Professor Jim Lucey, Medical Director at St. Patrick's University Hospital was a recent guest on RTE Radio 1's Today with Pat Kenny show where he spoke about Panic Disorder and therapies. Listen to the podcast or read his blog below
A recent revelation from former President Mary Robinson that she experienced panic attacks at particularly stressful times during her presidency raised the profile of this condition in the public arena. There was even some commentary from columnists that panic was not a disorder, it was stated “that panic is simply to be alive”.
Is panic anxiety or panic disorder a normal part of living or a disabling condition which should be acknowledged and addressed?
Everybody experiences anxiety from time to time in life and some situations are likely to be more anxiety provoking than others. A person who is experiencing a trauma or a loss or sometimes the hazards of everyday living will feel intense anxiety perfectly normally. Indeed anxiety is a part of normal life and is an essential feature of the body’s natural warning system. Anxiety experiences prepare us to take fright and to prepare for fight and if necessary to take flight. Without the early warning system of anxiety we would be defenceless as a species.
When we experience anxiety we have a number of experiences which are caused by the outpouring of the adrenalin response to stress. Chemical messages from the brain cause our hearts to pound with so called palpitations or accelerated heartbeat. We also sweat and can tremble and shake. Many people experience sensations of shortness of breath or the feeling of choking, smothering, or even chest pain or discomfort. Some people experience nausea or abdominal distress during anxiety while others are dizzy with unsteady lightheaded feelings of faintness. Some people have a fear of losing control or going crazy and others may feel that the world has become unreal and that they are no longer attached to their real self. Others have sensations of pins and needles, chills or hot flushes. At its worst, anxiety can make one have a fear that one is going to die immediately. When these anxiety experiences appear in a cluster and in a crescendo lasting for more than 10 minutes and without provocation, we call this a panic attack.
The essential features of panic disorder is the presence of recurrent unexpected panic attacks, occurring without provocation and followed by one month of persistent concern about having another panic attack. Worry about the possible implications of these attacks or a significant behavioural change is also important, such behavioural changes include a tendency to avoidance or a change of pattern of living in order to prepare for or reduce the likelihood of another panic attack.
Why is it not part of living to experience panic? The truth is that the lifetime rate for panic disorder ranges for about 1.6% to about 4.7% of the population. Up to a quarter of the population will have isolated panic attacks. Women are more likely to develop panic attacks with agoraphobia, a tendency to avoid busy shops or crowded places. At least 9/10 people with panic disorder have developed at least one other mental health problem in their lifetime. Agoraphobia is 20 times more common amongst individuals with panic disorder than amongst those without it.
It seems hard to argue that this kind of limitation is part of normal living. Unfortunately those who have a greater frequency of attacks or attacks which are more persistent are more likely to have depression or other anxiety disorders. These people are more likely to be impaired in their social or personal life or in their work life and they are more likely to have suicidal episodes. Happily about 30% of patients with panic disorder remit without subsequent relapses over the next 5 years, whereby 25% of people have a waxing and waning course and nearly 45% of people who with this level of anxiety have an unremitting course unless treated.
There are many factors in the causation of panic disorder. Perhaps 40% of the risk is from genetic background. Newer imaging studies, studies looking at the brain show reduced volumes in certain key areas of the brain in people with panic disorder. These areas such as the amygdala and the temporal lobe are known to be associated with the anxiety responses. Certain key traumatic experiences in childhood are also associated with the development of anxiety later on in life; these include sexual and physical abuse of children. The highest association is between women who have experienced sexual abuse and panic disorder. The anxious temperament and a characteristic sensitivity to life event are also risk factors. This includes a tendency to worry that the panic itself may cause physical social or psychological consequences beyond discomfort of the panic attack.
Whereas anxiety is a normal emotional state when it occurs in response to an impending identifiable danger. Anxiety disorder is a state of chronic apprehension about future harm, particularly when in response to an unknown threat or when the source of the anxiety is internal or vague. This is characterised by tension, worry, negative mood and a feeling of insecurity.
Should it be treated and if so how do people know whether they are getting the right treatment?
The aim of treatment for panic disorder is not only to prevent further panic attacks but also to reduce or eliminate the associated anxiety which arises out of anticipation as well as the avoidance which arises from phobic fear. Treatment also helps to reduce the risk of comorbid conditions, such as depression or substance dependence.
The common treatments for panic disorder include: psychotherapy that is to say the talking treatment or medication, most typically with Serotonin re-uptake inhibitors.
Psychotherapy is essentially a conversation which involves listening to and talking with those experiencing mental health difficulties. The aim is to help understanding and to resolve the predicament. Clearly it is a broad term which is used to describe many modes of treatment ranging from psycho-analytical movements of Freud and his colleagues to the modern cognitive behavioural therapies based on learning theory.
Psychologists have described a number of features that are common to all of the psychotherapies; these include an intense emotionally charged relationship with a person who is experiencing mental health difficulty. This is associated with a rational for explaining the distress and with methods for dealing with that distress. There is a provision of new information about the future and the source of the problem and possible alternatives that hold a sense of hope or relief. There is also a non-specific method of boosting self-esteem, the provision of success experiences and the tolerance of emotional distress. Typically the therapy must be available, accessible, affordable and likable. The location for the therapy is recognised as a place of healing.
