SCIENCE / MEDICINE : The Panic Button : Combination of Therapy, Drugs Found Useful in Treating Phobics’ Problems

Jerilyn Ross, 25, was dancing on the outdoor patio of a 20th-floor restaurant in Salzburg, Austria. Suddenly she felt drawn, as if by a magnet, to jump over the edge. A bolt of terror shot through her. With pounding heart, she dove through the crowd to the elevator so she could get to the ground floor and safety.

Although the rest of her Austrian vacation was without incident, Ross’ life had been irrevocably changed. When she returned to Manhattan, she found she could not visit friends who lived above the 10th floor.

The panic attacks soon spread to other situations. After another episode struck her in the subway, she began to avoid it and wondered privately whether she was going crazy.

Ross had developed one of the most common psychological disorders in the United States today. As many as 15 million Americans suffer from phobias--irrational fears that cause a person to avoid certain places or situations.

At the center of the trouble is the panic attack, a sudden crescendo of uncontrollable anxiety. Most panic sufferers experience their first attack in their early 20s. Sometimes it is triggered by a traumatic event, but in other cases, it occurs out of the blue. The pounding heart, chest pain, dizziness and shortness of breath convinces some that they are dying of a heart attack.

Panic sufferers in the United States spend an estimated $206 million each year on unnecessary medical tests, as they search in vain for a heart problem or brain tumor that might be causing their symptoms. Three-quarters of all panic sufferers never discover that panic disorder is the real root of their problem.

Proper diagnosis could save them much expense and anguish, because recent research has shed light on some potential causes of panic and also has paved the way for effective drug treatment and psychotherapy. Today, 75% to 95% of those who get counseling--and, if necessary, medication--are cured.

Fifteen years ago, when Ross had her first panic attack, there were few places for a phobic to turn. Today research in the area is booming and Ross, a psychologist, is president of the 7,000-member Phobia Society of America. The group, which includes mental health professionals as well as people with phobias, held its annual meeting in San Francisco in late October.

Recent research, for instance, shows that phobias may have a physical and possibly an inherited basis. These findings can lead to newer forms of treatment.

At the meeting, Ross recalled a recent visit to Los Angeles, where she identified closely with people’s reports of the terror, confusion and loss of control that they felt during the recent earthquake.

“That’s how a phobic person feels,” she said, “but for no reason. Imagine suddenly feeling that way in the grocery line, or while driving down the freeway on a sunny day.”

The most common triggers of panic attacks are driving and trips to shopping malls, but the attacks can also be triggered by social encounters, such as crowded rooms or public speaking; things, such as spiders or snakes; bridges, heights or just about any situation or object imaginable.

Some people turn to drinking to help them face their panic. James Ballenger, director of the anxiety disorders program at the University of South Carolina, said recent studies suggest that as many as 30% of alcoholics may have been driven to drink by panic attacks.

Other people become phobic, avoiding situations rather than facing the possibility of having a panic attack. In a condition called agoraphobia--fear of open or public places--which afflicts up to 4% of Americans, panic progressively rules out more and more activities, until, in severe cases, the person is completely house-bound.

Phobics know their fears are irrational. They don’t really expect to fall off a bridge or tall building, or think harm will come to them in the grocery line. What they fear is that the panic attack itself will either kill them or make them lose control, with some catastrophic or embarrassing result.

For example, people with public-speaking phobias frequently fear that they will knock over the podium, or shout obscenities at the audience.

While phobics have been told for years they were just suffering from “a case of nerves,” recent research has shown that panic disorder is a real, physical condition.

Brain scans, which measure brain activity, have shown that panic sufferers have higher than normal activity in the region of the brain that makes adrenaline, a hormone that helps the body respond to dangerous or stressful situations. This may create a lower threshold for a built-in alarm system, causing the alarm to go off even when there is no danger.

Because this evidence gives researchers a better idea of the brain chemicals involved in panic, they may be better able to choose new drugs that could block panic attacks.

