Imagine this: you've just entered your office building. You're headed for the elevator at a trot--maybe a little late. You punch the button. Suddenly you feel an intense sense of foreboding. Then raw fear. Something terrible is about to happen. You feel as if you may die the next second.

The elevator doors open. But you're too frightened to get on. You stand there in the lobby with your heart pounding, barely able to breathe. Other office workers file past you, looking back over their shoulders to see if something is wrong.

Something is. What's happened and what happens regularly to one in fifty people is a panic attack, the "crisis phase" of panic disorder. The crushing fear of the panic attack most often passes after a few minutes, but in its wake it leaves a residue of uneasiness: when might the panic come again?

"I'm just freaking out and I feel like my body's freaking out. I mean the shaking and the breathing and the sweats, and the heart and the pain in the chest--I feel like I'm going to have a heart attack or something. Except I never do..."

Panic Disorder Sufferer

The Attack

Everyone has anxious times. Modern life, with its pace, its pressures to perform and produce, and its difficult relationships, seems at times almost to be a factory for stress. But the normal life's normal strains are not the stuff of panic disorder. The panic attacks stemming from the illness often strike in familiar places where there is seemingly "nothing to be afraid of." But when the attack comes, it comes as if there were a real threat, and the body reacts accordingly. Surroundings can take on an unreal cast, and a combination of symptoms sparks like the current in a crosswired fire alarm: the heart races, breathing gets shallower and faster, the whole nervous system signals: DANGER. The person suffering under this barrage may be convinced he or she is having a heart attack or stroke, or that he or she is going crazy or going to die.

Researchers have determined that panic attacks are usually classified as being part of a panic disorder if they occur frequently (one or more times during a given four-week period) and are accompanied by at least four of the following symptoms:

• Sweating
• Shortness of breath
• Heart palpitations
• Chest discomfort
• Unsteady feelings
• Choking or smothering sensations
• Tingling
• Hot or cold flashes
• Faintness
• Trembling
• Nausea or abdominal distress
• Feelings of unreality
• Fears of losing control, dying, or going insane

Not all attacks or all people have the same symptoms

The sense of danger and physical discomfort the attacks bring is so intense that many interpret them as the precursors of a heart attack or stroke, or the product of a brain tumor. Consequently, many panic disorder sufferers show up in emergency rooms where doctors unfamiliar with the illness judge that the patient is in no danger and send them home. This embarrassing process may repeat itself many times if the proper diagnosis isn't made.

"Most of my attacks came on when I was on the subway, and it got to the point where I couldn't take the subway anymore and it was affecting my work because I would be out of work a lot from not being able to take the subway. But eventually, I made myself take the subway, though I still experienced the attacks." (Panic Disorder Sufferer)

Trying to Avoid More Attacks

Once a panic disorder sufferer's first attack begins to ebb, he or she may be tempted to believe it was a fluke. The EKG showed nothing untoward; the emergency room doctor said to go home and get some rest, that he or she was probably only overtired. The jagged emotions seem like a dim memory until the next time.

When another attack does come, the panic disorder sufferer naturally begins to search for a cause. Often, he or she will begin to avoid situations or places where episodes have occurred. He or she may stop going to the ballpark, or avoid driving or riding elevators, since these activities seem to be triggers. The sufferer may even become reclusive, reasoning that it's better to suffer alone than to endure the attacks in the open where there's no escape from the fear and humiliation and little chance of help. This paring away of accustomed patterns is called phobic avoidance. It may help temporarily with the fear of the attack and its accompanying loss of control, but it makes a normal home and work life nearly impossible. It steals the savor from life. And it doesn't keep the attacks from happening.

Untreated panic disorder can produce other side effects. Fear of the fear the attacks bring, or anticipatory anxiety, can be one unfortunate outgrowth. The sufferer never knows when another attack will come, and is always steeled for it. Studies have shown that agoraphobia, literally "fear of the marketplace," is often coupled with panic disorder. It can drive those with panic disorder to skirt public places, though paradoxically they fear being alone. This pattern may progress to the point that the panic disorder victim fears leaving his or her home without a trusted companion, or fears leaving home, period. Obviously this is wearing to the sufferer's family and friends. Those who must leave the house for the office can also suffer front a sort of agoraphobia which leaves them shackled to their route between home and office, unable to deviate from their workaday pattern.

