Autonomic crises, or panic attacks - Symptoms

The main feature of vegetative manifestations is the presence of both subjective and objective disorders and their polysystemic nature. The most common symptoms of vegetative crises are: in the respiratory system - difficulty breathing, shortness of breath, a feeling of suffocation, a feeling of lack of air, etc.; in the cardiovascular system - discomfort and pain in the left half of the chest, palpitations, pulsation, a feeling of interruptions, a sinking heart.

Less frequently, gastrointestinal disorders occur - nausea, vomiting, belching, discomfort in the epigastric region. As a rule, dizziness, sweating, chill-like hyperkinesis, hot and cold waves, paresthesia and cold hands and feet are observed at the time of the crisis. In the overwhelming majority of cases, attacks end in polyuria, and sometimes in frequent loose stools.

A special study of objective changes (of the vegetative sphere of patients at the time of the paroxysm) revealed a change in complexion, a change in pulse rate (a slowdown to 50 and an increase to 130 per minute), fluctuations in blood pressure - either an increase to 190-200/110-115 mm Hg, or, much less frequently, a decrease to 90/60 mm Hg, a change in dermographism, a violation of the pilomotor reflex, a disorder of thermoregulation, a change in the orthoclinostatic test, and a violation of the Aschner reflex.

Thus, vegetative disorders at the moment of crisis are polysystemic and have both subjective and objective character, and often there is a dissociation between the subjective manifestation of vegetative disorders and their severity during objective registration. The reason for such dissociation is primarily psychological factors. It was shown that in healthy and sick people the frequency of complaints correlates with the factor of neuroticism; a more in-depth analysis allowed to identify psychological factors that contribute to the subjective manifestation of objective vegetative shifts (agravators) and its reduction (minimizers).

Thus, for patients who are more inclined to feel and express vegetative shifts in complaints (agravators), the following personality traits are characteristic:

1. concern about one's own body and the adequacy of physiological functions;
2. the release of anxiety and tension into physical symptoms;
3. baseline anxiety;
4. discomfort in uncertain and difficult situations;
5. excessive sensitivity to criticism;
6. drama and artistry;
7. a tendency to form particularly close bonds with others;
8. unstable thinking;
9. generalized fearfulness (especially vulnerable to real or imagined anxiety).

At the same time, minimizers:

1. evaluate themselves as independent and autonomous;
2. internally meaningful personalities;
3. have a high level of aspirations;
4. productive;
5. care about the adequacy of their own personality on a conscious and unconscious level;
6. type of psychological defense - denial, repression, isolation;
7. in their behavior they strictly correlate themselves with their own personal standard;
8. try to follow the chosen path;
9. introspectively treat themselves as an object;
10. ) are able to penetrate into their own motives and behavior;
11. are effective in cases of anxiety and conflict.

Emotional and affective components of vegetative paroxysm

Emotional and affective components of vegetative paroxysm may also differ in both character and degree of expression. Most often, at the time of an attack, especially at the onset of the disease, in the first crises, patients experience a pronounced fear of death, reaching the degree of affect. Often, in the further course of crises, fear loses its vital character and is transformed either into fears with a specific plot (fear of a heart accident, heart attack, stroke, fall, fear of going crazy, etc.), or into a feeling of unaccountable anxiety, internal tension, etc. In some cases, with the further course of the disease, a successful resolution of the crisis leads to the deactualization of fear, and over time, fear and anxiety almost completely regress.

Anxiety-phobic syndromes, however, do not exhaust the emotional phenomenology of the crisis: paroxysms are observed during which patients experience melancholy, hopelessness, depression, cry, feel a sense of self-pity, etc. In rare cases, during the crisis, pronounced aggression and irritation towards others, especially towards loved ones, arise, and the difficulty of coping with these emotions forces patients to seek solitude.

Finally, it should be noted that in a number of cases, from the very beginning and throughout the course of the disease, crises are not accompanied by any distinct emotional states. Experimental data (video monitoring) have shown that one and the same patient may experience vegetative crises (objectively recorded) both with and without emotional phenomena.

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Cognitive disorders in the structure of vegetative crisis

Cognitive disorders in the structure of a crisis are most often described by patients as a "feeling of derealization", "headache", a feeling of distant sounds, "like in an aquarium", "pre-fainting state". Close to these phenomena are the feeling of "instability of the surrounding world" or "oneself in this world", non-systemic dizziness, etc.

