Jackie, a 26-year-old fictional patient, went to the ER by ambulance complaining of chest pain that started "out of the blue" while she was shopping. Her heart was racing and she felt dizzy and short of breath. She thought she was having a heart attack and she was certain she was going to die. Jackie was urgently assessed and after several tests she was given a clean bill of health. The ER doctor told her the episode was actually a panic attack and urged her to see her GP. Jackie felt embarrassed and dismissed. She told friends, "He thought it was all in my head but you can't just imagine chest pain like that. It was the worse experience of my life".
In the months that followed, Jackie experienced several more panic attacks. As a result, she stopped going to the grocery store and cancelled all but essential outings for fear of having another attack. She privately wondered if she was losing her mind.
Panic attacks are sudden episodes of intense anxiety that often involve physical and emotional symptoms. Physical symptoms include chest tightening or pain, sweating, a racing or pounding heart, numbness or tingling, shortness of breath, nausea, or dizziness. These symptoms are commonly misinterpreted as a serious medical emergency. Panicked individuals describe emotional symptoms including intense fear, racing thoughts, or confusion, and often say, "I felt like I was dying", "I had to escape" or "I felt like I was going crazy".
Panic attacks start suddenly and symptoms generally peak in about 10 minutes, after which they slowly abate. Panic is usually provoked by some sort of stress. Episodes can happen to otherwise healthy people who are in an unusually stressful situation. They are also associated with some medical conditions and certain street drugs are known to provoke panic attacks in vulnerable individuals. Panic attacks are commonly associated with another mental illness, like depression or bipolar disorder.
Patients with panic disorder experience repeated, unprovoked or unexpected panic attacks. For at least some of the panic attacks associated with panic disorder, patients describe feeling fine, even relaxed or asleep, just before a panic attack occurs and they are unable to identify any provocation.
Panic disorder is associated with anxiety that continues after the panic attack has resolved. Patients with panic disorder worry about having another attack or that they might lose control. Sometimes they fear they're suffering from a serious medical condition that hasn't been diagnosed. As a result, they change their behavior to avoid situations that might provoke another attack.
Panic disorder is sometimes associated with agoraphobia, which is a fear of being in places or situations that feel unsafe or where escape might be difficult. This can include using public transportation, enclosed spaces like a movie theatre, crowds, stores, and at its worst, anywhere but home.
Women are twice as likely to develop panic disorder, which usually starts in early adulthood. If Jackie was forty and had never previously had a panic attack, her attacks would more likely be associated with another mental illness, like depression, rather than the onset of panic disorder.
Jackie's comment that her first panic attack was the worse experience of her life might seem over the top to some readers, because we often underestimate the seriousness of anxiety. Anxiety is horrible. It is often more difficult to treat than depression and treatment might take longer to be effective. The presence of anxiety considerably increases the risk of suicide. Any mental illness becomes more challenging to treat and more deadly when it is associated with anxiety.
Because there are many potential causes of panic attacks, the first step in preventing future attacks is to discover the cause. When there is a clear provocation, like a personal crisis (e.g. loss of a loved one, divorce), panic attacks may stop when the stress resolves and no treatment is required.
Jackie's most likely diagnosis is panic disorder. Fortunately, there are several possible treatment options. There is very good scientific evidence that psychotherapy, especially cognitive-behavioural therapy (CBT), is an effective treatment. However, CBT is often costly and sometimes difficult to access. For the highly motivated, there are free online CBT programs.
If psychotherapy is not an option, antidepressants are also effective treatments for panic disorder and other types of anxiety. Fortunately, there are many antidepressant options available, because not every medication will work for every patient. We need to help each patient find the most effective, best tolerated treatment. The combination of CBT and medication is likely superior to using either treatment alone, and both CBT and psychotherapy may be augmented with exercise, meditation or yoga.
Unfortunately, both CBT and medication take time to work. Sometimes anti-anxiety medications, called benzodiazepines (e.g. lorazepam, clonazepam), are prescribed to treat panic attacks. These medications should not replace other treatments, but they can provide rapid relief. Benzodiazepines should be considered "band-aids", to be used for a short time while other treatments are given time to fix the underlying problem.
Once panic symptoms improve with CBT or an antidepressant, the anti-anxiety band-aid should be removed. Benzodiazepines should be prescribed at the lowest dose and for the shortest time possible. They must be used with caution or avoided in the elderly, those with a history of substance abuse and those prescribed opioid pain medications.
Like many people enduring panic attacks, Jackie didn't believe she would ever get better. Panic attacks were taking over her life. Even if your panic attacks have been going on for as long as you can remember, they are treatable. The first step is to see your doctor and ask for help. For more information, check out reputable websites (e.g. Anxiety Disorders Association of Canada and AnxietyBC).
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