Panic attacks and panic disorder

A panic attack is a sudden, brief episode of intense discomfort or fear, accompanied by somatic or cognitive symptoms. Panic disorder consists of recurrent panic attacks, usually accompanied by fear of recurrence or avoidance behavior that might trigger an attack. Diagnosis is based on clinical findings. Isolated panic attacks may not require treatment. Treatment for panic disorder includes medication, psychotherapy (e.g., exposure therapy, cognitive behavioral therapy), or both.

Panic attacks are quite common, affecting approximately 10% of the population in a given year. Most people recover without treatment, although some develop panic disorder. Panic disorder is less common, affecting 2-3% of the population in a 12-month period. Panic disorder usually begins in late adolescence or early adulthood, and affects women 2-3 times more often than men.

Symptoms of Panic Attacks and Panic Disorders

A panic attack begins suddenly and includes at least 4 of 13 symptoms. Symptoms usually peak within 10 minutes, then gradually disappear over several minutes, leaving virtually no signs that a doctor can observe. Despite the discomfort, sometimes very severe, panic attacks are not life-threatening.

Symptoms of a Panic Attack

Cognitive

• Fear of death
• Fear of going crazy or losing control
• A feeling of unreality, strangeness, detachment from the surroundings

Somatic

• Chest pain or discomfort
• Dizziness, unsteadiness, weakness
• Feeling of suffocation
• Feeling hot or chilly
• Nausea or other discomfort in the stomach area
• Numbness or tingling sensation
• Heart palpitations or rapid pulse
• Feeling short of breath or having difficulty breathing
• Excessive sweating
• Tremors and shaking

Panic attacks may occur in other anxiety disorders, especially in situations that are associated with the underlying symptoms of the disorder (for example, a person with a fear of snakes may develop panic attacks when they see a snake). In true panic disorder, some panic attacks occur spontaneously.

Most patients with panic disorder experience anxiety, fear of another attack (anticipatory anxiety), and avoid places and situations where panic has occurred in the past. Patients with panic disorder often believe that they have a serious heart, lung, or brain disorder; they frequently visit their family doctor or seek help in emergency departments. Unfortunately, in these situations, the focus is on somatic symptoms, and the correct diagnosis is often not established. Many patients with panic disorder also have symptoms of major depression.

A diagnosis of panic disorder is made after ruling out medical conditions that may have similar symptoms and meeting the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).

Treatment of panic attacks and panic disorders

Some patients recover without any treatment, especially if they continue to confront situations in which panic attacks occur. In other patients, especially those left untreated, the disease becomes chronic and intermittent.

Patients should be advised that treatment usually helps control symptoms. If avoidance behavior has not developed, then explanatory talk about anxiety and support in returning to and staying in places where panic attacks occurred may be sufficient. However, in situations of long-term disorder, with frequent panic attacks and avoidance behavior, drug therapy in combination with more intensive psychotherapeutic interventions is necessary.

Many medications can prevent or significantly reduce anticipatory anxiety, avoidance, number and intensity of panic attacks. Different classes of antidepressants - SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin modulators, tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs) - are approximately equally effective. At the same time, SSRIs and SNRIs have certain advantages over other antidepressants due to a more favorable side effect profile. Benzodiazepines act faster than antidepressants, but their use is likely to develop physical dependence and such side effects as drowsiness, ataxia, memory impairment. Antidepressants are often prescribed in combination with benzodiazepines at the beginning of treatment, followed by gradual withdrawal of benzodiazepines after the effect of the antidepressant appears. Panic attacks often recur after stopping the medication.

Various psychotherapy methods are effective. Exposure therapy, in which the patient confronts his or her fears, helps reduce fear and complications caused by avoidance behavior. For example, a patient who fears fainting is asked to spin in a chair or hyperventilate to induce the sensation of fainting, thus demonstrating to the patient that the sensation of fainting does not yet lead to fainting. Cognitive behavioral therapy involves teaching the patient to recognize and control distorted thoughts and false beliefs and helps change the patient's behavior to more adaptive ones. For example, patients who describe an increased heart rate or a feeling of suffocation in certain places or situations and are afraid that they will have a heart attack are told that their anxiety is unfounded and that they should respond with slow, controlled breathing or other relaxation-inducing techniques.