Panic attack

Panic attacks are sudden periods of intense that may include, sweating, shaking, , numbness, or a feeling that something bad is going to happen. The maximum degree of symptoms occurs within minutes. Typically they last for about 30 minutes but the duration can vary from seconds to hours. There may be a fear of losing control or. Panic attacks themselves are not typically dangerous physically.

Panic attacks can occur due to a number of disorders including, , , , , and medical problems. They can either be triggered or occur unexpectedly. ,, and increase the risk of having a panic attack. Before diagnosis, conditions that produce similar symptoms should be ruled out, such as, , , , and drug use.

Treatment of panic attacks should be directed at the underlying cause. In those with frequent attacks, or  may be used. Breathing training and muscle relaxation techniques may also help. Those affected are at a higher risk of.

In Europe about 3% of the population has a panic attack in a given year while in the United States they affect about 11%. They are more common in females than males. They often begin during or early adulthood. Children and older people are less commonly affected.

Signs and symptoms
People with panic attacks often report a fear of dying or, flashing vision, or , numbness throughout the body, heavy breathing and , or loss of body control. Some people also suffer from, mostly due to blood flow leaving the head to more critical parts of the body in defense. These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the "", in which the hormone causing this response is released in significant amounts). This response floods the body with, particularly (adrenaline), which aid it in defending against harm.

A panic attack can result when up-regulation by the (SNS) is not moderated by the parasympathetic nervous system (PNS). The most common symptoms include, , s,  (or chest tightness), es, cold flashes, burning sensations (particularly in the facial or neck area), , ,  (or slight ), , , s (tingling sensations), sensations of  or , difficulty moving, and. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased and forms a  loop.

and are the predominant symptoms. People experiencing a panic attack may incorrectly attribute them to a and thus seek treatment in an. Because chest pain and shortness of breath are hallmark symptoms of cardiovascular illnesses, including and  (heart attack), a  (ruling out other conditions) must be performed before diagnosing a panic attack. It is especially important to do this for people whose mental health and heart health statuses are unknown. This can be done using an and mental health assessments.

Panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature. They are often experienced in conjunction with anxiety disorders and other conditions, although panic attacks are not generally indicative of a.

Causes
There are long-term, biological, environmental, and social causes of panic attacks. In 1993, Fava et al. proposed a staging method of understanding the origins of disorders. The first stage in developing a disorder involves predisposing factors, such as genetics, personality, and a lack of wellbeing. Panic disorder often occurs in early adulthood, although it may appear at any age. It occurs more frequently in women and more often in people with above-average intelligence. Various where one identical twin has an anxiety disorder have reported a 31–88% incidence of the other twin also having an anxiety disorder diagnosis.

Biological causes may include, , , , , , , , and inner ear disturbances. Dysregulation of the in the, an area of the brain stem, has been linked to panic attacks.

Panic attacks may also occur due to short-term stressors. Significant personal loss, including an emotional attachment to a romantic partner, life transitions, and significant life changes may all trigger a panic attack to occur. A person with an anxious temperament, excessive need for reassurance, hypochondriacal fears, overcautious view of the world, and cumulative stress have been correlated with panic attacks. In adolescents, social transitions may also be a cause.

People will often experience panic attacks as a direct result of exposure to an object/situation that they have a for. Panic attacks may also become situationally-bound when certain situations are associated with panic due to previously experiencing an attack in that particular situation. People may also have a cognitive or behavioral predisposition to having panic attacks in certain situations.

Some maintaining causes include avoidance of panic-provoking situations or environments, anxious/negative ("what-if" thinking), mistaken beliefs ("these symptoms are harmful and/or dangerous"), and withheld s.

Hyperventilation syndrome may occur when a person breathes from the chest, which can lead to overbreathing (exhaling excessive in relation to the amount of  in one's ). can cause and. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms, including rapid, , and , which can trigger panic attacks.

Panic attacks may also be caused by substances. Discontinuation or marked reduction in the dose of a substance such as a drug, for example an antidepressant , can cause a panic attack. According to the Harvard Mental Health Letter, "the most commonly reported side effects of smoking marijuana are . Studies report that about 20% to 30% of recreational users experience such problems after smoking marijuana."

A common denominator of current psychiatric approaches to panic disorder is that no real danger exists, and the person’s anxiety is inappropriate.

Panic disorder
People who have repeated, persistent attacks or feel severe anxiety about having another attack are said to have panic disorder. Panic disorder is strikingly different from other types of s in that panic attacks are often sudden and unprovoked. However, panic attacks experienced by those with panic disorder may also be linked to or heightened by certain places or situations, making daily life difficult.

Agoraphobia
is an which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape. Panic attacks are commonly linked to agoraphobia and the fear of not being able to escape a bad situation. As the result, severe sufferers of agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place". The word "agoraphobia" is an English adoption of the words  (αγορά) and  (φόβος). The term "agora" refers to the place where ancient Greeks used to gather and talk about issues of the city, so it basically applies to any or all public places; however the essence of agoraphobia is a fear of panic attacks especially if they occur in public as the victim may feel like he or she has no escape. In the case of agoraphobia caused by or, sufferers may be very embarrassed by having a panic attack publicly in the first place. This translation is the reason for the common misconception that agoraphobia is a fear of open spaces, and is not clinically accurate. Agoraphobia, as described in this manner, is actually a symptom professionals check for when making a diagnosis of.

