seizure or panic attack
Seizures
Definition
A seizure is a sudden change in behavior characterized by changes in sensory perception (sense of feeling) or motor activity (movement) due to an abnormal firing of nerve cells in the brain. Epilepsy is a condition characterized by recurrent seizures that may include repetitive muscle jerking called convulsions.
Description
Seizure disorders and their classification date back to the earliest medical literature accounts in history. In 1964, the Commission on Classification and Terminology of the International League Against Epilepsy (ILAE) devised the first official classification of seizures, which was revised again in 1981. This classification is accepted worldwide and is based on electroencephalographic (EEG) studies. Based on this system, seizures can be classified as either focal or generalized. Each of these categories can also be further subdivided.
Focal seizures
A focal (partial) seizure develops when a limited, confined population of nerve cells fire their impulses abnormally on one hemisphere of the brain. (The brain has two portions or cerebral hemispheres—the right and left hemispheres.) Focal seizures are divided into simple or complex based on the level of consciousness (wakefulness) during an attack. Simple partial seizures occur in patients who are conscious, whereas complex partial seizures demonstrate impaired levels of consciousness.
Generalized seizures
A generalized seizure results from initial abnormal firing of brain nerve cells throughout both left and right hemispheres. Generalized seizures can be classified as follows:
* Tonic-clonic seizures: This is the most common type among all age groups and is categorized into several phases beginning with vague symptoms hours or days before an attack. These seizures are sometimes called grand mal seizures.
* Tonic seizures: These are typically characterized by a sustained nonvibratory contraction of muscles in the legs and arms. Consciousness is also impaired during these episodes.
* Atonic seizures (also called "drop attacks"): These are characterized by sudden, limp posture and a brief period of unconsciousness and last for one to two seconds.
* Clonic seizures: These are characterized by a rapid loss of consciousness with loss of muscle tone, tonic spasm, and jerks. The muscles become rigid for about 30 seconds during the tonic phase of the seizure and alternately contract and relax during the clonic phase, which lasts 30–60 seconds.
* Absence seizures: These are subdivided into typical and atypical forms based on duration of attack and level of consciousness. Absence (petit mal) seizures generally begin at about the age of four and stop by the time the child becomes an adolescent. They usually begin with a brief loss of consciousness and last between one and 10 seconds. People having a petit mal seizure become very quiet and may blink, stare blankly, roll their eyes, or move their lips. A petit mal seizure lasts 15–20 seconds. When it ends, the individual resumes whatever he or she was doing before the seizure began, will not remember the seizure, and may not realize that anything unusual happened. Untreated, petit mal seizures can recur as many as 100 times a day and may progress to grand mal seizures.
* Myoclonic seizures: These are characterized by rapid muscular contractions accompanied with jerks in facial and pelvic muscles.
Subcategories are commonly diagnosed based on EEG results. Terminology for classification in infants and newborns is still controversial.
Causes and symptoms
Simple partial seizures can be caused by congenital abnormalities (abnormalities present at birth), tumor growths, head trauma, stroke, and infections in the brain or nearby structures. Generalized tonic-clonic seizures are associated with drug and alcohol abuse, and low levels of blood glucose (blood sugar) and sodium. Certain psychiatric medications, antihistamines, and even antibiotics can precipitate tonic-clonic seizures. Absence seizures are implicated with an abnormal imbalance of certain chemicals in the brain that modulate nerve cell activity (one of these neurotransmitters is called GABA, which functions as an inhibitor). Myoclonic seizures are commonly diagnosed in newborns and children.
Symptoms for the different types of seizures are specific.
Partial seizures
SIMPLE PARTIAL SEIZURES Multiple signs and symptoms may be present during a single simple partial seizure. These symptoms include specific muscles tensing and then alternately contracting and relaxing, speech arrest, vocalizations, and involuntary turning of the eyes or head. There could be changes in vision, hearing, balance, taste, and smell. Additionally, patients with simple partial seizures may have a sensation in the abdomen, sweating, paleness, flushing, hair follicles standing up (piloerection), and dilated pupils (the dark center in the eye enlarges). Seizures with psychological symptoms include thinking disturbances and hallucinations, or illusions of memory, sound, sight, time, and self-image.
COMPLEX PARTIAL SEIZURES Complex partial seizures often begin with a motionless stare or arrest of activity; this is followed by a series of involuntary movements, speech disturbances, and eye movements.
Generalized seizures
Generalized seizures have a more complex set of signs and symptoms.
TONIC-CLONIC SEIZURES Tonic-clonic seizures usually have vague prodromal (pre-attack) symptoms that can start hours or days before a seizure. These symptoms include anxiety, mood changes, irritability, weakness, dizziness, lightheadedness, and changes in appetite. The tonic phases may be preceded with brief (lasting only a few seconds in duration) muscle contractions on both sides of affected muscle groups. The tonic phase typically begins with a brief flexing of trunk muscles, upward movement of the eyes, and pupil dilation. Patients usually emit a characteristic vocalization. This sound is caused by contraction of trunk muscles that forces air from the lungs across spasmodic (abnormally tensed) throat muscles. This is followed by a very short period (10–15 seconds) of general muscle relaxation. The clonic phase consists of muscular contractions with alternating periods of no movements (muscle atonia) of gradually increasing duration until abnormal muscular contractions stop. Tonic-clonic seizures end in a final generalized spasm. The affected person can lose consciousness during tonic and clonic phases of seizure.
Tonic-clonic seizures can also produce chemical changes in the body. Patients commonly experience lowered carbon dioxide (hypocarbia) due to breathing alterations, increased blood glucose (blood sugar), and elevated level of a hormone called prolactin. Once the affected person regains consciousness, he or she is usually weak, and has a headache and muscle pain. Tonic-clonic seizures can cause serious medical problems such as trauma to the head and mouth, fractures in the spinal column, pulmonary edema (water in the lungs), aspiration pneumonia (a pneumonia caused by a foreign body being lodged in the lungs), and sudden death. Attacks are generally one minute in duration.
TONIC SEIZURES Tonic and atonic seizures have distinct differences but are often present in the same patient. Tonic seizures are characterized by nonvibratory muscle contractions, usually involving flexing of arms and relaxing or flexing of legs. The seizure usually lasts less than 10 seconds but may be as long as one minute. Tonic seizures are usually abrupt and patients lose consciousness. Tonic seizures commonly occur during non-rapid eye movement (non-REM) sleep and drowsiness. Tonic seizures that occur during wakeful states commonly produce physical injuries due to abrupt, unexpected falls.
ATONIC SEIZURES Atonic seizures, also called "drop attacks," are abrupt, with loss of muscle tone lasting one to two seconds, but with rapid recovery. Consciousness is usually impaired. The rapid loss of muscular tone could be limited to head and neck muscles, resulting in head drop, or it may be more extensive, involving muscles for balance and causing unexpected falls with physical injury.
CLONIC SEIZURES Generalized clonic seizures are rare and seen typically in children with elevated fever. These seizures are characterized by a rapid loss of consciousness, decreased muscle tone, and generalized spasm that is followed by jerky movements.
