Panic disorder is a condition where you have recurring panic attacks. Many people with panic disorder also develop agoraphobia. This means you avoid many places, and may not even go out from your home, due to fear of having a panic attack in a public place. Treatment with cognitive behavioural therapy and/or antidepressant medicines works well in over half of cases.
What is a panic attack?
A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without warning, and for no apparent reason. In addition to the anxiety, various other symptoms may also occur during a panic attack. These include one or more of the following:
- A thumping heart (palpitations).
- Sweating and trembling.
- Dry mouth.
- Hot flushes or chills.
- Feeling short of breath, sometimes with choking sensations.
- Chest pains.
- Feeling sick (nauseated), dizzy, or faint.
- Fear of dying or going crazy.
- Numbness, or pins and needles.
- Feelings of unreality, or being detached from yourself.
The physical symptoms that occur with panic attacks do not mean there is a physical problem with the heart, chest, etc. The symptoms mainly occur because of an overdrive of nervous impulses from the brain to various parts of the body during a panic attack. This overdrive of nervous impulses can lead to the body producing hormones which include adrenaline (epinephrine). This is sometimes referred to as a 'fight or flight' response. This kind of reaction is normal in people when we feel we are in danger. During a panic attack the body can react in the same way.
During a panic attack you tend to over-breathe (hyperventilate). If you over-breathe you blow out too much carbon dioxide which changes the acidity in the blood. This can then cause more symptoms such as confusion and cramps, and make palpitations, dizziness, and pins and needles worse. This can make the attack seem even more frightening, and make you over-breathe even more, and so on. A panic attack usually lasts 5-10 minutes, but sometimes they come in waves for up to two hours.
What is panic disorder?
At least 1 in 10 people have occasional panic attacks. If you have panic disorder it means that you have repeated (recurring) panic attacks. The frequency of attacks can vary. About 1 in 50 people have panic disorder.
In panic disorder, there may be an initial event which causes panic but then the attacks after that are not always predictable. If you have panic disorder, you also have ongoing worry about having further attacks and/or worry about the symptoms that you get during attacks. For example, you may worry that the thumping heart (palpitations) or chest pains that you get with panic attacks are due to a serious heart problem. Some people worry that they may die during a panic attack.
What causes panic attacks?
Panic attacks usually occur for no apparent reason. The cause is not clear. Slight abnormalities in the balance of some brain chemicals (neurotransmitters) may play a role. This is probably why medicines used for treatment work well. Anyone can have a panic attack, but they also tend to run in some families. Stressful life events such as bereavement may sometimes trigger a panic attack.
Panic disorder, agoraphobia and other fears
Some people with panic disorder worry about having a panic attack in a public place where it is difficult to get out of, or where help may not be available, or where it can be embarrassing. This may cause them to develop agoraphobia. About 1 in 3 people with panic disorder also develop agoraphobia. See separate leaflet called Agoraphobia.
If you have agoraphobia you have a number of fears of various places and situations. So, for example, you may be afraid to:
- Be in an open place.
- Enter shops, crowds, and public places.
- Travel in trains, buses, or planes.
- Be on a bridge or in a lift.
- Be in a cinema, restaurant, etc, where there is no easy exit.
- Be anywhere far from your home - many people with agoraphobia stay inside their home for most or all of the time.
You may also develop other irrational fears. For example, you may think that exercise or certain foods cause the panic attacks. Because of this you may fear (develop a phobia) for certain foods, or avoid exercise, etc.
Dealing with a panic attack
To ease a panic attack, or to prevent one from getting worse, breathe as slowly and as deeply as you can. Really focus on your breathing. Learning and using relaxation techniques may help. Many people find that deep breathing exercises are useful. This means taking a long, slow breath in, and very slowly breathing out. If you do this a few times, and concentrate fully on breathing, you may find it quite relaxing.
Some people find that moving from chest breathing to tummy (abdominal) breathing can be helpful. Sitting quietly, try putting one hand on your chest and the other on your abdomen. You should aim to breathe quietly by moving your abdomen with your chest moving very little. This encourages the lower chest muscle (diaphragm) to work efficiently and may help you avoid over-breathing.
What is the treatment for panic attacks and panic disorder?
No treatment is needed if you have just an occasional panic attack. It may help if you understand about panic attacks. This may reassure you that any physical symptoms you get during a panic attack are not due to a physical disease. It may help to know how to deal with a panic attack.
Treatment can help if you have repeated (recurring) attacks (panic disorder). The main aim of treatment is to reduce the number and severity of panic attacks.
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is a type of specialist talking treatment. It is probably the most effective treatment. Studies show that it works well for over half of people with panic disorder (and agoraphobia).
- Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as panic attacks and agoraphobia. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful, and false ideas or thoughts which you have. For example, the ideas that you may have at the beginning of a panic attack, wrong beliefs about the physical symptoms, how you react to the symptoms, etc. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks.
- Behavioural therapy aims to change behaviours which are harmful or not helpful. This may be particularly useful if you have agoraphobia with panic disorder where you avoid various situations or places. The therapist also teaches you how to control anxiety when you face up to the feared situations and places. For example, by using breathing techniques.
- Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours.
If you have CBT and it works, the long-term outlook may be better than with treatment with antidepressants. However, CBT may not be available in every area, and does not suit everyone.
These usually work well to prevent panic attacks in more than half of cases. (These medicines are often used to treat depression, but have been found to work well for panic disorder too, even if you are not depressed.) They work by interfering with brain chemicals (neurotransmitters) - such as serotonin - which may be involved in causing symptoms of panic.
- Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and may take up to eight weeks to work fully. A common problem is that some people stop the medicine after a week or so as they feel that it is doing no good. You need to give them time to work.
- Antidepressants are not tranquillisers, and are not usually addictive.
- There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used to treat panic disorder.
- If SSRIs do not work, imipramine or clomipramine is sometimes used.
Note: after first starting an antidepressant, in some people some anxiety symptoms become worse for a few days before they start to improve.
If it works, it is usual to take an antidepressant for panic disorder for at least a year. At the end of a course of treatment, you should not stop an antidepressant suddenly, but you should reduce the dose gradually under the supervision of a doctor. In about half of people who are successfully treated, there is a return of panic attacks when treatment is stopped. An option then is to take an antidepressant long-term. The attacks are less likely to return once you stop antidepressants if you have had a cognitive behavioural course (see below).
A combination of CBT and antidepressants may work better than either treatment alone.
Dr Tim Kenny
Dr Euan Lawson
Dr John Cox