Panic attack

Panic attack
An illustration of someone who is experiencing a panic attack, being calmed down and reassured by another person.
Classification and external resources
Specialty	Psychiatry
ICD-10	F41.0
ICD-9-CM	300.01
DiseasesDB	30913
MeSH	D016584

Panic attacks are periods of intense fear or apprehension of sudden onset accompanied by bodily or cognitive symptoms (such as heart palpitations, dizziness, shortness of breath, or feelings of unreality) of variable duration from minutes to hours.^[1] For example, if a child becomes extremely anxious over a thunderstorm, they may overreact and isolate themselves from the world. If it becomes too intense with no one to calm them down, it can lead to a panic attack.^[2] Panic attacks usually begin abruptly and may reach a peak within 10 to 20 minutes but may continue for hours in some cases.^[1][3] Panic attacks are not dangerous and should not cause any physical harm.^[4]

The effects of a panic attack vary. Some, notably first-time sufferers, may call for emergency services. Many who experience a panic attack, mostly for the first time, fear that they are having a heart attack or a nervous breakdown.^[5] Common psychological features associated with panic attacks include the fear of impending death or loss of sanity, and depersonalisation is relatively common.

Panic attacks are of acute onset, and acute debilitation (generally severe) may be followed by a period of residually impaired psychological functioning. Repeated panic attacks are considered a symptom of panic disorder.^[6] Screening tools such as the Panic Disorder Severity Scale can be used to detect possible cases of disorder and suggest the need for a formal diagnostic assessment.^[7][8]

Signs and symptoms

Sufferers of panic attacks often report a fear of dying or heart attack, flashing vision, faintness or nausea, numbness throughout the body, heavy breathing and hyperventilation, or loss of bodily control. Some people also suffer from tunnel vision, mostly due to blood flow leaving the head to more critical parts of the body in defense. These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the "fight-or-flight response", in which the hormone causing this response is released in significant amounts). This response floods the body with hormones, particularly epinephrine (adrenaline), which aid it in defending against harm.^[9]

A panic attack is a response of the sympathetic nervous system (SNS). The most common symptoms 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, difficulty moving, 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.^[10]

Often, the onset of shortness of breath and chest pain are the predominant symptoms; the sufferer incorrectly appraises these as signs or symptoms of a heart attack. This can result in the person who is experiencing a panic attack seeking treatment in an emergency room. However, since chest pain and shortness of breath are indeed hallmark symptoms of cardiovascular illnesses, including unstable angina and myocardial infarction (heart attack), especially in a person whose mental health status and heart health status are not known, attributing these pains to simple anxiety and not (also) a physical condition is a diagnosis of exclusion (other conditions must be ruled out first) until an electrocardiogram and a mental health assessment have been carried out.

Panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature.^[9] They are often experienced in conjunction with anxiety disorders and other psychological conditions, although panic attacks are not generally indicative of a mental disorder.

Causes

• Long-term, predisposing causes – The onset of panic disorder usually occurs in early adulthood, although it may appear at any age. It occurs more frequently in women and more often in people with above average intelligence. Various twin studies where one identical twin has an anxiety disorder have reported a 31–88% incidence of the other twin also having an anxiety disorder diagnosis. Environmental factors such as an overcautious view of the world expressed by parents and cumulative stress over time have been found to be correlated with panic attacks.^[9]
• Biological causes – obsessive compulsive disorder, Postural Orthostatic Tachycardia Syndrome, post traumatic stress disorder, hypoglycemia, hyperthyroidism, Wilson's disease, mitral valve prolapse, pheochromocytoma, and inner ear disturbances (labyrinthitis). Dysregulation of the norepinephrine system in the locus ceruleus, an area of the brain stem, has been linked to panic attacks.^[11]
• 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, including an emotional attachment to a romantic partner, life transitions, significant life change.
• 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.
• Hyperventilation syndrome – Breathing from the chest may cause overbreathing, exhaling excessive 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.
• Situationally bound panic attacks – Associating certain situations with panic attacks, due to experiencing one in that particular situation, can create a cognitive or behavioral predisposition to having panic attacks in certain situations (situationally bound panic attacks).
• Discontinuation or marked reduction in the dose of a substance such as a drug (drug withdrawal), for example an antidepressant (antidepressant discontinuation syndrome), can cause a panic attack.

