Therapy in L.A.

  article of the month
July 1999
By Carol Boulware, Ph.D.

This month therapyinla continues the series on Anxiety Disorders with a thorough exploration of Panic Disorders and Obsessive Compulsive Disorder. Next month we will complete the series with Post Traumatic Stress Disorder and Social Anxiety and some treatment options. The first part of this article is available in the archives at the end of the July article of the month.
--Editor, Joyce Parker, Ph.D.


Most people feel panic over something at least once in their lives. But when it happens frequently and with extreme intensity it may indicate a serious problem that needs attention. Panic Disorder, or panic attacks, often begin in the teenage years or in early adulthood.

A key characteristic of Panic Disorder, is that it usually comes without warning and without any apparent cause. The unpredictable nature of panic attacks adds to the distress of having to deal with this disorder. After a period of time of having attacks, the sufferer so dreads a repeat of this very unpleasant experience, that they often develop a fear of having another attack in addition to the initial disorder.

If attacks persist, it can become so distressful to the person that he or she may not want to leave their house. This is a primary cause of Agoraphobia, the extreme fear of going outside of one's "safety zone," usually the home. For reasons not yet known, women are twice as likely as men to suffer from panic attacks.


A Panic Attack, or Panic Disorder, is an unexpected experience of intense fear accompanied by physical symptoms of accelerated heart rate, rapid or difficult breathing, shaking, dizziness, sweating, hot or cold flashes, nausea , choking or smothering sensation. A person having a Panic Attack may think they are having a heart attack, since there is usually no apparent reason for the physical symptoms.

There is a mental or psychological aspect of panic attack which sufferers describe as a "sense of unreality," of feeling completely out of control or as though they are "going to die" or will "go insane."

"Fight or Flight" Response

Human beings have a built-in "fight or flight" response to a threatening situation. When perceived danger occurs, fear triggers a physical response where the pituitary gland excretes adrenaline into the bloodstream. The adrenaline enhances our ability to "fight" in our defense, or run ("flight") to save our lives. But when fear is triggered internally instead of by some actual physical danger, our bodies still experience the symptoms and physical readiness created by the adrenaline.

Panic Attacks are a serious disorder and can become disabling. The symptoms alone can be very frightening, especially when they come on without warning. People having Panic Attacks often show up in Emergency Rooms thinking they have a serious or life-threatening medical condition.

Possible Causes

Scientists do not know exactly why the body's natural "warning system" gets triggered when there is no actual danger. First attacks can be triggered by physical illness or major stress in a person's life. The causes may involve an interaction of mental, or psychological and physical events. When stress is severe, as with the loss of one's job or a death in the family, it may stimulate the part of the brain that controls fear response. Several very stressful events happening within a short period of time, can also set off panic attacks. In addition, panic attacks can accompany other types of anxiety disorders.

Stresses that may contribute to the onset of panic attacks are:
-- Serious relationship problems
-- Concerns about one's health
-- Physical illness
-- Tensions at the workplace
-- Poor self-esteem or self-hatred
-- Emotional problems
-- Worrying about finances
-- Legal problems
-- Physical or emotional abuse
-- A traumatic situation
-- Witnessing or being a victim of a crime

There is not yet a consensus among professionals about the exact nature of the causes. There are biological theories, behavioral theories and psychodynamic theories. There is also a brain-dysfunction theory and an inner-ear-dysfunction theory. But as yet, none of them has been proven to be the correct theory. Perhaps the true cause lies in a combination or synergy of factors. Researchers do know that panic attacks are connected to major life transitions that are inherently stressful, such as marriage, divorce, a first child, school graduation, a new job, etc. There may also be a heredity factor involved, since scientists have found that Panic Disorder can run in families.

