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Maintainer: Daniel R. Rhodes <firstname.lastname@example.org>
The following Frequently-Asked-Questions (FAQ) is a supplement to the
NIMH publications on panic disorder. It includes coping techniques,
reference books, newsletters, organizations, and locating a support
group. This evolving document posted monthly, is for information only
and does not represent professional medical advice. Corrections,
updates, additions, and article summaries are welcome. Please send your
contributions to Dan Rhodes <email@example.com> References
are cited within parenthesis.
Last updated Mar 1, 2006.
TABLE OF CONTENTS
+ Added since last posting
& Updated since last posting
1. What causes the symptoms of a panic attack?
2. What are the origins of panic disorder?
3. Is panic disorder a biological or psychological disorder?
4. How can I cope with anxiety and panic attacks?
5. What is the long term course of panic disorder?
6. What are new medications for panic disorder?
7. Can I become addicted to tranquilizers?
8. How can I find an anxiety disorders specialist or support group?
9. How can I get the most benefit from therapy?
10. What books and articles are recommended for anxiety and
11. Where are web sites with information about anxiety disorders?
1. WHAT CAUSES THE SYMPTOMS OF A PANIC ATTACK?
Adapted from "Mastery of Your Anxiety and Panic", D.H. Barlow and
M.G. Craske, Graywind Publicatons, Albany NY, 1994.
When confronted with a real or perceived threat, the automatic "fight or
flight" response may be triggered to prepare the body for immediate
action. This evolutionary development in many organisms normally
functions for survival and protection. It may become a panic attack
when the emergency response occurs in a situation where it is not
appropriate. Although the symptoms may be uncomfortable and
frightening, they are not dangerous.
The brain activates the sympathetic nervous system, causing the release
of adrenaline from the adrenal glands. This may be experienced as a hot
flush sensation. The rate and strength of the heartbeat increases to
supply more oxygen to the tissues. Contraction or expansion of
different blood vessels divert blood from the skin, fingers, and toes to
the large muscles. This reduces bleeding in case of an "attack", and
may cause a feeling of coldness or numbness in the hands or feet.
Breathing increases in rate and depth to exchange more oxygen to prepare
for exertion. Breathlessness, dizziness, and pain or tightness in the
chest may be experienced. Sweat glands are stimulated to prevent
overheating. The pupils of the eye dilate to admit more light and
increase peripheral vision to scan for danger. Sensitivity to bright
light, and visual disturbances may occur. The digestive system shuts
down to conserve blood for the muscles. A dry mouth and nausea may
result. Muscles tense to prepare for escape, but may cause spasms and
trembling when action is not taken. Thoughts are are focused on the
search for the threat, maintaining alertness and vigilance. If there is
no explanation for the emergency response, thoughts of loosing control,
going crazy, or dying may occur.
The fight or flight response is time limited because adrenaline is
metabolized by the body. When the perceived danger has passed, the
parasympathetic nervous system counteracts the activation of the
sympathetic nervous system, returning the body to a relaxed state.
2. WHAT ARE THE ORIGINS OF PANIC DISORDER?
Adapted from "Panic Anxiety and Its Treatments", Edited by
Gerald L.Klerman, M.D., et. al.
Genetic Factors: Studies show the risk of developing panic disorder is
15-17% in first degree relatives of panic disorder patients. The risk
for development in identical twins is 24-31%. This indicates that
panic disorder may be genetically transmitted.
Psychoanalytic Theories: Panic apprehension may be the emergence of
deeply rooted, primarily aggressive unconscious conflicts, that
originated in traumatic experiences in early childhood.
Learning and Behavior Theories: After the original spontaneous panic
attack, further attacks may occur through conditioning in the
situations where anxiety has been experienced. Phobic avoidance may
develop as patients seek to prevent further panic attacks. Panic
attacks may arise when anxiety is conditioned to internal stimuli, for
example, heart palpitations.
Cognitive Theories: Panic attacks may develop when a person
misinterprets the significance of certain bodily sensations as an
impending medical emergency. This leads to heightened anxiety and
greater nervous arousal, setting up a positive feedback loop. The
rapidly escalating anxiety may lead to a panic attack.
Childhood Separation Anxiety or Behavioral Inhibition: School phobia
and other childhood anxiety disorders may be early forms of panic
disorder. Children of parents with panic disorder are more likely to
exhibit fear and withdrawal in unfamiliar situations.
Parental Attitudes and Behavior: Patients with panic disorder often
describe their parents as overprotective, restricting, controlling,
critical, frightening, or rejecting.
Provocation Studies: Injection of sodium lactate can provoke panic
attacks, possibly by stimulation of the locus ceruleus in the brain
stem. Carbon dioxide, yohimbine, caffeine, and other agents have
provoked panic attacks in panic disorder patients. These agents have
been useful in studying the characteristics and mechanisms of panic
Biological Markers: Panic disorder patients may have abnormalities in
monoamine oxidase, serotonin uptake, alpha2-adrenoceptor and
3H-imipramine receptors in platelets, and serotonin or norepinephrine
metabolism. This may support the role of neurotransmitter
abnormalities in panic disorder.
Animal Models: Animal studies have implicated activation or
abnormality of several brain structures within the limbic system during
Brain Imaging: During PET scans, abnormal cerebral blood flow patterns
have been observed in the parahippocampal and hippocampal regions of
the brain in panic disorder patients.
Nocturnal Panic Attacks: Increased sleep latency, decreased sleep
time, decreased sleep efficiency, and increased rapid eye movement have
been observed in panic disorder patients.
Neurotransmitter Theories: Increased activity or reactivity in the
noradrenalin or serotonin neurotransmitter systems may cause or relate
to panic attacks. A subsensitivity of the benzodiazepine receptor
could decrease the effect of GABA, an inhibitory neurotransmitter. An
excess or deficit of a naturally occurring substance operating on the
benzodiazepine receptor may exist.
Suffocaton Alarm Theory: A suffocation alarm system within the brain
may be hypersensitive to an increase in carbon dioxide level. This
produces sudden respiratory distress followed by hyperventilation,
panic, and the urge to flee. (Klein DF, False Suffocation Alarms,
Spontaneous Panics, and Related Conditions, Arch. Gen. Psychiatry, 50,
Apr 1993, p 306-317)
Life Events: Significant life events involving a loss or threat within
the previous 12 months may contribute to the development of panic
Personality Factors: Patients may have unassertive, fearful,
dependent, passive, anxious, or shy personality traits which preceed
the development of panic disorder.
