A panic attack is a "discreet episode of intense fear reaching its peak in intensity within 10 minutes from onset. It is often associated with or accompanied by a fear the something awful is about to happen. Physical symptoms can also occur, including racing heart, palpitations, and shortness of breath, trembling, hot and cold flashes and stomach upset.

Panic attacks do not always signal a mental illness; they can be quite common in the general population. They are only considered part of a psychiatric illness if they cause significant distress or impairment.

What is Panic Disorder?

Panic Disorder is characterized by repeated panic attacks and worry or fear of having panic attacks. Not uncommonly, people begin to avoid situations that they associate with having had a panic attack. This can lead to agoraphobia (avoidance of places from which escape might be difficult if a panic attack occurs).

Between panic attacks, women may have varying degrees of nervousness and apprehension which is characterized by tense, agitated, vigilant and scanning behaviour.

For women previously diagnosed, the course of Panic Disorder during pregnancy varies. Some women experience a reduction in symptoms. If they were treated with medications, they may be able to tolerate medication reduction or discontinuation. Others may have an increase in symptoms and require an increase in anti-panic medication. There is some evidence that biological changes in pregnancy may increase symptoms in some women.

In late pregnancy and in the postpartum period, hormonal changes may trigger changes in some neurotransmitters in the brain which may lead to the onset of a panic attack.

What is the incidence of women who experience Panic Disorder during pregnancy of the postpartum period?

• 2 - 4% of pregnant women experience generalized anxiety or have panic disorder. About 40% of these women had symptoms before pregnancy.
• 4 – 6% of women experience panic disorder beginning in the postpartum period.

What are the risks for Panic Disorder?

Women are at greater risk of experiencing Panic Disorder in pregnancy or after birth if they have a previous history of Panic Disorder.

prior to pregnancy;	increased risk of developing symptoms during pregnancy,
during pregnancy	increased risk of developing symptoms postpartum
during previous pregnancies	may/or may not be at increased risk of developing symptoms during subsequent pregnancies (depending on prior treatment, other stressors and medical illness).

What are the signs and symptoms of a panic attack?

You may experience any four of the following 14 symptoms during a panic attack:

shortness of breath	choking or smothering sensation
palpitations or accelerated heart rate	tingling sensation (parasthesia)
chest pain or discomfort	sweating
hot flashes or chills	faintness
trembling or shaking	dizziness, light headedness or unsteady feelings
nausea or abdominal distress	depersonalization (feeling disoriented or that the world has become unreal)
fear of going crazy or doing something uncontrolled	fear of dying

Why should women with Panic Disorder seek treatment in pregnancy or postpartum?

• Untreated Panic Disorder in pregnancy may predispose women to greater illness and increased symptoms in the postpartum period.
• Treatment of Panic Disorder in pregnancy will increase coping skills of women in the postpartum period.
• Use of anti-panic medication in the postpartum period has been shown to decrease symptoms.
• Untreated Panic Disorder (and other anxiety disorders) may affect the mother-child relationship and the woman’s ability to cope in the postpartum period.

What are the treatment options for women with Panic Disorder?

Like most mental health challenges and disorders, patients with Panic Disorder benefit from a combination of treatments, including psycho education about the illness and support for the woman from family, friends, and/or community. The most common treatment options include:

Non-pharmacological Treatments

Cognitive Behaviour Therapy (CBT):

Cognitive Behaviour Therapy is one of the most effective treatments for Panic Disorder.  It is based on understanding the connection between the way we think and behave affecting the way we feel. In CBT, the therapist helps the patient identify distorted thoughts and replace them with more realistic thoughts. CBT for panic disorder also involves helping patients become more comfortable with physical feelings in their bodies that might trigger panic attacks.

CBT can be provided individually or in a group format. Patients with moderate to severe Panic disorder whose panic attacks are causing them great distress and interfering with their functioning may require treatment with medications in addition to CBT.

Medications (Pharmacotherapy)

The use of medication in pregnancy or after birth needs to be evaluated for individual women and depends on the severity of illness, level of distress and impairment and individual history. The goal is always to expose the pregnancy to the fewest number of medications at the lowest effective doses. It is best to ask your health care provider about your specific medications and treatment plan.

The most commonly used medications for panic disorder are the benzodiazepines (lorazepam, clonazepam) and the antidepressants, including the SSRIs (Selective Serotonin Reuptake Inhibitors) and the SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors) that also have a positive effect on anxiety.

Benzodiazepines: 

Benzodiazepines produce their effect within the central nervous system by interacting with neurotransmitters and brain receptors to cause a calming effect. Benzodiazepines are highly effective for treating acute panic attacks. The are usually prescribed on a p.r.n. or 'as necessary' basis during pregnancy and in breastfeeding mothers. Ideally, they should be used only for short periods of time and are not recommended for long term use. For the greatest benefit, benzodiazepines should be used in conjunction with CBT, supportive theraphy and possibly SSRIs.

SSRIs and SNRIs:

SSRIs and SNRIs act by reducing the overall level of anxiety though altering the levels of the chemical messengers or neurotransmitters, serotonin and norepinephrine, in the brain. If the woman's level of anxiety is not responding fully to intermittent or regular use of a benzodiazepine, she may need treatment with an antidepressant. Generally SSRIs and SNRIs are used for continued treatment of Panic Disorder.

Anti-anxiety medication during pregnancy

The goal of treatment is to always minimize risk of fetal exposure to medications while limiting the risks of untreated anxiety or Panic Disorder in pregnancy.

Depending on the woman’s history, a benzodiazepine may be chosen if symptoms occur from time to time an antidepressant may be necessary for a woman who is constantly anxious or experiencing recurrent, frequent panic attacks. 

Benzodiazepines do cross the placenta and can affect the fetus. Any fetus exposed to benzodiazepines during pregnancy or delivery should be monitored for side effects of the drug. 

Babies exposed to SSRIs and SNRIs during pregnancy should be monitored at birth for mild symptom of exposure to the drugs. These symptoms usually resolve without any special treatment.

Anti-anxiety medication postpartum

Women who are breastfeeding, are often concerned about medication transmission to their baby through the breast milk.

While benzodiazepines are generally considered compatible with breastfeeding, they should be used cautiously. Benzodiazepiens do cross into the breast-milk in small quantities.

Treatment with SSRIs and SNRIs is considered safe in breastfeeding mothers. However, the concentration of antidepressants in the breast milk may vary and infants should be monitored closely.

More information about anxiety, panic attacks and treatment options may be found in the Guide Coping with Anxiety During Pregnancy and Following the Birth, available to download from the Resources Section.