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PANIC DISORDER

The purpose of this material is to explain Panic Disorder. It may help you to decide if you have this disorder. If there is reason to suspect Panic Disorder, the brochure suggests a reasonable approach to take so that a proper diagnosis can be made and, if necessary, treatment begun.

This is intended for educational information only. Treatment for appendicitis is not a 'do it yourself' project. Neither is treatment for Panic Disorder. If you believe, after reading this, that you might have Panic Disorder, you should see your physician who can either diagnose and treat you, or refer you to a specialist.

A Case History

Ann was watching television after a typical workday. She suddenly developed a peculiar and very strong feeling of being lightheaded and a smothering sensation as if there were no oxygen in the air she was breathing. Then a surge of pounding rapid heartbeat began. It came on so quickly and was so severe that she became panicked that she might be dying of a heart attack! Then she felt very shaky, sweaty, and unsteady. This whole experience reached peak intensity within 60 seconds. This was the eighth such attack this month.

PANIC

"Panic" was hardly the word to describe how terrified she was feeling. It went beyond any feeling of fear that she had ever experienced. Although she had gone to the emergency room several times, nothing seemed to be found by the doctors to explain why she kept having the attacks.

She frantically searched for her car keys so that she could get to the hospital immediately. She thought desperately, "What's wrong with me?"

What it feels like.

The main symptom of a Panic Disorder is the panic attack itself. Panic Disorder is a medical disorder characterized by severe and sudden episodes or "attacks" with several of the following symptoms:

It is important to mention that sudden episodes of the above symptoms caused by another reasonable cause are not panic attacks. Two such reasonable causes would be (1) a certain medical ailment that might mimic a panic attack, or (2) a life threatening experience immediately preceding the attack. If these reasonable causes are found not be the cause of the problem then there is the possibility of a Panic Disorder.

Panic attacks reach maximum intensity within a minute or two once they begin. They diminish slowly-over the next 30 minutes or the next several hours. It is common for the first attack to cause a person to go to an emergency medical facility. Subsequent attacks occur several times a month and are often as severe as the initial attack.

About three fourths of Panic Disorder patients are women. Panic Disorder begins most often when people are 20-30 years old. It begins less often in teenagers or persons in their forties. It is uncommon for the disorder to appear in the elderly for the first time.

It is important to note that although a few experts say it is more common in persons who experienced a separation experience as a child, many of experts feel that Panic Disorder afflicts emotionally healthy people. Persons with Panic Disorder are no more likely than the average American to have suffered from emotional problems at the time the disorder begins.

Afraid of Something.

Persons experiencing repetitive, severe panic attacks may simply have panic attacks and that is all. Other persons may begin to experience a progression of bothersome or distressing panic attack "side effects". This progression commonly occurs as follows:

1

A few weeks or months prior to the first panic attack there are sometimes minor symptoms such as rapid heart beat.

2

The first major panic attack occurs. The person often seeks emergency medical evaluation at this time. The initial examination is commonly normal.

3

Continued panic attacks cause the person to seek further medical evaluations which may be inconclusive. Many panic attack sufferers go for months or years before receiving the proper diagnosis and by that time may have seen over a dozen physicians, psychologists and counselors. This appearance of "doctor shopping" may cause others to regard the sufferer as a hypochondriac.

4

An individual with Panic Disorder may begin to avoid a certain activity because it occurs to them that it would be especially embarrassing or dangerous to have an attack while engaged in that activity. A typical sufferer of Panic Disorder might think, "It's bad enough to have an attack at all, but it would be dangerous to have one on Interstate 75 because I would be preoccupied with the attack and would not be a safe driver. I might wreck my car, injuring myself or someone else!" This avoidance behavior may appear to be a fear of driving when it is really a fear of having a panic attack while driving.

5

Tendencies to avoid circumstances in everyday life may increase and extend to more activities. This extensive avoidance behavior is referred to as agoraphobia.

