Panic Disorder
Panic disorder is characterized by sudden episodes of acute apprehension or intense fear that seem to occur "out of the blue," without any apparent cause. Intense panic usually lasts no more than ten minutes, but, in some instances, can return in "waves" for a period of several hours. During the panic itself, any of the following symptoms can occur:
- Shortness of breath or a feeling of being smothered
- Heart palpitations—pounding heart or accelerated heart rate
- Dizziness, unsteadiness, or faintness
- Trembling or shaking
- Feeling of choking
- Sweating
- Nausea or abdominal distress
- Feeling of unreality—as if you're "not all there" (depersonalization)
- Numbness or tingling in hands and feet
- Hot and cold flashes
- Chest pain or discomfort
- Fears of going crazy or losing control
- Fears of dying
At least four of these symptoms are present in a full-blown panic attack, while having two or three of them is referred to as a "limited-symptom attack." Your symptoms would be diagnosed as panic disorder if you:
- have had two or more unexpected panic attacks and
- at least one of these attacks has been followed by one month (or more) of persistent concern about having another panic attack, or worry about the possible implications of having another panic attack.
It's important to recognize that panic disorder, by itself, does not involve any specific fears or phobias. The panic doesn't occur because you are thinking about, approaching, or actually entering a phobic situation. Instead, it occurs spontaneously and unexpectedly for no apparent reason. Many therapists believe, however, that a panic attack actually follows a very rapid and unconscious sequence of thoughts. Some situation, thought, or physical sensation causes your mind to unconsciously think: 1) "This is dangerous!" 2) "I'm unable to cope!" and 3 (something like) "Guard against danger!" The result is that your body suddenly responds with its normal "fight or flight " response, an emergency response that you're pre-wired with to deal with in true emergencies. With a panic attack , though, there is no real emergency. Yet your mind and body respond as if you had decided you are in true danger. Automatically, this triggers many of the body symptoms listed above. In turn, your mind may respond to these body symptoms with more fear and up the ante of your perception of being in danger.
You may have two or three panic attacks without ever having another one again or without having another one for years. About 10% of otherwise healthy people report at least one panic attack per year. On the other hand, you may have several panic attacks followed by a panic-free period, only to have the panic return a month or two later. Sometimes an initial panic attack may be followed by recurring attacks three or more times per week unremittingly until you seek treatment. In all of these cases, there is a tendency to develop anticipatory anxiety or apprehension between panic attacks focusing on the fear of having another one. This apprehension about having another panic attack is one of the hallmarks of panic disorder.
If you are suffering from panic disorder, you may be very frightened by your symptoms and consult with doctors to find a medical cause. Heart palpitations or an irregular heartbeat may lead to EKG and other cardiac tests, which, in most cases, turn out normal. (Sometimes mitral valve prolapse, a benign arrhythmia of the heart, may coexist with panic disorder.) Fortunately, an increasing number of physicians have some knowledge of panic disorder and are able to distinguish it from purely physical problems.
A diagnosis of panic disorder is made only after possible medical causes—including hypoglycemia, hyperthyroidism, asthma, premenstrual syndrome, reaction to excess caffeine, or withdrawal from alcohol, tranquilizers, or sedatives—have been ruled out. The causes of panic disorder involve a combination of heredity, excessive or prolonged activation of certain parts of the brain, and cumulative stress in your life. Sudden losses or major life changes may trigger the onset of panic attacks.
People tend to develop panic disorder during late adolescence or their twenties. It is twice as common among women as among men. In a many cases, panic is complicated by the development of agoraphobia (as described in the following section). Between one and two percent of the adult population has "pure" panic disorder, while about five percent, or one in every twenty people, suffers from panic attacks complicated by agoraphobia. About half of people with panic disorder also suffer from varying degrees of depression.
All of the following strategies are considered state-of-the-art treatments for panic disorder.
Relaxation Training
Practicing abdominal breathing several times a day and some form of deep muscle relaxation on a daily basis. These practices help to reduce the physical symptoms of panic as well as frequent anticipatory anxiety you might experience about having a panic attack. In abdominal breathing, you take in a deep breath of air through your nose while breathing into your stomach, pause for a moment, and then breathe out slowly through your nose or pursed lips. Keep repeating this for a minute or two. You may additionally imagine exhaling air down through your legs and out your toes, saying the word "Relax."
Deep muscle relaxation is accomplished through actively tensing and relaxing sixteen different muscle groups in your body , one after another (progressive muscle relaxation), or passively relaxing all of your muscles from head to toe, by listening to a guided relaxation visualization. For detailed information on the topic of relaxation, see chapter 4 of The Anxiety & Phobia Workbook.
Exercise
A program of daily, aerobic exercise (running, biking, swimming, aerobic classes at a health club, and so on) is very helpful in reducing all types of panic, anxiety and worry. Unless you have physical limitations, daily exercise is recommended as a part of treatment. Chapter 5 of The Anxiety & Phobia Workbook covers the topic of physical exercise in depth.
Attitude Shift
An important part of learning to cope with panic is to change your attitude away from trying to fight or escape (run away from) the onset of panic symptoms. Instead, you learn to move toward the panic, to develop the paradoxical attitude of accepting and embracing panic symptoms the moment they arise. The result is a significant reduction in fearful thoughts and accompanying physical symptoms of panic. It takes some time to make this attitude shift, but it makes a big difference. Some people go further, actually trying to bring on a panic attack the moment symptoms arise. For them, such an approach can paradoxically cancel out any further fear of the panic. Panic symptoms diminish, of course, once you stop being afraid of them or trying to avoid them.
Identifying and eliminating catastrophic thoughts (such as "I'm trapped!", "I'm going to go crazy!", "This will never end!" or "I'm going to have a heart attack!") that tend to trigger panic attacks. To manage panic, catastrophic thoughts are replaced with coping statements such as: "This feeling isn't comfortable, but I can accept it." "This is an opportunity for me to learn to cope with my panic attacks." "This isn't an emergency; it's OK to think about what I need to do." Or "I'll just let my body do its thing. This will pass." It takes some time and rehearsal of these coping statements to fully internalize them.
Interoceptive Desensitization
Practicing voluntary habituation to the body symptoms of panic, such as rapid heartbeat, sweaty hands, shortness of breath, or dizziness. Such symptoms are created deliberately, typically in the therapist's office, though they can be done on your own. For example, dizziness might be induced by spinning in a chair or rapid heartbeat by running up and down stairs. Repeated exposure to unpleasant body symptoms promotes desensitization, which basically means getting used to them to the point where they no longer frighten you.
Medication
SSRI antidepressant medications such as Zoloft, Lexapro, or Celexa—or benzodiazepine medications such as Xanax, Ativan, or Klonopin—may be used to reduce the severity of panic symptoms. Such medications are best used in conjunction with the first five strategies above. Click on the button for medications for further information.
Lifestyle & Personality Changes
Some of the lifestyle changes that can reduce your tendency to have panic attacks include stress management, regular exercise, eliminating stimulants and sugar from your diet, slowing down and creating "downtime," and altering attitudes about perfectionism, the excessive need to please, and the excessive need to control.
