increases the risk of cardiovascular disease (cvd). those affected also have a reduction in heart rate variability. cardiovascular disease people who have been diagnosed with panic disorder have approximately double the risk of coronary heart disease. certain stress responses to depression also have been shown to increase the risk and those diagnosed with both depression and panic disorder are nearly three times more at risk. diagnosis according to the dsm-5 a panic attack is part of the diagnostic class of anxiety disorders. it is not considered a specific disorder on its own, with the symptoms of a panic attack regarded as characteristics of another disorder during which the panic attack occurs. dsm-5 criteria for a panic attack is defined as "an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of the following symptoms occur": palpitations, and/or accelerated heart rate sweating trembling or shaking sensations of shortness of breath or being smothered feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, lightheaded, or faint derealization (feelings of unreality) or depersonalization (being detached from oneself) fear of losing control or going insane sense of impending doom paresthesias (numbness or tingling sensations) chills or heat sensations in dsm-5, culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen. such symptoms should not count as one of the four required symptoms. some or all of these symptoms can be found in the presence of a pheochromocytoma. screening tools such as the panic disorder severity scale can be used to detect possible cases of disorder and suggest the need for a formal diagnostic assessment. treatment panic disorder is usually effectively treated with a variety of interventions, including psychological therapies and medication. cognitive-behavioral therapy has the most complete and longest duration of effect, followed by specific selective serotonin reuptake inhibitors. a 2009 review found positive results from therapy and medication and a much better result when the two were combined. lifestyle changes caffeine may cause or exacerbate panic anxiety. anxiety can temporarily increase during withdrawal from caffeine and various other drugs. increased and regimented aerobic exercise such as running has been shown to have a positive effect on combating panic anxiety. there is evidence that suggests that this effect is correlated to the release of exercise-induced endorphins and the subsequent reduction of the stress hormone cortisol. there remains a chance of panic symptoms becoming triggered or being made worse due to increased respiration rate that occurs during aerobic exercise. this increased respiration rate can lead to hyperventilation and hyperventilation syndrome, which mimics symptoms of a heart attack, thus inducing a panic attack. the benefits of incorporating an exercise regimen have shown the best results when paced accordingly. meditation may also be helpful in the treatment of panic disorders. muscle relaxation techniques are useful to some individuals. these can be learned using recordings, videos, or books. while muscle relaxation has proved to be less effective than cognitive-behavioral therapies in controlled trials, many people still find at least temporary relief from muscle relaxation. breathing exercises in the great majority of cases, hyperventilation is involved, exacerbating the effects of the panic attack. breathing retraining exercise helps to rebalance the oxygen and co2 levels in the blood. david d. burns recommends breathing exercises for those with anxiety. one such breathing exercise is a 5-2-5 count. using the stomach (or diaphragm)—and not the chest—inhale (feel the stomach come out, as opposed to the chest expanding) for 5 seconds. as the maximal point at inhalation is reached, hold the breath for 2 seconds. then slowly exhale, over 5 seconds. repeat this cycle twice and then breathe 'normally' for 5 cycles (1 cycle = 1 inhale + 1 exhale). the point is to focus on breathing and relax the heart rate. regular diaphragmatic breathing may be achieved by extending the out-breath by counting or humming. although breathing into a paper bag was a common recommendation for short-term treatment of symptoms of an acute panic attack, it has been criticized as inferior to measured breathing, potentially worsening the panic attack and possibly reducing needed blood oxygen. while the paper bag technique increases needed carbon dioxide and so reduces symptoms, it may excessively lower oxygen levels in the bloodstream. capnometry, which provides exhaled co2 levels, may help guide breathing. therapy according to the american psychological association, "most specialists agree that a combination of cognitive and behavioral therapies are the best treatment for panic disorder. medication might also be appropriate in some cases." the first part of therapy is largely informational; many people are greatly helped by simply understanding exactly what panic disorder is