panic disorder

Panic Disorder

Özge DURAN & Hüseyin GÜRTEKİN 170102012-180102019

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Panic attack

They are short-term episodes of fear that occur suddenly and unexpectedly, with physical and cognitive symptoms.
Experiencing panic attacks is not a mental problem per se. These seizures can be seen in many other anxiety disorders or physical problems.

The distinguishing features of panic disorder are that they occur unexpectedly. The person worries about the occurrence of these seizures (anticipatory anxiety). Avoidance of situations where it is not possible to escape or seek help when these seizures occur causes the development of agoraphobia.

When a panic attack is identified, if there is no diagnosis of panic disorder, the condition associated with it should be determined: for example, post-traumatic stress disorder with panic attack.

What happens during a panic attack?

During a panic attack, the person; (DSM-5)
Palpitations, feeling the heartbeat or an increased heart rate, Sweating, trembling or shaking,
shortness of breath or feeling like suffocating, shortness of breath,
Chest pain or feeling of tightness in the chest,
nausea or abdominal pain,
Dizziness, feeling light-headed, feeling like you’re going to fall or pass out,
Unrealism, feeling as if the environment is not real or feeling as if the person is a stranger, feeling separated from one’s self,
Fear of losing control or going crazy, fear of death,
Numbness or tingling sensation in the body,
Symptoms include chills, chills or hot flashes and dry mouth.
If at least 4 of these symptoms occur together in a seizure in about 10 minutes, we call it a panic attack.

Are panic attacks and panic disorder the same thing?

No. Panic attack is not a mental disorder, disorder or diagnosis per se.
It is an attack of fear or distress in which a number of emotional, physical and mental symptoms occur in a cluster and intensely.

Panic disorder is a type of mental illness. If you are having panic attacks and you are worried about “What if I have an attack”, “What if I lose my control during the attacks, if I go crazy, if I go crazy”, “What if I have a heart attack” or if you change your lifestyle because of the attacks, you have started to avoid certain activities and places For example, if you avoid traveling, being alone at home, then this situation has become a mental disorder called panic disorder.

In other words, having a panic attack alone is not enough for a person to be diagnosed with a mental disorder. Panic attacks are rare and occasional events that almost everyone can experience in many mental disorders or situations in natural life. It can be seen in every person. Panic disorder is a mental disorder that includes panic attacks. In short, we can call panic disorder a panic attack phobia. Because you have anxiety and extreme fear of having a panic attack at any moment, so you limit your life.

Panic Disorder in DSM-5

❑Recurrent and unexpected panic attacks. A panic attack is an extreme sense of fear and anxiety that rises suddenly and peaks within a few minutes.

❑At least one panic attack in the last month has been experienced with one or both of the following conditions:

❑Fear of having a panic attack again or worrying about the outcome of the attack (e.g. heart attack, going crazy, losing control, etc.)
❑Significant negative behavior change due to attacks (development of avoidance behavior)

❑The problem may be caused by substance use or a medical condition.
cannot be explained by signs.
❑The attacks cannot be explained by another mental illness.

diagnostic errors

11% of those who have panic attacks interpret it as a psychological symptom.
Most of them apply to other clinics
Cardiology: chest pain (50-60%); palpitations, arrhythmias, shortness of breathNeurology: Dizziness and numbness:

Gastroenterology: diarrhea, pain, nausea, irritable colon syndrome, ENT: Difficulty in swallowing, balance disorder;
Obstetrics: hot flashes
Pulmonary diseases: hyperventilation and shortness of breath.

Gender-linked Characteristics

It was observed that 70% of panic disorder patients were women.

Panic disorder with agoraphobia male/female: 3/1

Male/female without agoraphobia: 2/1

In women, the duration of illness is shorter, the risk of developing phobic avoidance, other anxiety disorders, and major depression is higher.

In males, the duration of illness is longer, phobic avoidance and comorbidity of depression are less.

Starting Age

• It is most common in late adolescence, mid-20s.

• The second peak is the mid-30s.

• Few cases are in childhood or over 45 years of age.

  is beginning.

• It starts at an earlier age in men.

• Early onset is remarkable in those with a family history.

How many types of panic attacks are there?

Panic attacks are generally of 3 types:

1) Attacks that occur in a certain environment or situation:

It is the type of attacks that we can see in many mental disorders. For example, a person with a dog phobia may have a panic attack when they encounter a dog. A person with social anxiety may have a panic attack when speaking out in public. In such cases, a diagnosis of panic disorder is not made. Whatever the real ailment is, it is diagnosed.

