The Nature and Treatment of Panic

I have been treating panic disorder and other anxiety disorders over the past two decades, and I have found some specific approaches to be most helpful. Below are two cases that illustrate the nature of panic attacks and panic disorder. If you’ve experienced similar symptoms, I hope this will help you understand more about the disorder and how treatment will help you.

These are not uncommon experiences. Each year about a third of the population experiences a panic attack as a normal reaction to a stressful or potentially dangerous event. A near car crash, unexpected bad news, a sudden noise during the night, and public speaking are common triggers for panic attacks. However, because people in such situations are aware of what is triggering their sudden rush of fear, they usually don’t even label it a panic attack.

But for about 3.5 percent of the population, panic attacks occur frequently and are unexpected; those people live in fear of future attacks and their consequences (such as passing out, having a heart attack, or “going crazy”), and they change their behavior to avoid them. This is called panic disorder. When people also experience anxiety about situations where it may be difficult to escape or get help, or they avoid such places, they may also receive a diagnosis of panic disorder with agoraphobia, which occurs in about 1.5 percent of the population. Women are about two and one half times more likely to experience panic disorder, and it also tends to be more severe and chronic for them.

Panic Disorder And Other Anxiety Disorders
It is not unusual for people who come to our clinic to have been misdiagnosed with panic disorder. Someone who has panic attacks in social situations may actually have social anxiety disorder or people whose panic attacks occur only in particular situations, such as driving across a bridge or inside an enclosed space, may have a specific phobia. Panic may occur in response to intrusive thoughts for those with obsessive-compulsive disorder (OCD), as a reaction to traumatic memories for someone with posttraumatic stress disorder (PTSD), or in someone with generalized anxiety disorder (GAD) who worries about life problems.

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Research tells us that people who develop panic disorder do so because they are vulnerable biologically and psychologically. They may have a genetic predisposition to react to certain events emotionally and negatively, as in having a panic attack. In other cases, people may have had early experiences with adults who interpret physical sensations as dangerous, or their observing physical suffering in others leads them to believe that their own physical symptoms are dangerous.

Many people I treat report that their panic attacks last all day or for many days, rather being short-lived rushes of fear or terror. This usually means that they are lumping together their initial panic attack, which typically develops abruptly and reaches a peak within ten minutes, with continued worry about the attack, its potentially dire consequences, when the next attack may occur, and how their lives might be affected; whether they can go to work, function in social situations, and the impact of their condition on their lives and those of their family members.

Without treatment, panic disorder can significantly impair your quality of life, including leading to poor health, isolation from family and friends, as well as marital, financial, and workplace problems. People with panic disorder account for 20 percent of emergency room visits and are about 13 times as likely to visit the ER as the general population. The good news is that treatment leads to success and freedom from panic disorder symptoms.

Types of Treatments
Cognitive-behavioral therapy, or CBT, is the most widely used and effective psychosocial treatment for panic disorder. And when medication is appropriate, the selective serotonin reuptake inhibitors (SSRIs) are usually recommended first. Certain tricyclic antidepressants such as imipramine, other antidepressants such as venlafaxine, and high-potency benzodiazepines are also effective. Interestingly, research suggests that the SSRIs and tricyclic antidepressants are equally effective and tolerable in short-term trials. My conclusion from reviewing the research is that CBT, the SSRIs, and tricyclic antidepressants are roughly equally effective, and that combined CBT and antidepressants may be more effective mainly when a person also has significant agoraphobia.

In the long term, CBT appears more effective in maintaining treatment gains and preventing relapse. CBT has been shown to help patients taking medications for panic disorder to successfully taper off the medications. According to a study at my former anxiety clinic, among those who completed their treatment for panic disorder, including all their follow-up sessions, 92 percent were panic-free and also showed significantly less anxiety and depression.

Treating Panic
Usually, I begin treatment by asking clients to tell me in detail about their very first panic attack. Most people with panic disorder vividly remember this event. Often the periods preceding and accompanying the first attack contain more stressful life events than usual. I also ask my clients to describe in detail their most severe recent attack, which may have similar symptoms and fears as the first one. Next I share The Panic Cycle model below, and then fill it in with the individual’s specific details.

Looking at Susan’s experience at the beginning of this article, we are reminded that she reported her first panic attack as having come out of the blue. Using The Panic Cycle model, I uncovered a rapid series of events that culminated in panic. When Susan was watching her son play tennis, she was moving her head from side to side, which created dizziness. She interpreted her dizziness as a possible dangerous stroke, which prompted her fight-or-flight response (physiological changes, such as increased heart rate, in response to stress). This caused more light-headedness as blood from her brain was redirected to her muscles and other organs to prepare her to flee from danger. Susan interpreted the increased light-headedness as more evidence that she was having a stroke, which prompted her to call her husband to take her to the emergency room.

A careful review of Steve’s first panic attack in the grocery store revealed that he may have responded to a subtle danger signal, too. As we talked about his experience, Steve remembered feeling a sharp pain in his chest that became the trigger for the panic attack. As it turned out, a coworker the same age as Steve had recently suffered a heart attack. It seemed likely that this set the stage for Steve to interpret his chest pain as a heart attack, and that’s what triggered his sudden increase in heart rate, light-headedness, wobbly legs, and a strong urge to escape from the situation.

These two cases demonstrate how clients and I work together to identify the panic triggers and prevent the progression from an initial panic attack to the development of panic disorder.

Some people may have learned that physical sensations are likely to be dangerous, as in the cases above. When my clients report muscle tension as triggers for panic attacks, I may teach muscle relaxation techniques and breathing skills. Both of these tools are ways to let go and accept scary thoughts and frightening body sensations while doing things that might have been avoided, such as attending your child’s soccer game. When you let go of tension in your muscles and breathe slowly and smoothly (not deeply), you are behaving as if you are not in danger.

I work with my clients to get them to observe and accept their symptoms non-judgmentally until they subside. For example, if my client is fearful of having panic symptoms in an elevator, we get inside an elevator together, where I coach him or her to accept scary thoughts and body sensations as they occur, relaxing muscles and breathing as if there is no feeling of danger. Success is accomplishing the task and accepting symptoms, instead of focusing on the level of anxiety.

Panic disorder can be a chronic disabling condition that significantly impairs your quality of life. Fortunately, a variety of proven treatments can help you reclaim your life and pursue the things you value.

Ricks Warren, PhD, ABPP, formerly the director of The Anxiety Disorders Clinic in Lake Oswego, Oregon, is currently clinical lecturer and psychologist in the Department of Psychiatry at the University of Michigan Medical School in Ann Arbor. He holds the Diplomate in Cognitive and Behavioral Psychology from the American Board of Professional Psychology and is the author of numerous publications on anxiety disorders and related topics.