Monday, 28 June 2010

Panic Attacks (Panic Disorder)

"All of a sudden, I felt a tremendous wave of fear for no reason at all. My heart was pounding, my chest hurt, and it was getting harder to breathe. I thought I was going to die."


"I'm so afraid. Every time I start to go out, I get that awful feeling in the pit of my stomach and I'm terrified that another panic attack is coming or that some other, unknown terrible thing was going to happen."

Panic attacks may be symptoms of an anxiety disorder. These attacks are a serious health problem in the U.S. At least 20% of adult Americans, or about 60 million people, will suffer from panic attacks at some point in their lives. About 1.7% of adult Americans, or about 3 million people, will have full-blown panic disorder at some time in their lives, with the peak age at which people have their first panic attack (onset) being 15-19 years. Another fact about panic is that this symptom is strikingly different from other types of anxiety; panic attacks are so very sudden and often unexpected, appear to be unprovoked, and are often disabling.


Once someone has had a panic attack, for example, while driving, shopping in a crowded store, or riding in an elevator, he or she may develop irrational fears, called phobias, about these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point at which the mere idea of doing things that preceded the first panic attack triggers future panic attacks, resulting in the individual with panic disorder being unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. Thus, there are two types of panic disorder, panic disorder with or without agoraphobia. Like other major illnesses, panic disorder can have a serious impact on a person's daily life unless the individual receives effective treatment.

Panic attacks in children may result in the child's grades declining, avoiding school and other separations from parents, as well as substance abuse, depression, and suicidal thoughts, plans, and/or actions.

What are panic attack symptoms and signs?

As described in the first example above, the symptoms of a panic attack appear suddenly, without any apparent cause. They may include

•racing or pounding heartbeat (palpitations);
•chest pains;
•stomach upset;
•dizziness, lightheadedness, nausea;
•difficulty breathing, a sense of feeling smothered;
•tingling or numbness in the hands;
•hot flashes or chills;
•trembling and shaking;
•dreamlike sensations or perceptual distortions;
•terror, a sense that something unimaginably horrible is about to occur and one is powerless to prevent it;
•a need to escape;
•nervousness about the possibility of losing control and doing something embarrassing;
•fear of dying.

Although the duration of a panic attack can vary greatly, it typically lasts for more than 10 minutes, is one of the most distressing conditions that a person can experience, and its symptoms can closely mimic those of a heart attack. Typically, most people who have one attack will have others, and when someone has repeated attacks with no other apparent physical or emotional cause, or feels severe anxiety about having another attack, he or she is said to have panic disorder. A number of other emotional problems can have panic attacks as a symptom. Some of these illnesses include posttraumatic stress disorder (PTSD), schizophrenia, and intoxication or withdrawal from certain drugs of abuse.

Certain medical conditions, like thyroid abnormalities and anemia, as well as certain medications, like stimulants and antimalarial medications, can produce attacks of anxiety. As individuals with panic disorder seem to be at higher risk of having a heart valve abnormality called mitral valve prolapse (MVP), this possibility should be investigated by a doctor since MVP may dictate the need for special precautions to be taken when the individual is being treated for any dental problem. While the development of panic attacks have been attributed to the use of food additives like aspartame, alone or in combination with food dyes, more research is needed to better understand the role such substances may have on this disorder.


Anxiety attacks that take place while sleeping, also called nocturnal panic attacks, occur less often than panic attacks during the daytime but affect about 40%-70% of those who suffer from daytime panic attacks. This symptom is also important because people who suffer from nocturnal panic attacks tend to have more respiratory distress associated with their panic. They also tend to experience more symptoms of depression and other psychiatric disorders compared to people who do not have panic attacks at night. Nocturnal panic attacks tend to cause sufferers to wake suddenly from sleep in a state of sudden fear or dread for no apparent reason. In contrast to people with sleep apnea and other sleep disorders, sufferers of nocturnal panic can have all the other symptoms of a panic attack. The duration of nocturnal panic attacks tends to be less than 10 minutes, but it can take much longer to fully calm down for those who experience them.

While panic disorder in adolescents tends to have similar symptoms as in adults, the disorder in younger children is less likely to have the thought-based or so-called cognitive aspects. Specifically, adolescents are more likely to feel unreal or as if they are functioning in a dream-like state (derealization) or be frightened of going crazy or of dying.

