Dr. MJ Bazos MD, Patient Handout
Panic Disorder: Treatment and Referral

Panic Disorder Is Real
Panic disorder is a chronic, relapsing, often debilitating condition that can have devastating effects on a person's work, family, and social interactions. Because its symptoms may mimic a variety of medical conditions, panic disorder frequently goes undiagnosed. It is not uncommon for people with panic disorder to see as many as 10 different doctors, undergo many unnecessary tests, and suffer for years before obtaining a correct diagnosis.
The good news is that, once diagnosed, panic disorder is highly treatable. In fact, appropriate treatment can reduce or completely prevent panic attacks in 70% to 90% of patients–particularly when panic disorder is recognized early. Even if patients relapse, recurrent attacks can be treated effectively. Tragically, today just one in three people with panic disorder receives appropriate treatment.

Symptoms of Panic Disorder
Panic disorder is characterized by panic attacks—acute episodes of terror accompanied by a sudden barrage of symptoms, including at least four of the following:

• Racing or pounding heartbeat
• Chest pains
• Dizziness
• Nausea
• Difficulty breathing
• Flushes or chills
• Sweating
• Tingling or numbness in the hands
• Dreamlike sensations or perceptual distortions
• Fear of losing control and doing something embarrassing
• Fear of dying
• Sense of impending doom

Panic attacks typically occur spontaneously, with no apparent trigger. In fact, they can even begin during sleep. Attacks usually last for a few minutes—rarely longer—yet they often feel like an eternity for the patient.
All too often, patients with panic disorder experience such extreme distress that they present repeatedly to emergency departments or other health care professionals. With each panic attack, they may fear they are dying from a heart attack, or suffering from a respiratory problem, neurological disorder, or gastrointestinal condition. They may also fear that they are losing control or becoming psychotic.

When a person has repeated panic attacks and feels severe anxiety about having another attack, he or she has panic disorder. Panic disorder tends to worsen over time if not effectively treated.

Proper Diagnosis Is Critical
The criteria noted above should distinguish panic disorder from everyday anxiety and stress. To help confirm a panic disorder diagnosis, consider the following approach:

• To differentiate panic disorder from other medically important conditions, the patient should, of course, have a thorough physical examination. Panic disorder symptoms mimic other conditions, such as myocardial infarction, cardiac arrhythmias, hyperthyroidism, and certain types of epilepsy.
• It is important to probe the emotional components of the patient's symptoms. Patients may focus on only one or two symptoms as they describe the attacks to you, concentrating only on their physical sensations and not on the fears they experience. By asking patients to describe their feelings about the attacks, you may be able to more quickly identify panic disorder. You will also be more likely to identify depression or other concurrent conditions that should be considered in the treatment plan.
• It can be constructive to probe for environmental factors that trigger panic attacks in some people. For example, in susceptible persons, attacks may occur during or within 6 months of such stressful life events as the death of a loved one, divorce, geographic relocation, childbirth, or surgery. Panic attacks can also be triggered by large doses of caffeine, some cold medicines, and cocaine and marijuana. If someone has a substance abuse problem, it will have to be treated before panic disorder can be addressed effectively.

Panic Disorder Can Seriously Harm Your Patients
Even though panic attacks do not represent an immediate danger to the life of the patient, panic disorder can have far more harmful consequences than many other serious medical conditions:

• Many people with panic disorder develop fears about situations they associate with panic attacks and begin to avoid them. Their lives become an ordeal of chronic fear, and they may become greatly restricted in their ability to carry out normal activities like grocery shopping, traveling, and even leaving home—a condition known as agoraphobia.
• Panic disorder can radically impair family, work, and social relationships. Patients may lose their jobs and independence.
• People with panic disorder may also suffer from clinical depression, substance abuse, obsessive-compulsive disorder, or irritable bowel syndrome. According to one study, 20% of people with panic disorder attempt suicide.
• Apart from the suffering experienced by the patient, untreated panic disorder is costly to both the patient and the medical system as a whole–because of repeated visits to doctors and emergency departments and unnecessary medical tests.