When somebody goes for psychotherapy they can expect a certain setting and a certain atmosphere of quiet. Ideally therapy takes place in a room with a therapist and the patient either facing each other or sometimes at an angle. In practice the patient lying on the couch is the traditional image in psychotherapy is seldom used. More formal psychoanalysts tend to avoid direct questioning or reassurance or even polite chatter, however more eclectic therapists encourage an engagement which is relaxing and positive.
Modern therapies known as the cognitive or behavioural therapies have a number of broad common features. Problems are seen as based on that maladaptive thoughts and behaviours which are learned and therefore can be unlearned. The primary interest of the therapy is in the here and now and of observable problems being addressed. There is a focus on measurable operationally defined problems with targets and goals. The therapy is structured and focused on directive sessions. There is a collaborate approach in which both the therapist and the sufferer work together towards agreed shared agendas. There is a use of self-monitoring and self-help assignments between the sessions and the evaluation of the treatment and his efficacy is agreed between both parties.
The clinical example is provided by Dr. Stirling Moorey who is a Senior Consultant Psychiatrist at the Maudsley and a Cognitive Behavioural Therapist. He describes this case of Philippa who is a 35 year old clerical worker with an 8 year history of panic and agoraphobia. Philippa was unable to use public transport or to walk any distance alone. Her coping strategy was to ride everywhere on her bike, but she could only do this during the daylight. She had 2 to 3 panic attacks per week and she felt pessimistic about the effectiveness about any therapy. She had been treated for 5 years in the past by an analytical psychotherapist and she reported little or no improvement with her symptoms of panic and avoidance. Philippa was a daughter of a man with alcoholism. She had witnessed her father acting in an uncontrolled and sometimes aggressive fashion. She felt that the family pretended that her father did not have any problems and had kept it secret from the world. She was brought up in a strict religious family but was no longer a religious person herself.
By asking questions about her symptoms and reducing some of the panic feelings in the session through imagery, the therapist was able to map the interactions between the thoughts and feelings and behaviours that she was experiencing. During a panic attack, she started to feel out of control as she became more and more anxious. She feared that she would suddenly start crying in public resulting in people rejecting her or even worse taking pity and trying to help her.
At the height of her panic she would have an image or herself as a mad woman lying on the floor flailing about and moaning. As therapy progressed she revealed that her sister had bipolar mood disorder and she feared that she too might become “mad”. She had not told her previous therapist this for fear of what they would think. She was living with her sister some years before when her sister had her first manic episode. Having seen her sister lose control and be admitted to hospital voluntarily she thought that this might happen to her. Whenever she got panic symptoms she interpreted the anxiety as meaning impending loss of control and she felt that a catastrophe would happen and the catastrophe would be that she would go mad and would be forcefully detained.
The initial phase of therapy was concentrated on listening to Philippa’s story, at the same time she was introduced to the ideas and structures of therapy and the idea of homework and assignments and self-help. An alternative picture or reasoning for her problems was offered. The basic ideas to get across at this stage was that thoughts are not reality. Therapy is about clearing a space to examine thoughts and beliefs to see if they are realistic or helpful. In the first session problems are defined and the patient’s goals for therapy are established. Behavioural techniques are used to test out negative thoughts with a view to initial symptom management. When patients present with depression, it is sometimes useful to give a schedule of activities to give a sense of mastery over life or to introduce pleasure with graded tasks to help patients achieve success step by step.
In anxiety relaxation or distraction may be taught, the aim of the cognitive therapist is to decrease the frequency of negative thinking and thus to improve symptoms.
Later on in therapy sessions, the idea of thinking errors is introduced, to remember well known errors of thinking such as
The final stages of therapy deal with the identification and challenge of dysfunctional assumptions and the preparation for future problems as a means of relapse prevention. Challenging dysfunctional thinking can involve the same questioning as in dealing with automatic thoughts; however the more abstract nature of this mix means that principles are less likely to change.
There is substantial evidence that therapy structured in this way is effective and for a wide range of anxiety disorders including panic. A number of studies have shown up to 85% of people becoming panic free with this therapy.
Obviously for those with comorbid depression, substance misuse or the coexistence of a number of anxiety disorders, such therapy becomes complex and the challenges increase. Patients may also benefit from the introduction of medication and a Serotonin reuptake inhibitor is a widely used form of therapy which is beneficial. Serotonin is a brain chemical which is a chemical messenger associated with the experience of calmness and with a capacity to complete a task. Enhancing Serotonin function is associated with elevation of mood and reduction of anxiety and also the completion of functional behaviours. Serotonin reuptake inhibitors are not addictive. In contrast to other medications used for anxiety such as Benzodiazepine, they can when indicated be taken for prolonged periods. Like all medications they have side effects and risks. Common side effects include nausea, diarrhoea, sweating and sexual dysfunction. Like other antidepressants they have no immediate benefit and their use may be unhelpful unless taken appropriately and under medical direction.
In contrast Benzodiazepines, so-called Valium-like drugs produce immediate effect in terms of reduction of anxiety, however these have no long term beneficial effect and are dependency provoking. Benzodiazepine should not be used in long term for anxiety disorder. The medication component of therapy for anxiety disorder should be supervised by a medial practitioner and needs to be part of an overall therapy package aimed at recovery.
Professor Jim Lucey | Medical Director