Vegetative 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 cardiovascular - discomfort and pain in the left side of the chest, palpitations, pulsations, sensations of interruptions, heart sinking.

Less often there are disorders from the gastrointestinal tract - nausea, vomiting, belching, unpleasant sensations in the epigastric region. As a rule, at the time of the crisis, dizziness, sweating, oznobopodobny hyperkinesis, heat and cold waves, paresthesia and coldness of the hands and feet. In the vast majority of cases, attacks result in polyuria, and sometimes with frequent loose stools.

A special study of objective changes (the vegetative sphere of patients at the time of paroxysm) made it possible to detect a change in the color of the face, a change in the pulse rate (slowing down to 50 and increasing to 130 per minute), fluctuations in blood pressure, or a rise to 190-200 / 110-115 mm Hg. Or, much less rarely, a decrease to 90/60 mm Hg. Changes in dermographism, violation of the pilomotor reflex, a disorder of thermoregulation, a change in the orthoclinostatic test, a violation of the Aschner reflex.

Thus, vegetative disorders at the time of crisis are polysystemic and are both subjective and objective, and often there is a dissociation between the subjective manifestation of autonomic disorders and their severity with objective registration. The reason for this dissociation is, first of all, psychological factors. It was shown that in healthy and sick patients the frequency of complaints correlates with the factor of neuroticism; more in-depth analysis has made it possible to identify psychological factors contributing to the subjective manifestation of objective vegetative shifts (agravators) and the reduction of it (minimizers).

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

1. concern for one's own body and adequacy of physiological functions;
2. the output of anxiety and stress in bodily symptoms;
3. initial anxiety;
4. discomfort in uncertain and difficult situations;
5. excessive sensitivity to criticism;
6. drama and artistry;
7. the propensity to form especially close ties with others;
8. unsustainable thinking;
9. generalized timidity (especially vulnerable to real or imagined anxiety).

At the same time, the minimizers:

1. evaluate themselves as independent and autonomous;
2. internally meaningful individuals;
3. have a high level of aspiration;
4. are productive;
5. care for the adequacy of one's own personality on a conscious and unconscious level;
6. type of psychological defense - denial, displacement, isolation;
7. in a manner of behavior they rigidly correlate themselves with their own personal standards;
8. try to follow the chosen path;
9. introspectively treat themselves as an object;
10. ) are able to penetrate their own motives and behavior;
11. effectively act in case of anxiety and conflict.

Emotional-affective components of autonomic paroxysm

Emotional-affective components of autonomic paroxysm also can differ both in nature and in severity. 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 a degree of affect. Often, in the course of further crises, fear loses its vital character and is transformed either into fears with a particular plot (fear of a catastrophe with a heart, heart attack, stroke, fall, fear of going insane, etc.), or into a feeling of unaccountable anxiety, etc. In some cases, in the course of further disease progress, the successful resolution of the crisis leads to the deactivation of fear, and over time, fear and anxiety almost completely regress.

The anxious-phobic syndromes, however, do not exhaust the emotional phenomenology of the crisis: paroxysms are observed, during which the patients experience anguish, despair, depression, cry, feel a sense of self-pity, etc. In rare cases, during a crisis there is a pronounced aggression, irritation towards others, especially close ones, and the difficulty of coping with these emotions causes 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 illness, crises are not accompanied by any distinct emotional states. Experimental data (video monitoring) showed that one and the same patient can have vegetative crises (objectively recorded) with both emotional phenomena and without them.

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

Cognitive disorders in the structure of vegetative crisis

Cognitive disorders in the structure of the crisis are most often described by patients as "a sense of derealization," "faintness in the head," a sense of removal of sounds, "like in an aquarium," a "pre-stupor state." Close to these phenomena are the sensation of "the instability of the surrounding world" or "myself in this world," of nonsystemic vertigo, etc.

[6], [7], [8], [9], [10],

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 "the feeling of a coma in the throat", "aphonia", "amavroz", "mutism", sometimes it is "a feeling of numbness or weakness in the limbs," more often in the hand and more often on the left; the height of the attack is sometimes "taken away the entire left half of the body." During the crisis sometimes there are some hyperkinesis, convulsive and muscular-tonic phenomena - this is an increase in chills to the degree of tremor, "hand twisting", stretching, twisting arms and legs, "feeling the need to stretch the body," turning into the elements of the "hysterical arc." In the period of an attack, the gait of patients often changes according to the type of psychogenic ataxia. All these symptoms are interspersed in the structure of the vegetative crisis and do not determine its clinical picture.

