Panic Attack, Agoraphobia, Generalized Anxiety Disorder Overviews

[Retired]

Panic disorder with agoraphobia: MedlinePlus Medical Encyclopedia
Update: 2/6/2008

Panic disorder with agoraphobia is an anxiety disorder in which there are repeated attacks of intense fear and anxiety, and a fear of being in places where escape might be difficult, or where help might not be available in case of a panic attack.

Causes
The exact cause of panic disorder is unknown, but it has to do with many different factors. Panic disorder can occur with or without agoraphobia, but agoraphobia develops in more than a third of cases.

Agoraphobia may be a learned behavior, because it involves a fear of having panic attacks in unprotected settings. Sometimes, panic attacks occur in areas where they have happened in the past.

Panic disorder can occur in children, but it usually starts around age 25. It can affect middle-aged and older adults as well. Studies have shown that women are 2 to 3 times more likely than men to be affected.

Symptoms
Panic attacks involve short periods of intense symptoms, such as those listed below, which peak within 10 minutes after they start:

Chest pain or discomfort
Choking
Dizziness or faintness
Fear of being out of control
Fear of dying
Fear of "going crazy"
Hot flushes or chills
Nausea or other stomach distress
Numbness or tingling
Palpitations
Shortness of breath
Sweating
Trembling
Symptoms of agoraphobia include:

Anxiety about being in places where escape might be difficult
Avoiding situations with great stress or anxiety about having a panic attack
Becoming house-bound for long periods
Fear of being alone
Fear of losing control in a public place
Feeling detached or separated from others
Feeling helpless and dependent on others
Exams and Tests

If your panic disorder has not been diagnosed, you may feel as if you are dying. Often, people will go to an emergency room or other urgent care center because they think they are having a heart attack.

A physical examination and psychological evaluation can help diagnose this condition.

The symptoms can be physical and the condition can be misdiagnosed. That's why it is important to rule out any medical disorders, such as problems involving the heart, hormones, breathing, nervous system, and substance abuse. These conditions can occur with panic disorders.

Which tests are done depend on the symptoms.

Treatment
The goal of treatment is to help you function better. The success of treatment usually depends in part how severe the agoraphobia is.

The standard treatment approach combines cognitive-behavioral therapy (CBT), which helps you understand and change the thoughts that are causing your condition, and an antidepressant medication. Selective serotonin reuptake inhibitors (SSRIs), such as Paxil, are usually the first choice of antidepressant.

Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor), are another choice. Other antidepressants and some antiseizure drugs may be used for severe cases.

Other anti-anxiety medications may also be prescribed. The health care provider may recommend benzodiazepines when antidepressants don't help.

Behavioral therapies that may be used together with drug therapy include:

Cognitive behavioral therapy
Pleasant mental imagery
Relaxation techniques
Other counseling and therapy techniques may help you gain an understanding of the illness and the factors that protect against or trigger it.

A healthy lifestyle that includes exercise, enough rest, and good nutrition can also help reduce the impact of anxiety.

Outlook (Prognosis)
Most patients can get better with medications or behavioral therapy. However, without early and effective help, the disorder may become more difficult to treat.

Possible Complications
Panic disorder may occur with other anxiety disorders or depression.
You may abuse alcohol or other drugs while trying to self-medicate.
You may be unable to function at work or in social situations.
You may feel isolated or lonely, depressed, or suicidal.
When to Contact a Medical Professional

Call for an appointment with your health care provider if you have symptoms of panic attacks.

Prevention
If you are likely to get panic attacks, it's important to get help early to prevent agoraphobia, which may affect your ability to work or deal with social situations outside the home.

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References
Moore DP, Jefferson JW. Handbook of Medical Psychiatry. 2nd ed. St. Louis, Mo: Mosby; 2004:162-163.

Rakel RE. Textbook of Family Practice. 6th ed. Philadelphia, Pa: WB Saunders; 2005:1440.

Schneier FR. Clinical practice: social anxiety disorder. NEJM. 2006;355:1029-1036.

