How to Stop Panic Attacks

A minor physical problem produces a few symptoms. The individual then becomes introspective and oversensitive to these physical sensations and uses them as a cue to become anxious. His heightened awareness and unnecessary concern will produce an increase in symptoms. If this continues, he can turn an insignificant physical problem into a major psychological distress.

There is no physical basis for the symptoms. Some combination of the following will help: education about the problem, reassurance, psychological treatment and medication treatment.

Through a comprehensive evaluation, your physician can determine which, if any, of these physical problems is associated with your symptoms. In most cases, curing the physical illness or adjusting medication will eliminate the symptoms. In some disorders, the symptoms remain as part of a minor disturbance, and you must learn to cope with them.

When a person suffers from panic attacks, one of the greatest obstacles to recovery can be the fear that these episodes are the indication of a major physical illness. And in some rare cases that is true. But predominantly, when a person continually worries about physical illness, that kind of worry intensifies or even produces panic attacks. In other words, the less you worry, the healthier you will become. For that reason, I strongly recommend that you adopt the following guidelines if you are experiencing anxiety attacks:

1. Find a physician whom you trust.
2. Explain your symptoms and your worries to him or her.
3. Let your physician conduct any evaluations or examinations necessary to determine the cause of your symptoms.
4. If your primary physician recommends that another medical specialist evaluate your problem, be certain to follow that advice. Make sure that your primary physician receives a report from the specialist.
5. If a physical problem is diagnosed, follow your physician’s treatment advice.
6. If your doctor finds no physical cause for your panic attacks, use the methods presented in the Panic Attack Self-Help Program to take control of your symptoms. If your symptoms persist, ask your physician or some other source for a referral to a licensed mental health professional who specializes in these disorders.

The most destructive thing you can do when faced with panic attacks is to steadfastly believe that your symptoms mean that you have a serious physical illness, despite continued professional reassurance to the contrary. That is why it is essential that you work with a physician whom you can trust until he or she reaches a diagnosis. No matter how many consultations with other professionals you need, allow one professional to have primary charge of your case and receive all reports. Do not continually jump from doctor to doctor. If you remain fearfully convinced that you have a physical ailment, even when there is a consensus to the contrary among the professionals who have evaluated you, then you can be certain of one thing: your fear is directly contributing to your panic episodes. In Part II you will learn how to control that fear and thereby take control of your symptoms.

Many physiological disorders produce paniclike symptoms. You will find them listed below.

Physiological Disorders with Panic-like Symptoms

Cardiovascular

• Angina pectoris
• Myocardial infarction (recovery from)
• Arrhythmia
• Postural orthostatic hypotension
• Coronary artery disease
• Pulmonary edema
• Heart attack
• Pulmonary embolism
• Heart failure
• Stroke
• Hypertension
• Tachycardia
• Mitral valve prolapse
• Transient ischemic attack
• Mitral stenosis

Respiratory

• Asthma
• Emphysema
• Bronchitis Hypoxia
• Collagen disease Pulmonary fibrosis

Endocrine/Hormonal

• Carcinoid tumor
• Pheochromocytoma
• Hyperthyroidism
• Premenstrual syndrome
• Hypoglycemia
• Pregnancy

Neurological/Muscular

• Compression neuropathies
• Myasthenia gravis
• GuillainBarr syndrome
• Temporal lobe epilepsy

Aural

• Benign positional vertigo
• Meniere’s disease
• Labyrinthitis
• Otitis media
• Mastoiditis

Hematic

• Anemia
• Iron deficiency anemia
• B12 anemia
• Sickle cell anemia
• Folic acid anemia

Drug Related

• Alcohol use or withdrawal
• Side effects of many medications
• Illicit drug use
• Stimulant use
• Medication withdrawal

Miscellaneous

• Caffeinism
• Head injury

Causes of a Racing or Rapid Heart Rate

Uncomfortable changes in heart rate are the most frequently reported symptoms of panic attacks. Over 80% of those experiencing panic list a rapid or irregular heart rate as a symptom.

