Anxiety and Panic Support

The Monthly-FAQ for the newsgroup:

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Monthly FAQ - updated 09/05/00

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,   References are cited within parenthesis.

+ 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  panic disorder?

  11. Where are web sites with information about anxiety disorders?

  12. Contributors


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.



Adapted from "Panic Anxiety and Its Treatments", Edited by Gerald L.Klerman, M.D., et. al.

Causal Factors

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. 

Developmental Factors

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 attacks.
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 anxiety states.
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 disorder.
Personality Factors:  Patients may have unassertive, fearful, dependent, passive, anxious, or shy personality traits which preceed the development of panic disorder.



Adapted from "Panic Disorder: The Medical Point of View" by William Kernodle, M.D.
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 with stress.
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 panic attack.
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 attacks.
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.



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  experience.

Exercises To Reduce General Anxiety

Exercises To Reduce Panic Symptoms

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 time.
  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.



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 below:
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 avoidance.



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 avoidance behavior.
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 with Serzone.
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.



Quoted from "Panic Disorder: The Medical Point of View", by William Kernodle, M.D.
"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).



Read (ASAP) and alt.recovery.panic-anxiety.self-help. We meet to share experiences with anxiety and panic for mutual support.
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:
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.
Midwest Center
106 N. Church St., Suite 200
Oak Harbor, OH 43449
Attacking Anxiety home study program, audio tapes
Phobics Anonymous
P.O. Box 1180
Palm Springs, CA 92263
(619) 322-COPE
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



Introductory Books
"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  obsessive-compulsive disorder.
"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, ISBN 0-935016-34-1.
"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 medication alternatives.
"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 available.
"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 recovery.
"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 patterns.
Self-help Workbooks
"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 treatment method.
"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: (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, ISBN 0-8050-4789-1
"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 antidepressant therapy.
"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 alternatives.
"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 histories.
"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, exercise, vitamins.
"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.
Clinical Textbooks
"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 application.
"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 disorders.
"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 disorders.
"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.
"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.
Review Articles
The following article abstracts were condensed from the MEDLINE and PsycINFO databases. Articles reprints may be ordered through your local public library.
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 alone.
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 disorders.
Edwards-S. and 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 systematic studies.
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 disorder.  As a supplement to drug therapy, cognitive behavioural therapy is effective.
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 impairment.
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 of panic.
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 also discussed.
Middleton-H-C. "Panic disorder: a theoretical synthesis of medical and psychological approaches." J-Psychosom-Res. 1998 Jan. 44(1). P121-32.
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 patients.
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 future study.
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.



National Institute of Mental Health
Publications on panic disorder
Anxiety Disorders Association of America
Conferences, research, helpful hints
National Panic/Anxiety Disorder Newsletter
Research, self-help techniques, books and tapes, studies, conferences
& The npadnews link is no longer available
Grohol Mental Health Page
Psychology, Support, and Mental Health Resources
Panic-Anxiety web page
Material on agoraphobia, panic attacks, and social phobia (was The Mining Company)
General mental health with a section on panic disorder
HealthGuide Online
Information about OCD, antianxiety medications, mental health topics
Free access to MEDLINE database
Free access to MEDLINE, research articles, conference news, weekly newsletter.   Registration required.
Detailed information on medications
& The fairlite link is no longer available
Distinction between panic and anxiety; also has up-to-date info on treatment with SSRI's.
& 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 following links.
Gary Bradski's web page
Anxiety disorder resources and books
Refer to the ASAP 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.

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