Archive for the ‘Panic Disorder’ Category

Panic and traveling

Question: Dear Dr. Jones, I treated with you about 15 years ago for agoraphobia–and was helped very much by your keen insight into this condition. Would you have time for a quick question? I’ve had a problem traveling long distances from home for most of my adult life. I’ve had periods of remission, lived well despite the condition, working as television reporter, etc. But the problem is, in short, I’ve always limited my travel fearing “the big one.” Now, I want to go to Europe before I’m too old to enjoy! Klonopin works well for me. Do you think if I just plain old up and flew off to Italy, I would not have a “breakdown” if I brought Klonopin?— even if when I got there, I became extremely panicked by facing such a long trip after a life time of fearing it? In case you advise to “work up to it” with smaller trips first–I do note that whenever I force myself to take a trip I always have some degree of panic/pain (although also enjoy the trip!) and one time I had violent panic one week driving 30 miles away–then, flew 1000 miles the next week with less fear! Then, came back and panicked again going 30 miles! For me, sucessive approximation doesn’t seem useful. Thanks so much for any information! Best,


Dear Kate,

Congratulations for not letting Agoraphobia/panic attacks control your life
to any large extent. Although I can’t make specific treatment
recommendations, there are several general principles that apply to your

First, panic attacks associated with travel in cars, planes, etc., are the
claustrophobic kind which are related to hypersensitivity to increasing
levels of CO2 in your blood – conditioned fear responses and anticipatory
anxiety results in shallow breathing and a build up of co2. The best way to
prevent this is to breathe properly – out first…see my website section on
panic attacks for the full technique. Practice this periodically and always use this technique when you
start to get anxious or panicky.

Klonopin is the strongest panic preventer but like most medications needs to
be taken in the right dose. Panic patients tend to take as little as they
can get by with instead of as much as they need. Usual daily dose is 2-3mg
but can be higher. It’s ok to sedate yourself on long flights if necessary.

Desensitization is situation specific – so that being able to fly 1000 miles
doesn’t mean you can necessarily drive long distances. Avoidance or using
escape makes you worse, as does hanging in there but having a horrible
experience. Using proper breathing and or adequate medication to get
through it makes you better. Some people need to add an SSRI or SNRI to
facilitate full desensitization. Positive self-talk and having distractions
can also help.

Good luck!
Dr. Jones

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I have been taking 3mg of Xanax daily for anxiety for 2 years. I have been diagnosed with agoraphobia. Are there any options for medication besides SSRI’s and SNRI’s? They seem to make my anxiety worse. I’ve also had cognitive behavioral treatment with little success. Please help me with any options for overcoming my fears.

Recovery from agoraphobia requires a good understanding of what it is, proper breathing and complete desensitization.  SSRI’s/SNRI’s are not required unless you are unable to progress with CBT, breathing correctly, and benzodiazepines – including as needed extra doses.  Some patients do better on Clonazepam, or Xanax XR, or Niravam.  If SSRI’s/SNRI’s are needed you have to start with a very low dose – the lowest I ever gave a patient was one granule of Effexor XR.

Treat agoraphobia like a bully that wants to run your life.  If you give an inch it will take a mile.  It’s okay to stop, breathe, take extra medication or call a support person, but don’t leave or avoid.

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Will I always need Lexapro and Klonopin if I successfully go through cognitive behavioral therapy?

It partly depends on what you’re taking the medications for.  Uncomplicated panic disorder without agoraphobia has the highest rate of complete remission.  Severe obsessive compulsive disorder, agoraphobia, or social anxiety disorder may require some long term medication to maintain remission.  Generalized anxiety without serious depression may respond fully to CBT.  A lot will depend on how good the CBT is and how hard you are willing to work on it.  For OCD I recommend Brainlock by Jeffrey Schwartz.  For panic disorder proper breathing is essential.  The following link has instructions for proper breathing.

For social anxiety stimulants are frequently helpful.

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"Dude, wait a minute, I can help you!"

That’s what I wish I would have said.  So I’m feeling guilty for just sitting there.  "I’m coming out!" I heard in a deep, but anxious voice.  I turned to see a large man built like a linebacker pushing his way against the flow of people walking down the aisle of a 747 American Airlines flight heading to DFW from the New Jersey airport.  Then I heard the flight attendant say, "where are you going?"  He replied, "I’m not going, I’m scared."  My first impulse was to jump up and go after him – I knew I could help.  I didn’t.  But I should have at least given him my card and said, "call me, I can help you."  Maybe he would have said no thanks but that’s no excuse.  I should have offered.  Why?

I feel obligated to offer help when I see someone in distress and I have the knowledge and  ability to help.  For 30 years I have had a special interest in panic disorder and associated phobias.  Fear of flying associated with panic disorder is easy to treat of course.  I don’t know for sure that he had panic disorder.  He might have had an irrational fear that the plane might crash.  Patients with panic disorder are afraid they are going to have a panic attack which can be a form of claustrophobia.  Fear of panic attacks frequently causes panic because the individual gets so tense that they can’t breathe properly and the combination of increased muscle activity (metabolism) and shallow breathing cause CO2 levels in the blood (hence the brain) to go up and patients with panic disorder have a lower threshold of CO2 tolerance.  Everybody at some CO2 level will panic because the brain is hard wired to let us know if we are in a poorly ventililated place – basically the lower brain centers send the message – "get out of here or you’re going to die!"  This can be life saving under some circumstances – but panic attacks are a "false alarm". 

What the man leaving the plane needed was first to understand the physiology and cause of his symptoms.  Second, he needed to be offered Niravam (fast acting alprazolam that dissolves on the tongue), or sublingual Klonopin that would quickly calm him down, raise his stress tolerance level, and help him maintain control.  He might also have needed psychological support – at least for the first few minutes.