ABSENCE SEIZURES Absence seizures are classified as either typical or atypical. The typical absence seizure is characterized by unresponsiveness and behavioral arrest, abnormal muscular movements of the face and eyelids, and lasts less than 10 seconds. In atypical absence seizures, the affected person is generally more conscious, the seizures begin and end more gradually, and do not exceed 10 seconds in duration.
MYOCLONIC SEIZURES Myoclonic seizures commonly exhibit rapid muscular contractions. Myoclonic seizures are seen in newborns and children who have either symptomatic or idiopathic (cause is unknown) epilepsy.
Demographics
Approximately 1.5 million persons in the United States suffer from a type of seizure disorder. The annual incidence (number of new cases) for all types of seizures is 1.2 per 1,000 and, for recurrent seizures, is 0.54 per 1,000. Isolated seizures may occur in up to 10% of the general population. Approximately 10–20% of all patients have intractable epilepsy (epilepsy that is difficult to manage or treat). It is estimated that 45 million people in the world are affected by seizures. Seizures affect males and females equally and can occur among all age groups. There seems to be a strong genetic correlation, since seizures are three times more prevalent among close relatives than they are in the general population.
Children delivered in the breech position have increased prevalence (3.8%) of seizures when compared to infants delivered in the normal delivery position (2.2%). Seizures caused by fever have a recurrence rate of 51% if the attack occurred in the first year of life, whereas recurrence rate is decreased to 25% if the seizure took place during the second year. Approximately 88% of children who experience seizures caused by fever in the first two years experience recurrence.
Approximately 45 million people worldwide are affected by epilepsy. The incidence is highest among young children and the elderly. High-risk groups include persons with a previous history of brain injury or lesions.
Diagnosis
Patients seeking help for seizures should first undergo an EEG that records brain-wave patterns emitted between nerve cells. Electrodes are placed on the head, sometimes for 24 hours, to monitor brain-wave activity and detect both normal and abnormal impulses. Imaging studies such as magnetic resonance imaging (MRI) and computed axial tomography (CT)—that take still "pictures"—are useful in detecting abnormalities in the temporal lobes (parts of the brain associated with hearing) or for helping diagnose tonic-clonic seizures. A complete blood count (CBC) can be helpful in determining whether a seizure is caused by a neurological infection, which is typically accompanied by high fever. If drugs or toxins in the blood are suspected to be the cause of the seizure(s), blood and urine screening tests for these compounds may be necessary.
Antiseizure medication can be altered by many commonly used medications such as sulfa drugs, erythromycin, warfarin, and cimetidine. Pregnancy may also decrease serum concentration of antiseizure medications; therefore, frequent monitoring and dose adjustments are vital to maintain appropriate blood concentrations of the antiseizure medication—known as the therapeutic blood concentration. Diagnosis requires a detailed and accurate history, and a physical examination is important since this may help identify neurological or systemic causes. In cases in which a central nervous system (CNS) infection (i.e., meningitis or encephalitis) is suspected, a lumbar puncture (or spinal tap) can help detect an increase in immune cells (white blood cells) that develop to fight the specific infection.
Treatments
Treatment is targeted primarily to:
* assist the patient in adjusting psychologically to the diagnosis and in maintaining as normal a lifestyle as possible
* reduce or eliminate seizure occurrence
* avoid side effects of long-term drug treatment
Simple and complex partial seizures respond to drugs such as carbamazepine, valproic acid (valproate), phenytoin, gabapentin, tiagabine, lamotrigine, and topiramate. Tonic-clonic seizures tend to respond to valproate, carbamazepine, phenytoin, and lamotrigine. Absence seizures seem to be sensitive to ethosuximide, valproate, and lamotrigine. Myoclonic seizures can be treated with valproate and clonazepam. Tonic seizures seem to respond favorably to valproate, felbamate, and clonazepam.
People treated with a class of medications called barbiturates (Mysoline, Mebral, phenobarbital) have adverse cognitive (thinking) effects. These cognitive effects can include decreased general intelligence, attention, memory, problem solving, motor speed, and visual motor functions. The drug phenytoin (Dilantin) can adversely affect speed of response, memory, and attention. Other medications used for treatment of seizures do not have substantial cognitive impairment.
Surgical treatment may be considered when medications fail. Advances in medical sciences and techniques have improved methods of identifying the parts of the brain that generate abnormal discharge of nerve impulses. Surgical treatment now accounts for about 5,000 procedures annually. The most common type of surgery is the focal cortical resection. In this procedure, a small part of the brain responsible for causing the seizures is removed. Surgical intervention may be considered a feasible treatment option if:
* the site of seizures is identifiable and localized
* surgery can remove the seizure-generating (epileptogenic) area
* surgical procedure will not cause damage to nearby areas
Prognosis
About 30% of patients with severe seizures (starting in early childhood), continue to have attacks and usually never achieve a remission state. In the United States, the prevalence of treatment-resistant seizures is about one to two per 1,000 persons. About 60–70% of persons achieve a five-year remission within 10 years of initial diagnosis. Approximately half of these patients become seizure-free. Usually the prognosis is better if seizures can be controlled by one medication, the frequency of seizures decreases, and there is a normal EEG and neurological examination prior to medication cessation.
People affected by seizure have increased death rates compared with the general population. Patients who have seizures of unknown cause have an increased chance of dying due to accidents (primarily drowning). Other causes of seizure-associated death include abnormal heart rhythms, water in the lungs, or heart attack.
Prevention
There are no gold standard recommendations for prevention, since seizures can be caused by genetic factors, blood abnormalities, many medications, illicit drugs, infection, neurologic conditions, and other systemic diseases. If a person has had a previous attack or has a genetic propensity, care is advised when receiving medical treatment or if diagnosed with an illness correlated with possible seizure development.
Resources
BOOKS
Goetz, Christopher G. Textbook of Clinical Neurology. 1st edition. Philadelphia: W. B. Saunders Company, 1999.
Goldman, Lee, and others. Cecil Textbook of Medicine. 21st edition. Philadelphia: W. B. Saunders Company, 2000.
Goroll, Allan H. Primary Care Medicine. 4th edition. Philadelphia: Lippincott Williams and Wilkins, 2000.
PERIODICALS
Dodrill, C. R., C. G. Matthew. "The role of Neuropsychology in the Assessment and Treatment of Persons with Epilepsy." American Psychologist (September 1992).
ORGANIZATIONS
Epilepsy Foundation. 4351 Garden City Drive, Landover, MD 20785-7223. (800) 332-1000. http://www.efa.org.
Laith Farid Gulli, MD
Alfredo Mori, MD, FACEM
panic attack
Panic attacks are sudden, discrete periods of intense anxiety, fear and discomfort that are associated with a variety of somatic and cognitive symptoms. The onset of these episodes is typically abrupt, and may have no obvious trigger. Although these episodes may appear random, they are considered to be a subset of an evolutionary response commonly referred to as fight or flight that occur out of context, flooding the body with hormones (particularly adrenalin) that aid in defending itself from harm.
According to the American Psychological Association the symptoms of a panic attack commonly last approximately ten minutes. However, panic attacks can be as short as 1-5 minutes, while more severe panic attacks may form a cyclic series of episodes, lasting for an extended period, sometimes hours. Often those afflicted will experience significant anticipatory anxiety in between attacks and in situations where attacks have previously occurred.