What is the treatment for panic attacks?


Thanks to research, there are a variety of treatments available for controlling panic attacks, including several effective medications, and specific forms of psychotherapy. In terms of medications, specific members of the selective serotonin reuptake inhibitor (SSRI), the selective serotonin and norepinephrine reuptake inhibitors (SSNRI), and the benzodiazepine families of medications are approved by the U.S. Food and Drug Administration (FDA) for effective treatment of panic disorder. Examples of such medications include sertraline (Zoloft) and paroxetine (Paxil) from the SSRI group, duloxetine (Cymbalta) and venlafaxine (Effexor) from the SSNRI group, and clonazepam (Klonopin) and lorazepam (Ativan) from the benzodiazepine group. Although alprazolam (Xanax) is often used to treat panic attacks, its short duration of action can sometimes result in having to take it several times per day. Medications from the beta-blocker family (for example, propranolol [Inderal]) are sometimes used to treat the physical symptoms associated with a panic attack.

Before SSRIs and SSNRIs became available, medications from the group known as the tricyclic antidepressants (TCAs) were often used to address panic disorder. Although TCAs have been found to be equally effective in treating panic attacks, SSRIs and SSNRIs have been proven to be safer and better tolerated, therefore TCAs are used much less often. When used in the appropriate person with close monitoring, these medications can be quite effective as part of treatment for panic disorder. However, as anything that is ingested carries risk of side effects, it is important to work closely with the prescribing doctor to decide whether treatment with medications is an appropriate intervention and if so, which medication should be administered. The person being treated should be closely monitored for the possibility of side effects that can vary from minor to severe, and in some cases even be life-threatening. Due to the possible risks to the fetus of a mother being treated for panic attacks with medication, psychotherapy should be the first treatment tried when possible in pregnant women. Some herbal supplements are being increasingly used to treat panic disorder. While the supplement kava has been found to be effective and generally safe for the treatment of mild to moderate panic disorder, care should be taken when taking dietary supplements, since many supplements are not regulated in terms of quality, content, or effectiveness.

The psychotherapy component of treatment for panic disorders is at least as important as medication treatment. In fact, research shows that psychotherapy alone or the combination of medication and psychotherapy treatment are more effective than medication alone in overcoming panic attacks. To address anxiety, cognitive behavioral therapy is widely accepted as an effective form of psychotherapy. This form of therapy seeks to help those with panic disorder identify and decrease the irrational thoughts and behaviors that reinforce panic symptoms. Behavioral techniques that are often used to decrease anxiety include relaxation techniques and gradually increasing exposure to situations that may have previously precipitated anxiety in the individual. Helping the anxiety sufferer understand the emotional forces that may have contributed to developing symptoms (panic-focused psychodynamic psychotherapy) has also been found to be effective.

Often, a combination of psychotherapy and medications produces good results. Improvement is usually noticed in a fairly short period of time, about two to three months. Thus, appropriate treatment for panic disorder can prevent panic attacks or at least substantially reduce their severity and frequency, bringing significant relief to 70%-90% of people with panic disorder.

There are also things that people with panic disorder can do to help make treatment more effective. Since substances like caffeine, alcohol, and illicit drugs can worsen panic attacks, those things should be avoided. Other tips for managing panic attacks include engaging in aerobic exercise and stress-management techniques like deep breathing and yoga, since these activities have also been found to help decrease the frequency and severity of panic attacks. Although many people breathe into a paper bag when afflicted by the hyperventilation that can be associated with panic, the benefit received may be the result of the individual believing it will help (placebo effect). Also, breathing into a paper bag when one is having trouble breathing can make matters worse when the hyperventilation is the result of conditions of oxygen deprivation, like an asthma attack or a heart attack.

In addition, people with panic disorder may need treatment for other emotional problems. Depression has often been associated with panic disorder, as have alcohol and drug abuse. Recent research also suggests that suicide attempts are more frequent in people with panic disorder. Fortunately, these problems associated with panic disorder can be overcome effectively, just like panic disorder itself.

Sadly, many people with panic attacks do not seek or receive treatment.

REFERENCES:
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American Psychiatric Association. Practice Guidelines for the Treatment of Patients With Panic Disorder. 2nd ed. Arlington, VA: 2009.
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