1. What Causes The Symptoms of a Panic Attack?
When confronted with a real or perceived threat, the automatic "fight or flight" response may be triggered to prepare the body for immediate action. This evolutionary development in many organisms normally functions for survival and protection. It may become a panic attack when the emergency response occurs in a situation where it is not appropriate. Although the symptoms may be uncomfortable and frightening, they are not dangerous.
The brain activates the sympathetic nervous system, causing the release of adrenaline from the adrenal glands. This may be experienced as a hot flush sensation. The rate and strength of the heartbeat increases to supply more oxygen to the tissues. Contraction or expansion of different blood vessels divert blood from the skin, fingers, and toes to the large muscles. This reduces bleeding in case of an "attack", and may cause a feeling of coldness or numbness in the hands or feet. Breathing increases in rate and depth to exchange more oxygen to prepare for exertion. Breathlessness, dizziness, and pain or tightness in the chest may be experienced. Sweat glands are stimulated to prevent overheating. The pupils of the eye dilate to admit more light and increase peripheral vision to scan for danger. Sensitivity to bright light, and visual disturbances may occur. The digestive systems shuts down to conserve blood for the muscles. A dry mouth and nausea may result. Muscles tense to prepare for escape, but may cause spasms and trembling when action is not taken. Thoughts are focused on the search for the threat, maintaining alertness and vigilance. If there is no explanation for the emergency response, thoughts of losing control, going crazy, or dying may occur.
The fight or flight response is time limited because adrenaline is metabolized by the body. When the perceived danger has passed, the parasympathetic nervous system counteracts the activation of the sympathetic nervous system, returning the body to a relaxed state.
2. What are the Origins of Panic Disorders?
Causal Factors
Genetic Factors: Studies show the risk of developing panic disorder is 15-17% in first degree relatives of panic disorder patients. The risk for development in identical twins is 24-31%. This indicates that panic disorder may be genetically transmitted.
Psychoanalytic Theories: Panic apprehension may be the emergence of deeply rooted, primarily aggressive unconscious conflicts, that originated in traumatic experiences in early childhood.
Learning and Behavior Theories: After the original spontaneous panic attack, further attacks may occur through conditioning in the situations where anxiety has been experienced. Phobic avoidance may develop as patients seek to prevent further panic attacks. Panic attacks may arise when anxiety is conditioned to internal stimuli, for example, heart palpitations.
Cognitive Theories: Panic attacks may develop when a person misinterprets the significance of certain bodily sensations as an impending medical emergency. This leads to heightened anxiety and greater nervous arousal, setting up a positive feedback loop. The rapidly escalating anxiety may lead to a panic attack.
Childhood Separation Anxiety or Behavioral Inhibition: School phobia and other childhood anxiety disorders may be early forms of panic disorder. Children of parents with panic disorder are more likely to exhibit fear and withdrawal in unfamiliar situations.
Parental Attitudes and Behavior: Patients with panic disorder often describe their parents as overprotective, restricting, controlling, critical, frightening, or rejecting.
Developmental Factors
Provocation Studies: Injection of sodium lactate can provoke panic attacks, possibly by stimulation of the locus ceruleus in the brain stem. Carbon dioxide, yohimbine, caffeine, and other agents have provoked panic attacks in panic disorder patients. These agents have been useful in studying the characteristics and mechanisms of panic attacks.
Biological Markers: Panic disorder patients may have abnormalities in monoamine oxidase, serotonin uptake, alpha2-adrenoceptor and 3H-imipramine receptors in platelets, and serotonin or norepinephrine metabolism. This may support the role of neurotransmitter abnormalities in panic disorder.
Animal Models: Animal studies have implicated activation or abnormality of several brain structures within the limbic system during anxiety states.
Brain Imaging: During PET scans, abnormal cerebral blood flow patterns have been observed in the parahippocampal and hippocampal regions of the brain in panic disorder patients.
Nocturnal Panic Attacks: Increased sleep latency, decreased sleep time, decreased sleep efficiency, and increased rapid eye movement have been observed in panic disorder patients.
Neurotransmitter Theories: Increased activity or reactivity in the noradrenalin or serotonin neurotransmitter systems may cause or relate to panic attacks. A subsensitivity of the benzodiazepine receptor could decrease the effect of GABA, an inhibitory neurotransmitter. An excess or deficit of a naturally occurring substance operating on the benzodiazepine receptor may exist.
Suffocation Alarm Theory: A sufocation alarm system within the brain may be hypersensitive to an increase in carbon dioxide level. This produces sudden respiratory distress followed by hyperventilation, panic, and the urge to flee.
