IU Panic Disorder and the Family CHAPTER 33 JOSE E. pe LA GANDARA, MD and ANGELA PEDRAZA, MD. Panic is a combination of fear with a cluster of physiologic symptoms appearing sud- denly, capable of reaching such intensity that the individual may misinterpret its source, often thinking that death may be imminent or that an unpredictable dangerous outcome, often undefinable, is about to take place. When no physical explanation of the sympto- matology can be found and the frequency of these unexpected episodes increases, cri- teria for the diagnosis of Panic Disorder may be met. The impact of this disorder on the patient, and the family, can be devastating. Closely associated to Panic Disorder is another psychiatric disorder known as ago- raphobia. This is a phobic condition that frequently does not allow the patient to func- tion or interact with others in public facilities or crowded places, and it predisposes the occurrence of panic attacks. In this chapter we further elaborate on definitions, epidemiology, etiology, diagno- sis, differential diagnosis, treatment, prognosis, and biopsychosocial aspects of the dis- order, including its effects on the patient, individual family members, and family dynamics, HISTORY Panic Disorder is a nosological entity that was first included by the Task Force of the American Psychiatric Association (APA) developing the third edition of the Diagnos- tic and Statistical Manual of Mental Disorders (DSM-II1) (1980). Subsequent revision of the third edition (DSM-IILR) in 1987 and the latest fourth edition (DSM-IV), pub- lished in 1994, have modified and attempted to clarify the criteria for diagnosis, but es- sentially it has remained the same. Both editions make a distinction between panic disorder presentation with and without agoraphobia. Panic Attacks Panic attacks are a syndrome consisting of acute, unexpected, unpredictable, relatively short-lived, very uncomfortable episodes of intense anxiety characterized by a clus- ter of symptoms and an unjustified, often undefinable fear that sometimes reaches ir rational magnitude. The fear can be specific, such as in the cases where people think that they are going to lose their mind or they may experience fear of an impending doom. Frequently, however, the panic attack manifests itself as an undefinable fear of the unknown Aenea eee eee renee510 Panic Disorder and the Family The most common symptoms that can be identified in a panic attack include: palpi- tations, pounding heart, accelerated heart rate, shortness of breath, feelings of choking, aphonia, changes in the tone of voice, chest pain or discomfort, nausea, abdominal dis. tress, dizziness, unsteadiness, lightheadedness, faintness, and diarrhea. Other symp- toms include: increased sweating, giddiness, trembling, hot or cold flashes, feelings of unreality (derealization), self-detachment (depersonalization), fears of losing control or going crazy, fears of dying, numbness or tingling sensation, and chills (Kaplan & Sadock, 1991). The DSM-IV definition of panic attack requires a minimum of four concomitant symptoms developing abruptly and reaching maximum intensity within ten minutes of initiation (APA, 1994). Clinically, however, in many cases, less than four symptoms are élicited in the history on examination, and the time elapsed since the initiation of the first symptom may be difficult to ascertain. Frequently at the time of the interview, pa- tients are overwhelmed by the unexplainable physical symptoms they are experiencing and so skeptical of the potential psychiatric nature of their condition that they are un- able to describe, remember, or separate each individual symptom or know the amount of time elapsed from the onset of the first symptom to the presentation of the complete syndrome. In the majority of cases, it is ten minutes or less. The symptoms start to dis- sipate within 15 minutes to one hour of initial presentation. In rare cases the symptoms persist for longer. A panic attack may be triggered by a number of external environmental circum- stances and situations or may be internally, unconsciously, and unwillingly generated in a stimuli-free environment for individuals who are susceptible. They may even occur in sleep during non-REM (rapid eye movement) sleep stages, particularly between stages Tand ITT, according to findings in Thomas Uhde’s Sleep Laboratory at the National Institute of Mental Health. Sleep latency preceding the sleep-related attacks was found to be elongated in contrast with nights in which no attacks took place, and patients with panic manifest an abnormal increase in anxiety related to sleep deprivation, when com- pared to normal subjects (Roy-Byrne, Meliman, & Uhde, 1988). Ina large number of cases, panic attacks are associated with the presence of phobias. Frequently itis the phobic situation that triggers the presentation of the syndrome (Den- boer, Westenberg, & Verhoen, 1990; Kovinsky et al., 1994; Roy-Byrne & Cowley, 1988; Ushiroyama et al,, 1992). Agoraphobia Agoraphobia is defined by DSM-1V (APA, 1994) as anxiety about being in places or sit uations from which escape might be difficult or embarrassing, or in which help may not be available in the event of having a panic attack or panic symptoms. Agoraphobic fears typically involve characteristic clusters of situations, such as being outside of the home alone; being in a crowd or standing in a line; being on a bridge; or traveling in a bus, train, or automobile. It has been suggested that the diagnosis of specific phobia be considered if the avoidance is limited to one or only a few specific situations: or social phobia should be considered if the avoidance is limited to social situations. This seem- ingly unspecified reference to symptom clusters and the suggestion that other related di- agnostic entities be considered sets the stage for an additional requirement regarding differential diagnosis of agoraphobia versus othet mental disorders, such as social pho- bia; specific phobias limited to a single situation, such as avoidance of riding in elevators,Etiology 511 escalators, or airplanes; obsessive-compulsive disorder in which the individual avoids dirt or touching potentially dirty objects because of obsessive fear of contamination; Post-Traumatic Stress Disorder, in which there is avoidance of stimuli the individual associates with the severe stressor that may have originated the activation of the disor- der of separation anxiety disorder and manifested by avoidance of leaving home or rel- atives due to the anxiety that such action provokes. Agoraphobia is recognized as an individual nosological entity in DSM-IV under the diagnosis Agoraphobia without History of Panic Disorder. While panic attacks are de- scribed specifically, they arc not considered an individual codable entity, probably be- cause they are made up of a cluster of symptoms that are common to a number of psychiatric as well as nonpsychiatric conditions. EPIDEMIOLOGY Panic disorder is a disease of worldwide distribution that will afflict at least one out of every 75 individuals during their lifetime (National Institute of Health [NIH], 1991), Other authors set the lifetime prevalence of the disorder at 1.5 to 2 percent of the pop- ulation (Kaplan & Sadock, 1991), The female-to-male ratio of panic disorder with ago- raphobia is thought to be 2:1, The mean age of presentation is 25 (Kaplan & Sadock, 1991). A NIH consensus conference, however, reports that the middle teens and carly adulthood are the most common age of onset, although it acknowledges that the onset may occur at any time (NIH, 1991). To illustrate the wide range of variability in age of onset, an article by Hassan and Pollard (1994) reported a group of 13 cases with initial onset at ages 60 or older. Thirty other patients over the age of 60 were also reported to continue to experience panic dis- order with a younger original age of onset. ‘Agoraphobia is estimated to have a lifetime prevalence of 0.6 percent. Approximately one-third of the individuals with panic disorder also have agoraphobia (NIH, 1991). Ac- cording to the same sources, at least 66 percent of patients with agoraphobia also suf- fer from panic disorder (Kaplan & Sadock, 1991; NUH, 1991). Agoraphobia has a mean age of onset in the mid 20s", and its appearance is commonly reported to occur follow- ing a traumatic event (Kaplan & Sadock, 1991). Patients with agoraphobia tend to have a more severe and complicated course of illness (NIH, 1991). ETIOLOGY Although the etiology of panic disorder is not known, a few theories have been postu- lated in an effort to find an explanation for the disorder. The theories range from bio- logical to psychological. In the next few paragraphs we attempt to present the most important hypotheses. Biological Theories In the last few years researchers have succeeded in creating a model for panic attack that allows them to study its phenomenology by provoking a paniclike syndrome while in- fusing sodium lactate intravenously to predisposed individuals (Roy-Byrne & Cowley,512 Panic Disorder and the Family 1988), An interesting finding that may prove helpful in understanding the pathophysi- ology of panic disorder is that patients who are successfully receiving treatment with alprazolam (Xanax) or imipramine (Tofranil) do not experience the symptomatology of the syndrome when rechallenged with sodium lactate infusion. In addition to sodium lactate, hyperventilation, carbon dioxide inhalation, yohim- bine, caffeine, isoproterenol, and a number of other panicogenic drugs that have been studied in the last few years (Kaplan & Sadock, 1991; Roy-Byrne & Cowley, 1988). One of those other drugs is Norplant, a subdermally implanted contraceptive contain- ing levonogestrel, a