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

Symptoms of vegetative crises can vary significantly both in severity and in the representation of various phenomena, and these differences are often observed in one patient. Thus, large (unfolded) seizures are distinguished when in the structure of paroxysm there are four symptoms or more, and small, or abortive, seizures, during which there are less than four symptoms. Practice shows that large crises occur much less frequently than small ones: their frequency varies from 1 time in several months to several times a week, while small attacks can occur up to several times a day. More often there is a combination of small seizures with large ones, and only in large patients there are only large seizures.

As already mentioned, the structure of vegetative crises can vary significantly depending on the dominance of one or another psycho-vegetative pattern. With a certain degree of conventionality, one can speak of "typical" vegetative crises, in the structure of which spontaneous bright vegetative disorders occur-choking, pulsation, chills, a feeling of emptiness in the head, etc., accompanied by a pronounced fear of death, fear of catastrophe with the heart, fear of getting off crazy. Probably, it is this category of crises that corresponds to the term "panic attack" adopted in the foreign literature. However, clinical practice shows that in its pure form such "typical" paroxysms are relatively rare. As a variant of the current, they often determine the debut of the disease.

Among other variants of paroxysm, it is necessary to note first of all the so-called hyperventilation seizures, the main and leading feature of which are hyperventilation disorders. The core of the hyperventilation crisis is a specific triad - enhanced breathing, paresthesia and tetany. As a rule, the attack begins with a feeling of lack of air, difficulty breathing, a feeling of coma in the throat, which prevents breathing, while there is rapid or deep breathing, which in turn causes respiratory alkalosis and its characteristic clinical signs: paresthesias in hands, feet, perioral a feeling of lightness in the head, a feeling of contraction and pain in the muscles of the hands and feet, convulsive contractions in them, the appearance of carpopedal spasms.

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

Phobic attacks of panic attack

A feature of this group of paroxysms is primarily their provocation by a specific phobic stimulus and occurrence in a situation potentially dangerous for the onset of this phobia. In such paroxysms, the leading is fear with a specific plot, which is already overgrown with vegetative phenomena. For example, because of a possible catastrophe with the heart in patients in situations of excessive workload, if necessary, remain alone, with emotional overload, etc., the fear of death sharply increases, accompanied by blanching, difficulty breathing, tachycardia, sweating, weight in the left half of the thoracic cells, frequent urination, etc. Often, such an attack can also be caused by the mental reproduction of a threatening situation.

The nature of phobias in this case can be very diverse - fear of the crowd, fear of open spaces, fear of falling, fear of redness, fear of an inadequate act, etc. One of the frequent phenomena accompanying these fears is non-systemic dizziness, a sense of "unstable gait," " the instability of the world. " It should be noted that one of the diagnostic difficulties in these situations is that in the presentation of complaints, patients tend to focus on the vestibular vegetative manifestations of paroxysm, and the phobic component remains in the shadows. Often this leads to the fact that patients for years are unsuccessfully treated for vestibular disorders of vascular origin, not receiving adequate pathogenetic therapy.

Conversion crises of panic attack

Conversion crises are characterized by the fact that functional-neurological phenomena are observed in their structure - weakness in the arm or in half of the body, numbness, loss of sensitivity, aphonia, mutism, sharp deterioration of vision up to amaurosis, convulsions in limbs, bending of the body, etc. In paroxysms of this type, there are painful phenomena in different parts of the body, often they have senestopathic elements: pains such as "piercing", "burning", "baking the head", a feeling of "transfusion", "running chills", spasms, etc. . These phenomena are revealed against the background of typical vegetative symptoms. A characteristic feature of seizures is the absence of fear and anxiety. In most cases, patients do not feel any mood changes at all, and sometimes they report internal tension, a feeling that "something will explode in the body," about longing, depression, a feeling of self-pity. Often after the cessation of attacks, patients experience a sense of relief, relaxation.

The types of paroxysms considered above unite the constellation of emotional and vegetative phenomena, which allows us to consider them as variants of one psycho-vegetative syndrome. Certain evidence of the legitimacy of this 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.

[11], [12]

The most common symptoms during a vegetative crisis

• feeling of lack of air or shortness of breath;
• heart palpitations or pulsations throughout the body;
• sweating;
• numbness or feeling of "crawling crawling" in the extremities or in the face;
• sensation of a "coma in the throat";
• waves of heat or cold;
• chills or shivering;
• feeling weak in the arm or leg;
• discomfort in the left side of the chest;
• feeling dizzy, unstable;
• a sense of the unreality of the world;
• deterioration of eyesight or hearing;
• sensation of faintness and prematureness or severe weakness;
• a pronounced fear of death;
• cramps in the hands or feet;
• unpleasant sensations in the stomach or intestines;
• feeling of inner tension;
• fear of going insane or doing an uncontrollable act;
• nausea, vomiting;
• frequent urination;
• loss of speech or voice;
• loss of consciousness;
• sensation that the body is stretched out, arched;
• change gait;
• mood changes (anger, depression, anxiety, aggression, irritability).

