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According to the DSM-IV-TR, panic disorder is characterized by spontaneous panic attacks and may occur alone or be associated with agoraphobia. A major feature of panic disorder is a fear of having another attack rather than the specific fear of a situation. With agoraphobia, there is a situational component to the panic attack. There are two distinct types of panic attack: spontaneous (non-phobic) and cue-induced (phobic). From a clinical perspective, it is important to accurately identify the type of panic attack because they differ in their physiologic nature and symptom presentation. There is also a significant difference in the treatment approach for each type.

Spontaneous panic attacks stem from an abnormal oversensitivity to carbon dioxide (CO2), what is called the “suffocation alarm.” The major symptoms of spontaneous panic attack are respiratory?shortness of breath, chest discomfort, palpitations, and choking or suffocation sensations. Spontaneous panic attacks often occur during relaxation and non-dream sleep.

Treatment therefore does not include benzodiazepines. Instead, it focuses on education and may include medications that help decrease sensitivity to the “suffocation alarm,” such as tofranil, anafranil, or a selective serotonin reuptake inhibitor (SSRI). Relaxation exercises would not be indicated as a behavioral intervention because they tend to decrease respirations, resulting in an increase in CO2, which can lead to a panic attack. Treatment for spontaneous panic attacks should include education on the physiological mechanism involved.

For women who suffer from spontaneous panic attacks, it is important to inform them that they are more vulnerable when they are premenstrual and immediately after childbirth. Vulnerability during these times is related to the sudden drop in progesterone levels. Progesterone acts to decrease CO2 levels in the brain by increasing respiratory rate. Thus when progesterone decreases, CO2 in the brain rises, resulting in an increased vulnerability to panic.

A cue-induced (phobic) panic attack is fear-based triggering of an adrenaline stress response (fight or flight). The symptoms are rapid heart rate, light-headedness, sweating, and trembling. Because of the anticipatory nature of the anxiety, benzodiazepines would be appropriate, along with education, relaxation exercises, and cognitive behavioral therapy (CBT).

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