Introduction

All of us do feel a bit nervous before an important meeting or an exam but when this nervousness and anxiety is triggered by even the smallest of factors such as being late, loud noises or not finding your presentation file it is possible that these are the first signs of panic disorder.

Panic disorder can only be understood if we know what are panic attacks? Panic attack can be described as a period of intense fear and anxiety which are accompanied by a wide array of symptoms. The symptoms can be mild to severe but there is one thing that is striking; there is a rapid onset. Attacks usually are of short duration of 20-30 minutes, reaching peak in approximately 10 minutes. Rarely panic attacks last as long as one hour. Panic attacks are usually associated with precipitating factors which cause anxiety and panic attack. But attacks may also occur at night during sleep or without any non-fearful factor associated. Attacks may also occur at the same place where it has occurred before.

Now when we know what panic attacks are, we can well understand the basic difference between an attack and disorder. A person can be said to have panic disorder if there are recurrent panic attacks and these attacks are not caused by alcohol or drug abuse, any medical condition or any other psychiatric disorder. Frequency varies from many attacks a day, to only a few attacks a year.

What causes panic attack?

Just like other psychosocial disorders panic attack/disorder is also seen to run in families. It is observed that it is genetically determined and has heritability but the environmental factors and critical stressors play a crucial role in development of clinical signs and symptoms.

What are the signs and symptoms?

1. Physical symptoms/signs are related to autonomic arousal which includes symptoms such as tremor, tachycardia, tachypnoea, hypertension, and sweating which are often compounded by Hyper Ventilation Syndrome in almost half of the cases. Some of the common physical symptoms are as follows:
   1. Sweating.
   2. Trembling or shaking.
   3. Chills or hot flashes.
   4. Chest pain or discomfort.
   5. Fear of dying (anger animus).
   6. Nausea or abdominal distress.
   7. Fear of losing control or going crazy.
   8. Sense of shortness of breath or smothering.
   9. Feeling of choking or difficulties swallowing
   10. Feeling dizzy, unsteady, lightheaded, or faint.
   11. Numbness or tingling sensations (paraesthesia).
   12. Palpitations, pounding heart, or accelerated heart rate.
   13. Derealisation or depersonalisation (feeling detached from oneself or one's surroundings).
2. Concerns of death from cardiac or respiratory problems may be a major focus, leading to patients presenting to emergency medical services.
3. Panic disorder may be undiagnosed in patients with unexplained medical symptoms like chest pain, back pain, GI symptoms including IBS, fatigue, headache, dizziness, or multiple symptoms.
4. Thoughts of suicide (or homicide) should be elicited as acute anxiety (particularly when recurrent) can lead to impulsive acts (usually directed towards self).
5. Risk of attempted suicide is substantially raised where there is comorbid depression, alcohol misuse, or substance misuse.

Who can have panic disorder?

Females are usually seen to be more prone to have panic disorder. Females are usually twice more at risk than males to have post-traumatic stress disorder. It either occurs in middle or late teenage or later in life in late forties or early fifties. But it seldom occurs after 65 years of age.

What are the associated complications?

There is a wide spectrum of disease that has been seen to occur in association with panic disorder. It is hard to say panic disorder is due to these conditions or vice-versa. Some of the conditions are agoraphobia, depressive disorder, other anxiety and related disorders like social phobia and obsessive compulsive disorder, alcohol and substance misuse, bipolar affective disorder, some medical conditions (e.g. mitral valve prolapse, hypertension, cardiomyopathy, COPD, IBS, migraine).

In these conditions there is usually the persistent worry about having another attack or the consequences of the attack which may lead to phobic avoidance of places or situations, and significant behavioural changes related to the attack.

How is it diagnosed?

A careful history by your psychiatrist may help in diagnosis. He may ask you following questions-

• The time of onset of attack
• Frequency of attacks
• Duration of attacks
• Precipitating factors

But it may also be confused with other anxiety or related disorder. Panic attacks may present as a part of the disorder. Sometimes substance or alcohol misuse or withdrawal of any of the habit forming substance may also present as panic disorder. Even mood disorders or psychiatric disorders secondary to medical conditions are also precipitating factors for panic disorder.

How is it treated?

1. Pharmacological method: Antidepressants and other classes of antipsychotic drugs are used but they should only be administered under the care of expert medical guidance.

2. Behavioural method: To treat phobic avoidance by exposure, use of relaxation, and control of hyperventilation have been shown to be quite effective.

3. Cognitive method: Teach about bodily responses associated with anxiety/education about panic attacks, modification of thinking errors.

4. Psychodynamic method: There is some evidence for brief dynamic psychotherapy, particularly emotion-focused treatment (e.g. panic-focused psychodynamic psychotherapy), where typical fears of being abandoned or trapped are explored.

Emergency treatment of an acute panic attack

• Maintain a reassuring and calm attitude as most panic attacks spontaneously resolve within 30 minutes.
• If symptoms are severe and distressing consider prompt use of prescribed medications (immediate relief of anxiety may help reassure the patient, provide confidence that treatment is possible and reduce subsequent emergency presentations).
• If first presentation, exclude medical causes (may require admission to hospital for specific tests).
• If panic attacks are recurrent, consider differential diagnosis for panic disorder and address underlying disorder (may require psychiatric referral).