Three complaints are common among patients who seek a doctor’s advice about their heart: “My heart feels like it’s pounding violently in my chest,” “My heart is racing, ” and “My heart feels like it skips a beat.” An arrhythmia is any irregularity in the heart’s rhythm. If the heart beats more rapidly than normal, this arrhythmia is called tachycardia. An unpleasant sensation in the heart, whether rapid or slow, regular or irregular, and of which one is consciously aware, is called a palpitation.

Physical Causes of Rapid or Irregular Heart Rate

• arrhythmia
• postmyocardial infarction
• tachycardia
• organic heart disease
• palpitation
• heart failure
• extrasystole
• infections
• coronary artery disease

Heart palpitation is typically an expected sensation when the force and rate of the heartbeat are considerably elevated. After strenuous exercise we are apt to notice the thumping of our heart against the chest wall. As we begin resting, that sensation may continue briefly until we recover from our exertion.

People who are prone to anxiety may have palpitations more frequently when they find themselves in psychologically uncomfortable situations. In fact, the great majority of complaints about the heart presented to physicians indicate a psychological rather than a physical problem. An anxious person may turn his attention to his physical symptoms instead of learning to cope with the situation causing the symptoms. After several episodes in which he experiences his heart “pounding” or “beating too fast,” he fears it is a sign of heart disease or some other physical disorder.

It is possible to consciously notice a few minor disturbances of the heart rhythm. For instance, some people describe sensations such as a “flop” of the heart, the heart “skipping a beat” or “turning a somersault.” We call this sudden forceful beat of the heart followed by a longer than usual pause an extrasystole. These premature contractions of the heart are usually of no serious significance and occur in many healthy individuals.

In fact, because of several research findings, we now know that arrhythmias of all kinds are common in normal, healthy individuals. In one recent study published in the New England Journal of Medicine, Dr. Harold Kennedy found that healthy subjects with frequent and complex irregular heartbeats seem to be at no more risk of physical problems than is the normal population. In general, researchers are finding that the majority of even the healthiest people have some kind of rhythm disturbance such as skipped beats, palpitations, or pounding in the chest.

Tachycardia, or rapid heartbeat, is the most common complaint associated with the heart and one of the typical reasons that patients seek medical attention. For many normal healthy individuals it is a daily occurrence in response to physical exercise or intense emotion. Any kind of excitement or trauma, even fatigue or exhaustion, can accelerate the action of the heart, especially in overly anxious individuals. Too many cigarettes, too much alcohol, and in particular, excessive amounts of caffeine can cause tachycardia on occasion. Infections such as pneumonia, as well as acute inflammatory diseases such as rheumatic fever, may also produce a rapid heartbeat.

Although most complaints of palpitation reflect a minor cardiac problem or a sign of anxiety, it is possible that they involve some kind of coronary artery disease. A narrowing of the arteries to the heart causes such diseases.

Recovery and rehabilitation after a heart attack can be a difficult psychological problem. Many people become afraid that too much activity or excitement might produce a second attack. It is no wonder then, that postmyocardial infarction patients become fearfully preoccupied with the sensations of their heart. Many will return to their doctor’s office or hospital emergency room with complaints of palpitations. Fourteen percent of cardiac patients later suffer from panic disorder, which is the worried anticipation of having an anxiety attack or heart attack. Chapter 6 of the self-help book Don’t Panic describes the way in which panic complicates recovery from a myocardial infarction.

Complaints of a “racing” heart can signal certain kinds of organic heart disease and heart failure. More often, however, the symptom of these ailments will be breathlessness (see the section on difficulty breathing). Infections, such as pneumonia and rheumatic fever, may also produce a rapid heartbeat.

Chest Pain with Anxiety Attacks

Almost 40% of physically healthy people with panic attacks experience pain in their chest. The thought that this pain might be a serious heart problem sends many sufferers to the Emergency Room for help.

The predominant complaint of those suffering from coronary artery disease is most likely to be a pain or pressure in the center of the chest. They may also feel such discomfort elsewhere in the chest or in the neck, jaw, or left arm, and occasionally may notice tachycardia (as mentioned above).