synthetic progestin (Wagner & Berenson, 1994). Other orally ad- ministered contraceptives also are included in the ever-increasing literature of agents reported to induce panic attacks (Deci et al., 1992; Ushiroyama ct al., 1992). ‘The efficacy of tricyclic antidepressants, monoamine oxidase inhibitors, and certain benzodiazepines in the treatment of panic disorders, now apparently also duplicated by the selective serotonin reuptake inhibitors (SSRI), has opened the way to the emergence of different but closely related theories to explained pathogenesis of panic disorders Some of these compounds selectively inhibit the reuptake of either norepinephrine or 5- OH triptamine (serotonin) and others inhibit both, with a greater or lesser inhibitory balance ratio between one and the other neurotransmitter, ‘Two different theories have been postulated based in the uptake inhibitory proper- ties. Both theories implicate the locus coeruleus directly or indirectly. One postulates that the locus coeruleus, which is the principal noradrenergic-containing nucleus in the brain, is involved in anxiety. The other postulates the serotonergic neuronal system’s in- volvement in anxiety disorders and panic disorders specifically (Denboer, Westenberg, & Verhoeven, 1990). Benzodiazepines receptor research work with anxiolitic and anxiogenic compounds affecting the benzodiazepine receptors such as colecistokynin (CCK), a usually inert peptide that provokes panic attacks in patients but not in normal controls, suggests that this receptor may be a key to the up- and down-regulation of anxiety states. Preliminary evidence cited in the literature from unpublished work of Roy-Byrne and Veith suggests that panic patients may be less sensitive to the catecholamine-reducing effects of ben- zodiazepines. Indeed the characteristic response of panic patients but not normal con- trols to CCK indicates the possibility of an imbalance in the sensitivity of the benzodiazepine recepior. Psychodynamic Theories In psychoanalytic theory, panic attacks are explained as being an unsuccessful defense against anxiety-provoking impulses. According to this view, the initial anxiety against which the patient consciously tried to defend him- or herself without success is now perceived as an unconscious overwhelming threat or fear that takes the new form of the multiple somatic symptoms characterizing the panic syndrome. Agoraphobia, on the other hand, is explained in psychoanalytic theory as the fear a child has of being aban doned. The defense mechanisms used are repression, displacement, avoidance, and sym- bolization. Behaviorists theorize that anxiety is a learned behavior resulting from either parental modeling or classic conditioning. They believe that panic attacks and agoraphobia de- velop simultaneously or that agoraphobia may even precede the development of panic at- tacks (Kaplan & Sadock, 1991)Differential Dingnosis $13 DIAGNOSIS The diagnosis of Panic Disorder is made on the basis of preset current arbitrary para- meters that have heen revised since the syndrome was first defined by DSM-III (APA, 1980). The current criteria are established by DSM-IV (APA, 1994) and require that the following three conditions be met: 1 The presence of both I and 2 below: 1, Recurrent unexpected panic attacks. 2. At least one of the attacks has been followed by a minimum of one month of either persistent concern about having additional attacks, or worry about the implication of the attack or its consequences, such as losing control, having a heart attack, fears of going crazy, and/or a significant change in behavior related to the attack. Il. The absence of the conditions specified in 3 and 4 below: 3. The panic attacks are not due to the direct physiological effects of a sub- stance such as medications or recreational drug abuse or 2 general medical condition such as hyperthyroidism. 4. The panic attacks cannot be explained by the presence of another predominant mental disorder such as social phobia, other phobias, obsessive-compulsive disorder, post-traumatic stress disorder, separation anxiety disorder, etc. II. Absence or presence of agoraphobia for the diagnosis of panic disorder without agoraphobia (300.01) or panic disorder with agoraphobia (300.21), respectively. DIFFERENTIAL DIAGNOSIS A thorough medical workup is indicated to rule out physical illnesses. Ruling out med- ical etiology can be a very challenging task, however, due to the multiplicity of organ systems implicated through symptoms that may be present in panic attacks, many of them mimicking symptoms resulting from a host of medical illnesses and vice versa. Sheehan, Ballinger, and Jacobson (1986), reported that in one sample group studied, all of the patients with panic disorder have previously consulted a physician at least once about this distress. Seventy percent of them had seen ten or