Panic disorder refers to the experience of recurrent and disabling panic attacks which last up to a few minutes and are accompanied by physical symptoms such as heart palpitations, shaking, shortness of breath, and dizziness.^1,2 

Fear of losing control, of going ‘crazy’, or of dying are also common during a panic attack. People with panic disorder often worry about experiencing further panic attacks and, as a result, may start avoiding activities or certain situations to minimise or avoid the possibility of a future attack.¹

In Australia, it is estimated that 5 per cent of the population will experience panic disorder in their lifetime, with women being more likely to be diagnosed with the disorder than men.^3,4 Symptoms of panic disorder can occur at any age, with the typical age of onset ranging from late adolescence to early adulthood.³

Panic attacks are the main symptom of panic disorder. A panic attack is a sudden surge of intense fear or discomfort which reaches a peak within several minutes and is accompanied by at least four of the following:¹

• heart palpitations, or racing/pounding heart
• shaking or trembling
• shortness of breath or a feeling of choking
• chest pain or discomfort
• nausea or abdominal upset
• chills or heat sensations/sweats
• dizziness, light-headedness, or feeling faint or unsteady
• numbness or tingling sensations
• derealisation (feelings of unreality) or depersonalisation (feelings of being detached from oneself)
• fear of losing control or of ‘going crazy’
• fear of dying.

Two types of panic attack have been identified: expected and unexpected. Expected panic attacks occur following a particular cue or trigger, for example, for some people being in a large crowd or in a lift might frequently trigger a panic attack. Unexpected panic attacks, on the other hand, do not have an identifiable cue or trigger and can occur at any time, even if the person is in a calm state or asleep.¹

For a diagnosis of panic disorder, a person must experience at least one unexpected panic attack followed by one month or more of:

• ongoing concern or worry regarding the experience of further panic attacks or their consequences; and/or
• changes in behaviour in order to prevent further attacks from happening, for example, the person may avoid situations where they fear a panic attack could occur, such as public transport.¹

Whilst no single cause has been found, a number of factors are thought to contribute to the development of panic disorder and its associated symptoms. These factors include:

• Genetic factors: People who have a first-degree relative with panic disorder have an increased chance of developing the disorder.⁵
• Neurobiological factors: Studies suggest that in individuals with panic disorder, fear circuitry in the brain may be oversensitive and be triggered by events that pose no threat to the person.^6-10
• Cognitive factors: People with panic disorder are thought to have a higher sensitivity to internal bodily sensations (e.g., heart rate, breathing patterns) and misinterpret any changes in these sensations as being life threatening. This increased sensitivity and the negative thoughts that follow are thought to trigger and contribute to panic symptoms.¹¹
• Stressors in childhood: Childhood maltreatment has been associated with the development of panic disorder.^{12, 13}Both direct and indirect experiences of physical illness in childhood, particularly respiratory conditions (e.g., asthma), may also play a role.¹⁴
• Stressors in adulthood: Stressors such as the death of a loved one, physical illness and injury, excessive alcohol/substance use, and social conflicts might trigger panic disorder.¹³
• Temperament: Personality factors, such as being highly anxious, tense, moody, and self-conscious, may also play a role in the development of panic disorder.^{13, 15}
• Smoking: Cigarette smoking can serve as a risk factor in the development of panic disorder and may contribute to the experience of panic attacks.¹⁶
• Substance use: The use of stimulants both illicit (e.g., cocaine¹⁷) and licit (e.g., caffeine¹⁸) is associated with an increased risk of panic attacks.

Be present

When you are experiencing a panic attack, try to acknowledge the situation and look at it realistically. Tell yourself, “I’m having another panic attack. This will be a good chance to try out one of my new coping strategies.” Ask yourself if you are really in physical danger or if you’re just experiencing discomfort. Remind yourself that you’ll get afraid, but then you’ll eventually calm back down again just like you always do. Try to resume whatever activity you were engaged in before the attack set in and try to be more present in the moment, using your surroundings to help steer your thoughts away from your fears.

