Britt Talley Daniel MD
7777 Forest Lane Suite B-220
Dallas, Texas 75230
Bill’s heart pounded so hard and fast that his chest started hurting and he broke out in a sweat. He thought he might be dying and was reduced to terror, suddenly, without cause. Then, almost as quickly as the attack occurred, it faded away. Thinking he had had a heart attack, Bill rushed to an emergency room, where he was examined and told everything was all right. But several days later, he had another attack, and others followed. Bill worried a lot that he was losing control of his life and might even be going crazy. He reported avoidance of social activities, moodiness, poor sleep, and a low level of energy.
Eventually, Bill was diagnosed as having panic disorder. The doctor explained that panic disorder results from a chemical imbalance in the brain that triggers attacks like Bill had been having. The doctor reassured Bill the attacks were not a sign of mental weakness or personal failure. Instead, they’re a sign that the body’s alarm mechanism, which prepares us to fight or run for safety, is out of order. The doctor assured Bill that his intense feelings of losing control or dying could be overwhelming or frightening but that no one had ever died from a panic attack. After a period of treatment with medication and psychological therapy, Bill now lives a more normal life.
Everyday people like Bill are rushed into emergency rooms with symptoms that might indicate anything from heart disease to asthma. About a third of the time, what they are experiencing is a panic attack—an unprovoked explosion of bodily sensations and fear. It has been shown that most panic disorder patients consult physicians other than psychiatrists 10 or more times before their condition is accurately diagnosed.
Panic disorder is characterized by sudden, brief episodes of physical and mental symptoms which, by definition, occur spontaneously or “out of the blue,” to differentiate it from anxiety attacks that have never occurred spontaneously and have always been secondary to a specific reason. For anxiety attacks the patient should have insight or a reason as to why the event occurred. Anxiety would come after a sudden attack by an assailant who wanted to kill you. There would be an evident reason for the symptoms resulting from such an attack. This is not true with panic disorder. Both panic attacks and anxiety turn on the brain’s “fight or flight” mechanism.
The essential feature of a panic attack is a discrete period of intense fear or discomfort that is accompanied by at least 4 of 13 physical or psychological symptoms. The attack has a sudden onset and builds to a peak rapidly, usually in 10 minutes or less. The attack also is often accompanied by a sense of imminent danger or impending doom and an urge to escape. The physical symptoms are: pounding or rapid heart rate, sweating, trembling or shaking, shortness of breath or smothering, choking, chest pain/tightness or discomfort, nausea or abdominal distress, feeling dizzy/lightheaded or faint, numbness or tingling sensations, and chills or hot flushes. The psychological symptoms are: derealization/feeling of detachment, fear of losing control or going crazy, and fear of dying.
The patient may report an intense desire to flee from wherever the attack is occurring. Patients commonly arrive at an emergency room or other medical setting believing that their symptoms represent a heart attack, stroke, or some other catastrophic medical condition. Panic attacks may become associated with a variety of situations in which patients feel an attack is more likely to occur, from which they would be unable to flee or get help quickly if an attack occurred, or in which they might be embarrassed if others should notice they are having an attack.
In reality, a panic attack is often not apparent to an observer, which is why a patient can successfully disguise this condition from others. The development of agoraphobia (fear of being in crowds or around other people) is common and is defined as fear of places or situations in which the patient feels ”trapped.” Patients may not have thought through why they fear or avoid situations when they initially present for treatment. As a result of this fear, they restrict travel or need a companion to enter phobic situations. Common agoraphobic situations are traveling in a car, bus, train, airplane, driving on highways, bridges, tunnels, heavy traffic, being in stores, malls, restaurants, elevators, theaters, church/temple, sitting in a meeting, standing in line, or being home alone.
The cause of panic disorder is still uncertain, but there are theories. A biologic basis is supported by a large volume of research. Certain chemicals may provoke panic attacks, in most panic attack victims, but not in most other people. Some of these chemicals are lactate, caffeine, and cocaine. Medications used to treat panic disorder have been shown to block these attacks. PET scans which reveal the metabolism of the brain show a chemical abnormality in a particular area of the brain of panic patients compared with people who do not have panic disorder. The fact that panic disorder runs in families also suggests a genetic, biologic component to the disease. Psychological theories regarding causes of panic disorder stress the idea that childhood stresses, such as the death of a parent, can predispose a person to phobic reactions. The type of personality that avoids conflict by suppressing feelings and avoiding confrontation is more likely to develop panic disorder. Panic disorder is closely linked to depression, generalized anxiety disorder, tension type headaches, and migraine.
Women get panic disorder about twice as often as men, but some experts suspect that males may be underreported. A large government study revealed that 1% to 2% of the adult population will get panic disorder at some point in their lives. That’s 2-3 million Americans. In addition, another 4% to 5% of adults report having panic attacks and symptoms of agoraphobia who do not qualify for a full diagnosis. The onset of panic disorder has a peak in late adolescene and a second peak in the mid 30s. In general, the treatments now available help reduce or alleviate the symptoms of panic disorder, so that people can lead more normal lives, but do not provide an actual cure.
General treatment of panic disorder includes attention to adequate rest (7-8 hours a night), regular aerobic exercise (20 minutes 3 X a week), a moderate work schedule (workaholism is defined as more that 55hrs/week), and regular vaction time off. Patients with panic disorder should not drink any alcohol at all because it does the same thing the benzodiazepine drugs do, such as Xanax, in that it turns off the part of the brain that starts the fight or flight response. However, because the effect of alcohol only lasts 2 hours, withdrawal symptoms and rebound occur, making panic symptoms worse after the alcohol is metabolized.
