Panic Attacks
Panic Attacks
Getting a Grip on Fear
Driving across a bridge, a young woman suddenly feels she's going to lose control. She worries she may suddenly drive off the bridge. Frantic, she stops in the middle of the road--terrified and unable to get out of the car.
Another woman begins graduate school in New York City. While riding the subway to class one day, her heart starts racing. Suddenly her palms are sweating, her breathing is rapid and she feels like she's got to get out. She gets off at the next stop and rushes home.
Finally, a woman who once dreamed of a career in acting now has a fear of leaving home. Even though she lives near the school her children attend, she cannot bring herself to go to any school events.
Each of these women has panic disorder, which affects from 3 to 5 percent of Americans. The third woman has panic disorder and also has agoraphobia, a condition in which individuals develop such an intense fear of going out that they can't leave their homes.
Twice as many women as men develop panic disorder, and as many as 5 percent of women will experience it sometime in their lives, says R. Bruce Lydiard, M.D., Ph.D., professor of psychiatry at the Institute of Psychiatry at the Medical University of South Carolina in Charleston.
Understanding the Disorder
Panic disorder usually begins between the ages of 20 and 40, says Dr. Lydiard. But women tend to develop it later than men, according to the National Comorbidity Survey conducted by the Institute for Social Research at the University of Michigan in Ann Arbor.
The disorder begins with an initial panic attack, which includes the typical symptoms of the fight-or-flight response: a racing heartbeat, hyperventilation and hot and cold flushes. An attack may also include chest pains, dizziness, trembling, shaking, sweating, choking and numbness. "These come on for some individuals as if a thunderbolt has hit," says Dr. Lydiard. With no apparent stimulus to make their bodies react this way, their internal alarm system goes off, he says.
While for some a panic attack consists of just physical symptoms, others may think they've lost control of their minds, he says. In addition to feeling like they are going crazy, some people experience an overwhelming fear of dying.
Not everyone who experiences one panic attack--and an estimated 10 percent of Americans report doing so--has panic disorder. For it to be diagnosed, according to Dr. Lydiard, there must be recurrent, unexpected panic attacks with the persistent fear of having another--or the fear of a medical or mental problem. Either the incidence of panic attacks or the fear of having an attack must persist for at least one month.
Panic disorder can be traumatic. "Most people who come in complaining of it are truly devastated by the experience," says David Katerndahl, M.D., director of research and education in the Department of Family Practice at the University of Texas Health Sciences Center in San Antonio.
"It's an extremely disabling disorder. If people develop any phobic avoidance, they tend to limit their life and their activities. They become afraid to drive, or at least drive alone. They may become afraid to leave their house and become progressively housebound. They may have to quit jobs because they feel they can't function with their panic attacks or because they can't even go to work because of their panic attacks."
Panic attacks can last from a few minutes to an hour, says Dr. Katerndahl. The most common time to have one is in the middle of the night, between 1:00 and 3:00 a.m., he says.
What's behind It
Researchers don't know exactly what causes panic disorder, but they do know there are factors that can place you at greater risk for it.
For one thing, if someone in your immediate family--a parent or sibling--has panic disorder, you may be at greater risk for developing it. In a study of 2,163 female twins conducted at the Medical College of Virginia in Richmond, researchers found that women with a family history of panic disorder had a 30 to 40 percent chance of experiencing it.
Researchers also believe there is a biochemical basis to the disorder. When the fight-or-flight response is activated, usually when the brain perceives that the body is under attack or being threatened, adrenaline is released. With panic disorder, this response is triggered spontaneously, without outside stimuli.
But what causes panic disorder to develop? That's the question that stumps researchers. In some individuals a traumatic event, such as an accident, a death in the family, a divorce or some other serious event, precedes it. Eighty percent of panic disorder patients recall experiencing a critical incident prior to their first attack.
Some women develop panic disorder around the time of a hormonal fluctuation, says Dr. Katerndahl. About one-third of women who report the problem say their attacks started during pregnancy or immediately after delivery, he says. During the two to three weeks after menstruation, many women with panic disorder tend to experience relative well-being. Then, during the week prior to the start of their next period, their panic worsens, says Dr. Lydiard.
Researchers aren't sure how hormonal changes trigger panic, but they suspect it may have something to do with fluctuations of progesterone levels and the relationship of those changes to carbon dioxide levels in the body, says Dr. Lydiard. People who have panic disorder are more sensitive to carbon dioxide than those who do not have it, he says. Experts hypothesize that in these individuals, carbon dioxide triggers a "false suffocation alarm," and the body responds with a panic attack. Progesterone is a potent respiratory stimulus. After pregnancy and prior to menstruation, progesterone drops, and as it does, carbon dioxide levels rise, says Dr. Lydiard.
