Josh is a 35-year-old man who came to me for help dealing with his long history
of panic attacks. They started after his army service and have continued off and
on ever since.
Josh explained that as a result of his panic attacks, he
only goes to work and avoids most social gatherings. Describing a typical
anxiety attack, he explained that his breathing becomes very heavy and he feels
like he is choking, gasping for air. His heart often pounds and he is certain
that he having a heart attack. He added that when he has a panic attack, he
feels like he is losing complete control and is going crazy, and finds himself
hyperventilating and terrified that he is going to die or that something
terrible will happen. He sought my help because he was tired of living a life of
fear and avoiding friends and social places. Josh’s wife also strongly
encouraged him to seek help and was hoping that professional treatment would
help alleviate his suffering.
Josh is not alone. Panic disorder affects
around 3.5 percent of the population during their lifetimes, affecting twice as
many women as men. At least 23% of the general population has reported an
isolated panic attack some time in their lives. The average age of onset for
panic disorder is from adolescence to 40. Panic disorder often cooccurs with
depression and other anxiety disorders, for instance on exposure to the feared
object in specific phobia, the fearprovoking memory in post-traumatic stress
disorder, the obsessive thought in obsessivecompulsive disorder, or a social
People like Josh frequently show up at hospital emergency rooms
with a whole array of frightening physical symptoms, which become the focus of
their anxiety and in fact trigger more anxiety. This is not surprising if one
considers the intensity and degree of physical manifestations present in a
typical panic attack. Many sufferers from panic disorder lose all semblance of
rationality when they are going through an attack. Furthermore, they live in
constant fear that the next attack is right around the corner.
avoidance of social situations and people outside of his work is one of the most
common fallouts of panic disorder. In describing his symptoms, Josh noted that
he had always taken buses to work, but after having a powerful anxiety attack
while waiting for a bus, he subsequently began to avoid bus travel. Instead, he
began to take taxis to work, which led to a major dispute with his wife because
of the expense involved.
THE BEST and most scientifically proven
treatment for panic disorder is a combination of psychiatric medication, usually
in the category of selective serotonin reuptake inhibitors (SSRIs), like Prozac,
together with cognitive-behavioral treatment (CBT). As a rule, there are some
important considerations to rule out when someone seeks out psychological help
for panic disorder.
A complete physical exam is always recommended to
make sure there are no underlying medical conditions that could be causing panic
symptoms. The therapist must make sure that there is no current drug use that
may be triggering the panic attacks.
Use of stimulants such as caffeine,
decongestants, cannabis and cocaine can cause panic attacks. It is also
important to know whether the panic attacks are part of a longterm pattern or
just some isolated cases. For example, an evaluation may reveal that a trigger,
such as being near or involved in a traumatic experience like a terror attack,
has brought on the panic attacks.
CBT helps patients to understand how
automatic thoughts and false beliefs/distortions lead to exaggerated emotional
responses, such as anxiety, and how they can lead to secondary behavioral
Josh found psycho-education about panic attacks to be very
helpful. Cognitive restructuring (CR), a central component of CBT, helped Josh
to change some of the negative thinking that reinforces and maintains a panic
episode. CR involves substituting positive thoughts (e.g. “I am only feeling a
little uneasiness” or “my feelings will soon be gone”) for the maladaptive
thoughts that accompany panic (e.g. clients feeling that they are having a heart
attack or going to die).
Two points that significantly helped him were to
understand that the panic attack rarely lasts more than 10 minutes and that many
of the symptoms that his body was producing would not really hurt him. It helped
to realize that his symptoms were the result of a rush of adrenaline released by
the brain during the panic episode. Experts understand that the individual’s
subjective reactions to the panic episode and the frightening events that follow
are a central culprit in escalating the attack.
While panic disorder is a
terrible and frightening psychiatric condition, help most definitely
The writer is a psychotherapist for children, adults and couples
and practices in Jerusalem, Tel Aviv and