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Panic Disorder
A Highly Treatable Anxiety Disorder
A Case History
Ann was watching television after a typical workday. She suddenly developed a peculiar and very strong feeling of being lightheaded and a smothering sensation as if there were no oxygen in the air she was breathing. Then a surge of pounding rapid heartbeat began. It came on so quickly and was so severe that she became panicked that she might be dying of a heart attack! Then she felt very shaky, sweaty, and unsteady. This whole experience reached peak intensity within 60 seconds. This was the eighth such attack this month.
PANIC
"Panic" was hardly the word to describe how terrified she was feeling. It went beyond any feeling of fear that she had ever experienced. Although she had gone to the emergency room several times, nothing seemed to be found by the doctors to explain why she kept having the attacks.
She frantically searched for her car keys so that she could get to the hospital immediately. She thought desperately, "What's wrong with me?"
What it feels like
The main symptom of a Panic Disorder is the panic attack itself. Panic Disorder is a medical disorder characterized by severe and sudden episodes or "attacks" with several of the following symptoms:
- Panic, Fear of Losing Control or Dying
- Pounding Heartbeat
- Difficulty Breathing
- Smothering Sensation
- Chest Pain or Discomfort
- Tingling Numbness of The Skin
- Choking Sensation
- Lump In Throat
- Hot or Cold Feeling
- Sweatiness
- Shakiness
- Nausea
- Feelings of Unreality (Familiar Things Feel Odd)
It is important to mention that sudden episodes of the above symptoms caused by another reasonable cause are not panic attacks. Two such reasonable causes would be (1) a certain medical ailment that might mimic a panic attack, or (2) a life threatening experience immediately preceding the attack. If these reasonable causes are found not be the cause of the problem then there is the possibility of a Panic Disorder.
Panic attacks reach maximum intensity within a minute or two once they begin. They diminish slowly-over the next 30 minutes or the next several hours. It is common for the first attack to cause a person to go to an emergency medical facility. Subsequent attacks occur several times a month and are often as severe as the initial attack.
About three fourths of Panic Disorder patients are women. Panic Disorder begins most often when people are 20-30 years old. It begins less often in teenagers or persons in their forties. It is uncommon for the disorder to appear in the elderly for the first time.
It is important to note that although a few experts say it is more common in persons who experienced a separation experience as a child, many of experts feel that Panic Disorder afflicts emotionally healthy people. Persons with Panic Disorder are no more likely than the average American to have suffered from emotional problems at the time the disorder begins.
Afraid of Something
Persons experiencing repetitive, severe panic attacks may simply have panic attacks and that is all. Other persons may begin to experience a progression of bothersome or distressing panic attack "side effects". This progression commonly occurs as follows:
A few weeks or months prior to the first panic attack there are sometimes minor symptoms such as rapid heart beat.
The first major panic attack occurs. The person often seeks emergency medical evaluation at this time. The initial examination is commonly normal.
Continued panic attacks cause the person to seek further medical evaluations which may be inconclusive. Many panic attack sufferers go for months or years before receiving the proper diagnosis and by that time may have seen over a dozen physicians, psychologists and counselors. This appearance of "doctor shopping" may cause others to regard the sufferer as a hypochondriac.
An individual with Panic Disorder may begin to avoid a certain activity because it occurs to them that it would be especially embarrassing or dangerous to have an attack while engaged in that activity. A typical sufferer of Panic Disorder might think, "It's bad enough to have an attack at all, but it would be dangerous to have one on Interstate 75 because I would be preoccupied with the attack and would not be a safe driver. I might wreck my car, injuring myself or someone else!" This avoidance behavior may appear to be a fear of driving when it is really a fear of having a panic attack while driving.
Tendencies to avoid circumstances in everyday life may increase and extend to more activities. This extensive avoidance behavior is referred to as agoraphobia.
Places, activities or circumstances frequently avoided by persons with Panic Disorder include the following:
Shopping malls
Department stores
Restaurants
Church
Meetings
Classes
Driving
Being alone
Airplanes
ElevatorsAfter months or years of continuous panic attacks and the restricted lifestyle caused by the typical avoidance behavior, the sufferer of Panic Disorder may become demoralized and psychologically or physically depressed.