Often Undiagnosed

Unfortunately, Panic Disorder frequently goes undiagnosed and, therefore, untreated. Some sufferers may rationalize their attacks for a long time as normal or "no big deal." Other people may call themselves nervous or "high strung." Sufferers may think that what's bothering them is not important because it is from a long time ago and try to shake it off. They may try to hide their attacks from family, friends or co-workers. They may lose their jobs due to their attacks. However, if Panic Disorder goes untreated for months or years, it may worsen to the degree of seriously interfering with the normal daily life of the person affected.

Sometimes the sufferer actually helps bring on an attack by responding to the physical symptoms with more fear. They may be so anxious about the onset of an attack that they will actually cause an attack themselves. Or, they may mistakenly think that a symptom is from anxiety when it is really a flu symptom or simply from physical exertion.

Treatment Options

Cognitive Behavioral Therapy is often helpful to treat anxiety. This treatment helps the sufferer to be prepared for the situations that might trigger panic attacks.

How Cognitive Behavioral Therapy helps patients with Panic Disorders:

  • Explains anxiety and how to identify symptoms; designs a treatment plan.
  • The patient learns to monitor panic attacks and keeps a record of anxiety inducing situations.
  • Relaxation and breathing techniques are taught.
  • Teaches other skills to help block automatic reaction to fearful situations.
  • Shows how to recognize thoughts and beliefs that trigger anxiety and change their interpretation from catastrophic to realistic.
  • Develops gradual steps for exposing the patient to situations that cause anxiety.
  • Homework to help practice in everyday life what is being learned in therapy.
Often a combination of medication and Cognitive Behavioral Therapy is an effective method of treating panic disorder.

Medications that interact with brain chemicals can reduce or prevent attacks and lessen anxiety. The main types for treating panic disorder are benzodiazepines and antidepressants. These must be taken on a regular basis, from six months to a year.


It is estimated that five million Americans are affected by OCD. This disorder exists when a person's compulsions and obsessive thoughts overpower their life to the point that they are unable to function normally. Unwanted, disturbing or distracting thoughts, and out-of-control behaviors are typical of OCD. These thoughts may be accompanied by a personality disorder, an eating disorder, attention deficit disorder, anxiety or depression.

A compulsion, which is an irresistible impulse or urge, usually includes elaborate and repetitive rituals and often interferes with the person's normal functioning. An obsession is the preoccupation with, and repetition of, a persistent thought or behavior. The person with an obsession usually finds them disturbing and intrusive, but cannot stop doing whatever they are obsessive about.

The reason these conditions are components of the same disorder is because most people with this problem suffer from both obsessions and compulsions. A smaller percentage has only one or the other. In most cases, OCD develops in early childhood, but may not be diagnosed until adulthood.

Some common compulsions are:
-- organizing and arranging things
-- checking the same thing over and over
-- counting and repeating
-- cleaning something over and over
-- shopping
-- gambling
-- lying

Some common obsessions are:
-- symmetry and order
-- talking, asking questions, confessing
-- germs and dirt
-- fear of making mistakes
-- working
-- sex
-- exercise

Possible Cause of OCD

Research indicates that OCD is a biology-based disorder involving the brain chemical, serotonin. Serotonin carries impulses to and from nerves for functions such as walking, eating and thinking. It is believed that very stressful events can cause an imbalance of this chemical in the brain of certain individuals and bring on OCD symptoms.

Treatment Options for OCD

If untreated, Obsessive-Compulsive Disorder is usually a lifelong illness. OCD has usually been treated with a tricyclic antidepressant. Recently, though, additional drugs that selectively act on the neurotransmitter serotonin, called SSRIs, or selective serotonin reuptake inhibitors, are now available for treating OCD.

Behavior therapy has also helped OCD patients, as has a combination of therapy and drugs.

© Copyright 1999 by Carol Boulware, Ph.D.

For more information, please call: Carol Boulware, Ph.D. (310) 395-3351

Offices: Santa Monica & Redondo Beach, CA

Dr. Boulware is a Cognative Behavior Therapist and has Advanced Level II training in EMDR. She practices in Redondo Beach and Santa Monica. She is a member of the Independent Psychotherapy Network.

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