Angina pectoris is an acute pain in the chest caused by interference with the supply of oxygen to the heart. It is a distinct pain, usually concentrated on the left side and sometimes spreading (radiating) to the neck and down the left arm. The feeling is of tightness, strangling, heaviness or suffocation. It is not a disease, but a symptom of some underlying disorder that reduces the supply of oxygen to the heart. Coronary artery disease or hypertension are the most common causes, with aortic stenosis, anemia or hyperthyroidism also possible causes.

Physical Causes of Chest Pain

• coronary artery disease
• angina pectoris
• heart attack

A heart attack (myocardial infarction, coronary thrombosis) occurs when the blood supply to the heart is significantly blocked. The main symptom is usually a crushing pain in the center of the chest, which may continue into the neck, jaw, arms and stomach. The pain may begin during exercise or a stressful event. Unlike angina, this pain does not stop when the exercise or event ends. A heart attack is a medical emergency. Medical help is needed immediately.

Physical Causes of Breathing Problems

Complaints of difficult, labored, or uncomfortable breathing (called dyspnea) can be a signal of a serious emergency or of a mysterious medical puzzle. Seek immediate professional evaluation if this problem has never been diagnosed. Most often a person will describe it as “not being able to catch my breath,” or “not getting enough air,” even while appearing to breathe normally. Certainly the inability to breathe properly can be alarming, and many persons will immediately react with anxiety, fear, or panic.

Physical Causes of Difficult Breathing (Dypsnea)

• bronchitis
• pneumothorax
• emphysema
• hemothorax
• asthma
• pulmonary edema
• pneumoconiosis
• mitral stenosis
• collagen disease
• left ventricular failure
• pulmonary fibrosis
• aortic insufficiency
• myasthenia gravis
• pericardial effusion
• Guillain Barre syndrome
• cardiac arrhythmia
• pleural effusion

Under normal circumstances, difficult breathing comes after any strenuous activity. If the degree of the problem seems out of proportion to the amount of exertion, concern is appropriate. Troubled breathing is sometimes experienced in pregnancy, since the uterus expands upward, reducing the possibility of a full inhalation. Severe obesity can also reduce the capacity of the lungs to inhale fully.

Most physical causes of dyspnea are associated with disorders of the respiratory and cardiac systems. Acute and chronic diseases of the lungs are the most common physical causes. Within the respiratory system, the problem usually stems from an obstruction of air flow (obstructive disorders) or the inability of the chest wall or lungs to expand freely (restrictive disorders). Each of these disorders makes the patient work harder to take each breath and decreases the amount of oxygen that he can absorb with inhalation. The three major obstructive disorders are bronchitis, emphysema, and asthma. In these problems a second common symptom is “chest tightness” upon awakening, shortly after sitting up, or after physical exertion.

The primary symptom of bronchitis is a deep cough that brings up yellowish or grayish phlegm from the lungs. With emphysema, the shortness of breath gradually becomes worse over the years. The distinct symptoms of bronchitis and the gradual onset of emphysema will usually prevent these disorders from being misdiagnosed as severe anxiety or panic.

Those suffering from asthma will complain of difficult breathing, a painless tightness in the chest, and periodic episodes of wheezing. Severe cases can cause sweating, increased pulse rate, and severe anxiety. The primary trigger of an asthma attack is an allergy to such things as pollen, dust, or the dander of cats or dogs. Attacks can also be caused by infections, exercise, psychological stress, or for no apparent reason. Some asthma sufferers anxiously anticipate the next attack, since an acute attack of asthma can come suddenly “out of the blue” and last for an uncomfortably long time. This fear of an impending attack can actually increase the likelihood of the next attack and can extend the length of each attack. Asthma is a good example of a physical disorder that can increase in severity because of anxiety or panic.

Chapter 6 of the self-help book Don’t Panic will describe the manner in which panic can contribute to difficulties in patients with chronic obstructive pulmonary disease. Special attention is given to chronic bronchitis, emphysema, and asthma.