Places, activities or circumstances frequently avoided by persons with Panic Disorder include the following:

Shopping malls
Department stores
Restaurants
Church
Meetings
Classes
Driving
Being alone
Airplanes
Elevators

6

After months or years of continuous panic attacks and the restricted lifestyle caused by the typical avoidance behavior, the sufferer of Panic Disorder may become demoralized and psychologically or physically depressed.

Some sufferers turn to alcohol in an attempt to self-medicate or to diminish the symptoms of the disorder. This greatly complicates the individual's life and ability to seek appropriate treatment.

Tragically, one out of every five untreated sufferers attempts to end his or her life, never realizing that there was hope and treatment available.

Is There Damage?

A person will not die from a panic attack. But, Panic Disorder does indeed cause damage. It is difficult to estimate the misery and loss of overall productivity that this disorder causes.

There is personal pain and humiliation and a restricted lifestyle. There are missed days of work due to panic attacks. There may be unemployment due to partial or complete disability. There is increased risk of alcoholism and suicide.

Add the unhappiness the disorder causes in the loved ones of panic disorder and the consequential loss of their productivity. You come to realize that the total magnitude of the damage that the disorder causes nationally is staggering. And we haven't even touched on the tremendous cost that the waste of misdiagnosis and unnecessary or inappropriate medical care adds to the damage estimate. Drug and alcohol abuse are the number one public concern of Americans. However, Anxiety Disorders affect more Americns than the combined toll of drug and alcohol abuse. And yet Anxiety Disorders are not even in the top fifty of Americans' public concerns The federal government has developed a plan to deal with this problem.

CAUSES & TREATMENT

What causes Panic Disorder?

Twenty years ago Panic Disorder was poorly understood even by most experts. It was called Anxiety Neurosis and was thought by some to stem from "deeply rooted" psychological conflicts and subconscious upsetting impulses of a sexual nature.

Now we regard Panic Disorder as more of a physical problem with a metabolic core. It is not an emotional problem, although after suffering from it, emotionally healthy persons may develop depression or other problems. There are different theories about where in the nervous system the problem exists.

There is considerable evidence pointing toward a DNA abnormality controlling the physiology of cholecystokinin, a neurotransmitter in the brainstem. (The brainstem is the part of the brain that controls heartbeat, breathing and other vital functions).

In 1999 Canadian medical scientist Jacques Branwejn announced that his colleagues and he discovered a genetic mutation that appears to put people at risk for panic attacks.

At a meeting of the Human Genome Organization in Edinburgh Scotland in 2002, Dr. Xavier Estevill, head of medical and molecular genetics at the Duran I Rynals Hospital in Barcelona Spain, discovered that a gene on some other chromosome, or some environmental factor early in development, may cause in some people an abnormality of chromosome 15. This defect may in turn make people more susceptible to panic attacks. It seems this genetic abnormality of chromosome 15 is not inherited because it is not present in all of the cells of those affected. Although this has been observed to occur in plants, this is the first discovery of such a chain of events in humans. Almost 100% of those with panic disorder or phobias had the duplication of genetic material on chromosome 15.

Few experts still cling to the notion that this is not a physical disorder. Scientific evidence clearly favors there being a physical cause of this disorder. It is regarded as a physical disorder much like Diabetes or Pneumonia.

Why am I claustrophobic?

Some people with panic disorder have only panic attacks. They occur out of the blue with no apparent rhyme or reason. Over half the people with panic disorder also experience, in addition to the unexpected panic attacks, fears of certain places or situations. Traditionally, this has been called agoraphobia, a word derived from two ancient words meaning market place fear. At the National Anxiety Foundation, we have found this term to be less useful in our present day understanding of the fears that typically bother persons with panic disorder. Claustrophobia is a far better understood term. Nearly all of the situations that bother persons that are thought of as having claustrophobia are also situations that bother many persons who have panic disorder.