Confined to such a limited lifestyle which puts so much strain on relations with friends and family, panic disorder sufferers also more easily become prey to depression and its complications than does the average person. Recent studies have suggested also that two out of three people with panic disorder also experience depression over their lifetime. Also, panic disorder sufferers often further complicate their illness with drug and alcohol abuse. This form of "self medication" is sadly ironic: researchers believe that drugs or alcohol themselves pull down mood and worsen anxiety, condemning the victim of panic disorder to a downward spiral of anxiety, depression, and more panic.

"But the thing that made me so frightened, I think, was just not knowing what was wrong with me." (Panic Disorder Sufferer)

What's Behind the Attack

Psychiatric research into the causes of panic disorder has been on the rise in recent years. Surveys have shown that more women than men are afflicted with panic disorder by a ratio of approximately two to one--and that panic disorder knows no racial, economic, or geographic boundaries. Because its victims often hide their illness and because healthcare professionals often do not diagnose it, it is difficult to gauge how widespread panic disorder is in the general population. In a recent study by the National Institute of Mental Health, 10 percent of those interviewed reported having had spontaneous panic attacks. The best recent estimate of those with panic disorder places the number of Americans suffering with panic disorder or phobias at 13 million. Apart front the very real suffering the disorder inflicts, the illness costs billions of dollars per year in the U.S., figured in terms of health care expenses, disability benefits, and lost wages. And as the disorder is more widely recognized and researched, those numbers may well climb.

While many studies have examined the emotional components of panic disorder, more recent studies have shown that panic disorder's roots are physical as well as psychological. Researchers have found that panic disorder runs in families, a fact which supports the idea that the condition may pass genetically from generation to generation. To explore this possibility, scientists are pursuing several promising lines of biological study, looking into the brain for clues to the causes of panic disorder. Scientists are studying the brain's chemistry to find out if panic comes from a problem with that organ's complex chemical communications system, the neurotransmitters. Other groups are examining the brain's structure to see if a problem there might cause information from the senses to short-circuit, triggering the panic reflex. Still another group is looking into the effect on the brain of various chemical compounds, such as sodium lactate and carbon dioxide.

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Many people who do not have panic disorder may have an occasional panic attack during periods of severe stress. But those with panic disorder have the attacks even after the stressful conditions have gone. The disorder typically begins when its victims are in their twenties. Often a serious event-such as the death of a parent or divorce will kick off the first attack.

"I went to [my family] doctor and he did a number of tests. He thought at first I had multiple sclerosis, but he ruled that out, finally, and said he wasn't sure what I had. So he sent me to a neurologist. The neurologist also did a number of tests and finally gave me a diagnosis of "non-specific idiopathic neuropathy." I asked him what that was and he didn't give me much of an explanation. He just said that maybe I should see a psychiatrist." (Panic Disorder Sufferer"

Getting Treatment

Panic disorder has been called one of the great impostors among illnesses because it is so easily mistaken for other medical or psychiatric problems, such as heart disease, thyroid problems, respiratory problems, or hypochondriasis. Those afflicted with the condition may trudge from doctor to doctor seeking help, and may even give up the hope of a cure, doubting their sanity. That's when a psychiatrist -- who is a specially trained medical doctor -- can help. Psychiatrists' training equips them to interpret correctly the symptoms of panic disorder, make a diagnosis, and treat the illness.

As with any other psychiatric illness, a psychiatrist will first ensure the patient has had a thorough physical exam. The psychiatrist will also try to piece together a complete knowledge of the patient's background, history of drug use (or abuse), and treatment history to gain the complete understanding needed to begin helping the panic disorder sufferer. The fact that other disorders--such as depression and agoraphobia--can exist along with panic disorder makes this process very important for the treatment program. If the treatment program is to help, it must address all the panic disorder sufferer's problems.

Researchers in government, the universities, and industry are working to expose the roots of the illness and are designing more effective means of diagnosing, treating, and controlling panic disorder. Today, psychiatrists treating panic disorder have a number of medicines and therapies they can use to help their patients. The psychiatrist will first seek to ease panic disorder's symptoms with education about the illness, medications if warranted, and behavioral treatment techniques such as relaxation training. Once the psychiatrist has helped the patient to make the symptoms less threatening, he will then help the patient to work against the agoraphobia, anticipatory anxiety, depression, and other ills these panic symptoms have themselves produced. Psychiatrist and patient will then continue to work together on the ongoing consequences of the illness and any other problems that nay exist side-by-side with (and often hidden by) panic disorder.

