Panic Disorder
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Direct answer
A panic attack is an abrupt surge of intense fear or discomfort that peaks within minutes, with at least four of thirteen characteristic physical and cognitive symptoms. Panic disorder requires recurrent, unexpected attacks plus at least one month of persistent worry about further attacks or their consequences, or maladaptive behaviour such as avoidance. First-line treatment is an SSRI started at a low dose together with cognitive behavioural therapy.
What you must remember
- The thirteen symptoms: palpitations, sweating, trembling, breathlessness, choking sensation, chest pain, nausea, dizziness or unsteadiness, chills or heat sensations, paraesthesias, derealisation or depersonalisation, fear of losing control, and fear of dying — four or more define the attack.
- Timeline: abrupt onset, peaking within minutes and usually settling within half an hour; the diagnosis is clinical, based on recurrence and anticipatory anxiety, not on a single attack.
- One-month rule: worry about attacks, their consequences, or avoidance behaviour for at least one month is required beyond the attacks themselves.
- Agoraphobia: fear and avoidance of situations from which escape might be difficult — commonly travels with panic disorder as its consequence.
- Rule-outs before diagnosing: arrhythmia, hyperthyroidism, phaeochromocytoma, hypoglycaemia, asthma, caffeine and stimulant intoxication; a first presentation with chest pain warrants ECG and appropriate cardiac evaluation.
- Treatment: SSRIs first-line (start low — initial activation can worsen symptoms), CBT including interoceptive exposure, imipramine as a classical alternative, and benzodiazepines only briefly because of dependence.
- Course: chronic but treatable; many patients present first to cardiology or emergency departments before reaching psychiatry.
Common confusion
A panic attack is a symptom that can occur in any disorder — in social anxiety before a performance, in PTSD on cue, in depression — whereas panic disorder needs recurrent unexpected attacks plus a month of anticipatory fear or avoidance. Panic disorder also differs from GAD in shape: discrete crescendo attacks versus persistent diffuse worry. The organic side matters: episodic palpitations with sweating and hypertension should suggest phaeochromocytoma, weight loss with tremor suggests hyperthyroidism, and episodic loss of awareness suggests seizure disorders rather than panic.
Exam-focused takeaway
NEET-PG tests the four-of-thirteen rule, the peaking-within-minutes timeline and the one-month consequence requirement as diagnostic discriminators. Stems typically describe a young patient with repeated emergency visits, normal ECG and troponin, and fear of dying during attacks — the answer is panic disorder, treated with an SSRI plus CBT. Drug questions favour low-dose SSRI initiation to avoid jitteriness, and a stem asking which therapy targets the fear of bodily sensations points to interoceptive exposure. Always keep the organic rule-outs ready as options, especially hyperthyroidism and arrhythmia in first-episode presentations.
Frequently asked questions
How many symptoms define a panic attack?
At least four of the thirteen characteristic symptoms peaking within minutes.
When does a panic attack become panic disorder?
When attacks are recurrent and unexpected and are followed by at least one month of anticipatory worry or avoidance behaviour.
What is the first-line treatment of panic disorder?
A low-dose SSRI with cognitive behavioural therapy; imipramine is a classical alternative and benzodiazepines only short-term.
Which conditions must be excluded before diagnosing panic disorder?
Cardiac arrhythmia, hyperthyroidism, phaeochromocytoma, hypoglycaemia, asthma and stimulant or caffeine intoxication.
What is interoceptive exposure?
A CBT technique that deliberately induces feared bodily sensations — such as dizziness from spinning — to break the catastrophic misinterpretation of those sensations.
How is agoraphobia related to panic disorder?
Agoraphobic avoidance frequently develops as a consequence of panic attacks and may become the main source of disability.