Panic Disorder

woman and doctor 1189207612 21Dec2020The Good News About Panic Disorder

The current information about panic disorder is almost all good news. A panic disorder diagnosis is not a mystery. A person who starts having panic attacks can go to any emergency department, or urgent care clinic, or the neighborhood physician down the street. Most capable physicians will be able to make the diagnosis of panic disorder and start a discussion with you about treatment options. They might refer you onward to someone more experienced in treating panic disorder, but at that point the solution is already in progress. 

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The Reasons Why Treating Panic Disorder Is So Straightforward

Both the approach to stop a panic attack and treatments to prevent panic attacks are well known. The medications we have now are good and getting better. Therapies for panic disorder help a lot, so much so that one or another type of therapy is now built into any treatment plan. So whether your panic attacks are new or you’ve had them for a while, be encouraged. All is getting better. As always, we are continually vigilant for anything new, and we’ll praise what works, debunk anything that doesn’t work, and encourage you to better health and better health care. So read on about panic disorder.

One of our readers (who didn’t say where he was from) commented:

I’m better now, but when I first started having panic attacks it was really bad. I’d have a panic attack and think I was dying right then and next thing my wife starts yelling at me asking why I’m doing that as though I can control it. I lost a friend because I had a panic attack right after our handball game. He said later he doesn’t believe in panic attacks and can’t put up with that nonsense. Why is it when a person has a panic attack other people get mad at them?

This is not a common problem, but, it’s not uncommon, either. The person having the attack is terrified. Having anger focused on them on top of the terror they’re feeling not only doesn’t help, the lack of support can make it worse. It’s worth trying to discuss it when everyone is calm. Some people get angry when they don’t understand. Others get angry when they’re frustrated because they want to help but don’t know what to do. If they’re good people and you explain the attacks when you’re both calm, they might come to understand. If you can coach them on what to do and what not to do, maybe they’ll respond better the next time. But if the other person is abrasive and doesn’t want to help and doesn’t believe in brain-based medical conditions, it might be just as well to have them out of your life. It just might not be worth the hassle.

Before We Start On Definitions…

Here’s a Story About Someone’s First Panic Attack

A healthy and relatively calm woman is walking quickly down the stairs to the subway. Relatively calm, but she has just been through a tense and upsetting interview for a new job. Suddenly she has a severe pain in her chest and feels dizzy. She grabs the metal stair rail, feeling nauseated, and then her vision goes strange. Everything seems to look small and far away then everything starts to go black. She can’t catch her breath and starts to fall despite her death grip on the metal handrail. Thinking to herself as she sinks to the ground, “Oh, God, what’s happening, I must be dying, I must be having a heart attack, I’m dying of a heart attack”. She tries to fumble in her purse for her cell phone but can’t think and can’t see what she’s doing.

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What Might Happen Next If Things Go Well

One of the people coming down the stairs sees her struggling, breathing hard, and sweating profusely. This Good Samaritan calls 911 and stays with her. Her chest pain has eased a bit but she says she can’t catch her breath. She’s still confused when the paramedics arrive. They get her into the ambulance and rush off to the Emergency Department. There the medical tests begin. Three hours later she’s feeling better though still upset and shaken by the whole experience. The emergency department physician comes in to talk with her. She says that the tests were all normal. She smiles at the woman and says, “You’ve had a panic attack.”

The Symptoms of a Panic Attack and Panic Disorder

The story above about the woman having her first panic attack provides a good description. A person having a panic attack is suddenly overcome with overwhelming anxiety and fear, unbelievably overwhelmed. Usually the attacks come “out of the blue” with no warning and no obvious reason for being anxious. If there is some stress that might have caused it (in her case, maybe the job interview) it doesn’t feel like it directly caused the attack. That stress feels like it’s in the past, not something that would cause a big problem right now. The person feels like they have lost all control of themselves. Sometimes people feel terrified that they are immediately going insane, completely out of their mind, right now. Or, more common, the person might think they’re dying, that they’ll be dead in a few moments. The terror might be worse during the first several attacks.

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As Time Goes By The Panic Attacks Become Just Annoying Rather Than Terrifying

Often when the individual thinks back on the panic attack it doesn’t make sense. How did this happen, why did it happen? Perhaps they might even feel a bit silly. Winding up in the Emergency Department over panicking. They don’t panic, they’re always fine. But, in that moment of frightening terror it feels as if insanity or death or something else is real and is right now. Then, surviving the first few, the next big fear is the worry that there’ll be another attack. With medication and therapy one learns how to manage through a panic attack. Over time, as they come under better control and understanding, they can start to feel more annoying than terrifying. Until, finally, they might just go away.

The Physical Part of Panic Attacks and Panic Disorder

There was a famous scientist in the 1920s, W. B. Cannon, that studied what a person’s (or an animal’s) body does when its life is threatened, and it braces itself to fight an enemy or run away. He called it the fight or run response. (Journalists have changed it to the “fight or flight” response. You know, because that rhymes.) When threatened and needing to choose between fighting for their life or running away, stress hormones are blasted into the blood stream. Heart rate speeds up, the heart pounds, and breathing is fast. The body slows blood flow to the gut for digestion in order to instead push all the blood to the large muscles. The body is readied almost instantly for a maximal burst of physical energy. Just as with exercise, all this muscle tension makes heat. So the body sweats to get rid of the excess heat.

