Panic attack
Encyclopedia
Panic attacks are periods of intense fear
or apprehension
that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours. Often, those afflicted will experience significant anticipatory anxiety and limited symptom attack
s in between attacks, in situations where attacks have previously occurred.
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 they are having a heart attack or a nervous breakdown
. Experiencing a panic attack has been said to be one of the most intensely frightening, upsetting and uncomfortable experiences of a person's life and may take days to initially recover from. Repeated panic attacks are considered a symptom of panic disorder. Screening tools like Panic Disorder Severity Scale
can be used to detect possible cases of disorder, and suggest the need for a formal diagnostic assessment.
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
, a numb sensation throughout the body, heavy breathing (and almost always, hyperventilation
), or losing control of themselves. 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 sympathetic "fight-or-flight response
") in which the hormone which causes this response is released in significant amounts. This response floods the body with hormones, particularly epinephrine
(adrenaline), that aid it in defending against harm.
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 flashes, cold flashes, burning sensations (particularly in the facial or neck area), sweating
, nausea
, dizziness
(or slight vertigo
), light-headedness, hyperventilation
, paresthesia
s (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.
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 usually indicative of a mental disorder.
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 lung
s 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.
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:
Note that while the DSM-IV-TR only lists the 13 specific symptoms above, it has been proposed that culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) be added to the DSM-V diagnostic criteria for a panic attack.
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 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). 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 of 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.
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.
s in that panic
attacks are often sudden and unprovoked.
Today 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.
helps people replace those thoughts with more realistic, positive ways of viewing the attacks.
One of another helpful treatment for panic disorders is meditation. Medication is the common treatment for the disorder, but meditation is a great help too.
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 and 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.
over the next five years. The researchers believe that panic attacks or more accurately their associated symptoms (chest pain
, shortness of breath
) 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. However, the study did not find that isolated cases of panic attacks in patients without panic disorder
or agoraphobia
would 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. Panic attack symptoms may be masking heart attack warnings and precursors. Chest pain, shortness of breath, unusual exhaustion and other heart attack symptoms should be evaluated by a physician to distinguish panic symptoms from heart disease symptoms.
s. These panic attacks are less comprehensive with fewer than 4 bodily symptoms being experienced.
It is not unusual for panic disorder sufferers to experience only one or two symptoms at a time, such as vibrations in their legs, or 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 truly does not require four or more symptoms to all be present at the same time. Pure causeless panic and the racing heart beat the panic causes are quite sufficient to indicate panic attack.
Fear
Fear is a distressing negative sensation induced by a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger...
or apprehension
Apprehension
In psychology, apprehension is a term applied to a model of consciousness in which nothing is affirmed or denied of the object in question, but the mind is merely aware of it....
that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours. Often, those afflicted will experience significant anticipatory anxiety and limited symptom attack
Limited symptom attack
A Limited Symptom Attack , also referred to as a Limited Symptom Panic Attack , is a milder, less comprehensive panic attack with fewer than 4 panic related symptoms being experienced . For example, a sudden episode of intense dizziness or trembling accompanied by fear that something terrible is...
s in between attacks, in situations where attacks have previously occurred.
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 they are having a heart attack or a nervous breakdown
Nervous breakdown
Mental breakdown is a non-medical term used to describe an acute, time-limited phase of a specific disorder that presents primarily with features of depression or anxiety.-Definition:...
. Experiencing a panic attack has been said to be one of the most intensely frightening, upsetting and uncomfortable experiences of a person's life and may take days to initially recover from. Repeated panic attacks are considered a symptom of panic disorder. Screening tools like Panic Disorder Severity Scale
Panic Disorder Severity Scale
The Panic Disorder Severity Scale is a questionnaire developed for measuring severity of panic disorder. The clinician-administered PDSS is intended to assess severity and considered a reliable tool for monitoring of treatment outcome...
can be used to detect possible cases of disorder, and suggest the need for a formal diagnostic assessment.
Sufferers of panic attacks often report a fear or sense of dying, "going crazy," or experiencing a heart attack
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
or "flashing vision," feeling faint or nauseated
Vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
, a numb sensation throughout the body, heavy breathing (and almost always, hyperventilation
Hyperventilation
Hyperventilation or overbreathing is the state of breathing faster or deeper than normal, causing excessive expulsion of circulating carbon dioxide. It can result from a psychological state such as a panic attack, from a physiological condition such as metabolic acidosis, can be brought about by...
), or losing control of themselves. Some people also suffer from tunnel vision
Tunnel vision
Tunnel vision is the loss of peripheral vision with retention of central vision, resulting in a constricted circular tunnel-like field of vision.- Medical / biological causes :Tunnel vision can be caused by:...
