More effective treatments for panic have emerged, usually involving a combination of medication and therapy.

Women are more likely to have panic attacks during their premenstrual period, and some develop postpartum panic disorder.

For Jennifer, the attack came in the middle of the night. It was as if someone had kicked her in the chest and her heart started pounding. She was certain she was having a heart attack and worried that she wouldn’t make it to the hospital in time. At the Emergency Department, however, tests showed nothing wrong with her heart, and she was sent home with reassurance...and a good measure of embarrassment.

According to the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV), a panic attack is “an episode of intense fear where four or more of the following symptoms develop suddenly and peak within 10 minutes:

• pounding heart, palpitations;
• sweating;
• trembling or shaking;
• sensations of shortness of breath or smothering;
• feeling of choking;
• chest pain or discomfort;
• nausea or abdominal distress;
• dizziness, lightheadedness, faintness;
• feelings of unreality or depersonalization;
• fear of losing control or going crazy;
• fear of dying;
• numbness or tingling sensations;
• chills or hot flushes.

Debilitating Consequences
Isolated panic attacks can occur to just about anyone, but when attacks recur with no apparent cause (such as a phobia or drug intoxication or withdrawal), the diagnosis is panic disorder, a problem that can get progressively worse and interfere significantly with family, work and social functioning.

Even more debilitating is agoraphobia. When a panic attack occurs in a public place, as it did for Kris, it can initiate a fear of having a repeat attack. After a few embarrassing incidents, the person may start avoiding shopping in a supermarket or, eventually, any store or shopping center. Kris suffered an attack in the supermarket, and she had to lean on her shopping cart, trembling, sweating and distressed for several minutes. She didn’t go to the doctor but left the store immediately–with a mixture of fear and embarrassment. In its most severe form, agoraphobia keeps some patients isolated at home, sometimes unable even to go to the bathroom alone.

Agoraphobia eventually occurs in 70 percent of persons with panic disorder and in most of those who seek treatment. Three times as many women as men have agoraphobia.

Why women are more vulnerable than men to panic attacks and to agoraphobia is unknown. Some have theorized that men may be less likely to report panic because of cultural conditioning. Instead, they say, many men may develop alcoholism or another

have had at least one attack in their lives. Women are twice as likely as men to suffer attacks and they are more likely to go on to develop more serious problems such as panic disorder or agoraphobia.

The identifying features are the abrupt onset and the intense symptoms–they are indeed attacks. According to the drug addiction in an effort to hide the panic or to self medicate for it.

The major reason, however, may be hormonal. Women are more likely to have panic attacks during their premenstrual period. And some women develop postpartum panic disorder. While there’s a common tendency to lump all emotional problems following the birth of a child under the diagnosis “postpartum depression,” each disorder has its unique symptoms.

Whenever it occurs, panic disorder frequently leads into depression. And persons with panic disorder or agoraphobia have a risk of suicide about
20 times that of the general population.

Genetic studies indicate a strong family connection. About 40 percent of persons with agoraphobia have a close relative with the disorder. The concordance rate for identical twins is 30 percent. What’s inherited is not known, but some believe it may be a heightened sensitivity to the action of certain neurotransmitters (such as norepinephrine) that are synthesized and released as part of the body’s natural alarm system.

Psychiatric medications found effective in treating panic disorder all affect the balance of norepinephrine and serotonin in the brain. They include selective serotonin reuptake inhibitors SSRIs) such as fluoxetine and sertraline; tricyclic antidepressants such as imipramine and monoamine (MAO) inhibitors such as phenelzine.

Malfunctioning of the alarm system–also associated with norepinephrine imbalances–can be caused by certain neurological and endocrine disorders, by drug intoxication or withdrawal, and by stimulants such as cocaine, amphetamines or even caffeine.

Hyperventilation–which causes levels of carbon dioxide in the blood to fall–can precipitate some of the symptoms of a panic attack. So can inhalation of air containing a high concentration of carbon dioxide. Some researchers have theorized that any imbalance of gases in the blood may bring on intense physical sensations in susceptible individuals.

Likewise, injections of sodium lactate can bring on panic symptoms in about 80 percent of persons with panic disorder but only about 20 percent of the general population. Lactate, in the form of lactic acid, is also produced by the muscles during vigorous exercise, when the body is straining to maintain an adequate oxygen supply.

More Effective Treatment
Many individuals suffering panic attacks unfortunately are never diagnosed. They show up at the doctor’s office or emergency room, as Jennifer did, consumed by fear. Tests show they are perfectly healthy except for the racing heart–a hallmark symptom of a panic attack.

