Treatment of panic disorder

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Editor, – In writing about the 'Treatment of panic disorder' (Aust Prescr 2000;23:124-6) Professor Tiller provides the standard definition used in psychiatry. The definition ignores the most outstanding characteristic of panic disorder and panic attacks: over-breathing. Indeed, the Diagnostic and Statistical Manual (DSM) does not provide a diagnosis for hyperventilation disorder which is a common affliction in the community and certainly so among those with mental disorders.1 Caught in this bind, Professor Tiller arrives at the task of management without any theoretical explanation of the measures he advocates.

I intend no criticism of the author. The fact that he deals with hyperventilation at all shows that he is well ahead of his academic colleagues and most working in the field. He has rediscovered the wheel earlier than they. The part that hyperventilation disorder played received full acknowledgment long ago1 and the symptoms of cerebral hypoxia caused by cerebral vasoconstriction were explained in the 19th century. All that knowledge disappeared in the face of psychopharmacotherapy. Psychiatrists have discarded the simple clinical recognition of the deep breaths taken by the anxious patient, the revealing account of light-headedness, pins and needles in the periphery, pain in the left side of the chest, the lumpin the throat, palpitations and panic. Instead of restoring normal breathing and confidence, doctors now take out the prescription pad and a reversible process becomes irreversible. Advanced as he is in rediscovering the wheel, Professor Tiller still has not quite grasped the principles of restoring normal breathing. Normal breathing is not deep. It is abdominal (diaphragmatic) rather than thoracic. Few people have paper bags these days. A plastic bag does just as well and does not make the noise which the author finds socially unacceptable. Tying a piece of tubing into the neck makes it easier to use it as a re-breathing bag. The real reason for not using it is that in most cases correct diagnosis, reassurance and instruction in normal breathing is all that is needed.2,3

David S. Bell
Mosman, NSW

Professor JWG Tiller, author of 'Treatment of panic disorder', comments:

Dr Bell is correct that the DSM does not emphasise over-breathing as a common characteristic of panic. This diagnostic classification tries to differentiate disorders, so it omits features such as over-breathing which may occur in several disorders. I used DSM IV as it is the most common diagnostic system used in Australian psychiatry. I did not attempt a treatise on respiration, not withstanding my interest in this area.4

When faced with hyperventilation, in getting patients to focus on slow, deep breaths, I have not assumed what they might regard as 'normal breathing'. As low respiratory rate is one element. If patients use slow shallow breathing they simply shift air predominantly in their dead space. They feel they are suffocating and their panic is reinforced. Hence the recommendation for slow, deep breathing as the first step in restoring normal breathing. The immediate response to hyperventilation may be exaggerated before 'normal' diaphragmatic breathing is re-established. I would not argue on the popularity of different types of bag, paper, plastic or otherwise. Nevertheless, it would be a spectacular sight to see a patient in the middle of public transport tying a tube into the neck of a plastic bag and then breathing in and out. I would suggest that this would be somewhat attention-grabbing and embarrassing.

My paper focused on psychological interventions rather than pharmacological, as the former will suffice for most patients. However, pharmacotherapy can be uniquely efficacious for some disabled individuals. In my review, rather than rediscovering the wheel, I hope I have simply given it a further push in what may be generally the right direction.

Editor, – The article on Panic disorder (Aust Prescr 2000;23:124-6) had its relevance enhanced by the subsequent commentary by comedian Garry McDonald, wherein reference was made to a book by Bronwyn Fox 'Anxiety attack: don't panic'. A footnote pointed out that this book was out of print.

However there is a more recent book by the same author on the same subject- 'Power over panic'5 - with a foreword by Garry McDonald. I believe it would be a worthy substitute for the now unobtainable earlier book.

Anthony Martin