There are a number of restrictive disorders of the respiratory system that cause difficult breathing. Some produce a rigidity of the lungs (pneumoconiosis, collagen disease, pulmonary fibrosis); other involve the interactions of muscles and nerves (myasthenia gravis, Guillain Barre syndrome); and still others prevent the lungs from expanding to full volume (pleural effusion, pneumothorax, hemothorax). A restrictive deficit in pulmonary function can also be caused by pulmonary edema, which usually stems from heart failure or occasionally from toxic inhalants.

Dyspnea may occur in any of the various diseases of the heart and lungs, but it is more prominent in those associated with lung congestion. For example, mitral stenosis occurs when a small valve between the left upper chamber and left lower chamber of the heart (the left atrium and left ventricle) becomes abnormally narrow. As blood is forced through the heart, pressure backs up into the lungs and produces congestion. It is this congestion that causes breathlessness.

Other possible cardiovascular problems that can lead to difficulty breathing include left ventricular failure, aortic insufficiency, pericardial effusion, and cardiac arrhythmia.

Why You Get Dizzy

A broad range of complaints falls under the categories of dizziness and vertigo.

Dizziness is a broad term that can include:

• lightheadedness
• faintness
• wooziness
• a “swimming” sensation in the head
• a floating feeling
• double vision
• a feeling of “everything spinning in circles” or of whirling in space.

Vertigo implies the more specific sensations of either the body or its surroundings turning or the head swaying or revolving. The physical causes of these two symptoms are numerous: problems of the middle and inner ear, dental problems, infections, head injuries, drug effects, and disorders of the cardiovascular, neurologic, and central nervous systems.

Physical Causes of Dizziness and Vertigo

• Meniere’s disease
• hypertension
• labyrinthitis
• postural orthostatic hypotension
• nystagmus
• stroke
• benign positional vertigo
• cerebral thrombosis
• ear infections
• cerebral embolism
• dental problems
• cerebral hemorrhage
• head injury
• transient ischemic attack

The ear is responsible for our sense of balance as well as hearing. The inner ear includes a structure called the labyrinth, which monitors the brain. When injury or infection disrupts the action of the labyrinth, vertigo may occur.

In Meniere’s disease, a common disorder of the labyrinth in adults, excess fluid builds up and increases the pressure within the inner ear, causing vertigo and occasionally a ringing or other noise in the ear (called “tinnitus”). Labyrinthitis is an infection of this same region, often caused by a virus, sometimes associated with an upper respiratory infection. This can produce severe vertigo, occasionally with some nausea and vomiting during the first episode. The individual may also experience a rapid flickering of the eyes (called nystagmus). Calcium crystals floating within the labyrinth can cause benign positional vertigo. In this condition, a shifting of position, such as rolling over in bed, can produce vertigo and nystagmus moments later, lasting no more than thirty seconds. Several kinds of ear infections, such as otitis media and mastoiditis, can cause vertigo but will additionally cause other distinguishing symptoms, such as drainage of fluid, fever, or redness of the eardrum. Dental problems, such as an abscessed tooth, malocclusion, or temporomandibular joint (TMJ) abnormalities, can also produce vertigo since the teeth are so closely aligned with the ear.

Any head injury can cause a cerebral concussion or a labyrinthine concussion, which may result in vertigo or a sense of feeling dazed, unsteady, or faint.

A number of cardiovascular and neurovascular diseases may affect a person’s sense of balance. Hypertension, or high blood pressure, is often a symptomless disease. However, a swimming or woozy sensation may be the initial symptom that brings a patient into a physician’s office for evaluation.

If dizziness and lightheadedness are experienced rising in the morning or when changing from a lying to upright position, postural orthostatic hypotension may be the cause. This is a problem of low blood pressure, producing poor circulation of blood through the body. Typically, when a person shifts positions, the blood vessels reflexively contract to maintain proper blood pressure. In hypotension, this mechanism fails to respond appropriately. Since the needed pressure is not maintained, the flow of blood to the brain is temporarily reduced, causing dizziness and even fainting. Diabetes, minor complications in pregnancy, or hardening of the arteries can cause postural hypotension. It can also be a side effect of antidepressant medication, major tranquilizers, and even medications prescribed for high blood pressure (hypertension).

