Autonomic crises, or panic attacks - Causes

Special epidemiological studies, the sample size of which reached 3000 people, convincingly showed that panic attacks are most common in the age group from 25 to 64 years, with some predominance in the group of 25-44 years, and least common in the age group over 65 years. Panic attacks that occur in elderly patients (over 65 years) are usually poorer in symptoms, there may be only 2-4 symptoms in a paroxysm, but the emotional components are usually quite pronounced. Characterizing elderly patients with panic attacks, one can note their physical, intellectual and emotional integrity, which is probably a necessary prerequisite for the occurrence of panic attacks in old age. Sometimes it is possible to find out that panic attacks in old age are a relapse or exacerbation of panic attacks observed in the patient from a young age.

Gender and Panic Disorders

The data of most epidemiological studies show a predominance of women over men in patients with PR. Our studies, as well as literature data, indicate a 3-4-fold predominance of women over men among patients with panic attacks. In an attempt to explain the predominance of women in PR, the importance of hormonal factors is discussed, which is reflected in the data of relevant studies on the relationship between the onset and course of PR and hormonal changes. On the other hand, it cannot be ruled out that the greater representation of women in PR is associated with psychosocial factors, namely, a different socio-economic level, reflecting the modern social role of women.

At the same time, the lower representation of men may be associated with the transformation of anxiety disorders into alcoholism. There are reports that almost half of men suffering from panic attacks have a history of alcohol abuse. It is suggested that alcoholism is a secondary manifestation of anxiety disorders, i.e., patients with panic attacks use alcohol as a "self-medication" for anxiety symptoms.

Duration of paroxysms

One of the diagnostic criteria for panic attacks is the duration of the attack, and although spontaneous panic attacks can last for an hour, the duration of most attacks is generally determined by minutes. Most patients estimate the duration of the attack by the time required to stop it (calling an ambulance, the effect of taking a drug). An analysis of the patients we studied showed that almost 80% of patients with panic attacks estimated the duration of most attacks in minutes and about 20% in hours. The duration of paroxysms with hysterical symptoms (FNS) was most often estimated in hours, and in a third of patients they could last for 24 hours, often occurring serially. The latter showed a significant range in the duration of attacks - from minutes to 24 hours.

Daily distribution of panic attacks (panic attacks during sleep and wakefulness)

An analysis of the literature and our own data show that most patients have experienced a panic attack during their nighttime sleep, but only 30-45% of patients have repeated episodes. Nighttime paroxysms can occur before patients fall asleep, wake them up immediately after falling asleep, appear in the first and second half of the night, arise from sleep or after some interval after waking up in the middle of the night. According to our (colleague M. Yu. Bashmakov, who examined 124 patients with panic attacks, more than half of the patients (54.2%) experienced both sleep and wakeful panic attacks simultaneously, and only 20.8% had exclusively sleep panic attacks. It is necessary to distinguish between a sleep panic attack and frightening dreams, due to which the patient wakes up, experiencing a feeling of fear and accompanying vegetative symptoms. These phenomena, despite their external similarity, are related to different stages of sleep. It has been established that sleep panic attacks occur during slow sleep, usually in the late period of stage 2 or early - 3 stage of sleep, while frightening dreams usually appear in the REM phase. According to Mellman et al. (1989), patients with sleep panic attacks more often than patients with wakeful panic attacks report that a relaxed state can be provoking factor for panic attacks. For patients with panic attacks of sleep, the following sequence of events can be considered as characteristic:

1. the appearance of panic attacks in sleep;
2. the emergence of a fear of sleep caused by them;
3. delaying bedtime and periodic sleep deprivation;
4. the emergence of periods of relaxation associated with sleep deprivation and the occurrence of panic attacks associated with both sleep deprivation and relaxation;
5. further increase in fear of sleep and restrictive behavior.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ]

Social maladjustment

Despite the relativity of the concept of social maladjustment, which does not take into account mainly family maladjustment, there are nevertheless objective criteria for assessing the degree of social maladjustment. The latter include: leaving work, a disability group with the possibility of financial support, the need for urgent medical care and hospitalization. In addition, it is necessary to take into account the impossibility of independent movement outside the home, the impossibility of staying alone at home, i.e. the degree of agoraphobic syndrome and restrictive behavior that determine social maladjustment.

Special studies conducted on large contingents showed that up to 30% of patients with PR resorted to emergency care, while in the population this figure is 1%. 35.3% of patients with PR were treated in hospital for emotional disorders, and 20% for somatic problems. 26.8% of patients with PR used financial support in the form of pensions or disability benefits.

Our own study of patients with various types of paroxysms showed that with the appearance of an atypical radical, the degree and quality of social maladjustment changes, which is probably associated with the personal premorbid, against which PA develops. In patients with atypical panic attacks (At.PA) and demonstrative seizures (DS), the degree of social maladjustment increases significantly, i.e. as the atypical radical increases in a paroxysm, social maladjustment also increases, and in the case of atypical panic attacks, "leaving work" and "disability group" are equally represented, while in the case of DS, rent-based attitudes in the form of "disability group" prevail. In the other three groups, social maladjustment was observed significantly more often, and it is obvious that if patients with DS received secondary benefits in the form of material, and possibly moral compensations ("role of the patient"), then patients in the groups of atypical panic attacks and Crit. - PR. They preferred not to work temporarily, not only not receiving social benefits, but often to the detriment of their financial situation.

Although in clinical practice and in the literature there is a concept of a spontaneous (unprovoked) crisis, or, as it is also called, a “crisis against a clear sky”, nevertheless, as a rule, this more often concerns the patient’s ignorance of the cause that provoked the crisis.

Factors that provoke a vegetative crisis (panic attack)

Factors	Importance of factors
	I	II	III
Psychogenic	The situation of the culmination of a conflict (divorce, explanation with a spouse, leaving the family, etc.)	Acute stress (death of loved ones, illness or accident, iatrogenesis, etc.)	Abstract factors that operate through the mechanism of identification or opposition (films, books, etc.)
Biological	Hormonal changes (pregnancy, childbirth, end of lactation, menopause)	Beginning of sexual activity, abortions, taking hormonal drugs	Menstrual cycle
Physiogenic	Alcoholic excesses	Meteotropic factors, insolation, excessive physical exertion, etc.

In clinical practice, as a rule, there is a constellation of different factors. It is necessary to emphasize the different significance of each of the factors listed in provoking crises. Thus, some of them can be decisive in provoking the first crisis (the culmination of a conflict, the death of a loved one, abortion, excessive alcohol consumption, etc.), while others are less specific and provoke repeated VCs (weather factors, menstruation, emotional and physical stress, etc.).

[ 6 ], [ 7 ]