Panic attack is an unpredictably occurring attack of severe fear or anxiety, combined with a variety of vegetative multiple organ symptoms. During an attack, a combination of several of the following symptoms may occur: hyperhidrosis, palpitations, difficulty breathing, chills, hot flashes, fear of madness or death, nausea, dizziness, etc. Confirmation of the diagnosis is the compliance of the clinic with the diagnostic criteria of panic paroxysms and the exclusion of somatic pathology, in which similar attacks may occur. The treatment is a combination of psychotherapeutic and drug methods of attack relief and therapy in the inter-crisis period, teaching and training the patient how to overcome paroxysms independently.
General information
The name “panic attack” was introduced by American specialists in 1980. Gradually, it has found widespread use and is now included in the International Classification of Diseases (ICD-10). Previously, the term “emotional-vegetative crisis” was used and similar paroxysms were considered within the framework of vegetative-vascular dystonia. In modern medicine, the concept of “panic attack” is being revised. Understanding the primacy of the psychological factor and the secondary nature of vegetative symptoms has led to the need to attribute such paroxysms to neurosis, and the vegetative disorders accompanying them to autonomic dysfunction, which is an integral part of a neurotic disorder.
Panic paroxysms are a widespread problem. Statistical sources indicate that up to 5% of the population have experienced similar conditions. The vast majority of them are residents of megacities. The most typical age of occurrence of the first attack is 25-45 years. In old age, a panic attack occurs with noticeably less symptoms and a predominance of the emotional component. In some patients, it is a relapse of paroxysms observed in youth.
A panic attack can occur as a single paroxysm or as a series of attacks. In the latter case, we are talking about a panic disorder. If earlier in medicine, a panic attack was the subject of curation exclusively by neurologists, today it is an interdisciplinary pathology, the subject of study of psychology, psychiatry and neurology. In addition, the psychosomatic coloration of seizures leads to a panic attack in the category of problems relevant to practitioners in many other fields of medicine — cardiology, gastroenterology, endocrinology, pulmonology.
Causes
There are 3 groups of factors that can provoke the occurrence of a panic attack: psychogenic, biological and physiogenic. In clinical practice, it has been noticed that a combination of several provoking triggers often acts. Moreover, some of them are decisive in the occurrence of a primary attack, while others initiate repetitions of a panic attack.
Among psychogenic triggers, conflict situations are the most significant — clarification of relationships, divorce, scandal at work, leaving the family, etc. In second place are acute traumatic events — an accident, death of a loved one, illness, etc. There are also abstract psychogenic factors that affect the psyche by the mechanism of opposition or identification. These include books, documentaries and feature films, television programs, and various Internet materials.
The biological triggers are various hormonal changes (mainly in women due to pregnancy, abortion, childbirth, menopause), the beginning of sexual relations, hormone intake, features of the menstrual cycle (algomenorrhea, dysmenorrhea). It should be noted that paroxysms caused by endocrine diseases — hormone-active tumors of the adrenal glands (pheochromocytoma) and thyroid diseases occurring with hyperthyroidism are not considered a panic attack.
Physiogenic triggers include acute alcohol intoxication, drug use, meteorological fluctuations, acclimatization, excessive insolation, physical overstrain. Some pharmacological drugs can provoke a panic attack. For example: steroids (prednisone, dexamethasone, anabolic steroids); bemegrid, used for anesthesia; cholecystokinin, used in instrumental diagnostics of the gastrointestinal tract.
As a rule, the appearance of panic attacks is observed in people with certain personal qualities. For women, this is demonstrativeness, drama, the desire to attract attention to themselves, the expectation of interest and participation from others. For men – initial anxiety, increased concern for their health and, as a result, excessive listening to the state of their physical body.
Pathogenesis
There are several theories trying to explain the mechanism of triggering and unfolding a panic attack. The absence of a direct connection of paroxysm with a traumatic situation, the inability of patients to determine what provoked it, the rapid onset and course of the attack — all this significantly complicates the work of researchers.
The starting point of the attack is considered to be disturbing sensations or thoughts that imperceptibly “float” on the patient. Under their influence, as with a really threatening danger, an increased production of catecholamines (including adrenaline) begins in the body, which leads to vasoconstriction and a significant increase in blood pressure. Even in patients with a normal premorbid background, arterial hypertension during a panic attack can reach 180/100 mm Hg. There is tachycardia and increased breathing. The concentration of CO2 decreases in the blood, sodium lactate accumulates in the tissues. Hyperventilation causes dizziness, feelings of derealization, nausea.
Hyperactivation of noradrenergic neurons occurs in the brain. In addition, cerebral chemoreceptors are activated, which are sensitive to lactate and changes in blood gas composition during hyperventilation. It is possible that at the same time neurotransmitters are released that block the inhibitory effect of GABA on the excitability of neurons. The result of neurochemical processes occurring in the brain is an increase in feelings of anxiety and fear, increased panic.
