| Panic attack Classification and external resources |
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| ICD-10 | F41.0 |
|---|---|
| ICD-9 | 300.01 |
| DiseasesDB | 30913 |
| MeSH | D016584 |
Panic attacks are sudden, discrete periods of intense anxiety, mounting physiological arousal, fear, stomach problems and discomfort that are associated with a variety of somatic and cognitive symptoms.[1] The onset of these episodes is typically abrupt, and may have no obvious triggers. Although these episodes may appear random, they are a subset of an evolutionary response commonly referred to as fight or flight that occur out of context. This response floods the body with hormones, particularly epinephrine (adrenaline), that aid in defending itself from harm.[2] Experiencing a panic attack is said to be one of the most intensely frightening, upsetting and uncomfortable experiences of a person's life.[2] According to the American Psychological Association the symptoms of a panic attack commonly last approximately thirty minutes. However, panic attacks can be as short as 15 seconds, while sometimes panic attacks may form a cyclic series of episodes, lasting for an extended period, sometimes hours. Often those afflicted will experience significant anticipatory anxiety and limited symptom attacks in between attacks, in situations where attacks have previously occurred.
Panic attacks are commonly linked to agoraphobia and the fear of not being able to escape a bad situation. Many who experience panic attacks feel trapped and unable to free themselves.
Panic attacks also affect people differently. Experienced sufferers may be able to completely "ride out" a panic attack with little to no obvious symptoms or external manifestations. Others, notably first-time sufferers, may even call for emergency services; many who experience a panic attack for the first time fear they are having a heart attack or a nervous breakdown.[3]
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Sufferers of panic attacks often report a fear or sense of dying, "going crazy", or experiencing a heart attack or "flashing vision", feeling faint or nauseous, heavy breathing, or losing control of themselves. These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the sympathetic "fight or flight" response).
A panic attack is a response of the sympathetic nervous system (SNS). The most common symptoms may include trembling, dyspnea (shortness of breath), heart palpitations, chest pain (or chest tightness), hot flashes, cold flashes, burning sensations (particularly in the facial or neck area), sweating, nausea, dizziness (or slight vertigo), light-headedness, hyperventilation, paresthesias (tingling sensations), sensations of choking or smothering, and derealization. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety, and forms a positive feedback loop.[4]
Often the onset of shortness of breath and chest pain are the predominant symptoms, the sufferer incorrectly appraises this as a sign or symptom of a heart attack. This can result in the person experiencing a panic attack seeking treatment in an emergency room.
Panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature.[2] They are often experienced in conjunction with anxiety disorders and other psychological conditions, although panic attacks are not always indicative of a mental disorder.
While the various symptoms of a panic attack may feel that the body is failing, it is in fact protecting itself from harm. The various symptoms of a panic attack can be understood as follows. First, there is frequently (but not always) the sudden onset of fear with little provoking stimulus. This leads to a release of adrenaline (epinephrine) which brings about the so-called fight-or-flight response wherein the person's body prepares for strenuous physical activity. This leads to an increased heart rate (tachycardia), rapid breathing (hyperventilation) which may be perceived as shortness of breath (dyspnea), and sweating (which increases grip and aids heat loss). Because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon dioxide levels in the lungs and then in the blood. This leads to shifts in blood pH (respiratory alkalosis or hypocapnia), which in turn can lead to many other symptoms, such as tingling or numbness, dizziness, burning and lightheadedness. Moreover, the release of adrenaline during a panic attack causes vasoconstriction resulting in slightly less blood flow to the head which causes dizziness and lightheadedness. A panic attack can cause blood sugar to be drawn away from the brain and towards the major muscles. It is also possible for the person experiencing such an attack to feel as though they are unable to catch their breath, and they begin to take deeper breaths, which also acts to decrease carbon dioxide levels in the blood.
Dr. David Carbonell describes panic attacks and Panic Disorder as a "trick". First, it tricks the sufferer into believing what they are experiencing is dangerous; for example, having a heart attack, fainting, insanity, and/or "doing something crazy", when a panic attack presents no danger. Second, it tricks those afflicted into doing anything they believe will help them, which can make the panic attacks worse. These activities would include avoidance behaviors, trying to control panic attacks (for example, by taking deep breaths), fighting panic attacks, superstitions and rituals to avoid panic attacks and excessive self-protection. (Carbonell 2004)
Heart palpitations
Diaphoresis or perspiration
Hyperventilation
Chills
Hot flashes
Chest pain
Dizziness
Lightheadedness
Tightness in throat
Tunnel vision
Trouble swallowing
A sense of impending death
Feeling like one is experiencing a myocardial infarction (heart attack)
Agoraphobia is an anxiety disorder which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape. As a result, severe sufferers of agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place". The word "agoraphobia" is an English adoption of the Greek words agora (αγορά) and phobos (φόβος), literally translated as "a fear of the marketplace" usually applies to any or all public places; however the essence of agoraphobia is a fear of panic attacks especially if they occur in public as the victim may feel like he or she has no escape and be very embarrassed of having one publicly in the first place. This translation is the reason for the common misconception that agoraphobia is a fear of open spaces, and is not clinically accurate.
People who have had a panic attack in certain situations may develop irrational fears, called phobias, of these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with panic disorder are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. This can be one of the most harmful side-effects of panic disorder as it can prevent sufferers from seeking treatment in the first place. It should be noted that upwards of 90% of agoraphobics achieve a full recovery. Agoraphobia is actually not a fear of certain places but a fear of having panic attacks in certain places.
