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without warning but may subsequently become associated with specific situations e.g. in a crowded shop, driving. Anticipatory anxiety and avoidance behaviour develop in response to this chain of events. The condition must be distinguished from alcohol withdrawal, caffeinism, hyperthyroidism and (rarely) phaeochromocytoma.

Patients experiencing panic attacks often do not know what is happening to them, and because the symptoms are similar to those of cardiovascular, respiratory or neurological conditions, often present to nonpsychiatric services e.g. casualty departments, family doctors, medical specialists, where they may either be extensively investigated or given reassurance that there is nothing wrong. A carefully taken history reduces the likelihood of this occurrence.

Treatment. The choice lies between a fast-acting benzodiazepine such as alprazolam (1-3 mg/day p.o.) and a drug with delayed efficacy but fewer problems of withdrawal such as a TCA, e.g. clomipramine (100-250 mg/day p.o.) or an SSRI, e.g. paroxetine (20-50 mg/day p.o.). The different time course of these two classes of agent in panic disorder is depicted in Fig. 19.5 (see also Tables 19.5 and 19.6).

Benzodiazepines rapidly reduce panic frequency and severity and continue to be effective for months; significant tolerance to the therapeutic action is uncommon. On withdrawal of the benzodiazepine, even when it is gradual, increased symptoms of anxiety and panic attacks may occur, reaching a maximum when the final dose is stopped. Indeed, about 20% of patients find they are unable to withdraw and remain long-term on a benzodiazepine.

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