Agoraphobia only

Both Agoraphobia and Claustrophobia

Claustrophobia only
Wide open spaces Aircraft
Automobile
Elevator
Classroom
Mall
Store
Church service
Seminar meeting
Subway
Etc.		 Hands handcuffed

There are two additional fears that people with panic disorder sometimes experience. One of the additional fears is of being away from help, especially medical help, should they have one of their attacks. A woman, for example, may not want to leave town because she is too far from a hospital, or a man may not want his wife to go away overnight on a business trip because there would be no one there to get him to the hospital if he were to become critically ill during her absence. A second additional fear is a fear of the opposite of claustrophobia - a fear of wide-open spaces, for example, a fear of standing in a vast parking lot at the mall. Perhaps the root of this fear of wide-open spaces is actually, again, a fear that one will be alone and too far from help should they have what feels like, and might be, a life-threatening attack.

The overwhelming majority of fears that people with panic disorder experience are ones of the claustrophobic type. A few years ago, Dr. Cox, the founder of the National Anxiety Foundation, may have stumbled across the reason for this. "After seeing perhaps one too many panic disorder patients after the end of a long day at work, I wondered why people with panic disorder always have the same fears, if they have any fears at all. I found it curious that of all the thousands of things and situations a person could be afraid of, in panic disorder, it is almost always one or two or three fears out of a list of only about a dozen situations. This phenomenon really began to fascinate and preoccupy me. One day, when I was trying to think of anything at all that every one of these things had in common. There were only three such factors:

1. They were all enclosed spaces.

2. There were always people in the spaces, even if it were only the person himself or herself.

3. There was a high ratio of the number of people to the volume inside the space.

As I was thinking the word 'people', the light bulb went off in my mind - carbon dioxide!"

Back in 1977 Dr. Cox and Ekkehard Othmer M.D. replicated the research of Drs. Ferris Pitts who was the first to publish experimental results describing the ability of an infusion of sodium lactate intravenously to trigger panic attacks in persons with panic disorder. Soon afterwards, other chemical triggers were discovered such as:
subcutaneous (under the skin) injections of adrenaline
breathing mixtures of carbon dioxide (5% carbon dioxide/95% room air) from a mask and tank
progesterone pills
massive amounts of caffeine.

Incidentally, carbon dioxide is not to be confused with carbon monoxide which is a deadly gas in exhaust from your car. Dr. Cox reasoned that people exhale carbon dioxide into the room or the vehicle that they are in, where it is not free to exchange with outdoor fresh air. Dr. Cox questioned that perhaps these confined, closed-in, claustrophobic environments have more carbon dioxide than outdoor fresh air. "I went to my medical texts and found out that we humans exhale about 500 liters (about 500 quarts) of pure carbon dioxide a day! I could find no record where anyone had measured carbon dioxide levels in the air in these claustrophobic places. So I set about designing a simple straightforward study to measure carbon dioxide in these environments."

Dr. Cox enlisted two colleagues in this work, the imminent international anxiety expert, Dr. David Sheehan, and Jeff Lawrence, Ph.D., a biochemist who did work on the anxiety receptor in the brain (GABA), and who was the president of PTRL, an international laboratory, a chemical analysis and synthesis laboratory in the USA and in Germany.

"Jeff and I took official EPA air collection bags and collected samples from our day to day travels - in elevators, in the car, in restaurants, in commercial aircraft, and in churches. My daughter and her neighbor friend took collection bags to school to collect samples from the classroom.Ó

When the air samples were analyzed for carbon dioxide content, the results were not what Dr. Cox had hoped for. "We hoped to see 3 or 4 % elevations in carbon dioxide in the air samples that were collected in the claustrophobic environment. The results were not coming back 3-4%, they were coming back 100% to just over 200% higher than outdoor fresh air carbon dioxide. This was very exciting. We felt like Watson and Crick when they discovered DNA. It is rare privilege in today's world when individuals discover something truly new and important."

