Dr. MJ Bazos MD,
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
Who Has Panic
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
Symptoms and Course of
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.
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
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.
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,
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.
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
Strategies for Coping
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.
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
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.
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
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.
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
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
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.
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
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
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
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
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.
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.
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.
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
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.
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
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
(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
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.
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
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
Also, it may be valuable
for family members to join or form a support group to share information and
offer mutual encouragement.