“One of the brightest side effects of Covid is fears, phobias and panic attacks.” Therapist talks about how to recover from corona

Medical information is reliable Checked by Shaidullin Renat Flyurovich

Panic attacks are attacks that occur unpredictably, accompanied by severe fear and anxiety. They are characterized by vegetative symptoms: increased sweating, chills, hot flashes, difficulty breathing, rapid heartbeat and others. It all depends on the individual characteristics of the body and the level of anxiety. If a person is in good health, he does not complain of weakness, and is not registered in the hospital - this condition is easier to tolerate.

The diagnosis is made on the basis of the clinical picture, if somatic pathology leading to similar attacks is excluded. The treatment of panic attacks at Dr. Isaev’s Clinic is complex, consisting of drug relief of symptoms and psychotherapeutic methods of influencing the patient. The period between crises can be kept under control if the patient is promptly trained in ways to independently overcome such a condition.

Our doctors work with patients anonymously. If you are afraid that your secret will leave the hospital, these fears are unfounded. We do not enter information into special databases and do not record the fact of contacting a psychiatrist. This means that people who contact us have no reason to worry about the confidentiality of facts relating to their mental state.

Signs of panic attacks

The term “panic attack” was introduced into medical use in 1980. Currently, it is included in the International Classification of Diseases; the patient is not able to independently cope with periodic attacks. He needs the help of a specialist; perhaps other pathologies will be identified during the examination.

A similar condition was previously considered within the framework of vegetative-vascular dystonia, but now this version is not relevant. The psychological factor is considered primary, and vegetative symptoms are considered secondary. Attacks are classified as neuroses, and the accompanying disorders at the physiological level are classified as autonomic dysfunction.

Panic paroxysms are common, especially common among residents of megacities. They experience frequent stress; the dynamic rhythm of life leaves no chance for relaxation and good sleep. The typical age for the first attack is between 25 and 45 years. In older people, panic paroxysms occur with less severe symptoms; they affect the emotional sphere to a greater extent.

Panic attack symptoms

A sudden and uncontrollable attack of anxiety with various somatic disorders indicates a disorder of the nervous system. If a person is in danger or feels his life is threatened, he has a peculiar reaction to a stressful situation. Increased heart rate, trembling in the limbs, vomiting - for such a case this is the norm. As soon as the danger passes, all physiological disturbances disappear and the condition returns to normal.

The difference between a panic attack is that the patient cannot explain its cause. Such attacks often begin in places where there are large crowds of people. This can happen on the subway, in a store, or on the street. Panic often occurs in a confined space, its intensity varies. If paroxysms are observed frequently and are regular, the patient may have a more serious mental disorder that requires immediate diagnosis and treatment.

Typical symptoms of panic attacks include:

• fear of death - it seems to a person that he will die right now, without having time to do what seems so necessary to him;
• a feeling of doom and unreality of what is happening;
• general physical weakness, infirmity;
• loss of control over your thoughts and actions;
• rapid heartbeat, there is a feeling that the heart is actually jumping out of the chest, that it cannot cope with the load and will stop;
• numbness of the limbs;
• nausea and vomiting;
• chills, fever;
• dizziness;
• increased sweating;
• dry mouth;
• difficulty breathing, shortness of breath similar to an asthma attack

These symptoms can intensify, which brings significant discomfort to a person’s life. He cannot predict how each next attack will end, and is constantly worried about what others will think of him at this moment.

The average duration of a panic attack can take from 10 minutes to 1 hour, an acute state - about 15 minutes. After an attack, patients feel overwhelmed and empty, they cannot work or perform household duties, and want to retire and relax.

In some cases, the symptoms are accompanied by disturbances in the functioning of the gastrointestinal tract: heartburn, vomiting, nausea, pain in the epigastric region. Patients complain about the loss of a sense of their own “I”; the personality seems to be watching itself from the outside and cannot intervene. Sounds become muffled and objects around you become blurry.

Panic attacks. Modern diagnostic methods.

Only a qualified neurologist-vegetologist can diagnose panic disorder, which manifests itself as panic attacks, identify its symptoms and prescribe optimal treatment.

At the initial examination, the vegetarian doctor must examine the patient’s normal reflexes, his muscular system, sensory organs, cognitive functions (memory, speech, perception), assess the general psycho-emotional state of the patient, taking into account all his complaints in order to collect a complete picture of the disease.

Next, there are several methods for diagnosing autonomic nervous disorder. One of them is the study of heart rate variability.

The patient performs a simple load: first he lies on his back, and after a few minutes he gets to his feet. In this way, we simulate a standard everyday situation when the minimum load is placed on our body. During this time, sensors attached to the patient's chest record the rhythm of his heart, and the doctor then compares the changes in rhythm in both positions. Such a study shows how adapted the human body is to the usual minimum load, which our autonomic nervous system normally copes with every day without the slightest difficulty.

How it works?

In a healthy state, our body responds adequately to any “stress”, any load (mental, physical, emotional). Therefore, when a healthy person gets up, the sympathetic part of the autonomic nervous system is activated in his body and the hormone adrenaline is produced, which means the heartbeat quickens. When a person lies down, his body should normally be in the mood for rest and relaxation. At the physiological level, this manifests itself as follows: the parasympathetic department of the autonomic nervous system becomes active and the hormone acetylcholine is released, which extinguishes the activity of adrenaline, and a phase of relaxation and replenishment of the body’s reserves begins.

