Panic attack

Panic attacks (also called panic crises) are episodes of sudden, intense fear or rapid escalation of normally present anxiety. They are accompanied by both somatic and cognitive symptoms. For example, heart palpitations, sudden sweating, shaking, choking, chest pain, nausea, dizziness, fear of dying or going crazy, chills or hot flashes.

Those who have experienced panic attacks describe them as a terrifying experience, often sudden and unexpected, at least the first time. It is obvious that the fear of a new attack immediately becomes strong and dominant.

The single episode then easily escalates into a full-blown panic disorder, more out of “fear of fear” than anything else. The person quickly becomes trapped in an enormous vicious cycle that often leads to what is called “agoraphobia. This is the fear of being in places or situations where it would be difficult or embarrassing to leave, or where help might not be available in the event of an unexpected panic attack.

Fear of panic attacks makes it difficult and anxiety-provoking to leave the house alone, to travel by train, bus, or car, to be in a crowd or in line, and so on.

Avoidance of all potentially anxiety-provoking situations becomes the dominant mode, and the patient becomes a slave to panic. He often forces all family members to adapt accordingly, never leaving him alone and accompanying him everywhere. A sense of frustration arises from being “big and tall” but dependent on others, which can lead to secondary depression.

Characteristics of panic attack

The main characteristic of panic disorder is the presence of recurrent and unexpected attacks. These are followed by at least 1 month of persistent worry about having another panic attack.

The person worries about the possible effects or consequences of the panic attacks and changes his or her behavior as a result of the attacks. In particular, he or she avoids situations in which he or she fears they may occur.

The first panic attack is usually unexpected, that is, it comes “out of the blue,” so the person becomes very frightened and often goes to the emergency room. Then they may become more predictable.

Diagnosis of panic attack

At least two unexpected panic attacks are required for diagnosis, but most people have many more.

People with panic disorder show characteristic concerns or interpretations about the implications or consequences of panic attacks. Worry about the next attack or its consequences is often associated with the development of avoidance behaviors. This can lead to true agoraphobia, in which case the diagnosis is panic disorder with agoraphobia.

Attacks are usually more frequent during periods of stress. Certain life events can act as precipitating factors, although they do not necessarily indicate a panic attack. The most commonly reported precipitating life events include:

  • marriage or cohabitation
  • separation
  • loss or illness of a loved one
  • being the victim of some form of violence
  • financial and job problems

Early attacks usually occur in agoraphobic situations (such as driving alone or riding a bus in the city) and otherwise often in a stressful context.

Stressful events, agoraphobic situations, hot and humid weather, and psychoactive drugs can actually trigger abnormal body sensations. These can be interpreted catastrophically, increasing the risk of developing panic attacks.

Symptoms of a panic attack

A panic attack has a sudden onset, a rapid peak (usually within 10 minutes or less), and lasts about 20 minutes (but sometimes much less or longer).

Typical symptoms of an anxiety attack are:

  • palpitation/tachycardia (irregular, pounding heartbeat, chest tightness, feeling of a pulse in your throat)
  • fear of losing control or going crazy (e.g., fear of doing something embarrassing in public, or fear of running away or losing control in a panic)
  • feeling lightheaded or unsteady (dizziness or lightheadedness)
  • fine or large tremors
  • sweating
  • feeling of suffocation
  • chest pain or discomfort
  • Feelings of derealization (perception of the outside world as strange and unreal, feelings of lightheadedness and detachment) and depersonalization (altered sense of self, characterized by feelings of detachment or alienation from one’s thoughts or body)
  • chills
  • hot flushes
  • paresthesias (numbness or tingling)
  • nausea or abdominal discomfort
  • feeling of choking (tightness or knot in the throat)

Intensity and pattern of panic attack symptoms

Not all of the symptoms are necessary to have a panic attack. There are many attacks that are characterized by some or all of these symptoms. The frequency and severity of symptoms vary greatly over time and under different circumstances.

For example, some people have moderately frequent attacks (e.g., once a week) that occur regularly for months. Others report short series of more frequent attacks, perhaps with less intense symptoms (e.g., daily for a week). These are interspersed with weeks or months without attacks or with less frequent attacks (e.g., twice a month) for many years.

There are also what are called paucisymptomatic attacks, very common in people with panic disorder, which are attacks in which only some of the panic symptoms occur without exploding into an actual attack. Most people with paucisymptomatic symptoms, however, have had full panic attacks with all the classic symptoms at some point in the course of the disorder.

