Psychiatric Associates

Panic Disorder

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What is Panic Disorder?

       Panic Disorder is a real illness that can be successfully diagnosed and treated. It's characterized by sudden and unexpected attacks of terror called Panic Attacks that are sometimes so severe that sufferers believe that they're dying, losing control, or going crazy. Sufferers can't predict when or where an attack will occur, and so spend their time between episodes worrying intensely about having another attack. An attack usually peaks within 10 minutes, but some symptoms may last much longer. People having Panic Attacks sometimes believe that they're having heart attacks and go to an Emergency Room, where they’re often misdiagnosed as having a medical condition or told that it’s all in their heads. Panic Attacks can occur anywhere from a few times a year to several times a day.
 
       Panic Disorder affects about six million American adults and is twice as common in women as in 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. Some people's lives become so restricted by their fears of having Panic Attacks that they avoid normal activities, such as shopping or traveling.

One Person's Story:
 
       "One day, without any warning and for no particular reason, I felt terrified. I was so afraid that I thought I was going to die. My heart was pounding, my head was spinning, I felt disconnected from reality, and I couldn't catch my breath. I would get these feelings every couple of weeks. I thought I was losing my mind. The more often it happened, the more afraid I became. I was always living in fear. I didn't know when I might have the next attack. I became so afraid that I didn't want to leave home. I was afraid to go back to any place where I'd had an attack.
 
       " It all started 10 years ago. I'd just graduated from college and started my first real job. I was sitting in a staff meeting and these feelings came out of the blue. I felt like I was having a heart attack. I left in the middle of the meeting and dialed 911. An ambulance came and took me to the ER. I was examined and given an EKG, but they couldn't find anything wrong. They told me it was all in my head and sent me home.
 
       " My fiancée saw how afraid I was and convinced me to call my family doctor. He told me that I had Panic Disorder. He prescribed medication that helped me feel less afraid. I've also been seeing a therapist to learn ways to cope with my fears. I have to work hard and it's scary, but I'm starting to feel like my old self again."
 
What are the symptoms of Panic Disorder?

       Panic Disorder is characterized by Panic Attacks that seem to come out of nowhere. Panic Attacks are sudden attacks of terror accompanied by at least four of the following:
  • an irregular heart beat, a pounding heart, or accelerated heart rate;
  • sweating;
  • trembling or shaking;
  • sensations of shortness of breath or smothering;
  • a feeling of choking;
  • chest pain or discomfort;
  • nausea or abdominal distress;
  • feeling dizzy, unsteady, lightheaded, or faint;
  • derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself);
  • fear of losing control or going crazy;
  • fear of dying;
  • paresthesias (numbness or tingling sensations, especially in the hands, feet, and/or face);
  • and chills or hot flushes.
What types of Panic Disorders are there?
 
       There are two types of Panic Disorder: Panic Disorder Without Agoraphobia and Panic Disorder With Agoraphobia. In Panic Disorder Without Agoraphobia, the person experiences recurrent unexpected Panic Attacks followed by one month of one or more of the following:
  • persistent concern about having additional attacks;
  • worry about the implications of the attack or its consequences (losing control, having a heart attack, or "going crazy");
  • and/or a significant change in behavior related to the attacks.
       In Panic Disorder With Agoraphobia, the sufferer experiences Panic Disorder and also Agoraphobia. Agoraphobia, which can also occur by itself, is characterized by fear of being alone in public places, especially places from which escape would be difficult if the person had a Panic Attack. Agoraphobia can be the most disabling of the Phobias, since it may significantly interfere with a person’s ability to function outside the home. Agoraphobia sufferers prefer to be accompanied by a friend, family member, or other trusted companion in such places as busy streets; crowded stores; closed-in spaces such as tunnels, bridges, and elevators; and closed-in vehicles such as subways, buses, and airplanes. They may insist on being accompanied every time that they leave home. People with severe Agoraphobia may simply refuse to leave home at all. People who develop Agoraphobia can become very disabled by it and should seek treatment as soon as possible.
 
What disorders often accompany Anxiety Disorder?