Life Events: Significant life events involving a loss or threat within the previous 12 months may contribute to the development of panic disorder.
3. Is Panic Disorder a Biological or Psychological Disorder?
This is a controversial subject that has divided research and treatment of panic disorder. All human behavior has a biological basis at the nerve cell level, but panic disorder also involves exaggerated thought and behavior patterns.
One theory that includes both biological and behavioral theories proposes that the components of panic disorder: the panic attack, anticipatory anxiety, and agoraphobia, are associated with three distinct areas of the brain. These areas are the brain stem, limbic system, and frontal cortex, respectively. Panic attacks are triggered by stimulation of areas in the brain stem that control the release of adrenalin. Stimulation of the locus ceruleus produces most of the physical symptoms of panic. Antidepressants seem to block panic attacks by reducing the firing rate of the locus ceruleus. The brain stem is also stimulated by higher brain areas which may be involved with stress.
The limbic system, involved with the emotions of rage, arousal and fear, is suspected to be the location for anticipatory anxiety. This area is rich with benzodiazepine receptors so benzodiazepine medications are most effective in the limbic area. Paths linking the brain stem with the limbic system can produce anticipatory anxiety following a panic attack and vice versa. The limbic system is also sensitive to changes in blood flow caused by hyperventilation. Abdominal breathing and relaxation decreases anticipatory anxiety by quieting the limbic system, blocking a potential trigger path for a panic attack.
Agoraphobia is a learned behavior pattern which is probably located in the frontal cortex. Cognitive-behavioral treatments are most effective at this higher level of the brain. Discharges from the brain stem may be interpreted by the frontal cortex as a dangerous, life-threatening event, and associations between the panic attack, environment, and thoughts are made. Decending paths from the frontal cortex enable catastrophic thoughts to stimulate the brain stem and cause panic attacks.
Thus the three areas of the brain all intercommunicate during different phases of a panic episode. According to the model, different treatments for panic disorder and agoraphobia affect different aspects of the illness and different parts of the central nervous system.
4. How Can I Cope With Anxiety and Panic Attacks?
You may be able to resolve the stress contributing to your anxiety. Medications can minimize the discomfort of panic attacks. Some people avoid medications because of side effects, while others are tapering off medication and need coping methods to handle the withdrawal effects.
Cognitive-behavior therapists incorporate coping techniques to reduce anticipatory anxiety and reduce the intensity and duration of panic attacks. The following techniques taken from literature and personal experience.
Exercises to Reduce General Anxiety
Aerobic Exercise: 20 minutes daily before your evening meal. Examples: swimming, walking, ski machine, stair climber, etc.
Progressive muscle relaxation: On waking up and before going to sleep. Tense each major muscle group for 10 seconds, think "relax" then release muscle tension while exhaling slowly. Pause for 20 seconds and repeat. Visualize your body becoming heavy.
Abdominal breathing: 10 minutes breathing slowly through your nose. Inhale expanding your stomach without moving your chest. Slowly exhale, think "calm". Your breathing rate should be 6-10 cycles per minute. Practice several times a day.
Autogenics exercise: Scan your body from head to toes. Use abdominal breathing and focus on each area of tension. As you exhale, visualize the area becoming warm and heavy.
Biofeedback: Tape a thermometer to your middle finger tip or use a heart rate monitor. Use the autogenic exercise to raise your finger temperature or lower your heart rate.
Maintain a daily routine: Wake up, eat 3 meals, take medication (if prescribed), and go to sleep at the same times every day.
Challenge your catastrophic thoughts with rational alternatives.
Avoid caffeine, nicotine, alcohol, antihistamines containing pseudoepinephrine, sleeping pills.
Exercises To Reduce Panic Symptoms
Golden Rules for Coping with Panic
5. What is the Long Term Course of Panic Disorder?
There is little data on the long term course of panic disorder. It has been accurately classified only since 1980 and few follow-up studies have been performed. 220 patients from the Cross-National Collaborative Panic Study were interviewed 2 to 6 years after participating in an 8 week trial of alprozolam, imipramine, and a placebo. Results are summarized below:
A two-year followup study was conducted on patients that received a 15 week panic control treatment. 81% of the patients were panic free, and 50% also recovered from anxiety and avoidance.
6. What Are New Medications For Panic Disorder?
Drugs that selectively block presynaptic neuronal reuptake of serotonin (SSRIs) are fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and venlafaxine (Effexor). Studies have documented that fluoxetine and fluvoxamine reduce panic attacks and avoidance behavior.
