Panic Disorder Treatment: Breaking the Cycle of Panic and Avoidance

Panic disorder presents symptoms through two distinct areas: the acute experience of the panic attack, and the subsequent patterns that develop around them.

During a panic attack:

• Racing or pounding heartbeat
• Shortness of breath or feelings of suffocation
• Chest pain or tightness
• Trembling or shaking
• Sweating and chills
• Dizziness, lightheadedness, or faintness
• Nausea or stomach discomfort
• Tingling sensations in hands and feet
• Feeling disconnected from self and reality
• Intense fear that one will die, lose control, or “go crazy”

Typically, panic attacks reach their peak intensity in ten minutes and are resolved in thirty minutes.[6] Because the sensation is so overwhelming, many people believe they are experiencing a heart attack or other life-threatening medical event and rush to seek emergency care.

Between panic attacks:

• Persistent anticipation of when the next attack will happen
• Avoiding certain places, activities, or situations in order to prevent triggering another panic attack
• Developing agoraphobic behaviors in more severe cases
• Chronic anxiety and hypervigilance about physical sensations
• Disruption to employment, interpersonal relationships, and daily life

While researchers continue to study the causes of panic disorder and understand it more clearly, several contributing factors have been identified:

• Neurobiological factors — Abnormality in the body’s alarm system, specifically the amygdala, and disruptions in the circuitry controlling the fight-or-flight response cause excessive activation despite no true danger; abnormalities in norepinephrine, serotonin, and GABA systems have been implicated.[7]
• Genetic predisposition — Panic disorder tends to run in families; first-degree relatives of individuals with panic disorder are at higher risk than average.[8]
• Psychological factors — Anxiety sensitivity (fear of anxiety symptoms), catastrophic misinterpretation of body sensations, and tendency to scan for and amplify internal bodily cues are central to maintaining symptoms of panic disorder.[9]
• Substance use and withdrawal — Some substances such as cocaine, amphetamines, and marijuana stimulate reactions that mimic panic attacks, while withdrawal from benzodiazepines and alcohol can produce panic attacks.[10]  A panic attack after drugs or during withdrawal can initiate a full panic disorder in vulnerable individuals.[11]
• Stress and trauma — Significant life stressors and traumatic experiences may prompt the development of full-blown symptoms of panic disorder in vulnerable individuals.[12]

Panic disorder will typically deteriorate with time if left untreated, as the fear of having another panic episode increases and so does the amount of time devoted to avoiding what might trigger it. 

You should seek assistance if:

• Panic attacks are occurring repeatedly and unexpectedly
• You spend an excessive amount of time thinking about your next episode
• Avoidance of situations, activities, and places is starting to limit your daily life
• Are using alcohol or drugs to control your panic
• Agoraphobia is developing due to your panic disorder
• Your job performance or personal relationships are affected
• Loved ones are noticing and concerned about a difference in your behavior related to fear of panic

Most people who receive adequate treatment for panic disorder see some degree of improvement in their symptoms, and many patients achieve complete remission of their symptoms.

If no treatment is received, however, the condition generally continues to worsen. The earlier someone receives treatment, the better the outcome.

The first step in developing an effective treatment plan for panic disorder is to perform a comprehensive clinical evaluation. This includes assessing the frequency and severity of your panic attacks, how much time is spent worrying about experiencing another, the extent to which you avoid certain situations, places, or activities, whether you also exhibit signs of agoraphobia, any co-occurring substance use or mental health condition, and any specific goals you want to accomplish during treatment. Each patient’s treatment plan is tailored to their needs. 

Some common aspects of panic disorder treatment include:

• Cognitive Behavioral Therapy (CBT) — CBT helps identify and challenge the catastrophic misinterpretation of body sensations that result in panic attacks and can help eliminate avoidance patterns that contribute to the persistence of the disorder. Interoceptive exposure, deliberately creating physical sensations characteristic of panic in a controlled environment, is a particularly useful CBT technique for panic disorder.[13]
• Exposure Therapy — Gradually exposing patients to environments and situations that trigger feelings of anxiety based on their previous avoidance behaviors to reduce avoidance and anticipatory anxiety.
• Distress Tolerance and Mindfulness — Developing skills that enable patients to be aware of their physical sensations and thoughts while experiencing anxiety without becoming overwhelmed. These techniques stop the escalation cycle of panic.