Panic Attacks

Panic attacks are sudden, discrete periods of intense anxiety, fear and discomfort that are associated with a variety of somatic and cognitive symptoms. The onset of these episodes is typically abrupt, and may have no obvious trigger. Although these episodes may appear random, they are considered to be a subset of an evolutionary response commonly referred to as fight or flight that occur out of context, flooding the body with hormones (particularly adrenalin) that aid in defending itself from harm.

According to the American Psychological Association the symptoms of a panic attack commonly last approximately ten minutes. However, panic attacks can be as short as 1-5 minutes, while more severe panic attacks may form a cyclic series of episodes, lasting for an extended period, sometimes hours. Often those afflicted will experience significant anticipatory anxiety in between attacks and in situations where attacks have previously occurred.

Panic attacks also affect people differently. Experienced sufferers may be able to completely 'ride out' a panic attack with little to no obvious symptoms. Others, notably first time sufferers, may even call for emergency services; many who experience a panic attack for the first time fear they are having a heart attack or a nervous breakdown.

Descriptions

Many who suffer from panic attacks state they are the most frightening experiences of their lives. Sufferers of panic attacks report a fear or sense of dying, "going crazy", and/ or experiencing a heart attack, feeling faint, nauseous, or losing control of themselves. These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the sympathetic "fight or flight" response).

A panic attack is a response of the sympathetic nervous system (SNS). The most common symptoms may include: trembling, shortness of breath, heart palpitations, chest pain (or chest tightness), sweating, nausea, dizziness (or slight vertigo), light-headedness, hyperventilation, paresthesias (tingling sensations), sensations of choking, smothering, derealisation, or the feeling that nothing is real. These physical symptoms are interpreted with alarm in people prone to panic attacks, this results in increased anxiety, and forms a positive feedback loop.

Triggers and Causes

• Long-Term, Predisposing Causes
  Heredity. Panic disorder has been found to run in families, and this may mean that inheritance genes plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it. Various twin studies where one identical twin has an anxiety disorder have reported an incidence ranging from 31 to 88 percent of the other twin also having an anxiety disorder diagnosis. Environmental factors such as an overly cautious view of the world expressed by parents and cumulative stress over time have been found to be causes (Bourne 2005).
• Biological Causes
  Generalised anxiety, obsessive compulsive disorder, Post Traumatic Stress Disorder, hypoglycaemia, hyperthyroidism, Wilson's Syndrome, mitral valve prolapse and inner ear disturbances, Vitamin b deficiency from inadequate diet or caused by periodic depletion due to parasitic infection from Tape worm can be a trigger of anxiety attacks.
• Phobias
  People will often experience panic attacks as a direct result of exposure to a phobic object or situation.
• Short-Term Triggering Causes
  Significant personal loss, significant life change, stimulants such as caffeine or nicotine, particularly in overuse, can act as triggers.
• Maintaining Causes
  Avoidance of panic provoking situations or environments, anxious/negative self-talk ("what if thinking"), mistaken beliefs ("these symptoms are harmful and/or dangerous"), withheld feelings, lack of assertiveness. 
• Medications
  Sometimes panic attacks may be a listed side effect of medications such as Ritalin (methylphenidate). These may be a temporary side effect, only occurring when a patient first starts a medication, or could continue occurring even after the patient is accustomed to the drug, which likely would warrant a medication change in either dosage, or type of drug. Nearly the entire SSRI class of antidepressants can cause increased anxiety in the beginning of use. It is not uncommon for inexperienced users to have panic attacks while weaning on or off the medication, especially ones prone to anxiety.
• Hyperventilation Syndrome
  Breathing from your chest may cause over breathing, exhaling excess carbon dioxide in relation to the amount of oxygen in one's bloodstream. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms including rapid heart beat, dizziness, and light-headedness which can trigger panic attacks.
• Situationally Bound Panic Attacks
  Associating certain situations with panic attacks, due to experiencing one in that particular situation, can create a cognitive or behaviourally predisposition to having panic attacks in certain situations (situationally bound panic attacks). It is a form of classical conditioning .
• Pharmacological Triggers
  Certain chemical substances, mainly stimulants but also certain depressants, can either contribute and thus trigger a panic attack or even a panic disorder, or directly induce one. This includes caffeine, amphetamine, alcohol and many more. Some sufferers of panic attacks also report phobias of specific drugs or chemicals, that thus have a merely psychosomatic effect, thereby functioning as drug-triggers by non-pharmacological means. 

