Panic Disorder (Recurring Panic Attacks)

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 antidepressant medicines and/or cognitive behaviour therapy 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:

• Palpitations or a thumping heart.
• Sweating and trembling.
• Hot flushes or chills.
• Feeling short of breath, sometimes with choking sensations.
• Chest pains.
• Feeling sick.
• Feeling 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.

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 recurring panic attacks. The frequency of attacks can vary. About 1 in 50 people have panic disorder.

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 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 you to develop agoraphobia. About 1 in 3 people with panic disorder also develop 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 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. Concentrate on breathing.
• breathe into a paper bag. By doing this you re-breathe your own carbon dioxide. This helps to correct the blood acid level that had been upset by over-breathing which makes symptoms worse (described above).

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 recurring attacks (panic disorder). The main aim of treatment is to reduce the number and severity of panic attacks.

Antidepressant medicines
An antidepressant medicine is the usual treatment. 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 straight away. 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, SSRI antidepressants (selective serotonin reuptake inhibitors) are the ones most commonly used to treat panic disorder.
• 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 course of CBT (see below).

Cognitive-behaviour therapy (CBT)
This 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.
   
• Behaviour 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-behaviour 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 is not available in every area, and does not suit everyone.

A combination of CBT and antidepressants and may work better than either treatment alone.

Further help and information

National Phobics Society
Zion Community Resource Centre, 339 Stretford Road, Hulme, Manchester, M15 4ZY
Tel: 0870 122 2325   Web: www.phobics-society.org.uk
A leading UK charity for anxiety disorders such as panic disorder, etc.

NO PANIC (National Organisation For Phobias, Anxiety, Neuroses, Information & Care)
93 Brands Farm Way, Randlay, Telford, Shropshire TF3 2JQ
Helpline: 0808 808 0545    Web: http://nopanic.org.uk

First Steps to Freedom
1 Taylor Close, Kenilworth, Warwickshire, CV8 2LW
Helpline: 0845 120 2916    Web: www.first-steps.org
For people with general anxiety, phobias, obsessional compulsive disorder, panic attacks, anorexia and bulimia, and those who wish to come off tranquillisers. Services include, telephone self-help groups, leaflets, booklets, videos, audio tapes including relaxation audio tapes.

© EMIS and PIP 2005   Updated: August 2005