Panic attacks also affect people differently. Experienced sufferers may be able to completely 'ride out' a panic attack with little to no obvious symptoms. Others, notably first time sufferers, may even call for emergency services; many who experience a panic attack for the first time fear they are having a heart attack or a nervous breakdown.(Wilson 1996)
Descriptions
Many who suffer from panic attacks state they are the most frightening experiences of their lives. Sufferers of panic attacks report a fear or sense of dying, "going crazy", and/ or experiencing a heart attack, feeling faint, nauseous, or losing control of themselves. These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the sympathetic "fight or flight" response).
A panic attack is a response of the sympathetic nervous system (SNS). The most common symptoms may include: trembling, dyspnea (shortness of breath), heart palpitations, chest pain (or chest tightness), sweating, nausea, dizziness (or slight vertigo), light-headedness, hyperventilation, paresthesias (tingling sensations), sensations of choking or smothering or derealization, or the feeling that nothing is real. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety, and forms a positive feedback loop.
Triggers and Causes
* Long-Term, Predisposing Causes- Heredity. Panic disorder has been found to run in families, and this may mean that inheritance genes plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it. Various twin studies where one identical twin has an anxiety disorder have reported an incidence ranging from 31 to 88 percent of the other twin also having an anxiety disorder diagnosis. Environmental factors such as an overly cautious view of the world expressed by parents and cumulative stress over time have been found to be causes (Bourne 2005).
* Biological Causes- Generalized anxiety, obsessive compulsive disorder, Post Traumatic Stress Disorder, hypoglycemia, hyperthyroidism, Wilson's Syndrome, mitral valve prolapse and inner ear disturbances (Labyrinthitis). (Bourne 2005) Vitamin b deficiency from inadequate diet or caused by periodic depletion due to parasitic infection from Tape worm can be a trigger of anxiety attacks.
* Phobias- People will often experience panic attacks as a direct result of exposure to a phobic object or situation.
* Short-Term Triggering Causes- Significant personal loss, significant life change, stimulants such as caffeine or nicotine, or the drugs marijuana or mushrooms, can act as triggers (Bourne 2005).
* Maintaining Causes- Avoidance of panic provoking situations or environments, anxious/negative self-talk ("what if thinking"), mistaken beliefs ("these symptoms are harmful and/or dangerous"), withheld feelings, lack of assertiveness. (Bourne 2005)
* Medications-Sometimes panic attacks may be a listed side effect of medications such as Ritalin (methylphenidate). These may be a temporary side effect, only occurring when a patient first starts a medication, or could continue occurring even after the patient is accustomed to the drug, which likely would warrant a medication change in either dosage, or type of drug. Nearly the entire SSRI class of antidepressants can cause increased anxiety in the beginning of use. It is not uncommon for inexperienced users to have panic attacks while weaning on or off the medication, especially ones prone to anxiety.
* Hyperventilation Syndrome- Breathing from your chest may cause overbreathing, exhaling excess carbon dioxide in relation to the amount of oxygen in one's bloodstream. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms including rapid heart beat, dizziness, and lightheadedness which can trigger panic attacks. (Bourne 2005)
* Situationally Bound Panic Attacks- Associating certain situations with panic attacks, due to experiencing one in that particular situation, can create a cognitive or behaviorally predisposition to having panic attacks in certain situations (situationally bound panic attacks). It is a form of classical conditioning (Bourne 2005). See PTSD
* Pharmacological Triggers - Certain chemical substances, mainly stimulants but also certain depressants, can either contribute pharmacologically to a constellation of provocations, and thus trigger a panic attack or even a panic disorder, or directly induce one. This includes caffeine, amphetamine, alcohol and many more. Some sufferers of panic attacks also report phobias of specific drugs or chemicals, that thus have a merely psychosomatic effect, thereby functioning as drug-triggers by non-pharmacological means.
Physiological considerations
While the various symptoms of a panic attack may feel that the body is failing, it is in fact protecting itself from harm. The various symptoms of a panic attack can be understood as follows. First, there is frequently (but not always) the sudden onset of fear with little provoking stimulus. This leads to a release of adrenaline (epinephrine) which brings about the so-called fight-or-flight response wherein the person's body prepares for strenuous physical activity. This leads to an increased heart rate (tachycardia), rapid breathing (hyperventilation) which may be perceived as shortness of breath (dyspnea), and sweating (which increases grip and aids heat loss). Because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon dioxide levels in the lungs and then in the blood. This leads to shifts in blood pH (respiratory alkalosis), which in turn can lead to many other symptoms, such as tingling or numbness, dizziness, burning and lightheadedness. Moreover, the release of adrenaline during a panic attack causes vasoconstriction resulting in slightly less blood flow to the head which causes dizziness and lightheadedness.
Symptoms
Physical
* An extremely unpleasant sensation of adrenaline over the entire body
* Sweating
* Shortness of breath (dyspnea)
* Racing or pounding heartbeat or palpitations
* Chest pain
* Dizziness or vertigo
* Lightheadedness
* Nausea / stomach pains
* Hyperventilation
* Choking or smothering sensations
* Uncontrollable itching
* Tingling or numbness in the hands, face, feet or mouth (paresthesia)
* Hot/cold flashes
* Trembling or shaking
* Feeling of claustrophobia
* Exhaustion
* Feeling of physical weakness or limpness of the body.
* Uncontrollable crying
Mental
* Loss of the ability to react logically to stimuli
* Loss of cognitive ability in general
* Racing thoughts (often based on fear; a repeated or illogical worry)
* Loud internal dialogue
* Feeling of impending doom
* Feeling of "going crazy"
* Extreme worried feeling
* Feeling of extreme nervousness
* Feeling out of control
* Vision is somewhat impaired; (eyes may feel like they are shaking.)
Emotional
* Terror, or a sense that something unimaginably horrible is about to occur and one is powerless to prevent it
* Fear that the panic is a symptom of a serious illness
* Fear of losing control
* Fear of death
* Fear of going crazy
* Flashbacks to earlier panic trigger
Perceptual
* Tunnel vision
* Heightened senses
* The apparent slowing down or speeding up of time
* Dream-like sensation or perceptual distortion (derealization)
* Dissociation, or the perception that one is not connected to the body or is disconnected from space and time (depersonalization)
* Feeling of loss of free will, as if acting entirely automatically without control
Mnemonic
The symptoms of a panic attack can be remembered with the mnemonic: STUDENTS FEAR the 3 Cs: Sweating, Trembling, Unsteadiness/dizziness, Derealization/depersonalization, Elevated heart rate (tachycardia), Nausea, Tingling, Shortness of breath, FEAR of dying, FEAR of losing control, FEAR of going crazy, 3 Cs - Choking, Chest pain, Chills.
Agoraphobia
Main article: Agoraphobia
Agoraphobia is an anxiety disorder which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape. As a 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 Greek words agora (αγορά) and phobos (φόβος), literally translated as "a fear of the marketplace". This translation is the reason for the common misconception that agoraphobia is a fear of open spaces, and is not clinically accurate.