2) Spontaneous panic attacks typical of panic disorder:

In panic disorder, there are attacks that occur suddenly out of nowhere, without any visible, discernible condition that will usually trigger the attack.
These attacks usually begin with a few precursors of bodily symptoms or sensations: palpitations, tremors, shortness of breath, dizziness, lightheadedness, feeling unreal. This first symptom is then followed by new symptoms and finally the feeling that the end is coming, the fear of death, catastrophic thoughts such as “I am going crazy”, “I am losing control”.

Since such attacks occur for no apparent reason, the person interprets them as a negative sign of serious conditions.

3) Panic attacks that tend to be situational:

They are attacks that occur in certain situations, but not always. For example, although the person often has an attack in the car, he does not always have an attack. Such panic attacks are usually panic attacks that are specific to agoraphobia. Agoraphobia is the fear of experiencing a panic attack or panic attack-like situations in environments or places where the person cannot get out immediately or get help. For this reason, the person avoids entering such environments and places. Agoraphobia often occurs as a negative consequence of panic attacks. For example, if you have a panic attack in a place where you can’t get out immediately, you avoid getting on the plane again with the fear of “What if I have a panic attack again”.

Maintaining Factors: Conditioning

❑Internal stimulus-responsive conditioning: Learning to fear internal stimuli – a fear of the heartbeat speeding up due to a panic attack matched by the accelerating heartbeat.
❑Exteroceptive conditioning to external stimuli: Fear of stimuli, events, or situations is learned due to matching panic attacks.

❑The bodily symptoms that occur during exposure to these internal and external stimuli are matched with catastrophic thoughts.

Sustaining Factors: Avoidance

❑Anxiety about physical symptoms increases sensitivity to normal physical symptoms. For this reason, situations and activities that cause such bodily symptoms during the day trigger panic attacks.

• ❑ Acceleration in heart rate due to fast walking

• ❑ Shaking from caffeine consumption

• ❑ Sweating due to heat and humidity

• ❑ Don’t get excited while watching a thriller

• ❑ Excitement during sexual intercourse
  ❑Can determine the situation in which the person is anxious (for example,
  The heart rate while sitting may not be frightening, but the acceleration while walking may be frightening) ❑The person begins to avoid activities that will trigger these physical symptoms. Avoidance perpetuates anxiety.

Cognitive Avoidance

Avoids fear by distracting or developing a dissociative reaction when the person enters fearful situations (eg agoraphobic situations).

• ❑ Counting

• ❑ Look around carefully

• ❑ Don’t think about other things

• ❑ Suggestion

• ❑ Don’t imagine being in the situation somewhere else

• ❑ Talking to people around

Safety Signs and Behaviors

When the person enters some situations where he or she may experience a panic attack with the objects, people and conditions that he/she has determined beforehand, his/her anxiety decreases in these situations.

• ❑ going out with someone

• ❑ Carrying cologne, medicine, water, paper bag

• ❑ Carrying things such as walking sticks, umbrellas, etc.

• ❑ Walk by the wall

• ❑ Not going out without a cell phone

• ❑ Frequent blood pressure measurement, heart rate monitoring, being near the hospital

• ❑ Do not stand or sit near exits

Nocturnal Panic Attacks

❑Nocturnal panic attacks that occur during sleep at night

Physical responses during sleep arousal due to bad dreams, nightmares, sleep paralysis, environmental stimuli, or usual bodily changes become the trigger (i.e., the conditioned stimulus) of stronger panic attacks. For this triggering, the person does not need to be conscious.

RELATIONSHIP AND ANXIETY

Hyperventilation is the state of over-breathing more than the body needs.
Like many bodily functions, breathing rate is largely determined by the brain stem in the nervous system.

It is automatically adjusted by the respiratory center (medulla and pons).
However, unlike other bodily functions, besides this automatic control, the person also breathes voluntarily.

can increase the rate of exchange (as when inflating a balloon).

Interestingly, contrary to what most people think, the respiratory centers in the brain make adjustments based on the carbon dioxide level, not the oxygen level in the blood, in determining the body’s breathing rate.

The most important change seen during hyperventilation is the contraction or narrowing of some blood vessels in the body. In this case, a narrowing or narrowing occurs especially in the blood vessels going to the brain and the amount of blood going to the brain decreases.

In other words, in case of hyperventilation, less oxygen begins to reach certain parts of the brain and body, despite the fact that more oxygen is taken.

