Panic disorder: Panic disorder for short is an acute anxiety disorder characterized by recurrent and significant autonomic symptoms such as palpitations, sweating, tremors, accompanied by a strong sense of near death or loss of control, fear of unfortunate consequences of panic attacks (panicattacks). Panic attack is a sudden experience of panic, the beginning of symptoms is often the patient’s self-perceived performance, the patient in some cases suddenly feel panic, a sense of loss of control, a sense of madness, a sense of collapse, as if death will come, panic, calling around for help, accompanied by severe autonomic dysfunction, its rapid onset and termination, its performance will last for several minutes or tens of minutes of acute symptoms, the attack is self-limiting.
The typical manifestation of panic attack is that the patient is carrying out daily activities, such as reading, eating, walking, meeting or doing housework, when a strong fear suddenly appears, as if he or she is about to die. This nervousness makes the patient unbearable. At the same time, the patient feels palpitations as if the heart is about to jump out; chest tightness and a feeling of pressure in the anterior chest area; or difficulty in breathing and blockage of the throat, as if he or she cannot breathe and is about to die of suffocation. As a result, the patient will scream, call for help or run out of the room, hold his head and run. Some of them have hyperventilation, dizziness, facial flushing, excessive sweating, unsteady gait, tremor, numbness of hands and feet, gastrointestinal discomfort, and other vegetative symptoms, as well as motor restlessness. This kind of attack, usually 5-20 minutes, is short and can be relieved by itself. After the relief, patients feel that everything is normal, but soon there can be a sudden relapse.
1. Premonitory anxiety
Most patients often worry about the reoccurrence of panic attacks in the interval after recurrent panic attacks, and thus are anxious, and some symptoms of hyperactive vegetative nerves may also appear.
2, help-seeking and avoidance behavior
During panic attacks, patients often ask for emergency help immediately because of the strong sense of fear, which is unbearable. In the interval of the attack, 60% of the patients are afraid of not getting help during the attack, so they actively avoid some activities, such as refusing to go out alone, not to go to crowded places, not to travel by car, or go out to be accompanied by others, etc.
3.Respond to panic attacks
Don’t fight with panic
In a panic attack and it seems to fight it will make things worse. It is important to emphasize that you should not deal with panic attacks in a stressful manner, nor should you deliberately try to suppress them or grit your teeth to chase them away. While we are meant to take positive rather than negative coping measures (discussed further below) to overcome panic, this does not mean fighting it.
Confront the symptoms, don’t run away
Giving in to the initial symptoms of panic or trying to run away from them is the equivalent of telling yourself that you can’t cope with the situation. In most cases this will only produce more panic. A more beneficial attitude would be, “Oh, these feelings are coming back, but my body can withstand these reactions and I can control it. I’ve successfully overcome it before, and so has this time.”
Accept it openly
When you try to fight the panic, you’re really only making yourself more nervous. Let’s think differently and let those symptoms that arise (such as palpitations, chest tightness, sweaty hands and feet, blurry eyes, etc.) happen and disappear as they come, which in turn will get you through the panic very quickly and easily. One of the keys to overcoming panic is not to panic and be anxious, no matter how unusual or uncomfortable these physical arousals are, but simply to calmly focus on the physical changes.
Let nature take its course
Instead of freaking out and fighting it, make peace with the symptoms and tell yourself it’s safe. For example, say to yourself, “This will pass,” “Just let your body go through the changes,” or “I’ve been through this before and gotten over it, so let’s do it this time! ” . In the next section we will list some positive coping statements.
4. Panic attacks are not heart attacks
A “panic attack” is a manifestation of anxiety disorder, and its typical symptoms are.
(1) Often the patient is in the midst of daily activities and suddenly experiences an intense fear as if he or she is about to die (near death feeling) or about to lose his or her mind (loss of control feeling), making the patient unbearable. At the same time, the patient feels palpitations, as if the heart is about to jump out of the mouth, chest tightness, chest pain, shortness of breath, and a sense of choking in the throat. As a result, the patient screams, calls for help, or runs outside. Some are accompanied by significant vegetative symptoms, such as hyperventilation, dizziness, excessive sweating, facial flushing or pallor, tremor, numbness of hands and feet, and gastrointestinal discomfort.
