Panic Attacks(Panic Disorder)


Panic attacks are sudden feelings of terror that strike without warning. These episodes can occur at any time, even during sleep. A person experiencing a panic attack may believe that he or she is having a heart attack or that death is imminent. The fear and terror that a person experiences during a panic attack are not in proportion to the true situation and may be unrelated to what is happening around them. Most people with panic attacks experience several of the following symptoms:


1. "Racing" heart

2. Feeling weak, faint, or dizzy

3. Tingling or numbness in the hands and fingers

4. Sense of terror, of impending doom or death

5. Feeling sweaty or having chills

6. Chest pains

7. Breathing difficulties

8. Feeling a loss of control



Panic attacks are generally brief, lasting less than ten minutes, although some of the symptoms may persist for a longer time. People who have had one panic attack are at greater risk for having subsequent panic attacks than those who have never experienced a panic attack. When the attacks occur repeatedly, a person is considered to have a condition known as Panic Disorder.



What are the symptoms of a panic attack?

As described above, the symptoms of a panic attack appear suddenly, without any apparent cause. They may include:


Racing or pounding heartbeat

Chest pains

Stomach upset

Dizziness, lightheadedness, nausea

Difficulty breathing,
a sense of feeling smothered

Tingling or numbness in the hands

Flushes or chills

Dreamlike sensations or perceptual distortions

Terror: a sense that something unimaginably horrible is about to occur and one is powerless to prevent it

Fear of losing control and doing something embarrassing

Fear of dying

A panic attack typically lasts for several minutes and is one of the most distressing conditions that a person can experience. Most who have one attack will have others. When someone has repeated attacks, or feels severe anxiety about having another attack, he or she is said to have panic disorder.



What are panic attacks?

Panic attacks may be symptoms of an anxiety disorder. These attacks are a serious health problem in this country. At least 1.7% of adult Americans, or about 3 million people, will have panic attacks at some time in their lives. The symptom is strikingly different from other types of anxiety in that panic attacks are so very sudden and often unexpected, appear to be unprovoked, and are often disabling.

Panic attacks can occur at any time, even during sleep. An attack generally peaks within 10 minutes, but some symptoms may last much longer.

Once someone has had a panic attack, for example, while driving, shopping in a crowded store, or riding in an elevator, he or she may develop irrational fears, called phobias, about these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where the individual with panic disorder may be unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. Thus, panic disorder can have as serious an impact on a person's daily life as other major illnesses, unless the individual receives effective treatment.



Are panic attacks serious?


Yes, panic attacks are real, potentially quite emotionally disabling, but they can be controlled with specific treatments. Because of the disturbing symptoms that accompany panic attacks, they may be mistaken for heart disease or some other life-threatening medical illness. People frequently go to hospital emergency rooms when they are having a panic attack, and extensive medical tests may be performed to rule out these other conditions.


Medical personnel generally attempt to reassure the panic attack patient that he or she is not in great danger. But these efforts at reassurance can sometimes add to the patient's difficulties: If the doctors use expressions such as "nothing serious," "all in your head," or "nothing to worry about," this may give the incorrect impression that there is no real problem and that treatment is not possible or necessary. The point is that while panic attacks can certainly be serious, it is not organ-threatening.




What causes panic attacks?


According to one theory of panic disorder, the body's normal "alarm system," the set of mental and physical mechanisms that allows a person to respond to a threat, tends to be triggered unnecessarily, when there is no danger. Scientists don't know exactly why this happens, or why some people are more susceptible to the problem than others. Panic disorder has been found to run in families, and this may mean that inheritance (genes) plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it. Often, the first attacks are triggered by physical illnesses, a major life stress, or perhaps medications that increase activity in the part of the brain involved in fear reactions.



Thanks to research, there are a variety of treatments available, including several effective medications, and specific forms of psychotherapy. In terms of medications, specific members of the selective serotonin reuptake inhibitor (SSRI) and the benzodiazepine families of medications are approved by the Food and Drug Administration to treat panic disorder. Examples of such medications include sertraline (Zoloft) and paroxetine (Paxil) from the SSRI group and clonazepam (Klonopin) from the benzodiazepine group. Medications from the beta blocker family (for example, propranolol) are sometimes used to treat the physical symptoms associated with a panic attack.


