Panic Disorders: So Prevalent, Under-Diagnosed and Over-Medicated Dr E.V. Rapiti, Cape Town, July 6th, 2025

Panic disorders from a doctor's perspective and experience

Panic Disorders: So Prevalent, Under-Diagnosed and Over-Medicated

Dr E.V. Rapiti, Cape Town, July 6th, 2025

“Panic disorder is so prevalent, yet remains grossly under-diagnosed and inappropriately treated with increasing doses of addictive anxiolytics that fail to solve the problem but are merely prescribed to feed the addiction—when psychoeducation and CBT should be the cornerstone of care.”

Case Histories

Case 1: Dubai detainee with benzodiapine addiction

A patient of mine was held in prison in Dubai for being in possession of drugs. She had been on 5 mg of alprazolam three times a day, prescribed by her psychiatrist years ago.

Every attempt to wean her off failed—she was deeply addicted. While in prison, her mother had to arrange for a supply of alprazolam to be sent by air, negotiating through a lawyer with the prison authorities.

Case 2: A Mother of Two and Failed Rehab Attempts

Another mother, also under the same psychiatrist, was on alprazolam 5 mg TDS for years. We tried desperately to get her into a rehabilitation centre to help her come off the drug, but all efforts failed.

Case 3: Postpartum Panic depression; Epilepsy and panic disorder

A 36-year-old woman, accompanied by her 71-year-old mother, had a history of epilepsy and severe panic attacks. She had been placed on high doses of anti-epileptics and anxiolytics for over six years. After suffering from postpartum depression, she developed a debilitating panic disorder—especially in crowds.

Case 4: Ten Years of Psychiatric Treatment for anxiety, No Change

A 35-year-old man came to me with persistent anxiety and paranoia. He had been under psychiatric care for over ten years, on high doses of fluoxetine and a benzodiazepine—yet remained unchanged.

Case 5: Addiction, Aggression, and Street Benzodiazepines

Another patient became so addicted to her benzodiazepines that she turned vulgar and aggressive towards her children when she couldn’t afford the medication. She sourced pills from the street or unscrupulous pharmacists who dispensed without scripts.

Benzodiazepines are now so accessible on the streets that children are becoming addicted (Votaw et al., 2019).

Long-term use is extremely risky—dependence may occur in up to 47% of patients within one month (Lader, 2008).

Case 6: The Boy Who Couldn’t Breathe, had palpitations and; Burped uncontrollably

A 17-year-old boy was referred to me by his mother. He presented with palpitations, chest tightness, and difficulty breathing. His greatest fear: that he was going to die.

He also had excessive burping and flatulence—diagnosed by another doctor as dyspepsia and treated unsuccessfully with PPIs.

A detailed history revealed overwhelming exam anxiety, low self-esteem, and a new habit of vaping that triggered symptoms.

He was diagnosed with panic disorder, psychogenic burping, and paranoia. He had stopped playing soccer out of fear that physical exertion would trigger heart failure.

He was treated non-pharmacologically with explanation, reassurance, breathing exercises, self-affirmation, and motivational guidance. The family was relieved he didn’t need medication.

Follow-ups showed significant improvement in his symptoms.

Case 7: Paralysis After Her Granny’s Stroke

I was called to assess a woman in her mid-twenties who had collapsed after learning that her grandmother had a stroke. Her entire body was stiff and painful. Hospital diagnosed her with severe anxiety and discharged her.

With support, muscle spasm treatment, and counselling, she recovered within a month and proudly passed her driver’s test soon after.

Case 8: Vomiting Triggered by Stress

A young woman presented with persistent vomiting and severe headaches. Medical workups found no cause. She was visibly distressed. After a short counselling session and a single injection of diazepam, she slept deeply in the car. The vomiting stopped by the next morning.

Case 9: Hiccups That Lasted Three Days

A young man came to me with uncontrollable hiccups for three days. He had not eaten or slept and feared he would die.

I suspected a psychological cause, though he denied significant stressors. After a diazepam injection and a five-day course of Ativan, the hiccups stopped. He returned the next day with a smile, grateful for his first night of rest. He was later counselled about stress and emotional control.

Understanding Panic Disorders and Their Triggers

In all these cases, the patients received little or no psychoeducation about their condition. No non-drug strategies were taught. They were uninformed of the dangers of long-term benzodiazepine use—despite evidence that dependency may occur after just a few weeks, especially at high doses (Lader, 2008).

When patients are told precisely what they have and how to deal with it, they feel empowered, confident and relieved.

When concern grew about benzodiazepine addiction, the pharmaceutical industry pivoted to SSRIs, claiming they were non-addictive. But this has been proven untrue. Up to 55% of long-term SSRI users experience withdrawal symptoms, and 46% report them as severe (Davies & Read, 2019).

SSRIs share nearly identical withdrawal symptoms to benzodiazepines in 37 out of 42 categories (Fava et al., 2015). Despite this, many patients remain unaware of the risks.

The industry’s argument—that depression is caused by low serotonin levels—has also been debunked. A comprehensive review found no consistent link between low serotonin and depression (Moncrieff et al., 2022).

