Panic Disorder
Am I Dying or Going Crazy? How Sick am I?
A Brief Discussion on Panic Disorder with Agoraphobia and It’s Adequate Treatment
1. There is Hope! If you have Panic Disorder you are likely not going to die from it, go crazy, lose control, and are not very sick or terminally ill, though you certainly are really feeling all these things and are very worried and frightened. These feelings, worries, thoughts, perceptions and physical symptoms are very real and not your imagination. Panic and its complications have already changed you life. You are having an extraordinarily amount of mental, emotional, and physical pain and suffering, some of which may be unnecessary, that can progress and cause serious complications. Unnecessary suffering because there are remarkably safe and effective medications that work quickly and safely to treat this disorder and prevent its complications. Even if you are getting some treatment medical or not, there may be room for improvement ,and you can even feel and do better. Most people with Panic Disorder can be symptom free, and get back to feeling like their old self. Nothing less than this should be the goal of treatment. For this to occur the right medication or medications, with or without other treatments, must be adequate in intensity and duration.
2. What is a Panic Attack? A panic attack is a very real and scary thing and is not just your imagination. It is an attack of intense fear, or emotional, mental or physical discomfort, reaching a peak in 10 minutes, in which four or more of the following 13 symptoms are present [A] palpitations, pounding heart, or a fast heart rate, [B] sweating, [C]trembling and shaking, [D] sensations of shortness of breath or smothering, [E] feelings of choking, [F] chest pain or discomfort, [G]nausea or abdominal distress, [H] feeling dizzy, unsteady, lightheaded, or faint, [I] feelings of unreality, like your in a dream or being detached from oneself,[J]fear of losing control or going crazy, [K] fear of dying, [L] numbness or tingling sensations,[M] chills or hot flashes.
3. What is Agoraphobia? Agoraphobia is [A] anxiety about being in places where escape might be difficult, embarrassing, or there may be no help if you had a Panic Attack, and [B] because of this worry, situations like being in public places, standing in line, on a bridge, traveling in a car, plane, train, etc, are avoided, or endured with great distress, or require the presence of phobic partner or companion.
4. What is Panic Disorder with or without Agoraphobia? Panic Disorder is when you have unexpected panic attacks over and over again, followed by at least by one month of serious worry of about having another attack, “When will it happen again?”, or worry about what the implications and consequences, “What does it mean and what will it do to me?’, or there is a significant change in behavior related to the attacks, “What have I been doing to avoid the attacks?. If one is avoiding places, or having too much distress in places, because of fears of the attacks or needs a companion, one also has Agoraphobia.
5. What are other Causes of Panic Attacks besides Panic Disorder? Panic Disorder is not diagnosed if the panic attacks are due to the following, [A] a General Medical Condition like thyroid, inner ear, seizure, or cardiac problems, [B] a Substance, like a drugs abuse and alcohol, over the counter or prescription medications, also vitamin, food supplements that may have stimulants like caffeine, [C] or during the course of ,or better explained by another mental health disorder , especially Schizophreniform with symptoms like bizarre, illogical, odd speech and behavior, and mood disorders in the Bipolar spectrum having severe depression, mood swings, with irritability, excitability, and anger management problems.
6. What is the Biological Basis of Panic Disorder? One theory if that there is an unpredictable, episodic, over reaction of the brain chemistry that has to do with the biologically necessary flight fight response that has a genetic basis. It has been estimated that first degree relative of individuals with panic disorder are up to 8 to 20 times more likely to develop panic disorder. The fight-flight response exits to prepare us to fight or flight when faced with actual or perceived danger with potential to threaten our physical and mental survival , a literal matter of life or death. When this occurs the body reacts with symptoms similar to a panic attack, with a faster heart rate, sweating, faster breathing, a heighten sense of vigilance, and anxiety, doom and dread to get ready to run or fight. One is motivated by a fear of death and to do what ever it takes to survive. The brain chemicals in part believed to be involved with this response have to do with the balance of serotonin, norepinephrine, and dopamine, which also form the theoretical basis of how the medication that are antipanic work. The unpredictable, episodic, over reaction based on a biologically based and driven brain chemical imbalance, is similar to what is seen in seizure disorders. Panic attacks like seizure episodes or attacks fuel other attacks, making the new attacks more intense and frequent and sometimes harder to treat, thus the importance of eliminating the attacks to prevent future attacks, and like with seizures to avoid complications, with the hope once attack free, the medication can be tapered with no further occurrence of attacks. The earlier one does this in the course of the disorder and at the earliest age better is the long term outcome.
