Pathological anxiety and panic attacks: a common disorder

Pathological anxiety and panic attacks: 8.5 million Italians have suffered from anxiety disorders, the most common psychiatric disorder in countries like Italy, at least once in their lives

If, in fact, the physiological fear is a natural response of our psyche to external stimuli that could lead to danger, when it becomes pathological, anxiety is configured as a real lifestyle, so the patient develops a constant tendency to worry, hypercontrol and hypervigilance, thus deluding himself to be calm but doing nothing but reinforcing dysfunctional states.

What is pathological anxiety

When we talk about generalised anxiety, phobias, catastrophic worries or panic attacks, we mean a series of non-functional responses of the psyche with respect to the real entity of the external stimuli with which one comes into contact and which, therefore, transform a physiological emotional condition (that of anxiety and fear necessary to face a danger) into a pathological situation that, if repeated, risks becoming chronic.

Normally, therefore, the anxiety-provoking stimuli we receive in our daily lives (for example, speaking in public, or taking a particularly difficult exam) trigger a physiological emotional response in our psyche, which, if it develops properly, helps us to deal with that particular difficulty.

If, on the other hand, the anxious response is abnormal in relation to the stimulus, it becomes dysfunctional and reduces our chances of success. In the case of pathological anxiety, in fact, it becomes difficult to manage somatic and psychic manifestations of the disease, which end up taking over.

Anxiety: what are the symptoms?

The main somatic manifestations of anxiety are: hot flushes or chills, pollakiuria, dysphagia or “lump in the throat”, trembling, muscle twitching, muscle tension or pain, easy fatigability, restlessness, dyspnoea and choking sensation, palpitations, sweating or cold, wet hands, dry mouth, dizziness or feeling faint, nausea, diarrhoea or other abdominal disorders, difficulty in falling asleep and maintaining a deep and satisfactory sleep.

Psychological manifestations of anxiety include feeling nervous or on edge, exaggerated alarm responses, difficulty concentrating, feeling light-headed, inability to relax, irritability, apprehensive attitude, fear of dying, fear of losing control, fear of being able to cope.

It is common for those who experience anxiety in its pathological form to have a tendency to worry, over-accountability, brooding and over- vigilance. In this way, anxiety is likely to become a real way of life, both mental, due to a continuous worsening amplification of reality and a constant expectation of harm with a feeling of helplessness, and practical, with avoidance of certain situations, loss of autonomy and need for reassurance and anticipatory anxiety.

What are panic attacks

One of the most common manifestations of pathological anxiety are panic attacks, which have an incidence in the general population of between 1.55 and 3.5% when they are a pivotal phenomenon of Panic Disorder and 14% if we refer to occasional panic attacks, symptoms that we could define as paraphysiological, not elements of a disease in this case.

It is an externalization of intense fear, which is accompanied by both somatic and cognitive symptoms and has a sudden onset and a climax, followed by a slow return to stability.

The DSM-V identifies a panic attack as a period of intense fear or discomfort accompanied by at least four out of 13 somatic or cognitive symptoms (attacks without at least four of these symptoms are defined as paucisymptomatic), which quickly peaks (in about 10 minutes, but less) and is often associated with a sense of impending danger or catastrophe and a need to get away.

Panic attacks: what are the symptoms?

The 13 somatic or cognitive symptoms that can occur in a panic attack are:

  • palpitation, heart palpitation or tachycardia;
  • sweating;
  • fine or large tremors; dyspnoea or choking sensation;
  • feeling of asphyxiation
  • chest pain or discomfort;
  • nausea or abdominal discomfort;
  • feeling of lurching, unsteadiness, light-headedness or fainting;
  • derealisation (feeling of unreality) or depersonalisation (being detached from oneself);
  • fear of losing control or going mad;
  • fear of dying;
  • paresthesias (numbness or tingling sensation);
  • chills or hot flashes.

Initially, panic attacks occur suddenly, without being linked to particular situations, but later on they begin to occur in relation to specific conditions and moments.

For this reason, specialists distinguish two different types of panic attacks: anticipatory and situational.

