Don't ignore that panic attack

People often present at hospital emergency rooms with frightening symptoms of a panic attack: intense fear, pounding heart, shortness of breath or choking, profuse sweating, discomfort in the abdomen, and a terrifying certainty that they are having a heart attack or “going crazy”. These attacks typically last less than 10 minutes.

First and foremost, the possiblity of a heart attack should be considered, relevant investigations done and emergency measures taken. Other medical conditions that can present similarly also need to be ruled out by a physician before being referred to a psychiatrist.

When I first met Amit in 1999 he had already been to a couple of cardiologists and several psychiatrists over five years. He was 29. He had been having episodes of severe panic for about five years, when he felt out of control and terrified. His heart would thump rapidly, almost audibly, and there would be a sensation like a caged bird fluttering its wings in his stomach. He would sweat profusely and his mouth would go dry. These attacks would occur 3–4 times a month, lasting about ten minutes each time. There would be no obvious trigger, at least none that could be linked logically to the panic attack. Prescribed medicines helped, but he was looking for a permanent cure. He had been referred to a psychologist but had not followed up on that.

A detailed history and evaluation ruled out other mental illnesses that present similarly. Physical conditions that present with panic attacks as a symptom had been investigated and ruled out by the referring physician.

Sasha, 24, presented with a history of panic attacks characterized by trembling all over, stomach cramps, palpitations, gasping for air, and sweat dripping off her hands. These attacks happened only in one situation: when she had to board a flight. As her work entailed frequent trips abroad, something had to be done about it.

Monica had been sent to a boarding school in India when she was seven. Until then she had lived abroad with her parents. She had tremendous difficulty adjusting to the new school and was often panic-stricken, especially as the threat of corporal punishment did exist, though administered rarely. She had come for a consultation because she was experiencing similar attacks of panic now, along with angry outbursts. She said she tended to be high-strung a lot of the time. Her behavior was affecting her six-year-old daughter, and making her feel inadequate as a parent.

Roy, 30, was referred to me by a physician for treatment of panic attacks. Seven years earlier, at 23, he had rushed to a hospital in a panic after experiencing pain in his chest and left shoulder. Examination and investigations had shown nothing abnormal. He soon happened to relocate to the US. As he was a stickler for punctuality and precision, and enormously particular about keeping things tidy and dust-free, the American way of life engendered far less anxiety in him. Panic attacks were infrequent in the five years he was there. On returning to India panic attacks increased, for which he consulted a physician.

Pheroza, 20, was anxious all the time. Having to meet her friends in college every morning had started giving her panic attacks because they picked on her for something or the other everyday: her well-maintained notes and books, her tidy clothes, her punctuality, her insistence on informing her mom if the group changed plans and she would be late reaching home—anything at all. As they constantly teased her about having OCD, she had read up about it and was worried that perhaps she did.

Clare, 25, was referred by her family doctor with a one-month history of severe anxiety. She said she had panic attacks 5–6 times a day and they lasted for hours. Though she considered her marital relationship to be good, she lived in fear of divorce as her parents-in-law disapproved of her and constantly attempted to turn their son against her, or so she said. Things seemed to have gotten worse in the past couple of months.

Alisha, 26, was an introvert who was uncomfortable at parties, especially those where she had to mingle and network with strangers to help her husband in his new business venture. These events were regular, at least three a week. She became aware of her acute fear when she had to enter a room where a party was on, and have people look at her and judge her. She found it hard to breathe, began perspiring, and felt a headache coming on. She tried to relax by having a drink before going to the party.

Of all these people, only Amit was diagnosed with panic disorder. Additional symptoms displayed by the others put them in different diagnostic categories, though they all presented with panic attacks. For example, Roy had an illness on the OCD spectrum, Sasha was aviophobic, Pheroza’s symptoms did not meet the criteria for a concrete diagnosis although she was undergoing mental discomfort, and Alisha had social anxiety.

Sudden attacks of paralyzing fear, regardless of etiology, can cause severe physical and mental distress. They can prevent people from living normal lives.

• Amit once had a panic attack and stopped his car in the middle of heavy traffic on his way to work. Traffic cops had to move his car to the curb and take him to a hospital.
• Sasha lost several opportunities to expand her business as she bolted from airports just before security check.
• Monica lost friends when her severe anxiety erupted as anger. She often whacked her daughter too.
• Roy developed high blood pressure and had to go on antihypertensive medicines at a young age.
• Pheroza had no psychiatric problem, just unnecessary worries that made her sad and scared.
• Clare drove herself into panic and depression by imagining negative scenarios.
• Alisha bagan to drink heavily to get through the parties and even blacked out twice.

Someone experiencing a panic attack for the first time usually reaches out to a friend or family member. A surprising number of people possess a strip or two of an anxiolytic medicine that was prescribed for them earlier, and offer a tablet to the sufferer. It works. The person continues to somehow source the same medication and use it on an as-needed basis.

In clinical practice I have seen people addicted to high doses of anxiolytic medicines for years, self-medicated. The underlying illness has never been investigated as they have never approached a mental health professional. They live in fear of running out of medicines as they are not easy to obtain without a prescription. Besides, having to miss doses due to unavailablity of medicines can cause severe withdrawal symptoms, including seizures and death, apart from distressing symptoms such as headache, vomiting, blurred vision, muscle pain, tremors and worsening of anxiety. They do not know this.

It is necessary to consult a mental health professional in case of frequent unexplained panic attacks. A psychiatrist or psychologist will be able to diagnose the underlying condition and tailor treatment accordingly. Self-diagnosis and treatment of panic attacks is akin to treating fever as an illness rather than as a symptom of an underlying illness. What is dismissed as ‘the flu’ could turn out to be malaria, dengue, meningitis or any of a host of infections.

Dr Shyamala Vatsa is a Bangalore-based psychiatrist who has been practicing for over twenty years. If you have any comments or queries you would like to share, please write to her at columns@whiteswanfoundation.org