But in patients with symptoms of panic attacks, an abnormal change in heart rhythms is observed: that is, when a person lies down, his pulse quickens and becomes faster and faster. That is, when a person gives his body the command to tune in to rest, the body understands the opposite - and prepares to run a short distance race. This is why people with disorders of the autonomic nervous system so often cannot sleep at night and never feel rested and alert.

Thus, the doctor concludes that the harmonious functioning of the sympathetic and parasympathetic parts of the nervous system is disrupted. This means you can move on to the next stage of the examination.

Among the innovative methods for diagnosing panic disorder are studies of the autonomic nervous system using infrared thermography. In an infrared image, a thermal imager clearly shows in which nodes (ganglia) of the autonomic nervous system the work is disrupted. It is with these vegetative nodes that the neurologist-vegetologist will subsequently work.

“Serious scientific research over the last decade has shown the high reliability and reliability of thermography. This allows this method to be used in medical practice to make a diagnosis in complex cases,” James Mercer, Professor, President of the European Thermography Society (EAT).

After treatment, you can take a repeat infrared photo, in which you will notice progress from the completed course. Areas with abnormal temperatures (bright red or dark blue) will change color in the image because their temperature regime is closer to normal.

Prerequisites and causes of panic attacks

There are several factors that can become prerequisites for the occurrence of such a condition.

• Genetic predisposition.

If the patient's close relatives suffered from uncontrollable attacks of anxiety and fear, there is a high probability that this disorder will manifest itself in adulthood.

• Severe stress.

Chronic nervous tension, constant quarrels and conflicts in the family or at work, divorce or the loss of a close relative lead to the emergence of inexplicable fear. This feeling is irrational, the patient often cannot explain why he experiences it, he has no objective reasons to be afraid.

• Thyroid gland dysfunction.

This organ is responsible for producing hormones that affect the condition of the body. Increased or decreased production of these substances provokes the occurrence of symptoms characteristic of panic attacks. Perhaps this is autonomic dysfunction that will not develop into paroxysm; in any case, a thorough examination is necessary.

• Low self-esteem.

If a person is guided by the opinions of strangers, is afraid of disgracing himself in society, is a suspicious person, he belongs to the risk group.

• Uncontrolled use of medications.

Often, in order to normalize their condition, patients use various medications - sedatives, sedatives, and blood pressure lowerers. The availability of such drugs and the lack of need for a prescription leads to the constant use of questionable self-prescribed drugs. If a certain dose does not help, the patient increases it, thereby harming his body. Negative consequences include exhaustion of the nervous system and frequent disruptions in its functioning. Also, mental disorders are a consequence of regular consumption of large volumes of energy drinks or drinks that contain a high percentage of caffeine - black tea, natural coffee.

• Alcohol.

Chronic addiction disrupts the functioning of the entire body, primarily affecting the nervous system. In the morning after drinking a large dose of alcohol, a feeling of irrational fear may arise. It often accompanies asthenic syndrome, in which all the patient’s thoughts are only about the next portion of alcohol. Panic attacks caused by alcoholism do not go away on their own; only qualified medical help will help you get rid of paroxysms and overcome addiction.

• Sleep disturbances.

If a person is awake at night and constantly lacks sleep, this depletes the nervous system. It begins to malfunction and gives incorrect commands to the body, which are expressed in fear and anxiety for no reason. Experts recommend sleeping at night; the daily sleep requirement is at least 8 hours. Daytime sleep for 1-2 hours is allowed; it is important during the period of recovery of the body.

• Phobias.

These are mental disorders in which a person is afraid of something specific. This could be a fear of heights, enclosed spaces, or places with large crowds of people. It is impossible to get rid of them on your own; you need the help of a psychologist or psychotherapist; in advanced conditions, you need to consult a psychiatrist.

Also among the possible causes of panic attacks are mental disorders; in this case, PA develops as a secondary disorder. For such conditions, a specific treatment regimen is selected.

If you do not consult a doctor in a timely manner, the intensity of symptoms increases with each new attack. As a result, a person strives for social isolation; the only true way out for him is the decision to stay at home and not go out. Our doctors will teach the patient to cope with attacks, he will be able to fully prepare for the onset of a panic attack, and will not be afraid of embarrassing himself in front of others.

Treatment of panic attacks and neuroses, how to get out of the vicious circle of fears?

1. First of all, believe that you are not crazy. What a panic attack is, 5% of the population knows. As a rule, people aged 20–30 years old, most often women, face the problem.
2. And most importantly, panic attacks can be cured. Don't be afraid to visit a specialist. The sooner you take this step, the sooner you will stop experiencing unbearable anxiety. You will begin to fearlessly leave the house again, work, and communicate normally with people. In a word, feel comfortable.

It is very important that in such a difficult period there is a person nearby who will believe. He will understand that uncontrolled anxiety is not a fiction, but a condition that really makes life unbearable. If you know someone who suffers from PA, be understanding and convince them to see a doctor.

What happens during an attack

The patient’s first attacks occur after a strong emotional shock; it is this that provokes the severity of the disease increasing each time. Next, a certain trigger is needed for the paroxysm to take possession of the person again.

