Panic attacks are episodes of sudden and intense fear or a rapid escalation of the anxiety normally present. They are accompanied by somatic and cognitive symptoms. For example palpitations, sudden sweating, tremor, feeling of choking, chest pain, nausea, dizziness, fear of dying or going crazy, chills or hot flashes. Those who have experienced panic attacks describe them as a terrible experience, often sudden and unexpected, at least the first time. It is obvious that the fear of a new attack immediately becomes strong and dominant. Let’s discover more about Panic Attacks symptoms and treatment of the most common anxiety disorder.

What are panic attacks

The single episode, therefore, easily results in a real panic disorder , more for “fear of fear” than anything else. The person quickly finds himself embroiled in a tremendous vicious circle that often leads to the so-called “agoraphobia”. That is, the anxiety about being in places or situations from which it would be difficult or embarrassing to walk away, or where help may not be available, in the event of an unexpected panic attack.

With the fear of panic attacks it becomes difficult and anxious to do even basic things in life. For example, leaving the house alone travel by train, bus or drive a car. Things like standing in crowd or in a queue are very common too.

The avoidance of all potentially anxious situations becomes the prevailing modality and the patient becomes a slave to panic. He often forces all family members to adapt accordingly, to never leave him alone and to accompany him everywhere. The result is a sense of frustration that comes from being “big and fat” but dependent on others, which can lead to secondary depression.

Characteristics of panic disorder

The essential feature of panic disorder is the presence of recurrent and unexpected attacks. These are followed by at least 1 month of persistent worry about having another panic attack.

The person worries about the possible implications or consequences of anxiety attacks and changes their behavior as a result of the attacks. Primarily he avoids situations where he fears that they may occur.

The first panic attack is generally unexpected. Therefor, it occurs “out of the blue”, for which the subject is enormously frightened and often goes to the emergency room. Then they can become more predictable.

Diagnosis of panic disorder

At least two unexpected panic attacks require for diagnosis, but most individuals have many more.

Individuals with Panic Disorder display characteristic concerns or interpretations about the implications or consequences of panic attacks. Concern about the next attack or its implications often associated with the development of avoidance behaviours. These can determine a real Agoraphobia , in which case Panic Disorder with Agoraphobia is diagnosed.

Attacks are usually more frequent in stressful times . Some life events can in fact act as precipitating factors, even if they do not necessarily indicate a panic attack . Among the most commonly reported precipitating life events are:

• marriage or cohabitation
• the break up
• the loss or illness of a significant person
• being a victim of some form of violence
• financial and work problems

The first attacks usually occur in agoraphobic situations (such as driving alone or traveling on a city bus) and often in some stressful context. Stressful events, agoraphobic situations, heat and humid climatic conditions, psychoactive drugs can in fact give rise to abnormal bodily sensations. These can be interpreted catastrophically, increasing the risk of developing panic attacks .

Symptoms of panic attack

The panic attack has a sudden onset, peaks quickly (usually within 10 minutes or less), and lasts about 20 minutes (but sometimes much less or longer).

Typical symptoms of panic attacks  are:

• Palpitations / tachycardia (irregular, heavy heartbeats, shaking in the chest, feeling the pounding in the throat)
• Fear of losing control or going crazy (for example, fear of doing something embarrassing in public or fear of running away when panic strikes or losing your temper)
• Sensations of dizziness, instability ( dizziness and vertigo )
• Fine or large tremors
• Sweating
• Feeling of suffocation
• Chest pain or discomfort
• Feelings of derealization (perception of the outside world as strange and unreal, feelings of light headedness and detachment) and depersonalization (altered perception of self characterized by a feeling of detachment or estrangement from one’s own thought processes or from the body)
• Chills
• Hot flashes
• Paresthesia (feelings of numbness or tingling)
• Nausea or abdominal discomfort
• Feeling of asphyxia (tightness or lump in the throat)

Intensity and course of panic symptoms

Not all symptoms are necessary for a panic attack . There are many attacks that characterize only or in particular by some of these symptoms. The frequency and severity of symptoms varies widely over time and circumstances.

For example, some individuals have moderately frequent attacks (eg, once a week), which occur regularly for months. Others report short series of attacks that are more frequent, perhaps with less intense symptoms (eg, daily for a week). These are interspersed with weeks or months without attacks or with less frequent attacks (eg, two every month) for many years.

There are also the so-called paucisymptomatic attacks , very common in individuals with Panic Disorder , which are attacks in which only part of the symptoms of panic occur, without exploding into a real attack. Most individuals with paucisymptomatic symptoms, however, have had complete panic attacks, with all the classic symptoms, at some time during the course of the disorder.

