Panic Disorder

Panic disorder is an anxiety disorder characterized by recurrent, unexpected panic attacks. This condition involves an intense feeling of fear or discomfort that peaks within a few minutes. During an attack, the individual experiences a sense of impending doom. According to DSM-IV, for diagnosis, at least one of the following must be present for at least one month following the attacks:

• Persistent worry about having additional panic attacks,
• Anxious expectations regarding the consequences of panic attacks (such as having a heart attack or losing control),
• Significant behavioral changes related to panic attacks (such as avoiding going out alone or avoiding exercise).

Panic disorder may occur alone or also in conjunction with agoraphobia (an anxiety disorder characterized by intense fear of being in places where escape might be difficult or help unavailable). When agoraphobia is present, individuals avoid situations where they believe a panic attack might occur and escape would be difficult.

The symptoms of panic attacks in panic disorder are sudden in onset and typically reach their peak within 10 minutes. In individuals with this disorder, at least four of the following 13 symptoms must be present:

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Shortness of breath or a sensation of smothering
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness, lightheadedness, feeling faint
• Derealization (feelings of unreality) or depersonalization (being detached from oneself)
• Fear of losing control or “going crazy”
• Fear of dying
• Numbness or tingling sensations
• Chills or hot flashes

Some individuals develop anticipatory anxiety after a panic attack; this leads them to restrict their lives due to fear of another attack. As a result, functioning may be impaired, social situations may be avoided, and emergency service visits may become recurrent.

_{An individual experiencing a sudden panic attack in public. Image generated by artificial intelligence.}

• Lifetime prevalence: 1.5% – 3%
• Women are affected 2 to 3 times more frequently than men.
• The typical age of onset is often in the early 20s.
• Panic disorder is a significant mental health issue both in the general population and in healthcare utilization.
• Approximately 30% to 50% of individuals with panic disorder also have agoraphobia.
• The prevalence of panic disorder is higher among first-degree relatives (indicating genetic vulnerability).
• Patients with panic disorder frequently present to cardiology, pulmonary, and emergency services with physical complaints.

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The exact cause of panic disorder is not fully understood, but it is believed to involve a combination of biological, genetic, psychological, and environmental factors.

• Genetic predisposition: Individuals with first-degree relatives who have panic disorder are at increased risk.
• Neurotransmitter dysregulation: Abnormalities in serotonin, norepinephrine, and GABA systems underlie panic attacks.
• Carbon dioxide sensitivity: Increases in CO₂ levels can trigger panic attacks.
• Brain structures: Findings indicate abnormal activity in the locus coeruleus, amygdala, and prefrontal cortex.

• Cognitive theories: Catastrophic misinterpretation of bodily sensations (such as interpreting palpitations as a heart attack) is a key trigger.
• Classical conditioning: Learned fears may be associated with situations where previous panic attacks occurred.
• Early life experiences such as childhood separation anxiety or other life events may play a role.

Before diagnosing panic disorder, other medical and psychiatric conditions that may produce similar symptoms must be ruled out:

• Cardiovascular diseases (e.g., arrhythmias, ischemic heart disease)
• Endocrine disorders (e.g., hyperthyroidism, pheochromocytoma)
• Respiratory diseases (e.g., asthma, COPD)
• Neurological disorders (e.g., epilepsy, vestibular disorders)
• Substance and medication use (e.g., amphetamines, caffeine, steroids)

• Generalized anxiety disorder
• Post-traumatic stress disorder
• Obsessive-compulsive disorder
• Somatoform disorders
• Substance-induced anxiety disorder