Clinical characteristics of the intercausal period In the period between crises, in the vast majority of patients, autonomic dystonia is observed within the psycho-vegetative syndrome, and its severity varies significantly from the minimum, when patients in the interictal period consider themselves to be practically healthy, to the maximum, at which patients find it difficult to draw a clear boundary between crisis and intercausal state.

Symptoms of vegetative disorders in intercreep period

• in the cardio-vascular system - cardio-rhythmic, cardial, cardio-senestopatic syndromes, as well as arterial hyper- and hypotension or amphotonia;
• in the respiratory system - shortness of breath, a feeling of suffocation, shortness of breath, a 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 thermoregulation and perspiration systems - noninfectious subfebrile condition, periodic chills, diffuse or local hyperhidrosis, etc .;
• in vascular regulation - distal acrocyanosis and hypothermia, vascular cephalgia, hot flashes; in the vestibular system - dizziness, a sense of instability;
• in the muscular system - aponeurotic cephalgia, muscular-tonic phenomena on the cervical, thoracic and lumbar level, manifested by algic 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 isolate the following emotional-psychopathological syndromes in patients with vegetative crises: anxiety-phobic, anxiety-depressive, asthenodepressive, hysterical and hypochondriacal.

In the first case, during the interictal period, an alarming mood background dominated, as a rule, these were fears for the fate and health of loved ones, anxious forebodings, more often - anxious anticipation of the attack and fear of its recurrence. Often, a stable sense of fear was formed after the first paroxysm and concerned the situation where it arose. So the fear of traveling in the metro, bus, fear of being at work, etc. Was formed. In the event of an attack of a house in the absence of relatives, the fear of one being at home was formed. As the disease progressed, fears were generalized, covering more and more situations in which the patient habitually existed.

Gradually, an avoidance or restrictive behavior of varying degrees of severity was formed. With its maximum severity, complete social disadaptation of the patients ensued: in practice, they could not move around the city on their own, stay alone at home, even on a visit to the doctor, such patients always came with relatives. With an average degree of severity of restrictive behavior, patients tried to avoid situations that could potentially cause an attack: they abandoned certain modes of transport, did not stay at home alone, and so on. With minimal severity of restrictive behavior, they tried to avoid situations that could provoke an attack (stuffy rooms, crowd, metro, etc.). However, if necessary, nevertheless could overcome themselves.

Our studies have shown that the maximum degree of organic behavior is more often observed in patients with severe anxiety-phobic components of the crisis. It was found that this category of patients had the greatest psychological disadaptation, which was judged by the height of the MIL profile. All this, probably, allows to consider the severity 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 regarded by many authors as the formation of an agoraphobic syndrome, that is, the fear of open spaces. It seems that in this case it is a broader interpretation of the term "agoraphobia". On the basis of the frequent combination of agoraphobia with crises or panic attacks, some authors consider it more appropriate to isolate agoraphobia from the phobic disorder heading and refer it to anxiety disorders.

Currently, there is a tendency to allocate in the inter-attack period generalized anxiety and anxiety expectations. Criteria for anxiety suggest that there is a relatively constant anxiety for at least a 3-week period and at least one of the following criteria:

1. the difficulty of falling asleep;
2. sweating, redness, dizziness, inner tremor, superficial (shortened) breathing;
3. muscle tension or tremor, constant concern for the future;
4. fussiness.

If the patient was expecting a crisis and was thinking about a future crisis or encountered a phobic situation, when a crisis could occur, then it is an anxiety trouble. If the alarm existed outside the connection with the crisis or its expectation, then a generalized alarm is assumed.

The phobic syndrome could exist in the form of social and other phobias (fear of insanity, 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, fast exhaustion, difficulty concentrating and concentrating attention, memory loss, etc.) and depressive (loss of pleasure or interest in ordinary activities, mood reduction or dysphoria, increased tearfulness, a sense of self-flagellation or increased and inadequate guilt, thoughts of death and suicide). Depressive syndrome sharply reduces the social activity of patients: patients restrict contacts with friends, cease to be interested in movies, literature, the circle of interests centers around the state of health and symptoms of the disease. Often this leads to a hypochondriacal development of symptoms, an even greater immersion in the disease.

Hysterical disorders in the intercausal period are, as a rule, reduced to somatic and behavioral demonstrative manifestations - urgent pain syndromes, transient functional neurological disorders (pseudo pareosis, astasia-abasia, mutism, amaurosis, aphonia, demonstrative seizures, etc.).

Clinical features of the course of vegetative crises

Clinical analysis makes it possible to distinguish at least three variants of the debut of vegetative crises.

