Dr

Fear...heart palpitations...terror, a sense of impending doom...dizziness...fear of fear. The words used to describe panic disorder are often frightening. But there is great hope: Treatment can benefit virtually everyone who has this condition. It is extremely important for the person who has panic disorder to learn about the problem and the availability of effective treatments and to seek help.

What Is Panic Disorder?
In panic disorder, brief episodes of intense fear are accompanied by multiple physical symptoms (such as heart palpitations and dizziness) that occur repeatedly and unexpectedly in the absence of any external threat. These "panic attacks," which are the hallmark of panic disorder, are believed to occur when the brain's normal mechanism for reacting to a threat—the so-called "fight or flight" response—becomes inappropriately aroused. Most people with panic disorder also feel anxious about the possibility of having another panic attack and avoid situations in which they believe these attacks are likely to occur. Anxiety about another attack, and the avoidance it causes, can lead to disability in panic disorder.

Who Has Panic Disorder?
In the United States, 1.6% of the adult population, or more than 3 million people, will have panic disorder at some time in their lives. The disorder typically begins in young adulthood, but older people and children can be affected. Women are affected twice as frequently as men. While people of all races and social classes can have panic disorder, there appear to be cultural differences in how individual symptoms are expressed.

Symptoms and Course of Panic Disorder
Initial Panic Attack. Typically, a first panic attack seems to come "out of the blue," occurring while a person is engaged in some ordinary activity like driving a car or walking to work. Suddenly, the person is struck by a barrage of frightening and uncomfortable symptoms. These symptoms often include terror, a sense of unreality, or a fear of losing control.

This barrage of symptoms usually lasts several seconds, but may continue for several minutes. The symptoms gradually fade over the course of about an hour. People who have experienced a panic attack can attest to the extreme discomfort they felt and to their fear that they had been stricken with some terrible, life-threatening disease or were "going crazy." Often people who are having a panic attack seek help at a hospital emergency room.
Initial panic attacks may occur when people are under considerable stress, from an overload of work, for example, or from the loss of a family member or close friend. The attacks may also follow surgery, a serious accident, illness, or childbirth. Excessive consumption of caffeine or use of cocaine or other stimulant drugs or medicines, such as the stimulants used in treating asthma, can also trigger panic attacks.

Nevertheless panic attacks usually take a person completely by surprise. This unpredictability is one reason they are so devastating. Sometimes people who have never had a panic attack assume that panic is just a matter of feeling nervous or anxious—the sort of feelings that everyone is familiar with. In fact, even though people who have panic attacks may not show any outward signs of discomfort, the feelings they experience are so overwhelming and terrifying that they really believe they are going to die, lose their minds, or be totally humiliated. These disastrous consequences don't occur, but they seem quite likely to the person who is suffering a panic attack.

Some people who have one panic attack, or an occasional attack, never develop a problem serious enough to affect their lives. For others, however, the attacks continue and cause much suffering.

Panic Attack Symptoms
Panic Disorder. In panic disorder, panic attacks recur and the person develops an intense apprehension of having another attack. As noted earlier, this fear—called anticipatory anxiety or fear of fear—can be present most of the time and seriously interfere with the person's life even when a panic attack is not in progress. In addition, the person may develop irrational fears called PHOBIAS about situations where a panic attack has occurred. For example, someone who has had a panic attack while driving may be afraid to get behind the wheel again, even to drive to the grocery store.
People who develop these panic-induced phobias will tend to avoid situations that they fear will trigger a panic attack, and their lives may be increasingly limited as a result. Their work may suffer because they can't travel or get to work on time. Relationships may be strained or marred by conflict as panic attacks, or the fear of them, rule the affected person and those close to them.

Also, sleep may be disturbed because of panic attacks that occur at night, causing the person to awaken in a state of terror. The experience is so harrowing that some people who have nocturnal panic attacks become afraid to go to sleep and suffer from exhaustion. Also, even if there are no nocturnal panic attacks, sleep may be disturbed because of chronic, panic-related anxiety.

Many people with panic disorder remain intensely concerned about their symptoms even after an initial visit to a physician yields no indication of a life-threatening condition. They may visit a succession of doctors seeking medical treatment for what they believe is heart disease or a respiratory problem. Or their symptoms may make them think they have a neurological disorder or some serious gastrointestinal condition. Some patients see as many as 10 doctors and undergo a succession of expensive and unnecessary tests in the effort to find out what is causing their symptoms.