Helpful Self-Talk 

When you start to feel yourself panic, try to talk yourself out of your feelings. Play the role of a concerned family member or friend who shows the lack of evidence in all of your worry based “what-ifs”. State the cause of your worry out loud, and then try to find fault with all of your reasoning. For example, if you say you’re feeling nervous about an upcoming meeting at work, take on the role of spoiler and state out loud, what you have done so that you are prepared, point to specific evidence that shows you can do your job (e.g. positive feedback, completing important tasks etc.), and remind yourself even if you feel uncomfortable or nervous on the inside, others are unlikely to notice this.

Breathe

During a full-fledged panic attack, your breathing becomes more rapid as your body prepares for a fight-or-flight reaction. Place one of your hands on your diaphragm and the other on your upper chest. Breathe slowly in through your nose and take a deep breath for five seconds. You’ll know you’re doing it correctly if the hand on your diaphragm rises as you breathe whilst the one on your chest stays still. Then slowly exhale through your nose for another five seconds. Focusing on the counting and hand placement can help take feelings of panic down several notches.

Exercise

Regular exercise can help release tension and lower blood pressure, two physical issues that many panic sufferers might face. Instituting an exercise regimen can have excellent long-term benefits, but it’s also useful as a quick fix. The next time you feel panic starting to creep in, pull out your jump rope or hop on the treadmill.

Relax

Relaxing your muscles is the perfect way to counter feelings of panic. One popular approach involves isolating various muscle groups and then contracting and relaxing them one by one. Close your eyes and focus on curling your toes for five seconds, then release them. Move onto your feet and then slowly work your way up your body, focusing on contracting and relaxing one muscle group at a time. You should feel a lot calmer by the time you reach your face muscles.

Distract yourself

When feelings of panic start to set in, distraction can be a good way to redirect your thoughts. A passive distraction such as watching TV might not be enough to shut off the panicky thoughts, so opt for a hobby that actively engages your mind such as reading or practising a foreign language.

Meditate

Many people who suffer from feelings of panic, anxiety, and nervousness find that meditating can help. During meditation, your body remains still as you focus on one particular object, word, or even your own breathing pattern. This is also beneficial even when you’re not in the middle of overwhelming panic. So try meditating for ten minutes every day.

Consider therapy

When your panic becomes too much for you to manage on your own, psychological therapy or counselling can be a good option. It can help you understand the roots of your panic and how reduce or remove unnecessary panic from your life. Cognitive behavioural therapy (CBT) can be particularly useful as it helps you to identify the negative thought patterns that contribute to panic attacks and change them into more positive ways of thinking.

Talk to your doctor

Some people suffering from panic disorders find medication can reduce symptoms. It can help take the edge off of an extreme situation so the physiology is less intense, making it more possible to cope.

Join or visit a support group

Support groups for people who suffer from panic attacks and phobias can be a tremendous help. Many people feel reassured knowing there are others who can identify with their feelings, and sufferers are able to share coping strategies and inspire one another.

Cognitive behaviour therapy (CBT) 

CBT is considered the most effective treatment for panic disorder. CBT is a type of psychotherapy that helps a person identify and modify unhelpful thoughts and behaviours that may lead to feelings of panic. CBT for panic disorder involves a range of strategies and techniques, including psychoeducation, self-monitoring, cognitive restructuring, exposure therapy, and relaxation.^19-21

Psychoeducation

Psychoeducation involves providing important information about how panic disorder develops in order to improve symptom awareness and empower the person to cope effectively with the disorder. Psychoeducation might also include information on the lifestyle factors that are thought to contribute to feelings of panic (e.g., smoking and the use of stimulants) and those that could decrease the experience of panic symptoms (e.g., regular exercise).^21-24

Self-monitoring

Monitoring a person’s thoughts, behaviours, and symptoms is a core feature of CBT. By asking a person to monitor their panic symptoms, the situations in which they occurred and any associated thoughts and behaviours, the psychologist can help develop therapeutic interventions to reduce the number of panic attacks experienced and the way in which the person responds to panic symptoms.¹⁹

