Panic Attack: Symptom, Treatment and Panic Cure

Panic attack is defined as a discrete period of intense fear or discomfort accompanied by somatic and psychic symptoms. The attack has a sudden onset and rapidly builds to a peak (usually in 10 minutes or less). It is accompanied by a sense of imminent danger or impending doom and an urge to escape.

A panic attack is also made up of severe, acute, systemic symptoms: cardiovascular (palpitations, pounding heart, accelerated heart rate), respiratory (dyspnea, chest pain or discomfort, sensations of shortness of breath or smothering), neurological-like (dizziness, trembling or shaking, paresthesias), sweating, nausea or abdominal distress, chills or hot flushes. Often the somatic symptoms mask or are predominant over anxiety and such patients are primarily referred to non-psychiatric physicians.

The psychic symptoms are: feelings of dizziness, unsteadiness, lightheadedness, or fainting, derealisation or depersonalization, fear of losing control or going crazy, fear of dying. Individuals seeking help for panic attacks will usually describe the fear as intense and report that they thought they were about to die, lose control, have a heart attack or a stroke, or ‘‘go crazy’’. They also usually report an urgent desire to flee from wherever the attack is occurring (escape behavior).

The attack usually lasts few minutes, but is generally followed by a sense of malaise, distress, uneasiness that may persist for several hours. The anxiety that is characteristic of a panic attack can be differentiated from generalized anxiety by its intermittent, almost paroxysmal nature and its typically greater severity. DSM-IV requires that a panic attack has an abrupt onset with a time lag to reach its peak of less than 10 minutes . Scupi et al. found, however, that panickers with prolonged onset do not differ significantly from rapid onset panickers on any clinical features. DSM-IV lists 13 symptoms, four of which are necessary in order to satisfy the criteria of panic attack. ICD-10 considers approximately the same set of symptoms.

The symptoms of panic may be present in a variety of situations: physical effort, use or withdrawal from drugs, medical conditions such as hyperthyroidism, pulmonary embolism, hypoglycemia, hyperparathyroidism, pheochromocytoma, vestibular dysfunction, seizure disorders, cardiac conditions (arrhythmia, supraventricular tachycardia). Generally, all the acute cardiopulmonary diseases and all the situations that cause a sudden and intense activation of the sympathetic system may produce the same symptoms as panic. For this reason DSM-IV criteria for panic attack require the explicit exclusion of organic causes [Criterion C: ‘‘The panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism)’’]. Even in the field of mental disorders panic attacks can be found in other conditions, including all the phobic states. In determining the differential diagnostic significance of a panic attack, it is important to consider the context in which it occurs.

Basically, there are two types of panic attacks, depending on the presence or absence of situational triggers: unexpected panic attacks, in which the onset of the panic attack is not associated with a situational trigger (occurring spontaneously, ‘‘out of the blue’’); and situationally bound panic attacks, in which the panic attack almost invariably occurs immediately on exposure to, or in anticipation of, a situational cue. A third variation could be that of situationally predisposed panic attacks, which are more likely to occur on exposure to the situational cue or trigger, but are not invariably associated with the cue and do not necessarily occur immediately after the exposure (e.g., attacks are more likely to occur while driving, but there are times when the individual drives and does not have a panic attack or times when the panic attack occurs after driving for half an hour). Unexpected panics and cued panics do not differ in terms of severity, while the relative frequency of symptoms differs according to the kind of panic. Subjects with unpredictable panic more often report symptoms such as dizziness, parasthesia, shaking, chest pain, and fear of going crazy or losing control. More than 90% of patients with unpredictable panic attack report feelings of loss of control and dizziness, which are less common among people suffering from situationally bound panic . The kind of phobic stimuli may also be associated with a different somatic symptom pattern: shortness of breath is a common symptom in panic attacks associated with agoraphobia, whereas blushing is common in panics related to social or performance anxiety .

As regards severity, DSM-IV differentiate ‘‘full-blown’’ panic attacks from‘‘limited-symptoms’’ attacks. The full-blown panic attack is accompanied by at least four of the estimated 13 somatic or cognitive symptoms. Attacks that meet all the other criteria but have less than four somatic or cognitive symptoms are referred to as limited-symptom attacks and these are very common in individuals with panic. Limited-symptom attacks may also occur in subjects without PD. Their lifetime prevalence has been estimated around 2% and their clinical significance remain dubious. Although this distinction is somewhat arbitrary, full-blown attacks are generally associated with a greater morbidity.

Apart from phobic states, where panic is a basic aspect of the disorder, panic attacks may be observed during the course of several other psychiatric conditions, including major depression, obsessive-compulsive disorder, borderline personality disorder, brief psychosis and others: in this case it is controversial whether the panic attack should be considered as part of the original symptomatology or rather as an independently occurring phenomenon. Classifications that privilege hierarchy tend to consider panic as secondary to the original state, whereas nosological systems that allow comorbidity enforce a double diagnosis.

The panic attack may occasionally occur in otherwise healthy people without any particular pathological consequence (so called sporadic or infrequent panic attacks). Sporadic panic has been revealed as extremely frequent, so much so as to exceed all the other types of panic that can be nosographically codified: a consistent number of cases (epidemiological figures vary from 2% up to 35%) in the population are reported to have had at least one panic attack without any further consequence.In respect to this data two possibilities can be suggested:

The panic attacks in themselves are not intrinsically pathological forms; in the majority of cases they do not reoccur and do not result in consequences on social adaptation or quality of life. Other factors are necessary in order to condition the frequent repetition of the crisis or/and their evolution into clearly pathological forms.

The second possibility is that sporadic panic attacks represent the weaker sub pathological form of PD. In this case, an early recognition of this form is essential in order to prevent their evolution into disorders of increased intensity.

There are also nocturnal panic attacks, characterised by sudden awakening, terror and hyperarousal. Nearly 40% of PD patients have panic attacks during sleep . The electroencephalographic studies point out that those panic attacks are not in REM sleep. Klein suggested that the presence of this sleep panic attack is specific to PD.

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