Panic attack

Panic attacks are sudden, discrete periods of intense anxiety, mounting physiological arousal, 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] Experiencing a panic attack is said to be one of the most intensely frightening and uncomfortable experiences of a person's life. (Bourne 2005).

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 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, and in situations where they feel "trapped". That is, where escape would be obvious and/or embarrassing.

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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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.^[4]

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.^[5] 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).

• Biological Causes - Generalized anxiety, obsessive compulsive disorder, Post Traumatic Stress Disorder, hypoglycemia, hyperthyroidism, Wilson's Syndrome, mitral valve prolapse, pheochromocytoma and inner ear disturbances (Labyrinthitis). (Bourne 2005) Vitamin b deficiency from inadequate diet or caused by periodic depletion due to parasitic infection from Tape worm can be a trigger of anxiety attacks.

• Phobias - People will often experience panic attacks as a direct result of exposure to a phobic object or situation.

• Short-Term Triggering Causes - Significant personal loss, life transitions, significant life change, stimulants such as caffeine or nicotine, or the drugs marijuana or psilocybin, can act as triggers (Bourne 2005).

• 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.

• Hyperventilation Syndrome - Breathing from your chest may cause overbreathing, exhaling excess carbon dioxide in relation to the amount of oxygen in one's bloodstream. Hyperventilation Syndrome can cause respiratory alkalosis and hypocapnia. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms including rapid heart beat, dizziness, and lightheadedness which can trigger panic attacks. (Bourne 2005)

• 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.^[6][7] 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.^[8]

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 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. Lastly, a panic attack can cause blood sugar to be drawn away from the brain and towards the major muscles. This can also cause derealization and lightheadedness.

The "Panic Trick" (Carbonell 2004)

Many experts and researchers including Dr. David Carbonell describe panic attacks and Panic Disorder as a "trick" (a very effecrive trick) on two crucial fronts. Firstly, it tricks the sufferer into believing what they are experiencing is dangerous (i.e. having a heart attack, fainting, insanity, and/or "doing something crazy") when a panic attack presents absolutely no danger whatsoever. Secondly, they trick the afflicted into doing anything and everything that they believe will help them when it actually makes the panic attacks worse- the second component of the trick. These activities would include avoidance behaviors, trying to control panic attacks, fighting panic attacks,superstitions and rituals to avoid panic attacks and excessive self-protection. That is to say, what people faced with panic attacks do, most often, perpetuates the panic and sometimes turns panic attacks into Panic Disorder.(Carbonell 2004)

Symptoms

Physical

• A sensation of adrenaline going through your entire body
• Sweating
• Shortness of breath (dyspnea)
• Racing or pounding heartbeat or palpitations
• Chest pain
• Dizziness or vertigo
• Lightheadedness
• Nausea / stomach pains
• Hyperventilation
• Choking or smothering sensations
• Uncontrollable itching
• Tingling or numbness in the hands, face, feet or mouth (paresthesia)
• Hot/cold flashes
• Trembling or shaking
• Feeling of claustrophobia
• Exhaustion
• Feeling of physical weakness or limpness of the body
• Uncontrollable crying
• An Uncontollable Sexual feeling,eg, (Erection)

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 excitement
• 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 that the panic will not subside
• Fear of losing control
• Fear of death
• Fear of living
• 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

Main article: 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.(Barry 2006). In Japan this condition is coined and down-played as Hikikomori, as it is rather commonly perceived by the Japanese psychiatrists as a state of mere laziness and indulgent behaviour forgiven by the mercy of the sufferers family. General perception amongst the Japanese are that Hikikomori sufferers are lazy freeloaders of the society.

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.

Panic disorder

Main article: 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.^[9]

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.^[10] However, this can prove to be fatal in some cases,^[11] and it is strongly advised against to engage in such a practice,^[11] 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.^{[citation needed]} SNRIs such as Venlafaxine can also be prescribed. Studies^[specify] 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.^{[citation needed]}

Treating a Panic Attack

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:

• Diaphragmatic Breathing or Abdominal Breathing- Breathing slowly and deeply through the nose using the diaphram and abdomen. (Bourne 2005)

• Staying in the Present- rather than having "what if" thoughts that are future oriented asking yourself, "what is happening now" and "how do I wish to respond to it". (Carbonell 2004)

• Acceptance and Acknowledgement- accepting and acknowledging the panic attack. (Carbonell 2004)

• Floating with the symptoms- allowing time to pass and floating with the symptoms rather than trying to make them better or fighting them. (Carbonell 2004)

• Coping Statements- repeated as part of an internal monologue i.e. " I will let my body do its thing this will pass" or " I can be anxious and still deal with this situation." "This does not feel great, but I can deal with it". (Bourne 2005)

• Temporary Escape- seeking a temporary withdrawal in a washroom or outside.

• Taking a benzodiazepine (tranquilizers)- to be used under the guidance and direction of a physician.

• Talking with a supportive person- a friend or spouse. (Bourne 2005)

• Cognitive Techniques- demanding more anxiety, observing rather than reacting to the panic symptoms, trying to make the symptoms worse, passive acceptance. (Barry 2006).

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

• Intentional hyperventilation: Creates lightheadeness, derealization, blurred vision, dizziness;
• Spinning in a chair: Creates dizziness, disorientation;
• Straw breathing: Creates dyspnea, airway constriction;
• Breath holding: Creates sensation of being out of breath;
• Running in place: Creates increased heart rate, increased respiration, perspiration;
• Body tensing: Creates feelings of being tense and vigilant.

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.

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 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.^[12] 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.

Limited Symptom Attack

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. (Bourne 2005)

References