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A BRIEF DIGEST ON EVERYTHING YOU EVER WANTED TO KNOW ABOUT PANIC DISORDER FOUR EFFECTIVE TREATMENTS
WILLIAM TODD GOLDMAN, M.D. AND FRANK B. MINIRTH, M.D.
I. DEFINITIONS. PANIC DISORDER is defined as the experiencing of two or more unexpected ("out of the blue") PANIC ATTACKS (usually lasting twenty to thirty minutes at a time), that are followed by at least one month of worry about having other panic attacks, the resulting consequences of having another attack, or significant changes in behavior as a result of having a panic attack. The panic attacks must not be a result of medical illness, medications, substances, alcohol, or illicit drug use. PANIC ATTACKS are 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 ten minutes: palpitations, pounding heart, accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheaded, or faint, derealization, depersonalization, fear of losing control or going crazy, fear of dying, paresthesias (numbness or tingling sensations), or chills or hot flushes" (Diagnostic Criteria from DSM-IV, 1994, American Psychiatric Association, page 199).
AGORAPHOBIA is defined as "recurrent unexpected Panic Attacks . . . at least one of the attacks has been followed by one month (or more) of one (or more) of the following: persistent concern about having additional attacks, worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy"), or a significant change in behavior related to the attacks . . . not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) . . . not better accounted for by another mental disorder . . ." (Diagnostic Criteria from DSM-IV, 1994, American Psychiatric Association, page 202). Agoraphobia may create a fear of being in situations or places from which escape may be impossible, which may lead to embarrassment, or make help difficult to get if severe anxiety or panic attacks were to occur. Because of this fear, many people avoid leaving home or "safe" places while alone; cannot use public transportation, fly, use elevators, or cross over bridges or through tunnels. II. DESCRIPTION.
A. Epidemiology. 1. Worldwide, one and one-half to three and one-half percent of the general population will have Panic Disorder sometime in their lives. 2. In any given year, one to two percent of the general population can be diagnosed with Panic Disorder. 3. One-third to one-half of people with Panic Disorder will also have Agoraphobia. 4. Women are two to three times more likely to suffer from Panic Disorder with recent divorce or separation noted as common findings. 5. The typical age of onset is young adulthood, although it can begin at most any age, even in children.
B. Comorbidity. 1. Depression occurs in forty to eighty percent. Suicidal thoughts and attempts are not uncommon 2. Obsessive-Compulsive Disorder 3. Phobias 4. Alcohol and/or Substance Abuse in twenty to forty percent
III. ETIOLOGY/CAUSES.
A. Psychological. 1. Cognitive-Behavioral Theories propose that anxiety and panic attacks are learned behaviors to environmental or sensory cues, such as parental behaviors in response to stress or through classical conditioning theories. Other ideas describe how minor internal body sensations can be experienced and sensed as dangerous; foreboding signs of disease, illness, or catastrophe (passing out, having a heart attack or stroke, for example).
2. Psychoanalytic Theories explain panic attacks as the result of severe anxiety generated in response to mild stressors because of underlying, unconscious connections with more serious, traumatic past experiences. For example, childhood fears of separation, of punishment, of losing the love of a parent.
B. Genetic. Studies have demonstrated a familial component to panic disorder, showing a four to eight times greater likelihood of a panic disorder patient having a first-degree relative with Panic Disorder as well. Additionally, identical twins (eighty-five percent concordance rate) are more likely to both have panic disorder than fraternal twins (twelve percent concordance rate), if one member of the twin pair is diagnosed.
C. Biological. 1. Neurotransmitters may be out of balance 2. Brain Imaging may show abnormalities 3. Substances such as sodium lactate infusion or breathing CO2 can cause panic attacks in certain individuals.
D. Medical. The list of physical conditions and medical illnesses that can mimic panic attacks is extensive. Therefore, it is essential that a complete medical evaluation and appropriate workup be completed to rule-out these possibilities so that any underlying medical disease can be treated appropriately. As broad categories, the following are known imitators of panic disorder: 1. Neurological Disease 2. Cardiovascular Disease 3. Pulmonary Disease 4. Endocrine Disease 5. Drug Intoxication States 6. Drug Withdrawal States 7. Vitamins
IV. TREATMENT.
A. Psychological. 1. Cognitive-Behavioral Therapy focuses awareness on bodily symptoms and subtle cues associated with panic attacks, and the automatic thoughts that are then formed. Often, a very catastrophic thought pattern develops and becomes automatic after several panic attacks (e.g., conviction that one is having a heart attack, stroke, going crazy, or going to die). This form of therapy is well tested and is proven to be just as effective, if not more so, than medications, especially with regards to side effects and long term benefits.
2. Group and Family Therapy helps to "normalize" the experience of panic and become aware of which areas in one's life (job, friendships, family, recreation, and/or church) have suffered because of panic attacks. Also, it provides a supportive and educational atmosphere for the patient and loved ones alike.
3. Insight-Oriented Psychotherapy primarily attempts to uncover the hidden meanings behind the anxiety and fears associated with panic attacks; is not as well founded or proven as Cognitive Behavioral Therapy, but may be of benefit to some patients once their panic disorder is better controlled.
B. Psychopharmacological. 1. SSRIs such as Paroxetine, Fluoxetine, and Sertraline. SSRIs are the newest treatment for panic disorder. Typically SSRIs have less overall side effects and different side effects than MAOIs or TCAs. SSRIs are generally safer and easier to use, with less interaction with other medications.
2. . Benzodiazepines such as Clonazepam,Alprasolam. Unlike the antidepressant medications above, which can take two to eight weeks to kick in, Benzodiazepines can begin helping within a few days, but their beneficial effect peaks after four to six weeks. They carry some risk of abuse and addiction, especially in persons with prior or current addictions, or strong family histories of addiction. These can cause sedation as well as mental slowing, and generally should be avoided in children and elderly persons.
3. TCAs such as Clomipramine, Imipramine. TCAs are well tested with a long history of success. They can have some annoying side effects that limit their use, and can be contraindicated in patients with certain medical problems or on certain medicines.
4. MAOIs such as Tranylcypromine and Phenelzine. MAOIs are proven to be as good or even better than the TCAs, but require fairly strict dietary awareness. These can be useful in the event of the failure of TCAs or SSRIs to adequately treat panic.
C. Medical. A medical evaluation along with baseline laboratory tests may be helpful when beginning assessment of panic disorder. As stated above, there are numerous medical illnesses and conditions that can mimic or worsen panic attacks, or that may preclude use of certain medications to treat panic disorder.
D. Spiritual. FIVE SPIRITUAL HELPS FOR PANIC DISORDER: 1. Take appropriate medical, psychological, and social steps as you do what you can to deal with panic, as you ultimately trust in the Lord. " . . . but victory belongs to the Lord" (Proverbs 21:31b, NASB).
2. Ask God for help. "I sought the Lord, and he heard me, and delivered me from all my fears" (Psalm 34:4)
3. Believe God can help you. "What time I am afraid, I will trust in thee" (Psalm 56:3).
4. Focus on God's presence with you. "Fear thou not; for I am with thee: be not dismayed; for I am thy God: I will strengthen thee; yea, I will help thee; yea, I will uphold thee with the right hand of my righteousness" (Isaiah 41:10).
5. Memorize and quote verses to yourself daily such as "Peace I leave with you, my peace I give unto you: not as the world giveth, give I unto you. Let not your heart be troubled, neither let it be afraid" (John 14:27).
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