People who have had a panic attack in certain situations — for example, while driving, shopping in a crowded store, going to a party, experimenting with psychedelic drugs, etc. — may develop irrational 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 panic disorder are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. This can be one of the most harmful side-effects of panic disorder as it can prevent sufferers from seeking treatment in the first place. Agoraphobia of this degree is extremely rare. It should be noted that upwards of 90% of agoraphobics achieve a full recovery. Agoraphobia is actually not a fear of certain places but a fear of having panic attacks in certain places, where escape would be difficult and/or embarrassing.
The thinking behind agoraphobia usually follows the line that were a panic attack to occur, who would look after the person, how would he or she get the assistance and reassurance they needed? The vulnerability grows from the feeling that once victims of agoraphobia are caught in the anxiety, they are suddenly unable to look after themselves and are therefore at the mercy of the place they find themselves in and the strangers around them. In its extreme form, agoraphobia and panic attacks can lead to a situation where people become housebound for numerous years.
It is important to note that agoraphobia is by no means a hopeless situation. Sufferers often do not realize that they have experienced these same situations before and nothing terrible occurred. Successful treatment is possible with the right combination of therapy and medication.
Agoraphobia is often described as a fear of having 'no place to run or hide' if one does have a panic attack. Common examples include: driving, airplanes, malls, moving out of the house, etc.
Panic disorder
Main article: 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 anxiety disorders in that panic attacks are often sudden and unprovoked.
Treatment
People with Panic disorder often can be successfully treated with therapy, particularly Cognitive Behavioral Therapy and/or anti-anxiety medication or antidepressants. (Bourne 2005)
Paper bag rebreathing
Some panic attack sufferers and even some doctors recommend breathing into a paper bag as an effective short-term treatment of an acute panic attack.[8] However, this can prove to be fatal in some cases, and it is strongly advised against to engange in such a practice, by well-respected medical studies dating back to 1989 and 1994.
Medication
The benzodiazepine class of drugs includes diazepam, lorazepam, alprazolam, and clonazepam. While these drugs are highly effective and very fast acting in stopping panic, they may not be the best solution.[citation needed] First, the body can build a tolerance to the drug, much like alcoholic beverages, making it need more to feel the same benefit. Second, because of this, there is a high risk of abuse and addiction in some people.
As such, some doctors may prefer to prescribe an antidepressant, particularly an SSRI (such as paroxetine, sertraline, fluvoxamine, or fluoxetine), which after an initial titration period may be effective at reducing anxiety. SNRIs such as Venlafaxine can also be prescribed. Studies have proven they may be more effective than the SSRIs for anxiety. NaSSAs such as Mirtazapine have also been found effective, particularly with individuals whose anxiety and panic causes insomnia.
Interoceptive Desensitization/Symptom Inductions
One particularly helpful and effective form of therapy is Cognitive Behavioral Therapy (CBT). Interoceptive Desensitization intends to desensitize the afflicted from the symptoms of panic attacks. In a study by Barlow & Craske (1989), 87% of the individuals that participated in the two of four treatments that involved Interoceptive Desensitization were free of panic at the end of treatment and these results were maintained at a 2-year follow up. In controlled studies of Interoceptive Desensitization treatments compared to other treatments, those treatments that included Interoceptive Desensitization were found to be significantly superior to other treatments such as muscle relaxation alone, or education or insight-oriented treatments. Interoceptive Desensitization often leads to a dramatic reduction in the frequency and intensity of panic attacks and as such should be implemented immediately under the guidance of a mental health professional. It is important the patient is given medical clearance and permission from a medical doctor before attempting these exercises.
Symptom Inductions generally occur for one minute and may include:
* Intentional Hyperventilation - Creates lightheadeness, derealization, blurred vision, dizziness,
* Spinning in a chair - Creates dizziness, disorientation
* Straw breathing - Creates dyspnea, airway constriction
* Breath holding - Creates sensation of being out of breath
* Running in place - Creates increased heart rate, increased respiration, perspiration
* Body Tensing - Creates feelings of being tense and vigilant
The key to the induction is that the exercises should mimic the most frightening symptoms of a panic attack. Symptom Inductions should be repeated 3-5 times per day until the patient has little to no anxiety in relation to the symptoms that were induced. Often it will take a period of weeks for the afflicted to feel no anxiety in relation to the induced symptoms. With repeated trials, a person learns through experience that these internal sensations do not need to be feared – the individual becomes less sensitized or desensitized to the internal sensation. After repeated trials, when nothing catastrophic happens, the brain learns (Hippocampus & Amygdala) to not fear the sensations, and the sympathetic nervous system activation fades.
Many people overcome Panic Disorder and sudden Panic Attacks on their own. It takes time, but in a sense, they ride out the panic attacks and eventually learn that nothing is going to happen during one. Often, they 'taper off' until they are not noticeable any longer. It is for this reason that some psychologists helping people with panic disorders induce them into an attack, so they can see for themselves that indeed, nothing will happen.
Increased Risk of Heart Attack and Stroke
A recent study suggests that menopausal women with panic disorder and many occurrences of panic attacks have a three-fold higher risk of suffering heart attack or stroke over the next five years. The researchers believe that panic attacks or more accurately their associated symptoms (chest pain, dyspnea) can be manifestations of undiagnosed cardiovascular disease, or result in heart damage due to cardiovascular stress in patients with panic disorder and many panic attacks over periods of years. The study did not find that isolated cases of panic attacks in patients without panic disorder or agoraphobia lead to immediate heart damage, nor did it prove that the correlation between panic disorder and strokes was causal, or that it couldnt be attributed to the cardiovascular effects of medication that many panic disorder patients receive, such as SSRIs and benzodiazepines.
Limited Symptom Attack
Many people being treated for panic attacks begin to experience limited symptom attacks. These panic attacks are less comprehensive with fewer than 4 bodily symptoms being experienced. (Bourne 2005)
References
1. ^ Diagnostic and Statistical Manual of Mental Disorders
2. ^ Bourne, E. (2005). The Anxiety and Phobia Workbook, 4th Edition: New Harbinger Press.
3. ^ Klerman, Gerald L.; Hirschfeld, Robert M. A. & Weissman, Myrna M. (1993), Panic Anxiety and Its Treatments: Report of the World Psychiatric Association Presidential Educational Program Task Force, American Psychiatric Association, pp. pp.44, ISBN 978-0880486842
4. ^ http://www.nlm.nih.gov/medlineplus/ency/article/000924.htm
5. ^ http://panicdisorder.about.com/cs/shfitness/a/caffeine.htm
6. ^ http://fondationmarievictorin.qc.ca/panic-and-anxiety-attack-medication.php
7. ^ http://familydoctor.org/137.xml
8. ^ http://www.netdoctor.co.uk/ate/mentalhealth/205625.html
9. ^ a b http://firstaid.about.com/od/shortnessofbreat1/f/07_paper_bags.htm
10. ^ http://www.nytimes.com/aponline/us/AP-Panic-Attacks-Heart.html
5. Weekes, Claire. Hope and Help for Your Nerves: Signot (1991)
6.Wilson, Reid. Don't Panic: Taking Control of Your Anxiety Attacks. Revised Edition, HC (1996)
External links
Definition
A seizure is a sudden change in behavior characterized by changes in sensory perception (sense of feeling) or motor activity (movement) due to an abnormal firing of nerve cells in the brain. Epilepsy is a condition characterized by recurrent seizures that may include repetitive muscle jerking called convulsions.
