Wednesday, April 18, 2012

Panic Attacks (Panic Disorder)

You retire and suddenly have all this free time with no commitments - but does that make you happy? Unfortunately, many people, who joined the group, have to admit that instead of the happiness and enjoyment, that should experience following this life transition, they are hit with terrible negative emotions and thoughts. We already reviewed depression and anxiety in our previous posts. Today, we will investigate panic attacks, condition, commonly associated with anxiety.

What are panic attacks?

Panic attacks are frightening but fortunately physically harmless episodes. They can occur at random or after a person is exposed to various events that may "trigger" a panic attack. They peak in intensity very rapidly and go away with or without medical help.

Panic attacks or symptoms of panic disorder are characterized by unexpected and repeated episodes of intense fear. While there are considered as physically harmless, in many cases they are accompanied by real physical symptoms such as chest pain, heart palpitations, shortness of breath, dizziness or abdominal distress.

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Who is likely to get panic attacks?

Scientists provide the statistical estimates that about 5% of the population are experience panic attacks during their lifetimes. Furthermore, about 1.7% of the adult U.S. population ages 18 to 54 - approximately 2.4 million people - experience symptoms of panic disorder in any given year. Women are twice as likely as men to develop panic disorder, and it typically first occurs in young adulthood. Roughly half of all people who have panic disorder develop the condition before age 25.

Until recently, it has been a long-standing concept that older people do not suffer from the condition known as panic disorder. Associate professor of psychiatry Dr. Javaid Sheikh claims that this concept is incorrect. "Contrary to popular belief, panic attacks do not disappear as people age," said Sheikh, founding director of Stanford's geriatric psychiatry program and associate chief of staff for mental health at the Menlo Park branch of the Veterans Affairs Palo Alto Health Care System. Because of the "general bias that older patients do not have panic attacks," researchers have largely neglected the problem as a topic of study, he said.

What are the varieties?

Panic attacks can range from mild to severe, and can occur infrequently or on a regular basis. It is not unusual for a person with panic disorder to develop phobias about places or situations where panic attacks have occurred, such as in supermarkets or while driving. If the frequency of panic attacks increases, the person may begin to avoid those situations all together, fearing another attack may occur and help would not be immediately available. This avoidance may eventually develop into agoraphobia, an inability to go beyond known and safe surroundings because of intense fear and anxiety.

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What are the causes of panic attacks?

Although scientific research has been conducted on the condition for many years, the exact cause or causes of panic disorder remain unknown. Certainly there is evidence that the tendency to have panic attacks can sometimes be inherited. However, there is also evidence that panic may be a learned response and that the attacks can be initiated in otherwise healthy people simply given the right set of circumstances. Research into the causes of panic attacks is ongoing.

However, several factors may play a role in the onset of panic disorder:
  • Heredity
  • A tendency toward exaggerated awareness of normal bodily reactions
  • Stressful life events

Research is inconsistent as to whether nutritional deficiencies (for example, zinc or magnesium deficiency) may be risk factors for panic disorder. While food additives like aspartame, alone or in combination with food dyes, are suspected to play a role in the development of panic attacks in some people, more research is needed to understand their role in this disorder.

What are the symptoms of panic attacks?

Clinical description of the panic disorder refers to experiencing recurrent unexpected Panic Attacks and at least one of the attacks has been followed by 1 month (or more) of one or more of the following:
  • Persistent concern about having additional attacks
  • Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
  • A significant change in behavior related to the attacks

So, to make a formal diagnosis of panic disorder, a person must experience either four panic attacks within a four-week period, or one or more attacks followed by at least a month of persistent fear of having another attack. During one of those attacks a minimum of four of the above noted symptoms must reach a peak within 10 minutes.

General symptoms which might be, or might not be present in any particular panic attach episode:
  • Palpations, pounding heart or accelerated heart rate
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded or faint
  • Feeling detached from oneself or feelings of unreality
  • Fear of losing control or of going crazy
  • Fear of dying
  • Numbness or tingling sensation
  • Chills or hot flashes

The panic attacks can be so disabling that the person is unable to express to others what is happening to them. A doctor might also note various signs of panic: The person may appear to be very afraid or shaky or be hyperventilating (deep, rapid breathing that causes dizziness).

Anxiety attacks that take place while sleeping, also called nocturnal panic attacks, occur less often than do panic attacks during the daytime, but affect about 40%-70% of people who suffer from daytime panic attacks. Individuals with nocturnal panic attacks tend to have more respiratory symptoms associated with panic and have more symptoms of depression and of other psychiatric disorders compared to people who do not have panic attacks at night. Nocturnal panic attacks tend to result in sufferers waking suddenly from sleep in a state of sudden fright or dread for no known reason. As opposed to people with sleep apnea and other sleep disorders, sufferers of nocturnal panic can have all the other symptoms of a panic attack. Although nocturnal panic attacks usually last no more than 10 minutes, it can take much longer for the person to fully recover from the episode.

Recent literature suggests that men and women may experience different symptoms during an attack. Women tend to experience a predominance of respiratory symptoms compared to men.

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Treatment for Panic Attacks

Treatment emphasizing a three-pronged approach is most effective in helping people overcome this disorder: education, psychotherapy and medication.


Education is usually the first factor in psychotherapy treatment of this disorder. The patient can be instructed about the body's "fight-or-flight" response and the associated physiological sensations. Learning to recognize and identify such sensations is usually an important initial step toward treatment of panic disorder. Individual psychotherapy is usually the preferred modality and its length is generally short-term, under 12 sessions. An emphasis on education, support, and the teaching of more effective coping strategies are usually the primary foci of therapy. Family therapy is usually unnecessary and inappropriate.

