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Panic Disorder: A Highly Treatable Disorder

The purpose of this material is to explain panic disorder. It may help you to decide if you have this disorder. If there is reason to suspect panic disorder, this document suggests a reasonable approach to take so that a proper diagnosis can be made and, if necessary, treatment begun.

A Case History

Ann was watching television after a typical workday. She suddenly developed a peculiar and very strong feeling of being lightheaded and a smothering sensation as if there were no oxygen in the air she was breathing. Then a surge of pounding rapid heartbeat began. It came on so quickly and was so severe that she became panicked that she might be dying of a heart attack! Then she felt very shaky, sweaty, and unsteady. This whole experience reached peak intensity within 60 seconds. This was the eighth such attack this month.


"Panic" was hardly the word to describe how terrified she was feeling. It went beyond any feeling of fear that she had ever experienced. Although she had gone to the emergency room several times, nothing seemed to be found by the doctors to explain why she kept having the attacks.

She frantically searched for her car keys so that she could get to the hospital immediately. She thought desperately, "What's wrong with me?" What It Feels Like.

The main symptom of a panic disorder is the panic attack itself.
panic disorder is a medical disorder characterized by severe and sudden episodes or "attacks" with several of the following symptoms:

    Panic, Fear Of Losing Control Or Dying
    Pounding Heartbeat
    Difficulty Breathing
    Smothering Sensation
    Chest Pain Or Discomfort
    Tingling Numbness Of The Skin
    Choking Sensation
    Lump In Throat
    Hot Or Cold Feeling
    Feelings Of Unreality (Familiar Things Feel Odd)
It is important to mention that sudden episodes of the above symptoms caused by another reasonable cause are not panic attacks. Two such reasonable causes would be (1) a certain medical ailment that might mimic a panic attack, or (2) a life threatening experience immediately preceding the attack. If these reasonable causes are found not be the cause of the problem then there is the possibility of a panic disorder.

Panic attacks reach maximum intensity within a minute or two once they begin. They diminish slowly-over the next 30 minutes or the next several hours. It is common for the first attack to cause a person to go to an emergency medical facility. Later attacks occur several times a month and are every bit as severe as the initial attack.

About three fourths of panic disorder patients are women. It seems to begin most frequently when people are 20-35 years old. It begins less often in teenagers or persons in their forties. It is uncommon for the disorder to appear in the elderly for the first time.

It is important to note that although a few experts say it is more common in persons who experienced a separation experience as a child, the majority of experts feel that panic disorder afflicts emotionally healthy people. Persons with panic disorder are no more likely than the average American to have suffered from emotional problems at the time the disorder begins.

Afraid of Something.

Persons experiencing repetitive, severe panic attacks may simply have panic attacks and that is all. Other persons may begin to experience a progression of bothersome or distressing panic attack "side effects". This progression commonly occurs as follows:

    1. A few weeks or months prior to the first panic attack there are sometimes minor symptoms such as rapid heart beat.

    2. The first major panic attack occurs. The person often seeks emergency medical evaluation at this time. The initial examination is commonly normal.

    3. Continued panic attacks cause the person to seek further medical evaluations which may overlook the seriousness of the problem. Numbers of panic attack sufferers go for as long as ten years before receiving the proper diagnosis and by that time may have seen over a dozen physicians, psychologists and counselors. This appearance of "doctor shopping" may cause others to regard the sufferer as a hypochondriac.

    4. An individual with panic disorder may begin to avoid a certain activity because it occurs to them that it would be especially embarrassing or dangerous to have an attack while engaged in that activity. A typical response would be, "It's bad enough to have an attack at all, but it would be dangerous to have one on Interstate 75 because I would be preoccupied with the attack and would not be a safe driver. I might wreck my car, injuring myself or someone else!" This avoidance behavior may appear to be a fear of driving when it is really a fear of having a panic attack while driving.

    5. Tendencies to avoid circumstances in everyday life may increase and extend to more activities. This extensive avoidance behavior is referred to as agoraphobia. Places, activities or circumstances frequently avoided by persons with panic disorder include the following:

      Shopping malls
      Department stores
      Being alone

    6. After months or years of continuous panic attacks and the restricted lifestyle caused by the typical avoidance behavior, the sufferer of Panic Disorder may become demoralized and psychologically or physically depressed.