I have seen many patients come to me after years of being on antidepressants with no benefit. They had cycled through several drugs but remained deeply unhappy. Why? Because life’s real challenges—not chemical defects—were at the root.

Life Events That Commonly Trigger Depression and Panic Disorders

These are some of the most common contributors I’ve seen:

1. Death in the family

2. Chronic illness (cancer, diabetes, arthritis, heart disease)

3. Disability or injury after an accident

4. Job loss, eviction, or financial collapse

5. Drug or alcohol addiction (self or family member)

6. Gender-based violence and elder abuse

7. Long-term use of benzodiazepines or SSRIs

8. Bullying, exam failure, rape, or street assault

9. Divorce, toxic relationships, or bereavement

10. Menopause and thyroid dysfunction

11. PTSD and unresolved trauma

Unless these root causes are addressed, no antidepressant will bring relief.

My Treatment Approach

In my experience, psychotherapy is more effective than drugs in most of these cases. Cognitive Behavioural Therapy (CBT), motivational counselling, and relaxation techniques empower patients to live with and manage their distress—rather than suppress it.

In families with addiction, I have seen parents find hope by attending support groups. Many had been on antidepressants for years because of abuse by an addicted spouse or child. After gaining emotional support and tools to cope, many came off medication and took control of their lives.

Recognising and Managing Panic Attacks

Panic disorders may not always have identifiable causes. But when triggers are known, patients can learn to avoid or confront them using CBT. Some common triggers include:

1. Fear of heights

2. Closed or dark spaces

3. Fear being in crowds

4. Worrying excessively

5. Dread of impending doom

6. Fear of mice and insects

During a panic attack, patients often feel they are dying. Symptoms can include:

1. Palpitations

2. Chest tightness

3. Tremors

4. Sweaty palms

5. Muscle weakness

6. Light-headedness

7. Fear of collapsing or losing control

Episodes often last seconds but leave the patient drained. Chest pain following an attack frequently leads to ER visits, as patients fear heart attacks.

Before a correct diagnosis is made, many suffer for years—undiagnosed and untreated. Many are never even diagnosed.

Non-Drug Interventions

1. Breathing exercises

2. Meditation and prayer

3. Relaxing music and hobbies

4. Daily affirmations and motivational self-talk

5. Sleep routines and sleep hygiene

6. Reducing stimulants like caffeine

7. Encouragement to speak openly to a confidant, counsellor, or priest

8. Referral to support groups for substance use or trauma

Patients are educated on the effects of sleep deprivation, which commonly causes irritability, depression, and dysfunctional relationships.

Proper rest is essential for emotional stability.

From experience, I estimate half of all patients I see with somatic complaints—like headaches, fatigue, and muscle pain—are actually suffering from underlying mental distress.

Unfortunately, doctors are not trained in mental health in their years in medical school. Counselling is time-consuming and emotionally demanding. It is a skill, and also an art. It takes patience, empathy, and genuine listening.

Sometimes, just listening is all it takes to help someone begin healing.

Final Thoughts

One special approach I’ve used successfully is motivational counselling combined with positive thinking. It works particularly well in individuals with low self-esteem.

I hope this article will serve as an eye-opener to those suffering silently. There is hope. Treatment doesn’t have to mean a lifetime of toxic drugs.

Dr E.V. Rapiti

Cape Town

July 6, 2025

Dr Rapiti is a family physician with a keen interest in mental health. He holds a diploma in mental health and is the author of "4 Steps 2 Healing", a self-help guide that has empowered both substance users and their families. He is a regular voice on community radio advocating for compassionate, practical mental health care.

References (APA 7th Edition)

Davies, J., & Read, J. (2019). A systematic review into the incidence, severity, and duration of antidepressant withdrawal effects. Addictive Behaviors, 97, 111–121. https://doi.org/10.1016/j.addbeh.2018.08.027

Fava, G. A., Gatti, A., Belaise, C., Guidi, J., & Offidani, E. (2015). Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: A systematic review. Psychotherapy and Psychosomatics, 84(2), 72–81. https://doi.org/10.1159/000370338

Hengartner, M. P., Davies, J., & Read, J. (2020). Antidepressant withdrawal – the tide is finally turning. Epidemiology and Psychiatric Sciences, 29, e52. https://doi.org/10.1017/S2045796020000175

Lader, M. (2008). Benzodiazepine harm: how can it be reduced? British Journal of Clinical Pharmacology, 66(4), 573–578. https://doi.org/10.1111/j.1365-2125.2008.03208.x

Moncrieff, J., Cooper, R. E., Stockmann, T., Amendola, S., Hengartner, M. P., & Horowitz, M. A. (2022). The serotonin theory of depression: A systematic umbrella review of the evidence. Molecular Psychiatry, 27(10), 4070–4076. https://doi.org/10.1038/s41380-022-01661-0

Votaw, V. R., Geyer, R., Rieselbach, M. M., & McHugh, R. K. (2019). The epidemiology of benzodiazepine misuse: A systematic review. Drug and Alcohol Dependence, 200, 95–114. https://doi.org/10.1016/j.drugalcdep.2019.02.033