Therapy can also teach relaxation and imagery techniques. These can be used during a panic attack to decrease immediate physiological distress and the accompanying emotional fears. Discussion of the client's irrational fears (usually of dying, passing out, becoming embarrassed) during an attack is appropriate and often beneficial in the context of a supportive therapeutic relationship. A cognitive or rational-emotive approach in this area is best. A behavioral approach emphasizing graduated exposure to panic-inducing situations is most-often associated with related anxiety disorders, such as agoraphobia or social phobia. It may or may not be appropriate as a treatment approach, depending upon the client's specific issues.

Group therapy can often be used just as effectively to teach relaxation and related skills. Psychoeducational groups in this area are often beneficial. Biofeedback, a specific technique which allows the client to receive either audio or visual feedback about their body's physiological responses while learning relaxation skills, is also an appropriate psychotherapeutic intervention.

All relaxation skills and assignments taught in therapy session must be reinforced by daily exercises on the patient's part. This cannot be emphasized enough. If the client is unable or unwilling to complete daily homework assignments in practicing specific relaxation or imagery skills, then therapy emphasizing such skill sets will likely be unsuccessful or less successful. This pro-active approach to change (and the expectations of the therapist that the client will agree to this approach) needs to be clearly explained at the onset of therapy. Discussing these expectations clearly up-front makes the success of such techniques much greater.


A lot of people who suffer from panic disorder can successfully be treated without resorting to the use of any medication. However, when medication is needed, the most commonly-prescribed class of drugs for panic disorders are the benzodiazepines (such as clonazepam and alprazolam) and the SSRI antidepressants. It is rarely appropriate to provide medication treatment alone, without the use of psychotherapy to help educate and change the patient's behaviors related to their association of certain physiological sensations with fear.

Phillip W. Long, M.D. notes that, "Clonazepam (Klonopin, Rivotril) and alprazolam (Xanax), are the treatment of choice in the treatment of Panic Disorder. Clonazepam and alprazolam are preferred to antidepressant drugs because of their less severe side effects." He also states that it is preferred to try the anti-anxiety agents before moving on to the antidepressants because of the increased side-effect profiles. Xanax can be addicting for individuals and should be used with care. Treatment with either clonazepam or alprazolam should be discontinued by tapering it off slowly, because of the possibility of seizures with abrupt discontinuation.


Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.

Patients can be encouraged to try out new coping skills and relaxation skills with people they meet within support groups. They can be an important part of expanding the individual's skill set and develop new, healthier social relationships.

There are some commonly recognized approaches to help reduce symptoms associated with panic attacks:
  • Natural stress relieving activities. Lowering stress levels with activities such as regular exercise, massage or simply walking it out can help to keep the symptoms under control because stress can trigger or aggravate panic disorder. It can be easier to cope with stress on a daily basis if you schedule in regular stress relieving sessions.
  • Breathing exercises. One of the best single anti-anxiety measures, controlling breathing and breath work can offer an immediate lessening of symptoms. Most people are not really conscious about the way they are breathing, but when people are anxious they tend to take rapid, shallow breaths that come directly from the chest. This type of breathing is called thoracic or chest breathing. Chest breathing causes an upset in the oxygen and carbon dioxide levels in the body, resulting in increased heart rate, dizziness, muscle tension and other physical sensations.
  • Progressive Muscle Relaxation. Progressive muscle relaxation (PMR) is a stress and anxiety management technique. If you have panic disorder, agoraphobia or another type of anxiety disorder, you may experience frequent muscle tension. In fact, chronic muscle tension may be so automatic that it seems normal, and you may have forgotten what it feels like when your muscles are completely relaxed. By employing the progressive muscle relaxation technique, you will be able to quickly rediscover the distinctions between relaxation and tension of various muscle groups.
  • Creative visualization. During a panic attack, lots of things can go through your mind. Some people think about disaster, or even death. Instead of letting your imagination focus on these negative thoughts, try to concentrate on positive images. Think of a place or a situation that makes you feel peaceful, relaxed or at ease. Once you know have this image in your mind, try to focus your attention on it. It should help to distract you from the situation, and it may also help ease your symptoms. Thinking positively can be challenging, particularly if you have got used to thinking negatively over a long period of time. Creative visualization is a technique that will need practice, but you may gradually notice positive changes in the way that you think about yourself and others.
  • Self-Modification Program. Self-modification programs focus on helping people manage unwanted or dysfunctional behavioral responses when dealing with their problems. For example, if you have panic attacks as a result of panic disorder, a common dysfunctional behavioral response is avoidance. Unfortunately, avoiding fearful situations does nothing to help in your recovery from PD.
  • Do not fight an attack. Fighting a panic attack can often make the experience worse. Trying to resist the attack and finding that you are unable to can increase your sense of anxiety and panic. Instead, during a panic attack, reassure yourself by accepting that although it may seem embarrassing, and your symptoms may be difficult to deal with, your attack is not life-threatening. Focus on the fact that your attack will have an end and try your best to let it pass.
  • Start a Panic Diary. If you have panic disorder or agoraphobia, a panic diary may help you to identify your panic attack triggers and your responses to anxiety-provoking situations. It is usually best to record in your panic diary as you are experiencing (or shortly thereafter) anticipatory anxiety or a panic attack.
  • Monitor your diet. Eating certain types of foods can help to calm you down naturally, so make sure you're not eating 'trigger' foods that may upset your nervous system balance. Meet with a nutritionist or dietician to create a healthy eating plan that's centered on wholesome foods that won't cause excessive anxiety.

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Panic Attacks Prevention

Following the practices of a healthy lifestyle can help, including eating well and getting regular exercise. Using mind-body approaches and relaxation techniques to reduce stress and anxiety can also help keep you centered and minimize the impact of panic attacks.

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Sources and Additional Information:


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