Panic disorder

Definition

A panic attack is a sudden, intense experience of fear coupled with an overwhelming feeling of danger, accompanied by physical symptoms of anxiety, such as a pounding heart, sweating, and rapid breathing. A person with panic disorder may experience repeated panic attacks (at least several a month) and feel severe anxiety about having another attack.

Description

Each year, panic disorder affects one in every 63 Americans. While many people experience moments of anxiety, panic attacks are sudden and unprovoked, having little to do with real danger.

Panic disorder is a chronic, debilitating condition that can have a devastating impact on a person's family, work, and social life. Typically, the first attack strikes without warning. A person might be walking down the street, driving a car, or riding an escalator when suddenly panic strikes. Pounding heart, sweating palms, and an overwhelming feeling of impending doom are common features. While the attack may last only seconds or minutes, the experience can be profoundly disturbing. A person who has had one panic attack typically worries that another one may occur at any time.

As the fear of future panic attacks deepens, the person begins to avoid situations in which panic occurred in the past. In severe cases of panic disorder, the victim refuses to leave the house for fear of having a panic attack. This fear of being in exposed places is often called agoraphobia.

People with untreated panic disorder may have problems getting to work or staying on the job. As the person's world narrows, untreated panic disorder can lead to depression, substance abuse, and in rare instances, suicide.

Causes & symptoms

Scientists aren't sure what causes panic disorder, but they suspect the tendency to develop the condition can be inherited. Some experts think that people with panic disorder may have a hypersensitive nervous system that unnecessarily responds to nonexistent threats. Research suggests that people with panic disorder may not be able to make proper use of their body's normal stress-reducing chemicals.

People with panic disorder usually have their first panic attack in their 20s. Four or more of the following symptoms during panic attacks would indicate panic disorder if no medical, drug-related, neurologic, or other psychiatric disorder is found:

• pounding, skipping, or palpitating heartbeat
• shortness of breath or the sensation of smothering
• dizziness or lightheadedness
• nausea or stomach problems
• chest pains or pressure
• choking sensation or a "lump in the throat"
• chills or hot flashes
• sweating
• fear of dying
• feelings of unreality or being detached
• tingling or numbness
• shaking and trembling
• fear of losing control

A panic attack is often accompanied by the urge to escape, together with a feeling of impending doom. Others are convinced they are about to have a heart attack , suffocate, lose control, or "go crazy." Once people experience one panic attack, they tend to worry so much about having another attack that they avoid the place or situation associated with the original episode.

Diagnosis

Because its physical symptoms are easily confused with other conditions, panic disorder often goes undiagnosed. A thorough physical examination is needed to rule out a medical condition. Because the physical symptoms are so pronounced and frightening, panic attacks can be mistaken for a heart problem. Some people experiencing a panic attack go to an emergency room and endure batteries of tests until a diagnosis is made.

Once a medical condition is ruled out, a mental health professional is the best person to diagnose panic and panic disorder, taking into account not just the actual episodes, but how the patient feels about the attacks, and how they affect everyday life.

Treatment

One approach used in several medical centers focuses on teaching patients how to accept their fear instead of dreading it. In this method, the therapist repeatedly stimulates a person's body sensations (such as a pounding heartbeat) that can trigger fear. Eventually, the patient gets used to these sensations and learns not to be afraid of them. Patients who respond report almost complete absence of panic attacks.

Neurolinguistic programming and hypnotherapy can also be beneficial in treating panic attacks, since these techniques can help bring an awareness of the root cause of the attacks to the conscious mind.

Herbs known as adaptogens may also be prescribed by an herbalist or holistic healthcare provider to treat anxiety related to panic disorder. These herbs are thought to promote adaptability to stress, and include Siberian ginseng(Eleutherococcus senticosus), ginseng (Panax ginseng), wild yam (Dioscorea villosa), borage (Borago officinalis), licorice (Glycyrrhiza glabra), chamomile (Chamaemelum nobile), milk thistle (Silybum marianum), and nettles (Urtica dioica). Herbal preparations of skullcap (Scutellaria lateriafolia ), lemon balm (Melissa officinalis), passionflower (Passiflora incarnata), and oats (Avena sativa ) may also be recommended to ease the symptoms of panic disorder. Nutritional supplementation with B vitamins, magnesium, and antioxidant vitamins are also useful for relieving anxiety.

Chinese medicine regards anxiety as a disruption of qi, or energy flow, inside the patient's body. The practitioner of Chinese medicine chooses acupuncture and/or herbal therapy to rebalance the entire system. In acupuncture, the kidney meridian is associated with fear and may be out of balance. Reishi (Ganoderma lucidum), or ling-zhi is a medicinal mushroom prescribed in TCM to reduce anxiety and insomnia. It is available in extract form, but because reishi can interact with other prescription drugs and is not recommended in patients with certain medical conditions, individuals should consult their healthcare practitioner before taking the remedy. Other TCM herbal remedies for panic disorder include the cordyceps mushroom (also known as caterpillar fungus.) There are several herbal formulas, depending on the pattern of imbalance in an individual.