, 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 sympathetic "fight-or-flight response
Fight-or-flight response
The fight-or-flight response was first described by Walter Bradford Cannon....
") in which the hormone which causes this response is released in significant amounts. This response floods the body with hormones, particularly epinephrine
Epinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...
(adrenaline), that aid it in defending against harm.
A panic attack is a response of the sympathetic nervous system
Sympathetic nervous system
The sympathetic nervous system is one of the three parts of the autonomic nervous system, along with the enteric and parasympathetic systems. Its general action is to mobilize the body's nervous system fight-or-flight response...
(SNS). The most common symptoms may include trembling, dyspnea
Dyspnea
Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...
(shortness of breath), heart palpitations, chest pain
Chest pain
Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.-Differential...
(or chest tightness), hot flashes, cold flashes, burning sensations (particularly in the facial or neck area), sweating
Sweating
Perspiration is the production of a fluid consisting primarily of water as well as various dissolved solids , that is excreted by the sweat glands in the skin of mammals...
, nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
, dizziness
Dizziness
Dizziness refers to an impairment in spatial perception and stability. The term is somewhat imprecise. It can be used to mean vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness....
(or slight vertigo
Vertigo (medical)
Vertigo is a type of dizziness, where there is a feeling of motion when one is stationary. The symptoms are due to a dysfunction of the vestibular system in the inner ear...
), light-headedness, hyperventilation
Hyperventilation
Hyperventilation or overbreathing is the state of breathing faster or deeper than normal, causing excessive expulsion of circulating carbon dioxide. It can result from a psychological state such as a panic attack, from a physiological condition such as metabolic acidosis, can be brought about by...
, paresthesia
Paresthesia
Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...
s (tingling sensations), sensations of choking
Choking
Choking is the mechanical obstruction of the flow of air from the environment into the lungs. Choking prevents breathing, and can be partial or complete, with partial choking allowing some, although inadequate, flow of air into the lungs. Prolonged or complete choking results in asphyxia which...
or smothering, difficulty moving and derealization
Derealization
Derealization is an alteration in the perception or experience of the external world so that it seems unreal. Other symptoms include feeling as though one's environment is lacking in spontaneity, emotional coloring and depth. It is a dissociative symptom of many conditions, such as psychiatric and...
. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety, and forms a positive feedback
Positive feedback
Positive feedback is a process in which the effects of a small disturbance on a system include an increase in the magnitude of the perturbation. That is, A produces more of B which in turn produces more of A. In contrast, a system that responds to a perturbation in a way that reduces its effect is...
loop.
Often, the onset of shortness of breath and chest pain
Chest pain
Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.-Differential...
are the predominant symptoms; the sufferer incorrectly appraises this as a sign or symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
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 usually indicative of a mental disorder.
Triggers and causes
- Long-term, predisposing causes — HeredityHeredityHeredity is the passing of traits to offspring . This is the process by which an offspring cell or organism acquires or becomes predisposed to the characteristics of its parent cell or organism. Through heredity, variations exhibited by individuals can accumulate and cause some species to evolve...
. 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. The onset of panic disorder usually occurs in early adulthood, although it may appear at any age. It occurs more frequently in women and often in people with above average intelligence. 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 correlated with panic attacks. - Biological causes — obsessive compulsive disorder, post traumatic stress disorder, hypoglycemiaHypoglycemiaHypoglycemia or hypoglycæmia is the medical term for a state produced by a lower than normal level of blood glucose. The term literally means "under-sweet blood"...
, hyperthyroidismHyperthyroidismHyperthyroidism is the term for overactive tissue within the thyroid gland causing an overproduction of thyroid hormones . Hyperthyroidism is thus a cause of thyrotoxicosis, the clinical condition of increased thyroid hormones in the blood. Hyperthyroidism and thyrotoxicosis are not synonymous...
, Wilson's diseaseWilson's diseaseWilson's disease or hepatolenticular degeneration is an autosomal recessive genetic disorder in which copper accumulates in tissues; this manifests as neurological or psychiatric symptoms and liver disease...
, mitral valve prolapseMitral valve prolapseMitral valve prolapse is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. There are various types of MVP, broadly classified as classic and nonclassic. In its nonclassic form, MVP carries a low risk of...
, pheochromocytomaPheochromocytomaA pheochromocytoma or phaeochromocytoma is a neuroendocrine tumor of the medulla of the adrenal glands , or extra-adrenal chromaffin tissue that failed to involute after birth and secretes excessive amounts of catecholamines, usually noradrenaline , and adrenaline to a lesser extent...