It is important to note that agoraphobia is by no means a hopeless situation. Sufferers often do not realize that they have experienced these same situations before and nothing terrible occurred. Successful treatment is possible with the right combination of therapy and medication.
People who have repeated, persistent attacks or feel severe anxiety about having another attack are said to have Panic Disorder. Panic Disorder is strikingly different from other types of anxiety disorders in that panic attacks are often sudden and unprovoked.[9]
In 1993 Jacob Markusson developed a technique he coined the POEM system, or Point Of Exit Methodology, whereby a patient focuses a pattern of thinking during the exit of the panic attack. The theory being that the sufferer can break the cycle of panic attacks and resume a panic-free life. The POEM system has been used effectively to give patients relief without the use of medication such as Paxil.
People with Panic disorder often can be successfully treated with therapy, particularly Cognitive Behavioral Therapy and/or anti-anxiety medication or antidepressants.[2]
Many panic attack sufferers as well as doctors recommend breathing into a paper bag as an effective short-term treatment of an acute panic attack.[10] However, this treatment has been criticised by others as ineffective and possibly harzardous to the patient, even potentially worsening the panic attack.[11] They say it can fatally lower oxygen levels in the blood stream,[12] and increase carbon dioxide levels, which in turn has been found to be a major cause of panic attacks. [13]
It is therefore important to discover whether hyperventilation is truly involved in each case. If it is, then rebalancing the oxygen/CO2 levels in the blood and/or re-establishing an even, measured breathing pattern is an appropriate treatment which may be also achieved by extending the outbreath either by counting or even humming.[14]
The benzodiazepine class of drugs includes diazepam, lorazepam, alprazolam, and clonazepam. These drugs are fast acting in stopping panic but long-term use can cause physical dependence[15].
Some doctors may prefer to prescribe an antidepressant, particularly an SSRI (such as paroxetine, sertraline, fluvoxamine, escitalopram or fluoxetine), which after an initial titration period may be effective at reducing anxiety. SNRIs such as Venlafaxine can also be prescribed. Studies have proven they may be more effective than the SSRIs for anxiety. NaSSAs such as Mirtazapine have also been found effective, particularly with individuals whose anxiety and panic causes insomnia. Smoking is one of the major causes of panic attacks. This may result from intake of carbon monoxide from the cigarette. Carbon monoxide prevents oxygen from binding to red blood cells so there is less oxygen in the bloodstream, which may yield an effect similar to hyperventilation.
All persons experiencing persistent and frequent panic attacks should consult their physicians. However, many experienced sufferers treat panic attacks with some the following methods and techniques:
Another form of treatment is 'Interoceptive Desensitization which intends to desensitize the afflicted from the symptoms of panic attacks. In a study by Barlow & Craske (1989), 87% of the individuals that participated in the two of four treatments that involved Interoceptive Desensitization were free of panic at the end of treatment and these results were maintained at a 2-year follow up. In controlled studies of Interoceptive Desensitization treatments compared to other treatments, those treatments that included Interoceptive Desensitization were found to be significantly superior to other treatments such as muscle relaxation alone, or education or insight-oriented treatments. Interoceptive Desensitization often leads to a dramatic reduction in the frequency and intensity of panic attacks and as such should be implemented immediately under the guidance of a mental health professional. It is important the patient is given medical clearance and permission from a medical doctor before attempting these exercises. The key to the induction is that the exercises should mimic the most frightening symptoms of a panic attack. Symptom Inductions should be repeated 3-5 times per day until the patient has little to no anxiety in relation to the symptoms that were induced. Often it will take a period of weeks for the afflicted to feel no anxiety in relation to the induced symptoms. With repeated trials, a person learns through experience that these internal sensations do not need to be feared – the individual becomes less sensitized or desensitized to the internal sensation. After repeated trials, when nothing catastrophic happens, the brain learns (hippocampus & amygdala) to not fear the sensations, and the sympathetic nervous system activation fades. Many people overcome Panic Disorder and sudden Panic Attacks on their own. It takes time, but in a sense, they ride out the panic attacks and eventually learn that nothing is going to happen during one. Often, they 'taper off' until they are not noticeable any longer. It is for this reason that some psychologists helping people with panic disorders induce them into an attack, so they can see for themselves that indeed, nothing will happen.
A recent study suggests that menopausal women with panic disorder and many occurrences of panic attacks have a threefold higher risk of suffering heart attack or stroke over the next five years. The researchers believe that panic attacks or more accurately their associated symptoms (chest pain, dyspnea) can be manifestations of undiagnosed cardiovascular disease, or result in heart damage due to cardiovascular stress in patients with panic disorder and many panic attacks over periods of years.[16] The study did not find that isolated cases of panic attacks in patients without panic disorder or agoraphobia lead to immediate heart damage, nor did it prove that the correlation between panic disorder and strokes was causal, or that it couldn't be attributed to the cardiovascular effects of medication that many panic disorder patients receive, such as SSRIs and benzodiazepines.
Many people being treated for panic attacks begin to experience limited symptom attacks. These panic attacks are less comprehensive with fewer than 4 bodily symptoms being experienced.[2]
16. # ^ Carbonell, David. (2004) Panic Attacks Workbook: A Guided Program for Beating the Panic Trick. Berkley, CA: Ulysses Press.