Sumant, a 25-year-old male had sudden chest pain, palpitations, excessive sweating and feeling of impending death. The attack lasted for about 10 to 15 minutes and then subsided even before treatment could be given and doctor could attend to him. At this time, the pulse rate was 104 per minute and blood pressure was normal. The Cardiogram (ECG) was normal except for fast heart rate. Other investigations done at a later stage (stress test, 2D-ECHO etc) were normal.

About 3 weeks later, the patient developed a similar episode while traveling by train. He was taken to a nearby hospital where medical examination and all the investigations were normal. Within a month, the patient had a third such episode.

This is a typical case of Panic disorder.

Panic disorder is characterized by spontaneous, unexpected, recurrent occurrences of panic attacks. Panic attacks are relatively short lived (usually less than 30 minutes) periods of intense anxiety or fear, which are accompanied by such symptoms as palpitations, chest pain, sweating and shortness of breath. The symptoms may be misdiagnosed as a serious medical condition (e.g. heart attack).

The essential feature of panic attack is a discrete period of intense fear or discomfort that is accompanied by at least 4 of the following body or cognitive symptoms.

1. Palpitations
2. Chest pain or Discomfort
3. Fear of dying
4. Sweating
5. Shortness of breath
6. Trembling
7. Nausea
8. Tingling in extremities
9. Feeling of choking
10. Hot flushes

Individual seeking treatment will usually describe the fear as intense and report that they were about to die, lose control, have a heart attack. They also usually report an urgent desire to flee from wherever the attack is occurring. With recurrent attacks, some of the intense fearfulness may wane.

There are three characteristic types of panic attacks with different relationships between the onset of the attack and the presence or absence of situational triggers.

1. Unexpected (uncued) panic attacks: in which the onset of the panic attack is not associated with situational trigger (ie occurring spontaneously).



2. Situationally bound (cued) panic attack: in which the panic attack almost invariably occurs immediately on exposure to, or in anticipation of, the situational cue or trigger an immediate panic attack in a particular person.



3. Situationally predisposed panic attack: which are more likely to occur on exposure to the situational cue or trigger but are not invariably associated with the cue and do not necessarily occur immediately after the exposure (eg attacks are more likely to occur while travelling in train or in crowded place, but there are times when the individual travels or is in crowd and does not have panic attack or panic occurs after some time.
   
   Medical examination at time of panic attack may sometimes reveal rapid fast pulse (tachycardia) and mild elevation of systolic blood pressure. In between panic attacks the medical examination is normal. The investigations like blood, urine, X Rays, ECG, 2D Echo, stress tests all are normal.