Panic attack 59743 226013629 2008-07-16T13:11:27Z 24.250.239.151 /* Descriptions */ {{Infobox_Disease | Name = Panic attack | Image = | Caption = | DiseasesDB = 30913 | ICD10 = {{ICD10|F|41|0|f|40}} | ICD9 = {{ICD9|300.01}} | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = | eMedicineTopic = | MeshID = D016584 }} '''Panic attacks''' are sudden, discrete periods of intense anxiety, mounting [[physiological]] arousal, fear, stomach problems (spastic colon) and discomfort that are associated with a variety of [[somatic]] and [[cognitive]] symptoms.<ref> Diagnostic and Statistical Manual of Mental Disorders</ref> The onset of these episodes is typically abrupt, and may have no obvious triggers. Although these episodes may appear random, they are a subset of an evolutionary response commonly referred to as [[fight-or-flight response|fight or flight]] that occur out of context. This response floods the body with [[hormones]], particularly [[epinephrine]] (adrenaline), that aid in defending itself from harm.<ref name=Bourne2005>Bourne, E. (2005). ''The Anxiety and Phobia Workbook'', 4th Edition: New Harbinger Press.</ref> Experiencing a panic attack is said to be one of the most intensely frightening, upsetting and uncomfortable experiences of a person's life.<ref name="Bourne2005" /> According to the [[American Psychological Association]] the symptoms of a panic attack commonly last approximately ten minutes. However, panic attacks can be as short as 1–5 minutes, while sometimes panic attacks may form a cyclic series of episodes, lasting for an extended period, sometimes hours. Often those afflicted will experience significant ''anticipatory anxiety'' and [[limited symptom attack]]s in between attacks, in situations where attacks have previously occurred, and in situations where they feel "trapped". That is, where escape would be obvious and/or embarrassing. Panic attacks also affect people differently. Experienced sufferers may be able to completely "ride out" a panic attack with little to no obvious symptoms or external manifestations. Others, notably first-time sufferers, may even call for emergency services; many who experience a panic attack for the first time fear they are having a [[heart attack]] or a [[nervous breakdown]].<ref> {{Citation | title=Don't Panic: Taking Control of Your Anxiety Attacks. Revised Edition, HC | first1=Wilson | last1=Reid | year=1996}}</ref> ==Descriptions== Many who suffer panic attacks state they are the most frightening experiences of their lives. Sufferers of panic attacks report a fear or sense of dying, "going crazy", or experiencing a [[myocardial infarction|heart attack]] or "flashing vision", feeling [[fainting|faint]] or [[vomiting|nauseous]], or losing control of themselves. 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). A panic attack is a response of the [[sympathetic nervous system]] (SNS). <!-- Comment: Removed because it is covered in physiology section During a panic attack, the body typically releases large amounts of [[adrenaline]] into the [[bloodstream]].{{Fact|date=July 2007}}--> The most common symptoms may include [[trembling]], [[dyspnea]] ([[shortness of breath]]), [[heart palpitation]]s, [[chest pain]] (or chest tightness), [[hot flash]]es, cold flashes, burning sensations (particularly in the facial or neck area), [[sweating]], [[nausea]], [[dizziness]] (or slight [[vertigo (medical)|vertigo]]), [[light-headedness]], [[hyperventilation]], [[paresthesia]]s (tingling sensations), sensations of [[choking]] or [[smothering]] or [[derealization]], the feeling that nothing is real. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety, and forms a [[positive feedback]] loop.<ref> {{Citation | title=Panic Anxiety and Its Treatments: Report of the World Psychiatric Association Presidential Educational Program Task Force | publisher=American Psychiatric Association | first1=Gerald L. | last1=Klerman | first2=Robert M. A. | last2= Hirschfeld | first3=Myrna M. | last3=Weissman | pages=pp.44 | year=1993 | isbn=978-0880486842}} </ref> <!--Removed: Anxiety generated by these internal sensations activates the SNS, creating more sensations and more SNS arousal. This causes a [[positive feedback]] loop that increases their anxiety and can lead to a panic attack or worsen one that has already developed.--> Often when [[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 results in the person experiencing a panic attack to seek treatment in an [[emergency room]]. The panic attack is distinguished from other forms of anxiety by its intensity and its sudden, episodic nature.