Prescriptions
Take care of panic attacks with therapy and drugs

By Dr. Landis Lum

Do these symptoms affect you, usually hitting out of the blue?: repeated occurrences of intense anxiety accompanied by frightening sensations of "pounding heart," chest pain, sweating, shortness of breath and dizziness, along with a fear of dying or losing control.

If your physical exams, blood tests and EKG are coming out normal, but you're still suffering these symptoms, you may have panic disorder. About 3 percent of people suffer panic disorder at some point in their lives.

Medically speaking, a panic attack is a sudden rush of fear or discomfort that peaks in less than 10 minutes. The attacks often come out of the blue, and often the patient suffers great worry about having more attacks. There is concern about possible consequences of the attacks (such as having a heart attack, fainting, vomiting, dying, going "crazy" or losing control) and various behavioral changes (for instance, avoidance of arousing activities, such as physical exercise and sex, or a dependence on certain objects in order to feel safe, such as a bottle of medication or a cellular telephone).

Agoraphobia — a fear of entering situations in which escape might be difficult or in which help might be unavailable in case of a panic attack — often also develops in people with panic disorder. Agoraphobics typically avoid crowds, stores, shopping malls, theaters, buses and planes; being alone, standing in lines and being in enclosed places. In some people, agoraphobia is so profound that they are unable to leave the confines of their own home.

What causes anxiety disorders? Panic disorder, agoraphobia, and obsessive-compulsive disorder tend to run in families. Evidence points at least in part to some physical cause: Dysfunction in a number of neurotransmitter systems in the brain have been found. However, upbringing and "learned anxiety" also play a role.

But patients shouldn't despair, as there are great treatments for panic disorder.

There is a growing consensus among experts that cognitive behavioral therapy (also called CBT for short), administered by a psychologist, psychiatrist or other therapist trained in CBT, should be the treatment of first choice for this disorder.

CBT consists of patient education, monitoring of panic symptoms, breathing retraining, cognitive restructuring (teaching patients to identify and change anxious thoughts and predictions), and exposure and desensitization to anxiety-provoking situations. Exposure to feared sensations and situations works best when it is practiced frequently (at least several times per week) for prolonged periods (long enough for the fear to decrease). CBT takes anywhere from 5 to 15 sessions, and some experts feel group therapy works better than individual therapy. There are even some great self-help manuals available to teach patients the principles of CBT.

Not only is CBT equal in effectiveness to drug therapy in the short term, but CBT is superior to drug therapy in the long term in terms of lower relapse rates after the therapy is stopped. In fact, an article from the August 2000 issue of Journal of Consulting & Clinical Psychology concluded that CBT was an especially cost-effective treatment option, as it had more permanent effects than drug treatment.

In terms of drug therapy, drugs such as fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa), which help to restore the normal serotonin balance in the brain needed for a sense of well-being, are safe and effective, but may take up to two or three months for maximum effectiveness.

Sedative-type drugs like clonazepam (Klonopin) and alprazolam (Xanax) are also effective and work more quickly, but unlike the serotonin-active drugs, they do not correct the underlying neurotransmitter imbalance leading to panic attacks in the first place, and carry the risk of dependence.

Panic disorder is a chronic affliction that causes much misery and disability. If you feel you have this, see your family physician or therapist right away for either CBT or drug therapy — and, potentially, a new lease on life.

Dr. Landis Lum is a family practice physician with Kaiser Permanente, and an associate clinical professor of family and community medicine at the University of Hawai'i's John A. Burns School of Medicine.

Hawai'i experts in traditional medicine, naturopathic medicine, diet and exercise take turns writing the Prescriptions column. Send your questions to: Prescriptions, 'Ohana Section, The Honolulu Advertiser, P.O. Box 3110, Honolulu, HI 96802; e-mail ohana@honoluluadvertiser.com; fax 535-8170. This column is not intended to provide medical advice; you should consult your doctor.