and how many others experience it. many people with panic disorder are worried that their panic attacks mean they are "going crazy" or that the panic might induce a heart attack. cognitive restructuring helps people to replace those thoughts with more realistic, positive ways of viewing the attacks. avoidant behavior is one of the key aspects that prevent people with frequent panic attacks from functioning healthily. exposure therapy, which includes repeated and prolonged confrontation with feared situations and body sensations, helps weaken anxiety responses to panic-inducing external and internal stimuli and reinforce realistic ways of viewing panic symptoms. in deeper-level psychoanalytic approaches, in particular object relations theory, panic attacks are frequently associated with splitting (psychology), paranoid-schizoid and depressive positions, and paranoid anxiety. they are often found to be comorbid with borderline personality disorder and child sexual abuse. paranoid anxiety may reach the level of a persecutory anxiety state. there was a meta-analysis of the comorbidity of panic disorders and agoraphobia. it used exposure therapy to treat patients over a period. hundreds of patients were used in these studies and they all met the dsm-iv criteria for both of these disorders. a result was that thirty-two percent of patients had a panic episode after treatment. they concluded that the use of exposure therapy has lasting efficacy for a client who is living with a panic disorder and agoraphobia. the efficacy of group therapy treatment over conventional individual therapy for people with panic disorder with or without agoraphobia appears similar. medication medication options for panic attacks typically include benzodiazepines and antidepressants. benzodiazepines are being prescribed less often because of their potential side effects, such as dependence, fatigue, slurred speech, and memory loss. antidepressant treatments for panic attacks include selective serotonin reuptake inhibitors (ssris), serotonin noradrenaline reuptake inhibitors (snris), tricyclic antidepressants (tcas), and mao inhibitors (maois). ssris in particular tend to be the first drug treatment used to treat panic attacks. selective serotonin reuptake inhibitors (ssris) and tricyclic antidepressants appear similar for short-term efficacy. ssris carry a relatively low risk since they are not associated with much tolerance or dependence, and are difficult to overdose with. tcas are similar to ssris in their many advantages but come with more common side effects such as weight gain and cognitive disturbances. they are also easier to overdose on. maois are generally suggested for patients who have not responded to other forms of treatment. while the use of drugs in treating panic attacks can be very successful, it is generally recommended that people also be in some form of therapy, such as cognitive-behavioral therapy. drug treatments are usually used throughout the duration of panic attack symptoms and discontinued after the patient has been free of symptoms for at least six months. it is usually safest to withdraw from these drugs gradually while undergoing therapy. while drug treatment seems promising for children and adolescents, they are at an increased risk of suicide while taking these medications and their well-being should be monitored closely. prognosis roughly one-third are treatment-resistant. these people continue to have panic attacks and various other panic disorder symptoms after receiving treatment. many people being treated for panic attacks begin to experience limited symptom attacks. these panic attacks are less comprehensive, with fewer than four bodily symptoms being experienced. it is not unusual to experience only one or two symptoms at a time, such as vibrations in their legs, shortness of breath, or an intense wave of heat traveling up their bodies, which is not similar to hot flashes due to estrogen shortage. some symptoms, such as vibrations in the legs, are sufficiently different from any normal sensation that they indicate a panic disorder. other symptoms on the list can occur in people who may or may not have panic disorder. panic disorder does not require four or more symptoms to all be present at the same time. causeless panic and racing heartbeat are sufficient to indicate a panic attack. epidemiology 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. a meta-analysis was conducted on data collected about twin studies and family studies on the link between genes and panic disorder. the researchers also examined the possibility of a link to phobias, obsessive-compulsive disorder (ocd), and generalized anxiety disorder. the researchers used a database called medline to accumulate their data. the results concluded that the aforementioned disorders have a genetic component and are inherited or passed down through genes. for the non-phobias, the likelihood of inheriting is 30–40%, and for the phobias, it was 50–60%.