Some sufferers turn to alcohol in an attempt to self-medicate or to diminish the symptoms of the disorder. This greatly complicates the individual's life and ability to seek appropriate treatment.
Tragically, one out of every five untreated sufferers attempts to end his or her life, never realizing that there was hope and treatment available.
Is There Damage?
A person will not die from a panic attack. But, Panic Disorder does indeed cause damage. It is difficult to estimate the misery and loss of overall productivity that this disorder causes.
There is personal pain and humiliation and a restricted lifestyle. There are missed days of work due to panic attacks. There may be unemployment due to partial or complete disability. There is increased risk of alcoholism and suicide.
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CAUSES & TREATMENT
What causes Panic Disorder?
Twenty years ago, Panic Disorder was poorly understood even by most experts. It was called Anxiety Neurosis and was thought by some to stem from "deeply rooted" psychological conflicts and subconscious upsetting impulses of a sexual nature.
Now we regard Panic Disorder as more of a physical problem with a metabolic core. It is not an emotional problem, although after suffering from it, emotionally healthy persons may develop depression or other problems. There are different theories about where in the nervous system the problem exists.
There is considerable evidence pointing toward a DNA abnormality controlling the physiology of cholecystokinin, a neurotransmitter in the brainstem. (The brainstem is the part of the brain that controls heartbeat, breathing and other vital functions).
In 1999 Canadian medical scientist Jacques Branwejn announced that his colleagues and he discovered a genetic mutation that appears to put people at risk for panic attacks.
At a meeting of the Human Genome Organization in Edinburgh Scotland in 2002, Dr. Xavier Estevill, head of medical and molecular genetics at the Duran I Rynals Hospital in Barcelona Spain, discovered that a gene on some other chromosome, or some environmental factor early in development, may cause in some people an abnormality of chromosome 15. This defect may in turn make people more susceptible to panic attacks. It seems this genetic abnormality of chromosome 15 is not inherited because it is not present in all of the cells of those affected. Although this has been observed to occur in plants, this is the first discovery of such a chain of events in humans. Almost 100% of those with panic disorder or phobias had the duplication of genetic material on chromosome 15.
Few experts still cling to the notion that this is not a physical disorder. Scientific evidence clearly favors there being a physical cause of this disorder. It is regarded as a physical disorder much like Diabetes or Pneumonia.
There is hope and help
Is there hope for persons with Panic Disorder? Yes. Panic disorder is very treatable. And nearly everyone responds well to proper treatment. Treatment consists of several steps:
A
First a person must be educated about this disorder. Simply learning some of the things mentioned in this brochure will improve matters somewhat by giving hope where there perhaps was despair. Understanding and knowledge gives confidence and a positive expectation so important to the success of any medical treatment.
B
Next, it is necessary to find a medication which can eliminate the panic attacks completely, if at all possible. Psychiatrists experienced in treating Panic Disorder have had success using any one of three kinds of medicines:
1
Certain Antidepressants. Paxil and Paxil CR (paroxetine) and Zoloft (sertraline) are examples of antidepressants that are useful in treating Panic Disorder and have official FDA approval for that indication. Most antidepressants appear to alleviate panic attacks. Physical dependence does not occur on such medicine.
Successful treatment requires full strength dosage and it usually takes four to six weeks for the medicine to begin to block the panic attacks. Full benefit may take up to 3 months.
Perhaps half of persons trying this type of medicine are made initially worse to a greater or lesser degree. Certain properties of the medicines tend to trigger more than the usual number of attacks or more severe attacks in the first several days of treatment. This temporary discomfort can be considered a short term investment of worsening in return for a long term gain of recovery. In most patients this potential temporary worsening can be alleviated by taking smaller than usual starting doses of the medication. In unusually sensitive patients experienced expert clinicians have even used 1/64 or 1/32 of the usual starting dose.
As a rule, the less expensive antidepressants (imipramine) have more bothersome ordinary side effects than the newer, more expensive ones (Paxil, Paxil CR, or Zoloft).