I can try to rationalize "it was none of my business" (cop out).  I could remind myself  "no good deed goes unpunished" (frequently true but cop-out) or I could think well at least he didn’t get gunned down – remember the poor guy in Florida?  (See previous blog).  Maybe he’ll go on line and end up on the Anxiety Disorders Association of America website,, where I’m listed as a resource.

If you or anyone you know suffers from fear of flying make sure to get the treatment needed.  There’s a lot of things we can’t do anything about, this isn’t one of them.


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Panic Personified

Kim Bassinger was interviewed during an HBO special on Panic Disorder.  She described her recovery from Panic Disorder in an unusual but very successful way.  During her recovery period she developed a technique to change her negative thinking and attitudes.  She decided to talk to her fear.  She said, “how do you have so much power over me?”  Fear answered, “I get in your face and talk loud!”  Then she asked, “how can I defeat you?”  Fear replied, “don’t  believe a word I say!”

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Panic Disorder: Did You Know?

  • In the U.S., 1.6% of adults (3 million) will have Panic Disorder in their lifetime.
  • First degree relatives of those with PD are 17x more likely to have PD than the general population
  • 30% of people with PD abuse alcohol
  • Twice as many woman as men have PD
  • Most panic attacks start in the mid 20’s
  • Proper treatment reduces or prevents panic attacks in 70-90% of cases
  • 29-44% of those with PD also have Irritable Bowel Syndrome
  • 43% of ER patients with chest pain actually have PD
  • Panic patients may see an average of 10 doctors before a correct diagnosis is made
  • 50% of those with PD will have clinical depression during their lifetime.
  • PD is abnormal activation of the part of the brain called the amygdala
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Cognitive Behavioral Treatment for Panic Disorder

Cognitive behavioral therapy for Panic Disorder focuses on fears of bodily symptoms, catastrophic thinking, and avoidance behavior.  This is done by identifying specific ways in which the patient can reduce anxiety.

Cognitive restructuring – Identifying and countering fear of bodily sensations and focusing thoughts away from the negative consequences of such sensations.

Individuals with PD often have distortions in thinking that cause a cycle of fear.  When the person experiences physical symptoms, such as racing heart, they react with catastrophic thinking, e.g., “I’m having a heart attack”.  Cognitive restructuring helps the person to recognize thoughts and feelings and to modify their fear response to them.  By changing catastrophic thought patterns the person gains more control over the symptoms, e.g., “it’s only uneasiness and it will pass”.   

Breathing retraining – Learning how to use anxiety management techniques and lifestyle changes (see page 2) to control physiologic reactions.  

Exposure therapy – Helps the person accept and face some fear and anxiety in order to cope with phobic situations.  This is done by facing the feared situation and actually doing it.  The person must enter real world situations that cause anxiety, e.g., driving a car on the expressway. Exposure therapy requires considerable time and discipline from the patient.  Exposure exercises must be practiced routinely and monitoring must be continuous.  The patient has to be willing to confront the feared situations. It is easier to establish a hierarchy from the least to the most difficult task.  It’s ok to pause, breathe, and/or take medication, but then proceed.

Avoidance behavior makes panic disorder worse. Resist the urge to stop or avoid those things that trigger fear and/or physical symptoms

Desensitization – Occurs with persistence and practice.  This involves exposing the patient to fear cues, specific things or situations that trigger panic attacks.

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Proactive Anxiety Response

Practice paced breathing

Proper breathing is very important for control of anxiety and panic.  It is also the best relaxation technique for control of nervousness and panic.  Underbreathing (slow/shallow) increases carbon dioxide retention.  This triggers the suffocation response in panic prone people, leading to compensatory overbreathing.  Conversely, overbreathing (hyperventilation) decreases carbon dioxide and causes feelings of depersonalization (feeling detached from oneself), dizziness, numbness, and confusion.

When anxious or tense, it is easier to breathe out first:

  • Step one:  Slowly exhale through the open mouth making a “s h h h h” sound.  Listen to the sound, or feel muscles relax, letting go of tension.
  • Step two:  Breathe in through the nose slowly, (mouth closed) and count, 1—2—3—4
  • Step three:  Hold to count of  1—2—3—4    

Find distractions

Focus attention on something outside yourself.  This might include listening to music, going for a walk, or calling a friend.

Use conditioned relaxation response

Make relaxation a part of daily routine.  Set aside time to practice your favorite relaxation activity.  This might be working out, playing sports, games, cards, movies, listening to music.  When relaxation is regularly practiced, the body forms a memory of what it feels like to be relaxed.  This memory is a tool you can use when you feel anxious.  Practice relaxing in anxiety provoking situations.

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Hypervigilance and Panic

Panic patients listen too closely to body sensations, feel anxious, have “what if” thoughts, and scan their environment for possible danger.

Panic patients are always in a state of hypervigilance-most especially they listen to their bodies and they “hear everything”.  They can almost feel ions crossing membranes!  They release adrenaline, preparing for “fight or flight”.  The adrenaline revs them up and it snowballs-then they are having a panic attack!

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Medication for Acute Episodes and Prevention

  • Xanax (Alprazolam)   

  • Niravam (Alprazolam orally disintegrating tablets)

  • Klonopin Wafers (Clonazepam)

  • Ativan (Lorazepam)

A common question asked is “how much should I take?”  “Take enough, not too much.” 

This is like a firefighter calling headquarters and saying, “I have a grass fire starting here, how much water should I put on it?”   “Put out the fire.  Don’t flood the valley.”

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