3. IS PANIC DISORDER A BIOLOGICAL OR PSYCHOLOGICAL DISORDER?
Adapted from "Panic Disorder: The Medical Point of View" by William
This is a controversial subject that has divided research and
treatment of panic disorder. All human behavior has a biological basis
at the nerve cell level, but panic disorder also involves exaggerated
thought and behavior patterns.
One theory that includes both biological and behavioral theories
proposes that the components of panic disorder: the panic attack,
anticipatory anxiety, and agoraphobia, are associated with three
distinct areas of the brain. These areas are the brain stem, limbic
system, and frontal cortex, respectively. Panic attacks are triggered
by stimulation of areas in the brain stem that control the release of
adrenalin. Stimulation of the locus ceruleus produces most of the
physical symptoms of panic. Antidepressants seem to block panic
attacks by reducing the firing rate of the locus ceruleus. The brain
stem is also stimulated by higher brain areas which may be involved
The limbic system, involved with the emotions of rage, arousal and
fear, is suspected to be the location for anticipatory anxiety. This
area is rich with benzodiazepine receptors so benzodiazepine
medications are most effective in the limbic area. Paths linking the
brain stem with the limbic system can produce anticipatory anxiety
following a panic attack and vice versa. The limbic system is also
sensitive to changes in blood flow caused by hyperventilation.
Abdominal breathing and relaxation decreases anticipatory anxiety by
quieting the limbic system, blocking a potential trigger path for a
Agoraphobia is a learned behavior pattern which is probably located in
the frontal cortex. Cognitive-behavioral treatments are most effective
at this higher level of the brain. Discharges from the brain stem may
be interpreted by the frontal cortex as a dangerous, life-threating
event, and associations between the panic attack, environment, and
thoughts are made. Decending paths from the frontal cortex enable
catastrophic thoughts to stimulate the brain stem and cause panic
Thus the three areas of the brain all intercommunicate during different
phases of a panic episode. According to the model, different
treatments for panic disorder and agoraphobia affect different aspects
of the illness and different parts of the central nervous system.
Reference: "Neuroanatomical Hypothesis for Panic Disorder", by J.M.
Gorman, M.R. Liebowitz, A.J. Fyer, and J. Stein, American Journal of
Psychiatry, 146:2, Feb. 1989.
4. HOW CAN I COPE WITH ANXIETY AND PANIC ATTACKS?
You may be able to resolve the stress contributing to your anxiety.
Medications can minimize the discomfort of panic attacks. Some people
avoid medications because of side effects, while others are tapering
off medication and need coping methods to handle the withdrawal effects.
Cognitive-behavior therapies incorporate coping techniques to reduce
anticipatory anxiety and reduce the intensity and duration of panic
attacks. The following techniques taken from literature and personal
Exercises To Reduce General Anxiety
Aerobic exercise: 20 minuites daily before your evening meal.
Examples: swimming, walking, ski machine, stair climber, etc.
Progressive muscle relaxation: On waking up and before going to
sleep. Tense each major muscle group for 10 seconds, think "relax"
then release muscle tension while exhaling slowly. Pause for 20
seconds and repeat. Visualize your body becoming heavy.
Abdominal breathing: 10 minutes breathing slowly through your nose.
Inhale expanding your stomach without moving your chest. Slowly
exhale, think "calm". Your breathing rate should be 6-10 cycles per
minute. Practice several times a day.
Autogenics exercise: Scan your body from head to toes. Use abdominal
breathing and focus on each area of tension. As you exhale, visualize
the area becoming warm and heavy.
Biofeedback: Tape a thermometer to your middle finger tip or use a
heart rate monitor. Use the autogenic exercise to raise your finger
temperature or lower your heart rate.
Maintain a daily routine. Wake up, eat 3 meals, take medication (if
prescribed), and go to sleep at the same times every day.
Challenge your catastrophic thoughts with rational alternatives.
Avoid caffene, nicotine, alcohol, antihistamines containing
pseudoepinephrine, sleeping pills.
Exercises To Reduce Panic Symptoms
* Use abdominal breathing (see above).
* See, touch, and feel the objects around you.
* Tell yourself the feelings are not harmful.
* Tell yourself the feelings will pass.
* Visualize a peaceful scene.
* Let you mind go blank.
* Passively accept your symptoms.
* Sing or hum a tune.
* Read a book.
* Talk to a friend.
* Pet your dog or cat.
* Take a walk.
* Take a warm bath.
* Splash cold water on your face.
* Clean the house or wash the car.
Golden Rules for Coping With Panic
Adapted with permission from Anxiety Disorders Association of America,
6000 Executive Blvd., Rockville, MD, 20852.
1. Remember that although your feelings and symptoms are very
frightening, they are not dangerous or harmful.
2. Understand that what you are experiencing is just an exaggeration of
your normal bodily reactions to stress.
3. Do not fight your feelings or try to wish them away. The more you
are willing to face them, the less intense they will become.
4. Do not add to your panic by thinking about what "might" happen. If
you find yourself asking, "What if?", tell yourself "So what!".
5. STAY IN THE PRESENT. Notice what is really happening to you as
opposed to what you think "might" happen.
6. Label your fear level from zero to ten and watch it go up and down.
Notice that it stays at a very high level for a relatively short
7. When you find yourself thinking about the fear, CHANGE YOUR "WHAT
IF" THINKING. Focus on and carry out a simple and manageable task.
8. Notice that when you stop adding frightening thoughts to your fear,
it begins to fade.
9. When the fear comes, expect and accept it. Wait and give it time to
pass without running away from it.
10. Be proud of yourself for your progress thus far, and think about
how good you will feel when you succeed this time.
