is a 41 year old lawyer. Recently, while visiting relatives in upstate
New York, he awoke from his sleep in a state of panic. His heart
was pounding and he was experiencing chest pain. "I was convinced
I was having a heart attack!" Bob's family rushed him to the
local hospital where he was seen immediately in the emergency room.
After several tests the physician concluded that Bob was in perfect
health. Bob was both relieved and perplexed: "But what caused
the symptoms I experienced?" "That was just a nervous attack" said
the physician, "just go home and relax." Uneasily, Bob
left the hospital. He felt fine for two days. But while Bob was packing
his car to return home, his heart suddenly began pounding and racing,
he was experiencing severe chest pain, and could barely catch his
breath. Bob ran inside to get his wife: "I know I'm having a
heart attack - the doctor must have missed something in the emergency
room the other night!" Once again they rushed off to the emergency
room. A different physician was present this time. He repeated all
of the tests done two days before. After reviewing the test results
the physician concluded that Bob was in perfect health. Bob could
only wonder, "What is causing these symptoms?"
term panic attack was officially described by the American Psychiatric
Association's classification system -- the DSM -- in 1980. Panic
attacks are "discrete periods of intense fear or discomfort....
often there is a feeling of impending doom." At the very least,
the first attack occurs unexpectedly--that is to say, it is not necessarily
triggered by a situation which would cause one to experience anxiety.
In addition, the DSM definition of panic requires the presence of
at least four of the following symptoms (shortness of breath, dizziness,
faintness, palpitations, trembling or shaking, choking, nausea, depersonalization,
numbness or tingling sensations, flushes or chills, chest pain, fear
of dying, fear of going crazy or of doing something uncontrolled).
Thus, panic attacks can be best characterized as a sudden burst of
intense fear accompanied by uncomfortable and uncontrollable physical
sensations. Typically, the attacks appear to be spontaneous when
their first occur. However, overtime, the attacks become associated
with various situations that can eventually provoke the attacks.
is Panic Disorder?
Disorder is the official name listed in the DSM for the disorder
patients suffer from repeated panic attacks. In addition to panic
attacks, most patients with panic disorder often experience agoraphobia
as well. Agoraphobia refers to the fear of going into certain situations
because it may trigger a panic attack. This is often the most disabling
part of the disorder, as it can greatly reduce one's ability to function.
Common agoraphobia situations include shopping malls, bridges, elevators,
planes, driving long distances, being at home alone, tunnels, buses/trains,
and traveling a significant distance away from home. The level of
agoraphobia in panic disorder patients is quite variable, and even
fluctuates from time to time within an individual. Some patients
are unable to leave their own home, others are able to leave home
and hold a job but avoid many situations, and still others are frightened
of many situations but do not avoid them.
In addition to panic disorder attacks and agoraphobia, patients
with panic disorder often suffer from chronic anxiety and depression.
chronic anxiety is often related to the feeling that the attacks can
happen at anytime, so patients become constantly on edge, waiting for
the next attack to occur. Ironically, a patient will often "talk" him
or herself into a panic attack just by worrying about it. The depression
is often related to the feeling that his or her life is not going to
get back to "normal." Patients often become sad, hopeless
about the future, and suffer a loss of self-esteem.
" I know there is something physically wrong
is the single most widely held belief by people who suffer from panic
attacks, especially when the attacks first begin. Since panic attacks
are composed of physical sensations, it is logical that patients
believe there is a physical disturbance. Indeed, patients will go
from doctor to doctor attempting to find an explanation of their
symptoms. And despite the doctors reassurance that he or she is in
good health, the patient continues to believe that something is being
missed. Surprisingly, many panic disorder patients have told me that
they wish that someone would find something wrong with them. What
would cause a person to actually hope for a physical problem to be
found? It is because the unknown is very frightening and people will
imagine the worst. In my own practice, I have found that in almost
all cases, telling panic disorder patients that there are many other
people who complain of a similar problem; and providing an explanation
about panic attacks, puts their mind at ease and results in their
feeling somewhat better.
It is important to note that research does not suggest
that panic attacks are caused by a disease or physical
illness. It appears as though some
people have a nervous system that reacts a bit more to stress. Many
panic patients have their first attack during a period of chronic stress.
Panic attacks may be the result of interpreting harmless physical sensations
-- which and be very uncomfortable -- as being dangerous. Among the
most common thoughts are: "I am having a heart attack," "I
am going to faint or pass out," "I am going to lose control," "I
am going to go crazy!" Having these thoughts will actually worsen
What is Cognitive Behavior Therapy?
Behavior Therapy (CBT) for panic disorder is a psychological treatment
approach primarily developed by Dr. David Barlow at the Center for
Anxiety Disorders in Boston, and by Dr. Aaron Beck at the Center
for Cognitive Therapy, University of Pennsylvania School of Medicine,
in Philadelphia. CBT is as effective as state-of-the-art medications
in treating panic disorder.
CBT consists of the following components, each which
will be described briefly:
4. Relaxation Exercises
6. Interoceptive Exposure.
component is aimed at alleviating panic attacks, agoraphobic avoidance,
chronic anxiety, and depression
panic disorder (note:
clinician's may apply only those techniques that
they determine are relevant to your problem).
Throughout treatment, patients are educated about
panic attacks and the development of panic disorder.
panic disorder is
believed to be an important part of the recovery
Cognitive restructuring, a major
part of the treatment, is intended to correct distorted
thinking about panic attacks. The
goal is to have patients change their reaction to their emotional arousal
and panic symptoms, and learn to deal effectively with anxiety provoking
situations. During the early sessions of therapy, patients are asked
to self-monitor their thoughts, assumptions, and beliefs during anxiety
provoking situations and panic attacks. With the collaboration of the
therapist, patients begin to appreciate the role of cognition, beliefs,
and appraisals in the evocation or accentuation of anxiety and panic
attacks. During the later sessions, patients are taught to re-evaluate
the validity of these distorted thoughts, and change them to more rational,
adaptive ones. In particular, patients' "catastrophic misinterpretations" of
panic-related somatic cues -- the belief that these physical sensations
are a sign that he or she is dying at that moment -- are addressed.
Patients will repeatedly challenge their dysfunctional thoughts during
Breathing training teaches patients
a pattern of slow, regular breathing which prevents
an uncomfortable symptom of and cue
for panic attacks.
Relaxation exercises that involve
progressive muscle tension are often incorporated
to lower general anxiety
Situational exposure consists
of structured and repeated exposure to anxiety
- and panic provoking ("phobic") situations.
Based on the patient's individualized list of feared
situations, he or she
undergoes exposure to these situations while using
coping strategies learned during therapy, beginning
with the least feared and
moving to the most feared. This typically takes
place later on during
once a patient feels more in control of panic attacks.
The aim of situational exposure is to eliminate
When necessary, Interoceptive exposure may
be conducted. Interoceptive exposure involves the
repeated exposure to panic-like
physical sensations. Based on the patient's individualized
hierarchy of feared internal sensations (e.g.,
he or she undergoes systematic exposure to these
sensations. The feared sensations
may be produced using idiosyncratic methods such
as controlled hyperventilation or physical exertion
up a flight of stairs to get your
heart racing). This is necessary because patient's
often become fearful of harmless body sensations,
such as those
caused by exercise,
following books are recommended:
Peace from Nervous Suffering by Clare Weekes (Hawthorne,
Don't Panic: Taking
Control of Anxiety Attacks by
Reid Wilson (Harper & Row,