A similar factor may be close contact with other people, strong sound or unpleasant smell. Most often, triggers are associated with a traumatic situation. At first, the heart rate increases, the sweat glands begin to work to the maximum. They produce a large amount of sweat, perspiration appears on the forehead, and their hands become damp.

After a few minutes, panic sets in, the manifestation of which will vary from person to person. Some experience a strange feeling of confusion, forget where they are going, others are overcome by severe fear. They seem to freeze in one place, not finding the strength to make any movement.

The attack can last several minutes, for some it ends after one or two hours. The specificity of PA is the high rate of increase in symptoms. After the first attack, there is constant anxiety and concern for one’s health on a subconscious level. All organs and systems can operate uninterruptedly. Our clinic provides treatment for mental disorders; here you can undergo treatment for mental retardation and schizophrenia, and receive professional help in correcting the consequences of dementia and other pathologies.

Mechanism of attack

The human brain reacts to external stimuli in different ways, but triggers a single defense mechanism at the first sign of approaching danger. During a panic attack, a threat is signaled even if it does not actually exist. Tension in all parts of the nervous system increases fear. On a physiological level, this manifests itself in the production of large amounts of the stress hormone (cortisol), followed by a powerful surge of adrenaline.

The brain gives a command to the body to save life in any way, increasing the intensity of the manifestation of physical symptoms. If the threat is real, such hormonal surges can make a person stronger and more resilient, in this state he can do a lot. But if this happens in a state of rest, when there is no need to run anywhere and defend yourself, then there is a negative impact on mental health. The danger lies in losing control over your actions and thoughts.

Why does panic disorder develop?

Many experts believe that at least once in their life everyone experiences symptoms similar to a panic attack. But the majority do not focus on them; a pathological reaction is not triggered.

Panic attacks can also occur against the background of various somatic and functional disorders and psychopathologies.

The causes vary as much as the severity of the symptoms. If we summarize all the available data, we can identify several main triggers:

1. A long stay in a psychotraumatic situation is stress at work or study, which the body expresses with the help of psychosomatics.
2. Secondary benefit - often a panic attack carries some benefit: by feeling unwell, the patient avoids any tasks or responsibilities. Sometimes the presence of such a benefit is itself the cause of the disorder.
3. Somatic diseases. Often the symptoms of the disorder are caused by diseases of the endocrine system.

Treatment is aimed at both relieving symptoms and eliminating the underlying cause. Therefore, first of all, the specialist will try to find out what led to the unpleasant symptoms.

What happens if PA is not treated?

Each subsequent attack is accompanied by more acute sensations. A person may develop a new phobia - a strong fear of repetition of paroxysms; he continues to live in constant tension, expecting the situation to worsen. Regardless of the intensity of the physiological symptoms, this disorder is not fatal. Treatment of panic attacks is necessary to prevent the development of phobias, increased anxiety and nervousness.

The patient begins to radically change his life and adapt to his condition. He avoids places with large crowds of people, supermarkets, and stops using any public transport. Gradually, such a person isolates himself from society, prefers not to engage in professional activities, and spends all his time indoors. He stops communicating on confidential topics with his loved ones, and there is a risk of developing serious mental complications. Patients with panic attacks often suffer from neurasthenia, neuroses, sleep disturbances, depression, and asthenia. The nervous system is exhausted, the person tries to relieve the symptoms with self-selected medications.

Regularly recurring attacks lead to loss of appetite and disruption of the functions of important organs, in particular the gastrointestinal tract. Conscious refusal of food leads to physical exhaustion. In this case, treatment of dystrophy is often required; this process is lengthy and is not always completed successfully. It all depends on the condition of the body, the presence of internal reserves to fight the disease.

Risk factors

Scientists have identified a number of causes and risk factors, the presence of which can provoke signs of a panic attack. Among the main ones are:

• mental pathologies, especially panic, post-traumatic or so-called social anxiety disorders;
• social factors that provoke pronounced stress (death of loved ones, job loss, divorce);
• bad habits (smoking, alcoholism, drug use);
• abrupt withdrawal or reduction of the dose of certain medications (especially antidepressants);
• chronic diseases of the respiratory tract or cardiovascular, endocrine system, causing increased breathing and heart palpitations.

The key difference between panic attacks and all other types of anxiety disorders is the unprovoked, sudden nature of the attacks. If we explain what it is in simple words - a sudden feeling of panic, fear of death, in which the heart literally jumps out of the chest, there is a feeling that there is not enough air Source: Features of the pathogenesis, diagnosis and treatment of panic attacks in young people. Chukhlovina M.L. Neurology, neuropsychiatry, psychosomatics No. 3, 2022. pp. 37-41.

In people diagnosed with an anxiety disorder, attacks are often associated with something, or their manifestations intensify in certain situations, in places previously familiar to them. This seriously affects normal life, strong fears develop, severe phobias form, so the person avoids a number of scenarios or situations. There is a concern that the attack will happen again, and this only worsens the condition.

Diagnosis of the disease

PA is a specific mental disorder that causes difficulties in diagnosis. It is not always possible, even after an examination and conversation with a psychiatrist, to determine what caused this condition - problems with the cardiovascular system, autonomic dysfunction, mental disorder. The neurologist checks reflexes, listens to the lungs, measures blood pressure, and examines the patient's abdomen to rule out internal bleeding. It is important to establish that these are paroxysms, and not a heart rhythm disorder or a heart attack. The patient undergoes an electrocardiogram, MRI, breathing tests, and an ultrasound examination.