5. WHAT IS THE LONG TERM COURSE OF PANIC DISORDER?
There is little data on the long term course of panic disorder. It has
been accurately classified only since 1980 and few follow-up studies
have been performed. 220 patients from the Cross-National
Collaborative Panic Study were interviewed 2 to 6 years after
participating in an 8 week trial of alprazolam, imipramine, and a
placebo (Katschnig & Amering in Wolf & Maser). Results are summarized
39% had no panic attacks
60% had no or mild phobic avoidance
82% had no or mild work disability
45% were not taking medication
23% were taking benzodiazepines
12% were taking antidepressants
9% were taking benzodiazepines and antidepressants
11% were taking other psychoactive medications
31% recovered and stayed well
50% had recurrent or chronic moderate symptoms
19% had chronic severe symptoms
no suicides were reported
A two-year followup study was conducted on patients that received a 15
week panic control treatment (Barlow in Wolfe & Maser). 81% of the
patients were panic free, and 50% also recovered from anxiety and
6. WHAT ARE NEW MEDICATIONS FOR PANIC DISORDER?
Adapted from Gorman JM, New and Experimental Pharmacological
Treatments for Panic Disorder, in Wolfe & Maser:
Drugs that selectively block presynaptic neuronal reuptake of serotonin
(SSRIs) are fluoxetine (Prozac), sertraline (Zoloft), paroxetine
(Paxil), fluvoxamine (Luvox), and venlafaxine (Effexor). Studies have
documented that fluoxetine and fluvoxamine reduce panic attacks and
Many clinicians in the United States already prescribe fluoxetine and
sertraline for panic patients, often as the drug of first choice. The
serotonin reuptake blockers have a favorable side effect profile
compared with currently available antipanic drugs. However some
patients have a hypersensitivity reaction when fluoxetine treatment is
initiated at 20 mg/day. Consequently, initiation of therapy at lower
dosages is often recommended.
Buspirone, a 5-HT1a partial agonist, has been shown to be equally
effective as benzodiazepines in the treatment of GAD (Generalized
Anxiety Disorder). However, reports and clinical results indicate that
buspirone does not block panic attacks.
Adapted from Appleton WS, Prozac and the new antidepressants,
Plume Books, 1997:
Effexor (venlafaxine) is a serotonin and norepinephrine reuptake
inhibitor. Some studies have shown Effexor to be faster acting and
more effective than the SSRIs for severely depressed patients. The
short half life requires multiple daily doses. Blood pressure may be
increased at higher doses. Side effects are similar to the SSRIs.
Serzone (nefazodone) is a serotonin and norepinephrine reuptake
inhibitor that also blocks one serotonin receptor subtype. Its
effectiveness is equal to the TCAs and SSRIs for depressed patients.
Improved sleep and reduced anxiety may occur within one week. The
short half life requires multiple daily doses. Dizziness, drowsiness,
weakness, and lack of enery are common side effects which were reported
more often than with the SSRIs, but sweating, anxiety, sleeplessness,
and diarrhea were reported less often. Serzone has a lower incidence
of sexual side effects. Benzodiazepine levels are increased when taken
Remeron (mirtazapine) is a new class of antidepressant that enhances
serotonin and norepinephrine levels and blocks some serotonin receptor
subtypes. It also effects other neurotransmitters which may cause
weight gain and mild sleepiness. Studies show effectiveness equal to
the TCAs for depressed patients. One dose per day is sufficient. The
most common side effect is sleepiness, followed by dry mouth, weakness
and lack of energy, and weight gain. Sexual side effects are minimal.
Decreased white blood cell count was a rare side effect.
7. CAN I BECOME ADDICTED TO TRANQUILIZERS?
Quoted from "Panic Disorder: The Medical Point of View", by William
"Our society appears to have a phobia concerning benzodiazepines. I
believe this fear started many years ago when Valium was prescribed for
minor anxiety and patients were not made aware of the potential for
developing physical dependence. It is physical addiction that most
patients worry about with a benzodiazepine. I believe *addiction*
refers to a severe form of drug abuse in which the individual craves a
substance despite negative consequences and needs more and more for the
same effect. I do not think that patients with panic disorder crave the
benzodiazepines for their effect or frequently develop physical
tolerance (with the possible exception of substance abusers). It is
possible for patients to develop *physical dependence* on the
benzodiazepines when used at moderate to high doses over months or
years. However, this simply means that the benzodiazepine has to be
tapered slowly rather than stopped abruptly to avoid having a withdrawal
symptom" (p 115).
Always obtain medical advice before discontinuing a medicine such
as a benzodiazepine. While Dr. Kernodle down plays the possibility
of a user developing physical tolerance to benzodiazepines, sudden
discontinuance after long term chronic use of moderate to high doses
of benzodiazepines is known to create distressing and sometimes
life threatening physical problems in the majority of people.
8. HOW CAN I FIND AN ANXIETY DISORDERS SPECIALIST OR SUPPORT GROUP?
Read alt.support.anxiety-panic.moderated (ASAPM),
alt.support.anxiety-panic (ASAP) and
alt.recovery.panic-anxiety.self-help. We meet to share
experiences with anxiety and panic for mutual support.
Refer to the newsgroup ASAPM for Internet Relay Chat
support groups. [note: IRC channels are no longer
included in either FAQ.]
National Institute of Mental Health
Pamphlets on anxiety disorders.
National Mental Health Association
Referrals to local chapters
National Alliance for the Mentally Ill
(800)950-6264 or (703)524-7600
Referrals to local chapters
Anxiety Disorders Association of America
6000 Executive Blvd., Suite 513
Rockville, MD 20852
phone: (301)231-9350 email: firstname.lastname@example.org
List of anxiety disorders specialists and support groups
932 Evelyn St.
Menlo Park, CA 94025
Anxiety disorders therapy, telephone counseling, mail order products.
Contact for affiliated groups.
128 Country Club Drive
Chula Vista, CA 91911
Anxiety disorders home treatment program, audio tapes. Contact
for affiliated groups.
106 N. Church St., Suite 200
Oak Harbor, OH 43449
Attacking Anxiety home study program, audio tapes
P.O. Box 1180
Palm Springs, CA 92263
For information, send a self-addressed envelope with postage.
Contact for affiliated groups.
Agoraphobics Building Independent Lives (ABIL)
1418 Lorraine Ave.
Richmond, VA 23227
Affiliated groups throughout Virginia and vicinity
MIND (National Association for Mental Health)
22 Harley St.
London, W1N 2ED, U.K.