Concerns associated with panic attack

During a panic attack , automatic and uncontrolled catastrophic thoughts fill the person’s mind. She therefore has difficulty thinking clearly and fears that these symptoms are really dangerous. Some fear that the attacks indicate the presence of an undiagnosed, life-threatening disease (eg, heart disease, epilepsy). Despite repeated medical tests and reassurance, they may remain fearful and convinced that they are physically vulnerable.

Others fear that the symptoms of a panic attack indicate that they are “going crazy” or losing control, or that they are emotionally weak and unstable.

Panic Disorder Treatment

Psychotherapy for panic attacks

In the treatment of panic attacks with or without agoraphobia and anxiety disorders in general, the form of psychotherapy that scientific research has shown to be most effective is the “cognitive-behavioural” one.

It is a relatively short psychotherapy, usually on a weekly basis, in which the patient plays an active role in solving his problem. Together with the therapist, he focuses on learning the ways of thinking and behaviour that are more functional to the treatment of panic attacks. This is in order to break the vicious circles of the disorder.

For panic and agoraphobia, a treatment based on cognitive behavioural therapy is highly recommendable and first choice. Basically it is contraindicated to rely on drugs or other forms of psychotherapy without undertaking this form of treatment. The entire scientific community has in fact proved to be the most effective for the treatment of panic disorder .

Fundamental steps of psychotherapy

Cognitive techniques

In therapy, therapists use verbal strategies to modify automatic catastrophic thoughts (eg, I will have a heart attack, faint, etc.). This means that over time the person learns not to be afraid of the physical sensations of anxiety. Not being afraid of them, learning to live with them simply by waiting for them to pass, avoids the escalation of anxiety that leads to panic.

Behavioral techniques

Verbal strategies are associated with techniques aimed at modifying the problematic behaviors that maintain the disorder. First of all, it is necessary to gradually counteract the tendency to avoid feared situations (i.e. those from which there is no immediate escape route). It also serves to help the subject to expose himself to physical sensations that alarm him (e.g. tachycardia) through exercises in sessions and the resumption of avoided activities. For example, you accompany the patient on a path where having a coffee, running up the stairs, playing sports, etc., must become part of his life again. Finally, it is necessary to gradually abandon the so-called “protective behaviors”, which give illusory security. First of all, being accompanied by others, but also bringing along the drops of anxiolytic, the bottle of water or the mobile phone.

Experiential techniques

Finally, relaxation techniques and above all strategies that increase the subject’s ability to accept negative emotions can be useful. In particular, mindfulness meditation and the experiential techniques typical of Acceptance and Commitment Therapy (ACT) .

Further interventions

First of all, it is necessary to recover the freedom to move independently and obtain a sense of mastery over the panic phenomenon. Then the therapy can proceed by working on historical elements that have made the subject vulnerable. Therefore, the reconstruction of the life story, of the meaningful ties, of the sentimental and social relationships are important. Examine trauma, including the first experience of a panic attack. Techniques to process them emotionally, such as EMDR , may be employed .

Medicines for panic attacks

The pharmacological treatment of panic and agoraphobia , although often inadvisable (at least as a single treatment), is basically based on two classes of drugs: benzodiazepines and antidepressants , often used in combination.

In mild forms, the prescription of benzodiazepines alone may be sufficient as a temporary cure, but difficult to resolve. The most commonly used molecules are alprazolam, etizolam, clonazepam, lorazepam. These drugs, however, in the case of panic attacks and agoraphobia, are likely to be highly addictive and maintain the disorder. This is especially true if cognitive behavioural psychotherapy is not performed in parallel.

Tricyclics – TCAs – (e.g. chlorimipramine, imipramine, desimipramine), mono amino oxidase inhibitors (MAOIs) and especially selective serotonin reuptake inhibitors – SSRIs have proven effective in treating panic attacks and agoraphobia . – (e.g. citalopram, escitalopram, paroxetine, fluoxetine, fluvoxamine, sertraline), widely used today.

In fact, this last class of drugs presents, compared to the previous ones, greater handling and fewer side effects.

In cases of panic attacks and agoraphobia that do not respond to SSRI treatment, TCAs may used, although many clinicians use these molecules as their first use therapy.

MAOIs, despite being very effective drugs, have almost completely fallen into disuse due to the serious side effects that can occur if there is the association of some molecules or if the prescribed dietary restrictions are not respected.