Pathophysiology

While the symptoms of a panic attack may cause the person to feel that their body is failing, it is protecting itself from harm. The symptoms can be understood as follows.

First, there is frequently the sudden onset of fear with little provoking stimulus. This leads to a release of adrenaline (epinephrine) which brings about the fight-or-flight response when the 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. 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 can lead to 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 toward the major muscles. The person experiencing the attack might feel as if they are unable to catch their breath; they begin to take deeper breaths, which acts to decrease carbon dioxide levels in the blood.

Diagnosis

DSM-5 diagnostic criteria for a panic attack include a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within minutes:

Palpitations, and/or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or being smothered Feeling of choking Chest pain or discomfort Nausea or abdominal distress

Feeling dizzy, unsteady, lightheaded, or faint De-realization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going insane Sense of impending death Paresthesias (numbness or tingling sensations) Chills or hot flashes

In DSM-5, culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Some or all of these symptoms can be found in the presence of a Pheochromocytoma.

Classification

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. Panic attacks are commonly linked to agoraphobia and the fear of not being able to escape a bad situation. As the result, severe sufferers of agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place".^[12] The word "agoraphobia" is an English adoption of the Greek words agora (αγορά) and phobos (φόβος). The term "agora" refers to the place where ancient Greeks used to gather and talk about issues of the city, so it basically 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. In the case of agoraphobia caused by social phobia or social anxiety, sufferers may be very embarrassed by having a panic attack 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. Agoraphobia, as described in this manner, is actually a symptom professionals check for when making a diagnosis of panic disorder. Other syndromes like obsessive compulsive disorder or post traumatic stress disorder and social anxiety disorder can also cause agoraphobia; basically any irrational fear that keeps one from going outside can cause the syndrome.^[13]

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.

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.^[3] However, panic attacks experienced by those with panic disorder may also be linked to or heightened by certain places or situations, making daily life difficult.^[14]

Experimentally induced panic attacks

Panic attack symptoms can be experimentally induced in the laboratory by various means. Among them, for research purposes, by administering a bolus injection of the neuropeptide cholecystokinin-tetrapeptide (CCK-4).^[15] Various animal models of panic attacks have been experimentally studied.^[16]

Treatment

Panic disorder can be effectively treated with a variety of interventions, including psychological therapies and medication^[9] with the strongest and most consistent evidence indicating that cognitive behavioral therapy has the most complete and longest duration of effect, followed by specific selective serotonin reuptake inhibitors.^[17] Subsequent research by Barbara Milrod and her colleagues^[18] suggests that psychoanalytic psychotherapy might be effective in relieving panic attacks, however, those results alone should be addressed with care. While the results obtained in joint treatments that include cognitive behavioral therapy and selective serotonin reuptake inhibitors are corroborated by many studies and meta-analysis, those obtained by Barbara Milrod are not. Scientific reliability of psychoanalytic psychotherapy for treating panic disorder has not yet been addressed. Specifically, the mechanisms by which psychoanalysis reduces panic are not understood; whereas cognitive-behavioral therapy has a clear conceptual basis that can be applied to panic.

The term anxiolytic has become nearly synonymous with the benzodiazepines because these compounds have been for almost 40 years the drugs of choice for stress-related anxiety. Low doses of complete agonist benzodiazepines alleviate anxiety, agitation, and fear by their actions on receptors located in the amygdala, orbitofrontal cortex, and insula. Administration of benzodiazepines during a panic attack may result in complete relief from symptoms in as little as ten or fifteen minutes. Benzodiazepines do not treat the source of the underlying fear but rather offer rapid onset relief from the immediate symptoms.

Breathing exercises

In the great majority of cases hyperventilation is involved, exacerbating the effects of the panic attack. Deliberate deep breathing exercises help to rebalance the oxygen and CO₂ levels in the blood.^[19]

David D. Burns recommends breathing exercises for those suffering from anxiety. One such breathing exercise is a 5-2-5 count. Using the stomach (or diaphragm) — and not the chest — you inhale (feel your stomach come out, as opposed to your chest expanding) for 5 seconds. As you reach the maximal point at inhalation, hold your breath for 2 seconds. Then slowly exhale, over 5 seconds. Repeat this cycle twice and then breathe 'normally' for 5 cycles (1 cycle = 1 inhale + 1 exhale). The point is to focus on the breathing and relax the heart rate. Regular diaphragmatic breathing may be achieved by extending the outbreath by counting or humming.

