What are panic attacks?
Panic attacks are the defining symptoms of panic disorder, a painful psychiatric condition that affects 2.7 percent of, or roughly 6 million, Americans each year. Panic disorder is classified under the rubric of anxiety disorders in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013) the standard nomenclature for mental illness, which is used to diagnose and categorize disorders for the purpose of treatment, research, and insurance reimbursement. Untreated panic attacks can significantly diminish the quality of a person’s life, resulting in marital and social dysfunction, unemployment, and a heavy reliance on government entitlement programs such as Social Security income or disability insurance. Research has shown that a large percentage of people with panic disorder are also suicidal, depressed, or alcohol- or drug-dependent.
Panic attacks are overwhelmingly severe episodes of extreme fear that occur repeatedly, without warning, and under harmless circumstances. The episodes usually last for fifteen to twenty minutes and are typically experienced as waves of symptoms that encompass a wide variety of physical manifestations. These include heart palpitations, hot flashes or sudden chills, numbness or tingling sensations, chest pain or discomfort, choking sensations, sweating, trembling, dizziness or light-headedness, shortness of breath or hyperventilation, and abdominal distress or nausea. The psychological manifestations of panic attacks include powerful feelings of imminent danger, impending doom, or dread; paralyzing terror; an urgent need to escape from a situation; a sense of depersonalization or derealization; and a fear of losing control, “going crazy,” or dying.
People with panic disorder are frequently convinced that they are suffering from a serious medical illness or emergency, such as a heart attack, respiratory problem, or thyroid irregularity; therefore, they often visit the emergency room or the doctor’s office desperately seeking relief from their symptoms. They are usually subjected to a battery of medical tests that reveal no identifiable, underlying medical condition to which their symptoms can be attributed.
Panic attacks are so uncomfortable that they cause those who experience them to fear the next attack. Out of this worry, people start to avoid places or circumstances that they believe were involved in or caused previous episodes of panic. For example, if an attack occurred in a car, the person might avoid driving or driving alone. If an attack occurred in a shopping mall or sports arena, the person might stop frequenting such places. When attacks occur in a variety of settings, people with panic disorder can experience a complication known as agoraphobia, which means the fear of open spaces, but their concern actually derives from the more deep-seated fear of having another panic attack. Chronic anticipatory anxiety and avoidance behavior prevent people with panic disorder from enjoying many opportunities for travel or recreation. In extreme cases, they become homebound for decades, simply in an attempt to avoid a future panic attack.
The exact cause of panic attacks is unknown. However, researchers believe that they stem from a malfunction in the brain’s fight-or-flight response, which is located in the part of the brain known as the locus coeruleus. Like most mental illnesses, panic disorder is best explained by a combination of biological, psychological, and social factors.
Studies show that panic attacks are, in part, genetically determined. Having a first-degree relative (a parent or sibling) with the condition increases an individual’s chances of also having the condition. In addition, panic disorder is more common among identical twins than it is among fraternal twins, suggesting a genetic predisposition to the illness.
Women are two times more likely than men to suffer from panic attacks. Although panic attacks can strike anyone at any time in their lives, the first stages of the onset of panic disorder usually occur during late adolescence and early adulthood. First episodes are also common among people in their mid-thirties. Panic attacks are often precipitated by major life events or stressors, such as leaving home to attend college, getting married, having a first child, beginning a new career, or losing a loved one. They can also follow a serious illness.
Panic attacks are treated with a combination of medications and psychotherapy. The medications most commonly used are in the benzodiazepine and antidepressant families. Because of their short-lived effects and great potential for addiction and overdose, benzodiazepines, such as lorazepam (Ativan), alprazolam (Xanax), and clonazepam (Klonopin), are prescribed for only a limited period and never for a patient with a history of suicide attempts or substance abuse or dependence disorders. These medications also cause drowsiness and cannot be taken with alcohol—in fact, they can be fatal when mixed in high doses and large quantities with alcohol. People with panic disorder are prone to self-medicate with drugs and alcohol in an attempt to control their attacks. Such a strategy can exacerbate the severity and frequency of panic attacks and creates another problem for the patient, namely, a co-occurring substance use disorder.
The first antidepressants used to treat panic disorder belong to the category of psychiatric medications known as tricyclic antidepressants. The most popular is imipramine, which is used in larger doses to treat depression and in smaller doses to treat panic disorder. Imipramine is effective in relieving the symptoms of panic disorder, but its side effects, including dry mouth, constipation, urinary retention, and dizziness when arising from a sitting or prone position, are unpleasant for many patients. In addition, imipramine is contraindicated for a subset of patients with a certain type of heart problem.
With the advent of fluoxetine (Prozac) and other selective serotonin reuptake inhibitors (SSRIs)—paroxetine (Paxil) and sertraline (Zoloft)—the tricyclic antidepressants were no longer considered frontline medications in the treatment of depression or panic disorder. SSRIs were touted over the tricyclic antidepressants because of their excellent side effect profiles and extremely low risk of overdose. Like the tricyclic antidepressants, the SSRIs are effective in treating panic disorders and present no risk for addiction. However, SSRIs have other types of unpleasant side effects, such as weight gain and sexual side effects that include impotence, the inability to achieve orgasm, and retrograde ejaculation in which semen is ejected backward into the bladder.
To avoid the hazards associated with taking medications, many people opt for talk therapy as a way to manage their panic attacks. Several techniques have been used successfully to control panic attacks alone or in combination with medications. One method teaches patients to practice progressive muscle relaxation, which involves tensing and relaxing each part of their bodies while listening to instructions provided by their therapists, soothing music, or pleasant background sounds. Progressive relaxation is usually employed with deep breathing exercises or meditation strategies. These methods result in overall anxiety reduction, which lowers the likelihood of a panic attack. Patients can also use relaxation exercises when they feel an attack is imminent, thereby “flowing through” and short-circuiting the attack before it becomes full-blown. Gaining a sense of mastery over the attacks makes them less likely to reoccur, and when they do, they are less severe in their intensity.
The most widely used psychotherapy in the treatment of panic attacks is cognitive behavioral therapy. For example, cognitive restructuring is a process in which patients reframe or reinterpret the experience of panic. Teaching patients that panic attacks, albeit unpleasant, are not dangerous or harmful physically (for example, that they are not harbingers of heart attacks) can help significantly diminish anxiety or ruminations about future attacks. Another cognitive behavioral technique is interoceptive exposure, in which a patient allows the therapist to trigger or induce the symptoms of a panic attack in a controlled and safe setting, such as the doctor’s office. The patient learns to experience symptoms without fearing them or allowing them to progress to a full-blown panic attack. Another effective method to control panic disorder involves the systematic, in vivo exposure of patients to the real-world situations that they associate with panic attacks (for example, flying, driving, shopping, and leaving the house) while teaching them to stay relaxed in those situations. Practicing the ability to remain panic-free allows the patient to return to formerly threatening places or circumstances without the fear of experiencing a panic attack.
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