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Functional neurological symptoms of panic attack

Functional neurological symptoms relatively often appear in the structure of vegetative-vascular crises, and their number and severity can vary significantly. As a rule, we are talking about such phenomena as "a feeling of a lump in the throat", "aphonia", "amaurosis", "mutism", sometimes it is "a feeling of numbness or weakness in the limbs", more often in the arm and more often on the left, however, at the height of the attack, sometimes "the entire left half of the body is taken away". During the crisis, individual hyperkinesis, convulsive and muscle-tonic phenomena sometimes occur - this is an increase in chills to the degree of tremor, "twisting of the arms", stretching, twisting of the arms and legs, "a feeling of the need to stretch the body", turning into elements of a "hysterical arc". During the attack, the gait of patients often changes according to the type of psychogenic ataxia. All of the listed symptoms are inconstantly interspersed in the structure of the vegetative crisis and do not determine its clinical picture.

Thus, as follows from the above, in the structure of the crisis, along with vegetative symptoms, psychopathological and emotional-affective phenomena are practically obligatory, which allows us to define it rather as a psycho-vegetative or emotional-vegetative crisis - concepts that are essentially close to the term "panic attack".

The symptoms of vegetative crises may vary significantly in both their severity and the representation of various phenomena, and these differences are often observed in the same patient. Thus, a distinction is made between major (extensive) attacks, when the structure of the paroxysm contains four or more symptoms, and minor, or abortive, attacks, during which less than four symptoms are observed. Practice shows that major crises occur much less frequently than minor ones: their frequency fluctuates from once every few months to several times a week, while minor attacks can occur up to several times a day. A combination of minor attacks with major ones is more common, and only a few patients experience only major attacks.

As already mentioned, the structure of vegetative crises can vary significantly depending on the dominance of certain psychovegetative patterns. With a certain degree of conventionality, we can talk about "typical" vegetative crises, in the structure of which vivid vegetative disorders spontaneously occur - suffocation, pulsation, chills, a feeling of emptiness in the head, etc., accompanied by a pronounced fear of death, fear of a heart catastrophe, fear of going crazy. Probably, it is this category of crises that corresponds to the term "panic attack" accepted in foreign literature. However, clinical practice shows that in their pure form such "typical" paroxysms are relatively rare. As a variant of the course, they more often determine the onset of the disease.

Among other variants of paroxysm, the so-called hyperventilation attacks should be noted first of all, the main and leading feature of which is hyperventilation disorders. The core of the hyperventilation crisis is a specific triad - increased breathing, paresthesia and tetany. As a rule, the attack begins with a feeling of lack of air, difficulty breathing, a feeling of a lump in the throat that interferes with breathing, while rapid or deep breathing is observed, which in turn causes respiratory alkalosis and its characteristic clinical signs: paresthesia in the arms, legs, perioral area, a feeling of lightness in the head, a feeling of compression and pain in the muscles of the arms and legs, convulsive contractions in them, the appearance of carpopedal spasms.

In a hyperventilation crisis, as in a “typical” vegetative-vascular paroxysm, there are vegetative phenomena: tachycardia, discomfort in the heart area, dizziness, a feeling of lightness in the head, gastrointestinal tract disorders (nausea, vomiting, diarrhea, bloating, aerophagia, etc.), chill-like hyperkinesis and polyuria. Emotional phenomena are most often represented by a feeling of restlessness, anxiety, fear (usually death), but there may be melancholy, depression, irritation, aggression, etc. Thus, it is obvious that the clinical picture of a hyperventilation crisis is essentially very close to the picture of a vegetative-vascular paroxysm: this is probably due to the proximity of pathogenetic mechanisms. At the same time, from a pragmatic point of view (specific therapeutic approaches), it seems appropriate to distinguish hyperventilation crises from VC.

Phobic panic attacks

The peculiarity of this group of paroxysms is, first of all, their provocation by a specific phobic stimulus and their occurrence in a situation potentially dangerous for the occurrence of this phobia. In such paroxysms, the leading fear is a specific plot, which is already overgrown with vegetative phenomena. For example, due to a possible catastrophe with the heart, in patients in a situation of excessive load, when it is necessary to be left alone, with emotional overload, etc., the fear of death increases sharply, which is accompanied by pallor, difficulty breathing, tachycardia, sweating, heaviness in the left half of the chest, frequent urination, etc. Often, such an attack can also be caused by mental reproduction of a threatening situation.

