Beyond the Respiratory Dichotomy: A Psychosomatic and Psychotherapeutic Reappraisal of Panic Attacks

Background. Panic disorder (PD) has historically been subdivided into respiratory (RS) and non-respiratory (NRS) subtypes, based on Klein’s suffocation alarm hypothesis. Methods. A systematic search of MEDLINE was performed to identify empirical studies examining the RS/NRS distinction, autonomic physiology, and therapeutic implications.Results. Although this dichotomy has facilitated research, it is limited by tautological definitions, temporal instability, and limited clinical validity. For example, RS is defined by respiratory symptoms, and their observation in patients, yet it is subsequently “validated” by CO₂ hypersensitivity, creating circularity, or encouraging confirmation bias. In contrast, NRS is defined for most non-respiratory symptoms by default, therefore constituting a rather heterogeneous, residual category that lacks a unifying explanation of NRS function, and moreover neglects key clinical features such as dissociation, vestibular instability, and gastrointestinal distress. These shortcomings restrict its ability to inform treatment planning and prognostic assessment. In response, a polyvagal framework is proposed, conceptualizing panic attacks as transitions between autonomic states rather than as fixed subtypes. In this framework, RS-like profiles correspond to sympathetic hyperarousal with insufficient ventral vagal modulation, characterized by dyspnea, chest tightness, and catastrophic suffocation fears. NRS-like profiles correspond to dorsal vagal shutdown, characterized by dizziness, presyncope, nausea, and dissociative phenomena. Mixed or alternating features are commonly observed in clinical practice, highlighting the inability of the classical RS/NRS categorization to account for such phenomena, and hence a need to reconceptualize panic attack dynamics with a more comprehensive framework.Conclusions. Reconceptualizing panic disorder within polyvagal theory integrates neglected symptom domains, aligns semiology with identifiable physiological mechanisms, and provides a more coherent basis for clinical stratification.Clinical implications. This model suggests mechanism-based interventions: voluntary slow breathing, capnometry-assisted breathing, or yawning for sympathetic profiles; applied tension, progressive muscle contraction techniques, or vestibular rehabilitation for dorsal vagal shutdown; and co-yawning or ventral vagal stimulation as transdiagnostic adjuncts.Future directions. Validation through autonomic phenotyping, multimodal assessments, and randomized controlled trials is required to determine prognostic and therapeutic value of the proposed framework.