Panic attack

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2]

Synonyms and Keywords: Panic attack specifier

Overview

Panic attacks are sudden, discrete periods of intense anxiety, fear 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 trigger. Although these episodes may appear random, they are considered to be a subset of an evolutionary response commonly referred to as fight or flight that occur out of context, flooding the body with hormones (particularly adrenalin) that aid in defending itself from harm. [2]

According to the American Psychological Association the symptoms of a panic attack commonly last approximately ten minutes. However, panic attacks can be as short as 1-5 minutes, while more severe panic attacks may form a cyclic series of episodes, lasting for an extended period, sometimes hours. Often those afflicted will experience significant anticipatory anxiety in between attacks and in situations where attacks have previously occurred.

Panic attacks also affect people differently. Experienced sufferers may be able to completely 'ride out' a panic attack with little to no obvious symptoms. 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. (Wilson 1996)

Descriptions

Many who suffer from panic attacks state they are the most frightening experiences of their lives. Sufferers of panic attacks report a fear or sense of dying, "going crazy", and/ or experiencing a heart attack, feeling faint, nauseous, 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), sweating, nausea, dizziness (or slight vertigo, light-headedness, hyperventilation, paresthesias (tingling sensations), sensations of choking or smothering or derealization, or the feeling that nothing is real. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety, and forms a positive feedback loop.[3]

Often when 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 results in the person experiencing a panic attack to seek treatment in an emergency room.

The panic attack is distinguished from other forms of anxiety by its intensity and its sudden, episodic nature.[2] Panic attacks are often experienced in conjunction with anxiety disorders and other psychological conditions, although panic attacks are not always indicative of a mental disorder, nor are they uncommon. Up to 10 percent of otherwise healthy people experience an isolated panic attack about once per year, and 1 in 60 people in the U.S. will suffer from a panic disorder at some point in their lifetime. (Anxiety Disorders Association of America)

Triggers and Causes

  • Long-Term, Predisposing Causes- Heredity. Panic disorder has been found to run in families, and this may mean that inheritance genes plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it.[3]. Various twin studies where one identical twin has an anxiety disorder have reported an incidence ranging from 31 to 88 percent of the other twin also having an anxiety disorder diagnosis. Environmental factors such as an overly cautious view of the world expressed by parents and cumulative stress over time have been found to be causes (Bourne 2005).
  • Phobias- People will often experience panic attacks as a direct result of exposure to a phobic object or situation.
  • Maintaining Causes- Avoidance of panic provoking situations or environments, anxious/negative self-talk ("what if thinking"), mistaken beliefs ("these symptoms are harmful and/or dangerous"), withheld feelings, lack of assertiveness. (Bourne 2005)
  • Medications-Sometimes panic attacks may be a listed side effect of medications such as Ritalin (methylphenidate). These may be a temporary side effect, only occurring when a patient first starts a medication, or could continue occurring even after the patient is accustomed to the drug, which likely would warrant a medication change in either dosage, or type of drug. Nearly the entire SSRI class of antidepressants can cause increased anxiety in the beginning of use. It is not uncommon for inexperienced users to have panic attacks while weaning on or off the medication, especially ones prone to anxiety.
  • Situationally Bound Panic Attacks- Associating certain situations with panic attacks, due to experiencing one in that particular situation, can create a cognitive or behaviorally predisposition to having panic attacks in certain situations (situationally bound panic attacks). It is a form of classical conditioning (Bourne 2005). See PTSD
  • Pharmacological Triggers - Certain chemical substances, mainly stimulants but also certain depressants, can either contribute pharmacologically to a constellation of provocations, and thus trigger a panic attack or even a panic disorder, or directly induce one.[4][5] This includes caffeine, amphetamine, alcohol and many more. Some sufferers of panic attacks also report phobias of specific drugs or chemicals, that thus have a merely psychosomatic effect, thereby functioning as drug-triggers by non-pharmacological means.[6]

Physiological considerations

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), 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.

Symptoms

Physical

Mental

  • Loss of the ability to react logically to stimuli
  • Loss of cognitive ability in general
  • Racing thoughts (often based on fear; a repeated or illogical worry)
  • Loud internal dialogue
  • Feeling of impending doom
  • Feeling of "going crazy"
  • Extreme worried feeling
  • Feeling of extreme nervousness
  • Feeling out of control
  • Feeling of Threatening
  • Feeling of anti-social behaviour from other people
  • Feeling of excitment
  • Feeling of nagging from other people
  • Vision is somewhat impaired; (eyes may feel like they are shaking.)

Emotional

  • Terror, or a sense that something unimaginably horrible is about to occur and one is powerless to prevent it
  • Fear that the panic is a symptom of a serious illness
  • Fear of losing control
  • Fear of death
  • Fear of going crazy
  • Flashbacks to earlier panic trigger[citation needed]

Perceptual

  • Tunnel vision
  • Heightened senses
  • The apparent slowing down or speeding up of time
  • Dream-like sensation or perceptual distortion (derealization)
  • Dissociation, or the perception that one is not connected to the body or is disconnected from space and time (depersonalization)
  • Feeling of loss of free will, as if acting entirely automatically without control

Mnemonic

The symptoms of a panic attack can be remembered with the mnemonic: STUDENTS FEAR the 3 Cs: Sweating, Trembling, Unsteadiness/dizziness, Derealization/depersonalization, Elevated heart rate (tachycardia), Nausea, Tingling, Shortness of breath, FEAR of dying, FEAR of losing control, FEAR of going crazy, 3 Cs - Choking, Chest pain, Chills.