The nature of phobias can be very diverse - fear of crowds, fear of open spaces, fear of falling, fear of blushing, fear of inappropriate behavior, etc. One of the frequent phenomena accompanying these fears is non-systemic dizziness, a feeling of "unsteady gait", "instability of the surrounding world". It should be noted that one of the diagnostic difficulties in these situations is that in presenting complaints, patients, as a rule, focus on the vestibular-vegetative manifestations of the paroxysm, and the phobic component remains in the shadows. This often leads to the fact that patients are unsuccessfully treated for years for vestibular disorders of vascular genesis, without receiving adequate pathogenetic therapy.

Conversion crises of panic attack

Conversion crises are characterized by the fact that their structure includes functional neurological phenomena - weakness in the arm or half of the body, numbness, loss of sensitivity, aphonia, mutism, sharp deterioration of vision up to amaurosis, cramps in the limbs, arching of the body, etc. In paroxysms of this type, pain phenomena appear in different parts of the body, they often have senestopathic elements: pains of the "piercing", "burning", "head burning" type, a feeling of "fluid flowing", "goosebumps", spasms, etc. These phenomena are revealed against the background of typical vegetative symptoms. A characteristic feature of the attacks is the absence of fear and anxiety. In most cases, patients do not feel any mood changes at all, and sometimes report internal tension, a feeling that "something will explode in the body", melancholy, depression, a feeling of self-pity. Often, after the attacks stop, patients experience a feeling of relief and relaxation.

The types of paroxysms considered above are united by a constellation of emotional and vegetative phenomena, which allows us to consider them as variants of one psycho-vegetative syndrome. Certain evidence of the validity of such a view is the possible transitions of one type of paroxysms to another as the disease progresses, as well as the coexistence of different types of paroxysms in one patient.

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The most common symptoms during a vegetative crisis

• feeling of shortness of breath or difficulty breathing;
• strong heartbeat or pulsation throughout the body;
• sweating;
• numbness or a crawling sensation in the limbs or face;
• sensation of a "lump in the throat";
• heat or cold waves;
• chills or trembling;
• a feeling of weakness in an arm or leg;
• discomfort in the left half of the chest;
• feeling of dizziness, unsteadiness;
• a feeling of unreality of the surrounding world;
• deterioration of vision or hearing;
• a feeling of nausea and faintness or sudden weakness;
• pronounced fear of death;
• cramps in the arms or legs;
• discomfort in the stomach or intestines;
• feeling of internal tension;
• fear of going crazy or committing an uncontrollable act;
• nausea, vomiting;
• frequent urination;
• loss of speech or voice;
• loss of consciousness;
• a feeling that the body is stretching, bending;
• change in gait;
• mood changes (anger, melancholy, anxiety, aggression, irritability).

Clinical characteristics of the intercrisis period In the period between crises, the vast majority of patients experience vegetative dystonia within the framework of the psychovegetative syndrome, while its severity varies significantly from minimal, when patients in the interictal period consider themselves practically healthy, to maximum, at which patients find it difficult to draw a clear line between a crisis and an intercrisis state.

Symptoms of vegetative disorders in the intercrisis period

• in the cardiovascular system - cardio-rhythmic, cardialgic, cardio-senestopathy syndromes, as well as arterial hyper- and hypotension or amphotonia;
• in the respiratory system - shortness of breath, feeling of suffocation, difficulty breathing, feeling of lack of air, etc.;
• in the gastrointestinal system - dyspeptic disorders (dry mouth, nausea, vomiting, belching, etc.), abdominal pain, dyskinetic phenomena (flatulence, rumbling), constipation, diarrhea, etc.;
• in the thermoregulatory and sweating systems - non-infectious subfebrile temperature, periodic chills, diffuse or local hyperhidrosis, etc.;
• in vascular regulation - distal acrocyanosis and hypothermia, vascular cephalgia, hot flashes; in the vestibular system - dizziness, feeling of instability;
• in the muscular system - aponeurotic cephalalgia, muscular-tonic phenomena at the cervical, thoracic and lumbar levels, manifested by algia and arthralgia. For a detailed description of the symptoms of vegetative dystonia syndrome, see Chapter 4.

Clinical observations and psychometric studies (MIL and Spielberger tests) made it possible to identify the following emotional-psychopathological syndromes in patients with autonomic crises: anxiety-phobic, anxiety-depressive, asthenodepressive, hysterical and hypochondriacal.

In the first case, the interictal period was dominated by an anxious mood background, as a rule, these were concerns for the fate and health of loved ones, anxious premonitions, more often - anxious anticipation of an attack and fear of its recurrence. Often, a stable feeling of fear was formed after the first paroxysm and concerned the situation in which it arose. This is how the fear of traveling on the subway, bus, fear of being at work, etc. was formed. In the event of an attack at home in the absence of loved ones, a fear of being alone at home was formed. As the disease progressed, the fears generalized, covering more and more situations in which the patient habitually existed.