(2) The attack is sudden, peaking within 10 minutes and usually not more than one hour. The person is conscious and can recall the seizure afterwards. Although these seizures last for a short time, usually 5-10 minutes, rarely more than an hour, they can be relieved by themselves and remain as normal, but they can suddenly recur again soon. Patients have frequent seizures, at least three in a month, or the first typical seizure is followed by anxiety for fear of another seizure often lasting more than a month.
(3) Most patients are afraid of not getting help during an attack, so they actively avoid some activities, such as not wanting to go out alone, not wanting to go to a crowded place, not wanting to travel by car, etc., or asking others to accompany them when they go out (at this time, they also have a phobia of the square). Panic attack patients can also have depressive symptoms, and some have suicidal tendencies.
There are many reasons to get this mental illness, the main reason is related to his personality, such as the pursuit of absolute perfection and absolute security, so that their attitude to some things is not afraid of a million, but only in case. Excessive sensitivity and concern for one’s health.
The following methods are currently used to treat panic attacks.
(1) Cognitive-behavioral therapy: to be afraid of what to do. Panic attacks, is a psychological feeling, it is a very light real illness. To the more afraid to go out, the more you want to go out, the more afraid to do things will faint, the more you want to do, the more you want to go to the hospital to check, the more you do not want to check, you will find that their own worries turned out to be so superfluous.
(2) Running therapy: the patient is instructed to make gradual and regular running. Generally speaking, running therapy has a slower onset and higher withdrawal rate than drug therapy, but the efficacy is comparable. Particular attention should be paid to the fact that it is quite difficult to make the patient start regular running in the first 4 weeks, and the exercise program can only be carried out under the accompaniment of relatives, and with the implementation of the exercise program, most patients can persist and achieve satisfactory results.
(3) Medications are effective for panic disorder. For patients with infrequent episodes as well as limited episodes, short-term treatment with anti-anxiety medications can be helpful. For example, alprazolam has a good anti-panic effect and is effective for mild and moderate depression. For those with severe concomitant anxiety, clonidine may be used. Because panic disorder is an episodic disorder, treatment must be discontinued after 3 to 4 months of symptom control, but such a long period of treatment can again affect the withdrawal of medication, because rapid withdrawal can cause rebound anxiety.
5.Typical performance
(1) The typical manifestation of panic attack is that the patient is carrying out daily activities, such as reading, eating, walking, meeting, or running a household, when he suddenly feels palpitations, as if his heart is about to jump out of his mouth; chest tightness, chest pain, and a feeling of pressure in front of the chest; or difficulty in breathing, blockage of the throat, as if he cannot breathe and is about to suffocate. At the same time, a strong sense of fear appears, as if one is going to die or is about to lose one’s mind. This nervousness makes the patient unbearable. As a result, the patient screams and calls for help. Some patients experience hyper-ventiladtion, dizziness, a sense of unreality, excessive sweating, facial flushing or pallor, unsteady gait, tremors, numbness in the hands and feet, gastrointestinal discomfort, and other symptoms of vegetative hyperexcitability, as well as motor agitation. Such episodes last for a short period of time, usually 5-20 minutes and rarely more than an hour. The symptoms may resolve on their own, or the attack may end with yawning, urination, or falling asleep.
(2) Anticipatory anxiety Most patients, in the interval after recurrent panic attacks, are often anxious about having another attack, and may also have some symptoms of hyperactivity of the vegetative nerves and worry about not getting help during the attack.
(3) Help-seeking and avoidance behaviors During panic attacks, patients often ask for emergency help immediately because of the intense fear that is unbearable. In the interval of the attack, 60% of patients due to fear of not getting help at the onset, and thus actively avoid some activities, such as reluctance to go out alone, reluctance to go to crowded places, reluctance to travel by car, or go out to be accompanied by others; that is, secondary to square phobia.