Agoraphobia

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" however the essence of agoraphobia is a fear of panic attacks. 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 — for example, while driving, shopping in a crowded store, going to a party, experimenting with psychedelic drugs, etc. — 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. Agoraphobia of this degree is extremely rare. 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, where escape would be difficult and/or embarrassing.

The thinking behind agoraphobia usually follows the line that were a panic attack to occur, who would look after the person, how would he or she get the assistance and reassurance they needed? The vulnerability grows from the feeling that once victims of agoraphobia are caught in the anxiety, they are suddenly unable to look after themselves and are therefore at the mercy of the place they find themselves in and the strangers around them. In its extreme form, agoraphobia and panic attacks can lead to a situation where people become housebound for numerous years.

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.

Agoraphobia is often described as a fear of having 'no place to run or hide' if one does have a panic attack. Common examples include: driving, airplanes, malls, moving out of the house, etc.

Panic disorder

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.[7]

Differential Diagnosis

Epidemiology and Demographics

Prevalence

The prevalence of paranoid personality disorder is 2,700 to 11,200 per 100,000 (2.7% to 11.2%) of the overall population.[9]

Risk Factors

Diagnosis Criteria

DSM-V Diagnostic Criteria for Panic Attack[9]

Note: Symptoms are presented for the purpose of identifying a panic attack; however, panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g., “posttraumatic stress disorder with panic attacks”). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

Note: The abrupt surge can occur from a calm state or an anxious state.

  1. Palpitations, pounding heart, or accelerated heart rate
  2. Sweating
  3. Trembling or shaking
  4. Sensations of shortness of breath or smothering
  5. Feelings of choking
  6. Chest pain or discomfort
  7. Nausea or abdominal distress
  8. Feeling dizzy, unsteady, light-headed, or faint
  9. Chilis or heat sensations.
  10. Paresthesias (numbness or tingling sensations).
  11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
  12. Fear of losing control or “going crazy.”
  13. Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Natural History, Complications and Prognosis

Poor prognostic factors include:

Increased Risk of Heart Attack and Stroke

A recent study suggests that menopausal women with panic disorder and many occurrences of panic attacks have a three-fold 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.[10] 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 couldnt be attributed to the cardiovascular effects of medication that many panic disorder patients receive, such as SSRIs and benzodiazepines.

Treatment

People with panic disorder often can be successfully treated with therapy, particularly Cognitive Behavioral Therapy and/or anti-anxiety medication or antidepressants. (Bourne 2005)

Paper bag rebreathing

Some panic attack sufferers and even some doctors recommend breathing into a paper bag as an effective short-term treatment of an acute panic attack.[11] However, this can prove to be fatal insofar as the symptoms are related to a more serious ailment such as a heart attack,[12] and it is strongly advised against to engage in such a practice,[12] by well-respected medical studies dating back to 1989 and 1994.

Medication

The benzodiazepine class of drugs includes diazepam, lorazepam, alprazolam, and clonazepam. While these drugs are highly effective and very fast acting in stopping panic, they may not be the best solution.[citation needed] First, the body can build a tolerance to the drug, much like alcoholic beverages, making it need more to feel the same benefit. Second, because of this, there is a high risk of abuse and addiction in some people.[citation needed]

As such, some doctors may prefer to prescribe an antidepressant, particularly an SSRI (such as paroxetine, sertraline, fluvoxamine, 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.[citation needed] NaSSAs such as Mirtazapine have also been found effective, particularly with individuals whose anxiety and panic causes insomnia.

Interoceptive Desensitization/Symptom Inductions

One particularly helpful and effective form of therapy is Cognitive Behavioral Therapy (CBT). Interoceptive Desensitization 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.

Symptom Inductions generally occur for one minute and may include

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.

References

  1. Diagnostic and Statistical Manual of Mental Disorders
  2. 2.0 2.1 Bourne, E. (2005). The Anxiety and Phobia Workbook, 4th Edition: New Harbinger Press.
  3. Klerman, Gerald L.; Hirschfeld, Robert M. A.; Weissman, Myrna M. (1993), Panic Anxiety and Its Treatments: Report of the World Psychiatric Association Presidential Educational Program Task Force, American Psychiatric Association, pp. pp.44, ISBN 978-0880486842
  4. http://www.nlm.nih.gov/medlineplus/ency/article/000924.htm
  5. http://panicdisorder.about.com/cs/shfitness/a/caffeine.htm
  6. http://fondationmarievictorin.qc.ca/panic-and-anxiety-attack-medication.php
  7. http://familydoctor.org/137.xml
  8. Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  9. 9.0 9.1 9.2 9.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  10. http://www.nytimes.com/aponline/us/AP-Panic-Attacks-Heart.html
  11. http://www.netdoctor.co.uk/ate/mentalhealth/205625.html
  12. 12.0 12.1 http://firstaid.about.com/od/shortnessofbreat1/f/07_paper_bags.htm

5. Weekes, Claire. Hope and Help for Your Nerves: Signot (1991)

6.Wilson, Reid. Don't Panic: Taking Control of Your Anxiety Attacks. Revised Edition, HC (1996)


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