What is a panic attack?

A panic attack is a discrete period of intense fear or discomfort that peaks within minutes and includes symptoms such as palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, derealisation, fear of losing control or dying. Panic attacks can be expected (in certain situations) or unexpected.

Diagnostic criteria for Panic Disorder (brief)

• Recurrent unexpected panic attacks.
• At least one attack followed by ≥1 month of persistent concern about additional attacks, worry about consequences, or significant maladaptive change in behaviour (e.g., avoidance).
• Not attributable to substance use, medication, or another medical condition; not better explained by another mental disorder.

Common presentations & subtypes

• With agoraphobia: avoidance of places/situations where escape might be difficult (e.g., crowded places, public transport).
• Situationally predisposed: attacks often occur in specific contexts but also unexpectedly.
• Pure panic disorder: recurrent unexpected attacks without marked avoidance or agoraphobia initially.

Assessment checklist

1. Characterise attacks: onset, duration, frequency, triggers, typical symptoms, and whether expected or unexpected.
2. Screen for medical mimics: cardiac (arrhythmia, ischemia), pulmonary (PE, asthma), endocrine (thyroid, pheochromocytoma), vestibular and neurological causes.
3. Assess functional impact: avoidance, occupational/social impairment, driving limitations, and safety concerns.
4. Evaluate comorbidity: depression, other anxiety disorders, substance use (stimulants, caffeine), PTSD; assess suicide risk when indicated.
5. Consider brief investigations: ECG, thyroid function, basic metabolic panel, and toxicology when clinically warranted.

Immediate management of a panic attack

• Provide a calm, reassuring environment; normalise the experience and explain it will pass.
• Use grounding and breathing techniques: paced breathing (e.g., 4 in, 6 out), grounding prompts (5 things you can see), and muscle relaxation.
• Rule out medical emergencies if chest pain, syncope, focal neurological signs, or severe respiratory compromise are present—arrange urgent medical evaluation.

Evidence‑based treatments

• Cognitive‑Behavioural Therapy (CBT): first‑line—psychoeducation, cognitive restructuring of catastrophic misinterpretations, interoceptive exposure (provoking bodily sensations) and in vivo exposure for avoidance/agoraphobia.
• Interoceptive exposure: repeated, guided provocation of feared bodily sensations (e.g., spinning, hyperventilation) to reduce fear of sensations and break the panic cycle.
• Pharmacotherapy: SSRIs (sertraline, escitalopram, paroxetine) and SNRIs (venlafaxine) are first‑line medications; imipramine (TCA) effective but less tolerated. Short‑term benzodiazepines reduce acute anxiety but risk dependence—use cautiously with clear plans for taper.
• Combination therapy: CBT + SSRI can be considered for severe cases or when rapid symptom reduction needed; discuss benefits/risks with patient.

Practical CBT session structure (brief)

1. Psychoeducation: explain panic physiology and the vicious cycle of catastrophic misinterpretation.
2. Self‑monitoring: panic diary for triggers, symptoms, SUDS and coping strategies.
3. Cognitive work: identify and test catastrophic beliefs (“I’m having a heart attack”).
4. Interoceptive exposure: design graded exercises to elicit feared sensations and practise until habituation/re‑appraisal occurs.
5. In vivo exposure: address avoidance related to agoraphobia or situational fears; assign homework and reinforce progress.

Pharmacologic considerations & monitoring

• Start SSRIs at standard doses and counsel about initial activation—consider starting low and titrating; allow 6–12 weeks to assess response.
• Benzodiazepines (e.g., clonazepam, lorazepam) may be used short‑term for severe distress or until SSRIs take effect—avoid long‑term use where possible.
• Monitor for adverse effects, interactions (e.g., CYP interactions), and for alcohol or sedative misuse in patients prescribed benzodiazepines.

Practical tips for clinicians

• Use brief psychoeducation to demystify panic symptoms and reduce catastrophic interpretations.
• Implement interoceptive exposure early for patients motivated for therapy—track SUDS and habituation.
• Plan for relapse prevention, encourage gradual return to avoided activities, and coordinate care with primary care for medical reviews.

Key takeaways

• Panic Disorder is treatable—CBT with interoceptive and in vivo exposure is gold standard; SSRIs are effective pharmacologic options.
• Always exclude medical mimics and manage acute red flags urgently.
• Combine psychoeducation, exposure, and medication thoughtfully—monitor for safety and functional recovery.