7. General Principles of Medication Management in Panic Disorder: One is referred to my General Principles of Medication Management, and the medication subheadings in Generalized Anxiety Disorder, and in the anxiety section of Differential Diagnosis of Concentration Problems, and in and My Approach, What is Different? , for other and more comprehensive discussion of medication. People having Anxiety Disorders in general and Panic Disordered people especially often have very sensitive brain chemistry when it come to the good and negative effects of medication, which is further compounded by their heightened cognitive, emotional, perceptual, somatic interpretations of the medications effects. This requires the practitioner be available to give much support and education about the expected good and negative effects of the medication not only to the patient, but also their care takers, parents, loved ones, who may also be genetically and environmentally conditioned to be more prone to anxiety and anxiety disorders, and have similar perceptions and concerns. Based on these factors an initial medication trial should start very low and go slowly balancing this with the clinical need. The initial choice of medication though important is not as crucial as a sensitivity to the persons initial responses, and then making further adjustments or changes based on this and history from others.
8. Serotonin Responsive Uncomplicated Panic Disorder: By uncomplicated Panic Disorder, I mean that [A] the symptoms are not extreme in severity,[B] nor are there other mental health disorders considered primary,[C] nor any suspected that may only be partially expressed, or in a sense hidden by the dramatic nature of the Panic symptoms, complicating the picture, and representing another brain chemistry picture, and thus choice of medication. In most cases one of the serotonin based antianxiety, antidepressant, antipanic medications would be the medication of choice. These include and I am using the original brand names for the sake of simplicity and convenience, Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro, Effexor, and Cymbalta. One difference between these medications is the half life, or how long it takes for half of it to leave your system, with all of them lasting about 24 hours except Prozac whose second metabolite can last a week or longer, and this may give it certain advantages including lasting longer, with potentially less rebound when it is discontinued, and perhaps working a little slower, thus having less dramatic good and bad effects initially. Also Prozac was the first in the class so it has the longest history or use, and is recommended for people 18 years of age and younger. It is also what is called a dirtier medication meaning it doesn’t work so purely just on serotonin and this again may give it certain specific advantages and disadvantages. More on some of the other differences below. This group is called SSRI or SSNRI medications based on their mechanism of action that is, selective serotonin reuptake and/or norepinephrine inhibition. The medications in this group may all be statically effective, but there are huge differences in their good and bad effects, among individuals, even people in the same family, including siblings, and even in identical twins. If there is a difference among identical twins who are genetic biochemical clones one can only imagine the differences among others including close family member, compared to the population at large. Also related to this group are Desyrel, Remeron, and Buspar, share similar mechanism of actions though each having significant differences including in their general effectiveness and side effect profiles, and should be considered second line choices.
9. Specific Principle of Medication Management: Specific medication usage and adjustments must be based primarily on the individuals unique brain chemistry and how it expresses it self in positive and negative treatment response, and the urgency of the individuals clinical need. How much is the person suffering, how much impairment is there, and how fast do they want to get better? This can only be done by doing a careful medication trial. At the beginning of treatment especially if the symptoms are intense and frequent, multiple medications may be need for quicker symptom control. The goal is always treat the cause rather then just the symptoms by addressing the underlying biochemical imbalance specifically serotonin imbalance and the other cores of excitability that may be precipitating and maintain the panic attacks.
10. Specific Choice of Medication: The guide to picking one medication over another considering they are all generally effective is first choose one that either by individual or family history was previously helpful. If there is no previous positive treatment history any of the SSRI/SSNRI may be chosen. For children and teens under 18 years it generally recommended that Prozac be the first choice unless there is some individual or family history that would indicate otherwise. I usually tell patients about the uniqueness of Prozac, having the longest treatment history, working on more and different brain chemicals, having a longer duration of action , and perhaps less dramatic in positive and negative effects, especially initially and when it come times to taper off the medication. Paxil and Effexor though extremely effective often in specific individual may bind two strongly to the brain serotonin receptors and may cause rebound effects if one misses a few doses, and may be to discontinue from because of rebound effects, this is less likely to happen with the longer lasting Prozac. Some people get overly stimulated by the SSNRI medications Effexor and Cymbalta, because of the norepinephrine action, and in other these same medications because of norepinephrine effects actually have an enhanced anti anxiety and anti panic effect, plus in others this same effect helps physical symptoms likes aches and pains, and anxiety caused fatigue. As you can see there is no general principle but all based on ones individual response.