Causes of Panic Disorder
Research suggests that panic disorder has both biological and psychological components, which interact. Family and twin studies indicate that panic disorder involves some genetic vulnerability.

Recent studies suggest that people with panic disorder have a low tolerance for the body's normal physiological and psychological response to stress; their body's alarm response goes off with little or no provocation. The hypothesis that panic disorder patients may have learned to perceive essentially normal physiological events as being dangerous may help in understanding the lowered stress response threshold, giving rise to a "false alarm." Some researchers theorize that the disturbance in coping mechanisms is a product of repeated life stresses in predisposed individuals, leading eventually to panic disorder. Research also suggests that people with panic disorder may not be able to utilize the body's own naturally produced anxiety-reducing substances. It may be that the neuronal receptors that bind with these substances are abnormal in people with panic disorder.
Treatment Methods
Panic disorder can be treated effectively with cognitive-behavioral therapy (CBT), pharmacological therapy, and possibly a combination of CBT and medication. Patients generally begin to respond quickly to appropriate treatment. However, some treatments may work better than others for certain patients. So, it is important to monitor the response to treatment closely and reassess the treatment strategy if there is no improvement after 6 to 8 weeks.

Cognitive-Behavioral Therapy
CBT teaches patients to anticipate the situations and bodily sensations that are associated with their panic attacks. This awareness sets the stage for helping the patient to control the attacks. Specially trained therapists tailor CBT to the specific needs of each patient. The therapy usually includes the following components:

• Helping patients identify and change patterns of thinking that cause them to misperceive commonplace events or situations as dangerous and to "think the worst." Patients often are unaware of how deeply these anxiety-raising thoughts are ingrained.
• Teaching patients exercises to prevent the hyperventilation that often triggers a panic attack. The exercises also help the patient to replace alarmist thoughts such as, "I'm dying," with more appropriate ones, such as, "I'm just hyperventilating—I can handle this."
• Helping patients become less fearful by safely and gradually exposing them to situations and physical sensations they avoid or find frightening.
• CBT is a short-term treatment, typically lasting 12 to 15 sessions over several months. Patients with panic disorder who go through CBT are reported to have very few adverse effects and a relatively low relapse rate of panic attacks.

CBT requires special training. If you decide to refer your patients for cognitive-behavioral therapy, check to see if the professional has the requisite training and experience in this method of panic disorder treatment.

Medication
Several classes of medication can reduce or prevent panic attacks and therefore substantially decrease patients' anticipatory anxiety about having attacks. The medications most often used are:

• Antidepressants, including tricyclics, monoamine oxidase inhibitors, and serotonin reuptake inhibitors
• Certain high-potency benzodiazepines

Each of these classes of medications works differently and has different side effects. The latest information about the pharmacotherapy of panic and related disorders is available in clinical handbooks of psychotherapeutic medications. For most of these medications, treatment lasts 6 months to a year. With all of them, proper dosing and monitoring is essential.

The practitioner who administers medication for panic disorder should be well versed in the clinical use of the relevant psychotherapeutic medications. It is important to start with a low dose and increase it gradually. Build up to the recommended dosage for the particular medication you are prescribing, watching for troublesome side effects as well as for a decrease in panic attacks. The goal should be to stop the panic attacks. Make sure the patient is maintained on a dose that is in the therapeutic range. When withdrawing medication, reduce the dosage gradually, and watch for possible relapse. To improve compliance, it is important to educate the patient about the medication and its side effects.

Combining CBT and Medication
A combination of CBT and pharmacotherapy may offer rapid relief, high effectiveness, and a low relapse rate. The combination may be particularly helpful for patients with agoraphobia. NIMH is conducting a large study evaluating the effectiveness of combining these treatments.

Who Can Treat Panic Disorder?
Panic disorder patients can be treated by mental health professionals or by primary health care providers.

How To Talk To Your Patients About Panic Disorder
Many panic disorder patients are reluctant to seek treatment or have been frustrated by previous encounters with health care professionals. You can play a crucial role in motivating these people to get treatment.