Cognitive restructuring

Feelings of panic often stem from a person’s unhelpful thoughts and misinterpretations of panic symptoms (e.g., “my heart is beating fast… I must be having a heart attack”). Cognitive restructuring is a CBT technique which helps a person to identify and challenge these negative thoughts and develop a more rational and helpful style of thinking (e.g., “a racing heart does not mean I am having a heart attack”).^{19, 20}

Exposure therapy

Exposure therapy is a CBT technique where the psychologist guides a person through scenarios which are known to trigger feelings of panic. This may involve directly exposing a person to a feared situation (e.g., a crowded train) or by inducing physical sensations which the person finds distressing (e.g., a racing heart). Through a gradual process of exposure, often beginning with the least anxiety-provoking situation, the person builds a tolerance of the uncomfortable feelings and sensations that they experience during times of panic and learns to confront their fears with decreased levels of anxiety.^{19, 20}

Relaxation skills training and breathing retraining

Relaxation techniques, such as progressive muscle relaxation, have been found to improve symptoms of panic disorder by decreasing muscle tension and the body’s physical response to stressors.^{20, 21}Another technique which can be incorporated into CBT for panic disorder is breathing retraining which teaches people about the role of breathing in panic disorder and outlines strategies to correct unhelpful breathing patterns which commonly occur during panic attacks (e.g., rapid and shallow breathing).²⁵