11. Negative or Side effects: Generally this class of medication the SSRI/SSNRI are extremely well tolerated with no long term negative effects. Most people on this class of medication are doing so well with no negative effects it is difficult to get them to tapper off and stop them. When properly used they are remarkable medications. If the particular medication is started low enough and one goes slow enough, the negative effects should be minimal and easily tolerable. If there are still negative effects one may have to switch to liquid preparation so one can even start lower and go slower. In fact if one starts low enough the medicine should be neutral in its negative effects and positive effects, and then as it is gradually increased one will begin to feel the positive effects. If this is not case either the diagnosis is wrong, or it may just be the wrong medication for you, another one slightly different needs to be tried within the same class. The sheet the pharmacist gives you on side effects doesn’t reflect the fact that every negative ever reported has too be listed, what one needs to know are what are the most common side effects that lead to people stopping the medication, and are there any dangerous short and long term side effects. The most common negative effects that patient have raised as concerns are either to tired or too much energy like caffeine, emotion constriction/ flatness or an I don’t car attitude , appetite changes up or down, changes in libido or sex drive usually down, all of which as other side effects can be minimized or go away with adjusting the medication or changing it or adding a medicine for these problems, sometimes only temporarily. This is discussed further under adjunctive medication section. The most common side effect of psychiatric medications are in fact psychiatric and should not occur if it is the right medication and it properly adjusted. Serious psychiatric effects which should not occur if one start low and goes slow are worsening of what your trying to get better, like agitation, nervousness, more depression, increased rather decreased suicide ideas, loud thoughts, sounding like voices, rarely hallucinations, too happy, too sad, irritable, angry, too much too little sleep and again though there are idiosyncratic individual dramatic response, even these don’t occur quickly ,or usually, over night but gradually and if one or some one else sees them or suspects them , the medicine should be stopped and the doctor needs to called. The medicine should not make you feel too tired, or too energized, you should not feel different in a bad way, like being numbed out, zombied out, high or low, too jumpy or too calm, you should feel like your normal self but free of the problem feelings, thoughts and physical symptoms that were troubling and controlling you, now you should be in control of them. Common nuisance reactions are nausea, headache, insomnia, nervousness, weakness, decreased appetite, diarrhea, dry mouth, sweating, yet just as frequently they can do the opposite, in any case if they occur they should be mild and go away quickly never bad enough to consider stopping treatment. The negative effects should never out weigh the positive, and one shouldn’t have to suffer though them to get the good effects. If something unexpected happens assume it may be the medication and stop it and call the prescribing practitioner or your local emergency room.
12. Right Medication & Diagnosis, But Still Not Symptom Free& Back to My Old Self, Why? Why? Likely the reason is inadequate treatment. What is adequate treatment? Remember the analogy made about the similarity of Panic Disorder to Seizure Disorder, and eliminating all seizures and all panic, so that the episodes or attacks don’t fuel the next ,and make them worse and harder to treat. This requires adequate treatment which means the right medication, or medications at the right doses, for a sufficient length of time, it was suggested at least a year, to eliminate the Panic attacks, and to prevent relapses, re occurrences, and prevent complications. I use a process called micro diagnosis, and micro fine tuning and adjustment, sometimes of multiple medication to ensure even the smallest symptoms, that may only be on the surface have little connection to the original Panic symptom presentation be brought to the surface, that is micro diagnosed and adequately treated, for that minimal or forgotten , or insignificant symptom, just like the smallest seizure, or symptoms that might indicate a seizure focus, if it still exists, a small core of excitability, now that the big core is eliminated, is there and fueling or kindling the process, if it is there it needs to be discovered and properly treated and eliminated. A neurologist would do no less for a Seizure Disorder and psychiatric physician should do the same when I comes to a Panic Disorder. First rule do no harm, second rule treat the person the way you would want to be treated, I would want no or minimal negative effects, and maximum positive effects, until I was symptom free long enough so I was back to my old self, if not better, with the hope of getting off the medication, some day if I could. No less should be expected, when dealing with our most precious organ system, housing the chief executive the mind and its functioning.