Although breathing into a paper bag was a common recommendation for short-term treatment of symptoms of an acute panic attack,^[20] it has been criticized as inferior to measured breathing, potentially worsening the panic attack and possibly reducing needed blood oxygen.^[21][22] While the paper bag technique increases needed carbon dioxide and so reduces symptoms, it may excessively lower oxygen levels in the blood stream.^[23] To make matters worse, several studies show a link between panic attacks and the abrupt increase in CO₂ from the paper bag method: Use of the paper bag method may worsen feelings of panic in patients who might otherwise use measured breathing techniques with success.^[24]

Therapy

According to the American Psychological Association, "most specialists agree that a combination of cognitive and behavioral therapies are the best treatment for panic disorder. Medication might also be appropriate in some cases."^[25] The first part of therapy is largely informational; many people are greatly helped by simply understanding exactly what panic disorder is and how many others suffer from it. Many people who suffer from panic disorder are worried that their panic attacks mean they are "going crazy" or that the panic might induce a heart attack. Cognitive restructuring helps people replace those thoughts with more realistic, positive ways of viewing the attacks.^[26] Exposure therapy,^[27] which includes repeated and prolonged confrontation with feared situations and body sensations, helps weaken anxiety responses to these external and internal stimuli and reinforce the realistic ways of viewing panic symptom

In deeper level psychoanalytic approaches, in particular object relations theory, panic attacks are frequently associated with splitting (psychology), paranoid-schizoid and depressive positions, and paranoid anxiety. They are often found comorbid with borderline personality disorder and child sexual abuse. Paranoid anxiety may reach the level of a persecutory anxiety state.^[28]

Meditation may also be helpful in the treatment of panic disorders.

Dietary changes

Caffeine may cause or exacerbate panic anxiety. Anxiety can temporarily decrease during withdrawal from caffeine and other various drugs.^[29]

Exercise

Increased and regimented aerobic exercise such as running have been shown to have a positive effect in combating panic anxiety. There is evidence that suggests that this effect is correlated to the release of exercise-induced endorphins and the subsequent reduction of the stress hormone cortisol.^[30]

There remains a chance of panic symptoms becoming triggered or exacerbated due to increased respiration rate that occurs during aerobic exercise. This increased respiration rate can lead to hyperventilation and hyperventilation syndrome, which mimics symptoms of a heart attack, thus inducing a panic attack.^[31] Benefits of incorporating an exercise regimen have shown best results when paced accordingly.^[32]

Prognosis

Many people being treated for panic attacks begin to experience limited symptom attacks. These panic attacks are less comprehensive, with fewer than four bodily symptoms being experienced.^[9]

It is not unusual to experience only one or two symptoms at a time, such as vibrations in their legs, shortness of breath, or an intense wave of heat traveling up their bodies, which is not similar to hot flashes due to estrogen shortage. Some symptoms, such as vibrations in the legs, are sufficiently different from any normal sensation that they clearly indicate panic disorder. Other symptoms on the list can occur in people who may or may not have panic disorder. Panic disorder does not require four or more symptoms to all be present at the same time. Causeless panic and racing heartbeat are sufficient to indicate a panic attack.^[9]

See also

• Nervous breakdown

^[33]