Katon WJ. Panic disorder. NEJM. 2006;354:2360-2367.

Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283.

Update Date: 2/6/2008

Updated by: Christos Ballas, MD, Attending Psychiatrist, Hospital of the University of Pennsylvania, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

 

[Retired]

Agoraphobia: MedlinePlus Medical Encyclopedia
Update: 12/15/2008

Agoraphobia is a fear of being in places where help might not be available. It usually involves fear of crowds, bridges, or of being outside alone.

Causes
Agoraphobia often accompanies another anxiety disorder, such as panic disorder or a specific phobia. If it occurs with panic disorder, it usually starts in a person's 20s, and women are affected more often than men.

Symptoms
Anxiety or panic attack (acute severe anxiety)
Becoming housebound for prolonged periods of time
Dependence on others
Fear of being alone
Fear of being in places where escape might be difficult
Fear of losing control in a public place
Feelings of detachment or estrangement from others
Feelings of helplessness
Feeling that the body is unreal
Feeling that the environment is unreal
Unusual temper or agitation with trembling or twitching
Additional symptoms that may occur:

Abdominal distress that occurs when upset
Breathing difficulty
Chest pain
Confused or disordered thoughts
Intense fear of dying
Intense fear of going crazy
Dizziness
Excessive sweating
Heartbeat sensations
Lightheadedness, near fainting
Nausea and vomiting
Numbness and tingling
Skin flushing
Exams and Tests

The individual may have a history of phobias. Family, friends, or the affected person may tell the health care provider about agoraphobic behavior.

Signs include:
High blood pressure
Rapid pulse (heart rate)
Sweating
Treatment

The goal of treatment is to help you function effectively. The success of treatment usually depends on the severity of the phobia.

Systematic desensitization is a technique used to treat phobias. You are asked to relax, then imagine the things that cause the anxiety, working from the least fearful to the most fearful. Gradual exposure to the real-life situation also been used with success to help people overcome their fears.

Anti-anxiety and antidepressant medications are often used to help relieve the symptoms of phobias.

Outlook (Prognosis)
Phobias tend to be chronic, but respond well to treatment.

Possible Complications
Some phobias may affect job performance. People with this disorder may become housebound for years, which is likely to hurt their social and interpersonal relationships.

When to Contact a Medical Professional
Call for an appointment with your health care provider if you develop symptoms of agoraphobia.

Prevention
As with other panic disorders, prevention may not be possible. Early intervention may reduce the severity of the condition.


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References
Moore DP, Jefferson JW. Agoraphobia (panic disorder with agoraphobia and agoraphobia without history of panic disorder). In: Moore DP, Jefferson JW, eds. Handbook of Medical Psychiatry. 2nd ed. Philadelphia, Pa: Mosby Elsevier;2004:chap 84.

Katon W, Geyman JP. Anxiety disorders. In: Rakel RE, ed. Textbook of Family Medicine. 7th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 57.

Update Date: 12/15/2008

Updated by: Linda Vorvick MD, Family Physician, Seattle Site Coordinator, Lecturer, Pathophysiology, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine; and Timothy A. Rogge, MD, private practice in Psychiatry, Kirkland, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

 

[Retired]

Panic disorder: MedlinePlus Medical Encyclopedia

Panic disorder is an anxiety disorder that causes repeated, unexpected attacks of intense fear. These attacks may last from minutes to hours.

See also: Generalized anxiety disorder

Causes
The exact cause of panic disorders is unknown. Genetics may play a role. Studies suggest that if one identical twin has panic disorder, the other twin will also develop the condition 40% of the time. However, panic disorder often occurs in family members who are not blood relatives.

Panic disorder is twice as common in women as in men.

Symptoms usually begin before age 25. Although panic disorder may occur in children, it is often not diagnosed until they are older. People with this condition often have medical tests and exams for symptoms related to heart attack or other conditions before a diagnosis of panic disorder is made.

