May 28, 2009
Doc talk
Panic beyond control
By Dr Brian Yeo
It was not my usual Monday morning: two separate cases of panic attacks. One was a man, the other a woman and both were executives.
The middle-aged man sat in front of me, embarrassed, as I read the referral letter on his panic attacks. Earlier that morning, the middle-aged woman, also with a similar history, had come to see me.
Both said they experienced sudden episodes of rapid heart beat, breathlessness and sweating with feelings of going crazy or that they were about to collapse or die.
These symptoms occurred out of the blue and did not appear to be directly linked to, say, stress at work. Indeed, their latest panic attacks took place over the weekend, when they were not at work.
The executives had consulted doctors, visited hospital emergency departments and had been given various blood tests, chest X-rays and electrocardiographs (ECGs).
All the test results turned out to be normal. The male executive even had a recent scan of his head and no abnormalities were found.
In endeavouring to help, most of their relatives and friends took to reassuring them and asking them not to worry. Many wondered if they were under stress at their workplace or at home, and if they could avoid or resolve their situations.
Advice such as breathing into a bag or trying out relaxation exercises were usually proffered.
However, panic attacks are not the same as phobias. The feared situation is known in phobias and one can approach phobia treatment much more systematically. The feared situation can be gradually 'conquered' at a pace comfortable to the patient.
However, for patients with panic attacks, reassurances and advice can sometimes make them feel even more frustrated.
Panic attacks come on suddenly at any place without any link to any event or task, making patients feel that they have lost control of their lives.
When someone is in such a state of panic, it is very difficult to do breathing exercises or relaxation therapy or even to remember to calm oneself. The heart races and the person pants.
Another problem panic attack patients suffer from is anticipatory anxiety. Even without any recent panic attacks, they live in fear of an attack coming on while they are out.
As a result, many choose to stay at home and to go out only for work. Most take familiar routes with familiar people and would not dare to change their routines.
In the past, I have seen such cases manifest in students before examinations, in national servicemen or in young adults embarking on their first jobs.
The conventional wisdom was that, as one gets older and becomes more senior at work, one becomes more experienced in dealing with stress and, hence, the number of panic attacks will decrease.
However, there have been more executives and middle managers, especially from the finance and insurance industries, showing panic attack symptoms recently.
In treatment, the aim is to rebuild confidence quickly and stop the panic symptoms once they occur.
From my experience, having my panic attack patients prepare written statements, like 'This is my old friend panic. I know it's bad now but it will go away soon', or keep religious icons at hand helps.
This is because they can then tap into their sense of touch or sight, rather than just rely on the mind, to try and gather thoughts coherently in the midst of an attack.
For some, carrying and touching religious objects or talismans, with their attached calming memories, can convey added reassurance.
If all else fails, short-acting sedatives can be taken to stem an attack.
For some sufferers, just having these pills with them at all times is assurance enough, especially if the attacks are not frequent.
Once such a situation is stabilised, patients can be in a calmer state to go through counselling sessions and to review the stressful events in their lives.
The two executives I mentioned both continue to work and travel, but one of them needs to be on daily preventive medication for a few months.
Panic attacks are eminently treatable and patients need to be assured that they will not go mad or die.
Reassurance, quick relief and effective prevention are needed to get them to regain their self-confidence and recover eventually.
Dr Brian Yeo is a consultant psychiatrist in private practice and an adjunct associate professor at the department of psychological medicine at the Yong Loo Lin School of Medicine, National University of Singapore. He is also a certified master substance abuse counsellor and is currently the Singapore Medical Association representative to the Board of Management, Singapore Anti-Narcotics Association.
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