Panic disorder

What a panic attack actually is

A panic attack is a sudden surge of intense fear or discomfort that comes with a physical storm of symptoms: racing heart, shortness of breath, chest tightness, dizziness, sweating, trembling, nausea, a sense of unreality or detachment, and a powerful feeling that something is very wrong — sometimes including a fear that you’re dying or losing your mind. They peak within about 10 minutes and then ease, though the residual feeling can last for hours.

Panic attacks are not dangerous — though they feel like an emergency. Many people end up in the ER thinking they’re having a heart attack. After cardiac causes are ruled out, the diagnosis often turns out to be panic.

When panic attacks become panic disorder

You have panic disorder when:

• You’ve had recurrent unexpected panic attacks (not always tied to a specific trigger)
• You’ve started worrying about having another one
• You’ve started changing your behavior to try to prevent them — avoiding places, situations, exercise, caffeine, anything that might trigger one

Sometimes panic disorder leads to agoraphobia — avoiding situations where escape feels difficult or where help wouldn’t be available if a panic attack occurred. Crowded places, public transit, driving on highways, being far from home. We treat both.

How we treat panic

Medication

SSRIs are first-line for panic disorder. We usually start at a lower dose than for depression because panic patients are more sensitive to medication side effects in the first week or two. Most patients see meaningful improvement in 4–6 weeks at adequate dose. Common choices: sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), fluoxetine (Prozac).

For acute episodes, short-term use of a benzodiazepine (lorazepam, alprazolam) is sometimes appropriate — but we use this carefully, given the risk of dependence and the way it can interfere with the long-term recovery process.

CBT for panic

The therapy approach with the strongest evidence for panic is CBT specifically tailored for panic disorder, often called “panic-focused CBT.” It includes:

• Education about what panic is — understanding the fight-or-flight response demystifies it.
• Cognitive work on the catastrophic thoughts that fuel attacks (“I’m dying,” “I’m losing control”).
• Interoceptive exposure — deliberately bringing on physical sensations of panic in a safe setting until they stop being terrifying.
• Situational exposure — gradually re-entering avoided places.

Done well, CBT for panic produces lasting recovery in 70–80% of patients. Many people don’t need medication if they engage with the therapy.