Panic sufferers are often so sensitive to caffeine that a cup of coffee can bring on an attack. Researchers have found that injections of lactate, a substance produced by muscles during exercise, also will bring on a panic attack in panic sufferers, but not in others.

According to Dr. Thomas Uhde, chief of the unit on anxiety and affective disorders at the National Institute of Mental Health in Bethesda, Md., these findings suggest that panic sufferers are physiologically different in some ways from non-panickers.

Uhde also said that panic disorder seems to run in families. He cited genetic studies in which 25% of the children of panic sufferers also have panic attacks, and a Danish study that showed the disorder is five times more likely to be shared by identical twins than by fraternal twins.

Research is still a long way from pinpointing the cause of panic attacks, but it has provided several highly successful forms of therapy.

Just 10 years ago, little was known about treating panic and phobias. Classical psychoanalysis, which delves into the patient’s past, failed to cure 75% of the cases.

Ross recalled a phobic adult who discovered during analysis that he had been kidnaped and tortured as a child, and had blocked the experience from his memory. Although he now knew the probable root of his phobia, that knowledge didn’t help him leave the security of his home. Only when a therapist held his hand and led him from the house could he begin to face his fears.

This kind of therapy, called behavioral, or exposure, therapy, is very effective for phobics. With the support of a therapist, the phobic patient faces the situation that brings on panic.

If it is a grocery store, the patient may at first just sit in the parking lot, then on the next visit, just buy one item in the express lane, gradually building up tolerance.

The patient learns skills for riding out a panic attack, which usually lasts two to eight minutes, such as counting backward from 100 by threes, or counting stripes on a rug.

The important thing, Ross said, is to desensitize oneself by continuing to face the problem situation and practice getting through it.

For 75% of phobics, a 16-week therapy program, at a cost of under $2,000, will enable them to overcome their phobias and lead normal lives.

Sometimes the panic completely subsides. In other cases, it may remain but only be an uncomfortable feeling. Ross, who was cured by exposure treatment, said she still feels uneasy in tall buildings, but she knows what to do so that her panic doesn’t get out of control.

For Mary Ann Miller, a recovered agoraphobic who founded a self-help group for agoraphobics in Michigan, exposure therapy was not enough.

She had learned to cope with her anxiety, but was depressed at the thought of having to live with it for the rest of her life. “I could go to the grocery store, but who wanted to go?” she said.

Miller sought out another kind of help, called “cognitive therapy,” or, as she calls it, positive thinking.

Cognitive therapy, often used hand in hand with behavioral therapy, works well not only for phobics, but also for people with panic disorder alone who continue to go through their lives, enduring rather than avoiding unpleasant panic attacks.

The therapist challenges patients’ thinking about panic attacks and helps them see that their expectations of impending catastrophe are wrong.

Miller said panic sufferers feed their panic by playing out disaster scenarios in their minds. A phobic may think, “What if I have a panic attack at the wedding and I scream or fall in the aisle and make a fool of myself,” and then conclude that it is easier just not to go.

When cognitive therapy breaks the vicious cycle of this “what if . . . “ thinking, the panic attacks themselves usually subside.

Some phobics cannot even begin exposure or cognitive therapy because their fear of having another panic attack is too overwhelming. For these patients, anti-panic drugs may be a necessary first step.

Both anti-depressants and Xanax, a close relative of the anti-anxiety drug Valium, work very well to block panic attacks, said James Ballenger, an expert in drug treatment of anxiety. The drugs probably block the communication pathways in the brain that trigger the panic alarm.

Ballenger said drugs alone are rarely the best solution for panic disorder, because the panic symptoms may return when the patient stops taking the drugs. He said an integrated and personalized combination of drugs and psychotherapy can promise most phobics a panic-free future.

“When you apply either, or both of these treatments, that’s when you see the overwhelming majority do very well.”