more physicians in re- lation to their symptoms (Ashok & Sheehan, 1987). One could therefore easily conclude that by the time these patients enter the mental health system and are examined by a psy- chiatrist, they are fairly well worked up and most medical illnesses have been ruled out. That could be a dangerous assumption in light of the rapidly changing crisis of financ- ing health care. Discussion Panic disorder is a very difficult disorder to diagnose, requiring ample interviewing skills, clinical expertise, and experience. As with all other psychiatric disorders, an ac- curate diagnosis is the cornerstone of successful treatment intervention both psy- chopharmacotogically and psychotherapeutically. Unfortunately, many patients suffer the disorder for years, functioning only marginally. Their treatment addresses only some314 Panic Disorder and the Family of their anxiety symptoms, they do not receive the appropriate care, and they are misdi- agnosed in busy emergency rooms, by primary care physicians, or by mental health pro- fessionals who lack the time and/or expertise necessary to diagnose and treat such cases, Agoraphobia is said to accompany panic disorder in over 60 percent of the cases. It is thought that many patients develop agoraphobia as a result of classical conditioning, after experiencing a panic attack in a public place, such as a supermarket, Patients de- veloping agoraphobia tend to have a more severe and complicated course of illness. Psychopharmacologic Intervention ‘The psychopharmacologic treatment of panic disorder has been carefully studied, par- ticularly in protocols approved by the Food and Drug Administration, which are de- Signed to establish the safety and efficacy of new compounds and of currently approved compounds in order to gain additional approval for their use in panic disorder with and without agoraphobia and agoraphobia without panic disorder. The compounds studied include benzodiazepines, tricyclic antidepressants, monoa- mine oxidase inhibitors, SSRI, atypical antidepressants, azospirone group compounds, beta blockers, calcium channel blockers, and antiseizure medi ‘The literature contains many case studies and anecdotal reports representing suc- cesses and failures using a number of other compounds. Of the benzodiazepine group, alprazolam (Xanax), which is classified among the most potent compounds in this chem- ical group, was the first one approved for panic disorders. Two other high-potency ben- zodiazepines, lorazepam (Ativan) and clonazepam (Klonopin), also have proven to be effective in panic disorders. Of the tricyclic group, the most studied is imipramine (Tofranil), which has shown significant efficacy over placebo and compared favorably with other compounds in sev- eral clinical trials. While all the tricyclics, including desipramine (Norpramin), one of imipramine’s metabolites, are said to have antipanic properties, a recently published study claims that chlomipramine (Anafranil), the only tricyclic with strong serotonin te- uptake inhibitory properties, is superior to imipramine for this indication (Modigh, Westberg, & Erickson, 1992). Of the SSRI group, fluvoxamine has been studied specifically for this indication through at least one clinical trial sponsored by & multicenter pharmaceutical company. In other independent individually designed studies, fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) also have been reported to be effective in the treatment of panic disorders (Hoehn-Saric, McCleod, & Hipsley, 1993). In our clinical experi- ence, all three above-mentioned, approved SSRI antidepressants have proven clinically effective when used for the maintenance of patients with panic disorder. Other com- pounds also have been reported in the literature to be efficacious, including the anx olitic buspirone (Bu Spar) and the antiepilectics carbamazepine (Tegretol) and valporic acid (Depakene). ns. Psychotherapeutic Intervention Icis generally understood and accepted that the efficacy of traditional psychodynamic psychotherapy is poor and quite inadequate in the treatment of panic disorder, although some authors still list insight-oriented psychotherapy as a beneficial alternative, be- cause it helps the patient understand the unconscious meaning of the anxiety and theDifferential Diagnosis $15 symbolism of the avoided situation, the need to repress impulses, and the secondary gain of the symptoms (Kaplan & Sadock, 1991). Increasingly, however, experts in the field have endorsed a combination of cognitive and behavioral therapy accompanied by other useful therapeutic techniques, such as breathing exercises, guided imagery, and relaxation training, to replace psychodynamic psychotherapy in the treatment of this disorder. Cognitive-behavioral psychotherapy supplemented by these above techniques has been demonstrated to be at least as effective as