"It all began to make sense then. I thought that I understood finally why these people with panic disorder so frequently have their first attack in claustrophobic environments. The high levels of carbon dioxide in aircraft cabins produced by all those people who have raced to the gate with heavy carry-on bags in tow are exhaling clouds of carbon dioxide into this airtight metal tube-like cabin. The carbon dioxide levels shoot up. The people with panic disorder, who are hypersensitive to this carbon dioxide, start to feel the anxiety effects of these elevated levels. Then the cabin door is closed with a dull 'whoomp' sound and the carbon dioxide continues to rise further. A person with panic disorder is more apt to have a panic attack at this point due to carbon dioxide exposure inside the aircraft. They want to get off because they are feeling that familiar dreadful feeling that can only be relieved by getting out of the confined space and into the open air. In most situations, like a Wal-Mart, they can go right outside and, if so, just as soon as they get outside, they start to feel better. Now we know why they feel better. It's not because they have some irrational fear of Wal-Mart or of an aircraft cabin. These people with panic disorder and claustrophobia are usually psychologically average, normal people. They just happen to be hypersensitive to certain chemical factors in the environment and to ones even in their own bodies."

More on this carbon dioxide matter will be discussed under the "There is hope and Help" section.

There is hope and help

Is there hope for persons with Panic Disorder? Yes. Panic disorder is very treatable. And nearly everyone responds well to proper treatment. Treatment consists of several steps:

A

First a person must be educated about this disorder. Simply learning some of the things mentioned in this brochure will improve matters somewhat by giving hope where there perhaps was despair. Understanding and knowledge gives confidence and a positive expectation so important to the success of any medical treatment.

B

Next, it is necessary to find a medication which can eliminate the panic attacks completely, if at all possible. Psychiatrists experienced in treating Panic Disorder have had success using any one of three kinds of medicines:

1

Certain Antidepressants. Paxil & Paxil CR (paroxetine), Zoloft (sertraline), and Prozac (fluoxetine) are examples of antidepressants that are useful in treating Panic Disorder and have official FDA approval for that indication. Many antidepressants may alleviate panic attacks. Physical dependence does not occur on such medicine.

Successful treatment requires full strength dosage and it usually takes four to six weeks for the medicine to begin to block the panic attacks. Full benefit may take up to 3 months.

Perhaps half of persons trying this type of medicine are made initially worse to a greater or lesser degree. Certain properties of the medicines tend to trigger more than the usual number of attacks, or more severe attacks, in the first several days of treatment. This temporary discomfort can be considered a short term investment of worsening in return for a gain of long term relief. In most patients this potential temporary worsening can be alleviated by taking smaller than usual starting doses of the medication. In unusually sensitive patients, experienced clinicians have even used 1/64 or 1/32 of the usual starting dose.

Paxil (paroxetine) is an example of a new antidepressant which has few side effects and has FDA indications for treatment of panic disorder. A newer and improved form of Paxil is Paxil CR. It is enteric coated so it is less likely to bother the stomach. It is time-released. It has even less side effects than regular Paxil (paroxetine). The other two antidepressants that have FDA approval for treating panic disorder are Zoloft (sertraline) and Prozac (fluoxetine). Experts vary in their preference of these medications. Dr. Stephen Cox, founder of the National Anxiety Foundation, favors Paxil CR. "There is a problem with using antidepressants to treat persons with panic disorder. When these persons take antidepressants, for the first several days they are often made worse, rather than better. Experienced doctors know to expect this and prescribe the medicines that they have found in their personal experience to be less apt to cause this known risk of worsening of either the frequency or the severity of panic attacks. In my own experience, Paxil CR seems less likely to intensify the patient's symptoms the first few days. In my experience, Prozac has been harsh to people with panic disorder with respect to this temporary worsening risk. I think Zoloft lies somewhere between Paxil and Prozac. I do think that Zoloft seems definitely closer to Paxil in this regard than it does to Prozac."