Clinical manifestations of panic disorder refer to recurrent, sometimes unpredictable, anxiety or panic attacks that come on suddenly, cause extreme distress, and last for a few minutes or more Some attacks in panic disorder are not limited to occurring in a specific predictable situation. Panic attacks are followed by a persistent fear of having another attack. Includes 3 parts
6. symptoms
Sudden shortness of breath, dizziness or mild headache, fainting, tremor or shaking, feeling of unreality, dry mouth, difficulty concentrating thoughts or speech, blurred vision, chest tightness, chest pain, tightness or pain in the chest, or difficulty breathing, blocked throat, as if unable to breathe, imminent suffocation, palpitations, heart beating violently as if the heart is about to jump out of the mouth; numbness in the hands and feet, choking sensation, sweating, hot flashes or chills, desperate to escape, nausea, muscle tension. Fear of death to lose control or go crazy. At the same time, there is a strong sense of fear, as if about to die or about to lose their minds.
This nervousness makes the patient unbearable. As a result, some people scream for help, some experience hyperventilation, dizziness, non-real sensations, excessive sweating, facial flushing or pallor, unsteady gait, tremors, numbness in the hands and feet, gastrointestinal discomfort, and other symptoms of autonomic hyperexcitability, as well as motor agitation. In a panic attack, the patient generally tries desperately to escape from a situation with a particular function in the hope that the panic will stop, or seeks help to prevent a collapse, heart attack, or madness. These attacks are sudden, with clear consciousness and short duration, usually 5-20 min (peaking within 10 min), rarely more than 1 h, and can resolve on their own; or end with yawning, urination and sleep. After the seizure, the patient feels as usual and can recall the seizure, but can soon have another seizure suddenly. Anticipatory anxiety Most patients are often worried about having another attack during the interval after recurrent panic attacks, so they can also show some symptoms of autonomic hyperactivity, which is called anticipatory anxiety and can last for more than one month. Attention should be paid to differentiate it from generalized anxiety.
Help-seeking and avoidance behavior panic attacks due to the strong sense of fear, patients can not stand, often immediately request emergency help in the interval of the attack 60% of patients due to fear of the onset of the lack of help, and therefore actively avoid some activities such as reluctance to go out alone reluctance to go to a crowded and lively place reluctant to travel by car, or go out to be accompanied by others; that is, secondary square phobia panic attacks sometimes (not always) can lead to a square fear-like avoidance of certain situations in which it is difficult or embarrassing to avoid, or feel unable to get help from others immediately. Therefore, panic disorder with agoraphobia and panic disorder without agoraphobia can be divided into two types Occasional panic attacks (i.e., panic attacks that are not frequent enough to make a diagnosis of panic disorder) can also occur in other psychiatric disorders, especially in other anxiety disorders.
7. Comorbidities
Cases of panic disorder are often accompanied by depressive symptoms The suicidal tendencies of such patients increase the need for clinical attention.
Diagnosis The disease often has no obvious cause sudden onset of a variety of autonomic symptoms, especially palpitations, tightness of breath, dizziness and sweating are most prominent; in a short period of time the symptoms develop sharply to reach a peak accompanied by strong fear; the duration is very short and then remits on its own intermittent period, except for the expected anxiety fear of re-emergence, there can be no discomfort symptoms. The intervals can be long or short. Frequent episodes combined with anticipatory anxiety can easily be misdiagnosed as generalized anxiety disorder. Many cases are secondary to agoraphobia DSM-IV distinguishes this disease into two subtypes: panic disorder with agoraphobia and panic disorder without agoraphobia combined with major depressive disorder should be diagnosed separately.
According to the diagnostic criteria of ICD-10 panic attacks are diagnosed on the basis of at least three episodes within a month each not exceeding 2 h episodes significantly interfering with daily activities the interval between two episodes is not markedly symptomatic except for fear of further episodes. and have the following characteristics.
(1) There is no real danger in the context of the seizure.
(2) It is not limited to known or predictable situations (see specific phobias or social phobias).
(3) There is little or no anxiety between panic attacks (although there is often a fear of the next panic attack).
(4) Not the result of a physical fatigue physical illness (e.g., hyperthyroidism) or substance abuse.
Key points
The client has had at least one panic attack and has a persistent fear of recurrence or complications, or the attack has resulted in significant behavioral changes lasting at least one month
Determine if the episode is accompanied by a panic attack
Exclude panic attacks caused by substance use and physical illness
Exclude panic attacks secondary to other psychological disorders
Differentiation
As a group of syndromes, panic attacks can be seen in a variety of psychiatric and somatic disorders. The diagnosis of panic disorder can only be made after the exclusion of these disorders. The most confusing symptoms are mitral valve prolapse, sudden onset of palpitations, chest pain, tightness and fatigue and even syncope, but no dizziness, sweating, tremors, facial fever or chills, and depersonalization, sense of near death, or sense of loss of control.