British Association for Counselling
1 Regent Place
Rugby, Warwickshire CV21 2PJ, U.K.
office: 01788 550899 information: 01788 758328
British Psychological Society
St. Andrews House
48 Princess Road East
Leicester, LE1 7DR, U.K.
phone: 0116 254 9568
Royal College of Psychiatrists
17, Belgrave Square
London, SW1X 8PG, U.K.
phone: 0171 235 2351
9. HOW CAN I GET THE MOST BENEFIT FROM THERAPY?
* Find a mental health professional who has training and experience in
treating anxiety disorders.
* If you have difficulty communicating with your doctor or therapist,
find another one.
* Keep a log of your anxiety level, panic attacks, and preceeding
events. Discontinue this activity if it is not productive.
* Prepare notes before appointments with your doctor or therapist.
* Self-help workbooks may be useful in conjunction with your therapy.
* Between appointments practice your anxiety reduction exercises.
Gradually expose yourself to the situations you fear.
* Ask your doctor about common side effects of medications. Notify your
doctor immediately if you experience adverse side effects.
* Take your medication on a regular schedule for the duration agreed
upon with your doctor.
* Antidepressant medications often take 4-6 weeks before you experience
an improvement in your symptoms.
* Do not increase or decrease your medication dose without consulting
with your doctor. Many medications must be tapered off slowly to
moderate withdrawal symptoms.
10. WHAT BOOKS ARE RECOMMENDED FOR ANXIETY AND PANIC DISORDERS?
"From Panic to Power", Lucinda Bassett, Harper-Collins, New York, NY,
1995, ISBN 0-06-017320-3.
"Healing Fear: New Approaches to Overcoming Anxiety", Edmund
Bourne, Ph.D., Publishers' Group West, 1998 ISBN 1572241160. The
author of "The Anxiety and Phobia Workbook" offers proven strategies
for battling anxiety, inspired by his struggle with his own
"Healing Anxiety with Herbs", Harold H. Bloomfield, M.D., Harper
Collins, New York, NY, 1998, ISBN 0-06-019127-9.
"Hyperventilation Syndrome", Dinah Bradley, Celestial Arts, Berkeley,
CA, 1992, ISBN 0-89087-656-8. A physiotherapist writes about the
relationship between hyperventilaton and anxiety, breathing retraining,
exercise, and relaxation.
"The Feeling Good Handbook", David Burns M.D., William Morrow, New
York, NY, 1989, ISBN 0-688-01745-2. Practical cognitive-behavior
techniques for anxiety and depression.
"Coping with Panic: A Drug-Free approach to Dealing with Anxiety
Attacks", George A. Clum, Ph.D., Brooks/Cole Publishing Co., Pacific
Grove, CA, 1990, ISBN 0-534-11295-1. Cognitive-behavior approach with
extensive coverage of coping techniques.
"Overcoming Anxiety without Tranquilizers", Edward H. Drummond, M.D.,
Dutton Publishing, New York, NY, 1997, ISBN 0-525-94298-X. The author
contends that tranquilizers are overprescribed and exacerbate anxiety
symptoms. He provides coping methods, relexation exercises, and a
program for tapering off tranquilizers.
"Panic Free", Lynne Freeman, Ph.D., Barclay House, New York, NY, 1995,
"If You Think You Have Panic Disorder", Roger Granet, M.D. and Robert
McNally, Dell Publishing, New York, NY, 1998. Comprehensive coverage of
symptoms, causes, and treatments of panic disorder. The authors
consider PD as a disease and the book reads like an update to "The
Anxiety Disease" by David Sheehan.
"Triumph Over Fear: A Book of Help and Hope for People with Anxiety,
Panic Attacks, and Phobias", Jerilyn Ross, Bantam Books, 1994, ISBN
0-553-08132-2. Ross is president of the ADAA, and suffered from fear of
heights. Good coverage on treatment of phobias.
"The Anxiety Disease", David Sheehan, M.D., Bantam, 1986, ISBN
0-553-27245-4. Development phases of anxiety disorders and overview of
"Hope and Help for Your Nerves", Dr. Claire Weekes, Signet, 1969, ISBN
0-451-16722-8. A classic on coping and curing panic and anxiety by a
pioneer in the field. Thoughts and feelings accompaning anxiety.
Handling complicating problems. Desensitization by floating through
panic without adding fear. Coping with setbacks. Companion audio tape
"More Help for Your Nerves", Dr. Claire Weekes, Bantam, 1984, ISBN
0-553-26401-X. Update and extension of her earlier work. Explains her
principles of recovery: Facing, Accepting, Floating, Letting time pass.
Answers to frequently asked questions. Journals to patients in
"Peace from Nervous Suffering", Dr. Claire Weekes, Dutton, 1990, ISBN
0-451-16723-6. Extension of her work with emphasis on Agoraphobia.
Journals to patients in recovery.
"Don't Panic; Taking Control of Anxiety Attacks", R. Reid Wilson,
Ph.D., Harper, 1986, ISBN 0-06-091438-6. Panic attack coping skills.
Breathing and relaxation techniques. Developing supportive thought
"Master Your Panic and Take Back Your Life, 2nd Ed.", Denise F.
Beckfield, Ph.D., Impact Publishers, 1998, ISBN 0-886230-08-0. Includes
insight through writing, breathing retraining, relaxation, stress
management, exposure exercises, medications issues, relapse prevention.
"Mastery of your Anxiety and Panic II", David Barlow, Ph.D., and
Michelle Craske, Ph.D., Graywind Publications, Albany, NY, 1994, ISBN
1-880659-10-7. Structured workbook based on the panic control
"The Anxiety and Phobia Workbook (2nd edition)", Edmund J. Bourne,
Ph.D., New Harbinger, 1994, ISBN 1-57224-003-2. Summary of techniques
previously published by others. Section on nutrition and exercise.
Cognitive-behavior change methods.
"Panic Buster," Bonnie Crandall, Hatch Creek Publishing, 933 Forest
Ave. Ext., Jamestown, NY 14701, email: email@example.com (order
direct). A practical guide to help conquer panic attacks and
agoraphobia by one who has lived through them 20 years and recovered.
"The Relaxation and Stress Reduction Workbook, Third Edition", Martha
Davis, Ph.D., Elizabeth R. Eshelman, M.S.W., Matthew McKay, Ph.D., New
Harbinger Publications, Oakland, CA, 1988, ISBN 0-934986-63-0.
