What Every Physician Should Know About Panic Disorder
What is Panic Disorder?
Panic disorder is the fifth most common presenting problem in general practice, yet most physicians receive no formal training in its diagnosis and treatment. The typical patient with panic disorder will go to an average of 10 different physicians before they receive an accurate diagnosis. Of patients who heavily utilize medical resources, as many as 12 percent may actually suffer undiagnosed panic disorder.
The word "panic" derives from ancient Greek times. Pan, the Greek god of nature, liked to nap near ancient roads. If a traveler woke him, he would let out a terrifying scream, which induced terror so severe that many a traveler died. This terror came to be known as panic.
According the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV), panic disorder is characterized by the sudden onset of intense apprehension and the presence of at least 4 out of 14 possible symptoms. (See Table 1 for these symptoms.) Although the diagnosis of full blown panic disorder requires at least four of these symptoms, there are also a class of patients who suffer from limited symptom attacks which involve less than four symptoms, but are reported as fearful events nonetheless.
TABLE 1 List of DSM-IV Panic Symptoms
- Shortness of breath (dyspnea) or smothering sensations
- Palpitations or accelerated heart rate (tachycardia)
- Chest pain or discomfort
- Dizziness, lightheadedness, or unsteady feelings
- Nausea or abdominal distress
- Depersonalization or derealization
- Numbness or tingling sensations (parathesias)
- Flushes (hot flashes) or chills
- Trembling or shaking
- Fear of dying
- Fear of going crazy or doing something uncontrolled.
According to a study of 41 panic patients, the most commonly reported symptoms are: palpitations (98%), dizziness (95%), sweating (93%), shortness of breath (90%), fear of going crazy or losing control (90%), trembling (88%), hot or cold flashes (85%), and chest pain (76%).
How Common Is Panic Disorder?
Panic disorder is very common. Researchers in Virginia examined reasons why patients presented to their local physicians. After wanting a checkup, hypertension, cuts and bruises, and sore throats, anxiety was the fifth most common reason why people came to see their doctor, even before bad colds and bronchitis. Similar research found that 10-14% of patients who present to cardiologists actually suffer from panic disorder.
A National Institute of Mental Health study of 15,000 people in several urban areas found that the percentage of people who suffered from panic attacks or panic attacks with agoraphobia was 4.60% of the population. This suggests that between 9 and 15 million Americans may suffer from panic.
The Causes of Panic
What causes panic disorder? A variety of researches suggest that stress plays an important role in precipitating panic disorder. Eighty percent of panic patients report a negative life event that is associated with the onset of panic. These negative events fall into several categories. Interpersonal triggers such as marital or family conflict and the death or illness of a significant other are reported by 50% of panic patients. Physical stressors such as childbirth, miscarriage, hysterectomy, drug reactions, or major surgery are reported by 45% of patients.
Once precipitated by any of these causes, the initial panic attack is a terrifying experience. The patient experiences a number of unfamiliar symptoms, which are frightening. Usually, they interpret the symptoms as meaning that they are either dying or going crazy. This misinterpretation of course increases their anxiety, which in turn increases the symptoms. Soon they are caught in a vicious circle--the more they experience symptoms, the more they are convinced they are dying or going crazy, so the worse their symptoms become.
After several panic attacks even the slightest symptom that resembles the panic symptoms will trigger the misinterpretation process, thus leading to a panic attack. Additionally, the person begins to avoid situations or activities that result in panic attacks, so their lives become constrained. In extreme form, this avoidance can become agoraphobia, which is the near total avoidance of leaving the home.
What makes some people more prone to panic disorder? Although there is slight evidence that anxiety runs in families, it is premature to say that panic disorder is inherited. One common thread is that many panic patients have relatives with alcoholism or depression. Many are children of alcoholics. At one point researchers believed that mitral valve prolapse was associated with panic, but more recent research shows that panic patients are no more likely to have MVP than the general population.