psychopharmacologic treatment options alone. The consensus of experts indicates that medication will enhance the effectiveness of psychotherapy while, reciprocally, psy- chotherapy enhances the effectiveness of psychopharmacclogic treatment schemes (Mavissakalian, 1990). Lesser (1991) cites some advantages of this treatment approach over psychopharmacological treatment, including absence of side effects, chemical de- pendence, and dose finding. Improvement derived from cognitive-behavioral treatment may be longer lasting than the improvement derived from psychopharmacological treat- ment strategies (Marks & O'Sullivan, 1988). ‘Cognitive-behavioral therapy of panic disorder is a modified application evolved from the original therapeutic strategies developed by Beck for treating depression (Beck, Rush, Shaw, & Emery, 1990) and later applied to-anxiety disorders, phobias, and per- sonality disorders (Beck, Emery, & Greenberg, 1985). A case presentation (Persons, 1992) described the evaluation and successful treat- ‘ment outcome using cognitive therapeutic techniques of a 29-year-old woman suffering from panic disorder that was manifested after the birth of her first and only child. Per- sons emphasized the importance of the formulation and a thorough understanding of the patient’s lifetime psychodynamic history, Also stressed is the nced, whenever relevant, to understand the psychodynamics of the patient's significant other fully, to help better understand the dynamics of the couple as a whole and its effects on each individual. ‘The efficacy of cognitive therapy has been demonstrated in numerous recent stud- ies, including those designed to compare the efficacy of psychopharmacologic inter- vention versus the psychotherapeutic approach. At least one (Klosko, Barlow, Tassinary, & Cerny, 1990) clearly shows comparable efficacy. A recent article reveals the results of a study carried out at the University of Iowa comparing fluvoxamine, cognitive ther- apy, and placebo in 75 outpatients with moderate to severe panic disorder. The study was a placebo-controlled, double-blind, multicenter clinical trial to compare safety and ef- ficacy of fluvoxamine versus placebo. A cognitive therapy balanced treatment cell was added in the individual site. In this study, both fluvoxamine and cognitive therapy ap- peared to be better than placebo; when both active treatment modalities were compared to each other, fluvoxamine was found to be significantly superior to both cognitive ther- apy and placebo. It should be noted that this was a relatively short-term study (Black etal., 1993). Itis generally agreed, however, that the best treatment approach not only for panic disorder with or without agoraphobia but also for other anxiety-related disorders is a combination of the cognitive-behavioral approach plus psychopharmacologic interven- tion rather than either one of the two approaches alone (Beck, 1992; Beck et al., 1985; Beck et al., 1990; Pruitt, 1992; Wright & Thase, 1992) Besides the individual psychotherapeutic modalities just discussed, group therapy, supportive groups, and/or marital and family therapy with a problem-oriented approach can be of significant value in the overall treatment of panic disorder with or without agoraphobia.516 Panic Disorder and the Family PROGNOSIS Uncomplicated, recent-onset panic disorder with and without agoraphobia and agora- phobia without panic disorder are treatable conditions with good prognosis when accu- rately diagnosed and properly managed. As with many other psychiatric conditions, however, comorbidity, chronicity, lack of education, lack of compliance, and prejudice complicate the picture and make prediction of treatment outcome less reliable, The prog- nosis obviously is affected by comorbity with substance abuse, such as alcohol abuse, recreational drug abuse, and caffeine, or with personality disorders or other psychi- atric, medical conditions that may cause the patient to be unreliable in treatment follow- up or that prevent or limit the administration of medication, psychotherapy, or both forms of treatment. Chronicity is a poor indicator no matter why it occurs. Chronic illness of any kind and chronic mental iliness in particular has a powerful effect on us. While chronic ill- ness in the absence of psychobehavioral pathology may strengthen character, chronic mental illness presupposes at least some maladaptive behavior, which in turn reflects the existence and preponderance of pathologic defense mechanisms, It is a very difficult task to reverse years of pathological learned behavior resulting from the application of abnormal defense mechanisms to compensate for a condition that exists constantly to a greater or lesser degree. For these reasons, we submit that chronic panic disorder, while not impossible to treat, has a guarded progno: Education, compliance, and prejudice are