Avoidant or restrictive behavior of varying degrees of severity gradually developed. When it was most severe, patients experienced complete social maladjustment: they were practically unable to move around the city independently, or stay home alone; even when visiting a doctor, such patients always came accompanied by their loved ones. When restrictive behavior was moderately severe, patients tried to avoid situations that could potentially trigger an attack: they refused certain types of transport, did not stay home alone, etc. When restrictive behavior was minimally severe, they tried to avoid situations that could trigger an attack (stuffy rooms, crowds, metro, etc.). However, if necessary, they could still overcome themselves.

Our studies have shown that the maximum degree of restrictive behavior is more often observed in patients with pronounced anxiety-phobic components of the crisis. It was found that this category of patients has the greatest psychological maladaptation, which was judged by the height of the MIL profile. All this probably allows us to consider the degree of expression of restrictive behavior as one of the important clinical criteria for the severity of the disease, which is especially important when choosing the nature of therapy and adequate doses of pharmacological drugs.

The emergence of secondary fears and restrictive behavior is considered by many authors as the formation of agoraphobic syndrome, i.e. fear of open spaces. It seems that in this case we are talking about a broader interpretation of the term "agoraphobia". Based on the frequent combination of agoraphobia with crises or panic attacks, some authors consider it more adequate to separate agoraphobia from the category of phobic disorders and classify it as an anxiety disorder.

Currently, there is a tendency to distinguish between generalized anxiety and anticipatory anxiety in the interictal period. The criteria for anxiety are proposed to be the presence of relatively constant anxiety for at least a 3-week period and at least one of the following criteria:

1. difficulty falling asleep;
2. sweating, redness, dizziness, internal trembling, shallow (shortened) breathing;
3. muscle tension or tremors, constant worry about the future;
4. fussiness.

If the patient expected a crisis and thought about a future crisis or encountered a phobic situation when a crisis could occur, then we are talking about phobic anxiety. If the anxiety existed without connection with the crisis or its expectation, then the presence of generalized anxiety is assumed.

Phobic syndrome could exist in the form of social and other phobias (fear of going crazy, fear of falling in the presence of people, fear of a heart attack, fear of having a tumor, etc.).

Asthenodepressive syndrome manifests itself as asthenic symptoms (increased fatigue, lethargy, general weakness, irritability, rapid exhaustion, difficulty concentrating and concentrating, memory loss, etc.) and depressive symptoms (loss of pleasure or interest in normal activities, decreased mood or dysphoria, increased tearfulness, a feeling of self-flagellation or increased and inadequate guilt, thoughts of death and suicide). Depressive syndrome sharply reduces the social activity of patients: patients limit contacts with friends, lose interest in movies, literature, the circle of interests is concentrated around the state of health and symptoms of the disease. Often this leads to hypochondriacal development of symptoms, even greater immersion in the disease.

Hysterical disorders in the intercrisis period are usually reduced to somatic and behavioral demonstrative manifestations - these are urgent pain syndromes, transient functional-neurological disorders (pseudoparesis, astasia-abasia, mutism, amaurosis, aphonia, demonstrative seizures, etc.).

Clinical features of the course of vegetative crises

Clinical analysis allows us to identify at least three variants of the onset of vegetative crises.

The first option: a vegetative crisis with pronounced vegetative symptoms and vivid vital fear occurs suddenly in the midst of complete health, and it can be spontaneous or provoked by some factors (stressful events, excessive physical exertion, alcohol excesses, minor surgical interventions with anesthesia, etc.). As a rule, in these cases, patients remember the exact date of the onset of the disease. Spontaneous crises at the onset occur 3-4 times more often than provoked ones. The division of crises into spontaneous and provoked is to a certain extent arbitrary, since with a detailed clinical analysis of anamnestic data in patients with spontaneous crises, as a rule, it is possible to identify an event or situation that led to the emergence of the crisis. In this case, the concept of "spontaneity" most likely reflects the patient's ignorance of the cause of the crisis.

Second option. The debut is gradual:

• against the background of asthenodepressive disorders, vegetative symptoms gradually become more complex, manifesting themselves as abortive crises without emotional coloring, and when exposed to additional harmful factors, a full-blown emotional-vegetative crisis develops;
• in the presence of anxiety-phobic syndrome, periods of increased anxiety or phobias are accompanied by abortive crises, and then, just as in the previous case, additional harm leads to the development of a bright, full-blown vegetative crisis.