Medical treatment consists of using benzodiazepine drugs such as Xanax (alprazolam), taken once a day as XR 1-2 mg, or short acting .25-.5 Xanax which lasts 4 hours and can be dosed as needed or up to 3-4X/day. Also Klonopin (clonazepam) 0.5 mg which lasts 6 hours and can be taken as needed or up to 3/Xday. These drugs act acutely and will shut off the brain now. They often will be given at the start of treatment with an SRI type drug to cover panic symptoms and any nervous or jittery symptoms that may come while the SRI is starting to work. SRI means Serotonin Receptor Inhibitor and refers to a class of drugs that are used to treat depression, generalized anxiety, and panic disorder. They increase the “nice, calming” brain neurochemical, serotonin, but they take several weeks to work. Prozax, Zoloft, Paxil, Effexor, and Celexa all take about 3-4 weeks to kick in. This is called induction. Lexapro can start working in 7-14 days. During the beginning induction period the patient, who is already experiencing panic symptoms, may get more nervous and jittery. It has to be explained to the patient that he has to endure these startup symptoms. Xanax or Klonopin may be given to cover these “getting on the medicine” symptoms and then they may be discontinued in a few weeks when the SRI starts to take effect. Once the SRI starts to work, the Xanax or Klonopin may be tapered and sometimes discontinued. A problem with the use of SRIs is that sometimes the patient has to be tried on several different drugs to get one that fits them—that relieves their symptoms but doesn’t cause side effects. Consider that in this selection and use of the medication the doctor only has clinical guidelines to go by; it’s like treating diabetes without a blood sugar, or hypertension without taking the pressure. Some patients feel like stopping the medication at the beginning, but this should be avoided without calling the office, talking to the doctor, taking the Xanas and Klonopin regularly and daily, and attempting to persevere. In fact toughness and resilence is sometimes required here and the patient will then be rewarded with feeling much better later. You just have to hold on, especially with drugs like Prozac or Zoloft which take three to four weeks to work. Lexapro works faster.
Some doctors use Betablockers like Inderal or Aetenolol or the older antidepressants like Elavil (amitriptyline) or Pamelor (nortryptyline) to treat panic disorder, but the current American Psychiatric Association recommendation is to use an SRI drug. They just work better. Also since Xanax and Klonopin are benzodiazepine drugs and are classified as narcotics and can conceivably be abused, some doctors use Buspar, a nonbenzodiazepine drug which is a minor tranquilizer for anxiety which is not classified as a narcotic. They just don’t work as well as Xanax and Klonopin and in America something like about 60% of patients with anxiety or panic disorder are treated with benzodiazepines.
Treatment options for difficult to treat panic disorder is attention to lifestyle issues, a full dose of an SRI, Xanax 4X/day or Klonopin 3X/day, cognitive psychotherapy with a counselor for 3-6 months, consultation with a psychiatrist, and behavioral therapy. Not every patient needs this full court press type treatment (a basketball term), but some do. Another problem with treatment is that because panic disorder is a psychiatric syndrome, patients commonly just don’t want to admit to themselves and to others that they have such a problem and they resist treatment. They commonly state “I just don’t like to take medication,” as if anyone does. However, once these patients are on therapy for the first time they may feel normal and they may revert back to further attacks when they stop the medication. Sometimes it is difficult for the doctor to know how long to use the medication, but some patients do well with long-term therapy for years. If the patient has only had one or two panic attacks, treatment with a benzodiazepine drugs when the attack occurs may be all that is needed, but if the attacks are more severe, then more aggressive therapy as needed. Maintenance treatment with medication is recommended for at least 12-24 months in most patients, and in some cases, indefinitely.
A last problem with the use of serotonin receptor drugs is that when the patient comes off of them, especially if they are stopped suddenly, they may have withdrawal symptoms. This is worse with short acting drugs like Paxil and not so bad with longer acting drugs like Prozac. The symptoms of discontinuation can include insomnia, vivid dreams, an electric shock sensation, nausea and vomiting, fatigue, myalgia, chills, crying spells, and anxiety/agitation. Simply going back on the medication at the same dose will stop the symptoms. Short acting serotonin receptor inhibitor drugs like Paxil should be tapered slowly by 5 mg a week. In general the physician can consider stopping therapy gradually over 2-6 months.
Criteria for a diagnosis of Panic disorder.
Recurrent unexpected panic attack, defined as a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:
(1) palpitations, pounding heart, or accelerated heart rate
(3) trembling or shaking
(4) sensations of shortness of breath or smothering
(5) feeling of choking
(6) chest pain or discomfort
(7) nausea or abdominal distress
(8) feeling dizzy, unsteady, lightheaded, or faint
(9) derealization (feelings of unreality) or depersonalization (being detached from oneself)
(10) fear of losing control or going crazy
(11) fear of dying
(12) paresthesias (numbness or tingling sensations)
(13) chills or hot flushes
At least one of the attacks followed by one month (or more) of one (or more) of the following:
Persistent concern about having additional attacks.
Worried that the implications of the attack or its consequences.
Tab The clinically significant change in behavior related to the attacks
DSM-IV Diagnostic and Statistical Manual of Mental Disorders Fourth Edition
What you should know about panic disorder by Pharmacia
Panic Disorder with or without agoraphobia by Nagy and Charney
Panic Disorder Wayne Katon M.D. N Engl J Med 2006; 354:2360-7
American Psychiatric Association 1400 K St. NW Washington, DC 20005
National Mental Health Association 1021 Prince St. Alexandria, VA 22314