<ref name=Bourne2005/> Panic attacks are often experienced in conjunction with anxiety disorders and other [[psychological]] conditions, although panic attacks are not always indicative of a [[mental disorder]], they are uncommon. <!-- Comment: Covered in Triggers section Panic attacks can be caused by very common problems such as low blood sugar [[hypoglycemia]], [[hyperthyroidism]], or the overuse of [[caffeine]] or [[nicotine]]. {{Fact|date=July 2007}}--> ==Triggers and causes== *'''Long-Term, Predisposing Causes''' &mdash; [[Heredity]]. Panic disorder has been found to run in families, and this may mean that inheritance [[genes]] plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it. 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 causes.<ref name=Bourne2005/> *'''Biological Causes''' &mdash; Generalized anxiety, [[obsessive compulsive disorder]], [[post traumatic stress disorder]], [[hypoglycemia]], [[hyperthyroidism]], [[Wilson's disease]], [[mitral valve prolapse]], [[pheochromocytoma]] and inner ear disturbances ([[labyrinthitis]]).<ref name=Bourne2005/> [[Vitamin B deficiency]] from inadequate diet or caused by periodic depletion due to parasitic infection from [[tapeworm]] can be a trigger of anxiety attacks. *'''Phobias''' &mdash; People will often experience panic attacks as a direct result of exposure to a [[phobic]] object or situation. *'''Short-Term Triggering Causes''' &mdash; Significant personal loss, including an emotional attachment to a romantic partner, life transitions, significant life change, [[stimulants]] such as [[caffeine]] or [[nicotine]], or the drugs [[marijuana]] or [[psilocybin]], can act as triggers.<ref name=Bourne2005/> * '''Maintaining Causes''' &mdash; Avoidance of panic provoking situations or environments, anxious/negative [[self-talk]] ("what-if thinking"), mistaken beliefs ("these symptoms are harmful and/or dangerous"), withheld [[feeling]]s, lack of assertiveness.<ref name=Bourne2005/> * '''Lack of Assertiveness''' &mdash; A growing body of [[evidence]] 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 consistently present in those that are afflicted with panic attacks.<ref name=Bourne2005/> * '''Medications''' &mdash; Sometimes panic attacks may be a listed side effect of medications such as [[Ritalin]] ([[methylphenidate]]). 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. *'''[[Hyperventilation]] Syndrome''' &mdash; Breathing from your chest may cause overbreathing, exhaling excess [[carbon dioxide]] in relation to the amount of [[oxygen]] in one's [[bloodstream]]. Hyperventilation Syndrome can cause [[respiratory alkalosis]] and [[hypocapnia]]. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms including rapid [[heart beat]], [[dizziness]], and [[lightheadedness]] which can trigger panic attacks.<ref name=Bourne2005/> *'''Situationally Bound Panic Attacks''' &mdash; Associating certain situations with panic attacks, due to experiencing one in that particular situation, can create a cognitive or behaviorally predisposition to having panic attacks in certain situations (situationally bound panic attacks). It is a form of classical conditioning.<ref name=Bourne2005/> See [[PTSD]] *'''Pharmacological Triggers''' &mdash; 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.<ref>[http://www.nlm.nih.gov/medlineplus/ency/article/000924.htm MedlinePlus Medical Encyclopedia: Panic disorder<!-- Bot generated title -->]</ref><ref>[http://panicdisorder.about.com/cs/shfitness/a/caffeine.htm Caffeine and Panic Disorder<!-- Bot generated title -->]</ref> 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.<ref>[http://fondationmarievictorin.qc.ca/panic-and-anxiety-attack-medication.php Psychosomatic And Drug-induced Panic Attacks<!-- Bot generated title -->]</ref><!