The DSM-V [1] defines panic disorder (PD) as the recurrent onset of sudden fear accompanied by somatic symptoms like palpitations, excessive sweating, and dyspnea. Other criteria include persistent anxiety about recurrence and its consequences or inappropriate behavioral changes. In order to diagnose PD, it is important to exclude medical illnesses, substance abuse, and other psychiatric disorders as the cause of the panic attacks.

The clinical presentation of panic attacks and PD can mimic the symptoms of coronary heart disease [2] and cardiomyopathies [2], making it difficult to differentiate between the conditions clinically [3]. For example, symptoms like chest pain, palpitations, sweating, discomfort, and dyspnea are common to PD as well as myocardial infarction (MI), angina pectoris and pulmonary embolism. Other somatic symptoms of PD include cold clammy hands, headache, diarrhea, insomnia, weakness, intrusive thoughts, and ruminations. The attacks in PD are often related to certain places or situations. Patients develop anxiety about the recurrence of the attack and start avoiding these situations and places resulting in agoraphobia [4]. This can further lead to the development of safety behaviors like dependence on anxiolytic medications and avoiding being alone [4].

Although no gender differences have been observed in the expression of PD symptoms in children and adolescents, a higher incidence of PD has been observed amongst girls. Children and adolescents experience somatic symptoms similar to those seen in adults and these include palpitations, dyspnea, sweating, chest pain, nausea, abdominal discomfort, dizziness, restlessness and a sense of losing control [5] [6] [7].

Diagnosis of PD can be challenging as its clinical presentation resembles that of several serious acute conditions. Therefore the diagnosis is often based on the exclusion. History, physical examination and mental status examination are the pillars of PD diagnosis. An electrocardiography (ECG) should be obtained early during the workup to rule out myocardial ischemia and conduction abnormalities in all patients presenting with palpitations, chest pain, dyspnea, and sweating. Pulse oximetry will usually show either normal or slightly higher oxygen levels. Arterial blood gas analysis is performed to exclude metabolic acidosis and hypoxemia. In patients with a history of a syncopal event, ambulatory Holter monitoring should be considered. A D-dimer test, spiral computed tomography (CT scan), lower limb Doppler or ventilation-perfusion (V/Q) scanning is indicated to exclude pulmonary embolism especially in those at risk. Electroencephalography may be required to differentiate PD from partial complex seizures.

Laboratory studies should be performed to exclude substance abuse and other medical conditions. These include complete blood count, hemoglobin, urine toxicology, serum electrolytes, serum glucose, cardiac enzymes and, thyroid-stimulating hormone.

Orexin or hypocretin has been shown to play a role in the pathogenesis of panic in rats [8] and elevated levels have been observed in the cerebrospinal fluid of individuals with panic attacks.

Functional magnetic resonance imaging is not routinely recommended in the workup of PD although increased flow in the right parahippocampal region with decreased serotonin type 1A receptor binding in the anterior and posterior cingulate and raphe of patients with panic disorder has been noticed on positron emission tomography (PET) scanning [9]. Patients with PD have also been observed to have smaller temporal lobe volume on magnetic resonance imaging [10].

Treatment for Panic Disorder often involves a combination of psychotherapy and medication. Cognitive-behavioral therapy (CBT) is a common therapeutic approach that helps patients understand and change their thought patterns and behaviors related to panic attacks. Medications such as selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines may be prescribed to help manage symptoms. A tailored treatment plan is essential, as individual responses to therapy and medication can vary.

With appropriate treatment, many individuals with Panic Disorder can manage their symptoms effectively and lead fulfilling lives. The prognosis varies depending on the severity of the disorder, the individual's response to treatment, and the presence of any co-occurring mental health conditions. Early intervention and adherence to treatment plans are crucial for improving outcomes.

The exact cause of Panic Disorder is not fully understood, but it is believed to result from a combination of genetic, biological, environmental, and psychological factors. A family history of anxiety disorders, significant life stressors, and certain personality traits may increase the risk of developing Panic Disorder. Neurochemical imbalances in the brain may also play a role.

Panic Disorder affects approximately 2-3% of the population and is more common in women than men. It typically begins in late adolescence or early adulthood, although it can occur at any age. The disorder can be chronic, with periods of remission and relapse, and is often associated with other mental health conditions such as depression and other anxiety disorders.

The pathophysiology of Panic Disorder involves complex interactions between genetic, neurobiological, and environmental factors. Dysregulation of neurotransmitters such as serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) is thought to contribute to the disorder. Abnormalities in brain regions involved in fear processing, such as the amygdala and prefrontal cortex, may also play a role.

While there is no sure way to prevent Panic Disorder, certain strategies may help reduce the risk or severity of symptoms. These include managing stress through relaxation techniques, maintaining a healthy lifestyle with regular exercise and a balanced diet, avoiding excessive caffeine and alcohol, and seeking early treatment for anxiety symptoms. Building a strong support network can also be beneficial.

Panic Disorder is a common anxiety disorder characterized by recurrent panic attacks and a persistent fear of future attacks. It can significantly impact an individual's quality of life but is manageable with appropriate treatment. Understanding the disorder's symptoms, causes, and treatment options is crucial for effective management and improved outcomes.

If you or someone you know is experiencing symptoms of Panic Disorder, it is important to seek help from a healthcare professional. Panic Disorder is a treatable condition, and with the right support and treatment, individuals can learn to manage their symptoms and lead fulfilling lives. Remember, you are not alone, and help is available.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
2. Tully PJ. A good time to panic? Premorbid and postmorbid panic disorder in heart failure affects cardiac and psychiatric cause admissions. Australas Psychiatry. 2015;23:124 –7.
3. Tully PJ, Cosh SM, Baumeister H. The anxious heart in whose mind? A systematic review and meta-regression of factors associated with anxiety disorder diagnosis, treatment and morbidity risk in coronary heart disease.J Psychosom Rese. 2014;77:439 –48.
4. Roy-Byrne PP, Craske MG, Stein MB. Panic disorder. Lancet. 2006;16:1023-32
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6. Ehlers A. Somatic symptoms and panic attacks: a retrospective study of learning experiences. Behav Res Ther. 1993;31:269-78.
7. Diler RS, Birmaher B, Brent DA, et al. Phenomenology of panic disorder in youth. Depress Anxiety. 2004;20:39-43.
8. Johnson PL, Truitt W, Fitz SD, et al. A key role for orexin in panic anxiety. Nat Med. Jan 2010; 16(1):111-5.
9. Neumeister A, Bain E, Nugent AC, et al. Reduced serotonin type 1A receptor binding in panic disorder. J Neurosci. Jan 21 2004; 24(3):589-91.
10. Vythilingam M, Anderson ER, Goddard A, et al. Temporal lobe volume in panic disorder--a quantitative magnetic resonance imaging study. Psychiatry Res. Aug 28 2000; 99(2):75-82