       Panic Disorder commonly occurs along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the Panic Disorder. Medical illnesses accompanying Panic Disorder include but aren't limited to dizziness, cardiac arrhythmias, hyperthyroidism, asthma, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). Mitral valve prolapse and thyroid disease are more common among individuals with Panic Disorder. Other Anxiety Disorders are also common, especially in those with more severe symptoms. Social Phobia and GAD have been reported in 15% to 30% of those with Panic Disorder, Specific Phobia in 2% to 20%, and OCD in up to 10%.

What causes Panic Disorder?

       There's no single cause for Panic Disorder. Rather, it most likely results from a combination of genetic, biochemical, environmental, and psychological factors. Panic Disorder is a disorder of the brain. Brain-imaging scans such as magnetic resonance imaging (MRI) have shown that the parts of the brain responsible for regulating mood, thought, sleep, appetite, and behavior function abnormally in people with Panic Disorder. In addition, important neurotransmitters (chemical messengers) are out of balance. This knowledge doesn't explain WHY people develop Panic Disorder, however.

       Studies of twins indicate that if one develops Panic Disorder the other is highly likely to as well, suggesting a genetic component. People who have relatives with Panic Disorder are up to eight times more likely to develop Panic Disorder than people who don't. When Panic Disorder develops in childhood or adolescence the likelihood rises to twenty times. Panic Disorder also occurs in people without family histories of anxiety, however. The probability that anyone will experience Panic Disorder results from the interaction between multiple genes and environmental or other factors. In addition, trauma, the loss of a loved one, a difficult relationship, or any other significantly stressful situation may trigger Panic Disorder. Subsequent episodes of Panic Disorder may not have an identifiable trigger, though.

How is Panic Disorder diagnosed?

       Panic Disorder is one of the most treatable of all the Anxiety Disorders, responding in most cases to certain kinds of medications or certain kinds of psychotherapy, which helps change thinking patterns that lead to fear and anxiety. Even the most severe Panic Disorder is highly treatable. As is true of most medical and psychological disorders, the earlier that treatment begins the more effective it is and the higher the likelihood that recurrences can be prevented.

       The first step toward getting help is to see your Primary Care Provider (PCP), the medical provider whom you see for other disorders. Certain medications and medical conditions can cause the same symptoms as Panic Disorder. Your PCP can rule out these conditions by conducting a physical examination, asking questions, and/or ordering lab tests. If medications and medical conditions can be ruled out, your PCP will then prescribe an appropriate medication and/or refer you to a mental health professional for further evaluation.

       A mental health professional will conduct a complete diagnostic evaluation, including a discussion of any family history of Panic Disorder, other Anxiety Disorders, and other psychological disorders and a complete history of symptoms. This history will include when your Panic Attacks started; how long you've been having Panic Attacks; how severely anxious you are; whether or not you've had Panic Disorder or another Anxiety Disorder before; if so whether or not you received treatment and how successful that treatment was; whether or not alcohol and/or substance abuse are involved; whether or not there are other psychological disorders present; and whether or not you feel suicidal and/or are planning to harm or kill yourself.  

How is Panic Disorder treated?

       Effective therapies for Panic Disorder are available, and research is uncovering new treatments that can help most people with Panic Disorder lead productive, fulfilling lives. The most common treatments are medication, psychotherapy, and a combination of the two. Medication can’t cure Panic Disorder, but it can keep it under control while you participate in psychotherapy. The most common medications used to treat Panic Disorders are antidepressants, anti-anxiety drugs, and beta-blockers. Antidepressant medications were developed to treat depression but are also effective for anxiety. Although these medications begin to alter brain chemistry after the very first dose, their full effects require a series of changes to occur in the brain, so it usually take about four to six weeks for symptoms to begin to fade. It’s therefore important to take an antidepressant long enough for it to work for you.

       Antidepressants normalize the functioning of neurotransmitters (chemical messengers) in the brain, primarily serotonin, norepinephrine, and dopamine. These particular chemical messengers are involved in regulating mood, although there's still no complete understanding of how this occurs. These medications include newer types, such selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), and older types, such as tricyclics/tetracyclics (TCAs) and monoamine oxidase inhibitors (MAOIs). Wellbutrin (bupropion) is a unique antidepressant, unrelated to any other, which, while it's more effective for depression than anxiety, is sometimes used to treat anxiety by itself or in conjunction with an SSRI.
 