Symptoms
With panic disorder, at least four of the following symptoms suddenly occur within 10 minutes. Attacks may be followed by at least 1 month of persistent fear of having another attack.

Chest pain or discomfort
Dizziness or faintness
Fear of dying
Fear of losing control
Feeling of choking
Feelings of detachment
Feelings of unreality
Nausea or upset stomach
Numbness or tingling
Palpitations or pounding heart
Sensation of shortness of breath
Sweating, chills, or hot flashes
Trembling or shaking
There are often extreme changes in behavior at home, school, work, or with family. People with the disorder often worry about the significance of their panic attacks. They may think they are "going crazy" or having a heart attack.

A person with panic disorder often lives in fear of another attack and may be afraid to be alone or to be far from medical help.

Exams and Tests
A health care provider will perform a physical examination, including blood tests and a psychiatric evaluation. Medical disorders must be ruled out before panic disorder can be diagnosed.

Disorders related to substance abuse should also be considered, because some can mimic panic attacks. Substance abuse also can occur when people who have panic attacks try to cope with their fear by using alcohol or illegal drugs.

Cardiovascular, endocrine, respiratory, and nervous system (neurologic) disorders can be present at the same time as panic disorders. Specific tests will vary from person to person depending on the symptoms.

Many people with panic disorder first seek treatment in the emergency room, because the panic attack feels like a heart attack.

Treatment
Anti-anxiety medications, antidepressants, and cognitive behavioral therapy (working with a therapist) have been successfully used to treat panic disorders.

Medications act on the central nervous system to reduce anxiety and related symptoms.

Benzodiazepines are a commonly used class of anti-anxiety medications. They include alprazolam (Xanax). However, people can become dependent on or addicted to drugs in this class of medications. Ideally, these drugs are used only on a temporary basis.

Antidepressants called SSRIs (selective serotonin reuptake inhibitors) are the most commonly used medications for panic disorder. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro). If SSRIs do not help, longer term use of benzodiazepines may be considered if you do not have a history of drug dependence and tolerance.

Monoamine oxidase inhibitors (MAOIs), such as phenelzine (Nardil), tranylcypramine (Parnate), and isocarboxazid (Marplan), are only used when none of the other drugs work. MAOIs are the most effective medications for panic disorder, but they have serious side effects and they can interact with other drugs and foods. They should only be prescribed by a psychiatrist who is experienced in their use.

Behavioral therapies should be used together with drug therapy. These include:
Cognitive-behavioral therapy
Cognitive restructuring (learning to recognize and replace panic-causing thoughts)
Exposure
Pleasant mental imagery
Relaxation techniques
Behavioral treatment appears to have long-lasting benefits.

Regular exercise, adequate sleep, and regularly scheduled meals may help reduce the frequency of the attacks. Reduce or avoid the use of caffeine and other stimulants.

Outlook (Prognosis)
Panic disorders may be long-lasting and difficult to treat. Some people with this disorder may not be cured with treatment. However, most people can expect rapid improvement with drug and behavioral therapies.

Possible Complications
Avoiding situations or places that might bring on an attack
Other anxiety and mood disorders
Dependence on anti-anxiety medications is a possible complication of treatment. Dependence involves needing a medication to be able to function and to avoid withdrawal symptoms. It is not the same as addiction, which involves the uncontrolled use of a substance despite negative results. Dependence and addiction often occur together, but dependence itself is not always a problem.

When to Contact a Medical Professional
Call for an appointment with your health care provider if panic attacks are interfering with your work, relationships, or self-esteem.

Prevention
If you get panic attacks, avoid the following:

Alcohol
Stimulants such as caffeine and cocaine
These substances may trigger or worsen the symptoms.

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References

Fava GA, Rafanelli C, Grandi S, et. al. Long-term outcome of panic disorder with agoraphobia treated by exposure. Psychol Med. 2001;31(5):891-898.

Katon WJ. Clinical practice: panic disorder. N Engl J Med. 2006;354(22):2360-2367.

Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69:621-632.