13. Common Error & Problems that Lead to Inadequate Treatment: There are both medication management errors and diagnostic errors. [A] The most common error I’ve seen is , the right medication is chosen and being used but the dose is not maximized. The dose should be increased as long as there are symptoms causing distress or leading to impairment, like your still avoid situations and places, though you haven’t had a recent panic attack, the only thing that would limit the increases are prohibitive side effects. The medicine titration upward should not be stopped because of some arbitrary cut off by the drug manufacturer, but as determined by your unique brain chemistry and your physician. [B] The second most common error is, the duration of treatment with medication is not sufficient to achieve complete symptom relief, and prevention of relapses and complications. This should be at least 9 months to a year, depending on your response, and the severity of the disorder and complications. Two examples would be that you used alcohol and abuse able drugs to cope with your panic, and your fearful you may relapse, or you have complicating physical problems like headaches, asthma, stomach and intestinal problems that have not flared up much if at all, both of these are reasons to stay on the medication longer.[C] Medication is not fine tuned based on need and negative effects to ensure compliance, and lack of compliance leads to medication being stopped too early. You need to discuss with your doctor any negative effect no matter how small so the medication can be fine tuned, so that even nuisance side effects are minimal or not even present. [D] Symptoms that are mild are not reported as significant, and or the evaluator doesn’t uncover these less than obvious symptoms though mild may still be fueling continuation of the disorder. All symptoms no matter how insignificant you think they are need to discussed so that do they do not fuel the process making matters worse, causing other complications, and causing relapses. The symptoms of panic may show them self with not only emotional fearful and anxious feelings, but also thinking problems like concentration, or thought blocking, racing thoughts, or perceptual like pin and needle feelings, aches and pains, almost any physical symptom can be a panic attack equivalent , especially if it comes and goes in episodes and there seems to no other cause or explanation, or mood changes like irritability that comes bouts, also any sleep disturbance, bad dreams, waking up in middle of night, eating problems like bouts of hunger. [E] Complicating disorders are missed, or considered insignificant, and or not treated and may be fueling the disorder. The common unreported depression, even a low grade depression like being down in the dumps, periodically sad and gloomy and negative, not back to your old self that may need a different medication approach. Other complications include ,other anxiety disorders like compulsions or rituals being present, too much generalized worry, social anxiety . you may be so happy that your panic is better that you don’t realize that you can do even better, and don’t have to live with these biologically based problems that usually respond to medication adjustments. The third major complication is using too much alcohol or other drugs of abuse, including over the counter medication, food supplements, energy drinks, all of which may have natural substances like ginseng, caffeine, gingko, taurine that may be fueling your attacks. Alcohol and other sedating substances may cause worsening of panic directly and in rebound.[F] Multiple medications are not used to get adequate symptom relief. As with any biological base problem to use increased blood pressure, or asthma as examples, often smaller doses of multiple medication work better than just one medication in high doses. This is a common strategy that should be tried if you are still having panic, avoidance or any other symptoms that may be complicating and fueling the disorder. [G] Other historians are not used to confirm adequacy of treatment adequacy determined by symptom relief and that impairment has been diminished so that the patient has returned to the previous or higher level of functioning. You may be aware what is happening to your body and how you feel and think, but other outward manifestations of your panic disorder may show them selves in way that only other people may notice, like how the panic is effecting your work, or leisure time, social life, and relationships in you family.[H] Sufficient support and education was not given by the prescriber based on lack of history, or insufficient information and lack of availability. Your doctor or his representative, should be available to you to answer any questions or problems you may be having with the medication or issues you are not sure about as they relate to the panic disorder. No question is too small to be asked, let the practitioner decide if it is important. The more you know the less anxious you will be. ,[I] Adjunctive non medication treatments were needed and not recommended or used. Medication is extremely effective in most cases but there my other coping strategies you may need to change long term behavior and relationship patterns conditioned and learned based on your anxiety and panic, and these may not be medication responsive, which may be helped with social, behavioral and cognitive therapy. [J] Bad fit with your prescribing practitioner. You must feel reasonably comfortable with your physician, practitioner, or therapist , and if you aren’t you need to discuss this, and try to work it out, and if you cant, you will need to find new professionals with whom you have a better fit. The trust, comfort one has in the therapeutic relationship is equally important to the treatments and medication used. The medication may only work as well as it represents the healthy therapeutic nature of you relationship with the prescriber.
14. Use of Adjunctive Medication, Trazadone, Inderal, Welbutrin, BuSpar, Xanax and Klonipin: There are many medications that are helpful only a few will be discussed here. They are used either together with the core or main medication the SSRI/NRI, either temporarily or as a longer term treatment to help it work better or to help manage some negative effect , or symptoms of the panic disorder or the medication. Inderal is a beta blocker that is useful for managing tremor, and the physical manifestations of panic like the rapid heart rate, sweating, flushing also having a use for stage fright. Initially there may be sleep difficulties and Trazadone which is an antidepressant that is sedating is often useful for sleep, which is better choice than a traditional sleeping pill that may be habit forming and cause rebound anxiety and panic. Klonipin which is a anti panic medication on its own, but may be habit forming and lead to excessive tiredness and sleepiness, but still has usefulness for the quick and initial control of the panic attacks, and to be used as a PRN, that is as needed medication for panic and worry, until the core medication kicks in. Xanax is highly addicting medication that I usually avoid for that reason and also because it is so short acting it cause rebound panic even in the middle of the night with patient needing a dose at that time, but there are people whose brain chemistry is so specific for this medication that it is the only medication that helps on a PRN basis, and they don’t abuse it though they a very likely to become dependent on it. Also Klonipin and Xanax if combined with alcohol can cause much impairment and memory loss, and if one overdoses with alcohol can lead to coma and death. BuSpar is a safe and mild anti anxiety medication with some mild anti panic, and anti depressant properties that can be used PRN or as a standing dose to supplement the core medication. Welbutrin marketed as an anti depressant doesn’t work on serotonin at all, but on dopamine and norepinephrine, and has many uses, including for ADHD, and for people who what I call brain chemistry that responds like an ADHD brain, in that this very stimulating medication can be very calming and have an anti anxiety effect in this specific brain chemistry. People who smoke often can benefit from its properties also. Also when there is too much flattening of the emotions and loss of libido with the SSRI/NRI, a little Welbutrin can help, as it can help with symptoms of depression and pure concentration that may be complicating the panic disorder.