The question arises, "Why take a medicine that has a 50% chance of making you worse?" It turns out, the worsening, if it occurs at all, is only temporary. In the first few days of continued use, it passes. Then people with panic disorder, with continued use of the medication, enter into a neutral period where they are actually no worse than when they started this medicine, but they are no better either. After about 3-6 weeks, they hopefully begin to experience fewer attacks, or less severe attacks, or both. Dr. Cox comments on this, "Experienced doctors will use less initial dose when prescribing this medicine for panic disorder than they would if they were prescribing it for depression. If I prescribe Zoloft (sertraline) for panic disorder, I start with 25 mgs. not 50 mgs. (the usual dose for depression). I don't often prescribe Prozac (fluoxetine) for panic disorder. I usually prescribe Paxil CR and I personally find it so unusual to temporarily worsen panic disorder that I commonly start not with the lowest dose of 12.5 mg, but with 25 mg, the same usual dose used for depression. I sometimes prescribe Xanax (alprazolam), in the form of Xanax XR, along with the Paxil CR in the beginning of treatment if I need to give this patient immediate relief. I have no problem with prescribing Xanax XR alone for persons with panic disorder if that is appropriate. There is a study by Munford, et al, that suggests to me that Xanax XR is substantially less apt to be abused by persons who are prone to abuse drugs. Fortunately, persons with panic disorder are not prone to be the type persons who abuse drugs. Usually, if a genuine panic disorder patient is not taking their Xanax as prescribed, they are more than likely taking less than has been prescribed."

There is still one question that stumps medical science. Why do so many patients with panic disorder get worse when they first start taking antidepressant medication? Dr. Cox has his own theory about this puzzle that goes back to the carbon dioxide sensitivity that was discussed at the beginning of the panic disorder section. "When Dr. Sheehan, Dr. Lawrence, and I published our research on the higher levels of carbon dioxide in environments of claustrophobia, I presented this discovery at the annual NCDEU meeting that year. A man approached me and commented that he noted that I mentioned that antidepressants lowered the brain cell sensitivity to carbon dioxide. He said that that effect is actually a biphasic effect. Antidepressants first make brain cells more sensitive to carbon dioxide, then after a while, with continued use, they make the brain cells less sensitive to carbon dioxide. I was excited to learn of this and I asked him if he knew who discovered that, as I wanted to read more about it. He responded humbly, "I did." This researcher was Dr. Sheldon Preskorn, the prominent expert in antidepressant therapy. Few people realize it, but Dr. Preskorn did extensive basic science research of great importance before he became noted as a clinical expert and a teacher of clinicians.

"If you ask most doctors or representatives of pharmaceutical companies that make antidepressants about why antidepressants make people with panic disorder worse in the beginning of treatment, they will repeat back something they have heard about serotonin causing initial worsening of neuronal sensitivity or such. The trouble is, when you ask them to get you a scientific reference on that, they come up mostly empty handed. It is a theory and a widely held theory."

Dr. Cox continues his comments, "The carbon dioxide theory, on the other hand, is based on scientific observations that fit the scientific data and clinical observations. I remain convinced this is the main reason why antidepressants make people with panic disorder worse at first and better in the long run. It is this biphasic effect of antidepressants upon brain cell carbon dioxide sensitivity which is abnormal in persons with panic disorder."

2

High Potency Benzodiazepine Tranquilizers. Some examples are Xanax and Xanax XR (alprazolam), Ativan (lorazepam) and Klonopin (clonazepam). Xanax (alprazolam) is the most thoroughly studied of this group. Xanax (alprazolam) was already used for a decade to treat Panic Disorder when it was approved for use in Panic Disorder by the FDA in 1990. Klonopin is also approved by the FDA for treating Panic Disorder. Ativan is regarded by most clinicians as being effective but is not approved for this use by the FDA as of this writing. These medicines are quite effective and usually have few side effects at proper doses. They block panic attacks almost immediately in the first day or two of treatment.

Several dosage increases over a period of several weeks are customary. Ultimately, no further increases are required.