This search for medical help may continue a long time, because physicians who see these patients frequently fail to diagnose panic disorder. When doctors do recognize the condition, they sometimes explain it in terms that suggest it is of no importance or not treatable. For example, the doctor may say, "There's nothing to worry about, you're just having a panic attack" or "It's just nerves." Although meant to be reassuring, such words can be dispiriting to the worried patient whose symptoms keep recurring. The patient needs to now that the doctor acknowledges the disabling nature of panic disorder and that it can be treated effectively.

Strategies for Coping with Panic
Agoraphobia. Panic disorder may progress to a more advanced stage in which the person becomes afraid of being in any place or situation where escape might be difficult or help unavailable in the event of a panic attack. This condition is called agoraphobia. It affects about a third of all people with panic disorder.

Typically, people with agoraphobia fear being in crowds, standing in line, entering shopping malls, and riding in cars or public transportation. Often, these people restrict themselves to a "zone of safety" that may include only the home or the immediate neighborhood. Any movement beyond the edges of this zone creates mounting anxiety. Sometimes a person with agoraphobia is unable to leave home alone, but can travel if accompanied by a particular family member or friend. Even when they restrict themselves to "safe" situations, most people with agoraphobia continue to have panic attacks at least a few times a month.

People with agoraphobia can be seriously disabled by their condition. Some are unable to work, and they may need to rely heavily on other family members, who must do the shopping and run all the household errands, as well as accompany the affected person on rare excursions outside the "safety zone." Thus the person with agoraphobia typically leads a life of extreme dependency as well as great discomfort.

Treatment for Panic Disorder
Treatment can bring significant relief to 70 to 90% of people with panic disorder, and early treatment can help keep the disease from progressing to the later stages where agoraphobia develops.

Before undergoing any treatment for panic disorder, a person should undergo a thorough medical examination to rule out other possible causes of the distressing symptoms. This is necessary because a number of other conditions, such as excessive levels of thyroid hormone, certain types of epilepsy, or cardiac arrhythmias, which are disturbances in the rhythm of the heartbeat, can cause symptoms resembling those of panic disorder.

Cognitive-Behavioral Therapy. This is a combination of cognitive therapy, which can modify or eliminate thought patterns contributing to the patient's symptoms, and behavioral therapy, which aims to help the patient to change his or her behavior.

Typically the patient undergoing cognitive-behavioral therapy meets with a therapist for 1 to 3 hours a week. In the cognitive portion of the therapy, the therapist usually conducts a careful search for the thoughts and feelings that accompany the panic attacks. These mental events are discussed in terms of the "cognitive model" of panic attacks.

The cognitive model states that individuals with panic disorder often have distortions in their thinking, of which they may be unaware, and these may give rise to a cycle of fear. The cycle is believed to operate this way: First the individual feels a potentially worrisome sensation such as an increasing heart rate, tightened chest muscles, or a queasy stomach. This sensation may be triggered by some worry, an unpleasant mental image, a minor illness, or even exercise. The person with panic disorder responds to the sensation by becoming anxious. The initial anxiety triggers still more unpleasant sensations, which in turn heighten anxiety, giving rise to catastrophic thoughts. The person thinks "I am having a heart attack" or "I am going insane," or some similar thought. As the vicious cycle continues, a panic attack results. The whole cycle might take only a few seconds, and the individual may not be aware of the initial sensations or thoughts.

Proponents of this theory point out that, with the help of a skilled therapist, people with panic disorder often can learn to recognize the earliest thoughts and feelings in this sequence and modify their responses to them. Patients are taught that typical thoughts such as "That terrible feeling is getting worse!" or "I'm going to have a panic attack" or "I'm going to have a heart attack" can be replaced with substitutes such as "It's only uneasiness–it will pass" that help to reduce anxiety and ward off a panic attack. Specific procedures for accomplishing this are taught. By modifying thought patterns in this way, the patient gains more control over the problem.

Often the therapist will provide the patient with simple guidelines to follow when he or she can feel that a panic attack is approaching. One therapist has offered a set of strategies that have helped some of her patients to cope with panic attacks.