15. Medication Strategies at the Beginning , Titration, Maintenance & Discontinuation Stages: I will be using specific medications for the purposes of example only and an other effective medication or medications could be used in similar ways. What I want to emphasize is the general process, the strategy, and some individual tactics, that will vary, and they should from person to person, and depending on the clinical needs of the individual and their responses. Medication management must be as individualistic as ones brain chemistry is unique.
16. Beginning & Titration Stage of Treatment: Again one is referred to my Principles of Medication Management in this series. After one is sufficiently educated and comfortable we begin a medication trial, and I emphasize it is a trial, with a SSRI medication like Prozac, starting with a very low dose, such as 5 mg, in the AM daily and then titrates or increases it as needed and the patient tolerates it, every week or two by another 5 mg, up to as dose that controls and finally eliminates the Panic attacks. The final dose range can be vary from as little as 5mg daily, but usually in panic states one has to push the dose up to higher ranges, and doses as high as 60 to 80 mg per day may be needed, depending on what if any negative effects may be present. Sometimes one may have to go faster depending on clinical need, though that usually isn’t necessary and may be counter productive, not giving the lower dose a chance to work. Many times it may be wiser to go slower depending on the persons anxiety level about changes and possible negative effects. Often at this stage Klonipin may be used on a as needed basis to control break through panic , and until the Prozac reaches a clinically therapeutic level, there are no labs or blood level, the correct dose is found by the positive response in the individual patient. Also Trazadone may be used temporally to help sleep if needed. Sleep is an excellent and reliable biological marker and can be used as barometer or measurement of the effectiveness of treatment specifically and generally.
17. Maintenance Stages of Treatment: The maintenance stage approaches , when the panic attacks are eliminated or under reasonable control, but I stress that in most people with uncomplicated Panic Disorder it is a reasonable goal to eliminate them as one would eliminate seizures, and the goal would be free from all panic. As one is treating in the beginning and early maintenance stages and begins to eliminate the most dramatic and troubling symptoms, other less troubling and sometime subtle symptoms become apparent. These other symptoms can almost anything effecting the mood, thinking, emotions, and physically, that comes and goes, occurs in bouts and episodes, that may be fueled and fueling the underlying core excitability, thus may considered panic equivalents. Example may be generalized worry, compulsions, headaches, stomach and intestinal distress, intermittent sleep problems, sad , irritable, and changing moods, thinking problems such as fast thoughts, thought blocking, poor concentration, still avoiding places and situations, sleep disturbances, use of alcohol and abuse able drugs to a name a few of the most common. These symptoms must be treated as aggressively and adequately as t the panic attacks themselves , for they may be also fueling the underlying core of excitability causing the panic disorder, with the appropriate medications and other treatments. Some examples were discussed in the Common Problem and Error section, and in Adjunctive Medication section. Other examples are recommending drug and alcohol counseling, if needed, being sure all medically base problems, especially psychosomatic illnesses such as asthma, stomach and intestinal problems, are under control. From a mental health perspective, if there is significant thinking problems or mood instability problems an atypical neuroleptic like Risperdal in small doses may be needed, if only on a temporary basis. Compulsions and rituals may require increasing the dose of the SSRI, a slowed down depression with poor concentration may require Welbutrin, irritability, anger issues, and migraines may require anticonvulsant-mood stabilizer - antimigraine medication like Depakote, if there is more sadness than anger with migraine, Lamictal may be an option.
18. Discontinuation Stage: Discontinuing the medication treatments should not be considered until the person is free of panic attacks, and other related symptoms, and thus being maintained for at least 9 to 12 months. Almost all of the medications used for Panic Disorder have no known long term side effects, and there is no harm and there may much to gain by choosing to discontinuing the medication later rather than sooner. Much has to do with the comfort of the individual patient, and how well they are now doing compared to how poorly they doing previously. When all agree it is time to discontinue the medications it must not be done quickly or over too short of a time span. The main and crucial reason for this is as follows, and this must be explained to the patient. It is critical to differentiate between return of symptoms of panic and other connected and related symptoms, and rebound symptoms from too quick of a taper over too short of a time. When it is decided to taper, if multiple medication are being used, only one medication at a time should be tapered, and at a rate that the patient is comfortable with, and slow enough to be able to tell rebound effects from symptom return. Much information sharing is needed here between the physician, the patient, and their family and other historical sources such as therapist and primary care practitioner, for a child their teachers. The slower one can go, the more likely one can tell the difference between rebound effects of the medication, symptom return, and environmental and other factors such as intervening physical illness. The bio psycho social environmental forces must be considered always from beginning diagnostically to the end of treatment. If at any time during the taper symptoms get to intense and frequent it is best to slow the taper down, and go back to the previous doses of medication, rather than precipitate a full blown panic attack, which can refuel the basic core of excitability and cause a relapse into another episode of Panic Disorder. To use Prozac as an example if the person was on 80 mg daily for one year, with no panic attacks, then it would be reasonable to taper it by 5 mg no faster then every 2 to 4 weeks, as the person tolerates, always erring on the side of going slower, so that the complete taper would be completed in a year to 18 months.
