The panic attack — it is unpredictable the arising attack of strong fear or the alarm which is combined with various vegetative polyorgan symptomatology. During an attack the combination of several following symptoms can be observed: , heartbeat, the complicated breath, a fever, inflows, fear of madness or death, nausea, dizziness, etc. As confirmation of the diagnosis serves compliance of clinic to diagnostic criteria of panic paroxysms and an exception of somatic pathology at which there can be similar attacks. Treatment represents a combination of psychotherapeutic and medicamentous methods of knocking over of the attack and therapy in the mezhkrizovy period, training and the patient's training in ways of independent overcoming paroxysms.
The name "panic attack" was entered by the American experts in 1980. Gradually it found wide circulation and now is included in the International classification of diseases (MKB-10). Earlier the term "emotional and vegetative crisis" was applied and similar paroxysms were considered within vegeto-vascular dystonia. In modern medicine there is a revision of the concept "panic attack". The understanding of primacy of a psychological factor and secondariness of vegetative symptoms resulted in need to carry such paroxysms to neurosises and accompanying them vegetative violations — to the vegetative dysfunction which is an integral part of neurotic frustration.
Panic paroxysms are a widespread problem. Statistical sources demonstrate that to 5% of the population faced similar states. The vast majority of them — residents of megalopolises. The most typical age of emergence of the first attack — 25-45 years. At advanced age the panic attack proceeds with considerably smaller symptomatology and prevalence of an emotional component. At some patients it is a recurrence of the paroxysms observed in youth.
The panic attack can arise as a single paroxysm or as a series of attacks. In the latter case it is about panic frustration. If earlier in domestic medicine the panic attack was a kuration subject only of neurologists, then today it is cross-disciplinary pathology, a subject of studying of psychology, psychiatry and neurology. Besides, psychosomatic coloring of attacks removes panic I attack in the category of the problems urgent for practicians in many other fields of medicine — cardiology, gastroenterology, endocrinology, pulmonology.
Allocate 3 groups of the factors capable to provoke emergence of the panic attack: psychogenic, biological and physiogene. In clinical practice it is noticed that the combination of several provocative triggers often works. And one of them are defining in emergence of primary attack, and others initiate repetitions of the panic attack.
Among psychogenic triggers conflict situations — a showdown, a divorce, scandal at work, withdrawal from a family, etc. are most significant. The sharp psychoinjuring events — accident, death close, a disease, etc. are on the second place. There are also abstract psychogenic factors influencing mentality on the mechanism of opposition or identification. Books, documentary and feature films, telecasts, various Internet materials concern to them.
Various hormonal reorganizations (mainly at women in connection with pregnancy, abortion, childbirth, a climax), the beginning of the sexual relations, reception of hormones, features of a menstrual cycle act as biological triggers (, ). It should be noted that the paroxysms caused by endocrine diseases — the hormonal and active tumors of adrenal glands (feokhromotsitom) and diseases of a thyroid gland proceeding with gipertireozy are not considered as the panic attack.
Sharp alcoholic intoxication, drug taking, meteorological fluctuations, acclimatization, excessive insolation, physical overstrain belong to physiogene triggers. Some pharmacological medicines are capable to provoke the panic attack. For example: steroids (Prednisolonum, dexamethasone, anabolic steroids); , used for introduction to an anesthesia; , the GIT applied in tool diagnostics of bodies.
As a rule, emergence of the panic attacks is observed at persons with certain personal qualities. For women it is demonstrativeness, dramatic character, desire to draw to themselves attention, expectation from others interest and participation. For men — initial uneasiness, the increased care of the health and, as a result, an excessive listening to a condition of the physical body. It is interesting, than to wish what people altruistic, more adjusted to give others for themselves, never face such problems as the panic attacks and other neurotic frustration.
Pathogenesis of the panic attack
There are several theories trying to explain the mechanism of start and deployment of the panic attack. Lack of a direct connection of a paroxysm with the psychoinjuring situation, inability of patients to define, than it was provoked, the prompt beginning and a current of an attack — all this considerably complicates work of researchers.
The disturbing feelings or thoughts which are imperceptibly "running" on the patient are considered as the starting moment of the attack. Under their influence as at really menacing danger, in an organism the increased development of catecholamines begins (including adrenaline) that HELL leads to narrowing of vessels and considerable rise. Even at patients with a normal premorbidny background arterial hypertension during the panic attack can reach 180/100 mm of mercury. There is tachycardia and increase of breath. In blood concentration of CO2 goes down, in fabrics the sodium lactate collects. The hyperventilation causes emergence of dizziness, feeling of a derealization, faintness.
In a brain there is a hyper activation of noradrenergichesky neurons. Besides, the cerebral hemoretseptor having sensitivity to a lactate and changes of gas composition of blood at a hyperventilation are activated. It is possible that along with it the neurotransmitters blocking the braking influence of GAMK on excitability of neurons are allocated. Increase of feeling of alarm and fear, strengthening of panic is result of the neurochemical processes happening in a brain.