, and inner ear disturbances (labyrinthitisLabyrinthitisLabyrinthitis is an inflammation of the inner ear, and a form of unilateral vestibular dysfunction. It derives its name from the labyrinths that house the vestibular system . Labyrinthitis can cause balance disorders....
). Parasitic infection can cause psychiatric symptoms. - 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, and as seen below, stimulants such as caffeineCaffeineCaffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...
or nicotineNicotineNicotine is an alkaloid found in the nightshade family of plants that constitutes approximately 0.6–3.0% of the dry weight of tobacco, with biosynthesis taking place in the roots and accumulation occurring in the leaves...
, 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 feelingFeelingFeeling is the nominalization of the verb to feel. The word was first used in the English language to describe the physical sensation of touch through either experience or perception. The word is also used to describe experiences, other than the physical sensation of touch, such as "a feeling of...
s, lack of assertiveness. - Lack of assertivenessAssertivenessAssertiveness is a particular mode of communication. Dorland's Medical Dictionary defines assertiveness as:During the second half of the 20th century, assertiveness was increasingly singled out as a behavioral skill taught by many personal development experts, behavior therapists, and cognitive...
— A growing body of evidenceEvidenceEvidence in its broadest sense includes everything that is used to determine or demonstrate the truth of an assertion. Giving or procuring evidence is the process of using those things that are either presumed to be true, or were themselves proven via evidence, to demonstrate an assertion's truth...
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 frequently present in those that are afflicted with panic attacks. - Medications — Sometimes, panic attacks may be a listed side effect of medications such as Ritalin (methylphenidateMethylphenidateMethylphenidate is a psychostimulant drug approved for treatment of attention-deficit hyperactivity disorder, postural orthostatic tachycardia syndrome and narcolepsy. It may also be prescribed for off-label use in treatment-resistant cases of lethargy, depression, neural insult and obesity...
) 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 unprescribed can cause panic attacks to develop as part of their withdrawal syndromeWithdrawal syndromeA withdrawal syndrome, also called a discontinuation syndrome, occurs when a person suddenly stops taking or reduces the dosage of some types of medications...
or rebound effectRebound effectThe rebound effect, or rebound phenomenon, is the tendency of some medications, when discontinued suddenly, to cause a return of the symptoms it relieved, and that, to a degree stronger than they were before treatment first began...
. 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 dioxideCarbon dioxideCarbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...
in relation to the amount of oxygenOxygenOxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
in one's bloodstream. Hyperventilation syndromeHyperventilation syndromeHyperventilation syndrome is a respiratory disorder, psychologically or physiologically based, involving breathing too deeply or too rapidly...
can cause respiratory alkalosisRespiratory alkalosisRespiratory alkalosis is a medical condition in which increased respiration elevates the blood pH...
and hypocapniaHypocapniaHypocapnia or hypocapnea also known as hypocarbia, sometimes incorrectly called acapnia, is a state of reduced carbon dioxide in the blood. Hypocapnia usually results from deep or rapid breathing, known as hyperventilation....
. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms including rapid heart beatCardiac cycleThe cardiac cycle is a term referring to all or any of the events related to the flow or blood pressure that occurs from the beginning of one heartbeat to the beginning of the next. The frequency of the cardiac cycle is described by the heart rate. Each beat of the heart involves five major stages...
, dizzinessDizzinessDizziness refers to an impairment in spatial perception and stability. The term is somewhat imprecise. It can be used to mean vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness....
, and lightheadednessLightheadednessLight-headedness is a common and often unpleasant sensation of dizziness and/or feeling that one may be about to faint, which may be transient, recurrent, or occasionally chronic. In some cases, the individual may feel as though his or her head is weightless. The individual may also feel as...
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). It is a form of classical conditioning. Examples of this include college, work, or deployment. 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 deathSudden Cardiac DeathSudden cardiac death is natural death from cardiac causes, heralded by abrupt loss of consciousness within one hour of the onset of acute symptoms. Other forms of sudden death may be noncardiac in origin...
such as long QT syndromeLong QT syndromeThe long QT syndrome is a rare inborn heart condition in which delayed repolarization of the heart following a heartbeat increases the risk of episodes of torsade de pointes . These episodes may lead to palpitations, fainting and sudden death due to ventricular fibrillation...