Hyperventilation

This leads to two sets of effects:

Symptoms that occur due to a slight decrease in the amount of oxygen going to some parts of the brain in the center (dizziness, stupor, confusion, shortness of breath, blurred vision, detachment from the environment);

Symptoms due to less oxygen reaching certain body parts in the environment (increased heart rate, numbness and pins-and-needles in the arms and legs, numbness, coldness in the hands and feet, and sometimes contractions in the arms and legs)

The decrease in the amount of oxygen reaching the tissues is extremely small and this is completely harmless.

Again, it should be remembered that hyperventilation (probably due to reduced oxygen supply to some parts of the brain) can cause shortness of breath, shortness of breath, and even suffocation, making the person feel as if they are not getting enough air.

The most important point to remember about hyperventilation is that it is not DANGEROUS.

It should be noted that far from being harmful, hyperventilation is a natural biological response that aims to protect the body from danger.

• Excessive breathing is physically tiring. For this reason, the person may become hot, hot and sweaty.

• Because breathing too much is tiring, it can cause a feeling of tiredness and burnout.

• People who breathe excessively and rapidly use diaphragm breathing instead of chest breathing while breathing. This results in tensing and fatigue of the chest muscles. For this reason, they may feel chest tightness or even severe chest pain.

• Individuals who breathe excessively have the habit of sighing and yawning repeatedly. These tics are actually another form of hyperventilation because large amounts of carbon dioxide are quickly excreted through the lungs during yawning or drinking. Therefore, when fighting this problem, it is important to recognize and try to reduce the habitual sighing and yawning.

Treatment

Medicine

Which drugs are used in the treatment?

Anxiolytic drugs (eg benzodiazepine, alprazolam) and antidepressant drugs with anti-panic effect can be used in panic disorder. Medication is usually effective as long as it is used. In some patients, panic attacks may recur within a certain period of time after drug treatment is stopped. Therefore, it is necessary to continue long-term antidepressants in a protective way. But generally, if drug treatment is started for the first time due to panic disorder, it takes a while to stop the drug and see if there is a recurrence. If there is recurrence, drug treatment or psychotherapy can be applied according to the preference of the person.

When do the drugs show their effect?
The effect of anti-panic antidepressants usually begins within 4-6 weeks. If a quicker effect is desired, anxiolytic (anxiety-relieving) drugs can be used during this 6-week waiting period, which relieves distress and has an immediate effect. When the effect of antidepressants begins, anxiolytics are gradually discontinued, and the path is continued only with antidepressants. Antidepressants and drugs used as anti-panic drugs can sometimes increase the anxiety of the person if they are given at high doses at the beginning of the treatment. For this reason, using these drugs requires a specialist’s advice, generally starting with a small dose and increasing the dose gradually.
How long does drug therapy take?
It lasts between 6 months and 1 year. The important thing is to stop avoiding avoidance and return to normal life completely during this period. The more they stop their avoidance and return to normal life, the less the risk of recurrence when the drug is stopped. However, no matter how successfully the drug is treated, there is a risk of recurrence after the drug treatment is stopped.

Psychotherapy

In psychotherapy, the therapist tries to resolve the person’s problematic feelings, thoughts or behaviors through the relationship he or she establishes with the client.

The type of therapy that has been shown to be effective in panic disorder by various scientific studies is cognitive behavioral psychotherapy. In this psychotherapy, it is tried to change the mechanisms in the field of perception, thought and behavior that maintain panic disorder.

In recent years, some studies have shown that psychodynamic therapies focused on panic disorder are also effective. However, considering the number of studies, it can be said that the most effective treatment is cognitive behavioral therapy.

When you see someone having a panic attack…

• Stand next to the person having a panic attack and stay calm.

• If he has a medicine he uses during his attacks, give him the medicine.

• Take the person to a calm and quiet place.

• Don’t try to anticipate what the person needs. Ask him what he needs.

• Talk to the person in short, simple sentences.

• Avoid surprises, keep your movements predictable.

• Have the person repeat the same physical movement and focus on that movement. (e.g. raising and lowering arms above head.)

• Breathe in and out with the person to slow their breathing. You can also count slowly from 10 as you breathe in.

These sentences you can say to someone who is having a panic attack can help.

• • • • •

•

You can overcome this.

You’re doing very well, I’m proud of you.

Now tell me what you need.

Focus on your breathing and just think about the present moment.

It’s not where you are right now that’s bothering you, it’s your thoughts.

The emotion you’re feeling right now is scary, but it can’t hurt you.

Source

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10.Tukel R (2002). Panic Disorder, Journal of Clinical Psychiatry; Annex 3: 5-13
11.Türkçapar H., (2004), “Diagnostic Relationships of Anxiety Disorder and Depression”, Clinical Psychiatry, Appendix 4 pp: 12-16.

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