    Some sufferers turn to alcohol in an attempt to self-medicate or to diminish the symptoms of the disorder. This greatly complicates the individual's life and ability to seek appropriate treatment.

    A recent study suggests that, tragically, one out of every five sufferers attempts to end his or her life, never realizing that there was hope and treatment available.

Is There Damage?

A person will not die from a panic attack. But, panic disorder does indeed cause damage. It would be difficult to estimate the misery and loss of overall productivity that this disorder causes. There is personal pain and humiliation and a restricted lifestyle. There are missed days of work due to panic attacks. There may be unemployment due to partial or complete disability. There is increased risk of alcoholism and suicide.

Add the unhappiness the disorder causes in the loved ones of panic disorder and the consequential loss of their productivity. You come to realize that the total magnitude of the damage that the disorder causes nationally is staggering. And we haven't even touched on the tremendous cost that the waste of misdiagnosis and unnecessary or inappropriate medical care adds to the damage estimate. Drug and alcohol abuse are the number one public concern of Americans. However, Anxiety Disorders affect more Americans than the combined toll of drug and alcohol abuse. And yet Anxiety Disorders are not even in the top fifty of Americans' public concerns The federal government has developed a plan to deal with this problem.

Causes & Treatment

What causes panic disorder?

Twenty years ago panic disorder was poorly understood even by most experts. It was called Anxiety Neurosis and was thought by some to stem from "deeply rooted" psychological conflicts and subconscious upsetting impulses of a sexual nature.

Now we regard panic disorder as more of a physical problem with a metabolic core. It is not an emotional problem, although after suffering from it, emotionally healthy persons may develop depression or other problems. There are different theories about where in the nervous system the problem exists.

There is considerable evidence pointing toward an abnormality in the function of the locus ceruleus and its associated nerve pathways. The locus ceruleus is a tiny nerve center in the brainstem (the part of the brain that controls heartbeat, breathing and other vital functions).

A few experts still cling to the notion that this is not a physical disorder. The overwhelming opinion by the experts is that scientific evidence clearly favors there being a physical cause of this disorder. It is regarded as a physical disorder much like Diabetes or Pneumonia.

There is Hope and Help

Is there hope for persons with panic disorder? Panic disorder is very treatable. And nearly everyone so treated responds well. Treatment consists of several steps:

A. First a person must be educated about this disorder. Simply learning some of the things mentioned in this brochure will improve matters somewhat by giving hope where there perhaps was despair. Understanding and knowledge gives confidence and a positive expectation so important to the success of any medical treatment.

B. Next, it is necessary to find a medication which can eliminate the panic attacks completely, if at all possible. Psychiatrists experienced in treating panic disorder have had success using any one of three kinds of medicines:

    1. High Potency Benzodiazepine Tranquilizers. Some examples are alprazolam, lorazepam and clonazepam. Alprazolam (trade name Xanax) is the most thoroughly studied of this group. It was approved for use in panic disorder by the FDA in 1990. These medicines are quite effective and have few side effects at proper doses. They block panic attacks almost immediately in the first day or two of treatment.

    Several dosage increases over a period of several weeks are customary. Ultimately no further increases are required.

    Public concern about such medicines being dangerously addictive is unduly exaggerated in the case of persons with panic disorder.

    Scientific evidence shows surprisingly low rates of abuse of this and other medicines in persons with panic disorder. Physical dependence can develop with such medicines at larger dosages. The person who chooses such medicine for this disorder should accept the fact that they may require higher doses and may therefore be physically dependent on the medicine. They must not abruptly cease taking their medicine. Doing so would result in withdrawal symptoms. One does not abruptly stop such medicine. When it comes time to go off medicine it is decreased gradually by tiny reductions every one to three weeks). High Potency Benzodiazepine Tranquilizers are relatively expensive medications.

    2. Certain Antidepressants. Imipramine (one trade name is Tofranil) and fluoxetine (trade name Prozac) are examples of old and new antidepressants that are useful in treating panic disorder. Though approved by the FDA for treating depression, most antidepressants will block panic attacks. Physical dependence does not occur on such medicine.