Panic attacks: how to deal with it yourself

We categorically do not recommend self-medication. Such events aggravate the patient's condition. He cannot independently determine whether he has concomitant mental disorders.

Pharmacology taken uncontrolled can provoke an increase in symptoms and make the patient’s condition more severe. This complicates further therapy in the hospital, increases the time of recovery and complete restoration of the body. The Clinic of Dr. Isaev provides round-the-clock care for patients in serious condition who, due to mental disorders, are unable to care for themselves.

Treatment of panic attacks at Dr. Minutko’s clinic

Any therapy for panic attacks should begin with a diagnosis and search for their causes. Not all attacks are caused by mental pathology; sometimes the cause of panic attacks is a dysfunction of the temporal lobe of the brain. Differential diagnosis of panic attacks should be carried out to distinguish a panic attack as such from similar conditions in diseases of the endocrine, cardiovascular system, neurological, and organic diseases of the brain. It is also necessary to distinguish panic attacks from phobias in cases of schizophrenia, depression, and bipolar affective disorder.

At the clinic of Doctor of Medical Sciences Vitaly Leonidovich Minutko, differential diagnosis of a panic attack is carried out on the basis of objective criteria: blood tests for hormonal status, visceral, neural tests, neuroimaging methods, transcranial magnetic stimulation.

Treatment for panic attacks can be divided into several categories:

• drug therapy in an outpatient or hospital setting;
• non-drug treatment;
• prevention of panic attacks;
• providing emergency assistance;
• methods of relaxation and working with reactions to trigger stimuli.

Therapy for panic attacks is carried out in outpatient and inpatient settings. They are determined both by the patient's intention and the severity of the panic attacks. If a person is so overcome by fear that he cannot stay at home, and attacks occur every day, then it is better to go to the hospital.

Inpatient therapy for panic attacks is prescribed for:

• impossibility of living at home;
• frequently recurring attacks;
• concomitant depression;
• uncertainty about the cause of a panic attack;
• the need for comprehensive diagnostics;
• concomitant alcohol, medication, drug addiction.

Pharmacological treatment of panic attacks is carried out according to indications; in other cases, instrumental psychotherapy (biofeedback sessions) and psychotherapy sessions help.

If the fear is very strong and does not allow a person to leave the house, then in the clinic of Doctor of Medical Sciences Vitaly Leonidovich Minutko there is a service - calling a psychotherapist at home and the opportunity to undergo panic attack therapy at home. Drug therapy for panic attacks allows you to get rid of attacks when combined with behavioral psychotherapy. But it must be remembered that pharmacotherapy does not eliminate the causes of fear; it reduces the symptoms of panic and is used at the initial stage of treatment.

Therapy for panic attacks is carried out with the following groups of pharmaceuticals:

1. Benzodiazepines: Phenazepam, Lorazepam, Gidazepam, Midazolam, Temazipam, Clonazepam.

These drugs quickly relieve fear, anxiety, calm, and relax. But they can cause addiction and dependence.

2. Tricyclic antidepressants: Imipramine, Amitriptyline, Anafranil, Clomipramine. Effective for panic attacks with suicidal thoughts.

They have many side effects, but do not cause dependence or addiction.

3. Serotonin reuptake inhibitors: Zoloft, Cipralex, Fluoxetine.

They do not act immediately, but are not addictive and have no side effects, so they can be prescribed to patients with cardiovascular insufficiency.

4. Monoamine oxidase inhibitors: Pyrazidol, Moclobemide.

Requires a tyramine-free diet. Incompatible with other medications. The main side effect of these medications is increased blood pressure when consuming the following foods:

• peas, beans, soybeans;
• cheese products and cheeses;
• smoked meats, marinades;
• alcoholic drinks;
• sauerkraut.

Therapy for panic attacks should only be carried out by a psychiatrist; self-medication is not acceptable.

Treatment of panic attacks at the Minutko Clinic is based on the principle of safety. It is achieved:

• monotherapy - prescribing one drug under the control of its concentration and metabolites in the blood;
• the “therapeutic window” method, based on taking the drug in a minimally effective dose that does not cause toxic or side effects. For this purpose, pharmacogenetic diagnostics are carried out - the activity of cytochrome P450 genes (CYP2D6, CYPC9, CYPC19, CYP1A2), transporter genes (SLC6A2, SLC6A3, SLC6A4), receptor genes (HTR1A, HTR2A, HTR2C; DR2D, DRD3, DRD4), metabolic genes is determined dopamine (COMT), involved in the metabolism of psychotropic drugs.

Therapy for panic attacks is carried out using various methods of psychotherapy:

• behavioral - based on rethinking the source of fear, anxiety, panic, developing skills to manage one’s own emotions, learning techniques for reducing anxiety;
• psychoanalysis - based on identifying internal conflicts and resolving them;
• Gestalt therapy - aimed at considering the patient’s current psychological state and ways to resolve conflicts that lead to illness;
• classical hypnosis - used as a short-term method of assistance in patients who do not have a negative attitude towards this method of treatment;

• Ericksonian hypnosis - reduces anxiety, allows you to manage panic attacks based on resolving internal conflicts;
• family psychotherapy - allows you to harmonize relationships in the family, which has a therapeutic effect in case of panic attacks;
• Body-oriented psychotherapy is based on the connection between mental functions and the body. When exposed to the body, emotions are liberated, which can cause panic attacks;

Biofeedback is an instrumental type of psychotherapy in which independent control over the emotional state is restored. The patient is shown in images that are understandable to him the work of the autonomic nervous system, which in ordinary life is not accessible to consciousness.

