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Panic Disorders: Part 1

The spectrum of disorders associated with panic

The Spectrum of Disorders Associated with Panic
Panic attacks are among the most terrifying experiences a person can have. Panic disorders include panic with and without agoraphobia, simple phobia, posttraumatic stress disorder, and perhaps social phobias. The controversy over whether these disorders are closely related, and in what way is not addressed, since the research in this area is inconsistent and inconclusive. The focus here is on the current understanding of the biological underpinnings of the panic attack itself, as well as the psychosocial aspects of panic disorder.
Diagnostic Considerations

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Symptoms of panic disorder, according to the DSM IV, include two broad categories. First, a subjective sense of terror, going crazy, losing control, or dying must be present. Second, accompanying the subjective criteria, are a host of symptoms of hyperarousal of various body systems including cardiovascular (rapid pulse, palpitations, lightheadedness), respiratory (sighing, hyperventilation, shortness of breath, subjective sense of difficulty breathing or breathlessness), gastrointestinal (dry mouth, nausea, vomiting, diarrhea) urogenital (urge to urinate), cognitive (trouble thinking clearly), dermatologic (sweating, clamminess, flushing) and neurological (tremulousness, tingling, trouble with speech, dizziness, dissociation). Panic attacks may be spontaneous (ie without provocation of a situation or thought) or triggered.

Associated Features of Panic Disorders
Once a person has developed panic attacks a series of consequences may follow. He or she is likely to try to avoid situations that either would trigger panic (as in phobic panic) or place themselves in a situation where help might not be available. Since the patients with spontaneous panic would feel shortness of breath and suffocation feelings as a first symptom, they would be fearful of being in any situation that would impair their ability to either get help (if they felt they were suffocating) or to get fresh air. Eventually, perhaps thru a kindling mechanism caused by repetitive firing of the involved nuclei, a sense of anticipatory anxiety (fear of the possibility of a panic attack) would lead to constant over activity of parts of the brain involved in anticipatory fear (the raphe nucleus in the brain stem). This anticipatory anxiety component is not treatable by older medications such as imipramine (which was one of the first medications effective for panic). It requires other medications such as buspirone (Buspar) which act on the serotonin receptors of raphe nucleus neurons, or benzodiazepines, such as clonazepam (Klonopin) which act on other brain regions that mediate general levels of anxiety via the GABA (inhibitory) neurons and receptors. Some people with a triggered panic attack take a counter-phobic response, so for example, someone who has a panic attack when speaking in public, joins Toastmasters. In my case, when I was young (around 19) I needed to earn some money, so I took a job that involved climbing up 20 foot ladders (they seemed like they were 50 feet tall). At first I felt panicky (not a full panic), and so I desensitized myself by slowly going up the ladder, bit by bit. By the end of the first day, I was able to climb the ladder in a relaxed state of mind. Desensitization works only when there is a sense of control, ie, that one way or another, if you need to, you can terminate the panic.

Medical Conditions Associated with Panic Disorder
Patients with panic disorder have a higher likelihood of having mitral valve prolapse (MVP). MVP is a weakness of one of the valves of the heart. It is relatively benign, but does occasionally produce abnormal sensations including pounding heart, rapid heart rate, lightheadedness, dizziness, fainting, fatigue, difficulty breathing and chest pain. In one study, 34% of panic disorder patients had MVP. One of my first patients had a panic disorder which did not respond at all to any of the usual treatments (cognitive behavioral therapy, and various medication trials) and it turned out that she had a severe B12 deficiency. Her panic cleared completely with the first B12 injection. Other patients may have an underlying have seizure disorder (e.g., temporal lobe syndrome), adrenal or thyroid dysfunctions, with PMS, post-partum, post -menopausal, and with significant inflammation or infection (which alters brain production of serotonin, dopamine and glutamate). I recall one woman who had chronic inflammation as a result of both a chronic sinus condition and work in a very moldy environment.
Patients with bipolar disorder have a 20% chance of having a panic disorder and panic disorder is associated with increased risk of suicide, major depression and other anxiety disorders. Patients with panic disorder have a significantly higher rate of gastrointestinal complaints, such as irritable bowel syndrome . In general most panic disorder patients tend to describe themselves as always having been fearful and shy as children, have discomfort with aggression, and low self esteem. This description is reminiscent of the discussion on temperament.

 

Robert J. Hedaya, M.D., D.F.A.P.A., is a Clinical Professor of Psychiatry at the Georgetown University Hospital and Founder of the National Center for Whole Psychiatry.

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