Description
Seizure disorders and their classification date back to the earliest medical literature accounts in history. In 1964, the Commission on Classification and Terminology of the International League Against Epilepsy (ILAE) devised the first official classification of seizures, which was revised again in 1981. This classification is accepted worldwide and is based on electroencephalographic (EEG) studies. Based on this system, seizures can be classified as either focal or generalized. Each of these categories can also be further subdivided.
Focal seizures
A focal (partial) seizure develops when a limited, confined population of nerve cells fire their impulses abnormally on one hemisphere of the brain. (The brain has two portions or cerebral hemispheres—the right and left hemispheres.) Focal seizures are divided into simple or complex based on the level of consciousness (wakefulness) during an attack. Simple partial seizures occur in patients who are conscious, whereas complex partial seizures demonstrate impaired levels of consciousness.
Generalized seizures
A generalized seizure results from initial abnormal firing of brain nerve cells throughout both left and right hemispheres. Generalized seizures can be classified as follows:
* Tonic-clonic seizures: This is the most common type among all age groups and is categorized into several phases beginning with vague symptoms hours or days before an attack. These seizures are sometimes called grand mal seizures.
* Tonic seizures: These are typically characterized by a sustained nonvibratory contraction of muscles in the legs and arms. Consciousness is also impaired during these episodes.
* Atonic seizures (also called "drop attacks"): These are characterized by sudden, limp posture and a brief period of unconsciousness and last for one to two seconds.
* Clonic seizures: These are characterized by a rapid loss of consciousness with loss of muscle tone, tonic spasm, and jerks. The muscles become rigid for about 30 seconds during the tonic phase of the seizure and alternately contract and relax during the clonic phase, which lasts 30–60 seconds.
* Absence seizures: These are subdivided into typical and atypical forms based on duration of attack and level of consciousness. Absence (petit mal) seizures generally begin at about the age of four and stop by the time the child becomes an adolescent. They usually begin with a brief loss of consciousness and last between one and 10 seconds. People having a petit mal seizure become very quiet and may blink, stare blankly, roll their eyes, or move their lips. A petit mal seizure lasts 15–20 seconds. When it ends, the individual resumes whatever he or she was doing before the seizure began, will not remember the seizure, and may not realize that anything unusual happened. Untreated, petit mal seizures can recur as many as 100 times a day and may progress to grand mal seizures.
* Myoclonic seizures: These are characterized by rapid muscular contractions accompanied with jerks in facial and pelvic muscles.
Subcategories are commonly diagnosed based on EEG results. Terminology for classification in infants and newborns is still controversial.
Causes and symptoms
Simple partial seizures can be caused by congenital abnormalities (abnormalities present at birth), tumor growths, head trauma, stroke, and infections in the brain or nearby structures. Generalized tonic-clonic seizures are associated with drug and alcohol abuse, and low levels of blood glucose (blood sugar) and sodium. Certain psychiatric medications, antihistamines, and even antibiotics can precipitate tonic-clonic seizures. Absence seizures are implicated with an abnormal imbalance of certain chemicals in the brain that modulate nerve cell activity (one of these neurotransmitters is called GABA, which functions as an inhibitor). Myoclonic seizures are commonly diagnosed in newborns and children.
Symptoms for the different types of seizures are specific.
Partial seizures
SIMPLE PARTIAL SEIZURES Multiple signs and symptoms may be present during a single simple partial seizure. These symptoms include specific muscles tensing and then alternately contracting and relaxing, speech arrest, vocalizations, and involuntary turning of the eyes or head. There could be changes in vision, hearing, balance, taste, and smell. Additionally, patients with simple partial seizures may have a sensation in the abdomen, sweating, paleness, flushing, hair follicles standing up (piloerection), and dilated pupils (the dark center in the eye enlarges). Seizures with psychological symptoms include thinking disturbances and hallucinations, or illusions of memory, sound, sight, time, and self-image.
COMPLEX PARTIAL SEIZURES Complex partial seizures often begin with a motionless stare or arrest of activity; this is followed by a series of involuntary movements, speech disturbances, and eye movements.
Generalized seizures
Generalized seizures have a more complex set of signs and symptoms.
TONIC-CLONIC SEIZURES Tonic-clonic seizures usually have vague prodromal (pre-attack) symptoms that can start hours or days before a seizure. These symptoms include anxiety, mood changes, irritability, weakness, dizziness, lightheadedness, and changes in appetite. The tonic phases may be preceded with brief (lasting only a few seconds in duration) muscle contractions on both sides of affected muscle groups. The tonic phase typically begins with a brief flexing of trunk muscles, upward movement of the eyes, and pupil dilation. Patients usually emit a characteristic vocalization. This sound is caused by contraction of trunk muscles that forces air from the lungs across spasmodic (abnormally tensed) throat muscles. This is followed by a very short period (10–15 seconds) of general muscle relaxation. The clonic phase consists of muscular contractions with alternating periods of no movements (muscle atonia) of gradually increasing duration until abnormal muscular contractions stop. Tonic-clonic seizures end in a final generalized spasm. The affected person can lose consciousness during tonic and clonic phases of seizure.
Tonic-clonic seizures can also produce chemical changes in the body. Patients commonly experience lowered carbon dioxide (hypocarbia) due to breathing alterations, increased blood glucose (blood sugar), and elevated level of a hormone called prolactin. Once the affected person regains consciousness, he or she is usually weak, and has a headache and muscle pain. Tonic-clonic seizures can cause serious medical problems such as trauma to the head and mouth, fractures in the spinal column, pulmonary edema (water in the lungs), aspiration pneumonia (a pneumonia caused by a foreign body being lodged in the lungs), and sudden death. Attacks are generally one minute in duration.
TONIC SEIZURES Tonic and atonic seizures have distinct differences but are often present in the same patient. Tonic seizures are characterized by nonvibratory muscle contractions, usually involving flexing of arms and relaxing or flexing of legs. The seizure usually lasts less than 10 seconds but may be as long as one minute. Tonic seizures are usually abrupt and patients lose consciousness. Tonic seizures commonly occur during non-rapid eye movement (non-REM) sleep and drowsiness. Tonic seizures that occur during wakeful states commonly produce physical injuries due to abrupt, unexpected falls.
ATONIC SEIZURES Atonic seizures, also called "drop attacks," are abrupt, with loss of muscle tone lasting one to two seconds, but with rapid recovery. Consciousness is usually impaired. The rapid loss of muscular tone could be limited to head and neck muscles, resulting in head drop, or it may be more extensive, involving muscles for balance and causing unexpected falls with physical injury.
CLONIC SEIZURES Generalized clonic seizures are rare and seen typically in children with elevated fever. These seizures are characterized by a rapid loss of consciousness, decreased muscle tone, and generalized spasm that is followed by jerky movements.
ABSENCE SEIZURES Absence seizures are classified as either typical or atypical. The typical absence seizure is characterized by unresponsiveness and behavioral arrest, abnormal muscular movements of the face and eyelids, and lasts less than 10 seconds. In atypical absence seizures, the affected person is generally more conscious, the seizures begin and end more gradually, and do not exceed 10 seconds in duration.
