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Here is the second article about Panic Attacks and Agoraphobia. As before, since I am an M.D., I cannot express my point of view without being concerned about liability. So please note this disclaimer before reading further: Any medical information in this article is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional. I hope you find this article helpful.
Mark Eisenstadt, M.D.
Article 2 – The Biology of Panic and Agoraphobia One aspect of us is that we are biological beings – we have bodies. The physical responses to anxiety that we experience during panic attacks are based upon the biology of these bodies. Many of the responses are caused by the release of adrenaline. Releasing adrenaline is the way our minds tell our bodies that it is necessary to either run or fight. This is the so-called "fight or flight" response. In other words, when we are frightened by something, our bodies get ready to either run away or physically attack whatever scares us. How do we do this? First of all, our bodies go into high gear. Adrenaline causes our hearts to pump fast so that there is plenty of oxygen to give our muscles the strength to move fast and our brains the ability to think fast. But that oxygen needs to go to the right places. So the adrenaline directs the oxygen-carrying blood where it is needed and away from where it is not. It is needed in the muscles of arms and legs and in the brain. It is not needed in the skin and the digestive organs. Adrenaline is designed to cause the blood vessels of skeletal muscles and brain to enlarge so there can be more blood flow in these parts of our bodies. Meanwhile, the blood vessels of skin and digestive organs constrict in order to shunt blood away from where it is not needed. This results in "going pale with fear" because the blood has moved away from the skin. It also causes various sensations in the digestive organs such as cramps or "butterflies in the stomach". Naturally, the adrenaline causes our hearts to beat faster so we experience pounding. It also causes expansion of the breathing tubes in our lungs so that we get more oxygen. This, together with more rapid breathing, is the hyperventilation experienced during panic attacks. Hyperventilation has a number of effects of its own. Most of these result from lowering the amount of carbon dioxide in our bodies. When we breathe, we not only take in oxygen but we breathe out carbon dioxide. When we breathe fast, we lose the amount of carbon dioxide needed to keep us feeling normal. Loss of carbon dioxide causes us to feel dizzy, disoriented and to develop tingling and cramps in our hands and feet. (And many people think this was because they needed more oxygen!) Hence, breathing into a paper bag helps. We do not need much blood flow to our salivary glands so these shut down resulting in our having dry mouths. Our pupils dilate so we can take in the largest visual fields possible. This would presumably enable us to protect ourselves from whatever is coming at us from any direction. When startled, we notice that our hair may stand on end. This is much like the hair standing up on the back of a dog when it is threatened. All of these changes are the result of adrenaline. There are medications that block the effects of adrenaline. These are called beta-blockers. Two of the more common beta-blockers are Propranolol (Inderal) and Atenolol (Tenormin). They are used to prevent the effects of adrenaline. As a result, they make people feel much more comfortable. Of course, they do not take away the emotional fear or anxiety. But imagine how much better you would feel if your heart was not pounding, you did not have butterflies in your stomach and you were not hyperventilating. On the other hand, drugs that either cause the release of adrenaline or have the same effects as adrenaline make people who have Panic Disorder quite uncomfortable. These are called "Sympathomimetics" which simply means that they mimic the action of the sympathetic nervous system. (This is the part of the nervous system that reacts to adrenaline). These drugs include caffeine, ephedrine, pseudoephedrine, stimulants, epinephrine, norepinephrine and many others. They are found in many cold medicines, in dental anesthetics and in alternative treatments to give you energy sold at health food stores. It is important therefore that you avoid these drugs if you want to avoid getting adrenaline effects. For example, it is a good idea to tell your dentist that you have Panic Disorder and cannot take anesthetics that have epinephrine or norepinephrine in them. Because of this, I give my patients the following letter to give to their physicians: Information For Physicians Regarding Agoraphobia Your patient is working through a program for overcoming Agoraphobia. As part of this, I have advised giving you this information. Agoraphobia with Panic Attacks means that your patient may undergo a major autonomic discharge coupled with extreme fear at any time. Panic attacks are most likely to occur in situations that are difficult or embarrassing to leave at a moment’s notice. Your office is one such situation. Your patient is much less likely to have a panic attack if she feels she can leave whenever she needs to. Your understanding of this fact will help greatly. Panic symptoms include tachycardia, hypertension, extrasystoles, hyperventilation (experienced as shortness of breath), paresthesias, flushing, tremor, shaking, G.I. cramps, diarrhea, nausea, headache, vertigo and, rarely, syncope. They usually last for 5 to 20 minutes but can continue longer in some cases. Unfortunately, you may need to postpone your examination in order to obtain baseline data as opposed to panic-induced findings. Sympathomimetics, stimulants and lactate usually trigger panic attacks and should be avoided. Disorders of the thyroid, adrenal and glucose metabolism can do likewise and should be ruled out. Mitral Valve Prolapse is a common associated finding. Parenteral benzodiazepines (not oral) are one of the few effective treatments for a panic attack in progress. Unless there is some specific reason such as an unusually prolonged or severe episode, this treatment is generally not required. Finally, the most important point is that your patient has experienced many panic attacks and is working through a program for dealing with them. Consequently, your patient knows best what is needed. Physicians are therefore well advised to give patients the lead if a panic attack occurs during an appointment. Mark A. Eisenstadt, M.D.
Wishing you well until next month, Mark Eisenstadt, M.D. You can now find the third article Here
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