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Panic Attack: Disorder of the modern era!

Today, Panic Disorder is the most common psychiatric disorder following depression .  Panic Disorder, becoming widespread due to reasons such as the national disasters and economic crises experienced in recent years in our society, has an adverse effect on the social lives of many adults in the modern world. People have difficulty in adapting and coping with the new conditions and situations which they encounter, and may experience a resulting concern or panic. While it can arise at a later age, this disorder that arises as a result of events that are seen as a future crisis threat (natural disasters, separation, death of a loved one, etc) generally appears in early or late 20s.

Panic Attack and its indicators: 
We can define panic attacks as “intensive distress and fear spells that begin instantly, sometimes repeat, and leave the individual in desperation and fear”. According to the system of definition and classification of mental disorders published by American Psychiatry Association in 2000 (DSM-IV-TR), in order to diagnose panic attacks, four or more of the below-mentioned symptoms must be present. Panic attack starts with four or more symptoms together and reaches to the highest level within 10 minutes along with an intensive fear or distress condition. The following are among these symptoms:

1. Throb, sensation of heart beatings or increase of heart rate
2. Sweating
3. Tremble or shaking
4. Shortness of breath or sense of drowning
5. Gasping
6. Chest pain or distress feeling on chest
7. Nausea or stomach ache
8. Vertigo, feeling of dizziness 
9. Derealization or depersonalization
10. Fear of losing control or getting mad
11. Fear of death
12. Paresthesia (pins and needles sensations)
13. Chills, shivers or going hot all over

Again according to DSM-IV-TR, the main quality of Panic Disorder is the constant concern towards the generation of another panic attack for at least 1 month after the unexpected repeating panic attacks, feeling sad about the possible results of panic attacks and showing considerable behavioral change related to attacks. For example, a person who had a panic attack in a crowded shopping center may avoid going to such places in order not to experience a similar condition once more or they may travel with a bottle of water as a security measure with the fear of experiencing a panic attack anytime as they believe it will relieve them during a panic attack. Their panic attacks are not affiliated with the results of certain conditions causing similar symptoms. For example, excessive caffeine consumption or physiological impacts of a general medical condition like hyperthyroidism may create similar symptoms like panic attack. Thus, the individual consulting a specialist with panic attack complaints should first get a general medical control together with a history of substance usage (coffee, cigarette, alcohol etc.). 

Types of panic attacks happening in Panic Disorder:
1. Unexpected Panic Attacks: They are the attacks arousing by themselves without any reason or triggering factors. At least two unexpected panic attacks should be present in order to make a diagnosis, yet more attacks are seen in majority of people.
2. Panic Attacks According to Condition: They are the attacks arousing right after encountering a conditional trigger (inside a crowded shopping center, inside a vehicle in a traffic jam, etc.) almost all the time. People with Panic Disorder have panic attacks that show conditional tendency most of the time.

According to DSM-IV-TR, the frequency and intensity of panic attacks change considerably. For example, some people have moderate frequency (like once a week) that arouse regularly for months. Meanwhile, others may have attacks with less frequency (two times per month) for years or they may have no attacks for weeks or months. They talk about less frequent (every day for a week) attacks as “explosions”.
Certain conditions that cause panic attack
-Panic Disorder
-Phobias
-Hypochondriasis
-Post Traumatic Stress Disorder
-Obsessive Compulsive Disorder
-Other anxiety disorders
-Paranoia
-Schizophrenia
-Acute Stress Disorder

People with Panic Disorder experience physiological problems such as tachycardia, asphyxiation, feeling of faint, chest pain along with death, maniaphobia, loss of control fears during the panic attack. It is frequently encountered that patients having panic attacks besides these cardiovascular symptoms go to emergency services instead of psychiatric units thinking that they are having a heart attack. Many patients suffering from panic attacks, who are afraid of the presence of a vital undiagnosed disease, cannot be persuaded that they do not have a life-threatening disease, despite the assurances given by the doctors along with all medical examinations. Patients, who do not believe that they don’t have a physical problem, continue to look for a doctor repeatedly to be diagnosed. Such pursuits affect the economic status negatively, besides they reduce the quality of life in many fields such as emotional and relations with other people.     

Mentality in Panic Disorder: 

The mentality system following the sensation of a patient with Panic Disorder is given in below chart:

One of the most fearsome characteristics of panic attack is the feeling of loss of control. The patient, who has to show great effort not to lose focus, concentration, attention and motion control, also experiences an intense fear of death, due to the unexpected and unexplained physical sensations.The patient perceives this physical stress as a physical disorder, worries more; as a consequence, an increase is observed in their symptoms and an inevitable vicious cycle commences. We can clearly see the situation that we call the “vicious cycle of sensation-thought-emotional” of a patient having an attack in the following vitalization:

“Increase in heartbeat (sensation) - Here we go again! (thought) - worry (emotion) – Increasing difficulty in breathing (sensation) - It’s getting worse! (thought) - Fear (emotion) - Hot flush, sweating (sensation) - I am out of control! (thought) - Fear, crying (emotion) – numbness in arm and leg (sensation) - I am going to faint! (thought) - Self concentration (emotion) - Chest tightness (sensation) - I lost consciousness, I’m going to die! (thought)” Once again, the words “I feel strange”, “I feel like I am not here”, “I split up”, “This is the worst experience I have ever experienced” that we hear from the patient at the moment of the attack shows how confused the patient is, that they may lose their orientation and feel miserable.