    Successful treatment requires maximum dosage and it usually takes four to eight weeks for the medicine to begin to block the panic attacks. Perhaps half of persons trying this type of medicine are made initially worse to some degree. Certain properties of the medicines tend to trigger more than the usual number of attacks in the first couple of weeks or so. But this discomfort may have to be considered a short term investment in return for a long term gain of recovery. As a rule, the less expensive antidepressants (Tofranil) have more bothersome side effects than the newer more expensive ones (Prozac) .

    3. Phenelzine (trade name Nardil). This unique medicine, though more effective than any other medicine for this disorder, is rather complicated to use. It may be best to reserve it for cases where simpler medications have failed or cannot be used for some reason. Nardil is a safe medicine when used by an experienced physician in a patient who complies with the necessary diet and medication restrictions. Unsafe elevations of blood pressure for several hours can occur if one does not adhere to these restrictions while taking Nardil.

C. Once the panic attacks have been successfully blocked completely for about three months panic disorder patients usually get back to normal life without any additional assistance. However, many do not automatically overcome their tendencies to avoid the situations that they have been evading. Success in such patients is achieved by organizing a systematic approach of doing the very things that have been avoided. You begin going into the least difficult of avoided places. This exposure to the feared situations is practiced repeatedly until you are reasonably comfortable. Then proceed to the next more difficult avoided activity.

This highly successful approach is a common sense method based on the old adage "If you fall off the horse, get right back on." This cognitive behavior therapy approach may be helpful in resolving such fears. The person discovers that he can indeed perform the avoided activities and the medication prevents the attacks from occurring. Confidence is restored and normal life resumes with security, peace of mind and a sense that one is in control once again.

Seeking Help.

What Kind of Doctor Should I See to Get Help?

The first step should be to have a medical evaluation to determine the proper diagnosis. Your family physician is the good place to start. Tell him or her what has been happening to you and that you wonder if you might have panic disorder. Show the doctor this brochure. After evaluating you perhaps he or she will tell you that you do have a case of panic disorder. Then what? You may wish to see a psychiatrist. Psychiatrists are physicians (MD's). A psychiatrist who is experienced in treating panic disorder is the most qualified single professional to deal with the problem. There is a national shortage of psychiatrists. There may not be one in your area. In that case, seeing your regular doctor for medication to stop the attacks and consulting a psychologist, if necessary, for behavior therapy may work out nicely. Psychologists are not physicians (instead of M.D., they may have other abbreviations after their name such as Ph.D. or Ed.D. or Psy.D.). If a psychologist isn't available for behavior therapy, a social worker who is familiar with this therapy may be helpful. The Prognosis.

Remember, panic disorder is a serious but highly treatable medical illness. Almost everyone responds well to treatment and can return to normal functioning in weeks or months.

Reading Suggestions

The Anxiety Disease. David Sheehan M.D. Bantam Books in paperback, 1986. ---This is a fantastic book on panic disorder, and nobody with the disorder should go without having this one. It takes a very scientific approach to the disorder and explains in layperson terms the scientific facts regarding the cause and treatment of this afliction.

Panic Disorder. W. Kernodle - this up to date book is newer than most books on panic disorder. It explains the disorder from the medical perspective. It is a great book and I think it, with Dr. Sheehans book, gives a very complete and modern perspective to those wanting solutions for their problem.

Anxiety And Its Treatment. J. Greist M.D. and James Jefferson M.D. , and Isaac Marks, M.D. Warner Books, in paperback, 1986. --- This is a nice concise book which tries to address all the anxiety disorders. It focuses some on medication, a lot on behavior therapy and a great deal on self help. It is a quality work written by two of the big names in the anxiety field: Dr. Greist is an internationally recognized expert on obsessive compulsive disorder. Dr Marks is an expert on behavior therapy.

Anxiety. Goodwin, D.W. M.D., New York: Oxford University Press, 1986.

Further Information

Call 1-800 64-PANIC and the NIH will send you free information about panic disorder.

The National Anxiety Foundationan (NAF) is an additional source of information. Send $2 with a self addressed business envelope (the long regular envelopes that are 9 1/2 inches long and 4 inches wide) to NAF 3135 Custer Drive Lexington Ky 40517) for a booklet about panic disorder or OCD (obsessive compulsive disorder).

Information provided by:
National Anxiety Foundation, 3135 Custer Dr., Lexington, KY 40517-4001

For more information call NAF at (606) 272-7166 or (800) 755-1576.