Understanding Anxiety Attack Treatments

Meds Help for overcoming and stopping anxiety attacks

Once the signs of anxiety attacks are identified, supportive explanations, medication, and psychotherapy are all useful in reducing their intensity, frequency and hopefully, get rid of panic attacks all-together. 

What are anxiety attacks?

Anxiety attacks are sudden, unexpected bursts of extreme severe anxiety accompanied by at least four additional physical and/or cognitive panic signs and symptoms that include shortness of breath; palpitations, chest pain, or discomfort; dizziness or light-headedness; sweating; numbness and tingling; hot and cold flashes; abdominal discomfort or nausea; fear of dying, going crazy, or losing control; and feelings of depersonalization (feeling like a robot, out of one's body) or derealization (things look strange or unreal). Anxiety attack physical symptoms build to a peak within five to 10 minutes and subside more slowly over the next 30 to 60 minutes.

Individuals dealing with anxiety attacks often develop extreme anxiety disorder or apprehension about the possibility of future attacks, leaving them in a constant state of high anxiety and making it difficult for the clinicianto separate current anxiety from anxiety about future anxiety attacks. Individuals dealing with recurrent attacks may develop hypochondriacal concerns, fearing heart attack or stroke, or they may begin to avoid certain places, situations, and events that they feel are likely to bring on attacks, such as driving on highways, shopping in crowded stores, etc., an avoidance termed "agoraphobia." Coping with anxiety attacks accompanied by anticipatory anxiety, hypochondriasis, or agoraphobia indicate a diagnosis of panic disorder.

How frequently do anxiety attacks and panic disorder occur?

Several studies suggest that anxiety attacks are extremely common; an estimated 30 to 35 percent of the population has had a single anxiety attack.

Only one in 10 individuals -- about three percent of the population--who experiences a panic attack goes on to develop panic disorder. A single anxiety attack requires no intervention, but when anxiety attacks recur and produce additional effects of chronic apprehension, bodily preoccupation, or constriction of activity that affects the individual's day-to-day functioning, clinical intervention is required to help control anxiety attacks.

Like depression, panic disorder is twice as common in women as in men. It affects all ethnic and socioeconomic groups equally. Although onset at a later age is uncommon, panic disorder can occur in the elderly, both de novo and as a recurrence of panic disorder that appeared briefly and then disappeared years before. It is the most commonly encountered anxiety disorder seen in primary-care settings, affecting approximately eight percent of patients.

What is the key diagnosis of anxiety attacks?

The key element is awareness that patients rarely complain of anxiety attacks per se, deemphasizing the anxiety element and instead focusing on the physical manifestations of the attack. Common, disguised presentations of panic anxiety are chest pain with angiographically normal coronary arteries; "hyperventilation syndrome," an ill-defined entity that may be a variant of panic disorder; irritable bowel symptoms (IBS); unexplained dizziness; unexplained palpitations with no known cardiac pathology. In fact, any recurrent, paroxysmal burst of unexplained physical symptoms may represent a variant of panic disorder.

Recognition of panic with anxiety can be extremely difficult in individuals with additional bona fide medical conditions, such as angina or asthma. In these patients, superimposed panic can cause clinical deterioration of a previously well-controlled medical condition. Treatment limited to adjusting the previous medical regimen may be less helpful than treatment for anxiety attacks.

Are there other characteristics that help panic attack diagnosis?

The medical and psychiatric context of the anxiety attacks must be considered prior to confirming the diagnosis. Although most textbooks provide an exhaustive catalog of medical conditions that might produce panic attacks, including some rare endocrinopathies, the physician actually needs to consider fewer factors. Caffeine overuse is probably the most common contributing cause of severe panic attacks; it is infrequently the sole cause, but it can turn fairly mild panic disorder into a severe and debilitating panic attack. Abuse of stimulants, particularly cocaine, is another common cause of panic attacks and may result in persistent attacks that continue beyond cessation of cocaine use via a "kindling" or sensitization mechanism. Alcohol abuse is another common medical cause of attacks that occur when the effects of alcohol are wearing off, even in the absence of physiologic withdrawal, by the same kindlinglike mechanism. Over-the-counter pseudoephedrine stimulants may also contribute to panic attacks. Less common conditions that may cause panic attacks include hyperthyroidism, complex-partial or temporal-lobe epilepsy, and such car-diopulmonary events as pulmonary embolus or cardiac arrhythmia. These are all far more important and more often overlooked than such "zebras" as pheochromocytoma and carcinoid. Panic attacks may develop following a medical illness or event as a consequence of generalized physiologic stress, similar to the response to significant psychologie distress.

What to do when Anxiety Attacks

Deep breathing and visual concentration are great tips to stop panic attacks. Focus your attention elsewhere and know that it will eventually pass in a minute or two.

