Panic Disorder
by: Gordon Ball, Ph.D. – Columbia Presbyterian Hospital, New York, NY

As many as three percent of people in the United States suffer from panic disorder. Most people experience their first attack in their twenties, but attacks can start at any age, including the very young and very old. Most people describe their first panic attack as the most traumatic experience they have ever had. In general, we don’t know what causes the first attack, but extremely stressful situation seem to be one contributing factor. Fortunately, panic attacks are not life-threatening, and full-blown attacks tend to last for only a few minutes.

A panic attack is a frightening experience. Suddenly, out of nowhere, you may feel like you are having a heart attack, suffocating, or going crazy. You may have the feeling that something has gone wrong inside your body, and you are filled with dread and terror.

Chances are that you will begin to sweat profusely, and your heart will begin to pound. When this happens, many people end up in a hospital emergency room, which may seem a sensible place to go given how you feel. After being examined there, you will probably feel better because will most likely be told that you are perfectly fine, and not to worry because you “just had a panic attack and now it’s over.” You will likely feel calm and reassured.

Unfortunately, since an attack can seem to disappear as quickly as it happened, most people return to their lives afterwards as if nothing happened However, once you have a panic attack, your body is now on alert (or “sensitized”), and the chances of having another attack in the next few days or weeks is increased. If you do have a second or a third attack, you risk developing a condition called panic disorder.

Later attacks are generally less severe than the first, but are still extremely frightening. In some unfortunate people, panic attacks can occur daily. Sometimes the attacks are very unpredictable, but in most cases they tend to occur in situations similar to the first one.

Panic Attack Defined

According to the Diagnostic and Statistical Manual of the American Psychiatric Association (often referred to simply as “the DSM”), which lists and defines psychological disorders for health care professionals, a panic attack involves the sudden onset of intense apprehension, fear, or terror, often associated with feelings of impending doom. Common fears include dying, going crazy, or doing something uncontrollable during the attack. Other common symptoms include:

• trouble breathing
• heart palpitations
• chest pain or discomfort
• choking or smothering sensations
• dizziness or unsteadiness
• feelings of unreality
• odd body sensations
• hot and cold flashes
• sweating
• fainting
• trembling or shaking.

In order to be diagnosed as having panic disorder, you must have had at least four panic attacks, within the last month or be in extreme fear of having another panic attack.

How a Second Attack Happens
An important contributor to the occurrence of further panic attacks is related to where the first one occurred. For most people it happens in a situation from which it would not be easy to escape if they wanted to: for example in a plane, on a subway, in a classroom, in a tunnel, in a wide open space, on an elevator, or in a tall building. For example, if you had your first panic attack while riding on a subway train, chances are you will be quite nervous the next time you have to take the subway. The more nervous you are, the greater the chance that a new panic attack will happen. If you have already experienced a panic attack, you will almost certain to try to escape (in this case, from the subway) if you feel an attack coming on.

Once out of the subway, you will probably feel less panicky. A few experiences like this, and you will be avoiding the subway altogether. This is very typical in the development of panic disorder; people are afraid of putting themselves in situations where they might panic, and where escape is difficult. This development is diagnosed as “panic disorder with agoraphobia.”

Treatment

Medication
There are quite a number of medications that are effective in reducing the frequency of panic attacks. In the past, the most frequently prescribed medications were tricyclic antidepressants, like imipramine (Tofranil). In recent years, however, newer antidepressant medications called serotenorgic reuptake inhibitors, or ” SSRIs” have also been shown to be effective against panic attacks. The medications, which include such fluoxetine (Prozac), are swallowed as pills.
In most cases, medication will take effect in several weeks, and people can begin to slowly get back to a normal lifestyle. Unfortunately, some people cannot tolerate the side effects of the medication, and the risk of relapse is very high for those who stop taking their medication.

Cognitive-Behavior Therapy
Cognitive-behavior therapy is another approach to the problem. Although this treatment may take more effort on your part than taking a pill, the final result can be more lasting control over your panic attacks. Cognitive-behavior therapy involves a combination of learning breath control (breathing retraining), relaxation techniques, and exposure and response prevention. These techniques should be taught to you by a qualified cognitive-behavior therapist.
Breathing Retraining: When you start to panic, you automatically start to breathe rapidly (hyperventilate). This response more than any other produces sensations that can feel strange and frightening. . Breathing in a conscious and gentle way, using your diaphragm, helps you get control over many of these sensations. Learning breath control is the first step in controlling panic.

Relaxation Exercises: If you are beginning to feel panicky, your body automatically becomes tense, preparing for danger. This defensive behavior increases the unwanted internal sensations. Learning systematic relaxation techniques and then applying them in threatening situations is another technique that can help you control your panic attacks.

Graded Exposure and Response Prevention: A third important method for controlling panic is to face your fear in a gradual way. For instance, if your panic attacks occur while riding on crowded subways at rush hour, the chances are that you will feel only mild panic when riding a fairly empty train at midday. With this technique, you practice your breathing and relaxation skills in easier-to-handle situations before you progress to more frightening situations. This gradual exposure to the sensations you experience during panic attacks, along with the prevention of hyperventilation and tension during the exposure, are the essential ingredients for learning to control panic attacks.

Typically, After several weeks of training using these methods, many sufferers learn to control their panic, so that they can continue living normal productive lives. The risk of relapse is low following treatment, in contrast to people who discontinue medication treatment.

Combined Treatment
The combination of medication and cognitive-behavior therapy is probably the most rapid way of getting control over panic attacks. It is certainly the best choice if both medication and cognitive-behavior therapy have failed on their own. However, it usually means having to go to two doctors, both a psychiatrist and a behavior therapist. With combined treatment, you can be gradually weaned off the medication after several months, as long as you maintain your behavioral skills.

In Summary
Panic disorder and its related fears are usually the result of an automatic fear reaction that goes off by mistake. Unless you know how to control this reaction, it is likely to occur again, especially in similar situations. There are two effective way of handling it: medication or cognitive-behavior therapy. Both methods are effective in most people within a few weeks. Both work quite well, but although the medication method is easier, the behavioral method has more long lasting results.
© 2004 Healthology, Inc.