Panic Disorder

Panic disorder is characterized by uncontrollable episodes of fear and its physical manifestations, such as heart palpitations, sweating, and dizziness. Worry about having an panic attack may bring about the additional stress of chronic anxiety.

Definition

A person with panic disorder experiences sudden and repeated episodes of intense fear accompanied by physical symptoms such as chest pain, heart palpitations, breathlessness, vertigo or abdominal distress. Because these symptoms are so similar to those of a heart attack or other life-threatening medical conditions, panic disorder may not be diagnosed until extensive and expensive medical tests have ruled out other serious illnesses.

Even between panic attacks, it is common for sufferers to be extremely anxious. These people often develop phobias about places such as shopping malls—where previous episodes have occurred. They also develop fears about experiences that have set off an attack, such as an airplane flight. As panic attacks become more frequent, the person may begin to shun situations that might trigger another episode. This avoidance may lead to agoraphobia, the inability to leave familiar, safe surroundings because of intense fear and anxiety.

Panic disorder affects about 6 million American adults and is twice as common in women as men. Panic attacks often begin in late adolescence or early adulthood, but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited.

Symptoms

A panic attack begins suddenly, and most often peaks within 10 - 20 minutes. Some symptoms may linger for 1 or more hours afterwards. During a panic attack, the person believes he or she is "going crazy," having a heart attack, or about to die. Panic attacks cannot be predicted. At least in the early stages of the disorder, there is no cue or trigger that starts the attack. Recalling a past attack may trigger panic attacks. How often and in what pattern they occur can vary. Panic attacks may include anxiety about being in a situation where an escape may be difficult (such as being in a crowd or traveling in a car or bus). A person with panic disorder often lives in fear of another attack, and may be afraid to be alone or far from medical help.

To be formally diagnosed with panic disorder, a patient must have experienced either four panic attacks in four weeks, or one or more attacks followed by at least a month of continual anxiety about having another episode. With panic disorder, at least four of these symptoms occur during an attack:

• Palpitations, pounding heart, or accelerated heart rate• Sweating• Trembling or shaking• Shortness of breath or a sensation of smothering• A choking feeling• Chest pain or discomfort• Nausea or abdominal distress• Feeling dizzy, unsteady, lightheaded, or faint• Feeling detached from oneself or unreality• Fear of losing control or impending doom• Fear of dying• Numbness or tingling sensation• Chills or hot flashes

Panic attacks may change behavior and function at home, school, or work. People with the disorder often worry about the effects of their panic attacks. People with panic disorder may have symptoms of alcoholism, depression and/or drug abuse.

Causes

Heredity, other biological factors, stressful events, and thinking that magnifies normal reactions can all play a role in the onset of panic disorder. Although the precise causes are still unknown, they are the subject of many scientific studies. Some studies suggest that if one identical twin has panic disorder, the other twin will also develop the condition 40% of the time. However, panic disorder often occurs when there is no family history.

Researchers have conducted both animal and human studies to pinpoint the particular parts of the brain that are involved in anxiety and fear. Because fear evolved to deal with danger, it sets off an immediate protective response without conscious thought. This fear response is believed to be coordinated by the amygdala, a structure deep inside the brain. Although relatively small, the amygdala is quite complex, and recent studies suggest that anxiety disorders may be associated with abnormal activity in the amygdala.

Treatments

Panic disorder is treated with medications and cognitive-behavioral therapy (see below), a type of psychotherapy that teaches patients to view their attacks in a different way and demonstrates how to reduce anxiety. Appropriate treatment by an experienced professional can reduce or prevent panic attacks in 70 to 90 percent of people with the disorder. Most patients show significant progress after just a few weeks of therapy. Relapses may occur, but they can be treated effectively.

Antidepressants

Several medications initially approved to treat depression have been found to be effective for relieving panic disorder. These antidepressants must be taken for several weeks before symptoms begin to disappear. Patients must not get discouraged or stop taking their medications, which need time to work.

Among the latest antidepressants are the selective serotonin reuptake inhibitors, or SSRIs. These work in the brain on a chemical messenger called serotonin. SSRIs tend to have fewer side effects than the earlier generation of antidepressants. Patients may be slightly nauseated or jittery when they first take SSRIs, but in time that feeling goes away. Sexual dysfunction may be a side effect of these antidepressants, but an adjustment in dosage or a switch to another SSRI may correct the problem. Patients should discuss all side effects with their doctor so that any needed changes in medication can be made.

SSRIs commonly prescribed for panic disorder include Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®). SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. An initial low dose of these medications is gradually increased until it has a beneficial effect. SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.

The antidepressants known as tricyclics are also taken at low doses, and are slowly increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating panic disorders. They are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics can have side effects such as dizziness, drowsiness, dry mouth, and weight gain. If these problems persist, the patient may request a change in dosage or a switch in medications.

The oldest generation of antidepressant medications is the monoamine oxidase inhibitors, or MAOIs. Phenelzine, the most commonly prescribed MAOI, is helpful for patients with panic disorder. People who take MAOIs must watch their diet because these antidepressants can interact with some foods and beverages, including cheese and red wine, which contain a chemical called tyramine. MAOIs also interact with certain other medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anti-Anxiety Medications

The group of anti-anxiety medications known as benzodiazepines, including alprazolam (Xanax®) and lorazepam (Ativan®), may be prescribed for patients with panic disorder. These drugs alleviate symptoms quickly and have few side effects other than drowsiness, but because people can develop a tolerance to them-and would have to increase the dosage to keep getting the same effect-they are generally prescribed only for short time periods. Because of dependency issues, they are not recommended for patients who have abused drugs or alcohol. Reducing the dosage gradually should prevent possible withdrawal symptoms in patients going off benzodiazepines, but their anxiety may return once they stop taking the medication. Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.

Taking Medications*

Before taking medication for an anxiety disorder:• Ask your doctor to tell you about the effects and side effects of the drug.• Tell your doctor about any alternative therapies or over-the-counter medications you are using.• Ask your doctor when and how the medication should be stopped. Some drugs can't be stopped abruptly but must be tapered off slowly under a doctor's supervision.• Work with your doctor to determine which medication is right for you and what dosage is best.• Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

Cognitive-Behavioral and Behavioral Therapy

One form of psychotherapy that has been shown to be effective in treating several anxiety disorders, including panic, is cognitive-behavioral therapy (CBT). A major goal of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that trigger panic. It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her attacks are not really heart problems as previously feared; the tendency to put the worst possible interpretation on physical symptoms can be overcome.

The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. The therapist helps the patient to cope with the resultant anxiety. Eventually, after this exercise has been repeated a number of times, anxiety will diminish. If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.

To be effective, CBT or behavioral therapy must be directed at the person's specific anxieties and it is necessary to tailor it to the person's particular concerns. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign "homework"-specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder. Common parts of this therapy include:

• Gaining understanding of and control over distorted views of life stressors, such as other people's behavior or life events. • Learning to recognize and replace panic-causing thoughts to decrease the sense of helplessness. • Learning stress management and relaxation techniques to help when symptoms occur. • Practicing systematic desensitization and exposure therapy, in which you are asked to relax, then imagine the things that cause the anxiety, working from the least fearful to the most fearful. Gradual exposure to the real-life situation also has been used with success to help people overcome their fears.

If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time. Medication may be combined with psychotherapy, and for many people this is the best approach to treatment.

Sources

  • Archives of General Psychiatry
  • National Institutes of Health - National Library of Medicine
  • National Institute of Mental Health
  • Psychiatric disorders in America: the Epidemiologic Catchment Area Study
  • US Department of Health and Human Services
Last reviewed 11/24/2014