MYOCLONIC SEIZURES Myoclonic seizures commonly exhibit rapid muscular contractions. Myoclonic seizures are seen in newborns and children who have either symptomatic or idiopathic (cause is unknown) epilepsy.
Demographics
Approximately 1.5 million persons in the United States suffer from a type of seizure disorder. The annual incidence (number of new cases) for all types of seizures is 1.2 per 1,000 and, for recurrent seizures, is 0.54 per 1,000. Isolated seizures may occur in up to 10% of the general population. Approximately 10–20% of all patients have intractable epilepsy (epilepsy that is difficult to manage or treat). It is estimated that 45 million people in the world are affected by seizures. Seizures affect males and females equally and can occur among all age groups. There seems to be a strong genetic correlation, since seizures are three times more prevalent among close relatives than they are in the general population.
Children delivered in the breech position have increased prevalence (3.8%) of seizures when compared to infants delivered in the normal delivery position (2.2%). Seizures caused by fever have a recurrence rate of 51% if the attack occurred in the first year of life, whereas recurrence rate is decreased to 25% if the seizure took place during the second year. Approximately 88% of children who experience seizures caused by fever in the first two years experience recurrence.
Approximately 45 million people worldwide are affected by epilepsy. The incidence is highest among young children and the elderly. High-risk groups include persons with a previous history of brain injury or lesions.
Diagnosis
Patients seeking help for seizures should first undergo an EEG that records brain-wave patterns emitted between nerve cells. Electrodes are placed on the head, sometimes for 24 hours, to monitor brain-wave activity and detect both normal and abnormal impulses. Imaging studies such as magnetic resonance imaging (MRI) and computed axial tomography (CT)—that take still "pictures"—are useful in detecting abnormalities in the temporal lobes (parts of the brain associated with hearing) or for helping diagnose tonic-clonic seizures. A complete blood count (CBC) can be helpful in determining whether a seizure is caused by a neurological infection, which is typically accompanied by high fever. If drugs or toxins in the blood are suspected to be the cause of the seizure(s), blood and urine screening tests for these compounds may be necessary.
Antiseizure medication can be altered by many commonly used medications such as sulfa drugs, erythromycin, warfarin, and cimetidine. Pregnancy may also decrease serum concentration of antiseizure medications; therefore, frequent monitoring and dose adjustments are vital to maintain appropriate blood concentrations of the antiseizure medication—known as the therapeutic blood concentration. Diagnosis requires a detailed and accurate history, and a physical examination is important since this may help identify neurological or systemic causes. In cases in which a central nervous system (CNS) infection (i.e., meningitis or encephalitis) is suspected, a lumbar puncture (or spinal tap) can help detect an increase in immune cells (white blood cells) that develop to fight the specific infection.
Treatments
Treatment is targeted primarily to:
* assist the patient in adjusting psychologically to the diagnosis and in maintaining as normal a lifestyle as possible
* reduce or eliminate seizure occurrence
* avoid side effects of long-term drug treatment
Simple and complex partial seizures respond to drugs such as carbamazepine, valproic acid (valproate), phenytoin, gabapentin, tiagabine, lamotrigine, and topiramate. Tonic-clonic seizures tend to respond to valproate, carbamazepine, phenytoin, and lamotrigine. Absence seizures seem to be sensitive to ethosuximide, valproate, and lamotrigine. Myoclonic seizures can be treated with valproate and clonazepam. Tonic seizures seem to respond favorably to valproate, felbamate, and clonazepam.
People treated with a class of medications called barbiturates (Mysoline, Mebral, phenobarbital) have adverse cognitive (thinking) effects. These cognitive effects can include decreased general intelligence, attention, memory, problem solving, motor speed, and visual motor functions. The drug phenytoin (Dilantin) can adversely affect speed of response, memory, and attention. Other medications used for treatment of seizures do not have substantial cognitive impairment.
Surgical treatment may be considered when medications fail. Advances in medical sciences and techniques have improved methods of identifying the parts of the brain that generate abnormal discharge of nerve impulses. Surgical treatment now accounts for about 5,000 procedures annually. The most common type of surgery is the focal cortical resection. In this procedure, a small part of the brain responsible for causing the seizures is removed. Surgical intervention may be considered a feasible treatment option if:
* the site of seizures is identifiable and localized
* surgery can remove the seizure-generating (epileptogenic) area
* surgical procedure will not cause damage to nearby areas
Prognosis
About 30% of patients with severe seizures (starting in early childhood), continue to have attacks and usually never achieve a remission state. In the United States, the prevalence of treatment-resistant seizures is about one to two per 1,000 persons. About 60–70% of persons achieve a five-year remission within 10 years of initial diagnosis. Approximately half of these patients become seizure-free. Usually the prognosis is better if seizures can be controlled by one medication, the frequency of seizures decreases, and there is a normal EEG and neurological examination prior to medication cessation.
People affected by seizure have increased death rates compared with the general population. Patients who have seizures of unknown cause have an increased chance of dying due to accidents (primarily drowning). Other causes of seizure-associated death include abnormal heart rhythms, water in the lungs, or heart attack.
Prevention
There are no gold standard recommendations for prevention, since seizures can be caused by genetic factors, blood abnormalities, many medications, illicit drugs, infection, neurologic conditions, and other systemic diseases. If a person has had a previous attack or has a genetic propensity, care is advised when receiving medical treatment or if diagnosed with an illness correlated with possible seizure development.
Resources
BOOKS
Goetz, Christopher G. Textbook of Clinical Neurology. 1st edition. Philadelphia: W. B. Saunders Company, 1999.
Goldman, Lee, and others. Cecil Textbook of Medicine. 21st edition. Philadelphia: W. B. Saunders Company, 2000.
Goroll, Allan H. Primary Care Medicine. 4th edition. Philadelphia: Lippincott Williams and Wilkins, 2000.
PERIODICALS
Dodrill, C. R., C. G. Matthew. "The role of Neuropsychology in the Assessment and Treatment of Persons with Epilepsy." American Psychologist (September 1992).
ORGANIZATIONS
Epilepsy Foundation. 4351 Garden City Drive, Landover, MD 20785-7223. (800) 332-1000. http://www.efa.org.
Laith Farid Gulli, MD
Alfredo Mori, MD, FACEM
panic attack
Panic attacks are sudden, discrete periods of intense anxiety, fear and discomfort that are associated with a variety of somatic and cognitive symptoms. The onset of these episodes is typically abrupt, and may have no obvious trigger. Although these episodes may appear random, they are considered to be a subset of an evolutionary response commonly referred to as fight or flight that occur out of context, flooding the body with hormones (particularly adrenalin) that aid in defending itself from harm.
According to the American Psychological Association the symptoms of a panic attack commonly last approximately ten minutes. However, panic attacks can be as short as 1-5 minutes, while more severe panic attacks may form a cyclic series of episodes, lasting for an extended period, sometimes hours. Often those afflicted will experience significant anticipatory anxiety in between attacks and in situations where attacks have previously occurred.