-- will add information on so-called panicogens here later, that are often used in clinical studies to induce panic in mice, rats, etc. Alexa --> ==Physiological considerations== While the various symptoms of a panic attack may feel that the 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 response]] 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 [[paresthesia|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. == The "panic trick" (Carbonell 2004) == Dr. David Carbonell describes panic attacks and [[Panic Disorder]] as a "trick". First, it tricks the sufferer into believing what they are experiencing is [[dangerous]], for example having a [[heart attack]], [[fainting]], [[insanity]], and/or "doing something crazy", when a panic attack presents no danger. Second, it tricks those afflicted into doing anything they believe will help them, which can make the panic attacks worse. These activities would include avoidance behaviors, trying to control panic attacks (for example, by taking deep breaths), fighting panic attacks, [[superstitions]] and [[ritual]]s to avoid panic attacks and excessive self-protection. (Carbonell 2004) ==Symptoms== {{Refimprove|section|date=July 2007}} ===Physical=== * A sensation of [[adrenaline]] going through your entire body * [[Sweating]] * Shortness of breath ([[dyspnea]]) * Stomach problems ([[spastic colon]]) * Racing or pounding [[heart rate|heartbeat]] or [[palpitations]] * [[Chest pain]] * [[Dizziness]] or [[Vertigo (medical)|vertigo]] * [[Headache]] * [[Lightheadedness]] * [[Nausea]] / stomach pains * [[Hyperventilation]] * Choking or smothering sensations * Hot flashes * Cold flashes * Tingling or numbness in the hands, face, feet or mouth ([[paresthesia]]) * Feelings of "crawly," "itchy," or "cringy" skin sensations. * Burning sensations * [[Tremble|Trembling or shaking]] * Feeling of [[claustrophobia]] * Feeling like the body is shutting down/ dying * Tremors in the legs/shaking legs/thighs * Tingling spine * Feeling like one is experiencing a heart attack * [[Exhaustion]] * Muscle spasms * Feeling of physical weakness or limpness of the body * Grinding teeth or tensing other muscles repeatedly or for prolonged periods of time * Temporary blindness * Sizzling/ringing in ears/head ===Mental=== * Intense and/or frightening realizations of reality * Loss of the ability to react logically to stimuli * Loss of cognitive ability in general * Racing thoughts (often based on fear) * Irrational thoughts * Loud internal dialogue * Feeling like nothing is real * Feeling of impending doom * Feeling of "going crazy" or becoming [[insane]] * Feeling out of control * Feeling like no one understands what is happening * Vision is somewhat impaired (eyes may feel like they are shaking.) * Feeling that death will come any second * Avoidance behavior * Agoraphobia ===Emotional=== * [[Terror]], or a sense that something unimaginably horrible is about to occur and one is powerless to prevent it * Fear that the panic is a symptom of a serious illness * Fear that the panic will not subside * Fear of losing control * [[Thanatophobia|Fear of death]] * Fear of living * Fear of going crazy * Flashbacks to earlier panic trigger {{Fact|date=July 2007}} * Intense "scared" feeling * Fear of failure ===Perceptual=== * [[Tunnel vision]] * Heightened [[senses]] * The apparent slowing down or speeding up of time * Dream-like sensation or perceptual distortion ([[derealization]]) * [[dissociation (psychology)|Dissociation]], or the perception that one is not connected to the body or is disconnected from space and time ([[depersonalization]]) * Feeling of loss of [[free will]], as if acting entirely automatically without control ==Agoraphobia== {{main|Agoraphobia}} {{Refimprove|section|date=December 2007}} Agoraphobia is an [[anxiety disorder]] which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape. 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 language|Greek]] words [[agora]] (αγορά) and [[phobos]] (φόβος), literally translated as "a fear of the marketplace" usually 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 and be very embarrassed of having one 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. 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. It should be noted that upwards of 90% of agoraphobics achieve a full recovery. Agoraphobia is actually not a fear of certain places but a fear of having panic attacks in certain places. In its extreme form, agoraphobia and panic attacks can lead to a situation where people become housebound for numerous years (Barry 2006). In Japan this condition is coined and down-played as [[Hikikomori]], as it is rather commonly perceived by the Japanese psychiatrists as a state of mere laziness and indulgent behaviour forgiven by the mercy of the sufferer's family. General perception amongst the Japanese are that Hikikomori sufferers are lazy freeloaders of the society. That means Japanese sufferers may not actually seek out treatment due to the negative connotation of the disorder and become more dependent on their families, thus resulting in a [[self-fulfilling prophecy]] of sorts. It is important to note that agoraphobia is by no means a hopeless situation. Sufferers often do not realize that they have experienced these same situations before and nothing terrible occurred. Successful treatment is possible with the right combination of therapy and medication. ==Panic disorder== {{main|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 disorder]]s in that [[panic]] attacks are often sudden and unprovoked.