How to treat panic attacks

When you notice the first symptoms of PA, you need to contact a psychiatrist or neurologist. Drug treatment consists of prescribing sedatives and antidepressants that reduce anxiety and calm the nervous system. Such medications have a cumulative effect, the effect begins on the 3-4th day of administration, the result lasts for more than 7 days. Doctors prescribe mainly those medications that are not addictive. Stopping their use does not lead to a sharp deterioration in health.

Psychotherapy is very popular; a course of sessions allows you to get rid of uncontrollable attacks of fear for a long time, in most cases forever. Depending on the condition and form of the disease, the following directions are used:

• cognitive-behavioural;
• body-oriented;
• hypnosis;
• psychoanalysis;
• family therapy.

The cognitive behavioral approach has proven itself in the field of eliminating panic attacks, fears and phobias. Psychotherapists are of the opinion that informing the patient as fully as possible about his condition is the first step towards recovery.

The doctor explains the principle of the occurrence of paroxysms, as well as the reasons why they periodically appear. A set of classes aimed at teaching methods of meditation, visualization, and breathing techniques helps the patient, when he senses an approaching attack, to normalize his condition.

The technique of “breathing into a paper bag” is often used, which the patient should have with him, especially in crowded places. A sharp inhalation and exhalation reduces the supply of oxygen, stopping the attack. A body-oriented approach helps reduce anxiety and relax the nervous system. It is based on various breathing exercises that help achieve complete relaxation. Alternately tensing and relaxing the muscles of the limbs allows you to normalize your emotional state and get rid of fear.

Hypnosis is a popular technique that involves placing the patient in a trance state. He disconnects from the influence of external stimuli, but retains the ability to listen to the therapist’s commands. The patient is instilled with the idea that an attack of PA is not life-threatening; it is important to find ways to overcome the paroxysm. The doctor offers patients various auto-training techniques that act as prevention.

Psychoanalysis is a line of work that will be effective only in individual cases. The process itself takes several months or even years. The doctor’s goal is to find an internal conflict in the unconscious, to determine which psychotrauma became the trigger for the occurrence of attacks.

Family psychotherapy implies the involvement of all family members in the process, regardless of how many people from this microsociety suffer from attacks of uncontrollable fear. During a conversation with a specialist, relatives understand what feelings their loved one is experiencing, what the threat is, what words and actions can be used to support.

PsyAndNeuro.ru

Unfortunately, misconceptions about anxiety disorders and their differences from depression lead to misunderstandings about the role of anxiety in coronary heart disease (CHD), although the relationship between anxiety disorders and cardiovascular disease began to be studied more than 100 years ago. It is surprising that, despite the inextricable connection of anxiety with the functions of the cardiovascular system, the etiological and prognostic links between anxiety disorders and coronary artery disease have been addressed only recently, in the last decade.

Recent evidence suggests that anxiety disorders increase the risk of developing CHD; however, the potential mechanisms underlying the putative association of anxiety with cardiovascular health are complex and poorly understood. From a prognosis perspective, in patients with CAD, symptoms of anxiety and anxiety disorders increase the risk of major adverse cardiovascular events (eg, myocardial infarction, left ventricular failure, coronary revascularization, stroke), suggesting the importance of anxiety disorders in cardiac practice.

In this review, special attention is paid to panic disorder, since the symptoms of panic disorder largely overlap with the symptoms of coronary artery disease. Other anxiety disorders will be mentioned when their symptoms are relevant to the association of anxiety with CHD.

Anxiety may go undetected or misdiagnosed in a group of patients with known, suspected, or subclinical CAD. Surveys of experts show that doctors lack knowledge about panic disorder and its treatment. Clinicians are not well informed about the characteristics of panic disorder and its distinctive diagnostic features: recurrent and unexpected panic attacks accompanied by persistent worry or worry in anticipation of further panic attacks or their consequences, and maladaptive behavior, including avoidance behavior.

The clinical nuance is that many symptoms characteristic of a panic attack overlap with the clinical picture of coronary artery disease, as well as arrhythmias and cardiomyopathy, which makes differential diagnosis difficult. For example, chest pain and shortness of breath are panic symptoms but are also typical of myocardial infarction and angina.

The coincidence of subjective cardiorespiratory symptoms in anxiety and in cardiovascular diseases only complicates the understanding of the complex relationship between anxiety and coronary artery disease. Additionally, people with panic disorder may experience physical symptoms of undiagnosed medical conditions such as coronary spasm, microvascular angina, and slow coronary blood flow, in addition to CAD, defined as ⋝50% coronary artery stenosis.

Thus, it is likely that panic disorder is sometimes a misdiagnosis. Therefore, some authors caution that many cases of panic disorder may be misdiagnosed arrhythmias, and panic symptoms may subside once the arrhythmia is controlled. Other experts, on the contrary, believe that in the presence of cardiorespiratory symptoms that cannot be explained by diseases of the cardiovascular system, panic disorder or hypochondria can be assumed.

