Panic disorder

Panic attack in public place

Panic disorder or episodic paroxysmal anxiety is a mental disorder characterized by the spontaneous occurrence of panic attacks from several times a year to several times a day and the expectation of their occurrence. A characteristic feature of the disorder is recurrent bouts of pronounced anxiety (panic), which are not limited to a specific situation or circumstances and, therefore, are unpredictable.

Another name for this disease is episodic paroxysmal anxiety. Before the widespread classification of ICD-10 (10th revision of the International Statistical Classification of Diseases and Related Health Problems), this disease, depending on the leading symptom, was called differently: “cardioneurosis”, “VVD (vegetovascular dystonia) with a critical course”, “NDC (neurocirculatory dystonia).”

 

Signs and symptoms

In people with panic disorder, as a rule, there are a series of intense episodes of extreme anxiety – panic attacks. Panic attacks usually last about 10 minutes but can be short-term – about 1-5 minutes, and long-lasting – up to 30 minutes, while the feeling of anxiety can persist for 1 hour. Panic attacks can differ by the set of symptoms or be of the same type (i.e. tachycardia, sweating, dizziness, shortness of breath, tremor, experiencing uncontrolled fear, etc.). In some patients, these conditions are observed regularly – sometimes daily or weekly. External symptoms of a panic attack often lead to negative social consequences (e.g. embarrassment, censure, social exclusion). Nevertheless, patients who are aware of their disease can often have intense panic attacks with very small external manifestations of this condition.

To determine the severity of a panic disorder, a special scale is used; it also exists in the form of a self-assessment questionnaire as a test for panic attacks.

 

Diagnosis

Diagnostic criteria of ICD-10

  • Repeated, unpredictable attacks (not limited to any particular situation) of expressed anxiety (panic).
  • Anxiety-related autonomic pain symptoms, derealization, and depersonalization.
  • Secondary fears of death and madness.
  • Secondary avoidance of any situation in which a panic attack occurred for the first time.
  • Secondary fears of loneliness, crowded places, repeated panic attacks.
  • Panic disorder is the main diagnosis with the absence of any phobia as a primary disorder (otherwise, a panic attack is considered a sign of severe phobia).

A reliable diagnosis of the panic disorder requires that several severe anxiety attacks be observed for at least one month and meet the following criteria:

  1. Panic disorder occurs in circumstances not related to an objective threat (anxiety anticipation of an attack is possible).
  2. Panic disorder is not limited to a known, predictable situation.
  3. The presence of alarm-free periods between attacks.

 

Diagnostic Criteria of DSM-IV

  1. Repeated bouts of panic attacks.
  2. At least one attack was within 1 month (or more) with the following additional symptoms:
  • The continuing concern over anxiety attacks
  • Worrying about the consequences of an attack (for example, fear of losing self-control, myocardial infarction, fear of losing your mind).
  • Significant behavioral changes associated with attacks.
  1. B) The presence (or absence) of agoraphobia.
  2. C) Symptoms are not a consequence of the direct physiological effects of the substance (eg, drug abuse, medication) or any disease (eg, arterial hypertension, hyperthyroidism, pheochromocytoma, etc.).
  3. D) Symptoms cannot be attributed to the presence of other mental or behavioral disorders, such as somatoform autonomic dysfunction of the heart and cardiovascular system, hypochondria, social phobia, other phobias, obsessive-compulsive disorder, post-traumatic stress disorder, or separation anxiety disorder.

According to the DSM-IV-TR diagnostic and statistical guidelines, panic attacks are not considered a separate disease but are encoded as part of the diagnosis of other anxiety disorders. 

 

Treatment

Despite the mandatory presence of autonomic dysfunction in the attack and the often implicit nature of emotional disorders, the main methods of treating the panic disorder are psychotherapy and psychopharmacology.

 

Psychopharmacology

Antioxidants of the SSRI group are used (fluoxetine, paroxetine) – for a long time, at least 6 months; as well as tranquilizers (alprazolam, clonazepam) in a short course – up to 14 days.

For some time, highly active benzodiazepines, such as alprazolam and clonazepam, have been considered the first choice in the treatment of the panic disorder. But the lack of effectiveness against the symptoms of depression, which is often combined with panic attacks, and pronounced side effects have reduced their popularity. SSRIs became the first line of choice. 

In patients with a history of manic states, the use of benzodiazepines is preferable, since, unlike antidepressants, they do not provoke mania.

The use of so-called vegetotropic drugs (anaprilin, pyrroxan, belloid, bellaspone) in combination with vascular-metabolic therapy (cinnarizine, cavinton, trental, nootropil, piracetam, cerebrolysin) is ineffective, which undermines the belief in the possibility of cure and contributes to the chronicity of the disease.

Not all classes of psychotropic drugs are equally effective against panic. With the right approach, panic disorder responds well to treatment. An individual treatment plan is needed for each patient, which should be developed by the patient together with his attending physician.

 

Psychotherapy

Psychotherapeutic help (the help of a psychotherapist or psychologist) in case of panic disorder can help to realize a psychological problem, see how to solve it and work out a psychological conflict.

The effectiveness of cognitive-behavioral psychotherapy in the treatment of panic disorder has been proven. According to a meta-analysis, in the treatment of panic attacks, cognitive-behavioral psychotherapy had a higher rate of effect in comparison with pharmacological treatment and combination treatment (psychopharmacology combined with psychotherapy). When using cognitive-behavioral therapy, fewer patients interrupted treatment compared with pharmacological and combined treatment. There is evidence of greater anti-relapse activity of cognitive-behavioral psychotherapy in panic disorder compared with pharmacotherapy.

In particular, within the framework of cognitive-behavioral psychotherapy, the method of “stopping thoughts” can be used to eliminate anxious thoughts causing a panic attack. A technique such as a symptom replication under laboratory conditions can also be used. The technique of symptom replication in laboratory conditions is that using various techniques (Clark hyperventilation of the lungs, the use of caffeine or rapid climbing stairs), some of the physiological components of a panic attack are reproduced – sweating, heart palpitations, etc. Then the patient’s interpretations are revealed these physical sensations and emotional reactions. If the patient correctly interprets the sensations that have arisen, the psychotherapist draws his attention to the relationship between interpretation and emotional state (“You explain the heartbeat now by a run up the stairs, not a heart attack, and you are calm”). The therapist also offers the patient to look for an alternative explanation for the heartbeat in everyday life instead of the belief that the heartbeat is a definite sign of a heart attack, and rely on laboratory experience.

As part of cognitive-behavioral psychotherapy, patients can also be taught relaxation therapy techniques, Clark controlled breathing techniques during therapeutic sessions, after which the patient is recommended to use these skills between sessions, during episodes of intense anxiety.

 

In the treatment of the panic disorder, psychoanalysis is also used. From the point of view of psychoanalysts, the main cause of the panic disorder is repressed psychological conflicts that cannot be resolved, cannot be realized and resolved by a person due to various reasons.

 

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