A panic attack is a condition characterized by a sudden onset of symptoms of fear and anxiety, which peak within 10 minutes before resolving. Panic attacks may be triggered by stress, injury, emotional or physical trauma, substance use, or stimulant drugs. Recurrent panic attacks may cause significant emotional and psychological distress to an individual and may increase their risk of developing other psychological disorders. However, panic attacks are treatable and are most effective in the early stages of the illness.
Panic attacks refer to a period of intense fear characterized by an abrupt onset of at least 4 of 13 defined symptoms which peak rapidly within 10 minutes. Panic attacks may develop with or without a defined or predictable trigger. An individual who develops recurrent spontaneous and unexpected panic attacks is said to have a panic disorder.
Left untreated, panic attacks can lead to panic disorder which causes significant distress and disruptions in an individual’s life, leading to several complications such as poor school performance and loss of employment.
In addition, individuals with panic attacks are more likely to develop substance abuse and dependence. Panic disorder associated with other psychological disorders such as eating disorders, personality disorders, and substance use disorders may also increase the risk of suicide in an individual. People with panic attacks are also at a higher risk of developing certain medical conditions such as heart attack and asthma.
Common symptoms of panic attacks include:
The presence of a minimum of four of these symptoms confirm a panic attack. During a panic attack, an individual often experiences a sense of impending doom and a strong urge to escape or run away. Panic disorder is characterized by 4 or more panic attacks in a 4-week period, or 1 or more attacks followed by at least one month of fear of another panic attack.
The fear of a subsequent attack experienced by individuals with panic disorder results in behavior changes, such as avoiding certain locations or situations, as well as significant distress and worry about the potential consequences of an attack. These imagined consequences of an attack include losing control of oneself, feeling so embarrassed, dying, etc. This fear and anxiety can be extremely disabling, leading to significant personality changes characterized by isolation, passivity, and dependence.
There are different types of panic attacks – Unexpected panic attacks and situational panic attacks. Unexpected attacks have no apparent precipitating factor and situational panic attacks occur predictably in response to a certain trigger. However, both types are characterized by the typical symptoms of a panic attack. Common precipitants of a panic attack include:
First-line treatment options for panic attacks include medications and exposure and response prevention, a type of cognitive behavior therapy. The American Psychiatric Association recommends treating individuals with panic disorder when the symptoms begin to cause significant dysfunction in the patient’s life (e.g., family, social, work, leisure activities).
The goals of treatment for panic attacks include:
A lot of persons who suffer from panic attacks can experience significant relief of their symptoms without medications. However, when medications are needed, they are rarely used alone. They are often combined with psychotherapy, which helps the individual understand their symptoms and learn new behavioral responses.
Medications that have been shown to be effective in managing symptoms of panic attacks include benzodiazepines and antidepressants such as Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants serotonin and norepinephrine reuptake inhibitors (SNRIs). These medications are most effective when combined with cognitive behavior therapy and lifestyle changes.
These antidepressants are generally safe and have a low risk of serious side effects. SSRIs are recommended as the drugs of choice for the treatment of panic attacks. They work by boosting the amount of serotonin, a brain stimulant, in the brain. SSRIs approved by the Food and Drug Administration (FDA) for treating panic disorder include sertraline (Zoloft), paroxetine (Paxil), and fluoxetine (Prozac).
Tricyclic antidepressants are second-line medications for the treatment of panic disorder. They are often considered for managing panic disorder if an SSRI is contraindicated or if it does not produce improvement in symptoms after 12 weeks of treatment. Examples of tricyclic antidepressants include imipramine, Nortriptyline, and clomipramine.
These medications work by increasing the amount of serotonin and norepinephrine, which are excitatory chemicals, in the brain. Venlafaxine (Effexor XR) is an example of SNRI approved by the FDA for treating panic disorder.
Benzodiazepines are sedatives which work by inhibiting impulse transmission in the brain. They are typically reserved for persons with refractory panic disorder and are best used as an initial short-term adjunct to SSRIs, because of their high addictive potential. Benzodiazepine doses are tapered over weeks or months because an abrupt withdrawal may trigger panic.
Benzodiazepines approved by the FDA for managing panic disorder include clonazepam (Klonopin) and alprazolam (Xanax). These medications are not suitable for use in persons who have had problems with alcohol and drug use.
