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What Is a Panic Attack?

Bob is a 41 year old lawyer. Recently, while visiting relatives in upstate New York, he awoke from his sleep in a state of panic. His heart was pounding and he was experiencing chest pain. "I was convinced I was having a heart attack!" Bob's family rushed him to the local hospital where he was seen immediately in the emergency room. After several tests the physician concluded that Bob was in perfect health. Bob was both relieved and perplexed: "But what caused the symptoms I experienced?" "That was just a nervous attack" said the physician, "just go home and relax." Uneasily, Bob left the hospital. He felt fine for two days. But while Bob was packing his car to return home, his heart suddenly began pounding and racing, he was experiencing severe chest pain, and could barely catch his breath. Bob ran inside to get his wife: "I know I'm having a heart attack - the doctor must have missed something in the emergency room the other night!" Once again they rushed off to the emergency room. A different physician was present this time. He repeated all of the tests done two days before. After reviewing the test results the physician concluded that Bob was in perfect health. Bob could only wonder, "What is causing these symptoms?"

Panic Attack

The term panic attack was officially described by the American Psychiatric Association's classification system -- the DSM -- in 1980. Panic attacks are "discrete periods of intense fear or discomfort.... often there is a feeling of impending doom." At the very least, the first attack occurs unexpectedly--that is to say, it is not necessarily triggered by a situation which would cause one to experience anxiety. In addition, the DSM definition of panic requires the presence of at least four of the following symptoms (shortness of breath, dizziness, faintness, palpitations, trembling or shaking, choking, nausea, depersonalization, numbness or tingling sensations, flushes or chills, chest pain, fear of dying, fear of going crazy or of doing something uncontrolled). Thus, panic attacks can be best characterized as a sudden burst of intense fear accompanied by uncomfortable and uncontrollable physical sensations. Typically, the attacks appear to be spontaneous when their first occur. However, overtime, the attacks become associated with various situations that can eventually provoke the attacks.

What is Panic Disorder?

Panic Disorder is the official name listed in the DSM for the disorder from which patients suffer from repeated panic attacks. In addition to panic attacks, most patients with panic disorder often experience agoraphobia as well. Agoraphobia refers to the fear of going into certain situations because it may trigger a panic attack. This is often the most disabling part of the disorder, as it can greatly reduce one's ability to function. Common agoraphobia situations include shopping malls, bridges, elevators, planes, driving long distances, being at home alone, tunnels, buses/trains, and traveling a significant distance away from home. The level of agoraphobia in panic disorder patients is quite variable, and even fluctuates from time to time within an individual. Some patients are unable to leave their own home, others are able to leave home and hold a job but avoid many situations, and still others are frightened of many situations but do not avoid them.

In addition to panic disorder attacks and agoraphobia, patients with panic disorder often suffer from chronic anxiety and depression. The chronic anxiety is often related to the feeling that the attacks can happen at anytime, so patients become constantly on edge, waiting for the next attack to occur. Ironically, a patient will often "talk" him or herself into a panic attack just by worrying about it. The depression is often related to the feeling that his or her life is not going to get back to "normal." Patients often become sad, hopeless about the future, and suffer a loss of self-esteem.

" I know there is something physically wrong with me!"

This is the single most widely held belief by people who suffer from panic attacks, especially when the attacks first begin. Since panic attacks are composed of physical sensations, it is logical that patients believe there is a physical disturbance. Indeed, patients will go from doctor to doctor attempting to find an explanation of their symptoms. And despite the doctors reassurance that he or she is in good health, the patient continues to believe that something is being missed. Surprisingly, many panic disorder patients have told me that they wish that someone would find something wrong with them. What would cause a person to actually hope for a physical problem to be found? It is because the unknown is very frightening and people will imagine the worst. In my own practice, I have found that in almost all cases, telling panic disorder patients that there are many other people who complain of a similar problem; and providing an explanation about panic attacks, puts their mind at ease and results in their feeling somewhat better.

It is important to note that research does not suggest that panic attacks are caused by a disease or physical illness. It appears as though some people have a nervous system that reacts a bit more to stress. Many panic patients have their first attack during a period of chronic stress. Panic attacks may be the result of interpreting harmless physical sensations -- which and be very uncomfortable -- as being dangerous. Among the most common thoughts are: "I am having a heart attack," "I am going to faint or pass out," "I am going to lose control," "I am going to go crazy!" Having these thoughts will actually worsen the symptoms.

What is Cognitive Behavior Therapy?

Cognitive Behavior Therapy (CBT) for panic disorder is a psychological treatment approach primarily developed by Dr. David Barlow at the Center for Anxiety Disorders in Boston, and by Dr. Aaron Beck at the Center for Cognitive Therapy, University of Pennsylvania School of Medicine, in Philadelphia. CBT is as effective as state-of-the-art medications in treating panic disorder.

CBT consists of the following components, each which will be described briefly:

1. Education
2. Cognitive Restructuring
3. Breathing Training
4. Relaxation Exercises
5. Situational Exposure
6. Interoceptive Exposure.

Each component is aimed at alleviating panic attacks, agoraphobic avoidance, chronic anxiety, and depression associated with panic disorder (note: clinician's may apply only those techniques that they determine are relevant to your problem).

Throughout treatment, patients are educated about panic attacks and the development of panic disorder. An understanding of panic disorder is believed to be an important part of the recovery process.

Cognitive restructuring, a major part of the treatment, is intended to correct distorted thinking about panic attacks. The goal is to have patients change their reaction to their emotional arousal and panic symptoms, and learn to deal effectively with anxiety provoking situations. During the early sessions of therapy, patients are asked to self-monitor their thoughts, assumptions, and beliefs during anxiety provoking situations and panic attacks. With the collaboration of the therapist, patients begin to appreciate the role of cognition, beliefs, and appraisals in the evocation or accentuation of anxiety and panic attacks. During the later sessions, patients are taught to re-evaluate the validity of these distorted thoughts, and change them to more rational, adaptive ones. In particular, patients' "catastrophic misinterpretations" of panic-related somatic cues -- the belief that these physical sensations are a sign that he or she is dying at that moment -- are addressed. Patients will repeatedly challenge their dysfunctional thoughts during treatment.

Breathing training teaches patients a pattern of slow, regular breathing which prevents hyperventilation, an uncomfortable symptom of and cue for panic attacks.

Relaxation exercises that involve progressive muscle tension are often incorporated to lower general anxiety levels.

Situational exposure consists of structured and repeated exposure to anxiety - and panic provoking ("phobic") situations. Based on the patient's individualized list of feared situations, he or she undergoes exposure to these situations while using coping strategies learned during therapy, beginning with the least feared and moving to the most feared. This typically takes place later on during therapy, once a patient feels more in control of panic attacks. The aim of situational exposure is to eliminate agoraphobia.

When necessary, Interoceptive exposure may be conducted. Interoceptive exposure involves the structured and repeated exposure to panic-like physical sensations. Based on the patient's individualized hierarchy of feared internal sensations (e.g., dizziness, palpitations), he or she undergoes systematic exposure to these sensations. The feared sensations may be produced using idiosyncratic methods such as controlled hyperventilation or physical exertion (e.g., running up a flight of stairs to get your heart racing). This is necessary because patient's often become fearful of harmless body sensations, such as those caused by exercise, caffeine, and excitement.

The following books are recommended:

Peace from Nervous Suffering by Clare Weekes (Hawthorne, 1972).
Don't Panic: Taking Control of Anxiety Attacks by Reid Wilson (Harper & Row, 1987).

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