanced diet, eat regularly and avoid eating sugary food and drinks. Avoid caffeine, alcohol and smoking because they can contribute to panic attacks.

Complications of panic disorder

Panic disorder is a treatable condition. However, in order to make a full recovery, it's very important you seek medical help as soon as possible.

This is because treatment for panic disorder is much more effective if it's given at an early stage.

If left undiagnosed and untreated, panic disorder can become a very debilitating and isolating illness. It can also increase your risk of developing other psychological conditions.

Agoraphobia and other phobias

Agoraphobia is a fear of being in situations where escape might be difficult, or help wouldn't be available if things go wrong.

If you have agoraphobia, leaving home, entering public places and travelling alone can cause you intense anxiety. Many people who have agoraphobia avoid everyday activities because of their phobia.

Agoraphobia is one of the conditions that can develop alongside panic disorder. People with panic disorder can develop agoraphobia because of their fear of having a panic attack in a public place.

You may worry that a panic attack in a public place will be embarrassing, or that you'll have difficulty getting help if you need it. You may also worry about public places that you would have difficulty leaving (such as a train) if you were to have a panic attack.

If you have agoraphobia, it's likely that you'll find it difficult to leave the house, particularly if you're not with a trusted family member or a friend.

If you have panic disorder, you may also develop other fears and phobias, which can often seem irrational. For example, you may start to worry about a particular object or action that triggers your attacks, and so become fearful of those things.

Children

Panic disorder is more common in adolescents (teenagers) than in younger children.

Panic attacks can be particularly debilitating for children and young people. A severe case of panic disorder may affect their development and learning. The fear of having a panic attack may stop children from going to school and engaging in a healthy social life. They may also find it difficult to concentrate on their schoolwork.

Diagnosing panic disorder in children is usually a case of taking a detailed medical history and carrying out a thorough physical examination in order to rule out any physical causes for the symptoms they're having. Screening for other anxiety disorders may also be needed in order to determine what's causing their panic attacks.

Panic attacks in children are often dramatic events, including screaming and weeping and an increased breathing rate (hyperventilation). If a child displays the signs and symptoms of panic disorder over a prolonged period of time, a doctor may refer them to a specialist where they'll be given a further assessment and treatment.

If it's recommended, they may be given a course of psychotherapy, such as cognitive behavioural therapy (CBT).

Drug and alcohol misuse

Some studies have shown that conditions that cause intense anxiety, such as panic disorder, can also increase your risk of developing an alcohol or drug problem.

The side effects or withdrawal symptoms of both recreational (illegal) and prescribed (legal) drugs can increase the symptoms of anxiety.

Examples of legal drugs are:

• caffeine
• alcohol
• cigarettes

Examples of illegal drugs are:

• cannabis
• cocaine
• heroin