Panic Disorder Treatment

[David]

Introduction

Panic attacks and panic disorder can be very disabling conditions for
the people who suffer from them. Sometimes they can lead to avoidance
of any activity or environment which has been associated with feelings
of panic in the past. This can in turn lead to more severe and
disabling disorders such as agoraphobia.

Panic attacks typically begin in young adulthood, but can occur at any
time during an adult's life. A panic episode usually begins abruptly,
without warning, and peaks in about 10 minutes. It can last anywhere
from a few minutes to a half hour or longer. Panic attacks are
characterized by a rapid heart beat, sweating, trembling, and a
shortness of breath. Other symptoms can include chills, hot flashes,
nausea, cramps, chest pain, tightness in the throat, trouble
swallowing and dizziness.

Women are more likely than men to have panic attacks. Many researchers
believe the body's natural fight-or-flight response to danger is
involved. For example, if a grizzly bear came after you, your body
would react instinctively. Your heart and breathing would speed up as
your body readied itself for a life-threatening situation. Many of the
same reactions occur in a panic attack. No obvious stressor is
present, but something trips the body's alarm system.

Treatment emphasizing a three-pronged approach is most effective in
helping people overcome this disorder: education, psychotherapy and
medication.


Psychotherapy

Education is usually the first factor in psychotherapy treatment of
this disorder. The patient can be instructed about the body's "fight-
or-flight" response and the associated physiological sensations.
Learning to recognize and identify such sensations is usually an
important initial step toward treatment of panic disorder. Individual
psychotherapy is usually the preferred modality and its length is
generally short-term, under 12 sessions. An emphasis on education,
support, and the teaching of more effective coping strategies are
usually the primary foci of therapy. Family therapy is usually
unnecessary and inappropriate.

Therapy can also teach relaxation and imagery techniques. These can be
used during a panic attack to decrease immediate physiological
distress and the accompanying emotional fears. Discussion of the
client's irrational fears (usually of dying, passing out, becoming
embarrassed) during an attack is appropriate and often beneficial in
the context of a supportive therapeutic relationship. A cognitive or
rational-emotive approach in this area is best. A behavioral approach
emphasizing graduated exposure to panic-inducing situations is most-
often associated with related anxiety disorders, such as agoraphobia
or social phobia. It may or may not be appropriate as a treatment
approach, depending upon the client's specific issues.

Group therapy can often be used just as effectively to teach
relaxation and related skills. Psycho-educational groups in this area
are often beneficial. Biofeedback, a specific technique which allows
the client to receive either audio or visual feedback about their
body's physiological responses while learning relaxation skills, is
also an appropriate psycho-therapeutic intervention.

All relaxation skills and assignments taught in therapy session must
be reinforced by daily exercises on the patient's part. This cannot be
emphasized enough. If the client is unable or unwilling to complete
daily homework assignments in practicing specific relaxation or
imagery skills, then therapy emphasizing such skill sets will likely
be unsuccessful or less successful. This pro-active approach to change
(and the expectations of the therapist that the client will agree to
this approach) needs to be clearly explained at the onset of therapy.
Discussing these expectations clearly up-front makes the success of
such techniques much greater.


Medications

A lot of people who suffer from panic disorder can successfully be
treated without resorting to the use of any medication. However, when
medication is needed, the most commonly-prescribed class of drugs for
panic disorders are the benzodiazepines (such as clonazepam and
alprazolam) and the SSRI antidepressants. It is rarely appropriate to
provide medication treatment alone, without the use of psychotherapy
to help educate and change the patient's behaviors related to their
association of certain physiological sensations with fear.

Phillip W. Long, M.D. notes that, "Clonazepam (Klonopin, Rivotril) and
alprazolam (Xanax), are the treatment of choice in the treatment of
Panic Disorder. Clonazepam and alprazolam are preferred to
antidepressant drugs because of their less severe side effects." He
also states that it is preferred to try the anti-anxiety agents before
moving on to the antidepressants because of the increased side-effect
profiles. Xanax can be addicting for individuals and should be used
with care. Treatment with either clonazepam or alprazolam should be
discontinued by tapering it off slowly, because of the possibility of
seizures with abrupt discontinuation.

Self-Help
Self-help methods for the treatment of this disorder are often
overlooked by the medical profession because very few professionals
are involved in them. Many support groups exist within communities
throughout the world which are devoted to helping individuals with
this disorder share their commons experiences and feelings.