Smoller JW, Pollack MH, Wassertheil-Smoller S, et al. Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women's Health Initiative Observational Study. Arch Gen Psychiatry. 2007;64(10):1153-1160.

Update Date: 1/15/2009

Updated by: Christos Ballas, MD. Attending Psychiatrist, Hospital of the University of Pennsylvania, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

 

[Retired]

Generalized anxiety disorder: MedlinePlus Medical Encyclopedia
Update: 1/15/2009

Generalized anxiety disorder (GAD) is a pattern of frequent, constant worry and anxiety over many different activities and events.

Causes
Generalized anxiety disorder (GAD) is a common condition. The cause of GAD is not known, but biological and psychological factors play a role. Stressful life situations or behavior developed through learning may also contribute to GAD.

The disorder may start at any time in life, including childhood. Most people with the disorder report that they have been anxious for as long as they can remember. GAD occurs somewhat more often in women than in men.

Symptoms
Generalized anxiety disorder has the following symptoms:

Difficulty concentrating
Difficulty controlling worry
Excess anxiety and worry that is out of proportion to the situation most of the time
Excessive sweating, palpitations, shortness of breath, and stomach/intestinal symptoms
Fatigue
Irritability
Muscle tension -- shakiness, headaches
Restlessness or feeling keyed up or "on the edge"
Sleep disturbance (difficulty falling or staying asleep; or restless, unsatisfying sleep)
Depression and substance abuse may occur with an anxiety disorder.

Exams and Tests
A physical examination and psychological evaluation can rule out other causes of anxiety. The health care provider should rule out physical disorders that may mimic anxiety, as well as symptoms caused by drugs. This process may include different tests.

Treatment
The goal of treatment is to help the person function well. The success of treatment usually depends on the severity of the generalized anxiety disorder.

Cognitive-behavioral therapy (CBT) and medications are the mainstays of treatment.

Selective serotonin reuptake inhibitors (SSRIs) are usually the first choice in medications. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are another choice. Other antidepressants and some antiseizure drugs may be used for severe cases.

Other anti-anxiety medications may also be prescribed. Benzodiazepines may be recommended if antidepressants don't help.

Behavioral therapies that may be used with drug therapy include:

Cognitive behavioral therapy to change distorted and possibly harmful perceptions of severe anxiety
Pleasant mental imagery
Relaxation techniques
Other counseling and therapy techniques may help people gain an understanding of the illness and the factors that protect against or trigger it.

A healthy lifestyle that includes exercise, enough rest, and good nutrition can help reduce the impact of anxiety.

Support Groups
Support groups may be helpful for some patients with GAD. Patients have the opportunity to learn that they are not unique in experiencing excessive worry and anxiety.

Support groups are not a substitute for effective treatment, but can be a helpful addition to it.

Outlook (Prognosis)
The disorder may continue and be difficult to treat, but most patients see great improvement with medications or behavioral therapy.

Possible Complications
People with GAD may develop other psychiatric disorders, such as panic disorder or depression. Substance abuse or dependence may become a problem if you try to self-medicate with drugs or alcohol to relieve anxiety.

When to Contact a Medical Professional
Call your health care provider if:

You are experiencing the signs and symptoms of generalized anxiety disorder
You have been experiencing symptoms for 6 months or longer
Your symptoms interfere with your daily functioning

Alternative Names
GAD; Anxiety disorder
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References

Ebell MH. Diagnosis of anxiety disorders in primary care. Am Fam Physician. 2008;78:501-502.

Gale C, Davidson O. Generalised anxiety disorder. BMJ. 2007;334:579-581.

Schneier FR. Clinical practice: social anxiety disorder. New Engl J Med. 2006;355:1029-1036.

Katon WJ. Clinical practice: panic disorder. New Engl J Med. 2006;354:2360-2367.

Connolly SD, Bernstein GA, Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283.

Update Date: 1/15/2009

Updated by: Christos Ballas, MD, Attending Psychiatrist, Hospital of the University of Pennsylvania, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.