The most serious vascular ailment, requiring immediate medical attention, is stroke. A stroke occurs when the blood supply to the brain is significantly altered, causing damage to the brain itself. Three types of vascular problems produce stroke: cerebral thrombosis, cerebral embolism, and cerebral hemorrhage. In thrombosis, some portion of an artery that supplies blood to the brain has reduced in size. A large deposit of fatty tissue in that portion allows blood to clot, causing a partial or complete blockage of the blood flow to the brain. An embolism occurs when a bit of blood clot or arteriosclerotic plaque from the heart or the wall of a large artery breaks off and travels to an artery within the brain, where it lodges and causes the stroke. In a cerebral hemorrhage, the artery leaks or bursts, causing blood to seep into the surrounding brain tissues.

A transient ischemic attack is usually caused by a small blood clot or piece of fatty tissue (embolus). While passing through the blood vessels in the brain, it briefly becomes lodged and reduces the blood flow through that area. These symptoms resemble those of stroke, but are temporary and do not cause serious harm, since the clot or embolus eventually is dislodged. Although emergency medical attention is not necessary, a transient ischemic attack does require medical evaluation and possible measures to prevent recurrence.

Dizziness alone is insufficient cause to fear stroke. However, if you experience one or more of the following symptoms, you should consult your physician: numbness and/or tingling in any part of the body, blurred vision, confusion, difficulty speaking, loss of movement in the arms or legs. These symptoms can also indicate a panic attack rather than stroke. If you have experienced such a reaction several times and your doctor finds no sign of a physical disorder, you should consider the possibility that some psychological disturbance is precipitating these symptoms.

Physical Conditions that Cause Anxiety

Many physical illnesses can produce nervousness in individuals who are not emotionally troubled. Certain other physical disorders — those discussed in this section — can cause a cluster of symptoms that resemble those of panic.

Physical Causes of Multiple Symptoms

• hypertension
• mitral valve prolapse
• menopause
• premenstrual syndrome
• hyperthyroidism
• hypoglycemia
• pheochromocytoma
• anemia
• iron deficiency anemia
• folic acid anemia
• B12 anemia
• sickle cell anemia
• heart attack
• hypoxia
• carcinoid syndrome
• compression neuropathies
• temporal lobe epilepsy
• caffeinism
• amphetamines
• cocaine
• phencyclidine (pcp)
• hallucinogens
• marijuana
• alcohol withdrawal
• pulmonary embolism
• withdrawal from antidepressants, narcotics, sedatives, barbiturates, benzodiazepines, or beta blockers

The predominant cardiovascular disorder that can produce multiple symptoms is hypertension, caused by a narrowing of the arteries. As your heart pumps blood through your body, it exerts a certain amount of pressure on the arterial walls. If these passageways become constricted for some reason, it requires greater force to maintain a steady flow of blood. The entire circulatory system is then under strain, and hypertension is the diagnosis. This, as mentioned earlier, is often a symptomless disease, but you might notice such symptoms as palpitations, nervousness, dizziness, and fatigue, as well as a general sense of ill health.

Mitral valve prolapse is a common condition found in approximately 5 to 15 percent of the adult population. In this disturbance a valve leaflet within the heart balloons into the left upper chamber (the left atrium) of the heart during contraction. About half of all people with mitral valve prolapse will complain of heart palpitation sometime in their life. Other possible symptoms are rapid heartbeat, shortness of breath, dizziness, and an increased awareness of the heart’s action. This is a rather minor cardiac problem, but people can erroneously blame it as the sole cause of panic attacks. More often, though, it is the patient’s fearful preoccupation with the action of his heart that produces panic. You will find a more extensive discussion of mitral valve prolapse in Chapter 6 of the self-help book Don’t Panic.

Location of mitral valve and change in appearance after ballooning.

There is growing evidence that hormonal changes can dramatically affect a person’s physical disposition and mood. For instance, approximately 50 percent of women experiencing menopause report some major physical and/or emotional changes. Another 25 percent have uncomfortable, even distressing, symptoms that can include intense moments of palpitations, sweating, hot flashes, and anxiety. Premenstrual syndrome identifies a complex of symptoms, including panic, occurring in the days just before menstruation. You will learn more about premenstrual syndrome in Chapter 5 of the self-help book Don’t Panic.