Meditation and mindfulness training can be beneficial to patients with phobias and panic disorder. Hydrotherapy, massage therapy , and aromatherapy are useful to some anxious patients because they can promote general relaxation of the nervous system. Popular aromatherapy prescriptions for anxiety relief include essential oils of lavender , ylang-ylang, and chamomile. Relaxation training, which is sometimes called anxiety management training, includes breathing exercises and similar techniques intended to help the patient prevent hyperventilation and relieve the muscle tension associated with the fight-or-flight reaction of anxiety. Yoga, aikido, t'ai chi, and dance therapy help patients work with the physical, as well as the emotional, tensions that either promote anxiety or are created by the anxiety.

Finally, patients can make certain lifestyle changes to help keep panic at bay, such as eliminating caffeine and alcohol, cocaine, amphetamines, and marijuana.

There are also homeopathic remedies that may be helpful by seeing a trained homeopathic practitioner.

Allopathic treatment

Most patients with panic disorder respond best to a combination of cognitive-behavioral therapy and medication. Cognitive-behavioral therapy usually runs from 12-15 sessions. It teaches patients:

• How to identify and alter thought patterns so as not to misconstrue bodily sensations, events, or situations as catastrophic.
• How to prepare for the situations and physical symptoms that trigger a panic attack.
• How to identify and change unrealistic self-talk (such as "I'm going to die!") that can worsen a panic attack.
• How to calm down and learn breathing exercises to counteract the physical symptoms of panic.
• How to gradually confront the frightening situation step by step until it becomes less terrifying.
• How to "desensitize" themselves to their own physical sensations, such as rapid heart rate.

At the same time, many people find that medications can help reduce or prevent panic attacks by changing the way certain chemicals interact in the brain. People with panic disorder usually notice whether or not the drug is effective within two months, but most people take medication for at least six months to a year.

Several kinds of drugs can reduce or prevent panic attacks, including:

• Selective serotonin reuptake inhibitor (SSRI) antipressants like paroxetine (Paxil) or fluoxetine (Prozac), some approved specifically for the treatment of panic.
• Tricyclic antidepressants such as clomipramine (Anafranil).
• Benzodiazepines such as alprazolam (Xanax) and clonazepam (Klonopin).

Expected results

While there may be occasional periods of improvement, the episodes of panic rarely disappear on their own. Fortunately, panic disorder responds very well to treatment; panic attacks decrease in up to 90% of people after six to eight weeks of a combination of cognitive-behavioral therapy and medication.

Unfortunately, many people with panic disorder never get the help they need. If untreated, panic disorder can last for years and may become so severe that a normal life is impossible. Many people who struggle with untreated panic disorder and try to hide their symptoms end up losing their friends, family, and jobs.

Prevention

There is no way to prevent the initial onset of panic attacks. Antidepressant drugs or benzodiazepines can prevent future panic attacks, especially when combined with cognitive-behavioral therapy. There is some suggestion that avoiding stimulants (including caffeine, alcohol, or over-the-counter cold medicines) may help prevent attacks as well.

Key Terms

Agoraphobia

Fear of open spaces.

Aromatherapy

The therapeutic use of plant-derived, aromatic essential oils to promote physical and psychological well-being.

Benzodiazepines

A class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety or panic.

Cognitive-behavioral therapy

A type of psychotherapy used to treat anxiety disorders (including panic disorder) that emphasizes behavioral change together with alteration of negative thought patterns.

Selective serotonin reuptake inhibitors (SSRIs)

A class of antidepressants used to treat panic that affects mood by boosting the levels of the brain chemical serotonin.

Tricyclic antidepressants

A class of antidepressants named for their three-ring structure that increase the levels of serotonin and other brain chemicals. They are used to treat depression and anxiety disorders, but have more side effects than the newer class of antidepressants called SSRIs.

Further Reading

For Your Information

Books

• Bloomfield, Harold H. Healing Anxiety with Herbs. New York: Harper Collins, 1998.
• Sheehan, Elaine. Anxiety, Phobias and Panic Attacks: Your Questions Answered. New York: Element, 1996.
• Wilson, Robert R. Don't Panic: Taking Control of Anxiety Attacks. New York: HarperCollins, 1996.

Periodicals

• Katerndahl, David A. "Panic Attacks and Panic Disorder." Journal of Family Practice 43 (September 1996): 275- 283.

Organizations

• Anxiety Disorders Association of America. 11900 Parklawn Dr., Ste. 100, Rockville, MD 20852. (301) 231-9350.
• Anxiety Network Homepage. http://www.anxietynetwork.com.
• National Institute of Mental Health, Anxiety Disorders Education Program. Rm 15C-05, 5600 Fishers Lane, Rockville, MD 20857. (800) 64-PANIC. http://www.nimh.nih.gov/anxiety.

Gale Encyclopedia of Alternative Medicine. Gale Group, 2001.