       Anti-anxiety medications, primarily benzodiazepines, reduce daytime anxiety and excessive excitement and generally quiet or calm people. At low doses they have few side effects other than drowsiness and dizziness; at higher doses they produce significant drowsiness and facilitate sleep. (WARNING; It is especially important to limit or better yet avoid alcohol while taking any benzodiazepine.) Because they are potentially addictive, benzodiazepines are typically prescribed for only short periods of time, especially for people with histories of alcohol and/or drug abuse. An exception to this is people with Panic Disorder, who can generally take benzodiazepines for up to a year without risk of harm. Some people experience withdrawal or discontinuation symptoms if they stop taking benzodiazepines abruptly instead of tapering off of them gradually. Some also experience rebound anxiety, a resurgence of anxiety stronger than they felt before starting on the medication. Unfortunately, these problems inhibit some Primary Care Providers from prescribing benzodiazepines in adequate doses or, in some cases, prescribing them at all. Buspar (buspirone), which is not a benzodiazepine, is a unique antianxiety medication primarily used to treat Generalized Anxiety Disorder (GAD). Beta blockers such as Inderal (propranolol) are used to treat heart conditions, but can also be used to prevent the physical symptoms of Panic Disorder. If one medication doesn't work, be open to trying another. People who don't improve after taking one medication increase their chances of getting better by switching to a different medication or adding a second medication.

       Psychotherapy involves talking with a trained mental health professional, such as a Counselor, Psychiatrist, Psychologist, or Social Worker, to explore what is causing the Panic Disorder and how to manage or eliminate the symptoms. Some types of psychotherapy are short-term (10 to 20 weeks) and others are long-term (more than 20 weeks). Which might be suitable for you can be determined between you and the mental health professional whom you see. There are many types of psychotherapy, all of which can be effective in treating Panic Disorder, but two types, Cognitive-Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), have well-established histories of being effective. CBT helps people change negative and self-critical styles of thinking and behaving that contribute to or worsen anxiety, replacing them with more positive, functional, and adaptive ways. For example, CBT can help people experiencing Panic Disorder learn that their Panic Attacks are not really heart attacks. CBT often lasts about 12 weeks. Research indicates that the effects of CBT last longer than those of treatment with medication for people with Panic Disorder. If CBT is effective, a recurrence of the disorder can often be effectively treated quickly and easily with a brief refresher. IPT helps people understand and work through dysfunctional and/or maladaptive relationships that contribute to or worsen anxiety. It emphasizes the relationships between a person and other people rather than that person’s internal psychological processes. It’s intended to change the person’s symptoms by helping him deal more realistically and effectively with his family, marital, parental, and work situations.
 
       For those who are mildly or moderately anxious, psychotherapy alone is often the best treatment option. However, for certain people, especially those who are severely anxious, a combination of psychotherapy and medication may be necessary.
 
How can I help someone who is suffering from Panic Disorder?

       If you know someone who has suffers from Panic Disorder, odds are that his or her anxiety affects you, too. The first and most important thing that you can do to help a friend, family member, or coworker who has Panic Disorder is to help him get diagnosed and treated. You might have to schedule an appointment on behalf of the person or even go with him to see a provider. Encourage him to stay in treatment or to seek different treatment if no improvement occurs after six to eight weeks of medication or eight to 12 weeks of psychotherapy. In addition:
  • don’t downplay or trivialize the anxiety;
  • don’t demand improvement if the person isn't in treatment;
  • offer emotional support, understanding, and patience;
  • engage the person in conversation and, most importantly, listen nonjudgmentally;
  • never criticize or belittle feelings the person expresses, but rather point out realities and offer hope;
  • never ignore comments about suicide. Encourage the person to share these thoughts with his provider and/or mental health professional, and report them yourself if you believe the person won't;
  • invite the person to participate in walks, outings, and other activities. Keep trying even if he declines, but don't push him to do too much too soon. Making the person feel as if you have too many expectations of him may inadvertently cause feelings of failure;
  • and remind the person that with time and treatment the anxiety will inevitably improve.
© 2010
Dr. Thomas E. Hranilovich
Licensed Psychologist

Psychiatric Associates / 4084 Okemos Rd. / Suite A / Okemos, MI 48864
Phone: (517) 347-4848 / Fax: (517) 347-4844