A third hormonal problem is hyperthyroidism, the overactivity of the thyroid gland. This gland, located in the lower part of the neck, is controlled by a thyroid stimulating hormone produced in the pituitary gland. In hyperthyroidism, the normal control mechanisms are disrupted and the thyroid continues to produce an excessive amount of its own hormone, thyroxine. This overproduction causes a general speeding up of all chemical reactions in the body. The person may feel shaky and anxious, with heart palpitations, breathlessness, and increased perspiration — feeling as though he or she is experiencing a constant anxiety attack. Additional symptoms make this disorder easier to diagnose: increased appetite, but with weight loss instead of gain; thinning hair; chronic tension and a sense of needing to keep moving despite fatigue and physical exhaustion. Instead of feeling cold, as the anxious person might, the person suffering from hyperthyroidism will feel hot, and his skin will be warm to the touch. Your doctor may order a thyroid screening test for you if you have several of these symptoms.

Physicians treat hyperthyroidism in one of three ways: through anti-thyroid medication, by surgically removing either a lump in the thyroid or all the thyroid, or, more commonly, by administration of a radioactive iodine fluid that controls the overactivity of the gland.

Hypoglycemia is the experience of several unpleasant symptoms while there is a lower than normal level of glucose in the bloodstream. This state of low blood sugar generally produces a feeling of being uncomfortable, with cold, clammy skin and profuse sweating. Other symptoms can be dizziness, weakness, trembling, tingling in the lips and hands, palpitations, and fainting. The condition is most often found in diabetics who take insulin. However, many individuals erroneously believe that hypoglycemia is the cause of their panic symptoms and therefore fail to explore other possible diagnoses. For further information on hypoglycemia and panic, see Chapter 5.

The adrenal glands are located on top of each kidney. The adrenal medulla produces two hormones that play an important role in controlling your heart rate and blood pressure: epinephrine (adrenaline) develops within or near an adrenal gland and causes an increase in the production of this hormone. Tachycardia, sweating, anxiety, faintness, nausea and pallor — all resembling panic — can occur as a result of slight exercise, exposure to cold temperatures, or minor emotional upset. Typically the blood pressure will become extremely high, and the patient may have the frightening feeling of being about to die. This extremely rare disorder, called pheochromocytoma, is cured by surgically removing the tumor.

Anemia is the abnormal decrease of either hemoglobin or red blood cells. Red blood cells carry oxygen from the lungs to all parts of the body. Within each of these blood cells is the protein hemoglobin, which combines with the oxygen while in the lungs and then releases it into the tissues as the blood circulates through the body. Characteristic symptoms of anemia are lightheadedness, rapid heartbeat, difficulty breathing, and faintness. The anemic person may experience palpitations, because the heart is attempting to compensate for the lower levels of oxygen by pumping blood faster than normal. The diagnosis of iron deficiency anemia indicates that lower than normal levels of iron in the body limit the production of hemoglobin. Folic acid anemia and B12 anemia indicate that the body has insufficient amounts of these two essential vitamins, which are required for the production of healthy red blood cells. The inherited disease sickle cell anemia is found almost exclusively among people of African descent. In this condition, the red blood cells contain an abnormal hemoglobin, called hemoglobin S. This leads to deforming of the shape of each cell and thus impeding the smooth flow of blood into smaller vessels. Premature destruction of red blood cells, and anemia, results. A physician should diagnose and treat all forms of anemia.

Pulmonary embolism occurs when a blood clot detaches from the wall of a deep vein, moves through the bloodstream, and becomes lodged in the pulmonary artery close to or within the lungs. This reduces the volume of fresh blood returning to the left side of the heart and may produce sudden chest pain, rapid heart rate (tachycardia), rapid shallow breathing, and coughing up of bright red spit.

A heart attack often involves crushing chest pain as the predominant symptom, as mentioned earlier. Other symptoms can include dizziness, shortness of breath, sweating, chills, nausea and fainting.