Patients can be encouraged to try out new coping skills and relaxation
skills with people they meet within support groups. They can be an
important part of expanding the individual's skill set and develop
new, healthier social relationships.


Panic Disorder SYMPTOMS

People with panic disorder have feelings of terror that strike
suddenly and repeatedly with no warning. They can't predict when an
attack will occur, and many develop intense anxiety between episodes,
worrying when and where the next one will strike. In between times
there is a persistent, lingering worry that another attack could come
any minute.

When a panic attack strikes, most likely your heart pounds and you may
feel sweaty, weak, faint, or dizzy. Your hands may tingle or feel
numb, and you might feel flushed or chilled. You may have chest pain
or smothering sensations, a sense of unreality, or fear of impending
doom or loss of control. You may genuinely believe you're having a
heart attack or stroke, losing your mind, or on the verge of death.
Attacks can occur any time, even during non-dream sleep. While most
attacks average a couple of minutes, occasionally they can go on for
up to 10 minutes. In rare cases, they may last an hour or more.

Panic disorder strikes between 3 and 6 million Americans, and is twice
as common in women as in men. It can appear at any age--in children or
in the elderly--but most often it begins in young adults. Not everyone
who experiences panic attacks will develop panic disorder-- for
example; many people have one attack but never have another. For those
who do have panic disorder, though, it's important to seek treatment.
Untreated, the disorder can become very disabling.

Panic disorder is often accompanied by other conditions such as
depression or alcoholism, and may spawn phobias, which can develop in
places or situations where panic attacks have occurred. For example,
if a panic attack strikes while you're riding an elevator, you may
develop a fear of elevators and perhaps start avoiding them.

Some people's lives become greatly restricted -- they avoid normal,
everyday activities such as grocery shopping, driving, or in some
cases even leaving the house. Or, they may be able to confront a
feared situation only if accompanied by a spouse or other trusted
person. Basically, they avoid any situation they fear would make them
feel helpless if a panic attack occurs. When people's lives become so
restricted by the disorder, as happens in about one-third of all
people with panic disorder, the condition is called agoraphobia. A
tendency toward panic disorder and agoraphobia runs in families.
Nevertheless, early treatment of panic disorder can often stop the
progression to agoraphobia.
Specific Symptoms of Panic Disorder:

A person with panic disorder experiences recurrent unexpected Panic
Attacks and at least one of the attacks has been followed by 1 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")
* A significant change in behavior related to the attacks

Agoraphobia may also be present but isn't required in order to
diagnose panic disorder. The Panic Attacks may not be due to the
direct physiological effects of use or abuse of a substance (alcohol,
drugs, medications) or a general medical condition (e.g.,
hyperthyroidism).

The Panic Attacks are not better accounted for by another mental
disorder, such as Social Phobia (e.g., occurring on exposure to feared
social situations), Specific Phobia (e.g., on exposure to a specific
phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to
dirt in someone with an obsession about contamination), Posttraumatic
Stress Disorder (e.g., in response to stimuli associated with a severe
stressor), or Separation Anxiety Disorder (e.g., in response to being
away from home or close relatives).
General Treatment of Panic Disorder


Agoraphobia - SYMPTOMS

The essential feature of Agoraphobia is anxiety about being in places
or situations from which escape might be difficult (or embarrassing)
or in which help may not be available in the event of having a Panic
Attack or panic-like symptoms.

Agoraphobic fears typically involve characteristic clusters of
situations that include being outside the home alone; being in a crowd
or standing in a line; being on a bridge; and traveling in a bus,
train, or automobile.

A person who experiences agoraphobia avoids such situations (e.g.,
travel is restricted) or else they endure with significant distress or
with anxiety about having a Panic Attack or panic-like symptoms.
People with agoraphobia often require the presence of a companion.

Anxiety or phobic avoidance in agoraphobia can not be better accounted
for by another mental disorder, such as Social Phobia (e.g., avoidance
limited to social situations because of fear of embarrassment),
Specific Phobia (e.g., avoidance limited to a single situation like
elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in
someone with an obsession about contamination), Post Traumatic Stress
Disorder (e.g., avoidance of stimuli associated with a severe
stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving
home or relatives).

Agoraphobia is generally not diagnosed if Panic Disorder has already
been previously diagnosed. As with all mental disorders, the symptoms
listed above are not due to the direct physiological effects of a use
or abuse of a substance (e.g., alcohol, drugs, and medications) or a
general medical condition.