factors affecting the treatment outcome. All three are interrelated and cause patients to misinterpret what is happening. There- fore they may not be able to provide the clinician with a reliable history that will help him or her arrive at an accurate diagnosis, they may misjudge the improvement, or they may think that a cure has been achieved and therefore abandon treatment or deny the ex- istence of any difficulties for fear of ridicule and discrimination upon admitting to such “weakness or flaw in character.” Much education and change in societal attitudes are required to overcome those obstacles in the treatment of mental disorders and particu- larly panic disorder, IMPACT OF PANIC DISORDERS IN THE FAMILY Psychosocioeconomic Aspects Panic disorder’s socioeconomic impact is of great consequence not only to the patient but also to other family members and to marital relations. Panic disorders rank very high among psychiatric disorders and anxiety disorders in their disruptive consequences to the patient and immediate family members. Their scope of influence reaches to the extended family and society. With a mean presentation of 25 years of age, the disorders strike ata time when the individual, on the average, is reaching the most productive pe- riod in his or her life, placing the sufferer at a distinct disadvantage from other indi- viduals in the same age group. Implications to the Patient Tn addition to the obvious pain and suffering of the individual afflicted with panic dis- orders and the devastating experience of its distinct symptomatology, he or she alsoImpact of Panic Disorders in the Family $17 must endure psychological pain resulting from the social implications of his or her re- actions to the symptoms. This is particularly true of those individuals who develop pho. bic conditions, including the most ominous, agoraphobia, Individuals afflicted with this disorder see the routine of life disrupted by frequent routine or emergency visits to the physician's office and the emergency room believing that they are about to or have suffered a heart attack or some other life-threatening con- dition from which they may die, Often they are unable to drive or to ride an elevator, an airplane, a train, or other means of public transportation to attend any kind of activi- ties where groups of people will congregate, from grocery stores and shopping malls to religious services ot political or entertainment rallies. They must abstain from a vari- ety of common situations in modern life due to their fears. Patients thus begin to use avoidance as a pathological defense mechanism; if it persists, it confines them to the re- strictive walls of their own home. Individuals consequently see themselves as limited in their ability to function in society. Their ability to perform productive work, to apply their talents, and even to exercise limited financial independence are all profoundly af- fected by their illness. Such a predicament exerts lasting effects on the individuals” psy- chological and mental state and personality, in addition to the disorder itself. Implications to Society Besides losing the productive participation of the patients, society also is overburdened directly or indirectly by the cost of the wasteful use of resources, such as overutiliza- tion of medical services or expensive emergency room services. The lack of financial independence of such individuals also has an effect on society; after depleting the fam- ily’s financial resources, incapacitated individuals often have to apply for disability or early retirement and have to utilize state or federal financial, health, and nutritional assistance programs in order to exist. Implications to the Family ‘The family is gravely affected as a result of the illness. In spite of the high incidence of ‘comorbid psychiatric conditions that are found to coexist with panic disorder, in many instances individuals affected are normal if not outstanding members of society. Their life and that of their family will suffer a tremendous upheaval in a variety of psy- chosocioeconomic spheres as a result of the illness. ‘A recently published article reveals the results of a multicenter prospective study carried out in five tertiary care center hospitals, each located in five different areas of the United States (Kovinksy et al., 1994). The study focuses on the impact of serious illness on patient’s families. To evaluate the impact of illness on the family, patients and/or their surrogates were questioned regarding the frequency of adverse caregiving activities that became essential and the economic burden encountered. More than half of the families reported at least one severe caregiving or financial burden and the in- vestigators concluded that many families of seriously ill patients experienced these bur- dens and their accompanying stress and distress. Other studies