Symptoms of the panic attack
Often the panic attack acts as a symptom of the main pathology — a somatic disease (IBS, neurocirculator dystonia, stomach ulcer of a stomach, a chronic adneksit and so forth) or a mental disorder (morbid depression, a depression, hysterical or disturbing neurosis, neurosis of persuasive states, schizophrenia). Its features are the polisimptomnost and dissociation between objective and subjective symptoms caused by psychological factors.
The panic attack is characterized by the sudden unpredictable beginning which is not connected with existence of real danger, the avalanche increase and gradual subsiding of symptomatology, existence of the poslepristupny period. On average the paroxysm proceeds about 15 min., but its duration can vary ranging from 10 min. till 1 o'clock. The peak of clinical manifestations is usually stated on the 5-10th minutes of the attack. After the postponed paroxysm patients complain of "weakness" and "devastation", often describe the feelings the phrase "as if the skating rink on me was passed".
Act as the most frequent manifestations at the panic attack: feeling of shortage of air, feeling of "lump" with a throat or suffocation, short wind, breath difficulty; a pulsation, interruptions or sinking heart, heartbeat, pains in heart. Perspiration, passing on a body of cold or hot waves, a fever, dizziness, paresteziya, a polyuria at the end of an attack is in most cases noted. Symptoms from a GIT are less often observed — nausea, an eructation, vomiting, discomfort in an epigastriya. Many patients point to cognitive violations — feeling of faintness in the head, unreality of objects (derealization), feeling "as if are in an aquarium", impression of a priglushennost of sounds and instability of surrounding objects, loss of feeling own I am (depersonalization).
The emotional and affective component of the panic attack can vary both on type, and on intensity. In most cases the first panic attack is followed by the expressed fear of death reaching on the intensity an affective state. In the subsequent attacks it is gradually transformed to a concrete phobia (fear of a stroke or heart attack, fear of madness, etc.) or internal tension, feeling of inexplicable alarm. At the same time at some patients panic paroxysms in which is absent disturbing a component are observed, and the emotional component is presented by feeling of a hopelessness, melancholy, depression, pity to itself and so forth, in some cases — aggression to people around.
In structure of the panic attack functional neurologic symptoms can be interspersed. Among them there is a feeling of weakness in a separate extremity or its sleep, disorder of sight, an aphonia, a mutizm, development of a fever into a tremor, separate giperkineza, tonic violations with a reversing of hands and legs, a skryuchivaniye of hands, elements of "a hysterical arch". There can be an unnatural change of gait of the patient more reminding a psychogenic ataxy.
Distinguish the developed panic attack which is shown 4 and more clinical symptoms and abortive (small) in which clinic less than 4 symptoms are observed. At one patient alternation of the developed and abortive panic paroxysms is often noted. And the developed attacks happen from 1 time in several months to 2-3 times a week, and abortive are noted much more often — to several times a day. Only in some cases only the developed paroxysms take place.
The period between panic paroxysms can have various current. At one patients vegetative dysfunction is expressed minimum and they feel absolutely healthy. At others psychosomatic and vegetative frustration so intensive that they with difficulty can differentiate the panic attack from the mezhkrizovy period. The clinical picture of an interval between the attacks is also widely variable. It can be presented by the complicated breath, short wind, feeling of shortage of air; arterial hypo - and hypertensia, a kardialgichesky syndrome; meteorizm, lock, diarrhea, abdominal pains; periodic oznoba, subfebrilitety, gipergidrozy; dizzinesses, inflows, headache, hypothermia of brushes and feet, akrotsianozy fingers; artralgiya, musculotonic syndromes; emotional and psychopathological manifestations (astenovegetativny, ipokhondrichesky, disturbing , hysterical).
Eventually at patients the restrictive behavior progresses. Because of fear of repetition of the panic attack patients try to avoid the places and situations connected with emergence of the previous paroxysms. So there is a fear to go in a certain type of transport, to be at work, to stay at home to one, etc. Expressiveness of restrictive behavior is important criterion for evaluation of weight of panic frustration.
Diagnostics of the panic attack
Clinical inspection of the patient at the time of a panic paroxysm reveals objective symptoms of vegetative dysfunction. It is pallor or face reddening, increase (to 130 beats/min) or delay (to 50 beats/min) pulse, rise HELL (to 200/115 mm of mercury.), in some cases — arterial hypotonia to 90/60 mm of mercury., change of a dermografizm and orthostatic test, violation glazoserdechny (reduction of ChSS when pressing on the closed eyes) and pilomotorny (reduction of voloskovy muscles of skin in response to her irritation) reflexes. During the period between the attacks objective signs of vegetative violations can be also noted. The research of the neurologic status does not define any serious deviations.
The patients who transferred the panic attack have to undergo the comprehensive psychological examination including a research of structure of the personality, neuropsychological and patopsikhologichesky inspection. Polysystemacity of manifestations of panic paroxysms causes a wide range of the additional inspections necessary for an identification/exception of a background disease and differential diagnostics.