Panic attacks also affect people differently. Experienced sufferers may be able to completely 'ride out' a panic attack with little to no obvious symptoms. Others, notably first time sufferers, may even call for emergency services; many who experience a panic attack for the first time fear they are having a heart attack or a nervous breakdown.(Wilson 1996)
Descriptions
Many who suffer from panic attacks state they are the most frightening experiences of their lives. Sufferers of panic attacks report a fear or sense of dying, "going crazy", and/ or experiencing a heart attack, feeling faint, nauseous, or losing control of themselves. These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the sympathetic "fight or flight" response).
A panic attack is a response of the sympathetic nervous system (SNS). The most common symptoms may include: trembling, dyspnea (shortness of breath), heart palpitations, chest pain (or chest tightness), sweating, nausea, dizziness (or slight vertigo), light-headedness, hyperventilation, paresthesias (tingling sensations), sensations of choking or smothering or derealization, or the feeling that nothing is real. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety, and forms a positive feedback loop.
Triggers and Causes
* Long-Term, Predisposing Causes- Heredity. Panic disorder has been found to run in families, and this may mean that inheritance genes plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it. Various twin studies where one identical twin has an anxiety disorder have reported an incidence ranging from 31 to 88 percent of the other twin also having an anxiety disorder diagnosis. Environmental factors such as an overly cautious view of the world expressed by parents and cumulative stress over time have been found to be causes (Bourne 2005).
* Biological Causes- Generalized anxiety, obsessive compulsive disorder, Post Traumatic Stress Disorder, hypoglycemia, hyperthyroidism, Wilson's Syndrome, mitral valve prolapse and inner ear disturbances (Labyrinthitis). (Bourne 2005) Vitamin b deficiency from inadequate diet or caused by periodic depletion due to parasitic infection from Tape worm can be a trigger of anxiety attacks.
* Phobias- People will often experience panic attacks as a direct result of exposure to a phobic object or situation.
* Short-Term Triggering Causes- Significant personal loss, significant life change, stimulants such as caffeine or nicotine, or the drugs marijuana or mushrooms, can act as triggers (Bourne 2005).
* Maintaining Causes- Avoidance of panic provoking situations or environments, anxious/negative self-talk ("what if thinking"), mistaken beliefs ("these symptoms are harmful and/or dangerous"), withheld feelings, lack of assertiveness. (Bourne 2005)
* Medications-Sometimes panic attacks may be a listed side effect of medications such as Ritalin (methylphenidate). These may be a temporary side effect, only occurring when a patient first starts a medication, or could continue occurring even after the patient is accustomed to the drug, which likely would warrant a medication change in either dosage, or type of drug. Nearly the entire SSRI class of antidepressants can cause increased anxiety in the beginning of use. It is not uncommon for inexperienced users to have panic attacks while weaning on or off the medication, especially ones prone to anxiety.
* Hyperventilation Syndrome- Breathing from your chest may cause overbreathing, exhaling excess carbon dioxide in relation to the amount of oxygen in one's bloodstream. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms including rapid heart beat, dizziness, and lightheadedness which can trigger panic attacks. (Bourne 2005)
* Situationally Bound Panic Attacks- Associating certain situations with panic attacks, due to experiencing one in that particular situation, can create a cognitive or behaviorally predisposition to having panic attacks in certain situations (situationally bound panic attacks). It is a form of classical conditioning (Bourne 2005). See PTSD
* Pharmacological Triggers - Certain chemical substances, mainly stimulants but also certain depressants, can either contribute pharmacologically to a constellation of provocations, and thus trigger a panic attack or even a panic disorder, or directly induce one. This includes caffeine, amphetamine, alcohol and many more. Some sufferers of panic attacks also report phobias of specific drugs or chemicals, that thus have a merely psychosomatic effect, thereby functioning as drug-triggers by non-pharmacological means.
Physiological considerations
While the various symptoms of a panic attack may feel that the body is failing, it is in fact protecting itself from harm. The various symptoms of a panic attack can be understood as follows. First, there is frequently (but not always) the sudden onset of fear with little provoking stimulus. This leads to a release of adrenaline (epinephrine) which brings about the so-called fight-or-flight response wherein the person's body prepares for strenuous physical activity. This leads to an increased heart rate (tachycardia), rapid breathing (hyperventilation) which may be perceived as shortness of breath (dyspnea), and sweating (which increases grip and aids heat loss). Because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon dioxide levels in the lungs and then in the blood. This leads to shifts in blood pH (respiratory alkalosis), which in turn can lead to many other symptoms, such as tingling or numbness, dizziness, burning and lightheadedness. Moreover, the release of adrenaline during a panic attack causes vasoconstriction resulting in slightly less blood flow to the head which causes dizziness and lightheadedness.
Symptoms
Physical
* An extremely unpleasant sensation of adrenaline over the entire body
* Sweating
* Shortness of breath (dyspnea)
* Racing or pounding heartbeat or palpitations
* Chest pain
* Dizziness or vertigo
* Lightheadedness
* Nausea / stomach pains
* Hyperventilation
* Choking or smothering sensations
* Uncontrollable itching
* Tingling or numbness in the hands, face, feet or mouth (paresthesia)
* Hot/cold flashes
* Trembling or shaking
* Feeling of claustrophobia
* Exhaustion
* Feeling of physical weakness or limpness of the body.
* Uncontrollable crying
Mental
* Loss of the ability to react logically to stimuli
* Loss of cognitive ability in general
* Racing thoughts (often based on fear; a repeated or illogical worry)
* Loud internal dialogue
* Feeling of impending doom
* Feeling of "going crazy"
* Extreme worried feeling
* Feeling of extreme nervousness
* Feeling out of control
* Vision is somewhat impaired; (eyes may feel like they are shaking.)
Emotional
* Terror, or a sense that something unimaginably horrible is about to occur and one is powerless to prevent it
* Fear that the panic is a symptom of a serious illness
* Fear of losing control
* Fear of death
* Fear of going crazy
* Flashbacks to earlier panic trigger
Perceptual
* Tunnel vision
* Heightened senses
* The apparent slowing down or speeding up of time
* Dream-like sensation or perceptual distortion (derealization)
* Dissociation, or the perception that one is not connected to the body or is disconnected from space and time (depersonalization)
* Feeling of loss of free will, as if acting entirely automatically without control
Mnemonic
The symptoms of a panic attack can be remembered with the mnemonic: STUDENTS FEAR the 3 Cs: Sweating, Trembling, Unsteadiness/dizziness, Derealization/depersonalization, Elevated heart rate (tachycardia), Nausea, Tingling, Shortness of breath, FEAR of dying, FEAR of losing control, FEAR of going crazy, 3 Cs - Choking, Chest pain, Chills.
Agoraphobia
Main article: Agoraphobia
Agoraphobia is an anxiety disorder which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape. As a 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 Greek words agora (αγορά) and phobos (φόβος), literally translated as "a fear of the marketplace". This translation is the reason for the common misconception that agoraphobia is a fear of open spaces, and is not clinically accurate.
People who have had a panic attack in certain situations — for example, while driving, shopping in a crowded store, going to a party, experimenting with psychedelic drugs, etc. — may develop irrational 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 panic disorder are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. This can be one of the most harmful side-effects of panic disorder as it can prevent sufferers from seeking treatment in the first place. Agoraphobia of this degree is extremely rare. It should be noted that upwards of 90% of agoraphobics achieve a full recovery. Agoraphobia is actually not a fear of certain places but a fear of having panic attacks in certain places, where escape would be difficult and/or embarrassing.