References

1. MedlinePlus Encyclopedia Panic disorder
2. "Panic attack - Definition and More from the Free Merriam-Webster Dictionary". M-w.com. 2010-08-13. Retrieved 2012-06-15.
3. Panic Disorder – familydoctor.org
4. November 12, 2013. What is a panic attack? National Health Service. Retrieved: 4 February 2015.
5. Reid, Wilson (1996). "Don't Panic: Taking Control of Your Anxiety Attacks. Revised Edition, HC".
6. DSM-TR diagnostic criteria for panic disorder
7. Houck, P. R.; Spiegel, D. A.; Shear, M. K.; Rucci, P. (2002). "Reliability of the self-report version of the Panic Disorder Severity Scale". Depression and Anxiety 15 (4): 183–185. doi:10.1002/da.10049. PMID 12112724.
8. Shear, M. K.; Rucci, P.; Williams, J.; Frank, E.; Grochocinski, V.; Vander Bilt, J.; Houck, P.; Wang, T. (2001). "Reliability and validity of the Panic Disorder Severity Scale: Replication and extension". Journal of Psychiatric Research 35 (5): 293–296. doi:10.1016/S0022-3956(01)00028-0. PMID 11591432.
9. Bourne, E. (2005). The Anxiety and Phobia Workbook, 4th Edition: New Harbinger Press.
10. 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. p. 44. ISBN 978-0-88048-684-2.
11. Nolen-Hoeksema, Susan (2013). (Ab)normal Psychology (6th ed.). McGraw Hill. ISBN 9780078035388.
12. "Agoraphobia". MayoClinic.com. 2011-04-21. Retrieved 2012-06-15.
13. Psych Central: Agoraphobia Symptoms
14. "Anxiety Disorders"
15. Leicht, Gregor; Mulert, Christoph; Eser, Daniela; Sämann, Philipp G.; Ertl, Matthias; Laenger, Anna; Karch, Susanne; Pogarell, Oliver; Meindl, Thomas; Czisch, Michael; Rupprecht, Rainer (2013). "Benzodiazepines Counteract Rostral Anterior Cingulate Cortex Activation Induced by Cholecystokinin-Tetrapeptide in Humans". Biological Psychiatry 73 (4): 337–44. doi:10.1016/j.biopsych.2012.09.004. PMID 23059050.
16. Moreira, Fabrício A.; Gobira, Pedro H.; Viana, Thércia G.; Vicente, Maria A.; Zangrossi, Hélio; Graeff, Frederico G. (2013). "Modeling panic disorder in rodents". Cell and Tissue Research 354 (1): 119–25. doi:10.1007/s00441-013-1610-1. PMID 23584609.
17. Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. National Institute for Health and Clinical Excellence. Clinical Guideline 22. Issue date: April 2007 ISBN 1-84629-400-2
18. Milrod, B.; Leon, A. C.; et al. (2007). "A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder". American Journal of Psychiatry 164 (2): 265–272. doi:10.1176/ajp.2007.164.2.265. PMID 17267789.
19. Taylor, Jim and Shel (1997). Psychological Approaches to Sports Injury Rehabilitation. Google Books: Aspen Publications. p. 228. ISBN 0-8342-0973-X.
20. Breathing in and out of a paper bag
21. Bergeron, J. David; Le Baudour, Chris (2009). "Chapter 9: Caring for Medical Emergencies". First Responder (8 ed.). New Jersey: Pearson Prentice Hall. p. 262. ISBN 978-0-13-614059-7. Do not use a paper bag in an attempt to treat hyperventilation. These patients can often be cared for with low-flow oxygen and lots of reassurance
22. Hyperventilation Syndrome – Can I treat hyperventilation syndrome by breathing into a paper bag?
23. Breathing into a paper bag restricts the fresh air you are able to get. Without fresh air, less oxygen is inhaled. Breathing into a paper bag, it is argued, may dangerously lower the amount of oxygen in the bloodstream. Accurate diagnosis is essential, since in rare, documented cases heart attack patients incorrectly thinking they had hyperventilation syndrome may have worsened their heart attacks by failing to take appropriate measures while breathing into a paper bag.http://firstaid.about.com/od/shortnessofbreat1/f/07_paper_bags.htm
24. "Hyperventilation Syndrome - Treating hyperventilation syndrome by breathing into a paper bag". Firstaid.about.com. 2007-10-03. Retrieved 2012-08-13.
25. http://www.apa.org/topics/anxietyqanda.html
26. Cramer, K., Post, T., & Behr, M. (January 1989). "Cognitive Restructuring Ability, Teacher Guidance and Perceptual Distracter Tasks: An Aptitude Treatment Interaction Study". Retrieved 2010-11-19.
27. Abramowitz, Jonathan S.; Deacon, Brett J.; Whiteside, Stephen P. H. (2012-12-17). Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN 9781462509690.
28. Waska, Robert (2010). Treating Severe Depressive and Persecutory Anxiety States: To Transform the Unbearable. Karnac Books. ISBN 978-1855757202.
29. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev., p. 479). Washington, D.C.: American Psychiatric Association.
30. http://psychcentral.com/blog/archives/2013/07/17/3-tips-for-using-exercise-to-shrink-anxiety/[]
31. MedlinePlus Encyclopedia Hyperventilation
32. http://www.livestrong.com/article/103790-cardio-exercise-beginners[]
33. How to stop panic attacks? Informative and motivation website for the panic attack and anxiety family.