Dr. MJ Bazos MD,
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
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
Symptoms of Panic
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
- Difficulty breathing
- Flushes or chills
- Tingling or numbness in the hands
- Dreamlike sensations or perceptual distortions
- Fear of losing control and doing something
- 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
Proper Diagnosis Is
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
- 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
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
- 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.
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.
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
- 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.
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
Who Can Treat Panic
Panic disorder patients can
be treated by mental health professionals or by primary health care providers.
How To Talk To Your Patients About
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.