In 1871, Da Costa first described anxiety as a disorder, calling it irritable heart. Due to the fact that the main symptoms were chest pain, palpitations and dizziness, Da Costa considered the disorder to be the result of a disturbance of heart function caused by a hyperreaction of the nervous system. Freud identifies anxiety as a major symptom of the syndrome and coined the term anxiety neurosis. By 1980, panic disorder and generalized anxiety disorder were classified together as anxiety neuroses. Panic disorder (PD) consists of recurrent, unexpected panic/anxiety attacks at least once a month, accompanied by constant concern about the occurrence of a new attack, fear of the consequences of a new attack. At least 4 of the 13 characteristic symptoms occur during an attack:
(1) palpitations, severe palpitations, or rapid heart rate;
(2) Sweating;
(3) body trembling or shaking;
(4) sensations of shortness of breath or choking;
(5) feeling of suffocation;
(6) chest pain or discomfort;
(7) nausea or abdominal distress;
(8) feeling dizzy, unsteady, lightheaded, or fainting;
(9) derealization (feeling of unreality) or depersonalization (feeling as if separated from the body);
(10) fear of losing control or going crazy;
11) fear of death;
(12) paresthesias (stiffness or shaking sensations);
(13) chills or hot flashes.
In order to diagnose panic disorder, interictal anxiety with the expectation of another attack or avoidant behaviour must be present within one month of the panic attack.
Agoraphobia (AF) is not infrequently a complication of panic disorder, in which the sufferer experiences fear of being in places where they cannot get immediate medical help or cannot get out quickly (supermarket, open crowded spaces, cinema, intersections, etc.). Although conceptually separated into two distinct disorders, both are assumed to be within the same illness. Agoraphobia without panic is rare. The name agoraphobia is from the Greek and means "fear of the market". Patients with AF are often afraid that they will have a panic attack in public and embarrass themselves. They avoid places with lots of people such as stores, restaurants, theaters, and churches because they feel trapped. Many are afraid to travel long distances, cross bridges, drive in tunnels. Patients with agoraphobia often insist on being accompanied by loved ones to places they would otherwise avoid. In the most severe version of the disease, patients do not leave their home or stay in the room with an attendant.
According to an ECA study, 2-3% of women and 0.5-1.5% of men have panic disorder (Kessler et al., 1987). According to EPIBUL (2010), the lifetime prevalence of PD in our country is 1.1% of the population. The morbidity of AF without panic disorder is rare and is 0.1% of the population. Panic disorder and agoraphobia have a typical onset between 20 and 30 years of age, although the age of onset can vary; nearly 80% of patients with panic disorder develop the illness before age 30. Women are at least twice as likely as men to develop panic disorder and agoraphobia. There are usually no precipitating stressors prior to the onset of either illness. However, many patients report that panic attacks begin after an illness, an accident, or the breakup of a relationship; they develop after childbirth or after the use of medications such as LSD or marijuana. In the beginning, a panic attack causes patients to go to the emergency room, where EKG and lab tests show normal results. Many patients go through multiple often unnecessary medical procedures. Consultation with a psychiatrist takes place after determining there is no physical illness causing the anxiety. Panic attacks have a sudden onset, peak within a few minutes, and resolve after 5-30 min. Although most patients report that their panic attacks last for hours or all day, this is due to recurrence or mild symptoms that exist after the attack.
Psychoanalysis assumes that the extinction of early psychotrauma, a frequent defense mechanism, may be related to the development of panic. Evidence in this direction is the frequent separation anxiety in childhood in individuals who later develop PD. And according to learning theory, anxiety attacks are states of response to threatening situations.
Development and exit
Panic disorder and agoraphobia are chronic and lifelong. They tend to fluctuate in intensity and severity. Between 50-70% of panic disorder cases have some improvement over time. Patients with panic disorder are at increased risk for psychosomatic disorders - stomach ulcers, hypertension and have higher mortality rates than expected. Suicide risk is high in these patients, especially when combined with depression and alcohol intake. The most common complications of panic disorder are depression and alcohol or substance abuse. Depressive disorder develops in 50% of patients with panic disorder and agoraphobia, and can be severe, although often mild, in response to a particular psychotraumatic situation. 20% of patients develop alcohol abuse.
Differential diagnosis
It is very important to rule out somatic disease, as some of these proceed with panic (e.g., hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular nerve disease, hypoglycemia, and supraventricular tachycardia). Mitral valve prolapses are more common in people with panic disorder and amount to 30%. Most commonly, cardiac malformation has no haemodynamic significance but is probably relevant to the extrasystoles and palpitations in PD. Many patients with depression also have panic attacks or anxiety that resolves after the illness is controlled. Panic attacks may also be present in patients with GAD, schizophrenia, depersonalization disorder, somatization disorder, borderline personality disorder. When anxiety symptoms are the result of a specific stressor, the diagnosis of adjustment disorder with anxiety is appropriate.
Treatment
Panic disorder is usually treated with a combination of medication and individual psychotherapy.
Dr. Petya Terziivanova, MD
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