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Panic Attacks


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Panic attacks are very 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.  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 it in defending against harm.  Experiencing a panic attack is considered to be one of the most intensely frightening, upsetting and uncomfortable experiences of a person's life.  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.

The effects of a panic attack vary from person to person.  Some, notably first-time sufferers, may call for emergency services.  Many who experience a panic attack, mostly for the first time, fear they are having a heart attack or a nervous breakdown.


Descriptions

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 nauseated, 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 flushes, cold flushes, 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 derealisation.  These physical symptoms are interpreted with alarm in people prone to panic attacks.  This results in increased anxiety, and forms a positive feedback.

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. They are often experienced in conjunction with anxiety disorders and other psychological conditions, although panic attacks are not always indicative of a mental disorder.


Triggers and causes

Long-term, predisposing causes.

Heredity.  Panic disorder has been found to run in families, and this may mean that inheritance plays a strong role in determining who will get it.  However, many people who have no family history of the disorder develop it.  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.

Biological causes.  obsessive compulsive disorder, post traumatic stress disorder, hypoglycemia, hyperthyroidism, Wilson's disease, mitral valve prolapse, pheochromocytoma and inner ear disturbances (labyrinthitis).  Vitamin B deficiency from inadequate diet or caused by periodic depletion due to parasitic infection from tapeworm 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, including an emotional attachment to a romantic partner, life transitions, significant life change, stimulants such as caffeine or nicotine, or the drugs marijuana or psilocybin, can act as triggers.

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.

Lack of assertiveness.  A growing body of evidence supports the idea that those that suffer from panic attacks engage in a passive style of communication or interactions with others.  This communication style, while polite and respectful, is also characteristically un-assertive.  This un-assertive way of communicating seems to contribute to panic attacks while being consistently present in those that are afflicted with panic attacks.

Medications.  Sometimes panic attacks may be a listed side effect of medications such as Ritalin (methylphenidate) or even fluoroquinolone type antibiotics.  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.

Alcohol, medication or drug withdrawal.  Various substances, both prescribed and un-prescribed, can cause panic attacks to develop as part of their withdrawal syndrome or rebound effect.  Alcohol withdrawal and benzodiazepine withdrawal are the most well known to cause these effects as a rebound withdrawal symptom of their tranquillising properties.

Hyperventilation syndrome.  Breathing from the 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.

Situationally bound panic attacks.  Associating certain situations with panic attacks, due to experiencing one in that particular situation, can create a cognitive or behaviourally predisposition to having panic attacks in certain situations (situationally bound panic attacks).  It is a form of classical conditioning.  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.  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.

Chronic and/or serious illness.  Cardiac conditions that can cause Sudden Death such as Long QT syndrome; CPVT or Wolff-Parkinson-White syndrome can also result in panic attacks.  This is particularly difficult to manage as the anxiety relates to events that may occur such as cardiac arrest, or if an Implantable cardioverter-defibrillator is in situ, the possibility of having a shock delivered.  It can be difficult for someone with a cardiac condition to distinguish between symptoms of cardiac dysfunction and symptoms of anxiety.  In CPVT, anxiety itself can and does trigger arrythmia.  Current management of panic attacks secondary to cardiac conditions appears to rely heavily on Benzodiazepines; Selective serotonin reuptake inhibitors and/or Cognitive Behavioural Therapy.  Although often this group of people experience multiple and unavoidable hospitalisations as without an electrocardiogram it can be difficult to differentiate between symptoms of panic attack and cardiac symptoms in those with these types of diagnosis.


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.  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.


Symptoms

DSM-IV Diagnostic Criteria for Panic Attack

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

1)  palpitations, pounding heart, or accelerated heart rate

2)  sweating

3)  trembling or shaking

4)  sensations of shortness of breath or smothering

5)  feeling of choking

6)  chest pain or discomfort

7)  nausea or abdominal distress

8)  feeling dizzy, unsteady, lightheaded, or faint

9)  derealisation (feelings of unreality) or depersonalisation (being detached from oneself)

10)  fear of losing control or going crazy

11)  fear of dying

12)  paresthesias (numbness or tingling sensations)

13)  chills or hot flushes


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 travelling from this 'safe place'.  The word 'agoraphobia' is an English adoption of the Greek words agora and phobos, 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 realise that they have experienced these same situations before and nothing terrible occurred.  Successful treatment is possible with the right combination of therapy and medication.


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.


Treatment

People with panic attacks often can be successfully treated with anti-anxiety medication or antidepressants.


Paper bag re-breathing

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.  However, this treatment has been criticised by others as ineffective and possibly hazardous to the patient, even potentially worsening the panic attack.  It is said that it can fatally lower oxygen levels in the blood stream, and increase carbon dioxide levels, which in turn has been found to be a major cause of panic attacks.

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.


Medication

The benzodiazepine class of drugs includes diazepam, lorazepam, alprazolam, and clonazepam.  These drugs are fast acting in stopping panic but long-term use often leads to tolerance and physical dependence.  Benzodiazepines are best used for a few days to avoid the development of tolerance or dependence.  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 and panic attacks.  SNRIs such as Venlafaxine can also be prescribed, but may be addictive and may increase suicide ideation, but have less abuse potential than benzodiazepines.


Other treatments

All persons experiencing persistent and frequent panic attacks should consult their physician/doctor.  However, many experienced sufferers treat panic attacks with some the following methods and techniques:

Diaphragmatic breathing or abdominal breathing - breathing slowly through the nose using the diaphragm and abdomen. Do not breathe through the mouth. Focus on exhaling very slowly.  This will correct or prevent an imbalance of oxygen to carbon dioxide in the blood stream.

Taking anti-anxiety medication - to be used under the guidance and direction of a physician/doctor.

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, such as:

"No one has ever died from an anxiety attack."

"I will let my body do its thing.  This will pass."

"I can be anxious and still deal with this situation."

"This does not feel great, but I can deal with it".

"I am frightened of being frightened, therefore if I stop worrying about being frightened then I have nothing to be scared of."

Talking to a supportive person - someone who has experienced true panic attacks personally; someone who is highly trained in treating panic attacks; loved ones who can offer support and comfort.

Lying down - to prevent fainting during an attack.


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.  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.  For example one study albeit in the elderly found that the consumption of benzodiazepines combined with analgesics in elderly men is correlated with an increased risk of dying of ischaemic heart disease in a small study.  The study doesn't say if this is to be blamed on the benzodiazepine drug in this case nitrazepam, the analgetics or their combination.


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.


Look up Panic attack in Wiktionary, the free dictionary.


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