Attack vs disorder
- Panic attack = abrupt surge of intense fear peaking within minutes, ≥4 autonomic/cognitive symptoms (palpitations, dyspnoea, chest pain, dizziness, paraesthesia, derealisation, fear of dying/losing control). Non‑specific — occurs in many disorders and in health.
- Panic disorder = *recurrent unexpected* attacks + ≥1 month** of anticipatory worry or maladaptive behaviour change (often with secondary agoraphobia).
The differential you must clear first 🚩
Chest pain + dyspnoea + palpitations mandates consideration of ACS, arrhythmia, PE, asthma, hypoglycaemia, thyrotoxicosis, stimulant/caffeine, and sedative withdrawal. "It's just panic" is a diagnosis of exclusion, particularly at first presentation, older age, or atypical features. A psychiatric label must never short‑circuit a medical work‑up.
The mechanism that drives treatment — the panic cycle
Somatic sensation → catastrophic misinterpretation ("I'm having a heart attack") → ↑ arousal → ↑ sensation → ↑ fear. The therapeutic target is the misinterpretation: CBT with interoceptive exposure teaches that the sensations are benign; SSRIs are first‑line pharmacotherapy. Avoid standing benzodiazepines (they entrench avoidance and reduce exposure efficacy).
Pitfalls
- Reassuring "just panic" without excluding cardiac/PE causes.
- Benzodiazepine dependence and reinforced avoidance.
Pearls
- 🎯 Panic attack = phenomenon; panic disorder = recurrent unexpected attacks + a month of worry/avoidance.
- 🩺 The disorder is maintained by catastrophic misinterpretation — treat that, not just the arousal.
Next → The obsessive‑compulsive spectrum and its cardinal discriminators (Concept 22).