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Panic Disorder (Episodic Paroxysmal Anxiety)

WHAT IS PANIC DISORDER?

The basic feature of Panic Disorder is recurrent attacks of severe anxiety (see symptoms below), which is not restricted to any particular situation or set of circumstances and is therefore unpredictable.  As the problem develops, it is likely that more and more situations that the sufferer was in when a panic occurred will generate panic symptoms, so this ‘unpredictability’ can be a flexible area.  The physical symptoms are almost invariably accompanied by a fear of dying or going mad and this is usually followed by a persistent fear of having further attacks.

People suffering in this way often avoid the situations in which their panics occur as just mentioned, and become afraid of being alone or going into public places.  In this way phobic problems such as agoraphobia can develop from unpredictable panic.  However, to be diagnosed as Panic Disorder the person will not be experiencing panic in known or easily predictable situations such as would be expected in phobia (seeing a spider, being in a social situation etc.), and will not be suffering general anxiety symptoms, beyond the mentioned anticipatory anxiety (being afraid it will happen again), between attacks. A diagnosis of Panic Disorder requires the person to have had several attacks within the past month.

The person with Panic Disorder will also be worrying about the cause of the attack (fear of some severe physical problem such as a pending heart attack or stroke is very common).  He or she will probably also be exhibiting marked behavioural changes in response to the fear. Where panic occurs in a well established phobic situation or as part of a depressive illness, this will probably be the diagnosis rather than panic disorder.  There is also research that suggest that some panics fill the diagnostic criteria for PTSD (Post Traumatic Stress Disorder), so it can be seen that accurate diagnosis is not easy.  In fact it is common for people with Panic Disorder to be misdiagnosed over quite extensive periods before the real condition is recognised.

THE SYMPTOMS OF PANIC

Panic is not an easily defined term. It is frequently used to cover a wide range of discomforts but, in general, it denotes an abrupt surge of intense anxiety.  Clinically, for anxiety to be judged 'panic', it must include four or more of the following:

  • breathing difficulty
  • palpitations
  • feeling 'unreal'
  • pains or tightness in the chest        
  • trembling, dizziness or feeling unsteady
  • sweating
  • feeling faint
  • a fear of dying or of becoming insane, or of losing control
  • tingling in hands and feet (parasthesiae)
  • choking or smothering feelings. 
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SPONTANEOUS PANIC IS NOT JUST CONFINED TO PANIC DISORDER

In most cases, as said, panic is generated by some external cue, e.g. seeing a spider, being on a crowded underground train, or even thinking about these things.  This is phobic panic and people with a phobia are, by definition, going to experience panic (except for some blood and food phobics and in some forms of agoraphobia).  These phobic responses, what­ever the stimulating object or situation, are going to be very similar right across the phobic spectrum with virtually every pho­bic person experiencing some heart rate changes, muscle tension and sweating. 

Spontaneous panic is seen in most anxiety disorders. From Anxiety Care’s experience, anyone who has become extremely sensitive to their life situation and what affects it can be prone to panic.  Within the charity it has been likened to walking in a minefield.  People finding themselves in that situation could be expected to have an extreme reaction to anything happening under their feet.

However, as mentioned, more than half the people with agoraphobia (one of the most common anxiety disorders) do not experience spontaneous panic.  Spontaneous panic is also seen in people with severe depression, in some asthmatics and diabetics, in those taking caffeine, amphetamines or withdrawing from drugs or using alcohol to excess. Anxiety Care has encountered numerous young people, subject to panic attacks, who trace a direct link to their abuse of illegal drugs in previous years.  Having said that, normal young adults commonly report the occasional spontaneous panic, particularly if they have anxiety problems or tendencies, agoraphobic symptoms, or depression.  Panic Disorder sufferers are also more likely to have other medical conditions at the same time such as irritable bowel syndrome, asthma, migraine and ‘atypical chest pain’.  The latter condition refers to chest pain that is not related to the heart but which may come and go, be stabbing or burning and be in different places in the chest each time.

Clinical studies show that people with mental health problems and ‘normal’ people do not experience panic differently. But there seems to be an increased tendency towards spontaneous panic in those with a family history of anxiety or depression. 

