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Effective Treatments for Panic Disorder

June 10, 2009

What Is Panic Disorder?

Panic disorder is marked by sudden, severe, and recurrent anxiety responses called panic attacks, which seemingly occur for no reason.  Specific symptoms of panic attacks can vary, but typically include racing heart, heart palpitations, difficulty breathing, sweating, heaviness or tension in the chest, numbness or tingling sensations in the extremities, nausea or vomiting, and terrifying thoughts or images of dying or going crazy.  These symptoms usually begin to decrease within an hour, but can some times last for several hours.  For good reason, people with panic attacks often initially believe they are experiencing a medical emergency and seek help at the emergency room or their primary care doctor’s office.  Seeking immediate evaluation is appropriate, and the diagnosis of panic disorder should only be considered after other medical conditions have been ruled out.

What Causes Panic Disorder?

Panic is a normal and adaptive response to danger. Technically, this normal anxiety response is called an autonomic nervous system (ANS) discharge, and is the body’s way to react to immediate life-threatening dangers. A panic attack is a false alarm of this normal response triggered by misinterpretation of body sensations.  A majority of people experience at least one panic attack at some point in their lives, even though they may not be aware it was a panic attack.

The cognitive behavioral model of panic disorder assumes that there are many types of predisposing and precipitating factors that can place a person at a higher risk of having a panic attack.  Examples of predisposing factors include inherited genetic traits and lessons about danger taught from parents, while precipitating factors might include stress at work or helping a family member with medical problems.  Often, a panic attack is triggered by a mild physical sensation (such as an irregular heart beat) which leads to an automatic belief that something is wrong with the person’s body.  This belief then results in an anxiety response, which in turn, creates more physiological symptoms such as hyperventilation, sweating, difficulty breathing, racing heart, or tingling sensations.  Because these symptoms are real, they quickly become the focus of attention.  As the person increases focus on these bodily reactions, they tend to intensify.  Eventually, the person begins to believe that the symptoms are evidence of an inevitable catastrophe (e.g., death), and this interpretation triggers the false alarm for a full panic response (ANS discharge).  The physiological symptoms of the panic response are also very real and reinforce the misinterpretation that something is seriously wrong with the person’s body.

Many people who have a panic attack do not have ongoing recurrences, and do not develop panic disorder.  However, for some people, the false alarm continues to be activated and over time, even relatively minor physiological symptoms can become associated with panic attacks.  Understandably, people often feel confused, embarrassed, and fearful, and they tend to respond by withdrawing or avoiding situations they believe may trigger a panic response or places where escaping would be difficult (e.g., movie theatre).  The frequency and intensity of the symptoms often wax and wane, and people will often tolerate panic disorder for long periods before seeking professional treatment.

How Do We Treat Panic Disorder?

The first step of treatment is to seek a medical evaluation to become reasonably certain that a medical problem is not the cause of the symptoms.  Only after medical causes are deemed unlikely, can a provisional diagnosis of panic disorder be considered.  Understandably, some doubt usually remains in the patient’s mind about the possibility of an undiagnosed medical condition versus a diagnosis of panic disorder.  This doubt is normal and does not prevent the patient from benefiting from treatments for panic disorder.  Fortunately, there are highly effective treatments for panic disorder: medications and cognitive behavioral therapies.  The patient can choose either of the treatments independently or receive both treatments together, depending on her or his unique situation.

There are several medications that effectively reduce the frequency and intensity of panic attacks.  Most often, serotonin selective reuptake inhibitors (SSRIs) are prescribed as a first-line pharmacological approach.  The medications in this class include Prozac, Paxil, Zoloft, Luvox, Celexa, and Lexapro.  If these medications are not effective or well-tolerated, other medications such as tricyclics (TCAs) or monoamine oxidase MAO inhibitors can also be helpful.  Sedatives such as benzodiazepines (BZs: Klonipin, Valium, Ativan, or Xanax) can provide temporary relief from panic attacks.  However, they are generally not an effective long-term treatment because patients develop tolerance to BZs and the medications become less effective over time.  The best medication(s) for each patient is ideally decided jointly by the patient and doctor based upon any prior responses to medications and potential side effects.  It is not uncommon for patients to try several medications before finding the best one(s).

Cognitive behavioral therapy for panic disorder is also highly effective.  The treatment process is very structured in the beginning and includes detailed information about normal anxiety responses and panic attacks.  The patient and therapist work together to understand how this information applies to the patient’s particular experiences.  The process often begins by identifying physical sensations and thoughts during the panic attack.  The therapist also proposes multiple hypotheses about why how and why the panic attacks are occurring. The patient and therapist then find ways to test these hypotheses using a variety of strategies.  Sometimes, the patient learns specific breathing skills to increase or decrease panic symptoms and gain a sense of control over anxiety responses.  Eventually, as the patient learns that the sensations are not dangerous, the false alarm is no longer triggered and the panic attacks stop occurring.  Treatment usually lasts five to twenty sessions based upon how quickly the symptoms decrease.  When the symptoms are under control, the patient may decide to continue in therapy to explore ways to deal with sources of stress that may have contributed to the panic attacks.

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