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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Man to Man Man to Man

Panic Attacks--Just Nerves?

December 19, 2012

By Harvey B. Simon M.D.

Harvard Medical School

In November 2012, professional golfer Charlie Beljan won his first PGA tournament, but it wasn't easy or pretty. He staggered through the second round with a racing heart and feelings of breathlessness, which made his score of 64 seem downright miraculous.

After Beljan finished his round, he entered an ambulance instead of the clubhouse. His next stop was a Florida hospital, where he spent the night on a cardiac monitor. The 28-year old golfer was released in time to play the final 36 holes, which brought him victory and a check for $846,000. Beljan's doctors allowed him to resume play because they ruled out heart disease. They diagnosed him with a panic attack.

Charlie Beljan's story is uncommon, but panic attacks are surprisingly common. More than 20 percent of Americans experience at least one episode over the course of a lifetime. And up to a quarter of these people experience recurrent attacks or life-changing behaviors that earn a diagnosis of panic disorder.

Panic attacks are always frightening and can be disabling, but they can be treated and prevented if they are diagnosed correctly.

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A Typical Panic Attack

It starts without warning and without any obvious cause. In a flash, you go from feeling fine to feeling at death's door.

  • Your heart is pounding and your chest is tight.
  • You are breathing fast, but you can't get enough air.
  • Your mouth is dry, but your skin is covered with sweat.
  • Your stomach is churning and you feel nauseated.
  • Your limbs are shaking; you feel faint and dizzy.

It all seems unreal, yet you are really afraid of dying. Is it your heart? Not likely. Although many of these symptoms can accompany a heart attack, they are actually quite typical of a panic attack.

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Just Nerves?

We all get nervous from time to time. It's a normal human emotion, triggered by tense situations. Virtually everyone also experiences spells of anxiety. Unlike normal nervousness, anxiety is not triggered by an outside problem, but by something inside a person. But panic attacks are more than intense anxiety; they are sudden, uncontrollable episodes that are temporarily disabling.

Indeed, the sudden onset of intense fear is one of the major characteristics of a panic attack. At least four of the following symptoms must be present for a diagnosis of panic attack:

  • Pounding or racing heart
  • Sweating
  • Shaking or trembling
  • Shortness of breath or a sensation of smothering
  • Feeling of choking
  • Chest discomfort
  • Nausea or abdominal distress
  • Dizziness or lightheadedness
  • A feeling of unreality
  • Fear of dying
  • Fear of going crazy
  • Numbness or tingling
  • Chills or hot flashes

Source: American Psychiatric Association: Diagnostic and Statistical Manual, 4th Edition, 1994

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Causes of Panic Attacks

Panic attacks have been recognized by doctors for more than 100 years, but the term "panic" is much older. It comes from the Greek god Pan, who jumped out from hiding to terrify unsuspecting people.

Panic attacks occur most frequently between the ages of 25 and 45. Most people who suffer from them are otherwise physically and mentally healthy. Others have underlying psychological problems or medical illnesses, such as asthma.

Panic attacks can run in families; about 20 percent of sufferers have at least one relative with the disorder.

Despite lots of good research, doctors are not entirely sure what's responsible for panic attacks.

A surge in the stress hormone, adrenaline, can lead to many of the symptoms of panic. Metabolic factors and brain chemical imbalances may also play a role. And there seems to be a genetic link. Psychologic factors may set the sequence in motion, but it's clear that panic attacks are not "all in the head."

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Ruling Out Other Medical Problems

Most patients with panic attacks go to a primary care physician or cardiologist for help. It's a good place to start. Doctors should rule out medical problems that can resemble panic attacks. These include:

  • Caffeine toxicity
  • Drug abuse (particularly abuse of amphetamines)
  • Excessive levels of medications, such as the asthma drug theophylline
  • Withdrawal from sedatives or alcohol
  • Endocrine diseases, such as hypoglycemia (low blood sugar), an overactive thyroid or a pheochromocytoma (a benign tumor of the adrenal gland that produces excess adrenalin)
  • Cardiac disorders, particularly mitral valve prolapse and arrhythmias
  • Neurologic disorders, especially partial complex seizures

In most cases a thoughtful interview, careful physical exam and a few simple lab tests will rule out the medical suspects. Then appropriate treatment can begin.

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A Good Outlook

As bad as they feel, panic attacks are no cause for panic. Each attack is brief and self-limited. The episodes begin abruptly, peak in about 10 minutes, and resolve on their own in 20 to 30 minutes. The attacks leave the sufferer feeling exhausted, but healthy.

A person who has had just 1 or 2 panic attacks does not need long-term treatment. But recurrent attacks can be disabling. And feelings of worry and concern often remain in their wake.

Many people with panic disorder go on to develop agoraphobia (literally "fear of the marketplace"). This can lead to social isolation. Patients can also become depressed or anxious as a result of recurrent panic attacks.

Fortunately, there are effective treatments. In most cases, medications will provide excellent relief. Doctors usually recommend a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine (Prozac, generic) or paroxetine (Paxil, generic).

Because SSRIs take several weeks to kick in, doctors sometimes begin with a benzodiazepine, such as alprazolam (Xanex), to gain rapid control if panic attacks are severe or frequent. Other medications are available for men who do not respond to first-line treatment. No matter which medication the doctor and patient select, it is wise to begin with a low dose that can be increased gradually if necessary.

Medications have revolutionized the outlook for men with panic attacks; 80 percent to 90 percent enjoy nearly complete prevention and control of their symptoms.

Counseling can also be very helpful, particularly when it's time to taper the medications. Some people respond to traditional psychotherapy. Others do best with cognitive behavioral therapy or relaxation therapies, such as deep breathing and meditation.

A panic attack feels like impending death, but it's not. Even so, recurrent episodes can have severe, even disabling effects. Fortunately, modern therapy can help men with this puzzling disorder lead normal, productive lives, though few will go on to become PGA champions.

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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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