People who have had a panic attack in certain situations may develop fears, called phobias, of these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with.

Experimentally induced
Panic attack symptoms can be experimentally induced in the laboratory by various means. Among them, for research purposes, by administering a bolus injection of the cholecystokinin-tetrapeptide. Various animal models of panic attacks have been experimentally studied.

Neurotransmitter imbalances
Many s are affected when the body is under the increased stress and anxiety that accompany a panic attack. Some include, (gamma-aminobutyric acid), ,  and. More research into how these neurotransmitters interact with one another during a panic attack is needed to make any solid conclusions, however.

An increase of serotonin in certain pathways of the brain seem to be correlated with reduced anxiety. More evidence that suggests serotonin plays a role in anxiety is that people who take s tend to feel a reduction of anxiety when their brain has more serotonin available to use.

The main inhibitory neurotransmitter in the (CNS) is GABA. Most of the pathways that use GABA tend to reduce anxiety immediately.

Dopamine’s role in anxiety is not well understood. Some s that affect dopamine production have been proven to treat anxiety. However, this may be attributed to dopamine’s tendency to increase feelings of self-efficacy and confidence, which reduce anxiety in an indirect way.

Many physical symptoms of anxiety, such as rapid heart rate and hand tremors, are regulated by norepinephrine. Drugs that counteract norepinephrine’s effect may be effective in reducing physical symptoms of a panic attack.

Because glutamate is the primary excitatory neurotransmitter involved in the central nervous system (CNS), it can be found in almost every neural pathway in the body. Glutamate is likely involved in conditioning, which is the process by which certain fears are formed, and extinction, which is the elimination of those fears.

Pathophysiology
The symptoms of a panic attack may cause the person to feel that their body is failing. The symptoms can be understood as follows. First, there is frequently the sudden onset of fear with little provoking stimulus. This leads to a release of (epinephrine) which brings about the  when the body prepares for strenuous physical activity. This leads to an increased heart rate, rapid breathing which may be perceived as shortness of breath , and sweating. Because strenuous activity rarely ensues, the leads to a drop in  levels in the s and then in the. This leads to shifts in blood ( or ), causing compensatory  activating  mechanisms which translate this  shift into autonomic and respiratory responses.

Moreover, this and release of  during a panic attack cause  resulting in slightly less  to the head which causes  and. A panic attack can cause to be drawn away from the  and toward the major muscles. suggests heightened activity in the, , , and regions including the , , and. In particular, the has been suggested to have a critical role. The combination of increased activity in the (fear centre) and  along with decreased blood flow and blood sugar in the brain can lead to decreased activity in the  (PFC) region of the brain. There is evidence that having an anxiety disorder increases the risk of cardiovascular disease (CVD). Those affected also have a reduction in heart rate variability.

Cardiovascular disease
People who have been diagnosed with panic disorder have approximately double the risk of coronary heart disease. Certain stress responses to depression also have been shown to increase the risk and those diagnosed with both depression and panic disorder are nearly three times more at risk.

Diagnosis
diagnostic criteria for a panic attack include a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within minutes:


 * Palpitations, and/or accelerated heart rate
 * Sweating
 * Trembling or shaking
 * Sensations of shortness of breath or being smothered
 * Feeling of choking
 * Chest pain or discomfort
 * Nausea or abdominal distress


 * Feeling dizzy, unsteady, lightheaded, or faint
 * Derealization (feelings of unreality) or depersonalization (being detached from oneself)
 * Fear of losing control or going insane
 * Sense of impending doom
 * Paresthesias (numbness or tingling sensations)
 * Chills or hot flashes

In DSM-5, culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Some or all of these symptoms can be found in the presence of a.

Screening tools such as the can be used to detect possible cases of disorder and suggest the need for a formal diagnostic assessment.

Treatment
Panic disorder can be effectively treated with a variety of interventions, including psychological therapies and medication. has the most complete and longest duration of effect, followed by specific. A 2009 review found positive result from therapy and medication and a much better result when the two were combined.

Lifestyle changes
may cause or exacerbate panic anxiety. Anxiety can temporarily increase during withdrawal from caffeine and various other drugs.

Increased and regimented aerobic exercise such as running have been shown to have a positive effect in combating panic anxiety. There is evidence that suggests that this effect is correlated to the release of exercise-induced and the subsequent reduction of the stress hormone.

There remains a chance of panic symptoms becoming triggered or being made worse due to increased respiration rate that occurs during aerobic exercise. This increased respiration rate can lead to hyperventilation and, which mimics symptoms of a heart attack, thus inducing a panic attack. Benefits of incorporating an exercise regimen have shown best results when paced accordingly.

Muscle relaxation techniques are useful to some individuals. These can be learned using recordings, videos, or books. While muscle relaxation has proved to be less effective than cognitive behavioral therapies in controlled trials, many people still find at least temporary relief from muscle relaxation.