It often takes several weeks before an individual taking these medications for panic attacks begins to experience significant improvement in their symptoms. Regular evaluation of the patient is needed to help a physician determine if there is a need for changes in medications and dosage regimen and to monitor for exacerbations. This is because SSRIs can cause exacerbation of panic symptoms in the initial period of receiving treatment. This is the reason why physicians begin treatment with the lowest dose then increasing it as tolerated.
Exposure and Response Prevention is the treatment of choice for panic attacks and should be considered for all individuals who suffer from panic attacks. It may be combined with medications if necessary.
ERP involves exposing the individual to sequentially greater intensities of the anxiety-provoking stimuli. Over time, the person becomes desensitized to the stimuli and displays a better response to the experience. The frequent and graded exposure to the stimuli promotes cognitive restructuring in the patient, in which case the positive thoughts are substituted for the maladaptive thoughts which are associated with the attacks.
ERP helps a patient to reflect on and understand the automatic thoughts and ideas which lead to anxiety and other exaggerated emotional responses associated with panic attacks and how they cause behavioral distortions, ERP may be used alone or in combination with medications for the treatment of panic attacks. Generally, cognitive behavior therapy has higher efficacy, lower costs, and lower relapse rates than do medications.
ERP is most effective when it is commenced early after the patient’s symptoms begin. It is also most useful for patients with few associated psychological illnesses. Therapy is limited to 10-15 sessions every week and can be conducted in group or individual sessions. The patient’s progress is monitored at each session using standard rating scales and the patient’s self-monitoring reports.
People with panic disorder may also benefit from interoceptive exposure which involves encouraging patients to induce the internal sensations associated with panic attacks, such as increased heart rate, shortness of breath, and dizziness, by spinning, rapid breathing, and exercise and to interpret them as normal body sensations. This helps to modify their thoughts and beliefs when they experience panic attacks by interpreting symptoms as normal body sensations. This reduces the anxiety and social avoidance, in turn, reducing the frequency and severity of the attacks.
Intensive treatment usually involves inpatient care and is indicated for complicated panic disorder. However, it is indicated for patients who experience recurrent remissions and a severe co-morbid psychiatric disorder such as major depression, substance abuse disorders, or anxiety disorder. Patients with these co-morbidities have an increased risk of suicide and worsening of symptoms.
Furthermore, individuals who display signs of dangerous behavior, suicidal or homicidal ideation, or at risk of dangerous complications need intensive treatment. Considerations for hospitalization include intoxication or withdrawal from sedatives, severe anticipatory anxiety, and co-morbid medical conditions such as angina.
Intensive treatment may involve combination therapy of medications and cognitive behavioral therapy techniques. Medications may also include drugs which control specific symptoms, such as increased heart rate and anxiety.
In addition to medications and cognitive behavior therapy, there are other methods through which an individual suffering from panic attacks can achieve remission. These are lifestyle changes which are adjunctive to medications and psychotherapy for the treatment of panic attacks. Some of these include:
Support groups provide the necessary emotional support, education, and resources to help an individual with panic disorder achieve resolution of their symptoms. In support groups, people share their experiences and effective treatment techniques with others to help them cope better with their symptoms.
Individuals suffering from panic attacks can learn about panics and anxiety and realize that the bodily sensations they experience during an attack are normal and do not indicate an imminent disaster. In addition, support groups help people connect with one another, thereby building supportive relationships which may help to resolve the individual’s social withdrawal and anxiety.
Relaxation techniques such as yoga therapy strengthen the body’s relaxation response which promote relaxation, tranquility, and equanimity, all of which reduce the frequency and intensity of panic attacks. Yoga may also help a patient with panic disorder learn how to control their breathing. Deep breathing relaxes the muscles and the nerves, producing feelings of calmness, resolving and preventing panic symptoms.
Exercise is a natural anti-anxiety process, creating feelings of relaxation and calmness. Exercise promotes the release of endorphins which are described as the “feel-good hormones”, which relaxes the body and mind. A regimen of at least 30 minutes of rhythmic aerobic exercise on most days is recommended to achieve significant resolution of symptoms. Rhythmic aerobic exercise is one which requires moving both arms and legs, such as cycling, running, walking, swimming, and dancing.
Panic attacks could be debilitating, resulting in severe complications including relationship loss, poor work or academic performance, or suicide. Cognitive behavior therapy, in combination with medications, remains an effective tool for treating panic disorder and preventing complications. People with loved ones suffering from panic attacks should encourage them to commence therapy and regain control over their lives.
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