Anticipatory anxiety

Since it is an unexpected, intense, very unpleasant experience, often accompanied by the fear of losing control (physical or psychological), many (but not all) patients begin to develop a fear of reliving this experience (anticipatory anxiety) and thus tend to avoid situations in which they have been ill, fearing that the attacks are more likely to recur.

This can lead to other pathological conditions such as excessive worry about any physical symptoms considered abnormal or fear of being sick in front of other people.

This vicious circle is called the “March of Panic” by experts and is the main cause of Panic Attack Disorder.

Panic attacks and agoraphobia

Panic disorder is often associated with agoraphobia, i.e. the anxiety of being in situations and places from which it is difficult to get out or move away.

In fact, agoraphobia develops mainly in situations in which the patient is alone or in the midst of a crowd of people, or in places from which it is difficult, if not impossible, to leave, such as bridges, trains, buses or cars. These are contexts in which agoraphobia sufferers may develop a panic attack.

Therefore, agoraphobics sufferers will try to avoid those situations or places where they know a panic attack could occur, or, if it is not possible to do without, they will endure their stay in that place with great difficulty and will prefer to have someone trustworthy by their side who can help in case the panic attack occurs.

Diagnosing panic attacks

In order to make a correct diagnosis, the specialist will assess whether or not the panic attacks affecting the patient meet certain criteria:

  • Panic Disorder is diagnosed when the patient reports unexpected and recurrent panic attacks and after at least one of them one or more of the following symptoms have occurred for a month or more: worry of being subject to further panic attacks; worry about the consequences of the panic attack (from loss of control, to having consequences on the physical plane); significant alteration in behaviour related to the attacks.
  • Whether panic disorder is associated with agoraphobia.
  • Whether panic attacks are not caused by drug use, medication abuse or general medical conditions (such as hyperthyroidism).
  • If panic attacks are not related to other mental disorders such as: Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, or Separation Anxiety Disorder.

Treatment of panic disorder

The clinical management of panic disorder is an important and delicate aspect, since the risk for patients suffering from it is, in the long term, chronicity of the disorder.

In fact, the short-medium term therapeutic results foresee a remission index of about 90%, but in the follow-up phase, two years after the beginning of therapy, only 45% of the patients treated have maintained remission (or have improved their symptoms).

At the diagnosis stage it is therefore important to carry out a complete and accurate assessment of the disorder and, consequently, the most appropriate treatment, so as to highlight the steps of therapy that may be more critical and determine a positive or negative outcome of therapy.

The therapeutic treatment for panic disorder includes different phases: the initial intake of the patient, the acute phase of treatment, the maintenance phase of treatment (which can last from 6 to 12 months), the interruption of the pharmacological therapy, and the long-term follow-up.

Generally speaking, the treatment of choice for panic disorder involves a combination of pharmacological treatment and psychological-rehabilitation therapy of a cognitive-behavioural type in order to allow the patient to achieve a series of treatment objectives, such as: the resolution of spontaneous panic attacks, functional recovery (especially with regard to the limitations imposed by agoraphobia), the ability to return to manage their physical sensations and body without these being associated with fears.

A personalised diagnosis and assessment are always essential to formulate a diagnosis and therapeutic intervention that is as targeted as possible on the patient, but in general it can be said that pharmacological treatment is important to ‘block’ sudden panic attacks, in particular to reduce somatic symptoms, while cognitive behavioural therapy aims to reduce avoidance and orient people to a way of thinking that is functional to their physical sensations and fears.

As far as pharmacological treatment is concerned, the most commonly used ‘curative’ drugs are serotonergic antidepressants (SSRIs), the functioning of which should always be discussed in depth, especially in order to dismantle the various prejudices that people very often still have about so-called psychotropic drugs.

It is important to know that with serotonergic antidepressants (SSRIs)

  • there is a latency of response varying between 3-6 weeks;
  • there may be a worsening of the clinical picture in the first 2 weeks;
  • may involve side effects;
  • they are ineffective in 20-30% of cases;
  • their intake requires a maintenance phase of at least 6-12 months from the time of clinical response.

Finally, it is important to emphasise the importance, for the purposes of therapy, of a patient who is aware of his or her active role in the management of psychological distress and the symptoms that the disorder involves.

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