Extensive, practical coverage of anxiety reducing exercises.
"Managing Your Anxiety", Christopher McCullough, Ph.D., and Robert
Mann, Berkley Books, New York, NY, 1994, ISBN 0-425-14295-7. Includes
self care program.
"Anxiety, Phobias, and Panic; Taking Charge and Conquering Fear, 2nd.
Ed.", Reneau Peurifoy, MA, MFCC, Life Skills, Citrus Heights, CA,
1992, ISBN 0-929437-13-6. Workbook format for self improvement
program. Vulnerable personality traits. Cognitive restructuring
exercises. Companion audio tapes available.
"Overcoming Anxiety", Reneau Peurifoy, Holt & Co., New York, NY, 1997,
"The Panic Attack Recovery Book", Shirley Swede and Seymour S. Jaffe,
M.D., Signet, New York, NY, 1989, ISBN 0-451-16228-5. Program covers
diet, relaxation, exercise, attitude, imagination, social support, and
spiritual values. Includes personal recovery stories.
"An End to Panic", Elke Zuercher-White, Ph.D., New Harbinger Pub.,
Oakland CA, 1995, ISBN 1-57224-034-2.
Intermediate Level Books
"Prozac and the New Antidepressants", William S. Appleton, M.D.,
Plume, New York, NY, 1997, ISBN 0-452-27443-5. Practical information
about benefits and side effects of antidepressants, including new
medications under development.
"You Mean I Don't Have to Feel This Way?: New Help for Depression,
Anxiety, and Addiction", Colette Dowling, Bantam, New York, NY, 1993,
ISBN 0-553-37169-X. Biological orientation, excellent coverage of MAOI
"The Good News About Panic, Anxiety, and Phobias", Mark S. Gold, M.D.,
Bantam, 1989, ISBN 0-553-34916-3. Extensive coverage of physical
problems that mimic panic and anxiety disorders. Medical treatment
"The Essential Guide to Psychiatric Drugs", Jack M. Gorman, M.D., St.
Martin's Press, New York, NY, 1995, ISBN 0-312-95458-1. Readable,
comprehensive coverage of currently available drugs, application, and
side affects. Includes new antidepressant medications.
"The New Psychiatry", Jack M. Gorman, M.D., St. Martin's Press, New
York, NY, 1996, ISBN 0-312-14690-6.
"Understanding Biopsychiatry", Robert J. Hedaya, M.D., Norton, New
York, NY, 1996, ISBN 0393-70191-3.
"The 3-Pound Universe", Judith Hooper and Dick Teresi, Putnam, New
York, 1992, ISBN 0-87477-650-3. Recent research discoveries about the
chemistry and structure of the brain by two prominent science writers.
"Panic Disorder: The Medical Point of View, 4th Edition", William D.
Kernodle, M.D., Cadmus Publishing, Richmond, VA, 1997, ISBN
0-9631533-3-1. Emphasis on biological model, medication, case
"Healing the Anxiety Diseases", Thomas L. Leaman, M.D., Plenum Press,
New York, NY, 1992, ISBN 0-306-44128-4. Compassionate book by a
family physician explains the origins of anxiety symptoms. Advocates
treatment by a combination of medication and cognitive therapy.
"The Emotional Brain", Joseph LeDoux, Simon and Schuster, New York, NY,
1996, ISBN 0-684-80382-8. A neuroscientist explores historical and
current research on neural pathways associated with basic emotions, and
the role of the amygdala in the fear response.
"Beyond Prozac: Brain-Toxic Lifestyles, Natural Antidotes and New
Generation Antidepressants", Michael J. Norden, M.D., Regan Books,
New York, NY, 1995, ISBN 0-06-039151-0. A holistic approach to
coping with depression and anxiety. Recommendations on diet,
"The Biology of Mental Disorders", U.S. Congress, Office of Technology
Assessment, U.S. Government Printing Office, Washington DC, Sept. 1992
Summary of Government funded research on mental disorders.
"Panic Disorder: Clinical, Biological and Treatment Aspects", Gregory
Asnis and Herman van Praag, Eds., Wiley, 1995, ISBN 0-471-08999-0.
"Panic Disorder Theory, Research, and Therapy", R. Baker, Wiley, New
York, NY, 1992, ISBN 0-471-93317-1. Cognitive-behavior theory and
"Anxiety and its Disorders: The Nature and Treatment of Anxiety and
Panic", David Barlow, Ph.D., Guilford Press, New York, 1988, ISBN
0-89862-720-6. Technical but readable text on biology,
characteristics, processes, origins, and treatment of anxiety
"Anxiety Disorders and Phobias: a Cognitive Perspective", Aaron T. Beck
and Gary Emery, New York, Basic Books, 1990, ISBN 0-465-00385-0.
Theoretical cognitive models and practical treatments for anxiety
"Integrative treatment of anxiety disorders", James M Ellison (Ed),
American Psychiatric Press, Washington, DC, 1996. An overview of the
spectrum of anxiety disorders and reviews their treatment alternatives.
The integration of pharmacotherapy with cognitive-behavior
psychotherapy is emphasized throughout.
"A Primer of Drug Action", Robert M. Julien, M.D., W.H. Freeman, New
York, NY, 1995, ISBN 0-7167-2388-X. An authoratative account of the
effects of psychoactive drugs on the brain and behavior. Written in
nontechnical language with many illustrations.
"Panic Anxiety and Its Treatments", Edited by Gerald L. Klerman, M.D.,
et. al., American Psychiatric Press, Washington D.C., 1993, ISBN
0-88048-684-8. Excellent overview of current theories and treatments of
panic disorder with extensive reference list.
"Panic Disorder: A Critical Analysis", Richard J. McNally, Ph.D.,
Guilford Press, New York, NY, 1994, ISBN 0-89862-263-8. A balanced,
critical analysis of research and theory on panic disorder. Evaluation
of biological and psychological findings.
"Psychopharmacology of Panic", Stuart Montgomery, ed., Oxford University
Press, New York, NY, 1993, ISBN 0-19-262087-8.
"Panic disorder", Stanley Rachman and Padmal de Silva, Oxford
University Press, 1996. This book explains the causes and symptoms of
panic disorder, and provides information on effective treatments
available. The book is intended for sufferers of this debilitating
disorder, their families, and health care workers.