1. American Psychiatric Association. (2013).Diagnostic and statistical manual of mental disorders(5th ed.). Washington DC: Author.
2. World Health Organization. (2008).ICD-10: International statistical classification of diseases and related health problems (10th Rev.). New York, NY: Author.
3. McEvoy, P. M., Grove, R., & Slade, T. (2011). Epidemiology of anxiety disorders in the Australian general population: Findings of the 2007 Australian National Survey of Mental Health and Wellbeing.Australian and New Zealand Journal of Psychiatry, 45(11), 957-967. doi: http://dx.doi.org/http://dx.doi.org/10.3109/00048674.2011.624083
4. Yates, W. R. (2009). Phenomenology and epidemiology of panic disorder.Annals of Clinical Psychiatry, 21(2), 95-102.
5. Schumacher, J., Kristensen, A. S., Wendland, J. R., Nöthen, M. M., Mors, O., & McMahon, F. J. (2011). The genetics of panic disorder.Journal of Medical Genetics, 48(6), 361-368. doi: http://dx.doi.org/http://dx.doi.org/10.1136/jmg.2010.086876
6. Johnson, P. L., Federici, L. M., & Shekhar, A. (in press). Etiology, triggers and neurochemical circuits associated with unexpected, expected, and laboratory-induced panic attacks.Neuroscience & Biobehavioral Reviews. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.neubiorev.2014.07.027
7. Dresler, T., Guhn, A., Tupak, S. V., Ehlis, A.-C., Herrmann, M. J., Fallgatter, A. J., . . . Domschke, K. (2013). Revise the revised? New dimensions of the neuroanatomical hypothesis of panic disorder.Journal of Neural Transmission, 120(1), 3-29. doi: http://dx.doi.org/http://dx.doi.org/10.1007/s00702-012-0811-1
8. Pannekoek, J. N., van der Werff, S. J. A., Stein, D. J., & van der Wee, N. J. A. (2013). Advances in the neuroimaging of panic disorder.Human Psychopharmacology: Clinical and Experimental, 28(6), 608-611. doi: http://dx.doi.org/10.1002/hup.2349
9. Nardi, A. E., Freire, R. C., & Zin, W. A. (2009). Panic disorder and control of breathing.Respiratory Physiology & Neurobiology, 167(1), 133-143. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.resp.2008.07.011
10. Meuret, A. E., & Ritz, T. (2010). Hyperventilation in panic disorder and asthma: Empirical evidence and clinical strategies.International Journal of Psychophysiology, 78(1), 68-79. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.ijpsycho.2010.05.006
11. Pilecki, B., Arentoft, A., & McKay, D. (2011). An evidence-based causal model of panic disorder.Journal of Anxiety Disorders, 25(3), 381-388. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.janxdis.2010.10.013
12. Cougle, J. R., Timpano, K. R., Sachs-Ericsson, N., Keough, M. E., & Riccardi, C. J. (2010). Examining the unique relationships between anxiety disorders and childhood physical and sexual abuse in the National Comorbidity Survey-Replication.Psychiatry Research, 177(1-2), 150-155. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.psychres.2009.03.008
13. Klauke, B., Deckert, J., Reif, A., Pauli, P., & Domschke, K. (2010). Life events in panic disorder: An update on “candidate stressors”.Depression and Anxiety, 27(8), 716-730. doi: http://dx.doi.org/http://dx.doi.org/10.1002/da.20667
14. Peters, T. E., & Fritz, G. K. (2010). Psychological considerations of the child with asthma.Child and adolescent psychiatric clinics of North America, 19(2), 319-333. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.chc.2010.01.006
15. Benítez, C. I. P., Shea, M. T., Raffa, S., Rende, R., Dyck, I. R., Ramsawh, H. J., . . . Keller, M. B. (2009). Anxiety sensitivity as a predictor of the clinical course of panic disorder: A 1-year follow-up study.Depression and Anxiety, 26(4), 335-342. doi: http://dx.doi.org/http://dx.doi.org/10.1002/da.20423
16. Cosci, F., Knuts, I. J. E., Abrams, K., Griez, E. J. L., & Schruers, K. R. J. (2010). Cigarette smoking and panic: A critical review of the literature.Journal of Clinical Psychiatry, 71(5), 606. doi: http://dx.doi.org/http://dx.doi.org/10.4088/JCP.08r04523blu
17. Alvarado, G. F., Storr, C. L., & Anthony, J. C. (2010). Suspected causal association between cocaine use and occurrence of panic.Substance Use & Misuse, 45(7-8), 1019-1032. doi: http://dx.doi.org/http://dx.doi.org/10.3109/10826080903534509
18. Lara, D. R. (2010). Caffeine, mental health, and psychiatric disorders.Journal of Alzheimer’s Disease, 20, 239-248. doi: http://dx.doi.org/http://dx.doi.org/10.3233/JAD-2010-1378
19. McHugh, R. K., Smits, J. A. J., & Otto, M. W. (2009). Empirically supported treatments for panic disorder.Psychiatric Clinics of North America, 32(3), 593-610. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.psc.2009.05.005
20. Craske, M. G., & Barlow, D. H. (2008). Panic disorder and agoraphobia. In D. H. Barlow (Ed.),Clinical handbook of psychological disorders(4 ed., pp. 1-64). New York, NY: Guilford Press.
21. Sánchez-Meca, J., Rosa-Alcázar, A. I., Marín-Martínez, F., & Gómez-Conesa, A. (2010). Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis.Clinical Psychology Review, 30(1), 37-50. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.cpr.2009.08.011
22. Vilarim, M. M., Rocha Araujo, D. M., & Nardi, A. E. (2011). Caffeine challenge test and panic disorder: A systematic literature review.Expert Review of Neurotherapeutics, 11(8), 1185-1195. doi: http://dx.doi.org/http://dx.doi.org/10.1586/ern.11.83
23. Freire, R. C., Perna, G., & Nardi, A. E. (2010). Panic disorder respiratory subtype: Psychopathology, laboratory challenge tests, and response to treatment.Harvard Review of Psychiatry, 18(4), 220-229. doi: http://dx.doi.org/http://dx.doi.org/10.3109/10673229.2010.493744
24. Morgan, A. J., & Jorm, A. F. (2009). Outcomes of self-help efforts in anxiety disorders.Expert Review of Pharmacoeconomics & Outcomes Research, 9(5), 445-459. doi: http://dx.doi.org/http://dx.doi.org/10.1586/erp.09.47
25. Meuret, A. E., Rosenfield, D., Seidel, A., Bhaskara, L., & Hofmann, S. G. (2010). Respiratory and cognitive mediators of treatment change in panic disorder: Evidence for intervention specificity. Journal of Consulting andClinical Psychology, 78(5), 691-704. doi: http://dx.doi.org/http://dx.doi.org/10.1037/a0019552
26.