Symptoms
Often, a panic attack is a symptom of the main pathology — a somatic disease (coronary heart disease, neurocirculatory dystonia, gastric ulcer, chronic adnexitis, etc.) or a mental disorder (hypochondria, depression, hysterical or anxiety-phobic neurosis, obsessive-compulsive disorder, schizophrenia). Its features are polysymptomicity and dissociation between objective and subjective symptoms due to psychological factors.
A panic attack is characterized by a sudden unpredictable onset unrelated to the existence of a real danger, an avalanche-like increase and a gradual subsiding of symptoms, the presence of a post-onset period. On average, the paroxysm lasts about 15 minutes, but its duration can vary from 10 minutes to 1 hour. The peak of clinical manifestations is usually stated at 5-10 minutes of the attack. After suffering a paroxysm, patients complain of “bruising” and “emptiness”, often describe their feelings with the phrase “as if a skating rink had ridden over me”.
The most common manifestations of a panic attack are: a feeling of lack of air, a feeling of “coma” in the throat or suffocation, shortness of breath, difficulty breathing; pulsation, interruptions or fading of the heart, palpitations, pain in the heart area. In most cases, there is sweating, the passage of cold or hot waves through the body, chills, dizziness, paresthesia, polyuria at the end of the attack. Less often there are symptoms from the gastrointestinal tract — nausea, belching, vomiting, discomfort in the epigastrium. Many patients point to cognitive disorders — a feeling of nausea in the head, unreality of objects (derealization), a feeling “as if you are in an aquarium”, the impression of muffled sounds and instability of surrounding objects, loss of a sense of self (depersonalization).
The emotional-affective component of a panic attack can vary both in type and intensity. In most cases, the first panic attack is accompanied by a pronounced fear of death, reaching an affective state in its intensity. In subsequent attacks, it gradually transforms into a specific phobia (fear of stroke or heart attack, fear of insanity, etc.) or internal tension, a feeling of unexplained anxiety. At the same time, some patients have panic paroxysms in which there is no anxiety-phobic component, and the emotional component is represented by a sense of hopelessness, longing, depression, self—pity, etc., in some cases – aggression towards others.
Functional neurological symptoms may be embedded in the structure of a panic attack. Among them are a feeling of weakness in a separate limb or its numbness, visual impairment, aphonia, mutism, the development of chills into tremors, individual hyperkinesis, tonic disorders with twisting of arms and legs, twisting of arms, elements of the “hysterical arc”. There may be an unnatural change in the patient’s gait, more like psychogenic ataxia.
There is a developed panic attack, manifested by 4 or more clinical symptoms, and abortive (small), in which less than 4 symptoms are observed in the clinic. One patient often has an alternation of expanded and abortive panic paroxysms. Moreover, developed seizures occur from 1 time in several months to 2-3 times a week, and abortive ones are noted much more often — up to several times a day. Only in some cases, only expanded paroxysms take place.
The period between panic paroxysms may have a different course. In some patients, autonomic dysfunction is expressed minimally and they feel absolutely healthy. Others have psychosomatic and vegetative disorders so intense that they can hardly distinguish a panic attack from an inter-crisis period. The clinical picture of the interval between attacks is also widely variable. It can be represented by difficulty breathing, shortness of breath, a feeling of lack of air; arterial hypo- and hypertension, cardialgic syndrome; flatulence, constipation, diarrhea, abdominal pain; periodic chills, subfebrility, hyperhidrosis; dizziness, hot flashes, headache, hypothermia of the hands and feet, acrocyanosis of the fingers; arthralgia, muscle-tonic syndromes; emotional and psychopathological manifestations (asthenovegetative, hypochondriac, anxiety-phobic, hysterical).
Over time, restrictive behavior progresses in patients. Due to the fear of a repeat of the panic attack, patients try to avoid places and situations associated with the occurrence of previous paroxysms. So there is a fear of driving in a certain type of transport, being at work, being alone at home, etc. The severity of restrictive behavior is an important criterion for assessing the severity of a panic disorder.
Diagnostics
Clinical examination of the patient at the time of panic paroxysm reveals objective symptoms of autonomic dysfunction. These are pallor or redness of the face, increased frequency (up to 130 beats /min) or slowing (up to 50 beats /min) of the pulse, an increase in blood pressure (up to 200/115 mm Hg), in some cases — arterial hypotension up to 90/60 mm Hg, a change in dermography and orthostatic test, violation of the ocular heart rate (reduction of heart rate when pressing on closed eyes) and pilomotor (contraction of the hair muscles of the skin in response to its irritation) reflexes. In the period between attacks, objective signs of vegetative disorders may also be noted. The study of the neurological status does not determine any serious abnormalities.
Patients who have suffered a panic attack should undergo a comprehensive psychological examination, including a study of the personality structure, neuropsychological and pathopsychological examination. The polysystemic manifestations of panic paroxysms cause a wide range of additional examinations necessary to identify /exclude background disease and differential diagnosis.
