Panic Disorder : Context Not the Cause, Drugs May Help

by Food and Drug Administration (FDA)

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Context Not the Cause

In trying to come up with an answer, he says, people may misattribute the cause of the attacks to the context in which they occurred. For example, if someone has an attack while driving a car, that person may begin to believe there is something about driving — or about their destination — that causes the panic attack. This often leads to development of agoraphobia, a condition in which the person begins to avoid places where they fear a panic attack may occur. They may develop a fear of bridges, tunnels, shopping malls, grocery stores, or travel by public transportation, for example.

"What really underlies the fear is whether or not they'll be in a place or situation that is safe and where they can get immediate help in the case of a sudden or unexpected panic attack," says Uhde. "These patients have an increasingly constricted lifestyle. Ultimately, they can become homebound and, in some cases, patients may become totally constricted to a room within their house." Approximately one-third of patients with panic disorder develop agoraphobia, although there is no way to predict whether or not it will develop in a particular patient.

Griffith stopped going on business trips because, she says, "I had experienced enough of the 'heart jumping' thing that I thought, 'I don't want to be that far away from home. I don't want to be in a strange hotel room somewhere and have this happen to me.'" She also stopped eating at restaurants for a time, because she initially thought the attacks might have been related to eating out. "I would go out to dinner and have a sense of my heart skipping or start to get flushed and, because I was trying to diagnose myself, it seemed to me that it happened frequently when I went out to dinner. So I thought it might be spices or something in the food." ther disorders and diagnosis is often elusive. According to the NIH panel, many patients see 10 or more doctors before being accurately diagnosed.

Bad Nights

Menter's attacks began in 1981, when she was 20 years old. They occurred about twice a month. At first, she simply attributed them to "bad nights" or bad nightmares, even though she now says she knew they weren't nightmares.

"A nightmare is a story, a bad dream," she says. "When you wake up from a nightmare, you know the source of your fears. It's easy to examine it and reason it away. It's more abstract. A panic attack is just a sensation with no context. They're so real, and they can't be reasoned away."

Over time, Menter's attacks came more frequently, and finally, after two years of having attacks every night, she went to the doctor. He prescribed a low dose of the benzodiazepine alprazolam (Xanax) to relieve stress, but the medication didn't seem to help. Menter didn't seek help again until three years later when, in late 1989, she heard Uhde discussing sleep panic attacks in a radio interview.

"I was just stunned that somebody was describing what I thought I had exclusively all to myself," she says. "That was the major step — identifying it — because at that time I was almost convinced that I was just crazy. Finally, I could stick a label to it."

She called the National Institute of Mental Health in Bethesda, Md., the next day and entered a research program on panic disorder.

Drugs May Help

Treatment is not clear-cut; it must be tailored to the individual, taking into account the patient's history, other medical and psychological conditions, and degree of impact of the disorder on the patient's life.

Only one drug, alprazolam (Xanax), has been approved by FDA for treating panic disorder. Originally approved by the agency in 1981 to treat anxiety, alprazolam received approval for this new indication in November 1990. Side effects include drowsiness and lightheadedness, but the most serious risk is dependence.

"Withdrawal symptoms are common in patients who are trying to come off Xanax," says Thomas Laughren, M.D., of FDA's division of neuropharmacological drug products. "The risk of dependence and its severity appear to be greater in patients treated with relatively high doses [above 4 milligrams per day] and for longer periods of time [more than 8 to 12 weeks]. A higher dose may be an especially important predictor of the development of physical dependence."

Because dosages of more than 4 milligrams per day are often required in treating panic disorder, the risk of dependence among these patients may be greater than in those taking the drug at lower doses for less severe anxiety. The drug's labeling carries a warning about the risk of dependence and provides recommendations for initial dosing and increasing the dose in specific increments at specific intervals until therapeutic levels are achieved.

Other drugs have been reported to help reduce or eliminate panic attacks; however, FDA has not received any well-controlled studies to review them for this use. They include tricyclic antidepressants, such as imipramine (Tofranil), and monoamine oxidase (MAO) inhibitor antidepressants, such as phenelzine (Nardil).

While the tricyclics have no risk of dependence, they can cause a variety of adverse side effects, including low blood pressure, abnormal heart rhythms, weight gain, tremors, and seizures. Patients with certain heart problems, urinary retention, narrow-angle glaucoma, and other medical conditions should not take these drugs.

MAO inhibitors have also been used and also carry a low risk of dependence. Their side effects include low blood pressure, sexual dysfunction, and weight gain. In addition, patients on these drugs must follow a diet low in tyramine. This means avoiding high-protein foods that have been aged, fermented, pickled, or smoked, including cheeses, beer, wine, liver, salami, and yogurt.

About the Author

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