In cognitive therapy, discussions between the patient and the therapist are not usually focused on the patient's past, as is the case with some forms of psychotherapy. Instead, conversations focus on the difficulties and successes the patient is having at the present time, and on skills the patient needs to learn.

The behavioral portion of cognitive-behavioral therapy may involve systematic training in relaxation techniques. By learning to relax, the patient may acquire the ability to reduce generalized anxiety and stress that often sets the stage for panic attacks.

Breathing exercises are often included in the behavioral therapy. The patient learns to control his or her breathing and avoid hyperventilation—a pattern of rapid, shallow breathing that can trigger or exacerbate some people's panic attacks.

Another important aspect of behavioral therapy is exposure to internal sensations called interoceptive exposure. During interoceptive exposure the therapist will do an individual assessment of internal sensations associated with panic. Depending on the assessment, the therapist may then encourage the patient to bring on some of the sensations of a panic attack by, for example, exercising to increase heart rate, breathing rapidly to trigger lightheadedness and respiratory symptoms, or spinning around to trigger dizziness. Exercises to produce feelings of unreality may also be used. Then the therapist teaches the patient to cope effectively with these sensations and to replace alarmist thoughts such as "I am going to die," with more appropriate ones, such as "It's just a little dizziness–I can handle it."

Another important aspect of behavioral therapy is "in vivo" or real-life exposure. The therapist and the patient determine whether the patient has been avoiding particular places and situations, and which patterns of avoidance are causing the patient problems. They agree to work on the avoidance behaviors that are most seriously interfering with the patient's life. For example, fear of driving may be of paramount importance for one patient, while inability to go to the grocery store may be most handicapping for another.

Some therapists will go to an agoraphobic patient's home to conduct the initial sessions. Often therapists take their patients on excursions to shopping malls and other places the patients have been avoiding. Or they may accompany their patients who are trying to overcome fear of driving a car.
The patient approaches a feared situation gradually, attempting to stay in spite of rising levels of anxiety. In this way the patient sees that as frightening as the feelings are, they are not dangerous, and they do pass. On each attempt, the patient faces as much fear as he or she can stand. Patients find that with this step-by-step approach, aided by encouragement and skilled advice from the therapist, they can gradually master their fears and enter situations that had seemed unapproachable.

Many therapists assign the patient "homework" to do between sessions. Sometimes patients spend only a few sessions in one-on-one contact with a therapist and continue to work on their own with the aid of a printed manual.
Often the patient will join a therapy group with others striving to overcome panic disorder or phobias, meeting with them weekly to discuss progress, exchange encouragement, and receive guidance from the therapist.

Cognitive-behavioral therapy generally requires at least 8 to 12 weeks. Some people may need a longer time in treatment to learn and implement the skills. This kind of therapy, which is reported to have a low relapse rate, is effective in eliminating panic attacks or reducing their frequency. It also reduces anticipatory anxiety and the avoidance of feared situations.

Treatment With Medications. In this treatment approach, which is also called pharmacotherapy, a prescription medication is used both to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety. When patients find that their panic attacks are less frequent and severe, they are increasingly able to venture into situations that had been off-limits to them. In this way, they benefit from exposure to previously feared situations as well as from the medication.

The three groups of medications most commonly used are the tricyclic antidepressants, the high-potency benzodiazepines, and the monoamine oxidase inhibitors (MAOIs). Determination of which drug to use is based on considerations of safety, efficacy, and the personal needs and preferences of the patient. Some information about each of the classes of drugs follows.
The tricyclic antidepressants were the first medications shown to have a beneficial effect against panic disorder. Imipramine is the tricyclic most commonly used for this condition. When imipramine is prescribed, the patient usually starts with small daily doses that are increased every few days until an effective dosage is reached. The slow introduction of imipramine helps minimize side effects such as dry mouth, constipation, and blurred vision. People with panic disorder, who are inclined to be hypervigilant about physical sensations, often find these side effects disturbing at the outset. Side effects usually fade after the patient has been on the medication a few weeks.

It usually takes several weeks for imipramine to have a beneficial effect on panic disorder. Most patients treated with imipramine will be panic-free within a few weeks or months. Treatment generally lasts from 6 to 12 months. Treatment for a shorter period of time is possible, but there is substantial risk that when imipramine is stopped, panic attacks will recur. Extending the period of treatment to 6 months to a year may reduce this risk of a relapse. When the treatment period is complete, the dosage of imipramine is tapered over a period of several weeks.

