Panic Attacks: What they are and Treatment Options

Introduction to Panic

Panic is an intense, often overwhelming response to fear or perceived danger. Unlike general anxiety, panic is characterized by sudden, acute episodes that can manifest both physically and psychologically. These episodes, called panic attacks, are a hallmark of panic disorder and can significantly impair an individual’s quality of life. In our integrative psychiatry practice in Scottsdale, Arizona, panic disorder is one of the more common complaints reported by our clients. Lately, we are seeing more clients present with complaints of panic attacks related to other conditions, such as dysautonomia (e.g. POTS), insomnia, long covid, and brain injury (e.g. post-concussion symptoms). This article is intended to serve as a concise 'download' of what we know and what we are seeing.

What is a Panic Attack?

A panic attack is a sudden onset of intense fear or discomfort that peaks within minutes. Symptoms may include palpitations, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea, dizziness, chills, hot flashes, numbness, or a sense of impending doom (Silote et al., 2020). These episodes are typically unpredictable and can occur in situations that are not inherently dangerous.

Symptoms of Panic Attacks

Key symptoms of a panic attack include:

• Physical symptoms: Rapid heartbeat, chest pain, difficulty breathing, dizziness, and sweating.

• Cognitive symptoms: Feelings of unreality (derealization) or detachment from oneself (depersonalization), fear of losing control, or fear of dying.

What is Panic Disorder?

Panic disorder is a mental health condition characterized by recurrent and unexpected panic attacks, coupled with persistent worry about future attacks or behavioral changes aimed at avoiding triggers. It is distinct from other anxiety disorders due to the spontaneous nature of its symptoms.

Anxiety vs. Panic

Anxiety and panic are often confused but have distinct features:

• Anxiety: A chronic state of worry or apprehension about potential threats. Symptoms build gradually and are more diffuse (Tully et al., 2021).

• Panic: An acute, sudden onset of fear or terror, often without a clear trigger.

Anxiety Attack vs. Panic Attack

The term “anxiety attack” is less clinically defined than a panic attack. Anxiety attacks tend to develop gradually and are linked to specific stressors, whereas panic attacks are sudden and unpredictable (Marchi et al., 2022).

Panic and Anxiety Symptoms: Associations with Long COVID, Dysautonomia, and Brain Injury

Emerging research highlights potential links between panic and anxiety symptoms and conditions such as long COVID, dysautonomia, and brain injury. These associations may provide insights into the underlying mechanisms driving panic disorders.

Long COVID

Long COVID refers to persistent symptoms that continue or develop after the acute phase of COVID-19 infection. Among the most reported symptoms are anxiety, panic attacks, and dysautonomic features such as heart palpitations and shortness of breath. These symptoms may arise due to inflammation, immune dysregulation, or direct effects of the virus on the central nervous system.

Dysautonomia

Dysautonomia encompasses a range of disorders involving autonomic nervous system dysfunction. Conditions such as postural orthostatic tachycardia syndrome (POTS) can produce symptoms like rapid heart rate, dizziness, and chest discomfort, which overlap significantly with panic attack symptoms. Dysregulation of the autonomic system is thought to contribute to heightened physical sensations, which may exacerbate panic in predisposed individuals.

Brain Injury

Traumatic brain injury (TBI) and other forms of brain insult, such as hypoxic-ischemic injury, can lead to structural and functional changes in regions associated with fear and stress regulation, including the amygdala and prefrontal cortex. These changes can manifest as heightened anxiety and panic attacks, with symptoms often exacerbated by physical or emotional stress. Rehabilitation efforts should consider these neurobiological underpinnings when addressing panic and anxiety in brain injury survivors.

Treatment for Panic Attacks and Panic Disorder

Psychological Interventions

• Cognitive-behavioral therapy (CBT): Considered the gold standard for treating panic disorder. It focuses on identifying and challenging irrational fears and modifying avoidance behaviors.

• Exposure therapy: Gradual exposure to feared situations helps desensitize individuals and reduce avoidance.

Pharmacological Treatments

• Selective serotonin reuptake inhibitors (SSRIs): First-line pharmacological treatment for panic disorder due to their efficacy and tolerability.

• Benzodiazepines: Effective for acute symptom relief but carry risks of dependence and are typically not recommended for long-term use.