Physiological considerations

While the various symptoms of a panic attack may feel that the body is failing, it is in fact protecting itself from harm. The various symptoms of a panic attack can be understood as follows. First, there is frequently (but not always) the sudden onset of fear with little provoking stimulus. This leads to a release of adrenaline which brings about the so-called fight-or-flight response wherein the person's body prepares for strenuous physical activity. This leads to an increased heart rate , rapid breathing (hyperventilation) which may be perceived as shortness of breath , and sweating (which increases grip and aids heat loss). Because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon dioxide levels in the lungs and then in the blood. This leads to shifts in blood, which in turn can lead to many other symptoms, such as tingling or numbness, dizziness, burning and light-headedness. Moreover, the release of adrenaline during a panic attack causes vasoconstriction resulting in slightly less blood flow to the head which causes dizziness and light-headedness.

Symptoms

Physical

• An extremely unpleasant sensation of adrenaline over the entire body
• Sweating
• Shortness of breath
• Racing or pounding heartbeat or palpitations
• Chest pain
• Dizziness or vertigo
• Light-headedness
• Nausea / stomach pains
• Hyperventilation
• Choking or smothering sensations
• Uncontrollable itching
• Tingling or numbness in the hands, face, feet or mouth 
• Hot/cold flashes
• Trembling or shaking
• Feeling of claustrophobia
• Exhaustion
• Feeling of physical weakness or limpness of the body.
• Uncontrollable crying

Mental

• Loss of the ability to react logically to stimuli
• Loss of cognitive ability in general
• Racing thoughts (often based on fear; a repeated or illogical worry)
• Loud internal dialogue
• Feeling of impending doom
• Feeling of "going crazy"
• Extreme worried feeling
• Feeling of extreme nervousness
• Feeling out of control
• Vision is somewhat impaired; (eyes may feel like they are shaking.)

Emotional

• Terror, or a sense that something unimaginably horrible is about to occur and one is powerless to prevent it
• Fear that the panic is a symptom of a serious illness
• Fear of losing control
• Fear of death
• Fear of going crazy
• Flashbacks to earlier panic trigger

Perceptual

• Tunnel vision
• Heightened senses
• The apparent slowing down or speeding up of time
• Dream-like sensation or perceptual distortion (derealisation)
• Dissociation, or the perception that one is not connected to the body or is disconnected from space and time (depersonalisation)
• Feeling of loss of free will, as if acting entirely automatically without control

Agoraphobia is an anxiety disorder which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape. As a result, severe sufferers of agoraphobia may become confined to their homes, experiencing difficulty travelling from this "safe place". The word "agoraphobia" is an English adoption of the Greek words agora and phobos  literally translated as "a fear of the marketplace". This translation is the reason for the common misconception that agoraphobia is a fear of open spaces, and is not clinically accurate.

People who have had a panic attack in certain situations — for example, while driving, shopping in a crowded store, going to a party, experimenting with psychedelic drugs, etc. — may develop irrational fears, called phobias, of these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with panic disorder are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. This can be one of the most harmful side-effects of panic disorder as it can prevent sufferers from seeking treatment in the first place. Agoraphobia of this degree is extremely rare. It should be noted that upwards of 90% of agoraphobics achieve a full recovery. Agoraphobia is actually not a fear of certain places but a fear of having panic attacks in certain places, where escape would be difficult and/or embarrassing.

The thinking behind agoraphobia usually follows the line that were a panic attack to occur, who would look after the person, how would he or she get the assistance and reassurance they needed? The vulnerability grows from the feeling that once victims of agoraphobia are caught in the anxiety, they are suddenly unable to look after themselves and are therefore at the mercy of the place they find themselves in and the strangers around them. In its extreme form, agoraphobia and panic attacks can lead to a situation where people become housebound for numerous years.

It is important to note that agoraphobia is by no means a hopeless situation. Sufferers often do not realise that they have experienced these same situations before and nothing terrible occurred. Successful treatment is possible with the right combination of therapy and medication.

Agoraphobia is often described as a fear of having 'no place to run or hide' if one does have a panic attack. Common examples include: driving, airplanes, malls, moving out of the house, etc.

Panic disorder

People who have repeated, persistent attacks or feel severe anxiety about having another attack are said to have Panic Disorder. Panic Disorder is strikingly different from other types of anxiety disorders in that panic attacks are often sudden and unprovoked.

Treatment

People with Panic disorder often can be successfully treated with therapy, particularly Cognitive Behavioural Therapy and/or anti-anxiety medication or antidepressants.

Paper bag rebreathing

Some panic attack sufferers and even some doctors recommend breathing into a paper bag as an effective short-term treatment of an acute panic attack. However, this can prove to be fatal in some cases and it is strongly advised against to engage in such a practice, by well-respected medical studies dating back to 1989 and 1994