19. Non Medication Treatments- Behavior, Cognitive & Relationship Therapy: Non medication approaches may be needed either adjunctively or as the primary treatment, when the panic disorder isn’t too severe and the patient has the ability , motivation, patience, and follow through to actively participate and do home work assignment between sessions. It is crucial that a therapist be found that not has not only expertise in the individual treatment, but have added expertise in specifically apply their skills to Panic Disorder. The behavior therapist helps with modifying the behaviors and helping the person deal directly with the panic attacks and things they are avoiding. The cognitive therapist helps with the illogical thinking and distorted emotions that are both the result and cause of continued panic and avoidance. The traditional relationship therapist can help by focusing on problematic feeling and relationships as they relate to Panic Disorder. All of these professionals can be valued informants and consultants about the effectiveness of medication approaches.
20. Mindfulness Meditation and Anxiety: What is discussed here and in other places in a modification of mindfulness meditation and its techniques as a possible useful adjunct to dealing with anxiety and panic . One is referred to my article in this series on Mindfulness Meditation and Its Uses in Mental Health for a general overview and some specifics as it relates to, concentration, anxiety disorders, and specifically panic. There is a growing literature and practice on this called Mindfulness Based Stress Reduction that is being applied at some major medical centers for stress related mental health and chronic physical problems. The alert, calm, focused and knowing mind that one can develop and maintain through the practice of mindfulness and mindfulness meditation is ideally suited for application in mental health problems especially for anxiety problems and panic. It is relatively easy to learn but requires much individual time , effort, patience and practice to be able to use the techniques quickly , effectively , broadly in daily life. Many anxious and panic disorder people can not benefit from it until they have some relief with medication to help them so they can slow down, settle down, calm down enough to begin to practice the techniques. However these same people without medication can benefit just from trying to learn the technique alone without attaining a full meditative state or specifically applying it to their problems. The reason for this is that the very process of attaining the mindfulness meditative state is the same as the result or its goal, and that learning process in itself is quite therapeutic to the anxious worried mind.
21. Meditation-The Concentrative Technique: Meditative states based on concentration alone have one start by having one sit in a relaxed position and focus on an object such as the breath excluding any thing else that come into the mind. So relax and sit and breathe. Maintain your relaxed sitting posture with eyes open or closed what ever helps you to stay focused on the breath. Just follow the breath, stay focused on the breath in and out, at the exclusion of all other things that come into the mind. When you mind moves to anything else, no matter what, a thought, an emotion, a physical sensation, what ever, try to ignore it and return back to the breath. As one does this simple thing over and over again, sit, relax, focus on breath, get distracted, back to the breath, over and over again, the very process induces deeper and deeper relaxation, and deeper an deeper focus and concentration on the breath. If one focuses and concentrates on one thing at the exclusion of others, over and over again, while being relaxed, it automatically causes one to be more relaxed, more concentrated, more calm, more focused. Do this long enough and there is a gentle pleasant shift of consciousness, much like the experience of being in pleasant day dream, but with no content except the experience associated with a calm mind, relaxed body, focused on the breath, all uniting imperceptively, so that body, mind, breath are and function as one, that state is the meditative state. The more one practices this the better and quicker and deeper one experiences the calm relaxed focused mind. It is easy to see that just the practice of trying to get into the meditative state induces the slowing down, the settling down, the calming down, and the resulting ,alert ,calm ,relaxed ,focused mind that an anxious panic driven person want and needs.
22. Mindfulness Meditation the Theory: Mindfulness meditation adds a special knowing, or insight component or attentive awareness to the breathing and to everything else that enters the mind. I will not go into the specific here, but refer you again to the article on Mindfulness Meditation. But to summarize, to this alert calm focused mind the element of a wordless emotionally unbiased mirror like soft focused attentive awareness is added. A knowing of a thing for what it really is in the here and now, as an ever changing process that is connected to every thing else. That a Panic attack is not an isolated individual thing that should be over responded to by identification and thus taking over your life , or by trying to fight it, or by trying to run away from it, which is exhausting, worrying about when will it come again, this only makes one more anxious and fuels future panic, nor should you try to distract yourself from the a panic attack , should it be ignored, suppressed, rationalized away, on some level pretending they are not really there, but the are really there, and they come back.