The echocardiogram can be used to differentiate the symptoms, but some studies have reported that the two may be combined; it is believed that panic disorder can lead to mitral valve prolapse. If the panic disorder is controlled, mitral valve prolapse may disappear.
The diagnosis of this disorder begins with a routine medical evaluation to rule out the possibility of a physical illness causing the anxiety symptoms (e.g., heart disease, hyperthyroidism). Table 1 briefly lists the differences between panic attacks and heart attacks.
Panic attacks may occur in other phobias such as social phobia (when speaking to a group of people) or in specific phobias (e.g., when seeing spiders). In these phobias panic attacks can be predicted, and the diagnosis of panic disorder cannot be made only when they occur in a specific stimulus or situation.
Recurrent panic attacks and fear of reoccurrence can also occur during the course of depressive disorders. In some patients, depression can be secondary to panic disorder (i.e., the experience of panic disorder makes the patient depressed). It is important to remember that panic attacks are relatively brief and that patients who describe themselves as “panicking all day” are clinically presenting with a very anxious mood rather than a panic attack.
8. Tests
Laboratory
There are no specific laboratory tests for this disease
Other auxiliary
Patients with anxiety disorders have reduced EEG alpha rhythm and alpha activity is mostly in the higher frequency range; suggesting that patients with anxiety are often in a state of high alertness.
9. Treatment
The aim is to control panic attacks as early as possible to prevent recurrence and cause square terror.
(1) Early treatment When dealing with the first panic attack, explain to the patient that the physical symptoms caused by anxiety may seem scary but are actually harmless, and explain that the patient’s “fear of losing self-control or dying” is a cognitive impairment caused by anxiety, which will cause the anxiety to enter a vicious cycle, thus preventing the further formation of panic disorder. The patient should be informed of the importance of avoidance behaviors Avoidance of places that produce panic disorder can lead to square fear.
(2) Pharmacological treatment can be used as follows.
(1) tricyclic antidepressants: some antidepressants have an anti-panic attack effect when applied in high doses. Therefore, often used as the first-line drugs, more often choose promethazine daily dose of 50 to 300mg: can start with a small dose of 10mg or 25mg, gradually increase the daily dosage of most patients at least 150mg or more to see the effect. Clomipramine (chlorpromazine) (25-200mg/d) can also be used. For those who cannot tolerate anticholinergic side effects, dexipramine (nortriptyline) can be used instead; for elderly people who are prone to hypotension, nortriptyline can be used to reduce panic attacks similar to benzodiazepines, and rarely causes dependence and withdrawal reactions. However, it has a slower onset of action and more adverse effects, and the initial effect of amitriptyline on panic disorder is an increased level of arousal including anxiety, insomnia, and sympathetic arousal. Therefore, the drug needs to be started in small doses. Approximately 2/3 of patients who are effective with benzodiazepines or amitriptyline relapse after 6 weeks off the drug and require further treatment.
②5-hydroxytryptamine recycling inhibitors: can be used as first-line drugs especially for those who cannot tolerate the side effects of tricyclics; can be preferred for patients with combined obsessive-compulsive symptoms or social phobia. Commonly used drugs are: paroxetine (20-60mg/d), fluoxetine (5-20mg/d), sertraline (50-150mg/d) and fluvoxamine (150mg/d) in the morning taking SSRI (such as fluoxetine, paroxetine, fluvoxamine) SNRI (venlafaxine and its extended release) and NaSSA (mirtazapine) and other new antidepressants can also control panic seizures, and their effects are comparable to those of amitriptyline. This drug does not have the anticholinergic and cardiovascular system adverse effects of amitriptyline, but its unique adverse effects may make some patients unable to tolerate and discontinue taking the drug.
③ Monoamine oxidase inhibitors: For those who cannot tolerate other antidepressants; combined with atypical depression or social phobia can be the first choice of common drugs are: phenelzine (15-60-90mg/d) and tranylcypromine (10-80mg/d), taken in the morning.