Anxiety disorders may be related to excess mortality and to alcohol abuse. Research evidence finds that panic disorder patients have a greater than expected death rate from cardiovascular disease (males only) and from suicide. Suicide rates among panic patients are similar to depressed patient, indicating a significant risk. There is also evidence that anxiety disorders may be related to alcoholism. A number of studies suggest that at least half of alcoholics suffer from mild to severe anxiety disorders. These patients may drink in order to self-medicate their anxiety.
Diagnosis of Panic Disorder
The DSM-IV criteria for panic disorder are that a patient have suffered four or more episodes of intense fear within a four-week period, and have experienced at least four or more of the above list of symptoms (Table 1). An alternative criterion is that the person has experienced one or more attacks followed by a month of persistent fear of another attack.
It is important for the physician who suspects a patient may have panic disorder to first rule out organic causes for the attacks. Table 2 lists a variety of medical conditions that can cause symptoms similar to panic disorder.
Table 2. Medical Conditions That Can Produce Panic Symptoms
- Temporal lobe epilepsy
- Cushing syndrome
- Caffeine overdose
- Cocaine or amphetamine abuse
TREATMENT OF PANIC DISORDER
The physician can play an essential role in the diagnosis and treatment of panic. Many panic disorder patients will see numerous physicians in a fruitless quest for a physical cause of their symptoms. These patients can be frustrating to the physician because they typically are not comforted by a physician?s assurances that nothing is wrong with them. The sophisticated physician can save the patient much unnecessary testing and frustration by giving the patient a clear diagnosis that explains what they are experiencing.
Drug Treatment of Panic Disorder
Pharmacological treatment options include antidepressants such as fluoxetine (Prozac) and imiprimine (Tofranil) and MAO inhibitors such as phenelzine (Nardil), benzodiazapines such as alprazolam (Xanax), and beta blockers. Research suggests that imiprimine and other antidepressants only help panic when combined with behavioral treatment programs. Administered without such programs, antidepressants appear to have little effect on panic. Also, side effects of antidepressants often cause dropout from treatment. Further, relapse rates are high when the drug is discontinued.
Alprazolam is more effective at blocking panic attacks, but has several drawbacks. There have been reports of liver impairment. Dependence is a major problem, as Xanax appears to be quite addictive. Relapse rates upon withdrawal approach 100%.
Although some centers have used beta-blockers to treat panic, current research evidence suggests that this class of drugs is less effective than antidepressants or benzodiazepines. The one exception is for panic patients who also have mitral valve prolapse. These patients may benefit from beta-blockers.
The drawbacks of pharmacological approaches suggest that they should only be used in conjunction with behavior therapy, and even then, only in cases where a full course of behavior therapy has been tried and has not been successful.
Cognitive Behavioral Therapy for Panic Disorder
Recent breakthroughs in the treatment of panic have revolutionized psychological approaches. Previously, most behavioral treatment of anxiety took the approach of teaching people relaxation, and then getting people to expose themselves to situations in which they experienced panic. Although effective, these treatments failed to totally eliminate panic. Current treatments instead focus on directly training patients to cope with panic symptoms. The behavior therapist trains the patient in relaxation techniques and cognitive techniques that help the patient change his or her response to panic. The patient is then taught to systematically expose themselves to the internal cues they feel when panicking. For instance, one patient reported that his heart raced when he panicked, and that this scared him because he was afraid he would have a heart attack. He was encouraged to engage in stair climbing that elevated his heart rate so that he would learn that the symptoms were benign.
A variety of studies from around the world show that this new approach can eliminate panic in almost 100% of patients. Follow-ups of up to 2 years show that the improvements are maintained. These findings represent a significant breakthrough in the treatment of panic, offering patients an effective, safe, and permanent treatment for panic.
Treatment is time limited, usually 20 sessions or less. Because the patient learns concrete skills that remain with him or her, relapse is unlikely. Even patients who suffer severe panic will benefit from this specialized behavior therapy.
