Emotion › Abnormal Emotional Reaction › Anxiety

Panic Attack

A panic attack is a discrete episode of sudden, intense anxiety that rises rapidly to a peak within minutes, accompanied by severe physical symptoms such as a racing heart, breathlessness, chest tightness, dizziness, and a sense of losing control or impending doom. It is time-limited, usually subsiding within twenty to thirty minutes, but is often so alarming that the person fears something is seriously and immediately wrong with their body.

This has traditionally been distinguished from more general, sustained anxiety by its abrupt onset and discrete, episodic nature, and its physical intensity is often severe enough that patients first present to emergency medical services believing they are experiencing a heart attack or other acute physical crisis.

Recognition features

• Sudden onset of intense fear or discomfort, peaking within minutes
• Prominent physical symptoms: palpitations, chest pain or tightness, shortness of breath, dizziness, trembling, sweating, nausea
• Often accompanied by a fear of dying, losing control, or 'going mad'
• Time-limited, typically resolving within twenty to thirty minutes, in contrast to more sustained anxiety states

Eliciting it at interview

• Ask about discrete episodes of sudden, intense fear with physical symptoms, and how quickly they came on and how long they lasted
• Ask specifically what the person feared was happening during the episode (a heart attack, dying, losing control), since this cognitive content is characteristic
• Establish whether attacks occur unpredictably ('out of the blue') or are consistently triggered by a specific situation, which has implications for distinguishing this from a phobic pattern

Distinguishing features

• Differs from generalised anxiety by its discrete, episodic, rapidly peaking nature rather than a more constant background state
• Differs from a phobic reaction in that a panic attack can occur unpredictably, without a specific external trigger, though panic attacks can also occur in response to a feared situation
• The severity of physical symptoms often leads to initial medical rather than psychiatric presentation, which is itself a recognition point

Common misconceptions

• That a panic attack is simply a bad case of nerves; the physical intensity and the fear of dying or losing control are qualitatively distinct from ordinary worry
• That panic attacks always have an obvious trigger; unexpected, seemingly spontaneous attacks are a recognised pattern

Related phenomena

Anxiety · Phobia · Morbid Anxiety

Diagnostically relevant to

Panic Disorder (links open the DSM-5 Learning Lab)

Practice this

While sitting quietly at home with nothing in particular happening, a woman is suddenly overwhelmed by intense fear, her heart pounding, chest tight, and short of breath, convinced for several minutes that she might be dying, before the whole episode subsides within half an hour. What is this? · A man presents to the emergency department convinced he is having a heart attack, with chest pain, palpitations, and severe shortness of breath that came on abruptly ten minutes ago. Cardiac investigations are unremarkable. Before revealing the answer: what should be considered alongside cardiac causes? · A patient describes apprehension along with physical symptoms such as a racing heart and sweating. Before revealing the answer, decide what distinguishes anxiety from a panic attack. · A patient describes fear about the future. Before revealing the answer, decide what distinguishes anxious foreboding from a panic attack. · A patient describes episodes of intense fear. Before revealing the answer, decide what distinguishes a panic attack from a phobic reaction. · You are assessing a patient for panic attacks. Before revealing the answer, decide what you would ask about. · Explain why the severity of physical symptoms in a panic attack often leads patients to seek medical rather than psychiatric help first.

Illustration

While waiting in a supermarket queue, a 33-year-old man is suddenly gripped by a pounding heart, tight chest, and the overwhelming conviction that he is about to die, prompting him to leave his shopping and go straight to the emergency department, where by the time he is seen twenty minutes later the symptoms have almost entirely passed.

References

• Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 6, 'Disorders of Emotion'.