Panic attack disorder: feeling of imminent death and anguish

By Cristiano Antonino On Jul 21, 2022

Panic disorder is a psychiatric disorder in which reactions of intense fear, desire to escape, anguish and fear for one’s own safety, typically experienced in catastrophic or truly dangerous situations, are triggered by events and circumstances that are absolutely harmless and as such perceived by the majority of people, taking the form of a true ‘panic attack’

Panic attacks can be triggered even while one is quietly sitting in an armchair reading or watching television, or even in sleep, with both psychological and physical manifestations.

Panic disorder can begin at any time in life (but most often between the ages of 20 and 30)

It appears suddenly and in the most unsuspected circumstances, while one is performing an absolutely banal action that had never caused problems before.

Generally, the lowest common denominator of critical situations is being in places from which it is difficult to escape (in the passenger compartment of a car while driving alone, in a lift, on a ferry, in the underground, etc.) or in which one could not be rescued in the event of an illness (e.g. while in a crowd or alone in isolated places).

Panic disorder may manifest itself with panic attacks alone or in association with agoraphobia

In the latter case, the overall clinical picture is usually more severe and difficult to manage.

The panic attack is not dangerous to health either while it is occurring or afterwards, but the sensations experienced are so gripping and traumatic that those who experience them avoid the situation in which they occurred so as not to risk repeating the experience.

If not adequately treated, as the disorder evolves and the situations to be avoided multiply, the person suffering from panic disorder, over a period of 2-3 years, ends up withdrawing into himself, until he is no longer able to work, have a social life, or carry out the most mundane daily activities, such as going to the supermarket or the cinema alone.

The causes of the disease are not yet fully clarified

There is certainly a genetic predisposition, since family members of a person suffering from panic attack disorder are ten times more likely than the general population to develop it themselves, but specific genes responsible have not yet been identified.

Several studies have shown that patients with panic attack disorder are hypersensitive to carbon dioxide, to the extent that breathing in CO2-enriched air can trigger an attack similar to spontaneous attacks.

Other factors at play, especially in women, are hormonal fluctuations associated with the menstrual cycle (which can favour the onset of the attack) and pregnancy (which, on the other hand, is protective).

Symptoms and diagnosis of panic disorder

Recognising a panic attack is relatively simple when at least four of the following symptoms occur spontaneously, unjustifiably and suddenly, in addition to intense fear and discomfort

tachycardia and/or palpitations
feeling of suffocation and difficulty breathing;
nausea, abdominal pain or restlessness (pain in the centre of the chest);
sweating/heat flushes or, conversely, chills/tremors;
dizziness and loss of balance;
tingling and/or altered sensitivity in specific parts of the body;
loss of sense of reality or feeling of ‘detachment from oneself
feeling of imminent death;
feeling of being on the verge of going mad

It should be noted that a single panic attack can occur in the context of many medical (e.g. cardiological, gastrointestinal, neurological, etc.) and psychiatric conditions, even those not related to anxiety disorders (depression, post-traumatic stress disorder, substance abuse, etc.).

In order for a diagnosis of panic disorder to be made, attacks must be recurrent and must be followed by a period of at least one month during which the person concerned strongly fears the recurrence of the experience and/or its consequences (physical, psychological, social, etc.), modifying his or her behaviour with the intention of avoiding it. Furthermore, the manifestations must not be related to the presence of another physical or psychiatric illness or to the taking or discontinuation of drugs or substances.

Frequency and time distribution of panic attacks are highly variable

Some people, for example, may experience fairly regularly one attack per week while others may have numerous attacks concentrated in 2-3 weeks followed by symptom-free periods.

The characteristics of attacks can also vary, both between different people and within the same subject. In particular, there can be ‘complete’ attacks, characterised by intense fear and anxiety and at least four physical symptoms, or ‘partial’ attacks, characterised by fewer physical symptoms.

Classification of agoraphobia

If intense fear, anguish of imminent death and, possibly, physical symptoms of panic arise selectively when one is outside one’s home or the most reassuring living environments, one speaks of agoraphobia.

Typically critical contexts for the person suffering from agoraphobia are public transport and crowded places (indoors or outdoors), as well as all situations in which it may be difficult to call for help or to be rescued in the event of an illness (underground car parks, tunnels, events, concerts, non-humanised natural areas, motorways, etc.).

As in the case of panic disorder, the psycho-emotional and physical reactions of terror typical of agoraphobia are not commensurate with the seriousness of the situation one finds oneself in (as a rule, completely or almost harmless) and, after the first experience, lead one to avoid the places and contexts in which they were experienced.

If not promptly counteracted with appropriate therapies, this tendency has highly invalidating outcomes as the situations in which one may feel uncomfortable multiply and their cumulative avoidance ends up preventing the person concerned from engaging in common and necessary activities such as driving, going shopping, going to school or work, boarding a train or plane, standing in line at the bank, going to the cinema or theatre, etc.

Symptoms and diagnosis of agoraphobia

In order to make the diagnosis of agoraphobia, it is sufficient for unmotivated anxiety and concern for one’s safety to occur in at least two contexts among:

public or private means of transport
open spaces (car parks, markets, bridges, etc.);
crowded places (events, shopping centres, etc.);
closed places (cinemas, theatres, etc.);
long queues (of people or vehicles);
situations in which one is away from home alone.

If, in addition to psychological tension, situations of this kind trigger a full-blown panic attack, a double diagnosis is made, namely ‘Agoraphobia and Panic Disorder’.

Treatment of panic disorder and agoraphobia

The strategy to be followed to counter panic disorder depends on the severity of the clinical picture and when the patient turns to the doctor. Panic disorder is, in fact, a disorder with a periodic course, characterised by periods of flare-ups, with frequent attacks, and phases of well-being, free of symptoms.

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In the former case, a combined treatment, based on medication and psychotherapy, is usually required.

The management of agoraphobia is similar, but in this case it is particularly important to intervene early because the disorder worsens with the passage of time and the multiplication of situations to be avoided, becoming more difficult to treat.

Psychotherapeutic approach

In order to optimise the effects of drug therapy and to offer the person suffering from panic disorder and/or agoraphobia an effective means of self-management of the feelings experienced in the various circumstances of daily life, it is useful to combine medication with behavioural therapy aimed at ‘deconditioning from the phobic stimulus’, i.e. to loosen the link between critical situations and the patient’s anxious reaction.

This approach is particularly beneficial in the consolidation phase of treatment to reduce the patient’s tendency to avoid places and situations perceived as ‘fearful’.

The behavioural approach requires the person with panic disorder, instead of avoiding them, to gradually expose themselves to events that are perceived as stressful, to analyse them with the help of the specialist and to process them in a positive way in order to put the experience into a context of normality and deal with it better on subsequent occasions.

Supportive interventions

Follow regular life rhythms.
Sleep a sufficient number of hours each night.
Eat a healthy diet.
Exercise moderately every day.
Take all therapies prescribed by your doctor regularly, at the indicated dosages.
Avoid drinking alcohol and caffeinated beverages.
Do not smoke or try to reduce the number of cigarettes.
Attend self-help groups and share your experience with other people with a similar problem.