panic attack panic attack panic attacks are sudden periods of intense fear and discomfort that may include palpitations, sweating, chest pain or chest discomfort, shortness of breath, trembling, dizziness, numbness, confusion, or a feeling of impending doom or of losing control. typically, symptoms reach a peak within ten minutes of onset, and last for roughly 30 minutes, but the duration can vary from seconds to hours. although they can be extremely frightening and distressing, panic attacks themselves are not physically dangerous. panic attackan artistic rendition of someone experiencing a panic attack, being reassured by another person.specialtypsychiatrysymptomsperiods of intense fear, palpitations, sweating, shaking, shortness of breath, numbnesscomplicationsself-harm, suicideusual onsetover minutesdurationseconds to hourscausespanic disorder, social anxiety disorder, post-traumatic stress disorder, drug use, depression, medical problemsrisk factorssmoking, psychological stressdiagnostic methodafter other possible causes excludeddifferential diagnosishyperthyroidism, hyperparathyroidism, heart disease, lung disease, drug use, dysautonomiatreatmentcounselling, medicationsmedicationantidepressantprognosisusually goodfrequency3% (eu), 11% (us) the essential features of panic attacks remain unchanged, although the complicated dsm-iv terminology for describing different types of panic attacks (i.e., situationally bound/cued, situationally predisposed, and unexpected/uncued) is replaced with the terms unexpected and expected panic attacks. panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders, including but not limited to anxiety disorders. hence, panic attacks can be listed as a specifier that is applicable to all dsm-5 disorders. panic attacks can occur due to several disorders including panic disorder, social anxiety disorder, post-traumatic stress disorder, substance use disorder, depression, and medical problems. they can either be triggered or occur unexpectedly. smoking, caffeine, and psychological stress increase the risk of having a panic attack. before diagnosis, conditions that produce similar symptoms should be ruled out, such as hyperthyroidism, hyperparathyroidism, heart disease, lung disease, drug use, and dysautonomia. treatment of panic attacks should be directed at the underlying cause. in those with frequent attacks, counseling or medications may be used. breathing training and muscle relaxation techniques may also help. those affected are at a higher risk of suicide. in europe, about 3% of the population has a panic attack in a given year while in the united states they affect about 11%. they are more common in females than in males. they often begin during puberty or early adulthood. children and older people are less commonly affected. signs and symptoms people with panic attacks often report a fear of dying or heart attack, flashing vision or other visual disturbances, faintness or nausea, numbness throughout the body, shortness of breath and hyperventilation, or loss of body control. some people also experience tunnel vision, mostly due to blood flow leaving the head to more critical parts of the body in defense. these feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the "fight-or-flight response", in which the hormone causing this response is released in significant amounts). this response floods the body with hormones, particularly epinephrine (adrenaline), which aid it in defending against harm. a panic attack can result when up-regulation by the sympathetic nervous system (sns) is not moderated by the parasympathetic nervous system (pns). the most common symptoms include trembling, dyspnea (shortness of breath), heart palpitations, chest pain (or chest tightness), hot flashes, cold flashes, burning sensations (particularly in the facial or neck area), sweating, nausea, dizziness (or slight vertigo), light-headedness, heavy-headedness, hyperventilation, paresthesias (tingling sensations), sensations of choking or smothering, difficulty moving, depersonalization and/or derealization. these physical symptoms are interpreted with alarm in people prone to panic attacks. this results in increased anxiety and forms a positive feedback loop. shortness of breath and chest pain are the predominant symptoms. many people experiencing a panic attack incorrectly attribute them to a heart attack and thus seek treatment in an emergency room. because chest pain and shortness of breath are hallmark symptoms of cardiovascular illnesses, including unstable angina and myocardial infarction (heart attack), a diagnosis of exclusion (ruling out other conditions) must be performed before diagnosing a panic attack. it is especially important to do this for people whose mental health and heart health statuses are unknown. this can be done using an electrocardiogram and mental health assessments. panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature. they are often experienced in conjunction with anxiety disorders and other psychological conditions, although panic attacks are not generally indicative of a mental disorder. causes there are long-term, biological, environmental, and social causes of panic attacks. in 1993, fava et al. proposed a staging method of understanding the origins of disorders. the first stage in developing a disorder involves predisposing factors, such as genetics, personality, and a lack of well-being. panic disorder often occurs in early adulthood, although it may appear at any age. it occurs more frequently in women and more often in people with above-average intelligence. various twin studies where one identical twin has an anxiety disorder have reported a high incidence of the other twin also having an anxiety disorder diagnosis. biological causes may include obsessive-compulsive disorder, postural orthostatic tachycardia syndrome, post-traumatic stress disorder, hypoglycemia, hyperthyroidism, wilson's disease, mitral valve prolapse, pheochromocytoma, and inner ear disturbances (labyrinthitis). dysregulation of the norepinephrine system in the locus coeruleus, an area of the brain stem, has been linked to panic attacks. panic attacks may also occur due to short-term stressors. significant personal loss, including an emotional attachment to a romantic partner, life transitions, and significant life changes may all trigger a panic attack to occur. a person with an anxious temperament, excessive need for reassurance, hypochondriacal fears, overcautious view of the world, and cumulative stress have been correlated with panic attacks. in adolescents, social transitions may also be a cause. people will often experience panic attacks as a direct result of exposure to an object/situation that they have a phobia for. panic attacks may also become situationally-bound when certain situations are associated with panic due to previously experiencing an attack in that particular situation. people may also have a cognitive