Panic Disorder


Panic disorder is characterised by the occurrence of repeated panic attacks, which last anything from a few seconds to a few minutes, but which are experienced as extremely frightening and uncomfortable.

Typically, someone who suffers from a panic attack is overcome by intense feelings of terror and fear that occur initially out of the blue and last only a few minutes. During a panic attack, people may fear they are having a heart attack, or are going crazy. They report a racing or pounding heartbeat, chest pains, dizziness, light-headedness, nausea, a feeling of smothering, breathlessness, tingling or numbness in the hands, hot flushes or chills, a sense of unreality, and a fear of losing control.

People with panic attacks often consult various doctors and medical specialists, such as cardiologists, physicians, or neurologists, fearing that they suffer from a life threatening disease. It is not unusual for many years to go by before an accurate diagnosis is made. During this time sufferers tend to avoid situations or places (agoraphobia) where the initial attack(s) took place, fearing another attack. This can be very debilitating and unnecessarily limit their lives.

Who gets panic disorder?
Any person may possibly suffer from panic disorder, irrespective of gender, race, or socioeconomic status. Studies have shown that about 2 to 4 in every 100 persons may suffer from panic disorder at some time in their lives, and the figure for agoraphobia is even higher.

Panic disorder usually starts between late adolescence and mid-thirties, although children may also suffer from this disorder. The first attack often follows a stressful life event such as the death of a close family member or friend, a loss of a close interpersonal relationship or after a separation. Women are two to three times more likely to suffer from panic disorder than men.

What causes panic disorder?
It was initially thought that panic disorder was caused by psychological problems. It is now known though that brain chemistry and genetic factors play a role, as well as stressful life events or circumstances. First-degree relatives of people with panic disorder have a five times greater likelihood of developing panic disorder than the rest of the population.

What to do and where to go for help
The most important step is to consult a professional for an accurate diagnosis. Help is available and in most cases is effective in relieving symptoms. Both medication and psychotherapy is used, although a combination of these two treatment methods is often recommended. Self-help cognitive-behavioural techniques are also of value.

Medications for treating panic disorder include those that work immediately but have the limitation that they cause dependence (benzodiazepines), and those that work slowly but that can readily be discontinued (antidepressants). In general, it is suggested that the slow but sure path is the best in panic disorder. The term "antidepressant" is a poor one, as many of these agents are excellent antipanic medications. The most widely used antidepressant agents for treatment of panic disorder are the selective serotonin reuptake inhibitors (SSRIs) which are safe and easy to use.

Nevertheless, there are a number of important principles to bear in mind when using antidepressants for panic disorder. Most importantly, people with panic disorder often experience an increase in anxiety or other side effects if started on regular doses of antidepressants. It is therefore crucial to begin with as low a dose as possible and then to increase the dose only gradually. Several weeks of treatment, and relatively high doses of medication, may ultimately be necessary in order to bring an end to the panic attacks.

In addition, however, many people with panic disorder do find it useful to take benzodiazepines for a limited period of time. These agents are certainly useful if prescribed for a short period only. It is important to remember that benzodiazepines can subtly impair motor co-ordination, and therefore to be cautious when driving or operating machinery on these agents.

Perhaps the key element of the psychotherapy for panic disorder is "exposure" to feared stimuli. Many people with panic attacks begin to avoid places where they experienced panic; a vicious cycle then develops of more and more restrictions. Learning not to avoid is a crucial aspect of treatment. By continually practicing feeling anxious, and at the same time experiencing that this does not in fact lead to catastrophic results may ultimately overcome panic attacks.

As in the cognitive-behavioural treatment of other anxiety disorders, this approach is difficult insofar as it initially involves increased anxiety levels. There are, however, several ways to help decrease such feelings of anxiety.

First, practice "accepting" anxiety. Don't feel under pressure to relax; it's OK to feel anxious, and to simply practice facing these symptoms. Indeed, therapists may suggest ways of increasing "interoceptive exposure", that is teaching people to increase anxiety levels, and then encouraging them to simply accept this feeling of anxiety.

Second, take it slow. It may be useful to make a list from 1 (least anxiety provoking) to 10 (most anxiety provoking) that describes different situations that are being avoided. Gradually face each of the different kinds of situation labelled from 1 through to 10.

Third, relaxation exercise can be useful when anxiety levels mount during exposure to internal cues (e.g. feeling dizzy after rapid breathing) or external cues (e.g. moving up on the hierarchy of avoided situations). Visualizing a relaxing scene or a supportive person using all your senses and slow steady abdominal breathing may be useful.

Information supplied by the Mental Health Information Centre of South Africa (0800 600 411).

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