During a panic attack, the person’s mind is filled with automatic and uncontrolled catastrophic thoughts. The person has difficulty thinking clearly and fears that such symptoms are truly dangerous. Some fear that the attacks indicate the presence of an undiagnosed life-threatening condition (e.g., heart disease, epilepsy). Despite repeated medical examinations and reassurance, they may remain anxious and convinced that they are physically vulnerable.

Others fear that panic attack symptoms indicate that they are “going crazy” or losing control, or that they are emotionally weak and unstable.

Treatment for panic attacks

Psychotherapy for panic attacks

In the treatment of panic attacks with or without agoraphobia and anxiety disorders in general, the form of psychotherapy that scientific research has shown to be most effective is “cognitive behavioral” psychotherapy.

This is a relatively short form of psychotherapy, usually weekly, in which the patient plays an active role in solving his or her problem. Together with the therapist, he or she focuses on learning more functional ways of thinking and behaving to treat panic attacks. The goal is to break the vicious cycle of the disorder.

For panic and agoraphobia, treatment based on cognitive behavioral therapy is highly recommended and the first choice. Basically, it is contraindicated to rely on medication or other forms of psychotherapy without undergoing this form of treatment. In fact, the entire scientific community has shown that it is the most effective for the treatment of panic disorder.

Basic steps of psychotherapy

Cognitive techniques

In therapy, verbal strategies are used to modify automatic catastrophic thoughts (e.g., I’m going to have a heart attack, I’m going to faint, etc.). Over time, the person learns not to be afraid of the physical sensations of anxiety. By not being afraid of them, by learning to live with them by simply waiting for them to pass, one avoids the escalation of anxiety that leads to panic.

Behavioral techniques

Verbal strategies are combined with techniques aimed at modifying the problem behaviors that perpetuate the disorder. First and foremost, the tendency to avoid feared situations (i.e., those from which there is no immediate escape) must be gradually counteracted. It is also necessary to help the subject to expose himself to the physical sensations that frighten him (e.g., tachycardia) through in-session exercises and the resumption of activities that are avoided. For example, one accompanies the patient on a path where drinking coffee, walking up stairs, playing sports, etc. must become part of his life again. Finally, it is necessary to gradually abandon so-called “protective behaviors” that give an illusory sense of security. First of all, being accompanied by others, but also carrying around the drops of anti-anxiety medication, the water bottle, or the cell phone.

Experiential techniques

Finally, relaxation techniques and especially strategies that increase the subject’s ability to accept negative emotions can be useful. In particular, mindfulness meditation and experiential techniques typical of Acceptance and Commitment Therapy (ACT).

Other interventions

The first step is to regain the freedom to move independently and to gain a sense of mastery over the panic phenomenon. Therapy can then proceed by working on the historical elements that have made the individual vulnerable. Reconstruction of life history, significant relationships, emotional and social relationships are important. Any trauma, including the first experience of a panic attack, is examined. Techniques for emotional processing, such as EMDR, may be used.

Medication for panic attacks

The pharmacological treatment of panic and agoraphobia, although often inadvisable (at least as the only treatment), is based on two classes of drugs: benzodiazepines and antidepressants, often used in combination.

In mild forms, the prescription of benzodiazepines alone may be sufficient as a temporary cure, but hardly resolves. The most commonly used molecules are alprazolam, etizolam, clonazepam, and lorazepam. However, in the case of panic attacks and agoraphobia, such drugs are likely to be highly addictive and perpetuate the disorder. This is especially true if cognitive-behavioral psychotherapy is not used in parallel.

Among antidepressants, the tricyclics – TCAs – (e.g., chlorimipramine, imipramine, desimipramine) have been shown to be effective in the treatment of panic attacks and agoraphobia, the monoamine oxidase inhibitors (MAOIs), and especially the selective serotonin reuptake inhibitors – SSRIs – (e.g., citalopram, escitalopram), citalopram, escitalopram, paroxetine, fluoxetine, fluvoxamine, sertraline), which are widely used today.

In fact, the latter class of drugs is more manageable and has fewer side effects than the former.

In cases of panic attacks and agoraphobia that do not respond to treatment with SSRIs, TCAs can be used, although many clinicians use these molecules as first-line therapy.

MAOIs, while very effective, have been almost completely abandoned because of the serious side effects that can occur when certain molecules are combined or when prescribed dietary restrictions are not followed.

Insights

  • Andrisano, C., Chiesa, A., & Serretti, A. (2013). Newer antidepressants and panic disorder: A meta-analysis. International Clinical Psychopharmacology, 28, 33-45.
  • Gallagher, M. W. et al. (2013). Mechanisms of change in cognitive behavioral therapy for panic disorder: The unique effects of self-efficacy and anxiety sensitivity. Behaviour Research and Therapy, 51, 767-777.
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