or behavioral predisposition to having panic attacks in certain situations. some maintaining causes include avoidance of panic-provoking situations or environments, anxious/negative self-talk ("what-if" thinking), mistaken beliefs ("these symptoms are harmful and/or dangerous"), and withheld feelings. hyperventilation syndrome may occur when a person breathes from the chest, which can lead to over-breathing (exhaling excessive carbon dioxide related to the amount of oxygen in one's bloodstream). hyperventilation syndrome can cause respiratory alkalosis and hypocapnia. this syndrome often involves prominent mouth breathing as well. this causes a cluster of symptoms, including rapid heartbeat, dizziness, and lightheadedness, which can trigger panic attacks. panic attacks may also be caused by substances. discontinuation or marked reduction in the dose of a substance such as a drug (drug withdrawal), for example, an antidepressant (antidepressant discontinuation syndrome), can cause a panic attack. according to the harvard mental health letter, "the most commonly reported side effects of smoking marijuana are anxiety and panic attacks. studies report that about 20% to 30% of recreational users experience such problems after smoking marijuana." cigarette smoking is another substance that has been linked to panic attacks. a common denominator of current psychiatric approaches to panic disorder is that no real danger exists, and the person's anxiety is inappropriate. panic disorder main article: panic disorder people who have repeated, persistent attacks or feel severe anxiety about having another attack are said to have panic disorder. panic disorder is strikingly different from other types of anxiety disorders in that panic attacks are often sudden and unprovoked. however, panic attacks experienced by those with panic disorder may also be linked to or heightened by certain places or situations, making daily life difficult. agoraphobia main articles: agoraphobia and hikikomori agoraphobia is an anxiety disorder that primarily consists of the fear of experiencing a difficult or embarrassing situation from which the affected cannot escape. panic attacks are commonly linked to agoraphobia. people with severe agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place". the word "agoraphobia" comes from the greek words agora (αγορά) and phobos (φόβος), the term "agora" referring to the city centre in an ancient greek city. in japan, people who exhibit extreme agoraphobia to the point of becoming unwilling or unable to leave their homes are referred to as hikikomori. the phenomena in general is known by the same name, and it is estimated that roughly half a million japanese youths are hikikomori. people who have had a panic attack in certain situations may develop phobias of these situations and begin to avoid them. eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with panic disorder are unable to drive or even step out of the house. at this stage, the person is said to have panic disorder with agoraphobia. experimentally induced panic attack symptoms can be experimentally induced in the laboratory by various means. among them, for research purposes, by administering a bolus injection of the neuropeptide cholecystokinin-tetrapeptide (cck-4). various animal models of panic attacks have been experimentally studied. neurotransmitter imbalances many neurotransmitters are affected when the body is under the increased stress and anxiety that accompany a panic attack. some include serotonin, gaba (gamma-aminobutyric acid), dopamine, norepinephrine, and glutamate. more research into how these neurotransmitters interact with one another during a panic attack is needed to make any solid conclusions, however. an increase of serotonin in certain pathways of the brain seems to be correlated with reduced anxiety. more evidence that suggests serotonin plays a role in anxiety is that people who take ssris tend to feel a reduction of anxiety when their brain has more serotonin available to use. the main inhibitory neurotransmitter in the central nervous system (cns) is gaba. most of the pathways that use gaba tend to reduce anxiety immediately. dopamine's role in anxiety is not well understood. some antipsychotic medications that affect dopamine production have been proven to treat anxiety. however, this may be attributed to dopamine's tendency to increase feelings of self-efficacy and confidence, which indirectly reduces anxiety. many physical symptoms of anxiety, such as rapid heart rate and hand tremors, are regulated by norepinephrine. drugs that counteract norepinephrine's effect may be effective in reducing the physical symptoms of a panic attack. nevertheless, some drugs that increase 'background' norepinephrine levels such as tricyclics and snris are effective for the long-term treatment of panic attacks, possibly by blunting the norepinephrine spikes associated with panic attacks. because glutamate is the primary excitatory neurotransmitter involved in the central nervous system (cns), it can be found in almost every neural pathway in the body. glutamate is likely involved in conditioning, which is the process by which certain fears are formed, and extinction, which is the elimination of those fears. pathophysiology the symptoms of a panic attack may cause the person to feel that their body is failing. the symptoms can be understood as follows. first, there is frequently the sudden onset of fear with little provoking stimulus. this leads to a release of adrenaline (epinephrine) which brings about the fight-or-flight response when the body prepares for strenuous physical activity. this leads to an increased heart rate (tachycardia), rapid breathing (hyperventilation) which may be perceived as shortness of breath (dyspnea), and sweating. because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon dioxide levels in the lungs and then in the blood. this leads to shifts in blood ph (respiratory alkalosis or hypocapnia), causing compensatory metabolic acidosis activating chemosensing mechanisms that translate this ph shift into autonomic and respiratory responses. moreover, this hypocapnia and release of adrenaline during a panic attack cause vasoconstriction resulting in slightly less blood flow to the head which causes dizziness and lightheadedness. a panic attack can cause blood sugar to be drawn away from the brain and toward the major muscles. neuroimaging suggests heightened activity in the amygdala, thalamus, hypothalamus, and brainstem regions including the periaqueductal gray, parabrachial nucleus, and locus coeruleus. in particular, the amygdala has been suggested to have a critical role. the combination of increased activity in the amygdala (fear center) and brainstem along with decreased blood flow and blood sugar in the brain can lead to decreased activity in the prefrontal cortex (pfc) region of the brain. there is evidence that having an anxiety disorder