The most successful treatment programs combine three main forms of therapy: medication, cognitive and behavioral treatment. A number of medications that have worked well against depression also work against panic disorder, helping front 75 to 90 percent of its sufferers. These medications include tricyclic antidepressants, MAO inhibitors, and other drugs from the benzodiazepine group of minor tranquilizers. Preliminary evidence indicates there are more medications that will prove useful in treating the illness.

The cognitive and behavioral elements of treatment usually begin with education about the illness and encouragement to reenter situations to which the patient has become phobic along the history of the illness. Psychiatrists will then proceed with several forms of psychotherapy that help patients to change how they think (cognitive therapy) and how they act (behavioral therapy). Behavioral therapists are using desensitization techniques in which they teach panic disorder sufferers relaxation exercises and then gradually expose them to situations they have phobically avoided, teaching them to modify their breathing and to "reshape" their fearful thoughts to avoid panic attacks. They have found that, since panic disorder exists both alone and in tandem with depression and agoraphobia, they must modify treatment to fit individual cases. Follow-up treatment can also include in-depth psychodynamic psychotherapy that helps the patient to deal with the long-term consequences of the illness, which may have gone for years untreated.

Effective treatments and ongoing research are bringing new hope for recovery to sufferers of panic disorder. And continuing medical education is helping more and more physicians to recognize the disorder and get patients the help they need. Earlier diagnoses are significantly reducing the complications of untreated panic disorder and, with appropriate psychiatric treatment, nine out of ten sufferers will recover and return to normal life activities.

(c) Copyright 1989 American Psychiatric Association

Produced by the APA Joint Commission on Public Affairs and the Division of Public Affairs. This document contains text of a pamphlet developed for educational purposes and does not necessarily reflect opinion or policy of the American Psychiatric Association.

Additional Resources

Agras, M.W. Panic: Facing Fears, Phobias, and Anxiety. New York: W.H. Freeman, 1985.

Beck, Aaron, M.D. Anxieties and Phobias. New York: Basic Books, 1985.

DuPont, Robert L., M.D. Phobia: A Comprehensive Summary of Modern Treatments. New York: Brunner Mazel, 1982.

Goodwin D.W., M.D. Anxiety. New York: Oxford University Press, 1986.

Gorman, J.M., M.D., M.R. Leibowitz, M.D., and D.F. Klein, M.D. Panic Disorders and Agoraphobia. Kalamazoo, MI: Current Concepts in Medicine, 1984.

Greist, John H., M.D., James W. Jefferson, M.D., and Isaac M. Marks, M.D. Anxiety and Its Treatment: Help Is Available. Washington, DC: American Psychiatric Press, Inc., 1984.

Pasnau, Robert 0., M.D. Diagnosis and Treatment of Anxiety Disorders. Washington, DC: American Psychiatric Press, Inc., 1984.

Sheehan, David, M.D. The Anxiety Disease and How to Overcome It. New York: Charles Scribner & Sons, 1984.

Taylor, C. Barr, M.D. and Bruce Arnow, Ph.D. The Nature and Treatment of Anxiety Disorders. New York: Free Press, 1988.

Zane. Manuel D., M.D. and Harry Milt. Your Phobia. Washington, DC: American Psychiatric Press, Inc., 1984.

National Phobia Treatment Directory (Second Edition). Rockville, MD: Phobia Society of America, 1986.

Other Resources

American Academy of Child and Adolescent Psychiatry
(202) 966-7300

American Mental Health Fund 2735 Hartland Road, Suite 335 Merrifield, VA 22081
Freedom From Fear
(718) 351-1717

National Alliance for the Mentally Ill
(703) 524-7600

National Association of Private Psychiatric Health Systems
(202) 393-6700

National Community Mental Health Care Council
(301) 984-6200

National Institute of Mental Health Division of Communications
(301) 443-3673

National Mental Health Association
(703) 684-7722

Anxiety Disorders Association of America
(301) 231-9350