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ask the expert panic attacks

The Baltimore Sun

Many of us have experienced a pounding heart, sweaty palms, a feeling of constricted breathing -- perhaps before giving a speech, getting on an airplane, asking for a raise. But for some people, those same symptoms are accompanied by dizziness, shortness of breath and even a sense of impending doom. These people may be suffering from a panic attack, says Dr. Elias Shaya, chief of psychiatry at Good Samaritan Hospital. And although panic attacks can be potentially disabling, they also are considered treatable.

People often refer to panic attacks in casual conversation or even as a joke. What really constitutes a panic attack?

From a medical standpoint, a panic attack is a state of severe anxiety manifested by predominantly physical symptoms and some emotional symptoms.

The physical symptoms can involve a rapid heartbeat, a flushing sensation that goes down the neck or face, a sense that a person is suffocating, or something is stuck in their throat and they can neither swallow nor cough it up.

There also can be [gastrointestinal] symptoms: upset stomach, nausea or a feeling of a knot in the stomach. The person may experience perspiration, or feel dizzy, that they are about to pass out, and a tingling sensation in their fingers or face. If the panic attack progresses, it can cause a state of tension in the hands -- as though the person can't move his hands.

What causes a panic attack?

It can be triggered by anything. The trigger can be a real stimulus such as a person is about to be attacked by a fierce dog. And it also can be an exaggerated threat, say a phobia about enclosed or high places.

And then -- and this can get a little tricky -- a person can get a panic attack for no clear reason. It comes out of the clear blue sky. It can wake them up or it can happen when they are watching TV or reading, and they are stricken out of the blue. And that becomes really disturbing to them: It is on their minds much of the time, and they fear having another attack all the time, and that is when we call it panic disorder.

How many people are affected?

A panic attack isn't a condition -- it could happen to any of us at any time. I'm sure all of us have experienced something like it for a variety of reasons. But when we are talking about a panic disorder, then the statistics vary significantly from study to study: If we survey the entire American population over a year, anywhere between 1 [percent] and 8 percent suffer from it.

Are there people who seem particularly prone to having panic attacks?

Men or women can have a panic attack at any age. However, women seem to have them twice as often as men, and there is not a good understanding of why. Sometimes it is described that hormonal changes for women may trigger or make it subside. These are not very well established patterns though; these are relatively loose observations.

Do people who have panic attacks have other similarities?

It is believed to be a combination of genetic factors so it runs in families and there may be some environmental factors. In research settings, it is possible to trigger panic attacks by having volunteer subjects breathe higher levels of carbon dioxide or by giving them infusions of certain chemicals. Those may act as triggers in an experimental setting, but in real life it is not known what might bring panic disorder on anymore than it is for cancer or Parkinson's or rheumatoid arthritis.

How do you diagnose a panic attack?

Patients rarely initially come to me because most often their symptoms are physical symptoms -- pounding heart or breathing difficulty or GI symptoms. Very often patients think they are having a heart attack or a stroke. Very often their first visit to a doctor is at the ER because very often they don't perceive it as an emotional condition.

And mostly they are right: These are physical symptoms. Anybody whose heart is pounding or who can't breathe -- well, obviously they are going to feel anxious. And there is a sense of impending doom that goes along with these attacks. ... Typically only after having tests that show that their hearts are fine and that they are not having a stroke are they sent to a psychiatrist for treatment.

What do you tell patients whom you have diagnosed as having had a panic attack?

The first thing I tell them is that while this is a very disturbing or scary event, it is almost never a dangerous event. So I help them to understand that this is not something that is going to kill them or cause a heart attack. But it is a tremendously scary event. Once they believe this, some people say, 'I'm still having these attacks, but I am not getting as worked up over them.'

What else?

The other thing I try to explain is that this is a dysfunction in the brain -- almost like a seizure.

One theory explains it like this: In the brain, there is a kind of alarm system. For example, if I am asleep, and someone cuts off the oxygen supply in the room, my brain will wake me up. It is a good alarm system: Something in the brain senses danger and wakes us up, even when we are asleep.

In a panic attack, the alarm system is misfiring. It is sending a false alarm. There is nothing really dangerous, but the brain is giving the sensation that there is. Frequently, patients find this explanation reassuring.

We still need to treat the condition, but at least it makes patients feel a little easier to know it is a false alarm.

What is the treatment?

There are three components. First, we educate the patient about what it is and get them to understand it. Then there are medications that typically readjust the chemicals in the brain that are possibly making that misfiring happen.

Then we use a specific type of psychotherapy: behavioral cognitive therapy. This is particularly helpful with a condition called agoraphobia, which frequently accompanies panic attacks. [Agoraphobia is when a person develops an irrational fear of being in a place or situation, from which they feel that they cannot readily escape.]

The first part of the therapy is education. And there also is an element of teaching relaxation techniques. Through these, we help them work through the panic attacks as they happen. They learn to retrain the brain and prevent it from engaging in catastrophic and false thinking, which makes the physical symptoms much worse.

Can a patient who has panic attacks be cured?

Some people can be cured. Typically, you want them to be on the medications for a year at least. ... We don't know if the treatment is not the curative element. Sometimes we think the disorder itself is self-limiting like a cold -- a person with a cold is going to get better. Indeed in some people, the panic attacks simply will run their course. The problem is we have no way of knowing who is who. ... So we provide the treatment, and after about a year of stability we gradually have the patient come off the medications. After the medication is stopped, many people do well, but for some the attacks may come back. These people may need to be on the medication for a longer time.

Is there anything else you would like to say about panic attacks?

I think that a panic attack is one great example of how so-called mental disorders are misnamed. You can see that the majority of the symptoms of panic attacks are physical symptoms, and the emotional component is just one of many.

So calling it a mental condition -- is not only terribly stigmatizing and has been the cause of much discrimination, but it is inaccurate. ... I believe that to be true of all the conditions that people call mental disorders, and panic disorder is a great case in point.

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