The high-potency benzodiazepines are a class of medications that effectively reduce anxiety. Alprazolam, clonazepam, and lorazepam are medications that belong to this class. They take effect rapidly, have few bothersome side-effects, and are well tolerated by the majority of patients. However, some patients, especially those who have had problems with alcohol or drug dependency, may become dependent on benzodiazepines.

Generally, the physician prescribing one of these drugs starts the patient on a low dose and gradually raises it until panic attacks cease. This procedure minimizes side effects.

Treatment with high-potency benzodiazepines is usually continued for 6 months to a year. One drawback of these medications is that patients may experience withdrawal symptoms–malaise, weakness, and other unpleasant effects–when the treatment is discontinued. Reducing the dose gradually generally minimizes these problems. There may also be a recurrence of panic attacks after the medication is withdrawn.

Of the MAOIs, a class of antidepressants that have been shown to be effective against panic disorder, phenelzine is the most commonly used. Treatment with phenelzine usually starts with a relatively low daily dosage that is increased gradually until panic attacks cease or the patient reaches a maximum dosage of about 100 milligrams a day.

Use of phenelzine or any other MAOI requires the patient to observe exacting dietary restrictions, because there are foods and prescription drugs and certain substances of abuse that can interact with the MAOI to cause a sudden, dangerous rise in blood pressure. All patients who are taking MAOIs should obtain their physician's guidance concerning dietary restrictions and should consult with their physician before using any over-the-counter or prescription medications.

As in the case of the high-potency benzodiazepines and imipramine, treatment with phenelzine or another MAOI generally lasts 6 months to a year. At the conclusion of the treatment period, the medication is gradually tapered.

Newly available antidepressants such as fluoxetine (one of a class of new agents called serotonin reuptake inhibitors), appear to be effective in selected cases of panic disorder. As with other anti panic medications, it is important to start with very small doses and gradually raise the dosage.

What to Do if a Family Member Has an Anxiety Disorder
Combination Treatments. Many believe that a combination of medication and cognitive-behavioral therapy represents the best alternative for the treatment of panic disorder. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate. However, there is a need for more research studies to determine whether this is in fact the case.
Comparing medications and psychological treatments, and determining how well they work in combination, is the goal of several NIMH-supported studies. The largest of these is a 4-year clinical trial that will include 480 patients and involve four centers at the State University of New York at Albany, Cornell University, Hillside Hospital/Columbia University, and Yale University. This study is designed to determine how treatment with imipramine compares with a cognitive-behavioral approach, and whether combining the two yields benefits over either method alone.
Psychodynamic Treatment. This is a form of "talk therapy" in which the therapist and the patient, working together, seek to uncover emotional conflicts that may underlie the patient's problems. By talking about these conflicts and gaining a better understanding of them, the patient is helped to overcome the problems. Often, psychodynamic treatment focuses on events of the past and making the patient aware of the ramifications of long-buried problems.

Although psychodynamic approaches may help to relieve the stress that contributes to panic attacks, they do not seem to stop the attacks directly. In fact, there is no scientific evidence that this form of therapy by itself is effective in helping people to overcome panic disorder or agoraphobia. However, if a patient's panic disorder occurs along with some broader and pre-existing emotional disturbance, psychodynamic treatment may be a helpful addition to the overall treatment program.

When Panic Recurs
Panic disorder is often a chronic, relapsing illness. For many people, it gets better at some times and worse at others. If a person gets treatment, and appears to have largely overcome the problem, it can still worsen later for no apparent reason. These recurrences should not cause a person to despair or consider himself or herself a "treatment failure." Recurrences can be treated effectively, just like an initial episode.

In fact, the skills that a person learns in dealing with the initial episode can be helpful in coping with any setbacks. Many people who have overcome panic disorder once or a few times find that, although they still have an occasional panic attack, they are now much better able to deal with the problem. Even though it is not fully cured, it no longer dominates their lives, or the lives of those around them.