The thinking behind agoraphobia usually follows the line that were a panic attack to occur, who would look after the person, how would he or she get the assistance and reassurance they needed? The vulnerability grows from the feeling that once victims of agoraphobia are caught in the anxiety, they are suddenly unable to look after themselves and are therefore at the mercy of the place they find themselves in and the strangers around them. In its extreme form, agoraphobia and panic attacks can lead to a situation where people become housebound for numerous years.
It is important to note that agoraphobia is by no means a hopeless situation. Sufferers often do not realize that they have experienced these same situations before and nothing terrible occurred. Successful treatment is possible with the right combination of therapy and medication.
Agoraphobia is often described as a fear of having 'no place to run or hide' if one does have a panic attack. Common examples include: driving, airplanes, malls, moving out of the house, etc.
Panic disorder
Main article: 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 anxiety disorders in that panic attacks are often sudden and unprovoked.
Treatment
People with Panic disorder often can be successfully treated with therapy, particularly Cognitive Behavioral Therapy and/or anti-anxiety medication or antidepressants. (Bourne 2005)
Paper bag rebreathing
Some panic attack sufferers and even some doctors recommend breathing into a paper bag as an effective short-term treatment of an acute panic attack.[8] However, this can prove to be fatal in some cases, and it is strongly advised against to engange in such a practice, by well-respected medical studies dating back to 1989 and 1994.
Medication
The benzodiazepine class of drugs includes diazepam, lorazepam, alprazolam, and clonazepam. While these drugs are highly effective and very fast acting in stopping panic, they may not be the best solution.[citation needed] First, the body can build a tolerance to the drug, much like alcoholic beverages, making it need more to feel the same benefit. Second, because of this, there is a high risk of abuse and addiction in some people.
As such, some doctors may prefer to prescribe an antidepressant, particularly an SSRI (such as paroxetine, sertraline, fluvoxamine, or fluoxetine), which after an initial titration period may be effective at reducing anxiety. SNRIs such as Venlafaxine can also be prescribed. Studies have proven they may be more effective than the SSRIs for anxiety. NaSSAs such as Mirtazapine have also been found effective, particularly with individuals whose anxiety and panic causes insomnia.
Interoceptive Desensitization/Symptom Inductions
One particularly helpful and effective form of therapy is Cognitive Behavioral Therapy (CBT). Interoceptive Desensitization intends to desensitize the afflicted from the symptoms of panic attacks. In a study by Barlow & Craske (1989), 87% of the individuals that participated in the two of four treatments that involved Interoceptive Desensitization were free of panic at the end of treatment and these results were maintained at a 2-year follow up. In controlled studies of Interoceptive Desensitization treatments compared to other treatments, those treatments that included Interoceptive Desensitization were found to be significantly superior to other treatments such as muscle relaxation alone, or education or insight-oriented treatments. Interoceptive Desensitization often leads to a dramatic reduction in the frequency and intensity of panic attacks and as such should be implemented immediately under the guidance of a mental health professional. It is important the patient is given medical clearance and permission from a medical doctor before attempting these exercises.
Symptom Inductions generally occur for one minute and may include:
* Intentional Hyperventilation - Creates lightheadeness, derealization, blurred vision, dizziness,
* Spinning in a chair - Creates dizziness, disorientation
* Straw breathing - Creates dyspnea, airway constriction
* Breath holding - Creates sensation of being out of breath
* Running in place - Creates increased heart rate, increased respiration, perspiration
* Body Tensing - Creates feelings of being tense and vigilant
The key to the induction is that the exercises should mimic the most frightening symptoms of a panic attack. Symptom Inductions should be repeated 3-5 times per day until the patient has little to no anxiety in relation to the symptoms that were induced. Often it will take a period of weeks for the afflicted to feel no anxiety in relation to the induced symptoms. With repeated trials, a person learns through experience that these internal sensations do not need to be feared – the individual becomes less sensitized or desensitized to the internal sensation. After repeated trials, when nothing catastrophic happens, the brain learns (Hippocampus & Amygdala) to not fear the sensations, and the sympathetic nervous system activation fades.
Many people overcome Panic Disorder and sudden Panic Attacks on their own. It takes time, but in a sense, they ride out the panic attacks and eventually learn that nothing is going to happen during one. Often, they 'taper off' until they are not noticeable any longer. It is for this reason that some psychologists helping people with panic disorders induce them into an attack, so they can see for themselves that indeed, nothing will happen.
Increased Risk of Heart Attack and Stroke
A recent study suggests that menopausal women with panic disorder and many occurrences of panic attacks have a three-fold higher risk of suffering heart attack or stroke over the next five years. The researchers believe that panic attacks or more accurately their associated symptoms (chest pain, dyspnea) can be manifestations of undiagnosed cardiovascular disease, or result in heart damage due to cardiovascular stress in patients with panic disorder and many panic attacks over periods of years. The study did not find that isolated cases of panic attacks in patients without panic disorder or agoraphobia lead to immediate heart damage, nor did it prove that the correlation between panic disorder and strokes was causal, or that it couldnt be attributed to the cardiovascular effects of medication that many panic disorder patients receive, such as SSRIs and benzodiazepines.
Limited Symptom Attack
Many people being treated for panic attacks begin to experience limited symptom attacks. These panic attacks are less comprehensive with fewer than 4 bodily symptoms being experienced. (Bourne 2005)
References
1. ^ Diagnostic and Statistical Manual of Mental Disorders
2. ^ Bourne, E. (2005). The Anxiety and Phobia Workbook, 4th Edition: New Harbinger Press.
3. ^ Klerman, Gerald L.; Hirschfeld, Robert M. A. & Weissman, Myrna M. (1993), Panic Anxiety and Its Treatments: Report of the World Psychiatric Association Presidential Educational Program Task Force, American Psychiatric Association, pp. pp.44, ISBN 978-0880486842
4. ^ http://www.nlm.nih.gov/medlineplus/ency/article/000924.htm
5. ^ http://panicdisorder.about.com/cs/shfitness/a/caffeine.htm
6. ^ http://fondationmarievictorin.qc.ca/panic-and-anxiety-attack-medication.php
7. ^ http://familydoctor.org/137.xml
8. ^ http://www.netdoctor.co.uk/ate/mentalhealth/205625.html
9. ^ a b http://firstaid.about.com/od/shortnessofbreat1/f/07_paper_bags.htm
10. ^ http://www.nytimes.com/aponline/us/AP-Panic-Attacks-Heart.html
5. Weekes, Claire. Hope and Help for Your Nerves: Signot (1991)
6.Wilson, Reid. Don't Panic: Taking Control of Your Anxiety Attacks. Revised Edition, HC (1996)
External links
- UK based forum for sufferers of panic attacks
- American Association for Marriage & Family Therapy: Panic Disorder
- American Psychiatric Association
- American Psychological Association: Answers to Your Questions About Panic Disorder
- Anxiety Disorders
- Panic Attacks - personal experiences and community discussion
- Overcome panic attacks - advice and articles by clinical psychologist David Carbonell
- Forum giving advice and support for Panic Attacks, Social Anxiety, OCD and other anxiety issues
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