Panic Disorder (Panic Attacks)


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All of us experience minor degrees of panic from time to time. These feeling may be associated with a pending interview, presentation at work or an important social event.
A panic attack is much more severe. They typically last about 10 minutes and include the following symptoms:

  • Increased awareness of heart beating
  • An irregular, rapid, or pounding heartbeat
  • Perspiring
  • A sense of choking, suffocation, or shortness of breath
  • Vertigo or lightheadedness
  • Pain or other discomfort in the chest
  • A feeling that events are unreal or a sense of detachment
  • Numbness or tingling
  • Hot or cold flashes
  • A fear of impending death, though without basis in fact
  • Stomach nausea or upset
  • Thoughts of going insane or completely losing control

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The definition of a panic disorder from the Diagnostic and Statistic Manual IV (DSM-IV) is :

A panic attack is a discrete period of intense fear or discomfort, in which at least four (or more) of
the following symptoms developed abruptly and reached a peak within 10 minutes:

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, or faint
  • De-realization (feelings of unreality) or de-personalization (being detached from oneself)
  • Fear of losing control or going crazy
  • Fear of dying
  • Paraesthesiae (numbness or tingling sensations)
  • Chills or hot flushes

Why do people have panic attacks?

They are usually triggered by an event which causes some physiological symptoms of anxiety such as awareness of the heart beating (palpitations). This may be associated with other symptoms such as chest tightness or pain.  These symptoms are normal responses to anxiety provoking events (or even thoughts). They are caused by extra adrenaline being produced by the adrenal glands. The symptoms are misinterpreted by the person who believes that they are having a heart attack or other life threatening illness. These thoughts trigger worsening anxiety and the symptoms escalate. A vicious circle ensues with more adrenaline being produced which then worsens the symptoms and so on. There is a limit to how long the body can continue responding in this way and eventually the panic attack eases leaving the person exhausted. They then live in fear of the next attack.

Case example

“Michael had suffered panic attacks for 2 months. Here is his brief description: When my panic attacks start, I have chest tightness.  I feel as though I’m drowning or suffocating, and I begin to sweat; the fear overwhelms me. I  have to sit down in case I faint and feel like I’m going to die.”

Treatments for Panic Disorder

Pharmacological Treatments

Tricyclic Antidepressants:

These have been studied in many trials by psychologists. At least 15 trials have shown them to be effective in treating panic disorder and anxiety. The two drugs that have been shown to work are imipramine and clomipramine. The problem with tricyclic antidepressants is their troublesome side effects (e.g. blurred vision, weight gain and constipation).

Benzodiazepines:

Alprazolam was the first benzodiazepine to be approved by the US FDA for the treatment of panic disorder. Other drugs that have been shown to be effective in treating panic attacks are diazepam, lorazepam and clonazepam.
They are generally considered to be quick acting and safe. The main concerns are about tolerance, dependence and abuse. The main problem with prolonged benzodiazepine use is that patients develop physiological dependence that results in withdrawal symptoms (eg nervousness, sleep disturbance, dizzyness) when the drug is discontinued.

Selective Serotonin Reuptake Inhibitors (SSRIs)

These are currently considered the best choice of drug to treat panic disorder and PDA.  Many studies by psychologists  have demonstrated the effectiveness of the SSRIs, including paroxetine, citalopram, fluoxetine, fluvoxamine, and sertraline.

Studies comparing SSRIs with each other or with tricyclic antidepressants or benzodiazepines have been generally inconclusive with all treatments yielding similar results. Despite this SSRIs are generally preferred for treatment because they are better tolerated.

Other drugs:

Other medications that have been shown to work in treating panic disorder are: Mono amine oxidase inhibitor (MAOI) antidepressants and the SNRI antidepressant venlafaxine.

Psychological Treatments

Studies by psychologists have shown that the most effective psychological treatment for panic disorder is cognitive behavioural therapy. This treatment involves psychoeducation to explain the nature of the fight-or-flight response and the physiology of the anxiety system. Patients are taught that they experience “sensations” rather than “panics” and that these are harmless and normal. The second aim of  therapy is to pick out and challenge anxious beliefs and thoughts. The psychologist then works with the client to restructure and modify their thinking processes. Following this cognitive restructuring specific information about hyperventilation and its role in panic attacks is given. Some treatment programs then use the practice of breathing retraining but there is debate amongst psychologists about whether this part of the therapy is helpful. The final part of the the treatment involves repeated exposure to whatever it is that is causing the panic attacks. Clients are taught to practice the newly learnt thought patterns (cognitive restructuring) strategies, and they gradually learn to deal with the panic attacks. The success rate of this type of therapy has been shown to vary from about 40% to 90% in studies by psychologists. The success rate is usually about 70-80%.

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