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. …