DSM-5 Criteria for a Panic Attack

The episode must include at least 4 of the following 13 symptoms:

1. Palpitations, pounding heart, or accelerated heart rate

2. Sweating

3. Trembling or shaking

4. Shortness of breath or smothering sensations

5. Feelings of choking

6. Chest pain or discomfort

7. Nausea or abdominal distress

8. Dizziness, unsteadiness, lightheadedness, or faintness

9. Chills or heat sensations

10. Paresthesias (numbness or tingling sensations)

11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)

12. Fear of losing control or “going crazy”

13. Fear of dying

Important DSM-5 Clarifications

• Abrupt Onset: Symptoms develop suddenly and typically peak within minutes.
• Time-Limited: Most panic attacks peak within about 10–20 minutes, though some symptoms may last longer.
• Not a Diagnosis by Itself

A panic attack is not a mental disorder on its own. It is a specifier that can occur in the context of several disorders, including:

• Panic Disorder

• Social Anxiety Disorder

• Specific Phobias

• PTSD

• Major Depressive Disorder

• Substance/medication-induced conditions

• Medical conditions

Types of Panic Attacks (DSM-5 Specifiers)

The DSM-5 describes two main types:

1. Expected (Cued) Panic Attacks
   Occur in response to a known trigger (e.g., seeing a phobic object).

2. Unexpected (Uncued) Panic Attacks
   Occur without an obvious trigger.

Unexpected, recurrent panic attacks are required for a diagnosis of Panic Disorder.

Panic Attack vs. Panic Disorder

• Panic Attack = A single episode of intense fear with physical symptoms.

• Panic Disorder = Recurrent unexpected panic attacks plus at least one month of:

  • Persistent worry about additional attacks, or

  • Maladaptive behavioral changes related to the attacks (e.g., avoidance).

•  Psychotherapy (First-Line Treatment)

Cognitive Behavioral Therapy (CBT), Gold Standard

CBT is the most researched and effective treatment for panic attacks and panic disorder.

It helps by:

• Identifying and challenging catastrophic thoughts (“I’m going to die”)

• Reducing fear of bodily sensations

• Teaching coping and breathing skills

• Gradual exposure to feared sensations (interoceptive exposure)

Interoceptive exposure involves safely recreating physical sensations (e.g., spinning to induce dizziness) to reduce fear of them.

 Most people see improvement within 8–16 sessions.

Exposure Therapy

Used especially when panic attacks are linked to avoidance (e.g., driving, crowded places). Gradual exposure reduces fear over time.

Acceptance and Commitment Therapy (ACT)

Focuses on accepting anxiety symptoms instead of fighting them and committing to valued actions.

Medications

Medication may be recommended when:

• Panic attacks are frequent or severe

• Therapy alone isn’t enough

• There is significant functional impairment

First-Line Medications: SSRIs

• Sertraline

• Fluoxetine

• Paroxetine

• Escitalopram

These regulate serotonin and reduce panic frequency over time.
Effects usually begin in 2–6 weeks.

SNRIs

• Venlafaxine (FDA-approved for panic disorder)

Benzodiazepines (Short-Term Use Only)

• Alprazolam

• Lorazepam

• Clonazepam

They act quickly but carry risks:

• Dependence

• Tolerance

• Withdrawal symptoms

Typically used short-term or in specific cases.

Other Options

• Tricyclic antidepressants (e.g., imipramine)

• Beta-blockers (sometimes used for physical symptoms) like Propranolol, Metoprolol

• Alpha-Blocker like Clonidine

• Anti-histamine like Hydroxyzine

• Gabapentin

• Buspar

• Second generation antipsychotic like Seroquel, Haldol

Lifestyle & Self-Help Strategies

These are supportive but often helpful alongside therapy:

Breathing Techniques

Slow diaphragmatic breathing helps regulate hyperventilation.

Example:

• Inhale for 4 seconds

• Hold for 4 seconds

• Exhale for 6 seconds

Grounding Techniques

• 5-4-3-2-1 sensory exercise

• Naming objects in the room

• Cold water on wrists

Reduce Triggers

• Limit caffeine

• Reduce alcohol

• Avoid recreational drugs

• Maintain regular sleep

Regular Exercise

Improves stress regulation and reduces anxiety sensitivity.