Panic Disorder It’s Characteristics & Treatments
By Maureen L. Whittal, Ph.D., R.Psych
This article is reissued from the Winter 2005 Strides newsletter. Some of the information may be dated.
Imagine that you are sitting watching television and out of the blue your heart starts pounding, you are dizzy, you begin to sweat and it feels as if you are going to run out of air to breathe. As you are trying to catch your breath you begin to notice that your chest is tight then your arms and hands go numb and it feels like you are having an out of body experience. Your worst fear is coming true - ‘I'm having a heart attack and I won't be able to get to the hospital in time'.
If these episodes happen repeatedly you may be experiencing panic disorder (PD). PD involves the presence of repeated sudden rushes of intense fear along with the presence of a number of physical sensations that can be broadly described as falling into 1 of 3 categories: (1) respiratory (e.g., shortness of breath, derealization/depersonalization, dizziness), (2) cardiovascular (e.g., chest tightness, increased heart rate, sweating) and (3) gastrointestinal (nausea, diarrhea). The time from onset of the symptoms to when they are at their worst is quick, often with a few seconds, but typically within 5 minutes. They usually remain at their peak for 3-5 minutes, although it can seem like an eternity in the midst of a panic attack. However, the effects of an attack can last for a few hours.
Because these symptoms come on so fast with no apparent reason, it is natural to be frightened. People often think the worst - that they have some serious physical illness that might lead to death or that they are going crazy, or that they may do something uncontrollable and embarrass themselves. Understandably, people who experience repeated panic attacks often begin avoiding places or situations that are associated with the attacks, which is called agoraphobia. Typical situations that people avoid include crowds, driving, bridges/tunnels, malls, grocery stores, being by themselves. Sometimes the avoidance can be subtle (e.g. only going to the grocery store late at night or early in the morning when it is not busy, choosing an aisle seat near the exit in a theatre) or carry with them, items that make going out easier. These safety signals include medication, cell phones, vomit bags, water etc. People can also avoid sensations that remind them of the physical symptoms associated with panic (e.g., getting overheated, caffeine, alcohol, seeing scary movies, getting angry).
It is important to recognize the panic attacks are not unique to panic disorder. It is possible to have panic attacks if you have another anxiety disorder. For example, if the attacks happen only when you are worried about being evaluated negatively in a social situation, a diagnosis of social anxiety disorder may be more appropriate. Likewise, if you panic only when you leave the house and are worried that you might have left the door unlocked, obsessive-compulsive disorder is a more likely diagnosis. However, if you begin to fear the physical sensations themselves and develop anticipatory anxiety about future panic attacks, then panic disorder is the most likely diagnosis.
Treatment of panic disorder with or without agoraphobia Effective treatment of PD(A) falls into broad classes: medication and cognitive behavioral therapy (CBT) Medications:There are a number of medications that have been shown to be effective for PD(A) in research studies and many of those considered are the antidepressants known as selective serotonin reuptake inhibitors (SSRIs). Examples include Prozac, Luvox, Paxil and Celexa. Another class of medications that has been used in the treatment of PD(A) are benzodiazepines (e.g., Xanax, Ativan, and Klonopin). The benzodiazepines are used less frequently because they are addictive and can lead to inappropriate use.
Some of the benefits of medications include their wide availability (they can be prescribed by your family doctor) and they can be relatively inexpensive. However, many people experience negative side effects such as weight gain and sexual dysfunction. Occasionally people have problems coming off SSRIs and benzodiazepines as it is associated with increased physical sensations that people interpret as frightening. Cognitive-behavioral therapy.
CBT is the psychological treatment of choice for panic. Treatment begins with an explanation of what maintains panic, or what keeps it going. It is thought that people who have PD(A) experience a "catastrophic misinterpretation" of normal bodily sensations (e.g. a pounding heart is a sign of an impending heart attack). The thoughts of impending doom naturally increase anxiety/fear and a tendency to get to safety as well as increased muscle tension that in turn increases bodily sensations further increasing fears that something terrible is about to happen. A vicious circle quickly develops. We call this cycle fear of fear. Once you have experienced a few panic attacks, it becomes a fear of experiencing more. The fear of future attacks is called anticipatory anxiety, which can lead to increased awareness of bodily sensations that leads to more panic attacks.
Skills learned in CBT include diaphragmatic breathing (to reverse the effects of hyperventilation or shallow breathing), challenging the thoughts that lead to increased anxiety (e.g., ‘what if it never stops and I go crazy') and exposure to the sensations and situations that are associated with panic. As the core fear in panic is fear of physical sensations, people are given exercises to help them get used to their sensations (e.g., spinning in a chair, drinking caffeine). Lastly people are reintroduced to situations they avoid or tolerate with discomfort.
Although there is no cure, the existing panic treatments are very effective. Approximately two-thirds of people who take medication will experience noticeable improvement and about 80% of people who complete CBT (typically around 8-12 sessions) will be panic free at the end of treatment. CBT has better long term improvement rates but it is more difficult to find in the public system and can be expensive (e.g., $150/hour) if done privately. Fortunately, a less expensive self-help option exists (see below for a list of CBT self-help books).
In closing, if you are struggling with panic attacks, there is good reason to be hopeful. Effective treatments do exist and may be as close as a trip to your family doctor.
Dr. Maureen Whittal is a psychologist at the Vancouver CBT Centre (www.vancouvercbt.ca). She was the director of the Anxiety Disorders Clinic at the UBC Hospital. She specializes in psychosocial treatment of anxiety disorders. Dr. Whittal is also on Anxiety Canada's Scientific Advisory Board.