Panic Attacks and Panic Disorder

What is panic disorder? 

Almost everyone feels anxious sometimes. But panic attacks are identified by intense levels of anxiety, which you may misinterpret as a sign that you are having a heart attack, going insane, or losing control. Panic attacks can lead to feeling short of breath, tingling sensations, or ringing in your ears. They can also include feeling a sense of impending doom, trembling, feeling like you are choking, and heart pounding. Many people experience panic when they are asleep–possibly because the large decrease in pulse rate during sleep cues a compensating increase in pulse rate, resulting in feeling jolted out of sleep. You should see your physician in order to rule out medical causes such as hyperthyroidism, caffeine addiction, heart issues, or other causes.

Some individuals who have panic disorder also experience agoraphobia. People with agoraphobia fear situations where escape might be difficult or places where they might have a panic attack. For example, people with agoraphobia can avoid supermarkets, trains, airplanes, bridges, heights, tunnels, open fields, and elevators. And some people have agoraphobia but do not experience panic attacks.

Some people with agoraphobia experience anxiety in sunlight, some in dimming light. Heat is also a major factor in panic disorder. There is a dramatic increase in panic and agoraphobia during the summer, primarily because heat increases pulse rate, dizziness, and dehydration. There are more opportunities to be outside where the individual feels more vulnerable. The individual fears that he or she will have a panic attack in these situations,.

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What is the cause of panic disorder?

Many situations that people with panic disorder fear may be situations that were historically truly dangerous. For example, being trapped in a tunnel could lead to suffocation or collapse. Heights may be dangerous, and in open fields, the individual is more susceptible to predators (like lions or wolves). As a result, we now view many of the fears of agoraphobia as reminiscent of these earlier instinctive and adaptive fears. However, these situations are not dangerous today.

The person with panic disorder experiences either a desire to escape or a sensation of fainting. However, since escape may be blocked or fainting might be embarrassing, someone with panic can interpret these physical sensations as “false alarms” that something terrible is happening. He or she focuses on these internal sensations, thinking: “My heart is pounding–I’m going to have a heart attack” or “I’m feeling weak and dizzy—“I’m going to collapse”. We call these “false alarms” because they signal that something dangerous is about to happen when there is no danger present.

Research shows a genetic cause for panic disorder. However, agoraphobia and panic are not entirely inherited. In any given year, 30% to 40% of the general population will have a panic attack. However, most of these people will not have a catastrophic interpretation of the panic. The person who is more likely to develop panic disorder tends to have excessive self-focus on physical sensations and catastrophic thoughts about his or her sensations.

Initial panic attacks are often triggered by stressful situations. For example, leaving home, marital conflict, surgery, abortion, new responsibilities, or physical illness. Many people who have panic disorder also experience depression, partly as a consequence of their feeling out of control and being unsure how to handle their problem.

How do we treat Panic Disorder?

Cognitive behavioral therapy is the most effective treatment for panic disorder. Fortunately, there have been a number of studies examining the effects of CBT. These studies have been done at Oxford, University of Pennsylvania, SUNY at Albany, and at other universities and medical schools. Over the course of 20 to 25 sessions, the effectiveness of treatment ranges from 85% to 90%. In addition, once treatment is terminated, most patients who are tested one year later have maintained their improvement.

Medications for Panic Disorder

There are a number of medications that are useful in decreasing the arousal or panic. These include a wide range of anti-depressants, such as Tofranil, Prozac, Zoloft, as well as beta-blockers like Propanalol. These medications help reduce the experience of anxiety, but once you stop taking the medication your panic symptoms may return. As a result, we recommend that even if you use medication for panic disorder that you also include cognitive-behavioral therapy.

What are some of the steps in the treatment for panic disorder?

The treatment of panic is organized around several goals:
  1. Educating the patient about the nature of anxiety, panic, and agoraphobia
  2. Assessing the types of situations that you avoid or fear
  3. Evaluating the nature of your symptoms, their severity, frequency, and the situations that cue your anxiety, and
  4. Evaluation for other problems that may co-exist with panic. For example, depression, other anxieties, substance abuse, overeating, loneliness, and marital problems can occur at the same time as panic disorder.
Your therapist may include the following treatments:
  • Relaxation training
  • Rebreathing training (especially if you hyperventilate)
  • Gradual exposure to situations that trigger panic
  • Mindfulness
  • Identification of your thoughts and beliefs about your panic or arousal
  • Stress reduction
  • Training in general cognitive therapy principles (challenging your negative beliefs, your concern about losing control, your fears of negative evaluation, and your demands for certainty)
  • Assertion training (when needed), and
  • Training in the ability to recognize and reduce your panic symptoms when they occur.
  • In addition, other problems that you may have (such as depression) may also be addressed in the therapy.

What are some common misconceptions about panic?

Some people incorrectly believe that panic is a result of deep psychological problems. Of course, anyone with or without panic may have deeper problems, but panic disorder and agoraphobia are not necessarily related to deeper psychological problems. You may become depressed, dependent and self-critical because you have panic disorder. However, panic can be treated effectively without long-term therapy exploring your childhood experiences. People who experience panic often have unrealistic beliefs about anxiety. For example, thinking, “All anxiety is bad” and “I have to get rid of my anxiety immediately”. Some people misinterpret their anxiety as a sign of a dangerous medical condition. Others believe that because they have had panic attacks and agoraphobia for many years, they can never improve. Cognitive behavioral therapy, with or without medication, is often quite effective in the treatment of panic and agoraphobia.

Recommended Reading

Anxiety Free: Unravel Your Fears Before They Unravel You by Robert L. Leahy

The Worry Cure: Seven Steps to Stop Worry from Stopping You by Robert L. Leahy

Clinicians may find the following books on cognitive behavioral therapy to be helpful in treating anxiety:

Leahy, R. L., Holland, S. J., & McGinn, L. K. – Treatment Plans and Interventions  for Depression and Anxiety Disorders (2nd ed.)

Leahy, R. L. – Cognitive Therapy Techniques, Second Edition

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