Hypoxia means diminished availability of oxygen to the body tissues. It is a symptom of several possible underlying problems, such as altitude sickness or a pulmonary disorder. Symptoms can include difficulty breathing (dyspnea), rapid pulse, fainting and chest pain (angina pectoris).

A Carcinoid tumor, also called a argentaffinoma, is a small yellow growth occurring in the small intestine, appendix, stomach or colon. Carcinoid syndrome develops when a carcinoid tumor produces excess amounts of serotonin, a blood vessel constrictor. Exertion, intense emotion, or food or alcohol intake can trigger symptoms, which include one or more of the following: brief flushing of the neck and face, brief abdominal pain, diarrhea, racing heart (tachycardia), low blood pressure (hypotension), facial puffiness and difficulty breathing (caused by bronchoconstriction). Carcinoid tumors are rare.

Compression neuropathies, such as carpal tunnel syndrome, are disorders caused by some form of compression to localized nerves. Symptoms may include dysesthesia (a tingling or “pins and needles” feeling), similar to that which occurs during hyperventilation.

The symptoms of temporal lobe epilepsy (TLE) are highly variable, but in some cases sufferers experience them only as a sudden attack of immense fear or panic. In 60 percent of the cases, fear is the primary emotion. The patient may also have a feeling of unreality, as though he is far away from his surroundings (derealization), or may feel that his body is strange or dreamlike(depersonalization). Highly charged emotional responses such as these can lead to a misdiagnosis of the problem as a psychologically based one. A distinguishing feature of TLE can be the presence of an aura, a sudden experience that often takes the form of a strange aroma or taste at the moment of fear.

Caffeinism refers to the uncomfortable side effects that can occur with high intake of caffeine from coffee, tea, cola drinks, chocolate, and over the counter medication such as Excedrin and Anacin. Symptoms include anxiety, irritability, insomnia, headaches, stomach irritation, agitation, increased respiration, rapid heartbeat, and irregular heart rhythm. These side effects can occur with daily consumption between 250 mg to 500 milligrams. Between 20 and 30 percent of Americans consume more than 500 mg of caffeine a day (four to five cups of drip coffee contain a total of over 500 mg). Some panic prone persons are highly sensitive to caffeine, and symptoms can occur from less caffeine intake than the average person. If you experience any of these symptoms, you may wish to review your intake of all forms of caffeine. Use the following lists as a guide.

Caffeine in Medications*

• Vivarin 200 mg
• Fiorinal 40 mg
• Caffadrine 200 mg
• Medigesic 40 mg
• Cafergot 100 mg
• Triad 40 mg
• No Doz 100 mg
• Vanquish 33 mg
• Excedrin (Extra Strength) 65 mg
• Midol 32 mg
• Amaphen 40 mg
• Anacin 32 mg
• Esgic 40 mg
• Beta-Phed 32 mg
• Fiorecet 40 mg
• Empirin 32 mg
• *milligrams per each tablet/capsule

Caffeine in Beverages

Coffees, teas and cocoa (5-6 oz.)

• Drip Coffee, automatic 137 mg/cup
• Drip coffee, non-automatic 124 mg/cup
• Percolated Coffee 110 mg/cup
• Instant Coffee 60 mg/cup
• Decaffeinated Coffee 3 mg/cup
• Tea, brewed 40-65 mg/cup
• Instant tea 33 mg/cup
• Decaffeinated tea 1 mg/cup
• Hot Cocoa 5-13 mg/cup

Cola Beverages (12 oz.)

• Coca Cola 45 mg
• Dr. Pepper 61 mg
• Mountain Dew 55 mg
• Diet Mountain Dew 54 mg
• Tab 49 mg
• Pepsi Cola 38 mg
• 7-up, Sprite, Fresca, Hire’s Root Beer 0 mg

Caffeine in Chocolate

• Baker’s baking chocolate (1 oz) 25 mg
• Milk chocolate candy (1 oz) 6 mg
• Sweet dark chocolate candy (1 oz) 20 mg
• Chocolate milk (8 oz) 5 mg

Amphetamines, whether taken for treatment of depression, for weight control, or illicitly for recreation, can cause severe anxiety to the point of panic. This extreme reaction is also possible with illicit drugs such as cocaine, phencyclidine (PCP), and the hallucinogens (LSD, mescaline). It is possible that these drugs stimulate brain receptors associated with anxiety, making panic attacks more likely. Marijuana causes increased heart rate that can lead to a severe anxiety reaction.