Before SSRIs became available, medications from the group known as the tricyclic antidepressants (TCAs) were often used to address panic disorder. However, SSRIs have been proven to be safer and better tolerated therefore, TCAs are used much less often. When used in the appropriate person with close monitoring, these medications can be quite effective as part of treatment for panic disorder. However, as anything that is ingested carries risk of side effects, it is important to work closely with the prescribing doctor to decide whether medication treatment is an appropriate intervention and if so, which medication should be administered. The person being treated should be closely monitored for the possibility of side effects that can vary from minor to severe and in some cases even be life-threatening.


The psychotherapy component of treatment for panic disorders is equally as important as medication treatment. In fact, research shows that the combination of medication and psychotherapy treatment for panic disorder is more effective than either intervention alone. To address anxiety, cognitive behavioral therapy is widely accepted as an effective form of psychotherapy. That form of therapy seeks to help those with panic disorder identify and decrease the irrational thoughts and behaviors that reinforce panic symptoms. Behavioral techniques that are often used to decrease anxiety include relaxation techniques and gradually increasing exposure to situations that may have previously increased anxiety in the individual.


Often, a combination of psychotherapy and medications produces good results. Improvement is usually noticed in a fairly short period of time, about two to three months. Thus, appropriate treatment for panic disorder can prevent panic attacks or at least substantially reduce their severity and frequency, bringing significant relief to 70 to 90% of people with panic disorder.


There are also things that people with panic disorder can do to help make treatment more effective. Since substances like caffeine, alcohol, and illicit drugs can worsen panic attacks, those things should be avoided. It may be worth engaging in aerobic exercise and stress-management techniques like deep breathing and yoga, as those activities have been found to help decrease the frequency and severity of panic attacks.


In addition, people with panic disorder may need treatment for other emotional problems. Depression has often been associated with panic disorder, as have alcohol and drug abuse. Recent research also suggests that suicide attempts are more frequent in people with panic disorder. Fortunately, these problems associated with panic disorder can be overcome effectively, just like panic disorder itself.


Tragically, many people with panic attacks do not seek or receive treatment.




What happens if panic attacks are not treated?


Panic attacks tend to continue for months or years. While it typically begins in young adulthood, in some people the symptoms may arise earlier or later in life. If left untreated, it may worsen to the point where the person's life is seriously affected by panic attacks and by attempts to avoid or conceal them. In fact, many people have had problems with friends and family or lost jobs while struggling to cope with panic attacks. There may be periods of spontaneous improvement in the attacks, but it does not usually go away unless the person receives treatments designed specifically to help people with panic attacks.



Post-Traumatic Stress Disorder - Treatment

Post-traumatic stress disorder is a pattern of behavior that develops after a traumatic event. A traumatic event in this context is defined as one that may bring serious injury or death to oneself or to another person. Traumatic events capable of causing post- traumatic stress disorder include kidnapping, natural disasters (hurricanes, earthquakes, tornadoes, floods, )ect,physical and sexual abuse, combat, drug abuse, and near-death experiences.

Historically referred to as "soldier's heart" and "shell shock" because the behavior characteristic of post-traumatic stress disorder was seen in men after wartime combat, the symptoms and behaviors of post-traumatic stress disorder have been shown to occur in children, adolescents, and adults

Constellation of changes in post-traumatic stress disorder

Post-traumatic stress disorder is a constellation of changes in personality and behavior that begin after a traumatic event and persist for more than a month. Following the traumatic event, individuals who develop post-traumatic stress disorder may feel like the everyday world is no longer real and that they are in a dream- like state. They may feel that their minds are detached from their emotions as well as from their physical bodies, a condition referred to as dissociation.

Persons with post-traumatic stress disorder may continuously experience flashbacks. During these flashbacks they relive the traumatic event and reexperience feelings of intense fear and of inability to escape from the traumatic event. Every effort is taken to avoid actions or thoughts associated with the traumatic event in order to prevent these flashbacks.

