Dr Robert London

Panic Disorder Patients Need Us

Clinical Psychiatry News - Volume 36, Issue 3, Page 29 (March 2008)

After feeling chest tightness, shortness of breath, and dizziness, the patient got herself to an emergency department. While waiting to be seen, she experienced profuse sweating that was accompanied by shaking, tingling, and a sense of impending doom. Could this be a heart attack? Is she dying?

After more than 25 years of experience, cardiologist Dr. Edwin Weiss of the New York University Medical Center knows that some of these patients are suffering from panic disorder—a severe type of anxiety disorder.

In the few cases in which patients have good insight and no other comorbid psychiatric disorders, Dr. Weiss offers a quick treatment that simulates the light-headedness and dizziness of panic disorder. “Under my supervision, I have them blow in and out of a paper bag, and under their control, they experience the lightheadedness and dizziness. That shows them that they can be in control of the attack, rather than letting the attack be in control of them. For some, this is very helpful,” Dr. Weiss, who has a vibrant practice in New York, said in an interview.

But Dr. Weiss also refers many patients to psychiatrists. “That's what I consider good medical care,” he said.

In the 1980s and through the 1990s, “panic disorder” almost became a household term, and more people identified their own symptoms and sought out help, as they do now.

According to a literature review published a few years ago, 30% of emergency room patients with chest pain, after a work-up for coronary artery disease, were diagnosed with a panic disorder (Can. J. Psychiatry 2003;48:361–6). Ninety-eight percent of these panic disorder patients were undiagnosed when first evaluated. Clearly, specialty training and experience are needed to recognize and treat this disorder.

Managed care insurers would prefer to see these patients treated on the cheap by primary care physicians, but primary care physicians have enough on their hands without treating psychiatric illnesses. Also, primary care physicians are too quick to offer these patients medical management alone since they don't have the training or time for in-depth evaluations or are not equipped to do adequate treatment.

Medication can help greatly, but I believe that some therapeutic efficacy was lost when tricyclic antidepressants were replaced by the safer selective serotonin reuptake inhibitors. Furthermore, it has become clear to me that the anticipatory anxiety, which can be worse than the panic attack, can be helped with behavior modification and that starting a patient on benzodiazepines is sometimes unnecessary.

I have been treating patients with panic disorder for more than 30 years. In the early days, I prescribed imipramine for the panic and a benzodiazepine such as Librium (chlordiazepoxide) or Valium (diazepam) for 2–3 weeks to help patients cope with the anticipatory anxiety that occurred before the imipramine became effective. Both behavior modification alone and medications alone appeared effective. I have found that the combination of medication and behavior modification often works best, but many patients resist medication, or if they take it they don't like the side effects, so they can certainly reap great benefit from behavioral therapies alone in treating their panic disorder.

The learning, philosophizing, and action (LPA) technique has become a mainstay of my treatment. Learning about the disorder with a patient who has seen doctors other than psychiatrists and visited emergency departments for their symptoms is a great advantage because they have been given a clean bill of health. A cognitive challenge can be presented in the form of possibilities and probabilities, in which, over and over, we can review that almost anything is possible. The question becomes: What are the probabilities of dying or going crazy?

After going through several examples in my cognitive challenge—from the absurd (it's possible the sun won't come up tomorrow) to the less intense—I ask the patient to develop her own sets of possibilities and probabilities. At the end of her sets of examples, I prefer to have her end with a defining set that centers around the overwhelming anxiety that permeates her thinking in anticipation of a panic attack.

As automatic thoughts of anxiety and panic are explored in a newer perspective from the patient's own thinking, it appears that a desensitization process occurs. Together, we learn how to challenge thoughts of terror when there is none. We can philosophize about the origins of panic disorder, from a learned experience to a genetic loading, and sometimes just talking about it is helpful. Beware of slipping into the traditional weekly open-ended psychotherapy that gets to a lot of issues but sometimes fails to address what the patient wants treated.

In addition to this cognitive restructuring, I spend three or four visits with the patient beginning a relaxation/behavior modification program using relaxation, systematic desensitization, and reciprocal inhibition. Again, I am comfortable using the split-screen technique with visualization of anxiety, fear, and panic on the left side of the screen and a pleasant relaxing set of experiences on the right side.

The patient learns this technique, practices, and often becomes the master of the disorder. As I develop the strategy for panic attack treatment and resolution, I incorporate the same strategies for those who also suffer concurrently from agoraphobia, using possibilities and probabilities as well as the imagery and hierarchy of stressors on the split-screen technique. The cognitive dialogue and behavioral techniques I use have proven successful in my work.

Other approaches are worth discussing. For example, Dr. Iraida Kazachkova, a psychiatrist at Lutheran Medical Center and the Jewish Board of Family and Children Services, prefers a more focused, highly structured method to achieve the same results through cognitive restructuring desensitization and flooding.

Dr. Kazachkova would ask the patient: What time does the panic attack occur? What did you feel? What were your physical and emotional symptoms?

For example, if the patient says, “I feel like I'm choking and dying, and I must be going crazy,” through a dialectic, Dr. Kazachkova will go back and forth with these three types of questions, creating a dialogue that revisits the panic episode and the anxiety that is felt in anticipation of this attack. Many of these panic attacks will come paradoxically, so the ongoing repetitive dialogue is very important for success.

She uses a series of maneuvers in increasing and decreasing the intensity of the patient reliving the terror as these three questions get reworked with a variety of new answers leading to newer responses. She says that the flooding, desensitization, and cognitive challenges, set up in a dialogue and sometimes including material that is written down in preparation for a visit, are very effective in clarifying what cognitions need to be challenged.

This cognitive restructuring is aimed at helping the patient develop a coping mechanism in which the signs and symptoms mean less and less as newer types of thinking replace the fearful thoughts and terrifying physical symptoms. The anxiety, if it occurs, simply passes. This allows the patient to separate from any bodily symptoms that might occur.

This type of treatment, whether it uses my LPA technique or Dr. Kazachkova's dialectical method, requires hard, focused work on the part of the therapist. The aim of treatment is to resolve the panic disorder by thinking about it, challenging it, and bringing new thoughts and a new reality into one's own perception of the panic situation. The goal is not to drift away in some form of traditional psychodynamically oriented form of psychotherapy.

Many types of behavioral approaches to treating panic disorders do work. Finding one that fits you and your patient is an important part of therapeutic success.

Panic disorder treatment belongs in the mental health area of practice. More anxiety disorders programs need to part of hospital psychiatry programs so that these potential patients can get the care they need.

Let me know your thoughts and techniques on treating panic disorder, and I will try to pass them along to my readers.

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