The life time prevalence of panic disorder is between 1 to 4 % with a 6 month prevalence of 0.5 to 1 % and 3-5.6% for panic attacks. There is a high rate of panic attacks in medical settings like in cardiac clinic (16-65%). It is 2-3 times more common in females than males and has a bimodal peak age of onset (15-24 years and 45-54 years). It has a heritability risk of close to 43% in first degree relatives. Panic disorder is often associated with other comorbid psychiatric conditions, with a major depression accounting for up to 50-60%. Physical comorbidities include coronary artery disease, Asthma, migraine headache, irritable bowel syndrome etc. Factors such as divorce, separation, early parental loss, trauma (physical or sexual abuse) have been identified as environmental risk factors for panic disorder.

Common symptoms of panic disorder: palpitations, sweating, trembling, sensations of shortness of breath, feelings of choking, chest discomfort, abdominal distress, feeling dizzy/light-headed, heat sensations, paraesthesia, derealization/depersonalization, fear of losing control/going crazy and fear of dying. Smith et.al. reported that African -Americans had more symptoms of numbing/tingling of extremities and fear of dying or going crazy compared to the European-American population.

The clinical features of panic disorder are that the symptoms build up quickly, are severe and the individual fears a catastrophic outcome.

Panic disorder is a clinical diagnosis. According to the DSM-5 (Diagnostic and Statistical Manual -5th edition), a minimum of 4 of the earlier symptoms mentioned above are needed to make a diagnosis. There is also a persistent and anticipatory worry about having another panic attack or its consequences such as heart attack. This may be present with significant maladaptive change in behaviour related to the attack for more than 1 month. The panic attacks must not be due to substance use, medical conditions or another psychiatric disorder.

There are lots of medical conditions which can mimic panic disorder due to the fact that diseases of the lungs and heart in particular can present with any of the symptoms. Cardiovascular conditions such as Congestiuve cardiac failure, Angina and Myocardial infarction; pulmonary conditions such as Asthma and hyperventilation syndrome; Neurological conditions such as migraine and multiple sclerosis; Endocrinological conditions such as Addison’s disease, Cushing’s disease, hyper thyroidism and hypoparathyroidism; intoxication of amphetamine, cocaine and cannabis; withdrawal of alcohol, opioids and sedatives.

Panic attacks can occur in post-traumatic stress disorder and phobic anxiety disorders as well and will need to be carefully distinguished from panic disorder.

Investigations should be done to rule out all the organic causes of anxiety which have been listed as differentials of the conditions. Investigations such as chest X-ray, electrocardiogram, echocardiogram, EEG, Brain MRI/CT, PET scan, thyroid function test, serum heamoglobin, FBS, Cardiac enzymes, D-dimer assay, serum EUCR, and toxicology drug screen, could be done to rule out the differentials.

The goal of treatment includes lowering the frequency and intensity of panic attacks, reducing anticipatory fears and avoidance behaviours, managing comorbid psychiatric conditions, symptoms remission and ensuring return to premorbid level of functioning. The treatment involves both pharmacotherapy and psychotherapy.

The following classes of drugs are useful in pharmacotherapy: Selective serotonin re-uptake inhibitor (SSRI) , serotonin-norepinephrine re-uptake inhibitor (SNRI) tricyclic anti-depressants (TCA), Benzodiazepines and monoamine oxidase inhibitor. Common examples of SSRI’S are paroxetine, fluoxetine, citalopram and escitalopram while that of TCA’S are clomipramine and imipramine. Alprazolam is the benzodiazepine of choice as many controlled trials have demonstrated its efficacy while the SNRI of proven efficacy is Venlafaxine. The medications are given for a period of 8 to 12 months.

Psychotherapy involves psycho-education as well as cognitive behavioural therapy, and other therapies that may be of value based on the specific needs of the individual patient. Psychoeducation remains an important part of therapy by frequently reassuring the patients and educating them on the nature of the illness.

Follow up is necessary at intervals for the period of the use of medications and therapy options.

There are no particularly preventive measures

Panic disorder is characterized by recurrent panic attacks and symptoms are particularly disabling due to similarity with other organic conditions which are of more severe consequences such as cardiac arrest. Patients with these symptoms in our locality are not particularly pleased with seeing a psychiatrist, and have to be educated on being treated by a psychiatrist. However, after improvement they are grateful on making the decision. I recommend that more training of the medical officers on these symptoms will make these patients to be referred on time and get quick relief from the disabling symptoms.