What to know about the condition, diagnostic issues and treatment.
AÂ panic attack is a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause. Attacks are associated with feelings of loss of control, fear of death or serious illness. Â
Panic attacks are important clinical events that can have adverse consequences. We need to understand how to deal with them and the accompanying problems.
A panic attack has three elements: physiological, cognitive and behavioural.
The physiological aspects of panic attacks are intense, diffuse and often mistaken for other medical problems. A prominent feature is changes in heart rate with dropped beats – one of the reasons why patients fear having a heart attack and present at hospital. Breathing changes are very common. Difficulty taking in air leads to hyperventilation; this, in turn, causes a chemical reaction which depletes calcium at nerve endings and can lead to paraesthesia: tingling, numbness and electrical sensations at nerve endings, particularly affecting the face, hands and feet. This can be mistaken for a neurological event such as a stroke.
Other physiological changes include gastrointestinal disturbance, particularly stomach spasms or contractions, bowel problems leading to diarrhea, nausea and even vomiting. A notable symptom is a feeling of choking or a lump in the throat, known as globus hystericus.
Muscular tension and spasm, trembling and neck stiffness can cause scalp tension and headaches.
Visual and hearing changes may lead to photophobia, blurred vision with difficulty focusing while hearing can either be distant or oversensitive to sounds (hyperacusis).
Depersonalisation or derealisation often accompanies the episode. Patients describe this as detachment, feeling cut off from events around them – like being surrounded by glass curtain. In more extreme cases they may have autoscopy: looking down on themselves.
The cognitive changes are intense panic or fear of dying, collapse or going mad. There might be a fear of heart attack or a stroke. Fear of collapsing in a public place can be embarrassing or distressing. This is important because many people with agoraphobia – the fear of crowded public places – will recall how the first attack occurred in a supermarket or public place and the subsequent fear is what keeps them indoors.
Patients may flee from where they are when the attack occurs. Rarely they have fugue states where they travel somewhere without being aware of how they got there. A common response is to call for help and attend ED where they often have physical conditions excluded without recognition of the underlying cause.
These are the cardinal features that of panic attacks. Attacks are acute and can last for several minutes, in some cases an hour or two; However, if they go on for longer, then the diagnosis must be reviewed
Diagnostic Issues
If panic attacks persist and occur on a regular basis, then the diagnosis of Panic Disorder is made. The DSM-5 criteria are recurrent panic attacks, with one or more attacks followed by 1 month of fear of another panic attack.
Panic attacks can occur with other anxiety disorders. When associated with agoraphobia a decision needs to be made which is the predominant or primary feature as this will determine the treatment approach. The same applies to Social Anxiety Disorder (social phobia) as they can have attacks when feeling exposed or confronted in public. Agoraphobia, it should be noted, is treated with CBT and desensitisation, not medication.
Two other conditions confused with Panic Disorder are Generalised Anxiety Disorder (GAD) or Health Anxiety Disorder (HAD, formerly hypochondriasis). GAD, a condition that remains controversial, is best understood as a chronic state of anxiety, rather than one of acute episodes. HAD is a state of constantly interpreting even minor health or physiological changes as indicating serious illness, followed by treatment seeking. Both of these conditions often indicate an underlying depressive illness.
Panic attacks are associated with considerable morbidity, the most important consequence being depression which is why the use of antidepressants can have a dual function in treatment. It is worth remembering that anxiety, including panic attacks, is often the presenting feature of a depressive disorder.
A most important feature is that panic attacks are associated with a higher level of suicide – this must never be ignored and attended to by taking a careful history and ensuring that adequate support is available.
Attacks can be a feature of a preexisting psychiatric illness such as schizophrenia, obsessive compulsive disorder or mania. It is important not to forget that drug addiction, especially with benzodiazepines, can lead to attacks as the blood level drops.
From a forensic point of view, people who have a panic attack in a store or supermarket may flee and then be arrested for shoplifting.
Panic attacks can also occur with physical illness. The list is long with typical examples being temporal lobe epilepsy, viral infections, lupus, pneumonia, myocardial infarction, stroke or hyperthyroidism; rarer conditions include phaeochromocytoma or mitral valve prolapse (Barlow’s syndrome). It is important to exclude any physical causes while not reinforcing the patient’s belief that something has been missed.
Treatment
An immediate intervention is to treat hyperventilation but most important is reassurance: once the patient understands that the worst thing that can happen with a panic attack is to collapse or fall over and that will put an end to the attack; panic attacks never kill but they do lead to exaggerated illness behaviour and health anxiety.
Paramedics often give hyperventilating patients a bag to blow into to recycle the exhaled carbon dioxide but this is unnecessary; it is easier to simply cup the hands over the mouth and nose while rebreathing.
Benzodiazepines, which have a worse reputation than they deserve, are the first-line treatment and the best preparation is alprazolam (Xanax) which comes in 2mg, 5mg and 10mg tablets. It has the shortest half-life of the benzodiazepines which is why it works so well. For someone in the acute stage, 5mgs TDS is recommended. As there are now strict regulations on Xanax prescriptions (as well as cost), longer acting and more available drugs are oxazepam (Serepax) or lorazepam (Ativan) which have half-lives of 8-12 hours.
It is correct to be concerned about long-term use leading to dependence and a good approach is to use alprazolam for the acute stage, followed by weaning off oxazepam or lorazepam. The problem with Valium, which is very effective for anxiety, is its long half-life, extending over several days, so it is best to avoid in these situations.
Coincident with the use of benzodiazepines in the acute stage are antidepressants. They are all equally effective, but SSRIs have the best side effect profile and so are the drug of choice. As they can take up to two weeks to be effective, the interregnum is filled by using the benzodiazepines.
Treatment has two phases: acute and long-term. Acute phase is to provide rapid relief with accompanying explanation of what is occurring. This is followed by CBT and, if necessary, desensitisation. This is usually done by a psychologist, but some doctors have training to do this.
There are now many Anxiety Disorder Clinics at hospitals or private facilities that run excellent programs. While some clinics require a medical referral, others allow patients to register online for treatment. As a rule, they do not support use of medication so this is a good approach to follow after the acute phase.
Summary
Panic attacks are acute and distressing events that can have serious consequences. Prompt recognition and treatment will provide reassurance and prevent long-term consequences.
Robert M Kaplan is a forensic psychiatrist and lecturer at the School of Medicine, Western Sydney University. He writes on crime and current issues in psychiatry.