A diagnosis of an anxiety disorder does not exclude cardiovascular disease, and the presence of high anxiety does not indicate the absence of coronary artery disease. Concerns about the heart and its function are often observed before coronary catheterization and coronary revascularization. Ideally, confirmation of an anxiety disorder diagnosis should be made by an experienced mental health professional.

The main psychiatric diagnostic systems, DSM and ICD, stipulate that a diagnosis of panic disorder cannot be made if panic symptoms appear as a direct result of diseases such as coronary artery disease. According to this principle, a more appropriate diagnosis would be “anxiety related to physical illness.” This distinction is important for diagnostic nomenclature, but not for anxiety treatment, which is independent of the diagnosis of CAD.

With regard to anxiety detection, due to differences in clinical training, studies quantifying the prevalence of panic disorders in patients with CAD are heterogeneous. Non-psychiatrists estimate the prevalence of panic disorder to be lower compared to specialists with psychiatric training. The prevalence of panic disorder in studies that were not blinded for the presence of coronary artery disease was estimated to be lower than in studies that were blinded. Because the authors of the published studies did not assess general health status, it is unclear whether physicians tend to attribute physical symptoms to the presence of CAD.

Anxiety, as a rule, is not associated with the severity of IHD, and in this sense, anxiety is perhaps similar to subjective pain, the severity of which cannot reliably judge the degree of physical injury. The lack of association between anxiety and the severity of CAD may be explained by the fact that panic disorder is characterized by anxiety sensitivity, usually defined as fear of sensations and symptoms associated with arousal of the autonomic nervous system. As a consequence, cardiorespiratory symptoms are typically exacerbated by cognitive and behavioral processes, including hypervigilance, hypervigilance, catastrophizing, and avoidance, which lead to lower thresholds for somatic awareness.

There is a fairly strong relationship between anxiety and subjective assessment of CAD symptoms, such as chest pain and shortness of breath. Not surprisingly, patients with anxiety are more likely to perceive physical symptoms as serious and are more likely to end up in emergency departments not with a heart attack but with a panic attack or non-cardiac chest pain.

On the other hand, there is evidence that anxious patients end up in the emergency department with myocardial infarction more often than patients with myocardial infarction but without anxiety.

In the group of patients with confirmed coronary artery disease, the prevalence of anxiety disorders is 10-23%. The most common types of anxiety disorders in CHD are panic disorder and generalized anxiety disorder (GAD). Other common anxiety disorders include agoraphobia, which is often comorbid with panic disorder, social phobia, specific phobias, and anxiety-related disorders such as post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD).

Prevalence of anxiety in IHD and in the general population [1]

Etiological and prognostic studies have demonstrated a connection between GAD, panic disorder, PTSD and cardiovascular diseases. The presence of etiological and prognostic associations is noteworthy because most studies tend to emphasize the role of depression in CAD, but 50% of patients with CAD and a depressive disorder also have an anxiety disorder. Anxiety disorders are highly comorbid with depressive disorders and this comorbidity significantly complicates treatment, so if one disorder is present, evaluation for the presence of the other disorder should be performed.

The existence of etiological connections between anxiety and IHD began to be discussed more than 100 years ago, but comprehensive research on this topic began only recently. Several large and well-powered longitudinal case-control studies have demonstrated that anxiety is associated with coronary artery disease, myocardial infarction, and sudden cardiac death.

Retrospective studies show that increased anxiety during the 24-hour period before a heart attack increases the risk of heart attack by 2-9 times the effect on heart attack risk that anxiety episodes experienced at other times have. This may be explained by the fact that episodes of acute and excessive anxiety affect the state of plaques in the coronary vessels, as a result of which they are destroyed and coronary occlusion develops; however, due to the retrospective nature of the studies, the results should be interpreted with caution.

Panic disorder increases the likelihood of developing coronary heart disease, severe adverse cardiovascular events, and heart attack. The risk remains significant after adjusting for depression. A parallel study of depression and anxiety disorders is important because the etiological risk of CHD is influenced differently by individual disorders and comorbidities. In particular, panic disorder without comorbid depression is associated with cardiovascular disease, cerebrovascular disease, and peripheral vascular disease. Stratification of anxiety disorders according to the presence of comorbid depression suggests that anxiety increases the risk of CHD as well as depression. Authors of several studies caution that reverse causation cannot be ruled out for etiological associations because most cohort studies did not perform coronary angiography at baseline. For this reason, subclinical CAD could be misdiagnosed as panic attacks.

Anxiety symptoms are associated with relatively poor treatment outcome or recurrence of major adverse cardiovascular events in patients with coronary artery disease or heart attack. Analysis of anxiety disorder subtypes revealed different associations with CHD. GAD is primarily associated with poor treatment outcomes. This conclusion about the role of GAD may be explained by the lack of prognostic research on other anxiety disorders, particularly panic disorder and PTSD.

There remains some uncertainty regarding whether anxiety disorders contribute to the poor prognosis of CAD. The American Heart Association and the German Heart Association recommend that researchers focus their efforts on identifying the independent effects of anxiety disorders and their subtypes on cardiovascular prognosis.