; catecholaminergic polymorphic ventricular tachycardiaCatecholaminergic polymorphic ventricular tachycardiaCatecholaminergic Polymorphic Ventricular Tachycardia is an electrophysiological disorder of the heart that occurs in genetically predisposed individuals...
or Wolff-Parkinson-White syndromeWolff-Parkinson-White syndromeWolff–Parkinson–White syndrome is a disorder of the heart in which the ventricles of the heart contract prematurely due to an accessory pathway known as the bundle of Kent. This accessory pathway is an abnormal electrical communication from the atria to the ventricles...
can also result in panic attacks. This is particularly difficult to manage as the anxietyAnxietyAnxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
relates to events that may occur such as cardiac arrest, or if an implantable cardioverter-defibrillatorImplantable cardioverter-defibrillatorAn implantable cardioverter-defibrillator is a small battery-powered electrical impulse generator which is implanted in patients who are at risk of sudden cardiac death due to ventricular fibrillation and ventricular tachycardia. The device is programmed to detect cardiac arrhythmia and correct it...
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. However, people in this group often experience multiple and unavoidable hospitalisations; in people with these types of diagnoses, it can be difficult to differentiate between symptoms of a panic attack versus cardiac symptoms without an electrocardiogramElectrocardiogramElectrocardiography is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body...
.
Physiological considerations
While the various symptoms of a panic attack may cause the victim to feel that their 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 responseFight-or-flight response
The fight-or-flight response was first described by Walter Bradford Cannon....
wherein the person's body prepares for strenuous physical activity. This leads to an increased heart rate (tachycardia
Tachycardia
Tachycardia comes from the Greek words tachys and kardia . Tachycardia typically refers to a heart rate that exceeds the normal range for a resting heart rate...
), rapid breathing (hyperventilation
Hyperventilation
Hyperventilation or overbreathing is the state of breathing faster or deeper than normal, causing excessive expulsion of circulating carbon dioxide. It can result from a psychological state such as a panic attack, from a physiological condition such as metabolic acidosis, can be brought about by...
) which may be perceived as shortness of breath (dyspnea
Dyspnea
Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...
), and sweating (which increases grip and aids heat loss). Because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon dioxide
Carbon dioxide
Carbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...
levels in the lung
Human lung
The human lungs are the organs of respiration in humans. Humans have two lungs, with the left being divided into two lobes and the right into three lobes. Together, the lungs contain approximately of airways and 300 to 500 million alveoli, having a total surface area of about in...
s and then in the blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
. This leads to shifts in blood pH
PH
In chemistry, pH is a measure of the acidity or basicity of an aqueous solution. Pure water is said to be neutral, with a pH close to 7.0 at . Solutions with a pH less than 7 are said to be acidic and solutions with a pH greater than 7 are basic or alkaline...
(respiratory alkalosis
Respiratory alkalosis
Respiratory alkalosis is a medical condition in which increased respiration elevates the blood pH...
or hypocapnia
Hypocapnia
Hypocapnia or hypocapnea also known as hypocarbia, sometimes incorrectly called acapnia, is a state of reduced carbon dioxide in the blood. Hypocapnia usually results from deep or rapid breathing, known as hyperventilation....
), which in turn can lead to many other symptoms, such as tingling or numbness
Paresthesia
Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...
, dizziness
Dizziness
Dizziness refers to an impairment in spatial perception and stability. The term is somewhat imprecise. It can be used to mean vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness....
, burning and lightheadedness
Lightheadedness
Light-headedness is a common and often unpleasant sensation of dizziness and/or feeling that one may be about to faint, which may be transient, recurrent, or occasionally chronic. In some cases, the individual may feel as though his or her head is weightless. The individual may also feel as...
. Moreover, the release of adrenaline during a panic attack causes vasoconstriction
Vasoconstriction
Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, particularly the large arteries, small arterioles and veins. The process is the opposite of vasodilation, the widening of blood vessels. The process is particularly important in...
resulting in slightly less blood flow
Blood flow
Blood flow is the continuous running of blood in the cardiovascular system.The human body is made up of several processes all carrying out various functions. We have the gastrointestinal system which aids the digestion and the absorption of food...
to the head which causes dizziness
Dizziness
Dizziness refers to an impairment in spatial perception and stability. The term is somewhat imprecise. It can be used to mean vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness....
and lightheadedness
Lightheadedness
Light-headedness is a common and often unpleasant sensation of dizziness and/or feeling that one may be about to faint, which may be transient, recurrent, or occasionally chronic. In some cases, the individual may feel as though his or her head is weightless. The individual may also feel as...
. A panic attack can cause blood sugar
Blood sugar
The blood sugar concentration or blood glucose level is the amount of glucose present in the blood of a human or animal. Normally in mammals, the body maintains the blood glucose level at a reference range between about 3.6 and 5.8 mM , or 64.8 and 104.4 mg/dL...
to be drawn away from the brain
Human brain
The human brain has the same general structure as the brains of other mammals, but is over three times larger than the brain of a typical mammal with an equivalent body size. Estimates for the number of neurons in the human brain range from 80 to 120 billion...
