Anxiety and Depression are the most common psychiatric disorders.
Your symptoms are suggestive of Panic Attacks, discrete periods of fear or
discomfort with characteristic symptoms that develope abruptly and reach a
peak within 10 minutes.
The characteristic symptoms of Panic Attack are pounding heart rate,
sweating, trembling, sensation of shortness of breath, chest pain,
nausea, dizziness, fear of losing control and fear of dying.
Depression may be secondary to the attacks or may worsen the attacks,
The symptoms of depression maybe depressed mood, disturbance of sleep or appetite, decreased interest, feelings of worthlesssness or hopelessnes.
An MRI would not aid in the diagnosis of depression or anxiety.
I recommend an evaluation by a psychiatrist.http://www.aafp.org/afp/20050215/733.htm…
Development of Panic Disorder
How do panic symptoms develop? A phobia of internal sensations is thought to drive the patient’s avoidance behavior. In addition to neurochemical and genetic models for the disorder, some researchers have proposed a cognitive model, in which patients learn to misinterpret thoughts and emotions as physical symptoms. For example, a woman who is afraid of being left alone when her husband leaves for work may experience that fear physiologically (e.g., shortness of breath, sweating), which in turn makes her feel more anxious (“What is wrong with me?”), deepening the spiral and leading to more symptoms. Another theory is that patients escalate otherwise benign body sensations into panic attacks (the behavioral model). For example, a man whose heart rate accelerates when he becomes angry may escalate that sensation and the resulting anxiety into the chest pain of a “heart attack.” Both examples demonstrate the patient’s phobia of internal sensations.
Treatment
Patients with panic disorder have several treatment options. Determining which treatment is best for a given patient is done through a shared decision-making process between the patient and physician. A suggested approach to treatment is outlined in Figure 1.
Figure 1http://www.aafp.org/afp/20050215/733.htm…
Treating Patients with Panic Disorder
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Figure 1. Algorithm for the treatment of panic disorder. (DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.; CBT = cognitive behavior therapy.)
antidepressants
Antidepressant medications have been shown to reduce panic severity, eliminate attacks, and improve overall quality-of-life measures in patients with panic disorder.3 Two recent meta-analyses9,10 found that selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are equally effective in reducing panic severity and the number of attacks. In these studies, 61 percent of patients were panic-free after six to 12 weeks of treatment, compared with 41 percent of control patients. These studies differ on whether SSRIs are better tolerated than TCAs. An earlier meta-analysis11 found SSRIs to be superior to TCAs. However, the benefits of SSRIs may have been overstated in the latter study because of its failure to account for publication bias (i.e., the greater likelihood that small studies finding no difference between treatments will not be published).
Table 212 lists dosing and cost information for the antidepressants that have been proved in randomized controlled trials (RCTs) to be effective in the treatment of panic disorder. The choice of antidepressant should be based on side effect profiles and patient preferences. Monoamine oxidase inhibitors also are effective in the treatment of panic disorder, but their use is limited by safety concerns.
cognitive behavior therapy
Cognitive behavior therapy includes applied relaxation, exposure in vivo, exposure through imagery, panic management, breathing retraining, and cognitive restructuring.
Cognitive behavior therapy (CBT) includes many techniques, such as applied relaxation, exposure in vivo, exposure through imagery, panic management, breathing retraining, and cognitive restructuring. Meta-analyses13-15 support the efficacy of CBT in improving panic symptoms and overall disability. Most of the RCTs included in these meta-analyses included eight to 15 sessions of CBT, although a few studies have reported similar efficacy with only four sessions.13 Meta-analyses have found that specialized cognitive therapy, behavior therapy, and combined CBTs are superior to general emotionally supportive psychotherapy in patients with panic disorder.16
In the CBT trials, an average of 73 percent of treated patients were panic-free at three to four months, compared with 27 percent of control patients (number needed to treat, 2),13 and 46 percent of treated patients remained panic-free at two years.14 Although these statistics are impressive, they represent studies in selected populations that may not reflect typical general practice patients. CBT appears to be effective over the long term (trials ranged from six months to nine years).13,14,17 However, these results should be interpreted with caution; the loss of patients to follow-up, unknown role of other therapies in maintaining remission, and lack of intention-to-treat analyses in many studies limit the reliability of CBT when used alone.
It is unclear which component of CBT is more important: cognitive therapy (e.g., identifying misinterpreted feelings, educating patients about panic attacks) or behavior therapy (e.g., breathing exercises, relaxation, exposure). However, the efficacy of exposure techniques alone, in which the patient repeatedly confronts the anxiety-provoking stimulus through imagery or in vivo, is well established in patients with panic disorder, particularly in patients with agoraphobia.13-15 When possible, referral to a therapist experienced in exposure techniques is preferred.
Self-Directed CBT. If referral for formal CBT is not an option, self-directed CBT videotapes and books have been proved effective in controlled studies,18 although less so than standard CBT.19 At least minimal contact with a therapist is necessary to reduce panic symptoms.20 Clum’s21 Coping with Panic: A Drug-Free Approach to Dealing with Anxiety Attacks is a widely available self-help book that has been studied in RCTs.
Alcohol Use and CBT. Some patients with panic disorder, particularly men, tend to self-medicate with alcohol, which interferes with therapy. A single study22 of alcoholic patients with panic disorder found that the addition of CBT to an alcohol-treatment program was no more effective than alcohol treatment alone in reducing panic symptoms.
antidepressants plus cbt
Although the evidence indicates that antidepressants and CBT alone are effective in treating panic disorder, it remains unclear whether one treatment modality is superior to the other. Several meta-analyses14,15 suggest that antidepressants are less effective than CBT in reducing panic symptoms; however, these studies have serious methodologic flaws.23 Studies conflict on whether combining antidepressants with CBT improves outcomes. Overall, a combination of antidepressant plus some form of CBT produces the greatest benefit in meta-analyses of short-term studies.24,25 The results of a more recent study26 indicated that CBT plus antidepressants initially was slightly more effective during therapy, but after all therapies were discontinued, patients who used CBT alone or CBT plus placebo had better outcomes than patients using combined CBT and antidepressants.
Studies also are conflicting about how long to continue antidepressant therapy (with or without CBT). Studies have shown a relatively low relapse rate after six months of antidepressant therapy.27 Moreover, continued antidepressant therapy beyond six months does not decrease relapse rates.28 A recent study29 that controlled for post-treatment therapy after CBT found no difference in relapse rates after continuing or discontinuing antidepressants. However, this study was too small to detect potentially important differences in outcomes.
benzodiazepines
Benzodiazepines are as effective as antidepressants in reducing panic symptoms and frequency of attacks, are well tolerated, and have a short onset of action.14,30 However, benzodiazepines may cause depression25 and are associated with adverse effects during use and after discontinuation of therapy.3 They also fare less well than antidepressants in other outcome measures such as global functioning.15 Patients with panic disorder and preexisting comorbid depression who are treated with benzodiazepines have poorer outcomes than patients taking antidepressants.31 One good-quality RCT32 found that the addition of 0.5 mg of clonazepam three times daily to 100 mg of sertraline per day resulted in less severe symptoms and fewer panic episodes at one week (41 versus 4 percent with sertraline alone) but not at four weeks. In patients who already are taking benzodiazepines for panic disorder, the addition of CBT can help maintain a low severity of panic symptoms when the benzodiazepine is discontinued.33http://www.aafp.org/afp/20050215/733.htm…

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