Managing Panic Attacks

Coping & Curing

A panic attack may occur out of the blue, or against a background of ongoing anxiety. The sufferer will be restless, agitated and wide-eyed. 

Hyperventilation may occur. Over-breathing reduces blood levels of carbon dioxide, causing alkalosis. This causes spontaneous discharge of the peripheral nerves, resulting in tetany and paraesthesiae in the motor and sensory nerves respectively. The tetany leads to breathlessness and a crushing chest pain, and the sensory involvement causes the 'pins and needles' sensation.

Apart from the agitation and the sense of urgency that the patient imparts and possibly tachycardia there is little else to find on clinical examination. In a calm and unhurried manner, check the patient's pulse and listen to their heart and lungs. In the breathless, a peak flow reading is helpful.

An attack of panic or hyperventilation is physiologically very demanding and cannot be sustained for more than a few minutes. Treatments for the acute episode are therefore of limited use as even an intravenous injection of a tranquilliser will take several minutes to work. The air of cairn and confidence imparted by the GP is probably the most effective remedy.

Benzodiazepines are useful in acute anxiety, work quickly, have few somatic side-effects, and are relatively safe in overdosage. Diazepam 5-10 mg three times a day for 2-3 days is about right, although it is best to use the smallest effective dose.

Specific techniques can be taught to patients who experience repeated episodes of acute panic. Breathing into and out of a paper bag restores the blood levels of carbon dioxide and so reduces the symptoms of panic.

Control of the breathing pattern to reduce overbreathing can also help, although controlled trials of respiration techniques have yielded disappointing results. A brief expenditure of physical energy can also be of benefit, probably employing the effects of distraction and endorphin release.

Another distraction technique is to encourage the patient to stand on one leg the concentration on balance provides the distraction.

The re-attribution approach encourages patients to deliberately overbreath so that they can realise for themselves that overbreathing produces symptoms.

When the attack has passed, a more detailed diagnosis can be established. Since treatment will tend to be prolonged, and will require insight and co-operation by the patient, this may safely be left to an early follow-up appointment.

Where a diagnosis of panic disorder is made, SSRIs and the TCA imipramine are beneficial. The hazards of long term benzodiazepine use probably outweigh the benefits. Cognitive therapy helps.

Treatment of panic disorder

* 87% of patients improve after 15 weekly sessions of cognitive
therapy
* 50% improve on benzodiazepine
* 36% improve on placebo

The term panic disorder excludes panic attacks attributable to the direct physiological effects of a general medical condition, substance, or another mental disorder.

practical points

    * Anxiety and panic are very common. Most cases do not come to medical attention.
    * A panic attack can be very alarming, and may prompt attendance at an A&E department.
    * A panic attack may occur out of the blue, or against a background of ongoing anxiety.
    * Medication, especially some antidepressants, is of proven benefit in GAD and panic disorder, but is not acceptable to all patients.
    * Buspirone (Buspar) has proven effectiveness in GAD at least in the short term.
    * Talking treatments, family help and especially cognitive behavioural therapy, are the treatments of choice in anxiety panic disorders but they do not suit all patients