23. Mindfulness Sees Panic Attacks Realistically: What mindfulness helps you do is see a panic attack for what it really is, and to experience it over and over again for what it really is. That a Panic Attack is a passing and temporary process, that comes and goes, nothing more and nothing else, and that it is part of a vast greater interconnect process, caused by other processes, and as you realize this over and over again, and what it this really means, and see over and over again its other connection and causes, its coming and going nature, the panic will gradually diminish in intensity, frequency and duration, until they go away. To make this point again in a more specific way.
24. Mindfulness Helps In Three Ways : Mindfulness helps with the panic attack in at least three ways. Mindfulness will allow you to be in the moment, and deal with the panic in an appropriate manner, and that is what you should be doing. Secondly you can see the panic for what it is, not a heart attack, a fatal illness, going crazy, but a intense symptoms of a treatable emotional problem an anxiety disorder, and not a psychosis. Thirdly you will see its deeper reality, that like every thing in nature, though painful, the panic has a beginning, a middle and an end, painful but temporary, not a permanent separate part of yourself, or you body , or your mind, but a changing temporary process, connected to many other processes for example to one’s breathing, in than when having the panic attack one over breathes, hyperventilates, which in a vicious cycle fuels the panic attack and the over breathing itself, and by being aware of just this one connection ones anxiety is immediately decreased and one now has the option to do something about the over breathing if one wants. There are many other connections some obvious some more subtle that as they are discovered can be just as anxiety relieving and useful that can be discovered by the application of mindfulness with or without meditation.
25. Other Ways Mindfulness Can Help: Mindfulness meditation can help prevent the attacks, diminish their intensity when they do occur, and aid in eliminating them by 1. helping you with hyperventilation, 2. by reducing generalized anxiety induced by the attacks 3. helping you deal with avoidance or agoraphobia 4.help you eliminate the attacks by systematic desensitization and 5. by explosive extinction, 6. help you with some of the symptoms such as muscle tension 7. help dealing with cognitive distortions, to name just some possibilities. You will likely find other connections as you explore your panic attacks and your responses to them.
26. Medications Used in Severe & Complicated Panic Disorder: When the core of excitability that causes Panic Disorder is severe it not only causes and intensification of all of the symptoms but also like a bad electrical focus in the brain that may cause a seizure, it can spread throughout the brain causing more wide spread chemical imbalances effecting other brain chemical systems, causing new , more intense and more wide spread symptoms, requiring multiple medications. Also other diagnoses may be present with Panic Disorder and require their proper and adequate medication management. Some less common yet biologically based and very treatable are ADHD which one would use a stimulant , or Welbutrin, or Straterra, psychoses like Schizophrenia and one would use an antipsychotic like Risperdal or Thorazine, for the Anxiety Disorders like OCD, higher doses of the SSRI usually suffice. The most common complicating diagnosis and sometimes the most difficult to treat is a mood problem usually Unipolar Major Depression, but there may be also a Mixed Bipolar process with wide and rapid mood swings having high energy, too happy, euphoric, manic episode passing through an irritable, nasty , mean, excitable, angry and rageful phase, before hitting bottom in a low energy depressed phase, that is Bipolar Depression which may resemble, but is not treated the same as a Unipolar Major Depression. This is easy to recognize if it happen in this order, but more times than not the opposite may occur the Bipolar Depression happens first. The Unipolar Depression usually responds to the same medications that one uses for Panic Disorder, with good results and no added complications or side effects. However if the brain chemistry that represents a Bipolar Depression has been present or is developing, or is suspected to develop, than the SSRI/NRI medication are not the medications of choice and can make matters much worse, causing cycling to a manic phase, psychosis, and suicidal and homicidal thinking and behavior, and this is the major serious side effect of the SSRI/NRI medications, especially for children and teens, but actually for anyone who is so predisposed. If there is a suspicion of bipolar brain chemistry, the SSRI/NRI’s never should be used, and if they were started they need to immediately discontinued if they can be, and the medications of choice would be one of the mood stabilizers. There are three classes of mood stabilizers, Lithium Carbonate in a class by itself, anticonvulsant mood stabilizers, Depakote, Tegretol, and Lamictal, and the Atypical neuroleptic medications like Risperdal, Zyprexa, Seroquel, Geodon, Abilify, Clozaril and some of the typical like Thorazine.