Depending on clinical manifestations of the attack to the patient can be appointed: ECG, daily monitoring of the ECG and HELL, phonocardiography, ultrasonography of heart, X-ray analysis of lungs, research of level of hormones of a thyroid gland and catecholamines, EEG, Ekho-EG, X-ray analysis of cervical department of a backbone, MRT of a brain, UZDG of cerebral vessels, FGDS, research of gastric juice, ultrasonography of an abdominal cavity. Often adjacent consultations of narrow experts — the psychiatrist, the cardiologist, the ophthalmologist, the gastroenterologist, the pulmonologist, the endocrinologist are required.
The diagnosis "the panic attack" is established in case of repeated emergence of the paroxysm reaching the peak of the manifestations within 10 min. which is followed by emotional and affective frustration in the range for intensive fear to discomfort in combination with 4 and more of below-mentioned symptoms: the speeded-up or strengthened heartbeat, a fever or a tremor, , dryness in a mouth (not connected with dehydration), thorax pain, breath difficulty, "lump" in a throat, suffocation, abdominal discomfort or dyspepsia, dizziness, depersonalization, a derealization, a preunconscious state, fear of death, fear to go crazy or lose control over itself, inflows of cold and heat, a paresteziya or a sleep. Existence at least of one of the first 4 symptoms is considered obligatory.
Except the listed symptoms also others can be observed: gait change, disorder of hearing and sight, pseudo-paresis, spasms in extremities, etc. These manifestations belong to atypical. Existence in clinic of a panic paroxysm of 5-6 such symptoms calls the diagnosis into question. The single panic attack developing as psychogenic reaction against the background of a psychological or physical overstrain, exhaustion after a long disease, etc. is not treated as a disease. It is necessary to speak about development of a disease at the repeated attacks which are followed by formation of psychopathological syndromes and vegetative frustration.
Treatment of the panic attack
As a rule, the panic attack is treated by joint efforts of the neurologist and psychologist (psychotherapist). Among methods of psychotherapy cognitive and behavioural therapy is most productive, according to indications the family and psychoanalytic psychotherapy is applied. The fundamental moment is the belief of the patient that the panic attack does not threaten his life, is not display of a serious illness and can independently be controlled by it. Revision by the patient of the relation to many life situations and people is important for recovery.
Among numerous non-drug control methods of symptoms of the attack also breath effective control is simplest. In the beginning it is necessary to make the deepest breath, then to hold the breath for a couple of minutes and to make the smooth gradual slowed-down exhalation. On an exhalation it is better to close eyes and to relax all muscles. Similar breathing exercise is recommended to repeat to 15 times, it is possible with some breaks on several usual breaths exhalations. Special training of the patient in methods of the slowed-down and quiet breath allows it to stop a hyperventilation during an attack and to interrupt a vicious circle of development of a paroxysm.
In medicamentous therapy use tetra-and tritsiklichesky antidepressants (, , , , , ). However their effect begins to be shown only in 2-3 weeks and reaches a maximum approximately by 8-10 week of treatment; in the first 2-3 weeks of therapy the aggravation of symptoms is possible. And suitable for long-term treatment serotonin capture inhibitors are considered the safest (, , fluoxetine, , tsipramit). But in the first weeks of their reception the insomniya, irritability, increase in uneasiness can be observed.
Benzodiazepines (clonazepam, to alprozala) which are characterized by bystry efficiency and lack of strengthening of symptomatology at the beginning of therapy act as medicines of the choice. Their shortcomings are low efficiency concerning depressive frustration, the possible formation of benzodiazepinovy dependence which is not allowing to apply medicines longer than 4 weeks. Benzodiazepines of bystry action (lorazepam, diazepam) were the most suitable for knocking over of already developed paroxysm.
Selection of pharmacotherapy of panic paroxysms is the complex challenge demanding the accounting of all psychological features of the patient and clinical symptoms of a disease. Duration of a medicamentous course, as a rule, makes not less than half a year. Cancellation of medicine is possible against the background of a full reduction of alarm of expectation if the panic attack was not observed within 30-40 days.
The current and weight of the panic attack in many respects is defined by personal features of the patient and reaction of people around. More bystry development and the heavy course of panic frustration is observed if the first panic attack was apprehended by the patient as a complete disaster. Sometimes weighting of a situation is promoted by the wrong reaction of physicians. For example, hospitalization of the patient on ambulance, testifies in his understanding about existence of serious problems with health and danger to life of the happened attack with it.
In the predictive plan an important point is as much as possible earlier the initiation of treatment. Each subsequent panic attack aggravates a condition of the patient, is perceived by it as the proof of existence of a serious illness, fixes fear of expectation of an attack and forms restrictive behavior. Untimely and inexpedient medical actions promote progressing of panic frustration. The timely adequate therapy which is combined with correctly directed efforts of the patient usually leads to recovery, and at a chronic current — to minimization of clinical manifestations and frequencies of the attacks.