Are the causes of panic disorder known?

Panic disorder occurs in individuals who have a biologic vulnerability or predisposition to attacks and are exposed to excessive physiologic or psychologie stress due to medical illness, stressful life events, or interpersonal conflicts. The greatly increased rate of attacks in individuals with a family history of attacks and in monozygotic vs. dizygotic twins suggests a partial genetic component. The specific and unique vulnerability of panic patients to certain chemical substances reinforces this. However, the higher rate of stressful life events in recently diagnosed panic patients supports the importance of environmental triggers. In addition, characteristic cognitive distortions in patients who tend to view life events as catastrophic and overreact to threat suggest an important modifying effect for cognition and personality in mediating the effects of stress on the vulnerable individual.

Is there a biologic test for panic disorder?

Although research has shown that infusion of certain substances into panic attack patients can produce a panic attack--a response that is absent in patients free of panic attacks -- these procedures are both experimental and inferior to a good clinical diagnosis. Patients requesting them are usually looking for "proof" that their problem has a medical basis. The doctor can provide information to address this concern without resorting to experimentation.

Which psychological contexts are most likely to evoke anxiety attacks?

Attacks often occur against a background of accumulating psychosocial stress; careful inquiry about recent stressful life events or changes, as well as family or marital problems, is imperative. Panic attacks and panic disorder can be one component of a more serious psychiatric disturbance. One such example is borderline personality disorder (BPD), in which the patient has a history of poor impulse control, chaotic interpersonal relations, erratic function, and social adjustment, with marked instability of mood. In the extreme, such patients may be diagnosed as suffering from a dissociative disorder such as multiple personality.

Somatization disorder may also be related to anxiety attacks; these patients have a history since their young adulthood of multiple, unexplained somatic symptoms that prompt numerous medical visits and procedures, including surgeries, without demonstrating organic pathology. In both BPD and somatization disorder, exclusive focus on panic is not helpful. Treatment of the underlying disorder is likely to ease the panic attacks. Although antipanic therapy may and should be tried in these patients, the response is likely to be disappointing when it is the sole intervention.

The situation is similar with patients suffering from major mood disorders -- bipolar or, more commonly, unipolar -- who experience panic attacks. Focus must be on treating the mood disturbance along with the panic attacks.

Is physician counseling helpful?

A great solution for panic attacks is that brief cognitive-behavior therapy is extremely effective for panic disorder. But because it requires specialized training, this approach is often not practical in a busy medical setting. A supportive and educational approach that explains the disorder in clear, positive medical terms and helps the patient feel knowledgeable about and in some control of the disorder may provide some symptom relief. Unlike medication, there is no need to decide how long to continue or when to withdraw treatment. Some studies have suggested that relapse is less likely with this nonpharmacologic approach. Specific manuals are available for patients and physicians and appear in the "Read On" section at the end of this discussion.

Is psychotherapy appropriate for these patients?

Most psychiatrists believe that combining psychotherapy and medication may have special benefits, particularly in reducing the possibility of relapse once panic attack medication is discontinued. Only cognitive-behavior therapy has been shown in controlled treatment trials to be effective for coping with panic disorder. However, preliminary studies of interpersonal psychotherapy, an approach that tries to improve social and personal relationships, and psychodynamic psychotherapy, which helps the individual work out inner conflicts that create stress and tension, both show promise. The patient's preference is perhaps the strongest factor to consider in recommending psychotherapy. A patient who is disinterested in, or antagonistic to, therapy should not be cajoled or forced into it.

How should panic disorder be monitored?

Because panic disorder is a multifaceted syndrome, the combinations of overcoming panic attacks and other manifestations may vary. These include anticipatory anxiety, such as constant nervousness or fear that an attack will occur in its usually unexpected manner; phobic avoidance, often rationalized as "I just feel it's easier to shop when it's less crowded" or "I'm not rushed enough to have to drive on the freeway"; associated depression; and significant social and occupational disability resulting from the panic disorder. Some or all of these panic attack symptoms are likely to improve to varying degrees. An initial record of the salient symptoms and their degree is critically important. Without this, accurate monitoring is impossible. Because initial response to treatment is likely to be partial, quantification is crucial to allow both doctor and patient to know if they are on the right track.

I routinely employ a customized diary, asking patients to record the number, duration, and intensity (on a scale from 0 to 10) of panic attacks every evening before retiring, as well as the intensity of other chronic symptoms (anxiety, depression) on a similar scale. Patients with prominent target symptoms, such as chest pain or palpitations, can record these anxiety symptoms, using an overall daily rating, as well as more intermittent episodes.

What is the optimal anxiety attack treatment?