focusing on similar questions corroborate these findings. Patrick and coworkers (1992) and Pruncho and Potashnick (1989) focus on the relationship between the patient’s illness and the heaith of family members as reflected in the increased uti- lization of health-related services by family members. Oppenheimer and Frey (1993)518 Panic Disorder and the Family report the results of a study of patients in 52 families conducted using DSM-IE-R (APA, 1987) criteria. They were classified into three groups, including major depression, pani¢ disorder, and a nonclinical control group. Family processes were examined using self Teport measures and a structured interview. The results suggested that compared to de- pressed and nonclinical contro] families, panic disorder families had unresolved life-cycle issues, were enmeshed, used triangulation, and failed to resolve conflict. ‘These findings indicate that dysfunctional family processes may be involved in the expression and maintenance of panic disorders. ‘The data suggest the need for family and marital therapy in addition to the previously discussed psychopharmacologic and cognitive-behavioral treatment approaches for panic disorder. Case History ‘The following history is that of a patient that has been followed in our office for the past Five years, with the diagnosis of Panic Disorder with Agoraphobia, The patient is a 43-year-old married female, who stated during her first visit that she experienced her first panic attack at age 26, while shopping at a mall. Her panic attack symptoms include palpitations, shortness of breath, hot flashes, hand tremors, fears of death, “heavy feeling in her head,” and feelings of depersonalization, The attacks at the onset of her illness were unexpected, and the symptoms lasted 15 to 20 minutes. She con- sulted her primary care physician, who concluded after a medical workup, there was no “physical” reason to justify her symptomatology. Benzodiazepines were prescribed. She reported that at age 31 her panic attacks increased in frequency and'she developed ago- raphobia, which was manifested by fears of going to the stores and fears of driving. These symptoms created significamt impairment in her ability to function at home and at work. Ie was at that time that she was referred to psychologist and psychiatrist for consultation, ‘The patient has been stable on 150 mg imipramine at bedtimne and 0.25 mg alprazolam 8 day as needed for anxiety, with almost complete resolution of her panic attacks. She re- mained however, with anticipatory anxiety, and this symptom was prevalent in her daily activities, which in turn affected her relationship with her family. Her daughters were ba- coming fearful of separating from their mother because of her fears of dying. The pa- tient’s symptomatology also was suggestive of the possibility of @ heart attack. Her husband believed she was a “hypochondriac,” since there was no physical abnormality to justify her symptoms, and felt overwhelmed and helpless in relieving her anxiety. Psy- chotherapy sessions with her husband and children were recommended to process her ill- ness and their interaction as a family. Her husband was educated about her disorder and his limitations in relieving her anxiety but of the significant benefit of being supportive of her complaints, reassuring that her symptoms would subside and that she would not die from @ panic attack. During subsequent visits it became apparent that incorporating this patient’s family in the care plan provided a better treatment outcome for her and her family than would have occurred without th CONCLUSION In this chapter we have discussed various biopsychosocial aspects of panic disorder, treatment strategies for the patient, and the emotional and socioeconomic burden the disorder causes for the patient, the individual family members, and the family as a whole. Before we conclude, however, we wish to emphasize our belief that as in many other psychiatric disorders, while the focus of psychopharmacologic and psychothera- peutic treatment is on the patient, overall management of the disorder requires attentionReferences $19 to and specific forms of interventions toward the family members individually, the cou. ple, and the entire family. The full range of therapies should include psychopharmaco- logic, individual supportive, and cognitive-behavioral therapy, plus couple, family, and group therapy, separately or in combination, to maximize treatment efficacy for all fam- ily members. REFERENCES American Psychiatric Association. (1980). Diagnostéc and statistical manual of mental disorders (Grd ed.). Washington, DC: Author. American Psychiatric Association. (1987). Diagnostic and statistical manwat of mental disor- ders (3rd ed., rev.). Washington, DC: Author. American Psychiatric Association. (1994). 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