<ref>[http://familydoctor.org/137.xml Panic Disorder: Panic Attacks and Agoraphobia - familydoctor.org<!-- Bot generated title -->]</ref> In 1993 Jacob Markusson developed a technique he coined the POEM system, or [http://www.saneadvice.com/point-of-exit-methodology-poem-system/ Point Of Exit Methodology], whereby a patient focuses a pattern of thinking during the exit of the panic attack. The theory being that the sufferer can break the cycle of panic attacks and resume a panic-free life. The POEM system has been used effectively to give patients relief without the use of medication such as Paxil. ==Treatment== People with [[Panic disorder]] often can be successfully treated with therapy, particularly [[Cognitive Behavioral Therapy]] and/or anti-anxiety medication or antidepressants.<ref name=Bourne2005/> ===Paper bag rebreathing=== Some panic attack sufferers and even some doctors recommend breathing into a paper bag as an effective short-term treatment of an acute panic attack.<ref>[http://www.netdoctor.co.uk/ate/mentalhealth/205625.html Breathing in and out of a paper bag]</ref> This balances the ratio of oxygen and carbon dioxide in the blood. Too much oxygen and too little carbon dioxide, caused by breathing too fast or too deeply through the mouth, contributes to the chain reaction of symptoms that occur in a panic attack. ===Medication=== {{Refimprove|section|date=July 2007}} The [[benzodiazepine]] class of drugs includes [[diazepam]], [[lorazepam]], [[alprazolam]], and [[clonazepam]]. These drugs are highly effective and very fast acting in stopping panic. Some doctors may prefer to prescribe an antidepressant, particularly an [[SSRI]] (such as [[paroxetine]], [[sertraline]], [[fluvoxamine]], [[escitalopram]] or [[fluoxetine]]), which after an initial [[titration]] period may be effective at reducing anxiety.{{Fact|date=October 2007}} [[SNRIs]] such as [[Venlafaxine]] can also be prescribed. Studies{{Specify|date=October 2007}} have proven they may be more effective than the [[SSRIs]] for anxiety.{{Fact|date=October 2007}} [[NaSSA]]s such as [[Mirtazapine]] have also been found effective, particularly with individuals whose anxiety and panic causes [[insomnia]].{{Fact|date=October 2007}} ===Herbs=== Some sufferers report that ingestion of [[Passion Flower]] (whether made into a tea or smoked) significantly relieves not only the symptoms of immediate attacks (abortive), but also acts as a prophylactic treatment as well (preventing an attack in the first place). {{Fact|date=June 2008}} ==Treatment== All persons experiencing persistent and frequent panic attacks should consult their [[physicians]]. However, many experienced sufferers treat panic attacks with some the following methods and techniques: * '''Diaphragmatic Breathing or Abdominal Breathing''' &mdash; Breathing slowly through the nose using the diaphragm and abdomen. Do not breathe through the mouth. Focus on exhaling very slowly. This will correct or prevent an imbalance of oxygen to carbon dioxide in the blood stream.<ref name=Bourne2005/> * '''Taking anti-anxiety medication''' &mdash; to be used under the guidance and direction of a [[physician]]. * '''Staying in the Present''' &mdash; rather than having "what if" thoughts that are future oriented asking yourself, "what is happening now" and "how do I wish to respond to it". (Carbonell 2004) * '''Acceptance and Acknowledgement'''- accepting and acknowledging the panic attack. (Carbonell 2004) * '''Floating with the symptoms''' &mdash; allowing time to pass and floating with the symptoms rather than trying to make them better or fighting them. (Carbonell 2004) * '''Coping Statements''' &mdash; repeated as part of an internal monologue **"No one has ever died from an anxiety attack." **"I will let my body do its thing. This will pass." **"I can be anxious and still deal with this situation." **"This does not feel great, but I can deal with it".