The first option: a vegetative crisis with pronounced autonomic symptoms and vivid vital fear arises suddenly in the midst of full health, while it can be spontaneous or provoked by any factors (stressful events, excessive physical exertion, alcohol excesses, small operative interventions with anesthesia, etc.). As a rule, in these cases, patients accurately remember the date of onset of the disease. Spontaneous crises in the debut occur 3-4 times more often than provoked ones. The division of crises into spontaneous and provoked to a certain extent is conditional, since in 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 a crisis. In this case, the concept of "spontaneity" most likely reflects the ignorance of the patient as to the cause of the crisis.

The second option. The debut is a gradual one:

• on the background of asthenodepressive disorders, the vegetative symptoms gradually become more complicated, manifested by abortive crises without emotional coloring, and under the influence of additional hazards an expanded emotional and vegetative crisis develops;
• in the presence of anxiety and phobic syndrome, periods of increased anxiety or phobias are accompanied by abortive crises, and then, as in the previous case, additional harmfulness leads to the development of a bright unfolded vegetative crisis.

The third option. The first developed vegetative crisis occurs suddenly, but against the background of already existing anxious or depressive disorders. According to the literature, clinical manifestations of anxiety or depression in one-third of cases precede the first crisis.

Thus, the first vegetative crisis can occur suddenly in the presence of complete health or against the background of the already existing psycho-vegetative syndrome or develop gradually, passing the stages of abortive crises, and when exposed to additional hazards, it results in a developed vegetative-vascular crisis.

The first developed vegetative-vascular crisis is a significant event in the history of life and illness of the patient. It should be mentioned that almost every person in life has experienced a vegetative crisis of one kind or another, usually in situations involving extreme emotional or physical impairment, after a prolonged debilitating illness, etc. However, in these cases we are talking about stressful psychophysiological reactions , and not about the disease, and only the recurrence of crises, the formation of the syndrome of autonomic dystonia 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 crises are not associated with a life-threatening situation and severe physical stress. But we must admit some conventionality of this division, since the frequency of seizures is very variable - from several a day or a week to one or less for half a year. At the same time, often a doctor meets with the situation when deployed (or large) crises are very rare, and abortive (small) almost daily. Probably, the frequency of recurrence of crises, regardless of frequency, is the criterion of the disease, and a single crisis that has arisen under extreme conditions can not be indicative of the debut of the disease.

An important factor for the further course of the disease is the assessment of patients with the first crisis. As shown by special studies, only 16% of the patients considered the first crisis as a manifestation of anxiety or "nervousness", while the others regarded it as a "heart attack," "the beginning of insanity," "the onset of somatic illness," "infection" , "Brain tumor", "stroke". For the course of the disease, this evaluation of the first crisis turned out to be very significant, because where it was realistic and close to the truth, secondary fears and restrictive behavior developed much later than in those cases when patients regarded the first crisis as a somatic disease. It was also established that in cases when patients could cite the causes that triggered the first crisis, the agoraphobic syndrome developed much later than in patients whose first crisis occurred spontaneously and was inexplicable for the patient.

During the course of the disease, there was a certain dynamics of both the vegetative crises themselves and the intercreeping period. Concerning the dynamics of crises, it can be noted that if the disease made its debut with a developed vegetative crisis with pronounced vital fear, vegetative disorders (elevation of arterial pressure, tachycardia), successful resolution of crises led to the deactivation of fear, while the vegetative shifts declined. Anxiety and fear were replaced by feelings of longing, self-pity, depression, etc. Quite often crises with similar emotional and affective phenomena arose in the onset of the disease and differed only in degree of severity during the course of the illness. Usually during the disease, the fear of death was specified, which led to specific phobias at the time of the crisis, sometimes fears were clearly associated with certain vegetative-somatic symptoms of the crisis. So, the rise in blood pressure was associated with the fear of a stroke, cardiac rhythm disruptions or discomfort in the heart area formed cardio phobias, etc.

In those cases when the disease made its debut with specific phobias accompanied by vegetative shifts, spontaneous unfolded crises could appear during the course of the disease, which alternated with attacks of fear.

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

It was possible to note a certain correlation between the emotional-affective phenomena of the crisis and the nature of emotional and behavioral disorders in the inter-attack period. A typical version of the inter-engagement period was the alarming expectation of a crisis, the formation of secondary fears and restrictive behavior. In the same cases, when there was no anxiety and fear in the picture of the crisis, as a rule, there was no anxious waiting for attacks in the interictal period, there were no secondary fears and restrictive behavior. In the interictal period, patients with crises accompanied by hyperventilation disorders experienced emotional syndromes of anxious-hysterical, anxious-depressive and hypochondriacal plan, in patients with conversion crises, hysterical and asthenodepressive syndromes.

[13], [14],