Three factors play a role in the continuation of the disease along with the occurrence of panic attacks:

-Selective attention to the changes that occur in the body: The patient, who is afraid of the sensations he/she experiences, becomes more attentive than normality and begins to examine his/her body constantly. This internal focalization causes a number of sensations that many people cannot generally notice. The person, as soon as they realize it, begins to think that they have a serious physical or mental disorder.

Example: Auscultation of heart, taking the pulse, frequently measuring blood pressure etc.
-Security Behaviors: Patient displays behavior that makes them feel at ease during an attack. For instance, a patient, who is afraid of losing consciousness and fainting, can hold on to somewhere close. Such behaviors also support negative interpretations that the person has related to the disease. Taking this example into account, the patient, who holds on to a chair in order not to fall, can attribute the reason for not fainting to holding on to the chair. As a consequence of all of these, an increase may also be seen in symptom perception.

Example: Going out with someone reliable, carrying the phone numbers of hospitals and doctors, carrying water, referring often to physicians or emergency services of hospitals.

-Avoidance: A panic attack patient, who is worried about a heart attack, may avoid doing activities that they think exhausts the heart like sports and having sex. The patient attributes the reason for not having a heart attack to avoidance; thus this belief prevents the patient not to realize the reality that they don’t actually have a physical ailment.    

Example: Not to go out of the house, not to have a bath, not to get in public transportation, not to enter in crowded shopping malls etc.

Mode of Treatment:

Panic Disorder can be treated to a large extent as a result of an accurate implementation. While only psychotherapy is sufficient in newly started or mild cases, clinical studies have proven that an intervention consisting of a combination of pharmacological and psychotherapeutic treatments is often efficient in the treatment of this disorder.Thus, the initial evaluation should definitely be carried out by a clinical psychiatrist, and the psychologist should come into play afterwards.

In the treatment, three basic approaches are applied as pharmacological, psychodynamic and cognitive-behavioral therapy.

Pharmacology: Drug use is frequently utilized as an alternative to cognitive-behavioral therapy and/or in company with the therapy. Although the use of short-term medication is very useful in the treatment of acute attacks, it should never become a habit and should be avoided from long-term treatment since the drug tolerance (the necessity of use of an increased dosage to achieve the same effect) and the development of addiction is high. 
Panic Focused Psychodynamic Psychotherapy (POPP): The therapist investigates the subconscious meaning and significance of the attacks and fantasies experienced by the patient after informing and persuading the patient that the frightening physical senses are not a sign of any life-threatening physical disorder. POPP is comprised of 3 groups.
1. Relieving symptoms of panic attacks: The goal of the treatment at this stage is to research and investigate the symptoms of panic.
2. Preventing reoccurrence of panic attacks: In the second phase, attempts are tried to be prevented the recurrence /repetition of the disease through further investigation of internal conflict and dynamism based on the experienced panic.
3. Functional disorder: In this phase, the termination of treatment, the problem of separation and anger within the framework of the relation of the patient with the therapist is examined.

Cognitive-Behavioral Psychotherapy (BDP): As understood by the name, the cognitive and behavioral techniques are applied together in this treatment.The purpose of using these techniques is to define and change the anxiety creating irregular and dysfunctional thoughts and beliefs that the patient has related to the anxiety.The experienced anxiety is tried to be normalized after being accustomed to the opinion that the beliefs and thoughts of the patient contribute to the panic attack. It is especially emphasized that the factors that sustain Panic Disorder in the CBD (selective attention, safety and avoidance behaviors to the changes occurred in the body) are reversed. The evaluation phase is important at the initial stage of treatment. The evaluation examines the following:
-Brief description of the experienced problem,

- Medications used,

- Previous treatments,

- Personal characteristics of the patient,

-Social and financial status of the patient

During the assessment, the therapist will review a number of areas including:

-Detailed description of the most recent panic attack experience to examine vicious cycle links,

-Description of the triggering factors of panic attacks,

-Changing the false interpretation of patients about the issue through examining the true cause and effect of panic attack symptoms by using cognitive methods and behavioral techniques,

- Working on the images (imagining the situation) at points where the oral techniques are inadequate,
-Overcoming the escape and safety behaviors,

- The removal of other psychological obstacles that may exist in order to ensure the progress,

-Preventing the reoccurrence. 

While the behavioral experiments include hyperventilation, body focus, other symptom-generating physical exercises and relaxation exercises, the techniques of cognitive method used in CBT include techniques such as identifying negative thoughts, informing, attracting attention, and verbal fight with the automatic thoughts of the patient. 

REMEMBER! Panic Disorder is one of the diseases with the highest rank of treatment, in case the patients with Panic Disorder believe that they are able to overcome this disorder and in case of the implementation of one of the abovementioned treatments or their combination is conducted under the supervision of a specialist.