Alcohol withdrawal can produce nervousness, rapid heartbeat, confusion, high blood pressure, and panic as well as other symptoms. Too rapid withdrawal from antidepressants, narcotics, sedatives, barbiturates, benzodiazepines (Valium, Librium, etc.), or beta blockers can cause symptoms such as anxiety, rapid heartbeat, high blood pressure, and panic, especially after long-term use.

Medications that Can Cause Anxiety

Sometimes a medication may cause unwanted side effects along with its needed effects. If these occur, you should check with your doctor. In addition to other possible side effects, each of the medications listed below may produce paniclike symptoms. (All medications are listed by their generic names.)

Aminophylline relieves shortness of breath and wheezing in acute bronchial asthma and to reduce asthma-like symptoms in chronic bronchitis and emphysema. Side effects can include nervousness, rapid heart rate and dizziness.

Heterocyclic antidepressants are used to treat depression and, more recently, panic attacks (see our medication section regarding the use of tricyclic antidepressants within the treatment of panic). Possible side effects are dizziness and irregular or rapid heartbeat.

Antidyskinetics are used in the treatment of Parkinson’s disease. Side effects may include dizziness, irregular heartbeat, and anxiety.

Atropine is a medication used to dilate the pupil of the eye. It can produce an unusually fast heartbeat. (A number of drugs are atropine-like in their effects. These are usually called anticholinergic medications.)

Inhaler forms of beta-Z adrenergic agents, such as isoproterenol and metaproterenol (Alupent) relieve acute bronchial asthma and bronchospasms associated with chronic bronchitis and emphysema. Side effects can include general anxiety, dizziness, rapid strong heartbeat, and shaky hands.

Cycloserine is an antibiotic medication. Side effects may include anxiety, irritability, confusion, dizziness and restlessness.

Digitalis is a medication used to improve the strength and efficiency of the heart, or to control the rate of the heartbeat. It can produce an unusually slow or uneven pulse.

Ephedrine is a medication used for lung problems. Side effects can be nervousness, restlessness, dizziness, difficulty breathing, palpitations, and rapid heartbeat.

Epinephrine is a medication used in treatment of the eyes, the lungs, and allergies. Side effects can include faintness, trembling, rapid heartbeat, palpitations, nervousness, and difficulty breathing.

Insulin helps control diabetes. Increasing the dose of insulin can occasionally trigger a hypoglycemic reaction, which includes sweating, cold clammy hands, dizziness, palpitations and trembling.

Isoniazid, an antiinfection medication, may produce rapid heartbeat and lightheadedness.

Monoamine oxidase (MAO) inhibitors belong within the antidepressant family. Along with reducing symptoms of depression, physicians use them in the treatment of panic attacks (see Chapter 19). Possible side effects are dizziness or lightheadedness, especially when getting up from a lying or sitting position, and rapid or pounding heartbeat.

Nitrates are used to improve the blood flow to the heart and to relieve angina. Possible side effects are dizziness, lightheadedness, and rapid heartbeat.

Prednisone is the most commonly used of the corticosteroids and is prescribed to relieve inflammation. Its side effects can include irregular heartbeat, nervousness, muscle weakness, and mood swings. Other corticosteroid medications may cause similar problems.

Reserpine is used to treat high blood pressure and certain emotional conditions, as well as a few other problems. Side effects may include dizziness, faintness, anxiety, and palpitations. Some individuals have even developed phobic reactions while taking reserpine.

Synthetic thyroid hormones are used for treating hypothyroidism. Excessive levels of these hormones can cause rapid heartbeat, palpitations, shortness of breath, nervousness, unusual sweating, and anxiety.