<ref name=Bourne2005/> * '''Talking with a supportive person''' &mdash; someone who has experienced true panic attacks personally; someone who is highly trained in treating panic attacks; loved ones who can offer support and comfort. * One particularly helpful and effective form of therapy is '''[[Cognitive Behavioral Therapy]]''' (CBT). This is the most generally accepted method of treatment{{Fact|date=June 2008}}. ===Interoceptive desensitization/symptom inductions=== Another form of treatment is 'Interoceptive Desensitization which intends to [[desensitize]] the afflicted from the symptoms of panic attacks. In a study by Barlow & Craske (1989), 87% of the individuals that participated in the two of four treatments that involved Interoceptive Desensitization were free of panic at the end of treatment and these results were maintained at a 2-year follow up. In controlled studies of Interoceptive Desensitization treatments compared to other treatments, those treatments that included Interoceptive Desensitization were found to be significantly superior to other treatments such as muscle relaxation alone, or education or insight-oriented treatments. Interoceptive Desensitization often leads to a dramatic reduction in the frequency and intensity of panic attacks and as such should be implemented immediately under the guidance of a [[mental health professional]]. It is important the patient is given medical clearance and permission from a [[medical doctor]] before attempting these exercises. The key to the induction is that the exercises should mimic the most frightening symptoms of a panic attack. Symptom Inductions should be repeated 3-5 times per day until the patient has little to no anxiety in relation to the symptoms that were induced. Often it will take a period of weeks for the afflicted to feel no anxiety in relation to the induced symptoms. With repeated trials, a person learns through experience that these internal sensations do not need to be feared – the individual becomes less sensitized or desensitized to the internal sensation. After repeated trials, when nothing catastrophic happens, the brain learns ([[hippocampus]] & [[amygdala]]) to not fear the sensations, and the [[sympathetic nervous system]] activation fades. Many people overcome Panic Disorder and sudden Panic Attacks on their own. It takes time, but in a sense, they ride out the panic attacks and eventually learn that nothing is going to happen during one. Often, they 'taper off' until they are not noticeable any longer. It is for this reason that some psychologists helping people with panic disorders induce them into an attack, so they can see for themselves that indeed, nothing will happen. ==Increased risk of heart attack and stroke== 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 [[stroke]] over the next five years. The researchers believe that panic attacks or more accurately their associated symptoms ([[chest pain]], [[dyspnea]]) 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.<ref>http://www.nytimes.com/aponline/us/AP-Panic-Attacks-Heart.html</ref> The study did not find that isolated cases of panic attacks in patients without [[panic disorder]] or [[agoraphobia]] 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 [[SSRI]]s and [[benzodiazepines]]. == Limited symptom attack == Many people being treated for panic attacks begin to experience [[limited symptom attack]]s. These panic attacks are less comprehensive with fewer than 4 bodily symptoms being experienced.<ref name=Bourne2005/> ==References== {{reflist|2}} == External links == * [http://www.nomorepanic.co.uk No More Panic] UK based website for sufferers of panic attacks * [http://www.adaa.org Anxiety Disorders Association of America] Information for families, clinicians and researchers * [http://www.apa.org/pubinfo/panic.html American Psychological Association: Answers to Your Questions About Panic Disorder] * [http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html US Surgeon General] *[http://www.wellsphere.com/wellmix360/Panic-attack Overview of Panic Attacks] *[http://panicdisorder.about.com/od/pdbasics/a/attackquiz.htm Quiz: Did I Have a Panic Attack?] * http://www.nopanic.org.uk/ [[Category:Anxiety disorders]] [[de:Panikattacke]] [[es:Ataque de pánico]] [[fr:Crise de panique]] [[ko:공황 발작]] [[is:Felmstursröskun]] [[it:Attacco di panico]] [[he:הפרעת פאניקה]] [[hu:Pánikroham]] [[nl:Paniekaanval]] [[no:Panikkangst]] [[pl:Zespół lęku napadowego]] [[pt:Ataque de pânico]] [[ru:Паническая атака]] [[fi:Paniikkikohtaus]] [[sv:Panikångest]] [[tr:Panik atak]] [[yi:פאניק אטאקעס]]