The third option. The first full-blown vegetative crisis occurs suddenly, but against the background of already existing anxiety or depressive disorders. According to the literature, clinical manifestations of anxiety or depression precede the first crisis in 1/3 of cases.

Thus, the first vegetative crisis can arise suddenly in the midst of complete health or against the background of an existing psychovegetative syndrome, or develop gradually, passing through the stages of abortive crises, and when exposed to additional harmful factors, result in a full-blown vegetative-vascular crisis.

The first full-blown vegetative-vascular crisis is a significant event in the patient's life and disease history. It should be mentioned that almost every person in life has experienced a vegetative crisis of varying severity, usually in situations associated with extreme emotional or physical stress, after a long-term debilitating illness, etc. However, in these cases we are talking about stress-related psychophysiological reactions, not about a disease, and only the repetition of crises, the formation of vegetative dystonia syndrome and psychopathological syndromes allow us to talk about the development of the disease.

It is believed that the development of psychovegetative syndrome with crises is possible if the patient experiences at least 3 crises within 3 weeks, and the crises are not associated with a life-threatening situation and severe physical stress. However, it is necessary to recognize some conventionality of such division, since the frequency of attacks is very variable - from several per day or per week to one or less per six months. At the same time, the doctor often encounters a situation when full-blown (or major) crises are very rare, and abortive (minor) ones - almost daily. Probably, the recurrence of crises, regardless of frequency, is a criterion for the disease, and a single crisis that occurs in extreme conditions cannot indicate the onset of the disease.

An important factor for the further course of the disease is the patient's assessment of the first crisis. As special studies have shown, only 16% of patients assessed the first crisis as a manifestation of anxiety or "nervousness", while the rest assessed it as a "heart attack", "the onset of madness", "the onset of some somatic disease", "infection", "brain tumor", "stroke". For the course of the disease, this assessment of the first crisis turned out to be very significant, since where it was realistic and close to the truth, secondary fears and restrictive behavior developed much later than in cases where patients assessed the first crisis as a somatic disease. It was also established that in cases where patients could provide reasons that provoked the first crisis, agoraphobic syndrome developed much later than in patients in whom the first crisis arose spontaneously and was inexplicable to the patient.

During the course of the disease, a certain dynamics of both the vegetative crises themselves and the intercrisis period were observed. Touching on the dynamics of crises, it can be noted that if the disease debuted with a full-blown vegetative crisis with pronounced vital fear, vegetative disorders (increased blood pressure, tachycardia), the successful resolution of crises led to the deactualization of fear, while the severity of vegetative shifts decreased in parallel. Anxiety and fear were replaced by feelings of melancholy, a feeling of self-pity, depression, etc. Often, crises with similar emotional-affective phenomena arose at the onset of the disease and throughout the disease differed only in the degree of severity. Usually, during the course of the disease, the fear of death became more specific, which led to specific phobias at the time of the crisis, sometimes fears were clearly associated with certain vegetative-somatic symptoms of the crisis. Thus, an increase in blood pressure was associated with the fear of stroke, irregular heartbeats or discomfort in the heart area formed cardiophobia, etc.

In cases where the disease debuted with specific phobias, accompanied by vegetative shifts, spontaneous full-blown crises could appear during the course of the disease, alternating with attacks of fear.

Vegetative crises with pronounced hyperventilation disorders (hyperventilation crises) at the onset of the disease often included pronounced anxiety and fear of death, which gradually regressed during the course of the disease, while functional-neurological phenomena appeared in the clinical picture of the crisis (tonic convulsions, different in pattern from tetanic, mutism, mono- and hemiparesis, elements of hysterical arc, ataxia when walking, etc.). In these cases, the crises in their structure approached demonstrative seizures, which allowed them to be classified as a vegetative crisis of a conversion nature. In some cases, hyperventilation, fear and anxiety could coexist with functional-neurological phenomena in the structure of a vegetative crisis.

A certain correlation could be noted between the emotional-affective phenomena of the crisis and the nature of emotional and behavioral disorders in the interictal period. A typical variant of the interictal period was anxious anticipation of the crisis, the formation of secondary fears and restrictive behavior. In those cases when anxiety and fear were absent in the picture of the crisis, as a rule, anxious anticipation of attacks was not formed in the interictal period, there were no secondary fears and restrictive behavior. In the interictal period, in patients with crises accompanied by hyperventilation disorders, emotional syndromes of an anxious-hysterical, anxious-depressive and hypochondriacal nature were observed, in patients with conversion crises - hysterical and asthenodepressive syndromes.

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