Panic Disorder

An attack may start with in response to an obvious cause, but can just as easily come "out of nowhere." The anxiety rises to an intolerable level, often consuming the individual's entire attention. Along with it come real and distressing physical sensations: the racing heartbeat, the sweating, the muscle tension, the trembling, the gasping for breath, the lump in the throat, the nausea. As the attack progresses strange sensations set in. The mouth and lips may begin to tingle; pinprick sensations appear along the hands and feet; the person may feel lightheaded and believe they are on the verge of losing consciousness. Often the primary emotion during such an attack is dread, with many sufferers in the midst of an attack believing they will die.

In response, many people with panic disorder start to make their world smaller. They avoid places and activities that they fear might trigger an attack. They live with a sense of dread that the next attack may be around the corner, and they may feel powerless to stop it. Over time, their life is often limited not only during the panic attacks but during the entire span between attacks. In an advanced and unfortunately common form, individuals may become largely housebound ("agoraphobic" in the language of the DSM 5).

A first step when dealing with panic attacks is to ensure that an underlying medical condition, especially a heart condition, is not causing the symptoms. At times, conditions such as a heart arrhythmia can cause many of the symptoms of panic disorder. When new and concerning symptoms such as shortness of breath, chest pain, and intense distress occur it is wise to have them urgently evaluated to rule out a medical cause. For some this involves a visit to the emergency room during the first attacks. If attacks have resolved, it is still wise to consult with a primary care physician to determine whether any testing (such as an electrocardiogram) is needed. When there is not an obvious general medical condition giving rise to these episodes, and when the symptoms appear consistent with the usual pattern for panic attacks, a trial of either psychotherapy or medication for panic disorder is a good next step.

Psychotherapy:

While the problem can be severe and disabling, Cognitive Behavioral Therapy (CBT) offers an approach that can produce substantial improvement on a relatively short timeframe for many people. The sessions typically start with education about the nature of panic attacks. This involves review of physiological changes that occur during a panic attack, such as activation of the sympathetic nervous system, an influx of adrenaline (epinephrine), and hyperventilation with subsequent increased expulsion of carbon dioxide. It also involves exploration of how panic attacks frequently involve a vicious cycle: you perceive distressing symptoms, which increases your anxiety level, which worsens the distressing symptoms, which in turn further worsens your anxiety level.

As treatment progresses, I typically recommend an exposure-based approach. We explore ways to non-judgmentally respond to symptoms of panic when they occur, mindfully surveying them and understanding them for what they are. We also review ways to remove the element of dread involved in panic. This can include efforts to bring on some of the symptoms of panic in a controlled setting, for instance through the use of techniques that have been termed "interoceptive exposure." As you learn to break the cycle between experiencing symptoms of panic and escalating to a full-blown attack, treatment often progresses to generalizing the approach learned to other settings that may have previously been avoided. This allows many people, even if they have suffered from panic attacks for a long while, to begin engaging with and enjoying activities and other aspects of life that they had thought were lost to them.

Because CBT involves establishing new ways of understanding and dealing with panic, the gains are often maintained well after treatment ends. Treatment can often be completed in a relatively short course, not infrequently in ten or fewer sessions.

Medications:

Medication-based treatment has also proven effective for panic disorder, either in combination with psychotherapy or as a standalone treatment. First-line options include Selective Serotonin Reuptake Inhibitor antidepressants (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitor antidepressants (SNRIs). Other options, such as certain blood pressure medications (beta blockers like propranolol) can also be helpful for reducing the physical symptoms of anxiety and panic. Many of these options are taken on a daily basis in order to reduce anxiety levels and decrease both the likelihood of a panic attack and the severity if one does develop.

As-needed medications can also be a part of an effective treatment plan; however, these are usually employed on a time-limited basis. In particular, benzodiazepines can sometimes be used to help stop panic attacks. While they can have a robust effect, they carry with them risks including the formation of dependence or addiction. In some cases utilization of as-needed medication can sometimes help provide confidence for an individual to start re-engaging with activities they previously avoided. In some cases, however, as-needed medication can serve as a perpetuating factor for panic disorder that prevents development of better ways to deal with the symptoms.

Engaging in treatment with a prescriber who is experienced in managing panic disorder and other conditions that frequently co-occur with it helps ensure an optimal psychopharmaceutical approach.