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.
Diagnostic criteria
DSM-IV Diagnostic Criteria for Panic AttackA 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:
- Palpitations, or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering
- 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
Note that while the DSM-IV-TR only lists the 13 specific symptoms above, it has been proposed that culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) be added to the DSM-V diagnostic criteria for a panic attack.
Agoraphobia
AgoraphobiaAgoraphobia
Agoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...
is an anxiety disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...
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 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
Greek language
Greek is an independent branch of the Indo-European family of languages. Native to the southern Balkans, it has the longest documented history of any Indo-European language, spanning 34 centuries of written records. Its writing system has been the Greek alphabet for the majority of its history;...
words agora
Agora
The Agora was an open "place of assembly" in ancient Greek city-states. Early in Greek history , free-born male land-owners who were citizens would gather in the Agora for military duty or to hear statements of the ruling king or council. Later, the Agora also served as a marketplace where...
(αγορά) and phobos
Phobia
A phobia is a type of anxiety disorder, usually defined as a persistent fear of an object or situation in which the sufferer commits to great lengths in avoiding, typically disproportional to the actual danger posed, often being recognized as irrational...
(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
Social anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...
or social anxiety
Social anxiety
Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...
, sufferers may be very embarrassed of 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
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
. Other syndromes like obsessive compulsive disorder or post traumatic stress disorder and Social Anxiety Disorder
Social anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...
can also cause agoraphobia, basically any irrational fear that keeps one from going outside can cause the syndrome.
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
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia
Agoraphobia
Agoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...
. 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 disorderAnxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...
s in that panic
Panic
Panic is a sudden sensation of fear which is so strong as to dominate or prevent reason and logical thinking, replacing it with overwhelming feelings of anxiety and frantic agitation consistent with an animalistic fight-or-flight reaction...
attacks are often sudden and unprovoked.
Treatment
Panic disorder can be effectively treated with a variety of interventions including psychological therapies and medication with the evidence that cognitive behaviour therapy has the longest duration of effect, followed by specific selective serotonin reuptake inhibitors. However, subsequent research by Barbara Milrod and her colleagues has shown that psychoanalytic psychotherapy is equally effective in relieving panic attacks as behavioral approaches and has fewer relapses. A psychoanalytic approach that identifies actual but dissociated causes of panic reactions may lead to rapid disappearance of symptoms.Today 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.
Psychotherapies
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". 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 restructuringCognitive restructuring
Cognitive restructuring, sometimes used synonymously with Debating, is the process of learning to identify irrational or maladaptive thoughts and challenge their veracity using strategies such as logical disputation....
helps people replace those thoughts with more realistic, positive ways of viewing the attacks.
One of another helpful treatment for panic disorders is meditation. Medication is the common treatment for the disorder, but meditation is a great help too.
Paper bag rebreathing
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. Critics say that this technique can fatally lower oxygenOxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
levels in the blood stream, and increase carbon dioxide
Carbon dioxide
Carbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...
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 and 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.
Increased risk of heart attack and stroke in menopausal women
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 strokeStroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
over the next five years. The researchers believe that panic attacks or more accurately their associated symptoms (chest pain
Chest pain
Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.-Differential...
, shortness of breath
Dyspnea
Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...
) 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. However, the study did not find that isolated cases of panic attacks in patients without panic disorder
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
or agoraphobia
Agoraphobia
Agoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...
would 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. Panic attack symptoms may be masking heart attack warnings and precursors. Chest pain, shortness of breath, unusual exhaustion and other heart attack symptoms should be evaluated by a physician to distinguish panic symptoms from heart disease symptoms.
Limited symptom attack
Many people being treated for panic attacks begin to experience limited symptom attackLimited symptom attack
A Limited Symptom Attack , also referred to as a Limited Symptom Panic Attack , is a milder, less comprehensive panic attack with fewer than 4 panic related symptoms being experienced . For example, a sudden episode of intense dizziness or trembling accompanied by fear that something terrible is...
s. These panic attacks are less comprehensive with fewer than 4 bodily symptoms being experienced.
It is not unusual for panic disorder sufferers to experience only one or two symptoms at a time, such as vibrations in their legs, or 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 truly does not require four or more symptoms to all be present at the same time. Pure causeless panic and the racing heart beat the panic causes are quite sufficient to indicate panic attack.
External links
- American Psychological Association: Answers to Your Questions About Panic Disorder
- Anxiety Disorders Association of America Information for families, clinicians and researchers
- Anxiety Disorders on the United States Surgeon General Website