Panic attacks are intense episodes of fear or discomfort that reach a peak within minutes, often accompanied by physical and cognitive symptoms such as palpitations, shortness of breath, dizziness, and fears of losing control or dying. Panic disorder occurs when an individual experiences recurrent panic attacks coupled with persistent concern about having more attacks or changes in behavior to avoid them. Panic attacks can occur unexpectedly or be triggered by specific situations. Panic disorder significantly impacts daily functioning and quality of life, leading to avoidance behaviors and, in some cases, agoraphobia. Understanding the psychological and physiological mechanisms underlying panic is critical for effective treatment. Evidence-based approaches such as cognitive behavioral therapy (CBT) have proven to be highly effective in managing panic attacks and panic disorder.
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According to DSM-5 and ICD-11, the key features of panic attacks include a range of physical and cognitive symptoms:
Palpitations, pounding heart, or accelerated heart rate.
Sweating, trembling, or shaking.
Sensations of shortness of breath or smothering.
Chest pain or discomfort.
Nausea or abdominal distress.
Dizziness, light-headedness, or fainting.
Chills or hot flushes.
Fear of losing control or going crazy.
Fear of dying.
Feelings of unreality (derealization) or detachment from oneself (depersonalization).
According to DSM-5, panic disorder is characterized by recurrent, unexpected panic attacks. Following at least one of these attacks, individuals experience persistent worry about future attacks or their consequences, such as fear of losing control or having a medical emergency. This worry often leads to significant changes in behavior, such as avoiding situations that might trigger an attack.
The ICD-11 criteria for panic disorder are similar but place greater emphasis on the presence of panic attacks as the defining feature. Unlike DSM-5, ICD-11 does not require that the panic attacks be unexpected, broadening the diagnostic scope.
Panic attacks can occur in various anxiety disorders or independently. Panic disorder is diagnosed when panic attacks are recurrent, unprovoked, and cause significant distress or behavioral change.
The lifetime prevalence of panic disorder is estimated at 2–3% in the general population, with higher rates observed in women (APA, 2013). Panic attacks, however, are more common, affecting up to 11% of individuals annually (Kessler et al., 2006).
Stressful Life Events: Traumatic or significant stressful experiences can be a risk factor for the development of panic disorder (e.g., Leskin & Sheikh, 2002).
Personality Traits: High levels of neuroticism or sensitivity to anxiety-related sensations (anxiety sensitivity) (McNally, 2002)
Genetic Vulnerability: A family history of anxiety or mood disorders increases risk (Hettema et al., 2001).
Medical Conditions: Certain physical conditions (e.g., cardiovascular or respiratory disorders) and substance use can contribute to the development of panic attacks.
This widely accepted model proposes that panic attacks result from the misinterpretation of benign bodily sensations (e.g., increased heart rate) as catastrophic (e.g., “I’m having a heart attack”). This misinterpretation creates a feedback loop that amplifies symptoms and intensifies panic.
Suggests that panic attacks are conditioned responses to internal or external cues (e.g., a crowded space). Over time, avoidance of these cues maintains the disorder.
This theory posits that individuals become sensitized to internal bodily sensations (e.g., dizziness) associated with previous panic attacks, leading to heightened fear responses when these sensations are experienced again.
Hyperventilation may play a role in triggering panic attacks by causing symptoms like dizziness and shortness of breath, which are misinterpreted as signs of danger. Hyperventilation is still recognized as a factor in some cases of panic attacks, but its role is now viewed as part of a more complex interaction between physiological, cognitive, and behavioral processes.
Psychodynamic theory focuses on the psychological dynamics associated with panic disorder, such as unconscious conflicts, disavowed feelings, and fantasies that contribute to panic symptoms (e.g., Busch & Milrod, 2010).
CBT is the most supported treatment for panic disorder (Rabasco et al., 2022). It targets the catastrophic misinterpretations of bodily sensations and aims to reduce avoidance behaviors. Techniques include:
Cognitive restructuring: Identifying and challenging catastrophic thoughts.
Interoceptive exposure: Gradual exposure to feared bodily sensations to reduce fear responses.
Behavioral experiments: Testing beliefs about the feared consequences of panic.
Exposure therapy focuses on gradual exposure to panic-inducing situations or internal sensations (interoceptive exposure) to diminish fear responses over time.
This approach teaches patients to use relaxation techniques (e.g., diaphragmatic breathing) to counteract physical symptoms of anxiety during panic attacks.
ACT encourages individuals to accept their bodily sensations and anxiety-related thoughts without judgment while pursuing valued goals (Eifert & Forsyth, 2005).
Psychodynamic approaches, such as Panic-Focused Psychodynamic Psychotherapy (PFPP; Milrod et al., 2007), seek to explore the feelings and subjective experiences associated with panic episodes, helping patients address the emotional conflicts associated with them. By understanding and resolving core conflicts, such as those related to attachment and dependency, patients can reduce their vulnerability to future panic episodes (Keefe et al., 2019).
Psychology Tools provides a variety of resources for therapists working with panic disorder, including:
Cognitive models and formulations for panic attacks and panic disorder.
Worksheets for cognitive restructuring and interoceptive exposure.
Handouts on understanding and managing panic symptoms.
Self-help materials for clients.
Audio exercises for relaxation and anxiety management.
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Busch, F., & Milrod, B. (2010). Psychodynamic treatment of panic disorder. In R. A. Levy & J. S. Ablon (Eds.), Handbook of evidence-based psychodynamic psychotherapy: Bridging the gap between science and practice (pp. 29–44). Humana Press.
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Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders. New Harbinger Publications.
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Keefe, J. R., Chambless, D. L., Barber, J. P., & Milrod, B. L. (2019). Treatment of anxiety and mood comorbidities in cognitive-behavioral and psychodynamic therapies for panic disorder. Journal of Psychiatric Research, 114, 34-40.
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Ley, R. (1985). Blood, breath, and fears: A hyperventilation theory of panic attacks and agoraphobia. Clinical Psychology Review, 5(4), 271–285.
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Milrod, B., Leon, A. C., Busch, F., Rudden, M., Schwalberg, M., Clarkin, J., ... & Shear, M. K. (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164, 265-272.
Rabasco, A., McKay, D., Smits, J. A., Powers, M. B., Meuret, A. E., & McGrath, P. B. (2022). Psychosocial treatment for panic disorder: An umbrella review of systematic reviews and meta-analyses. Journal of Anxiety Disorders, 86, 102528.