Written by: Petros Skapinakis, MD, MPH, PhD, lecturer of Psychiatry in the University of Ioannina Medical School, Greece. Eva Gerasi, postgraduate student in the Department of Psychiatry, University Hospital of Ioannina, Greece
First version: 26 Nov 2006. Latest revision: 29 Mar 2007.
Definition:
Attacks of panic are very common. However, only a few people continue to have frequent or distressing panic attacks that begin to interfere with their day-to-day functioning. When panic attacks are very frequent or when a person spends a considerable amount of time anticipating the next attack, then he/she may suffer from panic disorder. This disorder is characterized by unpredictable attacks of severe anxiety with pronounced autonomic symptoms not related to any particular situation.
Symptoms:
Panic attacks and anxiety attacks are characterized by acute development of several of the following anxiety attack symptoms reaching peak severity within 10 minutes:
- Escalating subjective tension
- Chest pain or discomfort, palpitations, "pounding heart", tachycardia
- Sweating, chills, or hot flushes
- Tremor or "shakes"
- Feeling of choking, smothering or shortness of breath
- Nausea, "butterflies", or abdominal distress
- Dizziness, feeling light headed or faint
- Derealisation, depersonalisation
- Paraesthesias (feelings like an ant crawling on your body)
- Feeling of dying, loss of control or "going crazy"
Note: Many of the similar symptoms can be caused by a heart attack. Panic attack and heart attacks can be difficult to distinguish.
Incidence:
Data from the OPCS 1995 household survey show the following incidence of anxiety- and panic-related disorders:
| Disorder | All adults | Men | Women |
| Anxiety Disorder | 5 % | 4 % | 5 % |
| Panic Disorder | 1 % | 1 % | 1 % |
| Obsessive Compulsive Disorder (OCD) | 2 % | 1 % | 2 % |
| Mixed Anxiety and Depression | 8 % | 5 % | 10 % |
Diagnosis:
We say someone suffers from panic disorder when there are:
- Recurrent unexpected panic attacks (with no specific stimulus)
- Concern about additional attacks (phobophobia)
- Worry about implications of attack (loss of control, "going crazy")
- Change in behaviour related to attacks
We must always be careful to exclude epilepsy and acute intoxication with or withdrawal from alcohol or illicit drugs (amphetamines, cocaine) or even caffeine.
Sever Anxiety Attacks
It is a very common, but dysfunctional and wrong believe that you might go mad or crazy if you have panic attacks. In the moments of the severe anxiety you think you might loose control or might get a stroke or any other possible severe brain condition or heart attack. But this is mainly caused by a rather normal acute alarm reaction of the body. This physiological response to acute danger activates the whole body and was very well suited to activate your body to fight or run away from an enemy or wild biest.
In such an acute danger it is not important to have a cool mind and to be able to think of all the pros and cons of a situation. The only important think is to activate the body.
Such an alarm reaction usually is time limited and will last for about 30 to 60 minutes. You might feel not perfectly o.K. after this time because there is still a stress reaction going on. But this acute stress reaction will not cause any harm to your brain. It is very unpleasant, but not at all dangerous. It is a physiological reaction, which is not very appropriate to our modern life.
Some patients have derealisation and feel very unreal if they have an anxiety attack. Again, this is unpleasant but not at all dangerous or a precursor of any brain disease.
Nocturnal Panic Attacks:
About 50% of all patients with panic disorder have nocturnal panic attacks, but most of the events will be happening during daytime activities. Research shows that only 10.2% of all panic attacks happen at night, but patients might be more severely concerned about these events.
A significant number of patients are afraid of the nighttime and do expect a loss of control or severe somatic consequences like a heart attack, stroke or other irrational cause of death. Of course this is most unlikely!
We know that most panic attacks are NOT caused by dreams. Records of sleep polysomnographia show a maximum of panic attacks during early sleep phase (phase II), not during the REM-phases associated with dreams. This is a major difference to nightmares! Nightmares happen during the second half of the night, so we are often able to remember the content of these dreams.
Pavor nocturnus is a very specific type of sleeping disorder, more common among children. It is defined by a sudden avakening with crying, strong anxiety symptoms and vegetative symptoms like heart palpitations, short breathening and sweating. This type of sleeping problems occur during deep phases of sleep (phase IV).
Arousals caused by sleep apnea syndromes are usually not characterized by extreme anxiety symptoms. But this sleep disorder might have an effect on the origin of panic attacks, because sleep apnea has an impact on heart frequency and blood pressure. Chronic arousal of anxiety during night could be a kind of dysfunctional protection against apnea during night.
The exact causes for panic attacks at night are not known. Other possible causes include an increase of CO2-concentration (False Suffocation alarm hypothesis) or changes of the parasympathotonic system due to autonomic dysfunction.
So panic attacks at night will be mainly influenced by the events of the last day, consumption of alcohol or drugs and a general higher arousal due to the anxiety disorder of the client.
Fear of Public Speaking
While it is a normal thing to feel nervous if you have to speak to a bigger audience, speech anxiety is characterized by an abnormal anticipation and perception in a situation where you have to communicate or present a topic.
Treatment of Panic Disorder
We can use either a fast acting benzodiazepine (like alprezolam, Xanor, etc.) usually for a short period only, or a tricyclic antidepressant (TRCAs), which are well tolerated but have a much slower onset of action. One can also use selective serotonin reuptake inhibitors (Fontex Prozac, Fluoxetin, Cipramil, Seroscand, etc.) at doses similar to those used in depression. TRCAs and SSRIs may exacerbate (increase the severity of) anxiety initially. Monoamine oxidase inhibitors are also effective (phenelzine up to 105 mg/day).
Benzodiazepines often lose their effect after some weeks, and quitting using them can give abstention symptoms for several weks or months.
Because of the risks with benzodiazepines, they are not recommended as first choice in anxiety treatment.
Psychological treatment:
Cognitive-behavior therapy, Gestalt-therapy, as well as other forms of psychotherapy, seem effective against some or all symptoms of panic disorder.
It is best to start with only psychotherapy, since it is often effective and then you will not have to use medicines for a long time. But sometimes SSRI-medicines can make psychotherapy more effective. Benzodizepines, on the other hand, may make psychotherapy less effective. Some doctors prescripe drug treatment combined with psychotherapy. Drug treatment should be timed to produce a "window" of responsiveness to psychological intervention.
Disclaimer: The documents contained in this web site are presented for information purposes only. The material is in no way intended to replace professional medical care or attention by a qualified psychiatrist or psychotherapist. It can not and should not be used as a basis for diagnosis or choice of treatment. If you find anything wrong, please notify us at cmc@dsv.su.se.
Sources, references:
- "ABC of mental health", edited by Teifion Davis and T K J Craig
- "The treatment of anxiety disorders, clinician's guide and patient manuals", G.Andrews, R.Crino, C.Hunt, L.Lampe, A.Page
- The personal experience of Petros Skapinakis, MD, MPH, PhD, lecturer of Psychiatry in the University of Ioannina Medical School, Greece.
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