When phobic and spontaneous panic is compared clinically, the latter seems to be stronger, with more likelihood of the person reporting loss of control and dizziness.  This would be understandable, as spontaneous panic would have no obvious source, or would feel as if it started from inside the person, rather than outside as when faced by the dreaded phobic object or situation.  And the unknown and invisible are usually more frightening than the things we can see, even if we don’t understand them.
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WHEN SPONTANEOUS PANICS OCCUR

Spontaneous panics can happen at any time with no apparent cause, although stressful events or situations, even laughing too hard or running upstairs, may trigger them in people who are particularly prone to the problem.  They can be infrequent - just an occasional inconvenience - or regular occurrences, coming singly or in 'bursts'. Usually such panic attacks peak in a few seconds or perhaps a minute.  Sometimes they can last for several minutes, and rarely, for an hour or more.  If a sufferer complains of very lengthy panics, lasting for hours, this is likely to be a burst of several panics that this person has linked together in his or her mind.  Panics may also occur during sleep.
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HOW THE CONDITION DEVELOPS

The most common age for onset seems to be from the mid-teens to early adulthoods although it can occur at any time. Some people experience minor symptoms, such as a rapid heart beat, a few weeks or months before their first attack.  There is American research that suggests that up to 12% of fourteen and fifteen year-olds in that country will have panic attacks and that around 20% of adults with the problem state that their first attack occurred before the age of ten.  This research isn’t encouraging as it states that, although only 1-2% of such children will develop full blown Panic Disorder; only 10-35% of these will recover fully and at least 50% will still be at least mildly affected years later.  This research also states that of those who take Panic Disorder into adulthood, half will develop agoraphobia and about 60% will suffer from depression.  These figures suggest, therefore, that some will have both agoraphobia and depression. Although, as stated, this research is based on American statistics, the figures in the UK cannot be expected to be hugely different.
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Avoidance

Often, with this problem, there will be occasional panic attacks that increase in frequency until the sufferer is living in dread of one occurring ‘out of the blue’. This often leads, as already said, to a fearful avoidance of situations where panic has, or may, occur even if the condition is a waxing and waning one that could not be described as chronic. This happens because, as with all panic, the people who experience it are likely to feel impelled to escape from the situation they are in at the moment the panic occurs.  As the symptoms usually ease very rapidly, this is likely to coincide with the escape.  It is; therefore, very easy to associate escape with the relief of symptoms and for this to become a chronic habit. Naturally, if the symptoms involve the possibility of humiliating oneself, such as stomach pains that the person fears will lead to uncontrollable diarrhoea, the likelihood of going out when these occur is very low.  This fear of humiliation can be very strong in younger sufferers and lead to severe social restrictions.

People who have suffered spontaneous panic for some time, and for whom such panic has become a serious problem are likely to be well known at their GP's surgery and may possibly have been dismissed as hypochondriacs by friends and family.  They will probably have had numerous tests for everything from heart malfunction to brain tumour - all negative - because the need to find 'the cause' can be very strong indeed.  These tests themselves can even aggravate the condition as they keep the idea of 'finding a cure' uppermost in the sufferer's mind, focusing thoughts on the body's every twitch and gurgle.  This preoccupation, coupled with the regular raising and dashing of hopes gives the condition vast importance in the sufferer’s mind, leads to dread of panic, and sometimes to the ability to bring one on at the slightest feeling that is remembered as once heralding a panic. 

The APA site quotes research that says that untreated Panic Disorder sufferers:

  • Are more prone to alcohol and other drug abuse
  • Have greater risk of attempting suicide
  • Spend more time in hospital emergency rooms
  • Spend less time on hobbies, sports and other satisfying activities
  • Tend to be financially dependent on others
  • Report feeling emotionally and physically less healthy than non-sufferers
  • Are afraid of driving more than a few miles away from home
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POSSIBLE CAUSES

People may have a tendency towards Panic Disorder. There is research that says that some sufferers report family members having the problem or some other emotional disorder such as depression; although with 1-2% of the population suffering in this way such a situation would not be that unusual. And some research suggests that people who experience panic are as emotionally healthy as anyone else. However, there does seem to be evidence that someone having a family member with an anxiety disorder has a greater likelihood of becoming subject to panic attacks. It is unclear whether this involves a ‘genetic inheritance’ or a response to an anxiety-provoking home environment, or a bit of both. Some researchers, in fact, believe it is a metabolic problem aggravated by a bad environment.