Several studies have confirmed the prognostic importance of GAD for recurrence of major adverse cardiovascular events. The presence of GAD approximately doubles the risk of severe adverse cardiovascular events. GAD is associated with an increased risk of poor outcomes from arterial bypass grafting.

Prognostic studies regarding anxiety symptoms also support an increased risk of recurrence of major adverse cardiovascular events and mortality. However, not all studies confirm a positive association between anxiety and severe adverse cardiovascular events. Some studies have found a reduced risk, suggesting a protective effect of anxiety. These results appear to be a statistical artifact of multicollinearity between anxiety and depression rather than evidence that anxiety improves cardiovascular prognosis.

The biobehavioral mechanisms linking panic and CAD are complex, bidirectional, and poorly understood. Biological risk factors mediating the relationship between anxiety and microvascular damage, such as slow coronary blood flow, microvascular angina, and arterial stiffness, are poorly documented.

Panic disorder may be associated with preexisting cardiometabolic risk factors, including hypertension, hyperlipidemia, obesity, kidney disease, and diabetes, so studying the relationship between anxiety and CHD will likely address what CHD and other chronic diseases have in common.

Regarding the behavioral mechanisms that are responsible for the development of atherosclerosis, cross-sectional studies involving patients with anxiety disorders show the predominance of such a behavioral risk factor as tobacco smoking. A strong comorbid association of anxiety disorders with alcoholism and substance abuse has been documented. The strong association between anxiety disorders and alcohol abuse implies a common etiology, common risk factors, or defective coping strategies.

Paradoxically, concerns about your health do not necessarily prompt lifestyle changes in terms of physical activity and diet. Psychometric indicators indicating increased anxiety about health are recorded simultaneously with indicators indicating an increased risk of developing coronary artery disease.

Another behavioral risk factor directly associated with CAD is cardiorespiratory fitness. Several longitudinal studies have shown that poor cardiorespiratory fitness is a predictor of depressive disorders in old age. It can be assumed that there is a similar relationship with anxiety disorders, as patients with panic disorder with high levels of somatic anxiety are almost three times more likely to report low levels of physical activity compared to people with low somatic anxiety.

The association of cardiorespiratory fitness and physical activity with anxiety disorders is more complex than that with depression. There is increasing recognition that exercise avoidance behavior is common among patients with anxiety disorders, especially those suffering from panic attacks. Exercise avoidance is associated with anxiety sensitivity and fear of somatic sensations, such as those caused by aerobic exercise.

This is supported by cardiopulmonary stress testing studies in which patients with panic disorder tend to refuse to continue testing at the same maximum oxygen uptake levels at which other subjects do not stop testing.

Avoidance of exercise and fear of physical sensations have clear consequences for patients with coronary artery disease undergoing cardiac rehabilitation. Persistent anxiety and somatization are strong predictors of decreased physical performance after cardiac rehabilitation.

Experiments aimed at inducing and quantifying the physiological symptoms of panic disorder use carbon dioxide inhalation (inhalation of a mixture of oxygen with 35% CO2). This can cause shortness of breath, dizziness and mild anxiety in most participants, and panic attacks in those who have or are at risk of panic disorder. During the experiment, subjective assessment of the strength of panic symptoms and anxiety was higher in the group of people with panic disorder than in control groups.

In a 2005 study [2], in 81% of patients with coronary artery disease with comorbid panic disorder, a carbon dioxide inhalation test induced myocardial ischemia. A 2014 study [3] used single-photon emission computed tomography to evaluate reversible panic-induced myocardial ischemia. In addition, heart rate, blood pressure and 12-lead ECG were measured. Only 10% of patients experienced myocardial ischemia in a panic state.

Because of this large difference in results, it remains unclear whether panic attacks lead to reversible myocardial ischemia. It is important to note that the ischemic consequences of induced panic in patients with high-risk CAD with comorbid panic disorder have not been documented.

Other studies of the cardiovascular response to panic have focused on the sympathetic nervous system as a mediator between the heart and brain. Increased sympathetic discharges during panic attacks are associated with changes in the QRS complex, in particular the QT interval. There is a link between decreased heart rate variability and anxiety disorders. A 2014 meta-analysis found that anxiety disorders are associated with significant reductions in HRV measured by time domain as well as frequency domain methods.

Other proposed mechanisms by which panic and anxiety contribute to the development of atherosclerosis and recurrence of severe adverse cardiovascular events include the increased inflammatory response noted in people with anxiety disorders, including patients with comorbid coronary artery disease. The most data has been collected on increased levels of C-reactive protein, which indicates an increased risk of developing coronary artery disease. It is also known that in anxiety disorders the levels of interleukins, tumor necrosis factor and adrenomedullin increase. Increased migration of anti-inflammatory immune cells may lead to increased platelet aggregation and instability of coronary plaques.

Treatment of panic disorder in patients with CAD has been largely ignored in the scientific literature, to the detriment of our understanding of anxiety disorders in CAD. Most of the evidence for treatment effectiveness actually comes from studies of depression in which reduction in anxiety was only a secondary outcome, or from studies using only self-reported anxiety.

A 2014 systematic review found that no controlled trials specifically targeted anxiety disorders in patients with CAD. This issue remains a blank spot in the literature and clinical practice.