Breathing exercises
In the great majority of cases is involved, exacerbating the effects of the panic attack. Breathing retraining exercise helps to rebalance the oxygen and CO2 levels in the blood.

recommends breathing exercises for those suffering from anxiety. One such breathing exercise is a 5-2-5 count. Using the stomach (or diaphragm)—and not the chest—inhale (feel the stomach come out, as opposed to the chest expanding) for 5 seconds. As the maximal point at inhalation is reached, hold the breath for 2 seconds. Then slowly exhale, over 5 seconds. Repeat this cycle twice and then breathe 'normally' for 5 cycles (1 cycle = 1 inhale + 1 exhale). The point is to focus on the breathing and relax the heart rate. Regular may be achieved by extending the outbreath by counting or humming.

Although breathing into a paper bag was a common recommendation for short-term treatment of symptoms of an acute panic attack, it has been criticized as inferior to measured breathing, potentially worsening the panic attack and possibly reducing needed blood oxygen. While the paper bag technique increases needed and so reduces symptoms, it may excessively lower  levels in the.

, which provides exhaled CO2 levels, may help guide breathing.

Therapy
According to the American Psychological Association, "most specialists agree that a are the best treatment for panic disorder. Medication might also be appropriate in some cases." The first part of therapy is largely informational; many people are greatly helped by simply understanding exactly what panic disorder is and how many others suffer from it. Many people who suffer from panic disorder are worried that their panic attacks mean they are "going crazy" or that the panic might induce a heart attack. helps people replace those thoughts with more realistic, positive ways of viewing the attacks. Avoidance behavior is one of the key aspects that prevent people with frequent panic attacks from functioning healthily. Exposure therapy, which includes repeated and prolonged confrontation with feared situations and body sensations, helps weaken anxiety responses to these external and internal stimuli and reinforce realistic ways of viewing panic symptoms.

In deeper level psychoanalytic approaches, in particular, panic attacks are frequently associated with , , and. They are often found comorbid with and. Paranoid anxiety may reach the level of a persecutory anxiety state.

Meditation may also be helpful in the treatment of. There was a meta-analysis of the comorbidity of panic disorders and agoraphobia. It used exposure therapy to treat the patients over a period. Hundreds of patients were used in these studies and they all met the DSM-IV criteria for both of these disorders. A result was that thirty-two percent of patients had a panic episode after treatment. They concluded that the use of exposure therapy has lasting efficacy for a client who is living with a panic disorder and agoraphobia.

The efficacy of group therapy treatment over conventional individual therapy for people with panic disorder with or without agoraphobia appear similar.

Medication
Medication options for panic attacks typically include s and antidepressants. Benzodiazepines are being prescribed less often because of their potential side effects, such as dependence, fatigue, slurred speech, and memory loss. Antidepressant treatments for panic attacks include selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors , s (TCAs), and s (MAOIs). SSRIs in particular tend to be the first drug treatment used to treat panic attacks. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants appear similar for short-term efficacy. SSRIs carry a relatively low risk due to the fact that they are not associated with much of a tolerance or dependence, and are difficult to overdose with. TCAs are similar to SSRIs in their many advantages, but come with more common side effects such as weight gain and cognitive disturbances. They are also easier to overdose on. MAOIs are generally suggested for patients who have not responded to other forms of treatment.

While the use of drugs in treating panic attacks can be very successful, it is generally recommended that people also be in some form of therapy, such as cognitive behavioral therapy. Drug treatments are usually used throughout the duration of panic attack symptoms, and discontinued after the patient has been free of symptoms for at least six months. It is usually safest to withdraw from these drugs gradually while undergoing therapy. While drug treatment seems promising for children and adolescents, they are at an increased risk of suicide while taking these medications and their well-being should be monitored closely.

Prognosis
Roughly one-third are treatment-resistant. These people continue to have panic attacks and various other panic disorder symptoms after receiving treatment.

Many people being treated for panic attacks begin to experience s. These panic attacks are less comprehensive, with fewer than four bodily symptoms being experienced.

It is not unusual to experience only one or two symptoms at a time, such as vibrations in their legs, shortness of breath, or an intense wave of heat traveling up their bodies, which is not similar to hot flashes due to estrogen shortage. Some symptoms, such as vibrations in the legs, are sufficiently different from any normal sensation that they clearly indicate panic disorder. Other symptoms on the list can occur in people who may or may not have panic disorder. Panic disorder does not require four or more symptoms to all be present at the same time. Causeless panic and racing heartbeat are sufficient to indicate a panic attack.

Epidemiology
In Europe about 3% of the population has a panic attack in a given year while in the United States they affect about 11%. They are more common in females than males. They often begin during or early adulthood. Children and older people are less commonly affected. A meta-analysis was conducted on data collected about twin studies and family studies on the link between genes and panic disorder. The researchers also examined the possibility of a link to phobias, obsessive-compulsive disorder (OCD), and generalized anxiety disorder. The researchers used a database called MEDLINE to accumulate their data. The results concluded that the aforementioned disorders have a genetic component and are inherited or passed down through genes. For the non-phobias, the likelihood of inheriting is 30%-40% and for the phobias, it was 50%-60%.