ADAVIC Information Sheets
Panic Disorder / Agoraphobia
Panic Disorder is a recognised anxiety disorder that affects between
1-2% of the population in community surveys. Whereas anxiety is a
normal feeling people experience when faced with threat, danger or
stress, Panic Disorder consists of recurrent unexpected attacks of
anxiety (panic attacks) which are defined by characteristic fear,
thoughts, physical symptoms and behaviour.
People with panic disorder experience the sudden onset of high levels
of anxiety and fear either spontaneously or in situations where others
would not be afraid. The attacks are accompanied by unpleasant physical
symptoms of anxiety including shortness of breath, tightness of the
chest, palpitations, sweating, shaking, dizziness, lightheadedness,
nausea and feelings of unreality or altered personal experience (de-realization/de-personalization).
Commonly the patient fears serious medical illness or death as a result
of the symptoms, misinterpreting the physical symptoms as catastrophic
signs of illness.
To qualify for a diagnosis of Panic Disorder, the attacks need to
be followed by persistent concern about additional attacks, worry
about the implications or consequences of the attacks or a significant
change of behavior due to the attacks. They need to persist for at
least one month after the initial episodes. Panic can also be complicated
by Agoraphobia which is recognised as anxiety or avoidance of being
in places where escape is difficult or impossible if one were to have
a panic attack.
Causes of Panic Disorder
While the research evidence remains limited, there is now reasonable
evidence to suggest an inherited component to many anxiety disorders
and Panic Disorder in particular. There is no doubt that members of
certain families seem particularly prone to the development of panic
attacks although it is unclear precisely what part of the panic disorder
syndrome is inherited. It may be that there is a genetic vulnerability
to experiencing episodes of increased anxiety and physical symptoms,
which combined with a tendency towards misinterpretation of these
symptoms, produces the long-standing complications and difficulties
associated with this disorder.
Furthermore there is no doubt that some people, when exposed to situations
associated with previous panic attacks, become anxious in anticipation
of future panic attacks and this in itself can sometimes trigger panic
in these situations or lead to avoidance of these places. This is
consistent with a learned response due to "conditioning". Finally
there is evidence from treatment studies with certain medications
that many of those suffering Panic Disorder may have changes in the
biochemistry of their brains. Further research in this area is needed.
Diagnosis and Assessment
While there are a limited number of medical conditions that can mimic
panic disorder and seem to cause panic attacks, by far the majority
of people who present with panic attacks suffer from Panic Disorder.
Nevertheless, it is important to discuss this matter with your general
practitioner in some detail when panic first develops. Equally it
is recognised that panic attacks and panic disorder can often masquerade
as other medical conditions due to the prominent and distressing physical
symptoms. In some cases patients may receive lengthy inappropriate
treatment for other conditions before the diagnosis of panic disorder
is actually made.
Treatment
Whilst initial treatment focused largely on the use of medications
for Panic Disorder, development of cognitive behavioral theories and
subsequent treatments for panic disorder over the past ten years or
so has lead to an explosion in interest in purely psychological treatment
of panic disorder. It is now recognised that rapid and effective psychological
treatment involving cognitive behaviour therapy (CBT) can produce
marked improvement, improvement that is commonly maintained in the
long term.
Simple psychological treatments include explanation of general aspects
of anxiety and Panic Disorder together with discussion of the possible
biological, psychological and social origins.
More specific information such as the panic cycle, the learned association
between panic attacks and agoraphobia as well as the pressure of the
characteristic physical symptoms, thoughts, fear and behaviour, (i.e.:
attempts to avoid or escape) is also important in the initial treatment
of this condition.
Other psychological methods that can be of help involve the use of
relaxation training or related techniques such as progressive muscular
relaxation and self-hypnosis. Slow breathing techniques (SBT) can
be used to successfully reduce acute and chronic hyperventilation
associated with panic attacks with SBT decreasing anxiety symptoms,
increasing the threshold for further panic attacks as well as providing
a method for control of panic symptoms during attacks. The regular
performance of pleasurable activities and exercise are also helpful
and support and counselling from a general practitioner, psychologist
or psychiatrist is also important.
More involved techniques for panic attacks include the use of cognitive
restructuring or cognitive therapy, graded exposure and interoceptive
exposure. Cognitive restructuring recognises that panic disorder is
a condition marked by misinterpretation of the importance of physical
symptoms and this method aims to directly challenge inappropriate
and irrational thinking during attacks and when anticipating future
attacks. Exposure techniques involve the gradual exposure to triggers
or situations that have been avoided because of fear of panic attacks,
with the acknowledgment that the learned avoidance or fear of these
situation can be gradually unlearned. Graded exposure involves exposure
to places and situations, while interoceptive exposure involves slow
exposure to physical feelings.
In addition, there are also a number of medications that can be helpful
in the treatment of panic disorder. These are usually reserved for
more severe cases involving frequent panic attacks, significant associated
agoraphobia or depression. Benzodiazepine medications can be useful
in the short term but because of their association with side effects
such as sedation, reduced co-ordination, memory and concentration,
together with the potential for dependence, these medications are
best used for short-term treatment of less than three months. Other
medications initially developed for depression including the tricyclic
antidepressants and the SSRI antidepressant medications can also be
helpful for panic disorder when used carefully. Importantly, these
medications can be used in combination with the psychological treatments
noted earlier.
Prognosis
While panic disorder is now recognised as causing significant problems
for a significant proportion of the population, there is now good
evidence that effective treatment exists and can significantly improve
patients' symptoms and quality of life. Treatment along the lines
described usually leads to significant improvement within six weeks,
with major improvement by three to six months. The condition may relapse
subsequently although there is some evidence to show that diligent
performance of the psychological strategies described leads to long
term improvement.
This information was provided by Dr. Scott Blair-West, Consultant Psychiatrist who can be contacted on 9428-9244. The Lenridge Practice, 184 Lennox st. Richmond. Vic. 3121