④High-performance benzodiazepines: Suitable for those who cannot tolerate various antidepressants; anticipatory anxiety or phobic avoidance is prominent, as well as cases requiring rapid results can be preferred. Commonly used drugs are: alprazolam and clonazepam. The latter drug has a longer duration of action and less withdrawal reaction benzodiazepines must be used in large doses and continue for several months in the control of panic attacks, but can cause dependence and withdrawal reactions. The conventional drug is alprazolam, which is more potent than diazepam at therapeutic doses and has a relatively weak sedative effect. 6 mg/d is usually needed to control panic attacks (comparable to 60 mg of diazepam).
⑤ Other drugs: venlafaxine (50-75mg/d) and nefazodone (200-600mg/d) can be tried in patients who have had poor results with other drugs.
Since the disease is prone to relapse various treatment periods should generally not be shorter than six months; some cases require maintenance medication for 3 to 5 years to achieve full remission.
(3) Psychotherapy is often required after controlling panic attacks with medication in order to eliminate anticipatory anxiety and phobic avoidance.
(1) supportive psychotherapy: explain the nature of the disease to patients to reduce the patient’s mental burden encourage patients to adhere to the treatment plan organize similar patients to participate in group therapy to help each other, can play a better effect.
②Cognitive behavioral therapy: cognitive therapy is a professional treatment conducted by clinical psychologists or psychiatrists. The short-term effect of cognitive therapy is comparable to that of medication and has a low relapse rate. However, the treatment needs to be carried out by a specialist and is more time-consuming.
Patients with chronic hyperventilation in the interictal period and acute hyperventilation during spontaneous or induced panic attacks can lead to hypocarbia and alkalosis, which can reduce cerebral blood flow and cause dizziness, confusion and depersonalization. The use of anti-panic medications to control panic attacks or behavioral training of breathing to teach patients to regulate their breathing rate without hyperventilation can result in a significant reduction in panic attacks
④Exposure therapy: expose the patient to somatic sensations during panic attacks through meditation to eliminate the patient’s fear of various autonomic reactions. For patients with phobic avoidance behavior or secondary to square terror, it is appropriate to take live exposure so that patients can gradually adapt to the fearful situation.
⑤ Relaxation training: can be contracted and relaxed in order from top to bottom of the head and face, upper extremity chest and abdomen, lower extremity groups of muscles to achieve the purpose of reducing anxiety. Patients can also learn health care qigong, relax the muscles of the whole body, regulate breathing, and eliminate distracting thoughts by holding the Dantian.
(6) Cognitive reconstruction: Provide reasonable explanations for the somatic sensations and emotional experiences at the onset of the disease so that patients can realize that these sensations and experiences are benign and do not cause serious damage to their health.
Prognosis
The disease usually begins in late adolescence or early adulthood, with another peak incidence between 35 and 40 years of age. It has been found that the disease can occur in childhood, and in some cases it may resolve completely within a few weeks, while those who have been ill for more than 6 months tend to enter a chronic fluctuating course. Patients without plains terror are better treated. The prognosis is poor in those with secondary plains terror. About 7% of cases have a history of suicide attempts, and more than half of patients have a combination of major depressive episodes, which increases the risk of suicide and warrants special attention.
Prevention
Due to the late development of psychiatry in the overall medical science and the complexity of the basic theory of the specialty itself, the etiology and pathogenesis of many common psychiatric disorders have not yet been elucidated. In fact, prevention of mental illness is not only an important issue in medical science but also an important task in the development of social culture and social welfare.
Related statistics
It is estimated that the lifetime prevalence of panic disorder is about 2-4%. A large epidemiological survey of adults in the United States in the 1980s showed that the lifetime prevalence of panic disorder was about 1.5%, the lifetime prevalence of panic attacks was 3.6%, and 9%-10% of people experienced a panic attack. another survey in the 1990s showed that the lifetime prevalence of panic disorder in the United States was 3.5%, with a male to female ratio of 2:5. There is a lack of corresponding data in China. Most panic disorders develop in early adulthood and range from 15-40 years of age, with an average age of 25 years. However, the disorder can occur in all age groups. Its occurrence is not related to socioeconomic status.