Other workers in this field, a growing number, believe that spontaneous panic is directly attributable to a biochemical abnormality of the nervous system or of the brain.  Where the brain is involved, the theory is that it gives wrong signals about how much Carbon Dioxide there is in the blood. If the brain believes there is too much, as in the person not breathing fast enough or being enclosed in a badly ventilated area, it sends chemical messages to the body to do something about it.  This might be in the shape of an adrenalin boost so the person can run away, and an order to make the lungs breath faster.  When this part of the brain is malfunctioning, seeing too much Carbon Dioxide when this is not true, such a chemical response might happen with no cause or in response to an extremely minor one. Then occurs the situation when a person can be calm or involved in no activity that is consciously making them anxious or breathless, and suddenly the body ‘explodes’ with the need to ‘run or die’. This would frighten anybody.
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‘Natural’ responses

Anxiety Care sees many people who can detail a lifetime of cautious behaviour that has lead to feeling threatened in any new situation.  This is often discussed in groups and some members have expressed the belief that which of the two ‘natural’ responses to life events, either as ‘challenge’ or ‘threat’, one habitually chooses, can make a huge difference to one’s life.  That is, people who accept new situations as a challenge, open up to them. They are interested and excited by the possibilities involved and, although they may be nervous, they have no inbuilt mistrust or expectation of failure.  Those who perceive most new situations as a threat, respond in a threatened way: they shut down, defend themselves, try to find a way out and mistrust what is on offer, expecting the worst.

These very different responses might be part of our genetic makeup, or something we learned, or perhaps a bit of both.  However it does seem that ‘threatened’ children have a greater chance of developing anxiety disorders.  They also appear to have a greater negative response to traumatic events such as deaths and disasters in the family, which can easily lead to panic attacks.

Whatever the cause, and as described above, there could be many variations and mixes, panic is most certainly not imaginary or something that can be ignored by the luckless individual suffering an attack. People cannot 'pull themselves together' or 'snap out of it'.  If they could, they undoubtedly would.  However, those contacting Anxiety Care often feel guilt and shame about the condition.  It is often apparent that they have spent great amounts of energy defending themselves against their family's irritation; or 'making up for their weakness' by keeping this family happy in other ways that usually work against their own self-esteem and real needs. This is energy that could be better used defeating the problem.

Some even become 'aggressive panickers' in self-defence.  They refuse to do anything that might bring on a panic, so ensuring some continuity at least.  Nobody can then accuse them of being better when it suits them.   This handicaps horribly, but at least people stop telling them 'you could if you tried'. This sort of response can be very common in young people and it is not unusual for a child or adolescent with panic problems to be, more or less, in charge of any activity involving him- or herself; laying down rules for what is and what is not acceptable. This might, temporarily reduce the number of times the young sufferer panics, but it causes a great deal of family unhappiness and is not a good way to go about dealing with panic when thinking about recovery options.  At the very best it will reduce the sufferer’s willingness to try anxiety-generating activities.  As anxiety presses against life, taking up as much space as is allowed it, and then struggling not giving any back, this is the road to severe restriction.

Panic symptoms, as said, cannot be ignored: they are real.  The aftermath of panic can be hard to shake off, too.  This may involve edginess; tiredness and temporary loss of co-ordination as the brain has had a shake-up and needs time to settle down again.  However, this does not mean that symptoms and residual effects of any kind should be looked on as 'proof' that there is some physical disorder present that can be taken away by the right doctor.  People who have panics can learn to overcome the feelings that they are going to die, collapse or go insane (some of the ways to do this are discussed in Self-Treatment for Phobias). 
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A NON-MEDICAL APPROACH TO RECOVERY

Sufferers need to break the 'inevitability cycle' of panic.  These attacks do NOT have to run their course each time with a definite and predictable, start, middle and ending.  The physical symptom that 'always' heralds an attack, does NOT have to do so.

Working out if there are triggers that set the panic off and finding ways to overcome the need to escape all help. Learning relaxation techniques can also be a useful tool in combating panic and there are many good systems. Public libraries have books and audio material on the subject.  However, if the sufferer has problems with his or her breathing, or believes that this is a problem, relaxation that involves controlled breathing exercises might not be a useful step; and some people are simply too anxious to undertake this type of work at all.