Many clinicians in the United States already prescribe fluoxetine and sertraline for panic patients, often as the drug of first choice. The serotonin reuptake blockers have a favorable side effect profile compared with currently available antipanic drugs. However some patients have a hypersensitivity reaction when fluoxetine treatment is initiated at 20 mg/day. Consequently, initiation of therapy at lower dosages is often recommended.
Buspirone, a 5-HT1a partial agonist, has been shown to be equally effective as benzodiazepines in the treatment of GAD (Generalized Anxiety Disorder). However, reports and clinical results indicate that buspirone does not block panic attacks.
7. Can I Become Addicted to Tranquilizers?
Quoted from "Panic Disorder: The Medical Point of View", by William Kernodle, M.D.
"Our society appears to have a phobia concerning benzodiazepines. I believe this fear started many years ago when Valium was prescribed for minor anxiety and patients were not made aware of the potential for developing physical dependence. It is physical addiction that most patients worry about with a benzodiazepine. I believe "addiction" refers to a severe form of drug abuse in which the individual craves a substance despite negative consequences and needs more and more for the same effect. I do not think that patients with panic disorder crave the benzodiazepines for their effect or frequently develop physical tolerance (with the possible exception of substance abusers). It is possible for patients to develop "physical dependence" on the benzodiazepines when used at moderate to high doses over months or years. However, this simply means that the benzodiazepine has to be tapered slowly rather than stopped abruptly to avoid having a withdrawal symptom" (p. 115).
8. How Can I Find An Anxiety Disorders Specialist Or Support Group?
Read alt.support.anxiety-panic and alt.recovery.panic-anxiety.self-help. We meet to share experiences with anxiety and panic for mutual support. Join the Internet Relay Chat channel #anx/pan on the Efnet or go to URL http://www.geocities.com/HotSprings/1277.
National Institute of Mental Health
(800) 64-PANIC
Pamphlets on anxiety disorders.
National Mental Health Association
(703)684-7722
Referrals to local chapters
National Alliance for the Mentally Ill
(800)950-6264 or (703)524-7600
Referrals to local chapters.
Anxiety Disorders Association of America
6000 Executive Blvd., Suite 513
Rockville, MD 20852
Phone: (301)231-9350 email: anxdis@aol.com
List of anxiety disorders specialists and support groups
TERRAP
932 Evelyn St.
Menlo Park, CA 94025
(800)274-6242
Anxiety disorders therapy, telephone counseling, mail order products.
Contact for affiliated groups.
CHAANGE
128 Country Club Drive
Chula Vista, CA 91911
(619)425-3992
Anxiety disorders home treatment program, audio tapes. Contact for
affiliated groups.
Midwest Center
106 N. Church St., Suite 200
Oak Harbor, OH 43449
(419)898-4357
Attacking Anxiety home study program, audio tapes
Phobics Anonymous
PO Box 1180
Palm Springs, CA 92263
(619)322-COPE
For information, send a self-addressed envelope with postage. Contact
for affiliated groups.
Agoraphobics Building Independent Lives (ABIL)
1418 Lorraine Ave.
Richmond, VA 23227
(804)266-9409
Affiliated groups throughout Virginia and vicinity
MIND (National Association for Mental Health)
22 Harley St.
London, WIN 2ED, U.K.
British Association for Counselling
1 Regent Place
Rugby, Warwickshire CV21 2PJ, U.K.
Office: 01788 550899 Information: 01788 758328
British Psychological Society
St. Andrews House
48 Princess Road East
Leicester, LE1 7DR, U.K.
Phone: 0116 254 9568
Royal College of Psychiatrists
17, Belgrave Square
London, SWIX 8PG, U.K.
Phone: 0171 235 2351
9. How Can I Get The Most Benefit From Therapy?
*Find a mental health professional who has training and experience in treating anxiety disorders.
*If you have difficulty communicating with your doctor or therapist, find another one.
*Keep a log of your anxiety level, panic attacks, and preceeding events. Discontinue this activity if it is not productive.
*Prepare notes before appointments with your doctor or therapist.
*Self-help workbooks may be useful in conjunction with your therapy.
*Between appointments practice your anxiety reduction exercises. Gradually expose yourself to the situation you fear.
*Ask your doctor about common side effects of medications. Notify your doctor immediately if you experience adverse side effects.
*Take your medication on a regular schedule for the duration agreed upon with your doctor.
*Antidepressant medications often take 4-6 weeks before you experience an improvement in your symptoms.
*Do not increase or decrease your medication dose without consulting with your doctor. Many medications must be tapered off slowly to moderate withdrawal symptoms.