Coexisting Conditions
Among the conditions that are frequently found to coexist with panic disorder are:
Simple Phobias. People with panic disorder often develop irrational fears of specific events or situations that they associate with the possibility of having a panic attack. Fear of heights and fear of crossing bridges are examples of simple phobias. Generally, these fears can be resolved through repeated exposure to the dreaded situations, while practicing specific cognitive-behavioral techniques to become less sensitive to them.
Social Phobia. This is a persistent dread of situations in which the person is exposed to possible scrutiny by others and fears acting in a way that will be embarrassing or humiliating. Social phobia can be treated effectively with cognitive-behavioral therapy or medications, or both.
Depression. About half of panic disorder patients will have an episode of clinical depression sometime during their lives. Major depression is marked by persistent sadness or feelings of emptiness, a sense of hopelessness, and other symptoms.

When major depression occurs, it can be treated effectively with one of several antidepressant drugs, or, depending on its severity, by cognitive-behavioral therapies.

Symptoms of Depression
Obsessive-Compulsive Disorder (OCD). In OCD, a person becomes trapped in a pattern of repetitive thoughts and behaviors that are senseless and distressing but extremely difficult to overcome. Such rituals as counting, prolonged handwashing, and repeatedly checking for danger may occupy much of the person's time and interfere with other activities. Today, OCD can be treated effectively with medications or cognitive-behavioral therapies.
Alcohol Abuse. About 30% of people with panic disorder abuse alcohol. A person who has alcoholism in addition to panic disorder needs specialized care for the alcoholism along with treatment for the panic disorder. Often the alcoholism will be treated first.
Drug Abuse. As in the case of alcoholism, drug abuse is more common in people with panic disorder than in the population at large. In fact, about 17% of people with panic disorder abuse drugs. The drug problems often need to be addressed prior to treatment for panic disorder.
Suicidal Tendencies. Recent studies in the general population have suggested that suicide attempts are more common among people who have panic attacks than among those who do not have a mental disorder. Also, it appears that people who have both panic disorder and depression are at elevated risk for suicide. (However, anxiety disorder experts who have treated many patients emphasize that it is extremely unlikely that anyone would attempt to harm himself or herself during a panic attack.)
Anyone who is considering suicide needs immediate attention from a mental health professional or from a school counselor, physician, or member of the clergy. With appropriate help and treatment, it is possible to overcome suicidal tendencies.
There are also certain physical conditions that are often associated with panic disorder
Irritable Bowel Syndrome. The person with this syndrome experiences intermittent bouts of gastrointestinal cramps and diarrhea or constipation, often occurring during a period of stress. Because the symptoms are so pronounced, panic disorder is often not diagnosed when it occurs in a person with irritable bowel syndrome.
Mitral Valve Prolapse. This condition involves a defect in the mitral valve, which separates the two chambers on the left side of the heart. Each time the heart muscle contracts in people with this condition, tissue in the mitral valve is pushed for an instant into the wrong chamber. The person with the disorder may experience chest pain, rapid heartbeat, breathing difficulties, and headache. People with mitral valve prolapse may be at higher than usual risk of having panic disorder, but many experts are not convinced this apparent association is real.

Finding Help for Panic Disorder
Often the person with panic disorder must undertake a strenuous search to find a therapist who is familiar with the most effective treatments for the condition. A list of places to start follows. The Anxiety Disorders Association of America can provide a list of professionals in your area who specialize in the treatment of panic disorder and other anxiety disorders.
Self-help and support groups are the least expensive approach to managing panic disorder, and are helpful for some people. A group of about 5 to 10 people meet weekly and share their experiences, encouraging each other to venture into feared situations and cope effectively with panic attacks. Group members are in charge of the sessions. Often family members are invited to attend these groups, and at times a therapist or other panic disorder expert may be brought in to share insights with group members. Information on self-help groups in specific areas of the country can be obtained from the Anxiety Disorders Association of America.

Help For The Family
When one member of a family has panic disorder, the entire family is affected by the condition. Family members may be frustrated in their attempts to help the affected member cope with the disorder, overburdened by taking on additional responsibilities, and socially isolated. Family members must encourage the person with panic disorder to seek the help of a qualified mental health professional. Also, it is often helpful for family members to attend an occasional treatment or self-help session or seek the guidance of the therapist in dealing with their feelings about the disorder.

Certain strategies, such as encouraging the person with panic disorder to go at least part way toward a place or situation that is feared, can be helpful. By their skilled and caring efforts to help, family members can aid the person with panic disorder in making a recovery.

Also, it may be valuable for family members to join or form a support group to share information and offer mutual encouragement.