Diet could also be looked at.  Excessive coffee drinking (perhaps any coffee drinking) should be curtailed and sufferers should learn to eat properly.   A good breakfast is essential, as is not eating too many sugary snacks, to avoid the ups and downs of blood sugar levels that can generate many mild, but panic like, symptoms or lay the ground for an attack. 

Lastly, all this work has to be continuous. Nobody should give up the techniques that they have discovered work for them when the panics ease off.  If such a person stops practising when he or she is just well enough to 'get by', the first major life problem that occurs will throw them back into anxiety, and probably panic, with all the hopelessness and despair that this will entail.  There must be a good deal of 'slack' available to handle the unforeseen crises, and that is only developed by hard work.  This gives resources of strength that will absorb the inevitable problems without incurring the panic reaction and so allows self-confidence to build.
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THE PSYCHOLOGICAL APPROACH TO RECOVERY

The symptoms of panic disorder that involve avoiding certain situation can be confronted with ‘graded exposure’.  This technique involves gradually entering feared situations for longer and longer periods, starting with what can just about be managed and increasing the time element; then moving on to more difficult exposures. A ‘ladder’ of steps should be worked out, involving increasing exposure in a natural progression starting with what can just about be managed, as just mentioned, and working up to what needs to be achieved with as many steps in between as necessary; even splitting up some steps into mini-steps if there is a sticking point.

Another aspect of this therapy is exposing to the symptoms of panic. That is, for example, if major symptoms are over-heating and sweating. The person might be encouraged to wear a couple of sweaters and stay in a warm room to learn that such body responses need have nothing to do with an imminent panic. Other symptoms could be approached in the same way. This activity can be a great help when a person is so sensitised to symptoms that have previously come immediately before an attack, that they virtually bring one on by over-reacting to the first hint of discomfort. 

A lot of anxiety is no better than a small amount when undertaking this work, in fact a huge fear response will tend to confirm in the sufferer’s mind that he or she is incapable of doing this activity and will make it very difficult for this person to try it again. The ‘trick’ of this kind of therapy is helping the person to tolerate increasing levels of anxiety in an environment that can be controlled.  The ‘flooding’ technique that many people fear is not recommended.  This is ‘throwing them in the deep end’; putting them in their most feared situation until the anxiety symptoms wear off as they inevitably will because the body cannot maintain a panic level of chemical arousal for very long. A few therapists still recommend this action but its success depends very much on the sufferer’s character and needs, and failure can instil an even greater fear of the situation.  Anxiety Care has heard many horror stories involving flooding and it is certainly not something that should be undertaken casually. The graded exposure approach is detailed in ‘Self-help for Phobias’ on the charity site.

Response Prevention’ will usually be an aspect of exposure therapy.  This simply involves staying in a situation that is inducing panic for a short period and then gradually increasing the time escape is resisted over daily practise for several days or weeks.  This technique is vital because responding instantly to rising anxiety by running away simply confirms to the body that this situation is indeed dangerous and should be avoided at all costs.  The part of the brain that deals with the fear response hasn’t got a lot of sense and only learns from experience, not by being told what to do; so continual practise is essential.  Even resisting for a few seconds is a start.

If these techniques are being supported by a carer or parent; particularly with young people, it is essential that the steps and response prevention attempts are worked out carefully with the sufferer.  Trying to force somebody to undertake steps or response resistance that is too severe only causes mistrust and unhappiness.  Conversely, allowing somebody to undertake steps that are far too easy, or letting them stay with the same step for unreasonably long periods, is more to do with keeping the sufferer happy than recovery work.  This gives the illusion that something is being done and feeds in to the disability and the sufferer’s need to feel comfortable with him- or herself. It is not real recovery activity at all.

Cognitive therapy’ linked to exposure work and response prevention seems to be the current treatment of choice for many anxiety disorders, although obtaining it on the NHS is not always, or often, easy.  This therapy involved being helped to understand the thought patterns and beliefs that are interfering with one’s life and that are aggravating the anxiety disorder.  The article on thinking that gets in the way of recovery on the charity website investigates this problem quite fully.
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THE MEDICAL APPROACH TO RECOVERY

In general, doctors will probably suggest one or other of the psychological approaches to recovery before they will consider medication.  However, this is not always the case and alternative approaches will depend on the seriousness of the handicap and, of course, the doctor’s preferences.  Where children and adolescents are concerned, most doctors are reluctant to offer medication as a primary response. This attitude is often supported by the parents.  This might change, however, if the child has depression too and is currently unable to attend school because of the level of handicap. Then there would be a ‘crisis’ element to the need, and treatment with a quicker recovery time might be considered.

