discovered serendipitously, and the multitude of medications within the
classes were derived by tinkering with the basic chemical structure to yield
a substance that was similar, but not enough to infringe on patents. Each
variation is, of course, presented as an improvement on the original.
There are two ways to understand how drugs work: from the inside,
by knowing what they do physiologically, and from the outside, by observing
how drugs make people feel and how they affect their actions. I’ve learned
what psychiatric drugs do by watching and listening to people who are
taking them. A few courses, and explanations by many medical colleagues,
have helped me understand what I was looking at, but in the end, like you,
all I know is what I see. Here are my observations about the drugs most
commonly used to treat explosions into fear:
Alcohol
The oldest, most common, and most effective medicine for attenuating
symptoms of excessive sympathetic arousal is alcohol. It is no longer pre-
scribed because of its dangerous side effects, but is used for self-medication
by millions of people.
Alcohol is a generalized central nervous system depressant that acts
quickly. It is absorbed into the bloodstream right from the stomach, and
enters the brain almost immediately. Alcohol enhances the action of the
neurotransmitter gamma-aminobutyric acid (GABA), which inhibits neu-
ronal firing in many parts of the brain. The effect is to relax muscles,
generally slow things down, and encourage the parasympathetic system
to take control. Alcohol also releases dopamine and serotonin, which bind
with receptors in the so-called pleasure centersof the brain.
Alcohol will stop a panic attack in its tracks, and make a person
feel pretty good, at least for a while. The problem is, it gets people
drunk, it’s addictive, and when it wears off, the panic attacks come back
with a vengeance.
Though alcohol is obviously never prescribed for fear disorders, it can
help us evaluate the medications that are. When a medication does too
much too quickly, it’s too easy to depend on it. Our bodies develop toler-
ance; it takes more and more to do less and less. Addictive substances
usually work fast and create tolerance. Most also stimulate pleasure centers.
I have had patients use alcohol successfully as a medication to prevent
panic attacks in specific situations, such as flying on an airplane, or having
84 ❧Explosions into Fear