"Essential Psychopharmacology", Stephen M. Shahl, M.D., Cambridge
University Press, New York, NY, 1996, ISBN 0-521-42620-0. Written for
medical students, this book effectively uses cartoons to illustrate the
principles of action of the latest psychoactive medications.
"The Nature and Treatment of Anxiety Disorders", C. Barr Taylor, M.D.
and Bruce Arnow, Ph.D., The Free Press, New York, NY, 1988,
ISBN 0-02-932981-7. Combines the psychological and biological approach
to anxiety disorders. The authors advocate a team approach to
"Treatment of Panic Disorder: A Consensus Development Conference",
Barry Wolfe, Ph.D. and Jack Maser, Ph.D., editors, American Psychiatric
Press, Washington, DC, 1994, ISBN 0-88048-685-6. Clinical text on
current research on panic disorder by experts in the field.
"Anxiety and Related Disorders: a Handbook", Benjamin Wolman and George
Striker, eds., Wiley, 1994, ISBN 0-471-54773-5.
"ADAA Reporter", The Anxiety Disorders Association of America, 6000
Executive Blvd., Suite 513, Rockville, MD, 20852, published quarterly,
$10/year, included with $25 membership dues.
"National Panic/Anxiety Disorder (NPAD) Newsletter", 1718 Burgandy
Place, Suite B, Santa Rosa, CA, 95403, published bi-monthly, $25/year.
"Anxiety Newsletter", The Anxiety Treatment Center, PO Box 80182,
Valley Forge, PA 19484. $25 for 12 issues, free complimentary issue.
The following article abstracts were condensed from the MEDLINE and
PsycINFO databases. Articles reprints may be ordered through your local
Bell-C-J. Nutt-D-J. Serotonin and panic. British Journal of Psychiatry.
1998 Jun. 172. P 465-71. Clinical trials have shown that of all the
serotonergic agents only the SSRIs are effective in panic disorder. They
are as beneficial as the TCAs and seem to be better tolerated which may
be particularly significant in view of the chronic nature of the
condition. Serotonin plays a role in panic disorder and serotonergic
dysfunction, however the results and evidence do not fit one theory
den-Boer-J-A. Slaap-B-R. Review of current treatment in panic disorder.
International Clinical Psychopharmacology. 1998 Apr. 13 Suppl 4.
P S25-30. We compared the properties of currently available treatment
options for panic attacks, including the benzodiazepines, tricyclic
antidepressants, monoamine oxidase inhibitors and selective serotonin
reuptake inhibitors (SSRIs). Experimental approaches in the development
of therapeutic agents of potential use against panic disorder were also
examined. It is clear that SSRIs are an effective treatment for panic
disorder, and their antidepressant activity also allows concurrent
treatment of comorbid depressive disorders, for which patients with
panic disorder are at high risk. However, despite the availability of
effective antipanic agents, some patients do not respond to treatment.
Deakin-J-F. The role of serotonin in panic, anxiety and depression.
International Clinical Psychopharmacology. 1998 Apr. 13 Suppl 4.
P S1-5. Anxiety and depressive disorders occur across a broad spectrum,
and each different disorder may involve distinct genetic and
neurobiologica/neurochemical mechanisms. Paradoxically, the
single-action selective serotonin reuptake inhibitors are effective in a
range of these disorders. However, the paradox may be resolved by an
understanding of the distinct ways in which serotonin modifies the
physiological coping mechanisms that become dysfunctional in these
Edwards-S. Uhlenhuth-E-H. Panic disorder and agoraphobia: a sufferer's
perspective. Journal of Affective Disorders 1998 Jul. 50(1). P 65-74.
This is a story by a woman about her life with panic, agoraphobia, and
depression. She tells us about the clinical features, the heritable
components, the environmental contributions, the developmental
penalties, the social consequences, and the therapies for these
conditions far more vividly than even the most dramatic of our
Bennett-J-A. Moioffer-M. Stanton-S-P. Dwight-M. Keck-P-E-Jr. A risk-
benefit assessment of pharmacological treatments for panic disorder.
Drug Safety. 1998 Jun. 18(6). P 419-30. Tricyclic antidepressants
(TCAs) have a proven efficacy, are affordable and are conveniently
administered. Selective serotonin reuptake inhibitors are also potential
first line agents and are well tolerated and effective, with a
favourable adverse effects profile. Benzodiazepines are an effective
treatment, providing short-term relief of panic-related symptoms.
Monoamine oxidase inhibitors, because of their adverse effects profile,
potential drug interactions, dietary restrictions, gradual onset of
effect and overdose risk, are not considered to be first-line agents.
Valproic acid (valproate sodium), shows potential for use in panic
As a supplement to drug therapy, cognitive behavioural therapy is
Jefferson-J-W. Antidepressants in panic disorder. J-Clin-Psychiatry.
1997. 58 Suppl 2. P 20-4; discussion 24-5. Tricyclic antidepressants,
monoamine oxidase inhibitors (MAOIs), serotonin selective reuptake
inhibitors (SSRIs), and other antidepressants have all been studied,
with varying results, in patients with panic disorder. The MAOIs are
believed by some clinicians to be the most potent anti-panic agents, but
their considerable side effects limit their use. The tricyclic
antidepressants imipramine and clomipramine are well established in
treating panic disorder, although today many clinicians choose an SSRI
as their first-line agent.
Ballenger-J-C. Davidson-J-R. Lecrubier-Y. Nutt-D-J. Baldwin-D-S.
den-Boer-J-A. Kasper-S. Shear-M-K. Consensus statement on panic
disorder from the International Consensus Group on Depression and
Anxiety. J-Clin-Psychiatry. 1998. 59 Suppl 8. P 47-54. The consensus
statement provides standard definitions for response and remission and
identifies appropriate strategy for the management of panic disorder in
a primary care setting.
