Panic Attacks (PAs) and Panic Disorder (PD)

TREATMENT

The good news today is that PD with or without agoraphobia is treatable. The result being the absence of PAs and anticipatory anxiety as well as elimination of phobic avoidance. The most efficacious therapies are pharmacotherapy and cognitive behavioural therapy (CBT), used alone or simultaneously. Treatment ought to commence following the first PA, unfortunately, for many it is delayed. As PD is often a chronic condition, some form of treatment throughout life may be necessary.

DRUG ASSISTED TREATMENT

The last decade has seen a tremendous development in the range of pharmacological treatments for PD. Today, five classes of drugs have consistently been shown to be effective. They include:

1. Selective serotonin reuptake inhibitors (SSRIs)
2. Serotonin and noradrenergic reuptake inhibitor (SNRI)
3. Noradrenergic and specific serotonergic antidepressant (NaSSA)
4. Reversible inhibitor of monoamine oxidase (RIMA)
5. Specific benzodiazepines

Today, the selective serotonin reuptake inhibitors (SSRIs) are the most frequently used medications (See Table 3). Treatment commences at a low dose and increased over several weeks until one is symptom free. The SSRIs are not only effective in controlling panic but are also beneficial in the treatment of co - occurring illness, particularly a mood disorder. When using SSRIs, some experience initial "jitters" that may be confused with anxiety; this effect is only a side effect and disappears in time.

Other antidepressants shown to be effective in the treatment of PD are Venlafaxine (Efexor-XR), Mirtazapine (Avanza) and Moclobemide (Aurorix). The Benzodiazepines, Alprazolam (Xanax) and Clonazepam (Rivotril) are widely used in PD. Both have a rapid onset of action and minimal side effects. Clonazepam has an advantage over alprazolam in having a longer duration of action thus medication is taken less frequently. Caution is necessary in using these medications to minimise physical dependence and withdrawal symptoms on discontinuation.

If one type of medication is without effect, another or a combination of medications should be tried. The question of how long pharmacological treatment ought to continue is unknown. Continued treatment for six months and preferably for one year prior to a slow withdrawal is often recommended. For many, the symptoms return upon discontinuation. Unfortunately, for most, PD is a chronic condition with studies suggesting that only 20% obtain full remission. Clinical experience suggests that rarely do those with PD abuse medication most, in fact, are indeed fearful of medication.

PSYCHOLOGICAL THERAPIES

COGNITIVE BEHAVIOURAL THERAPY

Cognitive behavioural therapy (CBT) is the most widely used psychological therapy in the treatment of PAs.

Cognitive therapy

The cognitions (thoughts, feelings and beliefs) in those who suffer PAs are related to the misinterpretation and catastrophising of bodily sensations, (see Table 4) and the developing beliefs that doubt their ability to cope in the event a PA occurring. Cognitive therapy identifies, modifies and replaces the faulty cognitions to ones that are more realistic. While CBT may be useful for some in the management of PAs, recent studies suggest that this therapy rarely leads to remission.

Behavioural Therapy

Behavioural therapy refers to strategies for overcoming avoidance behaviour and minimising the anxiety/panic symptoms that have occurred.

Types of behavioural therapy are:

a. Breathing Retraining

It is hypothesised that those who suffer PAs suffer from faulty breathing mechanisms resulting in over-breathing, shallow breathing, frequent sighing and hyperventilation. Most who suffer PAs also have concerns about the availability of fresh air.  They may, at times, avoid tight clothing around their neck and assure that fresh air is always available. Breathing retraining involves learning diaphragmatic breathing as a way of controlling an episode of panic and as a mode of relaxation.

b. Relaxation Therapy

Relaxation therapy can be useful in suppressing anxiety/panic symptoms.

c. Interoceptive Exposure-Therapy

Interoceptive exposure - therapy involves exposure to events that induce bodily sensations similar to those experienced during a PA. By repeatedly experiencing these sensations, an understanding develops and recognition occurs that the symptoms are not life threatening.

d. Exposure Therapy

Exposure therapy is imperative when agoraphobia develops. It involves exposure in a graded way to situations that are feared, the least fearful situations entered first. Prior to exposure therapy, the sufferer must feel confident that they can manage any panic or anxiety symptoms that may occur.

Catastrophising and misinterpreting body sensations

Body sensation		Catastrophising (misinterpreting)		Cognitive therapy (re - interpreting)
Dizziness		I am feeling dizzy, this means panic.		This is only dizziness, l can handle this.
Chest pain		I am feeling tight.		I can ride this chest pain through.
Palpitations		My heartbeat is increasing. Oh no, l am going to panic.		I have had palpitations before, they will pass.
Breathing		My breathing is getting more shallow, this means panic.		This breathing is just a sign of anxiety, that is all.

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