The Treatment Decision
Panic disorder can be treated with cognitive behavioral therapy or with medication. "Each has advantages and disadvantages," says Dr. Lydiard. It's often a matter of patient preference, he says.
With cognitive behavioral therapy, psychologists teach patients behavioral techniques that help them overcome the panic. If a woman doesn't want to take medication, cognitive behavioral therapy can be an excellent place to start, says Dr. Lydiard.
The Agony of Agoraphobia Some individuals with panic disorder also develop a condition known as agoraphobia--an intense fear of going places or being in situations where they might not be able to get help if they have a panic attack. From one-third to two-thirds of those who experience panic attacks have agoraphobia, says David Katerndahl, M.D., director of research and education in the Department of Family Practice at the University of Texas Health Sciences Center in San Antonio. Most are women, he says. Agoraphobia can be terribly disabling, says Dr. Katerndahl. One woman he knew missed her daughter's wedding because she was too afraid to leave home, while another was housebound for 20 years. Many people with agoraphobia work out of their homes and depend on drugstores and grocery stores that deliver. There's some question about what causes agoraphobia, but Dr. Katerndahl says an individual will experience a panic attack first. Agoraphobia can follow if the person associates the attack with the location where it occurred and gets anxious about returning. "Some work suggests that all you need is a single panic attack," he says. People who have no explanation for their panic attack are most at risk for agoraphobia. So how can women who've had a panic attack prevent themselves from developing agoraphobia? "The most important thing to do is to not avoid those situations you fear. As soon as you give in to the fear, you are on the road to agoraphobia," says Dr. Katerndahl. Most therapists suggest exposure therapy, in which a woman goes to the place she associates with her panic attack. If she had a panic attack in the mall, for instance, she would visit the mall on a schedule to reduce the fear. Exposure therapy is also used for those who've developed agoraphobia, says Dr. Katerndahl. There is no medication to treat the problem, he says. Some women with agoraphobia have trouble only when they are alone. They can go places and do things as long as they have company. For these women, exposure therapy would emphasize going places by themselves, says Dr. Katerndahl. When you're practicing exposure therapy, it helps to enlist the aid of a family member or friend, says Dr. Katerndahl. He or she can help you keep records of your activities and encourage you to keep it up.
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Cognitive behavioral therapy can be a potent and long-lasting form of treatment, says Dr. Lydiard. When it works, you may not need another form of treatment, ever. The downside, he says, is that it can be expensive, and it can be hard to find health professionals who know how to do it well. Individuals who are trying cognitive behavioral therapy should begin to see results within three months of starting treatment. If you are not seeing any results within that period, says Dr. Lydiard, consider a new therapist or some other form of treatment.
There are a number of drugs that can be used to treat panic disorder, but the most effective are benzodiazepines, including the drug alprazolam (Xanax), says Dr. Lydiard. Among its side effects are sedation and problems with coordination and memory. Physiological dependence is a very real possibility as well, says Dr. Lydiard, but withdrawal symptoms can be eased if individuals taper off the drug properly, he says.
Another drawback to benzodiazepines for the treatment of panic disorders is that they don't work for treating depression, which often appears along with panic disorder, says Dr. Lydiard. For that reason, many physicians use antidepressants such as fluoxetine (Prozac) as the first line of treatment.
An important issue for women to consider when making their treatment choice is pregnancy. While benzodiazepines and antidepressants have not been shown to be harmful during pregnancy, says Dr. Lydiard, one never knows. Women should plan to stop taking any medication before getting pregnant.
Getting Help
You don't have to be a prisoner of panic disorder. Here's some advice to help you cope.
Find the right doctor. If you think you may have panic disorder, find a doctor and begin treatment. The treatment recommended depends on the type of doctor you see, says Dr. Katerndahl. Psychologists are more likely to recommend cognitive behavior therapy, whereas family doctors and psychiatrists may lean more in the direction of medication.
Some health professionals don't recognize panic disorder, says Dr. Katerndahl. If you don't get a satisfactory explanation of your symptoms or don't get your questions answered, find another doctor.
Don't be ashamed. Panic disorder is not a psychological problem or an inherent personality flaw, says Dr. Lydiard. People around you may not understand what you are going through, but "this should be considered a medical condition just like migraine headaches or peptic ulcer or any other treatable medical condition," he says.
Should you require treatment over the long term, you should not view that as an inherent weakness, he says. The fact that doctors may use psychological techniques to treat panic disorder does not mean it's a purely psychological problem, he says.
Consider a support group. Support groups can be effective, says Diane Sholomskas, M.D., professor in the Department of Psychiatry at Yale University School of Medicine. The Anxiety Disorders Association of America has an Anxiety Disorders Self-Help Group Network; you can contact them at 6000 Executive Boulevard, Suite 513, Rockville, MD 20852.
