Kim Bassinger was interviewed during an HBO special on Panic Disorder.  She described her recovery from Panic Disorder in an unusual but very successful way.  During her recovery period she developed a technique to change her negative thinking and attitudes.  She decided to talk to her fear.  She said, “how do you have so much power over me?”  Fear answered, “I get in your face and talk loud!”  Then she asked, “how can I defeat you?”  Fear replied, “don’t  believe a word I say!”

• In the U.S., 1.6% of adults (3 million) will have Panic Disorder in their lifetime.
• First degree relatives of those with PD are 17x more likely to have PD than the general population
• 30% of people with PD abuse alcohol
• Twice as many woman as men have PD
• Most panic attacks start in the mid 20’s
• Proper treatment reduces or prevents panic attacks in 70-90% of cases
• 29-44% of those with PD also have Irritable Bowel Syndrome
• 43% of ER patients with chest pain actually have PD
• Panic patients may see an average of 10 doctors before a correct diagnosis is made
• 50% of those with PD will have clinical depression during their lifetime.
• PD is abnormal activation of the part of the brain called the amygdala

Cognitive behavioral therapy for Panic Disorder focuses on fears of bodily symptoms, catastrophic thinking, and avoidance behavior.  This is done by identifying specific ways in which the patient can reduce anxiety.

Cognitive restructuring - Identifying and countering fear of bodily sensations and focusing thoughts away from the negative consequences of such sensations.

Individuals with PD often have distortions in thinking that cause a cycle of fear.  When the person experiences physical symptoms, such as racing heart, they react with catastrophic thinking, e.g., “I’m having a heart attack”.  Cognitive restructuring helps the person to recognize thoughts and feelings and to modify their fear response to them.  By changing catastrophic thought patterns the person gains more control over the symptoms, e.g., “it’s only uneasiness and it will pass”.   

Breathing retraining - Learning how to use anxiety management techniques and lifestyle changes (see page 2) to control physiologic reactions.  

Exposure therapy - Helps the person accept and face some fear and anxiety in order to cope with phobic situations.  This is done by facing the feared situation and actually doing it.  The person must enter real world situations that cause anxiety, e.g., driving a car on the expressway. Exposure therapy requires considerable time and discipline from the patient.  Exposure exercises must be practiced routinely and monitoring must be continuous.  The patient has to be willing to confront the feared situations. It is easier to establish a hierarchy from the least to the most difficult task.  It’s ok to pause, breathe, and/or take medication, but then proceed.

Avoidance behavior makes panic disorder worse. Resist the urge to stop or avoid those things that trigger fear and/or physical symptoms

Desensitization - Occurs with persistence and practice.  This involves exposing the patient to fear cues, specific things or situations that trigger panic attacks.

Practice paced breathing

Proper breathing is very important for control of anxiety and panic.  It is also the best relaxation technique for control of nervousness and panic.  Underbreathing (slow/shallow) increases carbon dioxide retention.  This triggers the suffocation response in panic prone people, leading to compensatory overbreathing.  Conversely, overbreathing (hyperventilation) decreases carbon dioxide and causes feelings of depersonalization (feeling detached from oneself), dizziness, numbness, and confusion.

When anxious or tense, it is easier to breathe out first:

• Step one:  Slowly exhale through the open mouth making a “s h h h h” sound.  Listen to the sound, or feel muscles relax, letting go of tension.
• Step two:  Breathe in through the nose slowly, (mouth closed) and count, 1—2—3—4
• Step three:  Hold to count of  1—2—3—4    
• REPEAT STEPS

Find distractions

Focus attention on something outside yourself.  This might include listening to music, going for a walk, or calling a friend.

Use conditioned relaxation response

Make relaxation a part of daily routine.  Set aside time to practice your favorite relaxation activity.  This might be working out, playing sports, games, cards, movies, listening to music.  When relaxation is regularly practiced, the body forms a memory of what it feels like to be relaxed.  This memory is a tool you can use when you feel anxious.  Practice relaxing in anxiety provoking situations.

Panic patients listen too closely to body sensations, feel anxious, have “what if” thoughts, and scan their environment for possible danger.

Panic patients are always in a state of hypervigilance-most especially they listen to their bodies and they “hear everything”.  They can almost feel ions crossing membranes!  They release adrenaline, preparing for “fight or flight”.  The adrenaline revs them up and it snowballs-then they are having a panic attack!

• Xanax (Alprazolam)   

• Niravam (Alprazolam orally disintegrating tablets)

• Klonopin Wafers (Clonazepam)

• Ativan (Lorazepam)

A common question asked is “how much should I take?”  “Take enough, not too much.” 

This is like a firefighter calling headquarters and saying, “I have a grass fire starting here, how much water should I put on it?”   “Put out the fire.  Don’t flood the valley.”

Earl Campbell (football legend) was in his truck driving to Austin, Texas. He was stopped at a light in the small town of LaGrange. All of a sudden and for no reason he felt chest tightness, racing pulse, and shakiness. He panicked. He thought, “am I having a heart attack, dying, or going crazy”? This is a classic panic attack!

Panic attacks are physical reactions associated with an inappropriate adrenaline response in the body and excessive noradrenaline release in the brain. Though brief, they are terrifying, especially because they come on for no apparent reason or precipitating cause. Panic attacks can be thought of as a “false alarm” in the brain. There is some evidence that two types of panic attacks exist. One relates to hypersensitivity to increased CO and the other to hypersensitivity of the inner ear. Symptoms are acute and intense and vary for each individual. Agoraphobia is usually caused by panic attacks. What the agoraphobic fears is panic or panic related symptoms. He or she may begin to avoid certain situations because of panic attacks.

Although they come out of the blue, panic attacks are almost always preceded by increased stress within the recent few months. Stress includes any significant life change (good or bad), and any loss, as well as conflicts and life demands. The worst stress is associated with a feeling of being helpless to control factors that affect an individual’s life.

Stressors are cumulative and additive. Symptoms tend to occur when the amount of stress in life is greater than stress management (exercise, recreation, relaxing activities, laughter, positive relationships).

Treatment includes patient education, desensitization (behavioral techniques to reverse the phobic process), relaxation techniques (especially proper breathing), and cognitive training. Frequently medication is necessary to aid treatment, or used to shorten the treatment by accelerating the recovery process.

A panic attack is a “false alarm” in the brain. Our brains are hardwired to respond instantaneously, releasing everything we have physically and mentally in moments of crisis. Heroic stories of people lifting cars off of loved ones are examples of this.

In a panic attack we suddenly react physiologically, but there is no crisis. These attacks come “out of the blue.” Because there is no precipitating event, we wonder, “what’s wrong, am I dying, having a heart attack, or going crazy”?

Just as Pavlov conditioned dogs to salivate to a bell, a panic attack becomes conditioned to the environment in which the attack occurred. Anticipatory fear of having another attack can cause anxiety.

There is also a tendency to want to avoid or have great anxiety about situations or places where the panic attacks have occurred. Agoraphobia, or literally “fear of the market place,” is more specifically fear of panic attacks.