Serotonin selective reuptake inhibitors are recommended as drugs of
first choice with a treatment period of 12 to 24 months. Pharmacotherapy
should be discontinued slowly over a period of 4 to 6 months.
den-Boer-J-A. Pharmacotherapy of panic disorder: differential efficacy
from a clinical viewpoint. J-Clin-Psychiatry. 1998. 59 Suppl 8. P30-6;
discussion 37-8. This review considers the efficacy of Antidepressants
and high-potency benzodiazepines in reducing panic attack frequency and
in addition considers their ability to attenuate global anxiety,
depressive symptomatology, agoraphobic avoidance, and overall
impairment. The antidepressants are more effective than the
benzodiazepines in reducing associated depressive symptomatology and are
at least as effective for improving anxiety, agoraphobia, and overall
Nutt-D-J. Antidepressants in panic disorder: clinical and preclinical
mechanisms. J-Clin-Psychiatry. 1998. 59 Suppl 8. P 24-8; discussion
29. This review summarizes the biological evidence for the involvement
of serotonin in the pathogenesis of panic disorder and considers the 2
opposing theories that are urrently prevalent (5-HT excess and 5-HT
deficit). The serotonin selective reuptake inhibitors are increasingly
considered as first-line treatment for panic disorder, and the
interaction of these agents with the serotonergic system is considered.
Davidson-J-R. The long-term treatment of panic disorder.
J-Clin-Psychiatry. 1998. 59 Suppl 8. P 17-21; discussion 22-3. This
paper reviews data from long-term studies of drug treatment for panic
disorder to address issues of whether medication benefits persist,
whether improvement can continue over several months or years, the
tolerability of long-term treatment, patient selection for long-term
treatment, and when and how to stop medication. The main conclusion is
that long-term drug treatment of panic disorder is necessary, effective,
and safe. Withdrawal from all types of medication should be considered,
slow, planned, and individualized; some patients require an indefinite
duration of treatment.
Goldberg-C. Cognitive-behavioral therapy for panic: effectiveness and
limitations. Psychiatr-Q. 1998 Spring. 69(1). P 23-44. Controlled
studies have demonstrated that cognitive-behavioral therapy is superior
to other treatments for panic--85% of patients are panic-free at
posttreatment and improvements are maintained at follow-up. However, 26%
of waiting-list controls are also panic-free making the net percentage
of panic-free treated patients 59%. There is room for improvement in at
least 50% of patients, and a substantial number of patients continue to
take medication and seek additional treatment.
Yonkers-K-A. Zlotnick-C. Allsworth-J. Warshaw-M. Shea-T. Keller-M-B.
Is the course of panic disorder the same in women and men?
Am-J-Psychiatry. 1998 May. 155(5). P 596-602. Using observational,
longitudinal data from the Harvard/Brown Anxiety Disorders Research
Program, the authors analyzed remission and symptom recurrence rates in
panic patients with respect to sex.
This study extends previous findings by showing that not only are women
more likely to have panic with concurrent agoraphobia, but they are more
likely than men to suffer a recurrence of panic symptoms after remission
Bourin-M. Baker-G-B. Bradwejn-J. Neurobiology of panic disorder. J-
Psychosom-Res. 1998 Jan. 44(1). P 163-80. Various provocative
agents, including sodium lactate, carbon dioxide (CO2), caffeine,
yohimbine, serotoninergic agents, and cholecystokinin (CCK), have been
utilized as panicogenics in studies on healthy volunteers as well as in
panic disorder patients. An overview of the utilization of these agents
to study the neurobiology of panic disorder is presented. The possible
roles of several neurotransmitters and neuromodulators in the etiology
of panic disorder and in the actions of drugs used in its treatment are
Middleton-H-C. Panic disorder: a theoretical synthesis of medical and
psychological approaches. J-Psychosom-Res. 1998 Jan. 44(1). P
121-32. Medical approaches implicate disturbances of ascending brain
noradrenergic and serotonergic systems, and support related
pharmacotherapies. Contemporary psychological approaches focus upon
misinterpretations of bodily sensations and an undue appreciation of the
risk of life-threatening illness, and support cognitive/behavioral
psychotherapies. A synthesis is possible by developing the view that the
implicated ascending aminergic systems normally play a part in
"effortful" or context-sensitive behavior. A relative failure of this
under conditions of heightened arousal might be responsible for the
rigid patterns of fear, belief, and behavior that characterize these
Asmundson-G-J. Larsen-D-K. Stein-M-B. Panic disorder and vestibular
disturbance: an overview of empirical findings and clinical
implications. J-Psychosom-Res. 1998 Jan. 44(1). P 107-20. This review
focuses primarily on the literature pertaining to vestibular symptoms in
patients with panic disorder and panic symptomatology in patients with
vestibular complaints. We discuss clinical implications suggested by the
data, outline recommendations for treatment, and highlight some
directions for future investigation.
Sharp-D-M. Power-K-G. Treatment-outcome research in panic disorder:
dilemmas in reconciling the demands of pharmacological and psychological
methodologies. J-Psychopharmacol. 1997. 11(4). P 373-80. In the
following discussion a series of studies comparing pharmacological and
psychological treatments for panic disorder and agoraphobia are
reviewed. The review highlights areas where the competing demands of
research design and clinical applicability lead to dilemmas for the
researcher. Attempts to overcome such dilemmas are described and
alternative solutions discussed.
Beck-J-G. Shipherd-J-C. Zebb-B-J. How does interoceptive exposure for
panic disorder work? An uncontrolled case study. J-Anxiety-Disord. 1997
Sep-Oct. 11(5). P 541-56. The data indicate that IE alone is effective
in reducing panic, panic-related fears, and general anxiety. However,
the positive effects of IE do not appear to extend to agoraphobia,
related fears, or depressed mood. Two distinct within-session patterns
of fear response to IE were noted, one indicating habituation and the
other indicating a lack of fear reduction. Implications for
understanding fear reduction are discussed, along with directions for
Gorman-J-M. The use of newer antidepressants for panic disorder. J-Clin-
Psychiatry. 1997. 58 Suppl 14. P 54-8; discussion 59. Data from
research trials as well as clinical experience are accumulating to
indicate that the serotonin selective reuptake inhibitors
(SSRIs)--fluoxetine, fluvoxamine, paroxetine, and sertraline--and
perhaps venlafaxine, which inhibits both serotonergic and noradrenergic
reuptake, are useful antipanic medications. The possibility also exists
that these newer antidepressants such as SSRIs and venlafaxine are
superior in effectiveness to the previously available drugs and, when
combined with cognitive-behavioral therapy, might provide the best
treatment outcome for patients with panic disorder.