The two broad classes of effective treatment for panic attacks are pharmacotherapy and brief cognitive-behavioral therapy. Antidepressant pharmacotherapy is the mainstay of medical treatment to overcome panic attacks. Although tricyclic antidepressants are the most extensively studied compounds for controlling panic attacks, the newer selective serotonin reuptake inhibitors (SSRIs) are showing promise. The ease of administration, lower side-effect profile, and reported efficacy of Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine) have made them the treatment of choice of many psychiatrists who specialize in treating these disorders. To avoid initial over stimulation of the patient, which also occurs with tricyclies, the patient should start with lower doses of the SSRIs: 5 mg Prozac, 25 mg Zoloft, or 10 mg Paxil. Doses are then titrated to 10-20 mg Prozac, 50-100 mg Zoloft, or 20 mg Paxil over a one- to two-week period. Medication is taken in the morning; common side effects include gastrointestinal upset/nausea, agitation/restlessness, or insomnia. For patients with a sleep problem, the addition of a hypnotic such as Desyrel (trazodone) 50-150 mg may be necessary in the short run. For these patients, it may be advisable to select as primary treatment the more sedating tricyclic anti-depressants. Pamelor (nortriptyline) 10 mg at bedtime, with 10-mg increases every two to three days to 50 mg and then 25-mg increases every two to three days to 75-125 mg, is a good choice. Tofranil (imipramine) can also be used but must be titrated to 200-250 mg to be effective. In the case of all antidepressants, full response may take eight to 10 weeks; doctor and patient should not abandon therapy prematurely.

Aren't the benzodiazepines the only approved drug for panic disorder?

Because earlier antidepressants were off patent and there was no incentive for drug companies to spend millions of dollars for a new indication, Xanax (alprazolam) is the only drug approved by the FDA for treatment of panic disorder. An estimated 20 to 30 percent of panic patients may be non-responsive to or intolerant of antide-pressants. Many are unwilling to take monoamine oxidase inhibitors (MAOIs) because of exaggerated concerns about dietary interactions and the risk of hypertensive crisis and stroke. If these patients have no history of chemical dependency, ben-zodiazepines are a safe and effective treatment. Over the long term, patients tend toward lower, rather than higher, doses, with no loss of effect. Benzodiazepines are also justified as a first-line treatment for a panic patient in acute crisis who requires resolution of symptoms within days and is at risk for social or operational dysfunction if required to wait weeks for a therapeutic antipanic effect.

The two most commonly used benzodiazepines are alprazolam and Klonopin (clonazepam). Clonazepam is about 1.5 to two times more potent than alprazolam. A starting dose of 0.25-0.50 mg alprazolam three to four times daily is reasonable. A total daily dose of 2-6 mg will suffice for most patients. Psychiatric consultation should be obtained before allowing patients to take more than 6 mg per day, despite the fact that up to 10 mg is the largest FDA-approved dose. Patients must be carefully assessed for excess sedation. Psychomotor and cognitive impairment, which are usually dose-dependent, can be controlled without loss of anxiolytic efficacy, except in some elderly patients. During tapered discontinuance of these medications, there may be a time-limited increase in anxiety symptoms (Figure 2). However, a very slow taper, accomplished over three months, may result in an increase in symptoms in fewer than 10 percent of patients.

Is there a role for MAOI antide-pressants meds?

Prior to the introduction of SSRIs, MAOIs were the major alternative to tricyclic antidepressants. Patients unresponsive to tricyclics and those not responsive to other medications often responded quite well to MAOIs, giving these agents areputation for being especially effective in treatment-resistant patients. Phenelzine is the best-studied agent. It should be given in a dose of 1 mg/kg. Starting doses of 15-30 mg daily can be rapidly titrated to 60 mg within the first week. Most or all of the total 60-to 90-mg dose can be given in the morning to avoid insomnia.

How long should panic attack medicine be continued?

Recent evidence suggests that panic attack medications should be continued for at least six months. Relapse occurs in from 30 to 50 percent of patients, although rates vary because studies differ in their definition of recurrence: Some studies classify mild residual anxiety symptoms not interfering with function as recurrence of panic, while other studies do not. One recent study showed markedly lower relapse rates when medication was continued for 18 months vs. six months, supporting an advantage of longer-term treatment. Some studies indicate that relapse rates may be higher when benzodiazepines, as opposed to anti-depressants, are discontinued. This could reflect the withdrawal syndrome that often occurs and, though time-limited, may reinitiate panic symptoms. However, it may also reflect a symmetry between speed of onset and offset of therapeutic effect; relapse rates are higher in the first few weeks for benzodiazepines, but an increase in relapse rates over time in antidepressant-treated patients suggests that at three to six months, the relapse rates may be more comparable. Finally, medication should not be discontinued during times of high stress in the patient's life.