Anecdotal evidence suggests that many adolescents and their parents are very wary of ‘drugs’ in any form.  This may have something to do with the permanent ‘shock/horror’ stories in the media about illegal (and some legal) drugs and their dangers, or the problem of over prescribing and widespread addiction to tranquillizers that occurred some thirty years ago in the UK.  A minority of parents are also afraid to seek any kind of treatment for their child in case this becomes a permanent part of this young person’s record and affects his or her chances for a job or an advanced education course later in life.  The charity’s response is usually that, if the disorder is allowed to become chronic, this young person’s future education and/or career is going to be badly affected, or non-existent, anyway.  In one case, a family had to be helped to understand that their son was currently unemployable due to his extreme anxiety, and that following a course of medication when all else had failed was, at least, a chance to alter this situation.

The medication of choice seems to vary according to the prescribing physician. Tranquillizers used to be the main drug used, but they have no real affect if depression is also present. However there are some that seem to work well, mentioned in American research as ‘High Potency Benzodiazepines’. These might usefully be discussed with the prescribing physician. Tricyclic Antidepressants (TCA’s) are also sometimes used.  However, it does seem that, in general, people tend to tolerate the benzodiazepines more easily than the TCA’s. Serotonin Reuptake Inhibitors (SRI’s), another antidepressant often prescribed when obsessions and compulsions are involved with an anxiety disorder, are being used more often now and it could be that they are preferred by, perhaps, a majority of general practitioners. 

Benzodiazepines have a far more rapid effect on panic symptoms than do the other medications.  However, there is research that suggests that the relapse rate after termination of medication is more likely with benzodiazepines than with antidepressants. One or other of the benzodiazepines can also be used to ease surges of panic symptoms, unlike the other medications, as it has such a rapid effect. But if this type of medication is decided upon, it would have to be discussed fully with the prescribing physician whether this drug is only used ‘as necessary’ or as a daily dosage, or both.

Some people find that taking benzodiazepines helps bring them to a point where they can accept that the panics can be opposed.  That is, they don’t see the panics as an unstoppable force anymore when on benzodiazepines and can undertake psychological therapies with more confidence.  However, some mental health professionals do not like undertaking psychological approaches with people who are on this type of medication.  The theory seems to be that the person is not then seen to be facing the problem ‘head on’, but is being protected from fully confronting their fears by the tranquillising effect of the medication.  Anxiety Care has never favoured looking for the most difficult way to get better and has found that some people cannot attempt practical work without some chemical help. And in the charity’s experience, any kind of confrontive attempt is better than none. However, this ‘no meds’ stance by some therapists must be kept in mind if a sufferer, or the parent of a sufferer, is looking for professional help.

If antidepressants are preferred, there are a range of SRI’s, all in the same general ‘family’ but different enough for another to be tried if the first (or second) doesn’t work.  The response to these should be a lifting of mood within a few weeks (four to eight), and the reduction, or even elimination, of panic attacks. With young people, the doctor would probably start at the lowest recommended dose and work up if this wasn’t effective; so this might mean being patient beyond that four to eight week period and not insisting on a change of medication because the response is not rapid enough.

One major problem with medication of this sort is that it often has side effects that make the sufferer feel, at least, uncomfortable in the early weeks. These side effects occur before the benefits and as most people do not take medication until they can’t stand feeling this way any longer, feeling a bit worse for a while can then be, literally, intolerable. Anyone considering medication for themselves or their child must bear this in mind.

Side effects might involve varying levels of the following: restlessness, insomnia, stomach upset, nausea, vomiting and diarrhoea. With TCA’s there can be dry mouth, constipation, sedation, sweating and agitation. Anxiety Care has also encountered, with both, weight gain and a reduction in sexual arousal in men.  In some people side effects from any medication might seem like those associated with panic.  The latter can obviously be a major problem as, if the sufferers starts to believe that the medication is increasing panic symptoms, it will be very difficult to persuade this person to continue taking it.   It has also been know for people to have side effects that involve behavioural changes of the ‘disinhibition’ kind.  This is doing and saying silly things and being moody or more aggressive.  If the latter occur with an adolescent it would obviously need to be worked out whether or not this was simply part of the fairly normal teenage response to the world.