Liebowitz-M-R. Panic disorder as a chronic illness. J-Clin-Psychiatry.
1997. 58 Suppl 13. P 5-8. Panic disorder is a chronic illness that
waxes and wanes, and the prognosis is worse with comorbid agoraphobia,
depression, or personality disorder. Both medication and
cognitive-behavioral therapy have been found helpful in acute treatment
trials of panic disorder. However, recent studies suggest that
therapeutic gains are lost in many instances when treatment is stopped
after short-term medication or cognitive-behavioral therapy. Thus,
maintenance treatment appears necessary for many panic patients.
van Balkom AJ. Bakker A. Spinhoven P. Blaauw BM. Smeenk S. Ruesink
B. A meta-analysis of the treatment of panic disorder with or without
agoraphobia: a comparison of psychopharmacological,
cognitive-behavioral, and combination treatments. Journal of Nervous &
Mental Disease. 185(8):510-6, 1997 Aug. Antidepressants, psychological
panic management, high-potency benzodiazepines, and antidepressants
combined with exposure in vivo were superior to the control condition
for panic attacks. Exposure in vivo alone was not effective for panic
attacks. For agoraphobic avoidance, the combination of antidepressants
with exposure in vivo was superior to the other conditions. The
combination of antidepressants with exposure in vivo is the most potent
short-term treatment of PA.
Stein DJ. Bouwer C. A neuro-evolutionary approach to the anxiety
disorders. [Review] Journal of Anxiety Disorders. 11(4):409-29, 1997
Jul-Aug. The false suffocation alarm of panic attack is the most fully
elaborated of the neuro-evolutionary accounts of an anxiety disorder.
However, viable neuro-evolutionary approaches have also been offered for
other anxiety disorders, such as obsessive-compulsive disorder and
social phobia. Although the theoretical basis for such an approach has
become increasingly appealing over the last several years, this
foundation requires supplementation by further empirical research.
Shear MK. Mammen O. Anxiety disorders in primary care: a life-span
perspective. Bulletin of the Menninger Clinic. 61(2 Suppl A):A37-53,
1997 Spring. After reviewing prevalence rates for these disorders in
child, adult, and geriatric groups, the authors discuss
cross-generational transmission of illness and identify cross-cutting
themes, such as comorbidity of anxiety and depression, relationship
between anxiety disorders and quality of life, and links among
disability, adversity, and anxiety. They also discuss issues specific to
childbearing, motherhood, and bereavement, and conclude with a brief
summary of treatment approaches.
Nutt D. Management of patients with depression associated with anxiety
symptoms. Journal of Clinical Psychiatry. 58 Suppl 8:11-6, 1997.
Treatment options for depression with anxiety include tricyclic
antidepressants (TCAs) and serotonin selective reuptake inhibitors
(SSRIs). SSRIs are effective in anxiety disorders and against anxiety
symptoms in depressed patients. When the diagnosis of depression with
anxiety is established, it is important to institute prompt, effective
treatment in view of the potential risk of suicide.
Antidepressant discontinuation syndrome: update on serotonin reuptake
inhibitors, Journal of Clinical Psychiatry, 58, supp. 7, 1997.
Shatzberg AF, et. al.: Serotonin reuptake inhibitor discontinuation
syndrome: a hypothetical definition, 5-10. Lejoyeux M, Ades J:
Antidepressant discontinuation: a review of the literature, 11-16.
Haddad P: Newer antidepressants and the disconuation syndrome, 17-22.
Schatzberg AF, et. al.: Possible biological mechanisms of the serotonin
reuptake inhibitor disconuation syndrome, 23-27. Young AH, Currie A:
Physicians' knowledge of antidepressant withdrawal effects: a survey,
28-30. Kaplan EM: Antidepressant noncompliance as a factor in
disconuation syndrome, 31-36. Rosenbaum JF, Zajecka J: Clinical
management of antidepressant discontinuation, 37-40.
11. WHERE ARE WEB SITES WITH INFORMATION ABOUT ANXIETY DISORDERS?
National Institute of Mental Health
Publications on panic disorder
http://www.nimh.nih.gov/healthinformation/anxietymenu.cfm (Who's computer is this?)
Anxiety Disorders Association of America
Conferences, research, helpful hints
http://www.cyberpsych.org/adaa/ (Who's computer is this?)
Grohol Mental Health Page
Psychology, Support, and Mental Health Resources
http://www1.mhv.net/~grohol/ (Who's computer is this?)
Panic-Anxiety web page
Material on agoraphobia, panic attacks, and social phobia
http://www.algy.com/anxiety (Who's computer is this?)
The Mining Company
General mental health with a section on panic disorder
http://panicdisorder.mining.com/ (Who's computer is this?)
Information about OCD, antianxiety medications, mental health topics
http://www.healthguide.com/ (Who's computer is this?)
Free access to MEDLINE database
http://www.healthgate.com (Who's computer is this?)
Free access to MEDLINE, research articles, conference news, weekly
newsletter. Registration required.
http://www.medscape.com (Who's computer is this?)
Distinction between panic and anxiety; also has up-to-date info on
treatment with SSRI's.
http://www.mentalhealth.com (Who's computer is this?)
The Anxiety-Panic.Com search engine (devoted
to hundreds of anxiety related web sites
world-wide) and the ASAP Dictionary of Anxiety
and Panic Disorders can be found at the
http://anxiety-panic.com (Who's computer is this?)
http://anxiety-panic.com/dictionary (Who's computer is this?)
Gary Bradski's web page
Anxiety disorder resources and books
http://cns-web.bu.edu/pub/bradski/calm.html (Who's computer is this?)
Refer to the ASAPM weekly Mini-FAQ for more web sites.
Chuck posted the original NIH Consensus Statement. Gary Cooper,
Arthur Anderson, and Pierre Gaumond reviewed and corrected the FAQ.
Gary Cooper and Cathleen contributed to the resource list. Cathleen
contributed the quotation in section 7. Jane, Mally, Elliot, and Meghan
contributed to the web site list. Jim maintained and posted the FAQ for
a long time. Thanks to all.
The second nicest guy on the internet
For a copy of the ASAPM FAQs please e-mail me at
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