Panic disorder

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Panic disorder is an anxiety disorder characterized by recurrent, unexpected panic attacks - discrete episodes of intense fear or discomfort peaking in less than 10 minutes + accompanied by at least 4 of the 13 physical and cognitive symptoms defined by the DSM-5 - followed by persistent anticipatory anxiety («fear of being afraid») + and/or significant behavioral changes (avoidance of situations associated with the attacks) + lasting at least one month. With a lifetime prevalence of 2 to 4 % in the general population + a female predominance (F:H = 2:1) + and a peak incidence between the ages of 20 and 40, panic disorder is one of the most frequent and disabling anxiety disorders - not so much because of the objective dangerousness of the attack (which is nil - a panic attack causes no physical harm) + but because of the pernicious cognitive cycle it engenders: fear of internal physical sensations (catastrophizing interoception) → hypervigilance to bodily signals → catastrophic interpretation of normal sensations (palpitations = heart attack + dyspnea = asphyxia + dizziness = stroke) → sympathetic hyperactivation → increased sensations → crisis → avoidance → reinforcement of catastrophic cognitions. This cognitive-behavioral model by Clark (1986) forms the basis of cognitive-behavioral therapy (CBT) with interoceptive exposure - the gold-standard psychotherapeutic treatment for panic disorder, comparable in long-term efficacy to SSRIs and superior in terms of durability after treatment discontinuation. Agoraphobia - fear and avoidance of situations where escape would be difficult or help unavailable during a crisis (public transport + crowds + queues + bridges + elevators + open spaces) - develops in 30 to 50 % of cases of untreated panic disorder, and considerably worsens functional disability.

DSM-5 criteria - panic attacks

Sudden onset of intense fear or discomfort peaking within minutes + ≥ 4 of the following 13 symptoms:
Physical symptoms : palpitations + tachycardia + sweating + tremors + dyspnea + sensation of suffocation + chest pain or discomfort + nausea or abdominal pain + dizziness or vertigo + chills or hot flushes + numbness or tingling (paresthesias)
Cognitive symptoms: depersonalization (feeling of being detached from oneself) + derealization (feeling that the environment is unreal) + fear of losing control or «going crazy» + fear of dying
Panic disorder criteria : recurrent and unexpected attacks + followed for ≥ 1 month by at least: persistent anxiety about further attacks + and/or significant behavioural changes related to the attacks (avoidance) + the attacks are not due to a substance or medical condition + not better explained by another mental disorder

Differential diagnosis - exclude an organic cause

Cardiovascular : arrhythmias (supraventricular tachycardia + atrial fibrillation) + Wolff-Parkinson-White syndrome + angina → systematic ECG + Holter if recurrent palpitations
Endocrine : hyperthyroidism (TSH) + pheochromocytoma (urinary or plasma metanephrines + paroxysmal hypertension + headaches) + hypoglycemia (blood glucose during an attack) + carcinoid syndrome
Neurological : temporal epilepsy (partial seizures with vegetative component) + vertebro-basilar TIA + brain tumor
Respiratory : asthma + pulmonary embolism (dyspnea + sudden tachycardia)
Substances : excessive caffeine + cocaine + amphetamines + alcohol withdrawal + benzodiazepines
Minimum initial workup : CBC + ionogram + blood glucose + TSH + ECG + ± Holter if palpitations predominate → if clinical examination and workup normal → clinical diagnosis of panic disorder possible

