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letter
. 2008;10(4):332–333. doi: 10.4088/pcc.v10n0411d

Panic Disorder After the End of Chronic Alcohol Abuse: A Report of 2 Cases

Fatih Canan 1, Ahmet Ataoglu 1
PMCID: PMC2528232  PMID: 18787672

Sir: Comorbidity rates between alcoholism and panic disorder (PD) vary widely in several clinical trials.1,2 Some trials reveal alcoholism rates in PD similar to those in the general population (between 14% and 16%),3,4 and between 7% and 17% in agoraphobic patients,5,6 whereas other studies find higher rates ranging from 20.7% to 28%.7–9

Some studies have suggested that individuals seeking treatment of alcohol use problems and dependence often meet diagnostic criteria for panic attacks, panic disorder, and agoraphobia.10,11 Other investigations have indicated that persons seeking treatment of panic-related problems often meet diagnostic criteria for alcohol problems.12 Otto et al.,8 as one example, found that approximately 25% of persons seeking treatment for panic disorder had a history of alcohol dependence.

Panic attacks may be related to drinking aimed principally at reducing anxiety states and aversive bodily sensations. Yet such negative-affect–reduction drinking may, over time, have paradoxically anxiogenic effects by promoting heavier drinking, somatic dysregulation (e.g., recovery from heavy drinking episodes), and greater degrees of withdrawal symptoms. To the extent that individuals with panic attacks continue to drink heavily to escape or avoid such aversive alcohol-related internal states, they may be more likely to progress beyond heavy use and abuse to develop tolerance and withdrawal-related problems associated with alcohol dependence.13

Panic attacks, specifically, may be expected to developmentally precede alcohol use problems because recent investigations indicate that panic attacks may be a general risk marker for later substance use problems.14

Herein, we report 2 similar cases in which first panic attacks were experienced 1 month after abrupt cessation of alcohol abuse, indicating chronic alcohol use as a possible matter for development of panic disorder. Our cases, to the best of our knowledge, are the first in the literature in which panic disorder has developed after the cessation of chronic alcohol abuse.

Case 1

Mr. A, a 25-year-old barber, came to the psychiatry clinic with complaints consistent with a possible diagnosis of panic disorder according to the DSM-IV-TR criteria. Before he sought treatment at the clinic, he reported having up to 4 attacks per day, each lasting 1 to 2 hours on average and consisting of shortness of breath, chest pain, intermittently unreliable vision, nausea, diarrhea, and a sense of impending doom. For the most part, these symptoms appeared without warning, and over time he began to develop an intense underlying sense of anticipatory apprehension related to the unpredictable and uncontrollable appearance of these spells. Mr. A had had his first panic attack approximately 5 months earlier, 1 month after an abrupt cessation of an alcohol abuse period lasting 7 years. He had had almost no withdrawal symptoms except a feeling of dizziness that continued for 1 week.

Mr. A had been exhibiting antisocial behaviors, like frequent fights and incidents of shoplifting, since puberty, and he had a history of inhalant abuse between the ages of 17 and 20 years. During his sober times, Mr. A had realized that he was “a better man” (no fights, no arrests) and decided not to return to his “bad days.” But he had started drinking again when the panic disorder symptoms made him “crazy.” Three days after this restart, when he was arrested again because of a fight with the police, Mr. A made a definite decision to stop drinking, although alcohol had made his panic symptoms disappear completely. But the symptoms of panic attack had recurred after this decision, and he decided to see a psychiatrist. He reported no personal or family history of panic attacks. Mr. A was prescribed clomipramine 150 mg/day. The treatment has been helpful but his panic attacks have not entirely subsided with treatment.

Case 2

Mr. B, a 42-year-old automobile repairman, had a history of alcohol abuse for 16 years. He decided to stop drinking because of the unending insistence of his family and coworkers. He had had no withdrawal symptoms. However, approximately 1 month after the sudden cessation of alcohol abuse, he started to experience spontaneous episodes of panic attacks, with shortness of breath, chest pain, palpitations, trembling, and a fear that he was going to die. These attacks even interrupted his sleep; he would waken abruptly with a choking sensation. Two months after his first attack, Mr. B came for treatment, reporting a gradual increase in his symptoms that he related to his abrupt alcohol cessation. He stated that he would not drink again whatever happened but that he needed help for this new intolerable situation. He had no history of panic attacks before or during the alcohol abuse period. Mr. B was diagnosed with panic disorder according to the DSM-IV-TR criteria and was treated with paroxetine, initially 10 mg/day and gradually increased to 40 mg/day. He achieved remission of the panic attacks but was still presenting with limited symptom attacks related to stressful and threatening places or situations at 3 months' follow-up.

It is unclear whether panic attacks developmentally precede the onset of alcohol use problems or alcohol use problems precede the onset of panic attacks. The relative time to onset of the 2 disorders is a crucial issue that can shed light on etiopathogenic factors, in addition to having important practical implications. Clinical studies usually find that PD precedes alcoholism.15,16 In addition, comorbid patients typically report that they use alcohol to relieve anxiety or panic symptoms.17 In an experimental design, Kushner et al.18 demonstrated that alcohol acutely reduced panic in patients with PD. These studies lend support to the self-medication (or tension-reduction) hypothesis, which states that patients with anxious disorders drink to relieve their symptoms of panic, thus developing alcohol problems. Alcoholism would then be secondary to PD.19

However, there is also clinical evidence that alcohol use, in addition to its initial anxiolytic effects, causes long-term increase in anxiety and agoraphobia.15,20 A few clinical studies have also reported that alcoholism began before PD. In the Breier et al.6 study, 80% of patients (8 of 10) had alcoholism before their first panic attack. The clinical study by Goldenberg et al.21 failed to support the self-medication hypothesis. A reanalysis of the Epidemiologic Catchment Area study22 found that, in subjects with comorbid alcoholism and PD, alcoholism appeared first in 60% of cases, and in 33% of individuals PD had an earlier onset.

Gender difference is also a confounding issue in the relationship between alcohol use and PD. In men, alcoholism was found to be primary with respect to PD (but not with respect to agoraphobia), whereas in women, alcohol problems were more frequently secondary to PD.1

Both Mr. A. and Mr. B had experienced their first panic attacks 1 month after abrupt cessation of alcohol abuse. They had no history of panic attacks during or immediately after the alcohol abuse period. Mr. A. had used alcohol to relieve his anxiety after the onset of panic disorder symptoms. Alcohol withdrawal in chronic alcohol use is reported to enhance noradrenergic activation and increase the likelihood of experiencing panic attacks in neurodevelopmentally vulnerable individuals. Alcohol has been hypothesized to have a kindling effect on the emergence of panic attacks.23,24 Our cases may support this hypothesis; however, we do not consider panic disorder 1 month after the cessation of alcohol a withdrawal symptom.

Studies report an increase in anxiety and agoraphobia in alcoholic patients.15,20 Although some experimental research indicates that alcohol reduces panic in patients affected from PD,18 it is important to differentiate the short-term from the long-term effects of alcohol.

Although a short-term anxiolytic effect seems to validate the self-medication hypothesis, it is possible that alcohol use has a long-term panicogenic effect, particularly after cessation, as in our cases. Clinicians should be vigilant to psychiatric comorbidities in the patients who have alcohol use problems, especially in the abstinence period.

Acknowledgments

The authors report no financial or other relationship relevant to the subject of this letter.

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Articles from Primary Care Companion to The Journal of Clinical Psychiatry are provided here courtesy of Physicians Postgraduate Press, Inc.

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