Depending on the clinical manifestations of the attack, the patient may be prescribed: ECG, daily monitoring of ECG and blood pressure, phonocardiography, ultrasound of the heart, lung radiography, examination of thyroid hormones and catecholamines, EEG, Echo-EG, cervical spine x-ray, MRI of the brain, cerebral vascular ultrasound, EGD, gastric juice examination, Ultrasound of the abdominal cavity. Often, related consultations of narrow specialists are required — a psychiatrist, a cardiologist, an ophthalmologist, a gastroenterologist, a pulmonologist, an endocrinologist.
Diagnostic criteria
The diagnosis of “panic attack” is established in the case of a recurrence of paroxysm, reaching its peak within 10 minutes, accompanied by an emotional and affective disorder ranging from intense fear to discomfort in combination with 4 or more of the following symptoms: rapid or increased heartbeat, chills or tremors, hyperhidrosis, dry mouth (not related with dehydration), chest pain, difficulty breathing, “lump” in the throat, suffocation, abdominal discomfort or dyspepsia, dizziness, depersonalization, derealization, fainting, fear of death, fear of going crazy or losing control of yourself, hot and cold tides, paresthesia or numbness. The presence of at least one of the first 4 symptoms is considered mandatory.
In addition to these symptoms, others may be observed: gait changes, hearing and vision disorders, pseudoparesis, convulsions in the extremities, etc. These manifestations are atypical. The presence of 5-6 such symptoms in the clinic of panic paroxysm casts doubt on the diagnosis. A single panic attack that develops as a psychogenic reaction against the background of psychological or physical overstrain, exhaustion after a long illness, etc., is not treated as a disease. The development of the disease should be discussed with repeated attacks, accompanied by the formation of psychopathological syndromes and autonomic disorders.
Treatment
As a rule, a panic attack is treated by the joint efforts of a neurologist and a psychologist (psychotherapist). Among the methods of psychotherapy, cognitive behavioral therapy is the most effective, according to indications, family and psychoanalytic psychotherapy is used. The fundamental point is the patient’s belief that a panic attack does not threaten his life, is not a manifestation of a serious illness and can be independently controlled by him. It is important for recovery that the patient reviews his attitude to many life situations and people.
Among the numerous non-drug methods of controlling the symptoms of an attack, respiratory control is the simplest and most effective. First, you need to take the deepest possible breath, then hold your breath for a couple of minutes and make a smooth gradual slow exhalation. On exhalation, it is better to close your eyes and relax all the muscles. Such a breathing exercise is recommended to be repeated up to 15 times, possibly with some breaks for several ordinary breaths. Special training of the patient in slow and calm breathing techniques allows him to stop hyperventilation during an attack and interrupt the vicious circle of paroxysm development.
Tetra- and tricyclic antidepressants (clomipramine, amitriptyline, imipramine, nortriptyline, maprotilin, mianserin tianeptin) are used in drug therapy. However, their effect begins to manifest itself only after 2-3 weeks and reaches a maximum by about 8-10 weeks of treatment; in the first 2-3 weeks of therapy, symptoms may worsen. Serotonin uptake inhibitors (sertraline, paroxetine, fluoxetine, fluvoxamine, cipramil) are considered the safest and most suitable for long-term treatment. But in the first weeks of taking them, insomnia, irritability, increased anxiety may be observed.
The drugs of choice are benzodiazepines (clonazepam, alprozalam), characterized by rapid efficacy and the absence of increased symptoms at the beginning of therapy. Their disadvantages are low effectiveness against depressive disorders, the possible formation of benzodiazepine dependence, which does not allow the use of drugs for longer than 4 weeks. Fast-acting benzodiazepines (lorazepam, diazepam) proved to be the most suitable for relieving an already developed paroxysm.
The selection of pharmacotherapy for panic paroxysms is a complex task that requires taking into account all the psychological characteristics of the patient and the clinical symptoms of the disease. The duration of the drug course, as a rule, is at least six months. Withdrawal of the drug is possible against the background of a complete reduction of waiting anxiety, if a panic attack has not been observed for 30-40 days.
Forecast
The course and severity of a panic attack is largely determined by the personal characteristics of the patient and the reaction of others. A more rapid development and severe course of panic disorder is observed if the first panic attack was perceived by the patient as a complete catastrophe. Sometimes the wrong reaction of doctors contributes to the aggravation of the situation. For example, the hospitalization of a patient by ambulance indicates in his understanding the presence of serious health problems and the danger to life of an attack that happened to him.
In prognostic terms, an important point is to start treatment as early as possible. Each subsequent panic attack aggravates the patient’s condition, is perceived by him as proof of the presence of a serious illness, reinforces the fear of waiting for an attack and forms restrictive behavior. Untimely and inappropriate therapeutic measures contribute to the progression of panic disorder. Timely adequate therapy combined with properly directed efforts of the patient himself usually leads to recovery, and in chronic course — to minimize clinical manifestations and frequency of attacks.