By Eleanor Gilman
When Jane was 26 years old, she had her first panic attack. "I woke up in the middle of the night with my heart pounding, unable to breathe," she recalls. "I was scared that something was terribly wrong. I thought I was dying."
For ten years, the attacks continued during the day and at night, increasing from once in a while to once a week. "I was worn out and depressed," says Jane. "The doctors told me I was in good physical health, but my life was miserable."
As the attacks became more frequent, Jane felt an increasing need to stay home. Trips to the supermarket were disastrous; she would become dizzy, terrified, or immobilized. After a particularly bad attack while shopping, she stayed in bed for a month, getting up only to go to the bathroom or to get something to eat.
On three occasions Jane was rushed to the hospital with severe heart palpitations. Each time, test results were negative. Her physician finally recommended a therapist, who diagnosed her problem as panic disorder.
Jane's illness is a prevalent one. According to statistics from the National Institute of Mental Health, between 3 million and 6 million Americans will have panic disorder at some time in their life. Two-thirds of the sufferers are women. Panic disorder typically begins in the late teens or early to mid-20s, although it can develop at other times. The exact cause is unknown, but many researchers believe that a combination of biological and psychological factors is to blame. Diagnosis can be difficult, as Jane's story illustrates, because of the way panic disorder frequently mimics physical ailments.
Identifying panic disorder
The symptoms of panic disorder are terrifying. They can include a racing or pounding heartbeat, chest pain, dizziness or lightheadedness, nausea, difficulty breathing, tingling or numbness in the hands, fear of choking, and chills. Patients may also experience a sense of unreality; a fear of losing control, going "crazy," or doing something embarrassing; or a feeling that something horrible is about to happen. Because the symptoms are so intense, many patients may feel they are nearing death.
As the illness progresses, sufferers often develop a fear of recurring attacks, or anticipatory anxiety. Other disorders may also follow. Half the people with panic disorder will have an episode of clinical depression at some time in their life, and one-third will develop agoraphobia, the fear of being situations from which escape might be difficult or embarrassing.
The most common treatment strategies are cognitive-behavioral therapy (CBT) and medication. "Seventy to 90 percent of patients will see significant improvement using either treatment," says Una D. McCann, M.D., associate professor of psychiatry at the Johns Hopkins School of Medicine and former chief of the unit on anxiety disorders at the National Institute of Mental Health. "The choice of treatment depends on a mutual decision made by the patient and caregiver; it's generally based on [the patient's] personal preference."
Dr. McCann adds that while most physicians prescribe medication, they also advise patients to incorporate CBT techniques into their treatment program. Cognitive therapy involves the correction of distorted ideas and helps patients understand that their fears won't become a reality. It is generally used with behavioral therapy techniques such as deep breathing, progressive relaxation, or meditation, which calm the patient and help slow a racing heartbeat and rapid breathing.
Some experts believe that a patient is better off choosing one form of treatment over another. "Cognitive-behavioral therapy is superior to medication because of its lower relapse rates ... it teaches patients how to cope," explains Leslie Sokol, Ph.D., education coordinator at Beck Institute for Cognitive Therapy and Research, in suburban Philadelphia. "Once patients are armed with the knowledge that their bodily sensations aren't dangerous, they are equipped to face all of the situations and places they had been avoiding."
More people use medication for panic disorder, however. "Cognitive-behavioral therapy pays off, but it's easier to take a pill, and it works," notes Dr. McCann. "There's still a stigma surrounding any form of therapy, and there is a misunderstanding about what CBT entails," she explains. "People think that their therapist will be asking questions about personal relationships and childhood experiences. That's not true. But therapy is a lot of work for both the therapist and patient, and under managed care programs, many psychiatrists and psychologists don't have the time to do good CBT."
Medications for panic disorder fall into four categories:
Tricyclic antidepressants (TCAs)
Monoamine oxidase inhibitors (MAOIs)
Selective serotonin reuptake inhibitors (SSRIs)
Benzodiazepine tranquilizers (BZs)
According to Dr. McCann, "SSRIs are still considered the drugs of choice for the treatment of panic disorder because they have a better side effect profile than TCAs and MAOIs and because they have been well tested. And unlike benzodiazepines, SSRIs have no potential for the development of drug tolerance and dependence." She noted that "two newer antidepressants -- mirtazapine and nefazedone -- appear quite efficacious and may have fewer side effects than the other drugs, but they aren't as well-tested as SSRIs."
While diazepam (Valium), a benzodiazepine tranquilizer, helped calm Jane, she attributes her recovery to CBT, which helped her realize that what she feared wasn't real; the pounding in her heart wasn't a heart attack, and the funny feeling in her head wasn't a stroke. Her illness wasn't physical, and she wasn't dying. After being virtually housebound for two years, Jane attended her niece's wedding. "Isn't this marvelous? Now I can go places, make trips," she says. "I've reached the point of knowing that I can cope with my illness."
Eleanor Gilman writes frequently on health and medical subjects. She is co-author, with Lorna Weinstock, M.S.W., of Overcoming Panic Disorder: A Woman's Guide (Contemporary Books).
Rx.magazine feature story: My Sky is Falling
Outside link: Information on panic disorder from the American Psychological Association