• Other medications: Tricyclic antidepressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are also used.

Stellate Ganglion Block

The stellate ganglion block (SGB), a 'new kid on the block' procedure that involves injecting a local anesthetic near the stellate ganglion in the neck, has emerged as a potential treatment for anxiety and panic symptoms. A recent study demonstrated that SGB reduced anxiety symptoms by approximately 50% in a case series of 285 patients (Lynch et al, 2023). While primarily explored for post-traumatic stress disorder (PTSD), its efficacy in reducing severe anxiety symptoms suggests it could be a promising intervention for panic-related conditions. The mechanism is believed to involve modulation of the autonomic nervous system, thereby reducing hyperarousal and fear responses. This said, further research is needed to clarify its role specifically in panic disorder.

Ketamine for Panic and Anxiety

Burgeoning interest in Ketamine therapy leads many of our clients to ask us about its potential use for "panic attack symptoms".

Ketamine's Role in Anxiety Disorders

Ketamine, an NMDA receptor antagonist, has demonstrated efficacy in treatment-resistant anxiety disorders. Studies indicate that ketamine may reduce symptoms of generalized anxiety and social anxiety within hours of administration (Silote et al., 2020; Pastuszak & Wiglusz, 2023). However, its long-term effects and safety profile remain subjects of ongoing research (Marchi et al., 2022).

Ketamine’s Limitations for Panic Disorder

While ketamine shows promise for anxiety, its application for panic disorder is less robust. Panic disorder's sudden and episodic nature may not align well with ketamine’s pharmacodynamics, which are better suited for chronic anxiety symptoms (Tully et al., 2021). Moreover, concerns about ketamine’s dissociative side effects and potential for misuse further limit its utility in this population (Marchi et al., 2022).

Summary

Understanding panic disorder requires distinguishing it from broader anxiety disorders and recognizing the unique challenges it presents. Effective treatments range from psychotherapy to pharmacology, with emerging evidence highlighting new possibilities such as ketamine and stellate ganglion block for specific subsets of anxiety. While ketamine’s role in panic disorder remains limited, and SGB requires further research, both represent exciting avenues for future investigation.

About the Author: Dr. David George is the multiple-board certified founder of Neuregen Integrative Psychiatry and Neurologic Health in Scottsdale, AZ. Neuregen offers a range of services intended to support brain optimization and mental health, specializing in the problematic overlap of brain injury and mental health conditions. This includes panic attack and anxiety treatment.

References

Lynch, J., Mulvaney, S., Bryan, C., & Hernandez, D. (2023). Stellate Ganglion Block Reduces Anxiety Symptoms by Half: A Case Series of 285 Patients. Journal of Personalized Medicine, 13. https://doi.org/10.3390/jpm13060958

Marchi, M., Magarini, F., Galli, G., Mordenti, F., Travascio, A., Uberti, D., De Micheli, E., Pingani, L., Ferrari, S., & Galeazzi, G. (2022). The effect of ketamine on cognition, anxiety, and social functioning in adults with psychiatric disorders: A systematic review and meta-analysis. Frontiers in Neuroscience, 16.https://doi.org/10.3389/fnins.2022.1011103

Pastuszak, M., & Wiglusz, M. (2023). Comment on ‘Ketamine treatment for refractory anxiety: A systematic review’. British Journal of Clinical Pharmacology, 89. https://doi.org/10.1111/bcp.15723

Silote, G., De Oliveira, S., Ribeiro, D., Machado, M., Andreatini, R., Joca, S., & Beijamini, V. (2020). Ketamine effects on anxiety and fear-related behaviors: Current literature evidence and new findings. Progress in Neuro-Psychopharmacology and Biological Psychiatry. https://doi.org/10.1016/j.pnpbp.2020.109878

Tully, J., Dahlén, A., Haggarty, C., Schiöth, H., & Brooks, S. (2021). Ketamine treatment for refractory anxiety: A systematic review. British Journal of Clinical Pharmacology, 88, 4412-4426. https://doi.org/10.1111/bcp.15374

UpToDate. (n.d.). Panic disorder in adults: Epidemiology, clinical manifestations, and diagnosis. Retrieved from https://www.uptodate.com/contents/panic-disorder-in-adults-epidemiology-clinical-manifestations-and-diagnosis