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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,
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
"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
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
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.
Chest Pain Or Discomfort
Tingling Numbness Of The Skin
Lump In Throat
Hot Or Cold Feeling
Feelings Of Unreality (Familiar Things Feel Odd)
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:
A few weeks or months prior to the first panic attack there are sometimes
minor symptoms such as rapid heart beat.
Is There Damage?
The first major panic attack occurs. The person often seeks emergency
medical evaluation at this time. The initial examination is commonly normal.
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.
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.
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:
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
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:
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.
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:
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.
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.
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
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) .
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
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
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.
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.
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
Call 1-800 64-PANIC and the NIH will send you free information about panic
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
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.