Tips On Managing Panic Disorder Patients
The first and most important thing the physician can do is provide the panic disorder patient with a clear and reassuring diagnosis. Remember that the patient has had a series of very frightening and mysterious symptoms, and may believe that they have a serious illness such as heart disease or cancer. Explain to the patient that they suffer from panic disorder, not a serious physical illness. Go over test results showing the patient that they have normal findings. Explain that panic is a response to stress, and that the symptoms are real, disturbing, uncomfortable, but harmless. Be cautious that you do not convey the message that the symptoms are "all in the patient's head." Giving patients the message that their symptoms are real helps them to follow through with the referral and also maintains a more positive patient-physician relationship.
Table 3. Physician Guidelines to Follow When Treating a Panic Disorder Patient
- Find out what are the worries or fantasies that the patient has about his or her symptoms. Ask them what they feared or thought was wrong with them. (Typical fears are heart disease, stroke, neurological disease, or going crazy.) Then reassure specifically about those illnesses. Show how test and other clinical evidence does not fit the profile for these illnesses.
- Reassure the patient that there are no organic problems that are of any danger.
- Explain that the symptoms the person experiences are real, but are not caused by heart disease or any other physical illness. Tell patient that you know the symptoms are uncomfortable, but that they are harmless.
- Explain that they are suffering from panic disorder. Give information about causes, prevalence, and treatment of panic disorder.
- Refer to a cognitive behavioral psychologist as if you were referring to a subspecialty physician. Explain specifically what will happen and how treatment will help them. Tell the patient you will be calling the psychologist to let him or her knows you are referring a patient for treatment. Avoid vagueness and double messages such as "This might help," or "You might want to give Dr.Gottlieb a call." Be as firm in your referral, as you would be when making a referral to a cardiologist for a patient suffering heart disease.
- Give the patient the phone number of the psychologist, and schedule patient for a follow-up visit with you in 4 weeks. After referring a patient for behavior therapy, it is important that the physician maintain contact with the patient through scheduled follow-up visits. Scheduling monthly visits with the patient communicates the message that the physician and the psychologist are working together to treat the patient. During these visits the physician can reinforce the message that the patient is healthy, and that the symptoms they experience are harmless. This is a powerful intervention.
Here is an example of how not to talk to a panic disorder patient.
Physician: "Well, I can't find anything wrong with you. Maybe you're just under a lot of stress. Let me refer you to a psychologist, and maybe he can figure out what?s wrong with you. It's probably just in your imagination that you have these attacks."
Here's a better way to talk to your panic disorder patient.
Physician: "From the information you have given me as well as the exam I've performed, and the tests we ran, I would like to tell you what I think is going on. I'd like to reassure you that I found no evidence of any heart disease symptoms. Your symptoms of rapid heartbeat, palpitations, and so on do not appear to be coming from any physical problem. But your symptoms are real, and I'd like to talk with you about them.
"Have you ever heard of an illness called panic disorder? No. Well, panic disorder is a problem that about 4-5% of the population suffers from. In panic disorder the person experiences symptoms much like yours, for no apparent reason.
"Usually the disorder develops after a period of stress. The initial onset of the symptoms can be caused by a number of reasons, but then you begin to interpret those symptoms as a sign that there is something seriously wrong. You begin to get scared, and this in turn increases the severity of your symptoms. So it becomes a vicious cycle, where the more you focus on and worry about the symptoms the worse they get. Does that make sense? The symptoms are real physical symptoms, but they are being caused by certain thinking patterns, much like you would react in fear if you thought I had a hungry tiger in the next office.
"Do you have any questions about what I've told you? [Answer questions.] What I'd like to do is to refer you to see a behavioral psychologist who specializes in the treatment of panic disorder, and who will teach you a set of skills for reducing the panic feelings. Behavior therapy is an effective treatment for panic, and its effects are more reliable and more durable than drug treatments."
Treating the patient in this way will facilitate effective treatment and remission of panic disorder, with state-of-the-art cognitive behavioral treatment.
Copyright (c) 1992 Andrew Gottlieb
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