Ultimately, behavior becomes erratic and hyperactive, as if the individual were constantly defending himself. For example, the person may develop anxiety, have disturbed sleep, and be easily startled. Over the long run this behavior can lead to complete dysfunction with a sense of hopelessness, a total lack of self- esteem, and overwhelming fear of people. There also may be substance abuse (use of alcohol or narcotics, for example) and difficulty maintaining existing relationships.

Variable duration of the disorder In about half of the individuals with post-traumatic stress disorder, the condition resolves within six months while the other half continue to suffer for years. Post-traumatic stress disorder is considered to be acute if symptoms and behaviors last less than three months, chronic if symptoms and behaviors persist for more than three months, and delayed in onset if symptoms and behaviors begin at least six months after the traumatic event.

About 4% of the general population or approximately 10 million people develop post-traumatic stress disorder each year. It is twice as common in women as in men. In one study it was found to occur in 15% of war veterans up to19 years after combat. Several factors including psychological traits, genetics factors and life experiences may contribute to the likelihood of developing post-traumatic stress disorder.

For most patients with post-traumatic stress disorder, treatment has consisted of counseling, psychotherapy, or drugs. A combination of these approaches is sometimes employed. We will focus here on the drugs used for post-traumatic stress disorder.

Drug treatment of post-traumatic stress disorderThe erratic, hyperactive behavior, anxiety, and sleep disturbance associated with post-traumatic stress disorder were first thought due to over-activity of the sympathetic nervous system, the part of the nervous system that is active when there is fear. For this reason, children were treated with propranolol (Inderol) which blocks the sympathetic nervous system. However, propranolol proved to provide little benefit.

New research has revealed how severe trauma can produce long-term changes in the nerves in the brain. In particular, it is now believed that the problem is caused by alterations in the chemical substances that nerves in the brain use to communicate with each other, substances referred to as neurotransmitters. These alterations in neurotransmitters may be responsible for the symptoms and behaviors.

Treatment of post-traumatic stress disorder has therefore shifted to drugs that target these chemical substances. For example, antidepressants including imipramine and phenelzine (Nardil) that alter neurotransmitters such as serotonin, norepinephrine, dopamine, and acetylcholine have been found do more to reduce flashbacks and the feelings of helplessness more than placebo (a dummy pill). Unfortunately, however, side effects interfered with the long-term use of these drugs.

Trials with sertraline (Zoloft)

A trend that emerged from these studies was that greater improvement was seen with drugs that altered serotonin more than other neurotransmitters. This finding led to studies with sertraline (Zoloft) which alters serotonin in the brain. In two 12 week-long trials involving 385 patients -- mainly women who developed post- traumatic stress disorder after sexual or physical assault - sertraline (Zoloft) was compared with placebo. Sertraline (Zoloft) reduced both the number and intensity of symptoms by 50% compared with 30% for placebo. A third similar study found no difference in the response between sertraline (Zoloft) and placebo. A fourth study in war veterans with post-traumatic stress disorder also found no difference in response.

In sum, sertraline (Zoloft) may be effective in reducing symptoms in at least some but by no means all patients with post-traumatic stress disorder. In particular, sertraline (Zoloft) may be useful for women with post-traumatic stress disorder as a result of sexual or physical assaults. Nevertheless, the response to sertraline (Zoloft) was not much greater than the response to placebo, suggesting that the drug's effectiveness is limited.

Issues raised by the studies but not answered are whether men respond as well as women, whether post-traumatic stress disorder caused by different types of traumatic events will respond similarly, and whether patients with other psychological problems in addition to post-traumatic stress disorder also will respond to sertraline (Zoloft). None of the studies to date have addressed the issue of how effective sertraline (Zoloft) will be with long-term treatment or what happens if treatment is discontinued.

Newer drugs in development For now, treatment of post-traumatic stress disorder is likely to remain focused upon drugs that alter serotonin but are less likely to cause side effects. Nefazodone (Serzone) and mirtazapine (Remeron) are already being tested. It is likely that fluoxetine (Prozac), paroxetine (Paxil), and citalopram (Celexa) will soon be studied for the treatment of post-traumatic stress disorder.

Guide to Alternative Therapies
Contents:

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