All medications interact with each other to some extent so it is important for anyone taking medication of this kind, or supervising a young person’s doses, to make sure that any other medication or over-the-counter remedy will not cause problems.  Most pharmacists will ask if any medication sold is to be used by someone taking prescription drugs, but it is always a good idea to mention this if, for example, cold or cough remedies are being purchased, specially for a child.

Even if medication is successful and panic attacks are blocked completely, it is essential that the sufferer works through any residual problems with avoiding situations.  This is often put under the heading of: ‘better safe than sorry’ by sufferers, where the person who has panicked in the past is unwilling to risk it happening again and so stays out of certain situations with no real concern about this restriction.  The problem is, as has been mentioned earlier, anxiety is not a disorder to negotiate with.  It is focused on taking up as much space in a person’s life as it is allowed and is constantly pressing against the edges of this life.  When a person is focused, even subconsciously, on watching out for danger signs in situations that were not a problem prior to developing Panic Disorder, recovery is not complete.  And as Anxiety Care counsellors are always telling clients: one has to have enough slack in one’s life to take a knock and not fall to pieces.  That is, recovering just enough to function is a very dangerous situation to be in, particularly as the recovered person will almost certainly not want to be involved with further therapeutic work, as this will remind him or her of the disability.  However, if further work is not done, if this person is walking just on the good side of that line between functioning and not, the first crisis that comes along (and there will inevitably be one as there is in everyone’s life) is likely to tip him or her back into panic symptoms.  Then occurs the situation where this person is not only under stress from this new crisis but believes that he or she is ‘back where I was before’ with the panic disorder.  This can be a real self-confidence breaker and one that can be avoided by continuing with therapeutic activities.
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IMPORTANT NOTE ON ALL TREATMENTS

However much the therapist or family believes in a certain mode of treatment, if it isn’t working after two or three months, then the whole thing should be looked at again.  Some treatments don’t work for some people, whatever the professionals say or the sufferer or family wants to believe.  In such a situation a nasty little ‘can’t win’ catch should be also be watched out for, particularly with psychological treatments.  This is: ‘this treatment never fails; if it does it means the sufferer was doing it wrong.’  This is simply not true.  Particularly with exposure work and response prevention, the failure is more likely to be with the sufferer not being ready for the treatment or the structure of the steps being wrong; both of these more to do with the therapist than the person with the disorder.  In many parts of the UK, for example, people are offered exposure work when it becomes available: ‘their turn’, rather than when they are ready to do it.  And some centres appear to have fairly rigid limits on the amount of therapist-facilitated graded exposure work that is available, with the result that the sufferer has to fit his or her ‘recovery’ into what time is available rather than what is needed: not really the best approach to working out useful exposure steps.
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References

Answers to Your Questions About Panic Disorder, APA Online,
http://www.apa.org/pubinfo/panic.html

Jim Chandler MD, ‘Panic Disorder, Separation Anxiety Disorder, and Agoraphobia in Children and Adolescents’
http://www.klis.com/chandler/pamphlet/panic/panicpamphlet.htm

Fears, Phobias and Rituals. Marks, I.M, Oxford University Press, 1987

R.J. McNally and B.M. Lubach, ‘Are Panic Attacks Traumatic Stressors?’

American Journal of Psychiatry 1992; 149(6):824-6
http://www.the-last-dodo.demon.nl/pfg/artikelen/onderzoek2.htm

Panic Disorder: A Highly Treatable Disorder
http://www.mhsource.com/hy/naf-pani.html

Panic Disorder Defined, http://panicdisorder.about.com/library/weekly/aa102297.htm

Panic Disorder European Description, The ICD-10 Classification of Mental and Behavioural Disorders, World Health Organisation, Geneva, 1992
http://www.meantalhealth.com/icd/p22-an01.html

Tranquilizers, Master Glossary ‘T’
http:/www.usc.edu/dept/gero/AgeWorks/glossary/t.html

Treatment of Panic Disorder. NIH Consens Statement Online 1991
Sep 25-27; 9(2):1-24
http://text.nlm.nih.gov/nih/cdc/www/85txt.html

Your Survival Guide To Panic Attacks, Bev Aisbett, Thorsons, 1993

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