In the past, individuals like Jennifer were often prescribed a tranquilizer to help them “deal with stress.” Today, with increased knowledge about panic, more effective treatments have emerged–typically involving either medication, cognitive/behavioral therapy (CBT) or a combination of the two.

Generally, CBT involves teaching the patient ways of managing anxiety through proper breathing and dealing with thoughts that may be provoking the anxiety. The theory is that when patients become conscious of their thought patterns during a panic attack, they can learn to replace the scenario of doom with a more rational explanation.

A study published in the Journal of the American Medical Association [May 17, 2000] confirmed that:the combination of the tricyclic antidepressant imipramine and cognitive/behavioral therapy was more effective than placebo or either treatment on its own.

When patients and their doctors recognize what is happening, panic can be reduced, eliminated or managed–in at least 70 to 90 percent of cases.

Seems Like an Eternity But Only a Few Minutes
For the person suffering a panic attack, it seems like an eternity. It’s actually only a few minutes.

The typical panic attack reaches peak intensity in 5 to 10 minutes and is usually over within a hour. The symptoms are unlike those most individuals recognize as generalized anxiety but rather bring on thoughts of catastrophe or death.
[SOURCE: “Panic: Worry in the Extreme,” Harvard Women’s Health Watch, August, 2000]

Panic Has Early Onset
Panic attacks and panic disorder typically start occurring in late adolescence or young adulthood. Panic attacks are rare after age 65.
[SOURCE: Richard M. Glass, M.D., “Panic Disorder–It’s Real and It’s Treatable,” JAMA, May 17, 2000]

Many Patients Go for Alternative Therapies
A recent study published in the American Journal of Psychiatry [February, 2001] found that 53 percent of persons suffering anxiety or panic attacks tried alternative therapies–usually in addition to professional medical treatment. These therapies included relaxation training, spiritual healing, massage, imagery, hypnosis, special diets and herbal supplements.

A majority of respondents found these alternative therapies “very helpful.” Most admitted, however, that they didn’t tell their doctors about the alternative treatments. This failure to report could pose a problem if herbal supplements do not mix well with prescription medications or cause adverse interactions.
[SOURCE: “Alternative Treatment of Anxiety and Depression,” Harvard Mental Health Letter, October, 2001]

Smoking Increases Risk
Smokers have a dramatically increased risk of panic attacks, panic disorder and agoraphobia, according to two recent surveys of more than five thousand subjects.

In the National Comorbidity Survey, smokers had a risk of having a first panic attack three times that of the general public. And persons who quit smoking had a reduced incidence of panic disorder.

The Epidemiological Study of Young Adults in Southeast Michigan also found that daily smoking tripled the risk of panic disorder.

The increased risk among smokers could be due to carbon monoxide in the smoke or false suffocation alarms that occur when the smoker suffers shortness of breath due to chronic bronchitis or emphysema. In addition, nicotine is a stimulant that can increase anxiety levels.
[SOURCE: “Smoking and Panic,” Harvard Mental Health Letter, October, 2000]

Panic and Suicide Risk
In a survey of 1,580 inner city students, those who reported having a previous panic attack were three times more likely to have considered suicide and twice as likely to have made an attempt than students who had never had a panic attack.

REFERENCES:
David H. Barlow, Ph.D., Jack M. Gorman, M.D., M. Katherine Shear, M.D. and Scott W. Woods, M.D., “Cognitive-Behavioral Therapy, Imipramine, or Their Combination for Panic Disorder,” JAMA, May 17, 2000.
Cheryl Tatano Beck, “Postpartum Onset of Panic Disorder,” Journal of Nursing Scholarship, Summer, 1998.
“Forum: What Is Anxiety Sensitivity?” Harvard Mental Health Letter, October, 1998.
Richard M. Glass, M.D., “Panic Disorder–It’s Real and It’s Treatable,” JAMA, May 17, 2000.
Jack M. Gorman et al, “Physiological Changes During Carbon Dioxide Inhalation in Patients with Panic Disorder, Major Depression, and Prementstrual Dysphoric Disorder,” Archives of General Psychiatry, February, 2001.
David A. Katerndahl and Chad Trammell, “Prevalence and Recognition of Panic States in STARNET Patients Presenting with Chest Pain,” Journal of Family Practice, July, 1997.
“Panic Attacks and Panic Disorder, I and II” Harvard mental Health Letter, April and May, 1996.
“Panic: Worry in the Extreme,” Harvard Women’s Health Watch, August, 2000.
“Tips for Treatment, Panic Disorder,” Consultant, September, 1998.