Public concern about such medicines being dangerously addictive is unduly exaggerated in the case of persons with Panic Disorder.

Scientific evidence shows surprisingly low rates of abuse of this and other medicines in persons with Panic Disorder. Physical dependence does develop with such medicines at larger dosages (more than 3-4 mg per day).

Xanax XR seems to be less tempting to drug abusers according to a small study by Mumford, et al. Panic disorder patients often seem to prefer it to regular Xanax, according to Dr. Cox, "They say Xanax XR does not work any better than regular Xanax. They say it does not have any less side effects. But they seem to like it better due to the convenience of not having to take it at midday. Not having to take it but once or twice a day instead of three or four times a day causes some patients to feel, as they put it, Ôfree from Xanax'."

3

Nardil (phenelzine). This unique medicine, though more effective than any other medicine for this disorder, is rather complicated to use. It may be best to reserve it for cases where simpler medications have failed or cannot be used for some reason. Nardil is a safe medicine when used by an experienced physician in a patient who complies with the necessary diet and medication restrictions. Unsafe elevations of blood pressure for several hours can occur if one does not adhere to these restrictions while taking Nardil.

More information about Nardil, a MAOI medication, is linked to Dr. Ivan Goldberg's PsyCom.Net website for depression. http://www.psycom.net/depression.central.html.

C

Once the panic attacks have been successfully blocked completely for about three months Panic Disorder patients usually get back to normal life without any additional assistance. However, many do not automatically overcome their tendencies to avoid the situations that they have been evading. Success in such patients is achieved by organizing a systematic approach of doing the very things that have been avoided. They begin going into the least difficult of avoided places first. This exposure to the feared situations is practiced repeatedly until they are reasonably comfortable. Then they proceed to the next more difficult avoided activity.

This highly successful approach is a common sense method based on the old adage "If you fall off the horse, get right back on." This cognitive behavior therapy approach may be helpful in resolving such fears. The person discovers that they can indeed perform the avoided activities and the medication prevents the attacks from occurring. Confidence is restored and normal life resumes with security, peace of mind and a sense that one is in control once again.

Some professionals believe that Panic Disorder can be treated solely with talk therapy such as cognitive behavioral therapy or expensive cassette tapes. This area is controversial. The National Anxiety Foundation urges professionals and patients to employ the combination of both methods (medication and cognitive-behavioral therapy) until convincing research clarifies, once and for all, this controversy.

SEEKING HELP.

What kind of doctor should I see to get help?

The first step should be to have a medical evaluation to determine the proper diagnosis. Your family physician is the good place to start. Tell him or her what has been happening to you and that you wonder if you might have Panic Disorder. Show the doctor this brochure. After the evaluation perhaps the doctor will tell you that you do have Panic Disorder. Then what? You may wish to see a psychiatrist.

Psychiatrists are physicians (M.D., or less commonly, D.O.). A psychiatrist who is experienced in treating Panic Disorder is perhaps the most qualified single professional to deal with the problem. There is a national shortage of psychiatrists. There may not be one in your area, or your HMO may not allow you to be seen by one of their psychiatrists. In these instances, seeing your regular doctor for medication to stop the attacks and consulting a psychologist, if necessary, for behavior therapy is second best. Psychologists are not physicians (instead of M.D., they may have other abbreviations after their name such as Ph.D. or Ed.D. or Psy.D.). If a psychologist isn't available for behavior therapy, a social worker who is familiar with this therapy might be helpful in conjunction with your family physician.

THE PROGNOSIS.

Remember, Panic Disorder is a serious but highly treatable medical illness. Almost everyone responds well to treatment and can return to normal functioning in weeks or months.

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© 1992 - 2002 National Anxiety Foundation

The National Anxiety Foundation gives duplication permission to anyone wishing to reproduce this document or its contents for non-profit, educational purposes. The National Anxiety Foundation is a non-profit foundation. Its mission is to alleviate suffering and to save lives by educating the public about anxiety disorders.

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