Here are some examples of antidepressants thought by clinicians to be helpful for treating Panic Disorder; however, only Paxil, Paxil CR, and Zoloft have FDA indication for treating Panic Disorder:
Effexor (venlafaxine)
Paxil (paroxetine)
Sinequan (doxepin)
Tofranil (imipramine)
Zoloft (sertraline)
2
High Potency Benzodiazepine Tranquilizers. Some examples are Xanax (alprazolam), Ativan (lorazepam) and Klonopin (clonazepam). Xanax (alprazolam) is the most thoroughly studied of this group. Xanax (alprazolam) was already used for a decade to treat Panic Disorder when it was approved for use in Panic Disorder by the FDA in 1990. These medicines are quite effective and usually have few side effects at proper doses. They block panic attacks almost immediately in the first day or two of treatment.
Several dosage increases over a period of several weeks are customary. Ultimately, no further increases are required.
Public concern about such medicines being dangerously addictive is unduly exaggerated in the case of persons with Panic Disorder.
Scientific evidence shows surprisingly low rates of abuse of this and other medicines in persons with Panic Disorder. Physical dependence does develop with such medicines at larger dosages (more than 3-4 mg per day).
The person who chooses such medicine for this disorder should accept the fact that they may require higher doses (ultimately, 6mg per day is typical) and may therefore be physically dependent on the medicine. They must not abruptly cease taking their medicine. Doing so would result in withdrawal symptoms. One does not abruptly stop such medicine. When it comes time to go off medicine, it is decreased gradually by tiny reductions every one to three weeks. More information about this benzodiazepine kind of medication is linked: Click here for important information on Discontinuing Xanax (alprazolam).
3
Nardil (phenelzine). This unique medicine, though more effective than any other medicine for this disorder, is rather complicated to use. It may be best to reserve it for cases where simpler medications have failed or cannot be used for some reason. Nardil is a safe medicine when used by an experienced physician in a patient who complies with the necessary diet and medication restrictions. Unsafe elevations of blood pressure for several hours can occur if one does not adhere to these restrictions while taking Nardil.
C
Once the panic attacks have been successfully blocked completely for about three months Panic Disorder patients usually get back to normal life without any additional assistance. However, many do not automatically overcome their tendencies to avoid the situations that they have been evading. Success in such patients is achieved by organizing a systematic approach of doing the very things that have been avoided. They begin going into the least difficult of avoided places first. This exposure to the feared situations is practiced repeatedly until they are reasonably comfortable. Then they proceed to the next more difficult avoided activity.
This highly successful approach is a common sense method based on the old adage "If you fall off the horse, get right back on." This cognitive behavior therapy approach may be helpful in resolving such fears. The person discovers that they can indeed perform the avoided activities and the medication prevents the attacks from occurring. Confidence is restored and normal life resumes with security, peace of mind and a sense that one is in control once again.
Some professionals believe that Panic Disorder can be treated solely with talk therapy such as cognitive behavioral therapy or expensive cassette tapes. This area is controversial. The National Anxiety Foundation urges professionals and patients to employ the combination of both methods (medication and cognitive-behavioral therapy) until convincing research clarifies, once and for all, this controversy.
Seeking help
What kind of doctor should I see to get help?
The first step should be to have a medical evaluation to determine the proper diagnosis. Your family physician is the good place to start. Tell him or her what has been happening to you and that you wonder if you might have Panic Disorder. Show the doctor this brochure. After the evaluation perhaps the doctor will tell you that you do have Panic Disorder. Then what? You may wish to see a psychiatrist.
Psychiatrists are physicians (M.D., or less commonly, D.O.). A psychiatrist who is experienced in treating Panic Disorder is perhaps the most qualified single professional to deal with the problem. There is a national shortage of psychiatrists. There may not be one in your area, or your HMO may not allow you to be seen by one of their psychiatrists. In these instances, seeing your regular doctor for medication to stop the attacks and consulting a psychologist, if necessary, for behavior therapy is second best. Psychologists are not physicians (instead of M.D., they may have other abbreviations after their name such as Ph.D. or Ed.D. or Psy.D.). If a psychologist isn't available for behavior therapy, a social worker who is familiar with this therapy might be helpful in conjunction with your family physician.
The prognosis
Remember, Panic Disorder is a serious but highly treatable medical illness. Almost everyone responds well to treatment and can return to normal functioning in weeks or months.
Source: © 1992 - 2002 National Anxiety Foundation
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