A Panic Attack Readies You to Fight or Run from a Threat That’s Not There

A panic attack seems to be a burst of all the energy that goes into W. B. Cannon’s fight or run (or fight or flight) response. But, it happens without a real, physical, life-threatening enemy in front of you. The fear and feeling of threat arises from somewhere deep within your brain, and then boom, the attack hits, blasting hormones into your body for immediate action, fight or run. Often the person isn’t aware of the original source of this feeling of threat, just overwhelmed by the panic attack. Likely the true sense of threat was from some previous time, triggered in the present by some relatively trivial circumstance. The memory of the original threat had stayed buried until now, when this delayed reaction to it surged up as a panic attack.

Panic Disorder and Panic Attacks are Remarkably Frightening and Upsetting

Here’s the odd thing about panic disorder. It’s almost not possible to believe that the experience of a panic attack doesn’t hurt you. How can it feel so terrifying in the moment and yet medically not do any damage? The episode is so ghastly that people are not comforted to learn that a panic attack won’t kill you. Or, even harm you. But it’s true that, frightening as they are, especially the first few attacks, one can eventually learn to control them and tolerate them. And it’s also true, and good news, that they are not medically dangerous. Once a person understands the panic attacks and experiences a few attacks they can become less frightening. Each attack does go away at some point without any help. Even though you might go to an Emergency Department with the first few.

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Photo by RyanMcGuire

Well, Okay, Yes, But… They Scare Me to Death!

Well, yes, it’s unfortunate, but it’s not so simple as, “Okay, now I get it.” Despite a person having had panic attacks and knowing exactly what’s happening, no one wants to have one. Most certainly no one wants to have one in a public place or while driving. And, as our reader described above, even at home around people who know you, they might just get angry with you and your attacks. These facts mean that a person with untreated or inadequately treated panic disorder tends to go out less, to socialize less, and starts to become a loner. They might narrow life to only going to work or school. Other joys of social life might shrink. Without proper treatment having panic disorder can easily become socially crippling. If you’re a subscriber to our stie, see our page on Treatment-Resistant Panic Disorder.

Official Diagnosis of Panic Disorder

US-based physicians use the DSM 5 TR as the guide to diagnose panic disorder. (DSM 5 TR is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision). In DSM 5 TR panic disorder has the diagnosis code number 300.01.  Here’s a link to a Mayo Clinic page that lists the specific signs and symptoms used diagnose it.

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How Panic Disorder Is Usually Treated

The silver lining to this panic disorder dark grey cloud is that there are many good treatments for panic disorder. (For a more complete discussion see our free page on Panic Disorder Treatment.) There are a whole variety of therapies that don’t involve medications and several good medications that are greatly effective. There are a few medications that people can carry with them in case they feel an attack coming on or they have an actual panic attack. But just a medication by itself is not that helpful in the long run. The best treatment is a good physician-prescribed medication along with being in involved in one of the really good therapies known to be effective for panic disorder.

The Medications for Panic Disorder

The medications typically tried first are from a family of medications that usually come to mind for treating depression, the SSRIs (selective serotonin reuptake inhibitors). Panic disorder is not depression and most people with panic disorder are not depressed. It just so happens that these medications work for both. Another family of medications that was originally developed for depression, the “tricyclics” or TCAs, also at times work well for panic disorder. Finding the best medication depends both on how well a medication works and its side effects. The unfortunate part of this situation is that a period of trial-and-error is needed for you to find the best fit of good benefit and fewest side effects. Everyone hates trial-and-error but it’s definitely worth the effort.

More Medications for Panic Disorder

There’s also a group of medications that immediately come to mind for anxiety. These are popular benzodiazepine medications with familiar names (like Valium®, Xanax®, and Ativan®) that are used just to relieve here-and-now anxiety. But here’s the problem. Physicians, family members, friends, everyone gets concerned you, the panicky person, takes them long-term. Because, they’re too often not safe to take for a long time. There’s a real risk of abuse and addiction. There are some people who go down the road of using these benzodiazepine without working closely with their physician. One can become badly trapped by really needing to use these medications. They’re trapped because they need them to just keep from having withdrawal side effects, not because of the original panic disorder. And, the withdrawal side effects are totally awful.

upset woman with nurse

Educational Therapy – Psychotherapy – Behavioral Therapy

Many People Like the Therapies

All sorts of excellent therapies are available to help treat panic disorder. Over time these therapies help people to have fewer and fewer panic attacks, and they gradually become less and less severe.  And, when they do feel a bit of a panic, the panic attack is milder. There are “tricks and tips”, special ways of doing things, that when learned, practiced, and used, can be really helpful to make panic attacks less frequent and less severe, and certainly less frightening. One popular therapy is Cognitive Behavioral Therapy (CBT). It’s popular because it often works well and is easy to follow. It’s a therapy that’s makes rational sense to many people who see themselves as reasonable and logical and don’t want “psychotherapy”. Then there are relaxation skills, supportive group therapy, and individual interpersonal psychotherapy. Try more than one method, find what helps you the most, and make it yours.

Helpful links:

National Institute of Mental Health on Panic Disorder

Medline Plus on Panic Disorder  

Anxiety and Depression Association of America on Panic Disorder

The Mayo Clinic on Panic Attacks and Panic Disorder

American Psychological Association with Answers to Your Questions about Panic Disorder

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