27. Warning for Patients on SSRI/NRI’s!!!! Generally these are very safe and effective medications that have treated many people successfully with little or no problems, and have saved many lives in people with anxiety and Unipolar mood disorders. However, what ever your initial or working diagnosis if you develop symptoms similar to a bipolar process, it dose not mean you have Bipolar Disorder ,it may mean you have a sensitivity to this class of medications, or may have similar brain chemistry to bipolar and the medication may cause more problems than it helps including worsening your anxiety, panic, making you more depressed, confused, and even psychotic and manic, that can lead to destructive feelings, thoughts, and behaviors to self and others. There is usually a family history that should make one cautious about using these medications of mood swing disorders, drug and alcohol abuse, some seizure disorder and forms of migraine, antisocial behavior with anger management problems, psychosis like Schizophrenia to name the most common, and there are others. The symptoms to look for are what I mentioned above , plus those associated with bipolar disorder, primarily a changes in mood from too happy ,to too sad, to irritable, excitable, angry, mean, nasty with mood swings that also have some the following symptoms, including [A] increased distractibility and problems with concentration, focus and memory, or confusion [B] any serious change in sleep pattern, more sleep, less sleep, fragmented sleep, nightmare, increased dreaming, sleep walking and talking, waking up in middle of night, especially waking up and eating, and most especially a decreased need for sleep, with more or normal energy during the next day, [C] a rapid increase of a good mood, feeling too high and good, and other people notice, inflated self worth, feeling your on top of the world, you’re the boss, have to right, getting big ideas about the future, that are unrealistic,[D] a sense that your ideas are too fast, you cant shut down your mind, racing thoughts, [E] increased energy, you start doing more than usual, many things at once, maybe getting none completed, and you enjoy it, and you want to do more and more, get more done, you start multiple project, take on more work, [F] people notice you are talking faster, your thinking and speech is going off on tangents, slightly illogical and disorganized, [H] you are becoming more impulsive not thinking before you talk and act, not thinking of the consequences of you behavior, taking risks you normally wouldn’t take, especially pleasurable one. If these symptom occur, or you are suspicious they may be in you or some one you know, and the history above fits , you should immediately call your doctor, or the local emergency room if you are concerned and ask for advice about he symptoms and the medication, and about what should you do, stay on, stop it, wait, be seen. Bad things would not happen as often as they do with these wonderfully effective and life saving medications if people knew these warning signs and discussed them with the appropriate professionals.
28. Anxiety Confused With Akathisia: Akathisia is neurological syndrome closely related to the brain chemistry and neurology that causes some form of restless leg syndrome. I can be confused with anxiety and Panic Disorder, and can be caused by some of the very medications that are used to treat these problems. The person having this feels like they have to move all the time, mostly the legs, but it could be the whole body, and sometimes this spills over to the mind, and the mind has to keep moving, thus fast ideas and rapid speech. Like restless leg it may get worse in the evening when one is ready to go to sleep, or if one tries to sit , or lie down to rest, and just as one begins to rest or start to fall asleep there is an urge to move that is only relieved by moving and continuing to move. One gets tired and or sleepy and tries to rest , sit down, go to sleep and again it starts, no sooner is one resting when again this motor and mental restlessness start again only to be relieved by constant movement. This as you imagine can be very tiring, frustrating, exhausting mentally and physically leading to anxiety, for the person has no reason to be doing this and seems like some force is propelling them to keep moving and thinking and wont let them rest , relax, sleep. There person mentally and physical is on edge, with a growing short fuse, with increasing worry, anxiety, frustration, anger, irritability, until it can turn into rage. Some people start feeling like they are getting out of control, and feel like they may be going crazy, and start acting the part. They don’t take well to being told to sit still, just relax, calm down, because they just cant no matter how they try. This may be idiopathic that is self caused, like in restless leg, but it may also be caused by many medications, prescribed and OTC, and among the most common are psychiatric medications. Not all individuals are susceptible to this, a good example is the OTC med Benadryl, but I could be any anti histamine, or sedating medication in a susceptible individual where it causes an imbalance in dopamine, and acetylcholine. Common medications used in mental health that may do this in susceptible individuals would be on the top of the list, the neuroleptic antipsychotic medications like Thorazine, Haldol, Trilafon, Risperdal, Zyprexa, Seroquel, Geodon, Abilify, closely followed could by any of the antidepressants, like Prozac, Zoloft and others, Lithium Carbonate, Depakote, Tegretol, the list can go on and on. The important thing is to recognize this syndrome and if there is an offending agent stop it, or lower it, or taper it if you can, try an antidote, like Cotentin, Benadryl, yes it can be an antidote to, not just an offending agent, or Inderal a beta blocking blood pressure medication, or a medication like Klonipin or Ativan. The worse thing one can do is keep increasing the offending agent confusing the agitation with the underlying condition one is treating, like keep increasing the Prozac of an anxious, agitated depressed person, or the Risperdal or Abilify for the irritable, angry, rageful Bipolar or Schizophrenic person, only to make matters worse rather than better.