Pharmacological treatment

Drug	Dosage	Efficiency and comments
SSRIs (first-line treatment)	Sertraline (Zoloft®) 25-200 mg/d + escitalopram 10-20 mg/d + paroxetine 10-60 mg/d + fluoxetine 10-60 mg/d - start at a low dose (sometimes ½ usual dose) as SSRIs can transiently worsen anxiety at the start of treatment	50-80 % reduction in panic attacks + treatment of associated agoraphobia + 4-6 week efficacy + 2-4 week onset + 12-24 month maintenance recommended + adverse effects: initial nausea + insomnia + transient anxiety activation
IRSN (alternative)	Venlafaxine LP (Effexor®) 75-225 mg/d	Efficacy comparable to SSRIs + useful if comorbid depression + adverse effects: hypertension at high doses + withdrawal syndrome if abruptly stopped
Clomipramine (tricyclic)	25-150 mg/d	Very effective on panic disorder + but anticholinergic effects + cardiac risk + dangerous overdose → reserved for forms refractory to SSRIs
Benzodiazepines (limited use)	Clonazepam 0.25-2 mg × 2/d + or alprazolam 0.25-0.5 mg PRN	Rapid relief of acute attacks + but high risk of dependence + tolerance + rebound on discontinuation + may reduce the effectiveness of CBT (prevent habituation) → use only for short periods at the start of SSRI treatment + or occasionally → DO NOT prescribe as background treatment for panic disorder

Psychotherapeutic treatment - CBT with interoceptive exposure

CBT - principal components : psychoeducation (understanding the mechanism of the panic attack + the fight-or-flight response + hyperventilation) + cognitive restructuring (identifying + challenging catastrophic interpretations of physical sensations) + interoceptive exposure (deliberately provoking feared physical sensations - spinning in a chair + hyperventilation + climbing stairs → desensitization to sensations) + in vivo exposure to avoided situations (agoraphobia) → 12-20 weekly sessions
Interoceptive exhibition : central and distinctive component of CBT for panic disorder + the patient learns to voluntarily provoke the feared sensations in a safe context + without fleeing + by allowing the sensations to peak and diminish → breaking the fear-avoidance-reinforcement cycle + visceral desensitization
Effectiveness of CBT : 70-90 % complete remission + long-lasting efficacy after discontinuation (vs. more frequent relapse when SSRIs are discontinued) + superior to pharmacotherapy alone in the long term according to meta-analysis (Bandelow 2015) + SSRI + CBT combination = best option for moderate to severe forms with agoraphobia
Diaphragmatic breathing + cardiac coherence : complementary seizure management techniques + activation of the parasympathetic system + reduction of hyperventilation + to be taught at the first consultation

ℙ️ Benzodiazepines - although effective for rapid relief of panic attacks - can paradoxically hinder the recovery of panic disorder in the long term: they prevent habituation to anxious sensations (necessary for interoceptive desensitization) + reinforce the belief that the sensations are dangerous (as the patient seeks to suppress them) + and create physical and psychological dependence. Only use them for short periods at the start of SSRI treatment, if necessary + and never prescribe them as background treatment.

Medical consultation recommended

Consult a doctor if recurrent attacks of intense fear + palpitations + dyspnoea + chest pain + dizziness + or sensation of imminent death appear - an initial medical check-up (ECG + TSH + blood sugar) will help exclude an organic cause before confirming the diagnosis of panic disorder. Consult an emergency room if persistent chest pain + severe dyspnea + or palpitations with malaise occur for the first time - these symptoms may also suggest a cardiological emergency. For treatment of panic disorder with SSRIs and referral to CBT, Clinique Omicron offers medical consultations at its points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.

Consult at Clinique Omicron

Clinique Omicron's specialized physicians and nurse practitioners (IPS) diagnose panic disorder according to DSM-5 criteria, after ruling out an organic cause (ECG + TSH + glycemia), initiate treatment with low-dose progressive SSRIs (sertraline + escitalopram), teach crisis management techniques (diaphragmatic breathing + psycho-education on panic mechanism), avoid benzodiazepines as background treatment, refer to therapists trained in CBT with interoceptive exposure, and monitor response to treatment. Consultations are available at several points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.

The contents of this page are provided for information purposes only and do not replace the advice of a physician or psychiatrist. A panic attack, although extremely uncomfortable, causes no physical harm - it results from normal activation of the sympathetic system interpreted catastrophically. Benzodiazepines should not be used as background treatment for panic disorder, because of the risk of dependence and the impediment to recovery through CBT.

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