The complex nature of panic disorder accompanying coronary artery disease requires adaptation of standard cognitive behavioral therapy (CBT) methods. Treatment of panic disorder concomitant with ischemic heart disease or cardiomyopathy is complicated by the following points:

(a) diagnostic overlap between symptoms experienced in anxiety and heart disease;

(b) high risk associated with ignoring chest pain and delaying contacting a doctor in case of a possible myocardial infarction;

(c) CBT, based on the idea of ​​catastrophic distortion of bodily symptoms, must be modified to take into account real cardiovascular risk;

(d) experiments with induction of symptoms (eg, through hyperventilation) may be dangerous due to the risk of myocardial ischemia.

Transdiagnostic CBT and metacognitive therapy that target cognitive and behavioral processes common to anxiety and depression may be useful in treating anxiety.

Reviews of the current scientific literature show that when treating anxiety and depression in patients with coronary artery disease, effect sizes are lower than in groups of patients with other chronic diseases, such as diabetes. Large-scale studies in cardiology (ENRICHD, SADHART, CREATE) have demonstrated the complexity of treating depression and anxiety in coronary artery disease.

However, most studies have focused on the results of the same type of intervention - either the use of only psychotropic drugs, or only psychotherapy. Medical interventions, including CBT and psychotropic medications, have a small but significant effect on the risk of major adverse cardiovascular events.

Regarding psychotropic medications, the European Society of Cardiology EUROASPIRE IV study showed that in a group of patients hospitalized for coronary artery disease, anxiolytic medications were prescribed to only 2.4% of patients at hospital discharge and 2.7% of patients at follow-up. This estimate is consistent with other studies using systematic screening for depression and anxiety in cardiology, which show that psychotropic medications are still used significantly more often than CBT or other types of psychotherapy. It is unclear whether this is due to patient preference, clinician preference, or lack of resources to provide CBT.

Interestingly, the use of benzodiazepines after myocardial infarction is associated with a reduced risk of recurrent infarction. This relationship has a J-shaped curve in the graph, indicating the benefit of low to medium doses of benzodiazepines compared to high doses. Anxiolytic drugs with a sedative effect, such as benzodiazepines, should be used cautiously. They are generally not used in CBT. Regardless of the risk of addiction, the rationale for avoiding these medications in CBT is that taking anxiolytics can become part of a safety behavior strategy or a maladaptive coping strategy, and thereby interfere with healing by prolonging anxiety and increasing the need for medications during a panic attack or before situations causing anxiety.

Thus, CBT is generally considered the preferred treatment strategy for anxiety, with more reliable and durable treatment results in the long term without relapse [4]. For this reason, the use of benzodiazepines in the treatment of patients with coronary artery disease is usually limited, and serotonergic drugs are first-line drugs.

The effectiveness of serotonergic drugs, including SSRIs and SSRIs, in the treatment of depressive symptoms in patients with coronary artery disease was confirmed by the SADHART and CREATE studies. The risk of mortality is not reduced by taking SSRIs, but the risk of readmission is reduced (although there are reviews that suggest that taking SSRIs does not reduce the risk of readmission).

Possible pleiotropic effects of serotonergic drugs include a decrease in platelet aggregation ability and an improvement in endothelial function. Potential side effects include an increased risk of bleeding, as well as the ability of escitalopram to prolong the QTc interval, and therefore should not be prescribed at doses above 40 mg/day.

In addition to CBT and serotonergic medications, some experts suggest the use of supervised aerobic exercise as a treatment for CAD panic by providing experiential and interoceptive experience of somatic sensations such as shortness of breath, palpitations, and sweating. Aerobic exercises, as part of cardiac rehabilitation, provoke somatic symptoms in a safe and controlled environment. In patients with panic disorder, such exercise (for example, several 25-minute sessions on a treadmill) improves maximum oxygen uptake. It is also known that regular physical activity can have a positive effect on anxiety disorder symptoms. However, because people with anxiety and depression are less likely to participate in cardiac rehabilitation, studies showing the benefits of exercise for anxiety may only involve those who do not avoid exercise.

Author of the translation: Filippov D.S.

Source : Tully PJ, Cosh S., Pedersen S. (2020) Cardiovascular Manifestations of Panic and Anxiety. In: Govoni S, Politi P, Vanoli E (eds) Brain and Heart Dynamics. Springer, Cham.

Bibliography:

[1] Tully PJ, Cosh SM, Baumeister H. The anxious heart in whose mind? A systematic review and metaregression of factors associated with anxiety disorder diagnosis, treatment and morbidity risk in coronary heart disease. J Psychosom Res. 2014;77(6):439–48

[2] Fleet R, Lesperance F, Arsenault A, Gregoire J, Lavoie K, Laurin C, et al. Myocardial perfusion study of panic attacks in patients with coronary artery disease. Am J Cardiol. 2005;96(8):1064–8

[3] Fleet R, Foldes-Busque G, Grégoire J, Harel F, Laurin C, Burelle D, et al. A study of myocardial perfusion in patients with panic disorder and low risk coronary artery disease after 35% CO 2 challenge. J Psychosom Res. 2014;76(1):41–5.

[4] Clark DM, Salkovskis PM, Hackmann A, Middleton H, Anastasiades P, Gelder M. A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. Br J Psychiatry. 1994;164(6):759–69

Symptoms of a panic attack in women

PA in women occurs for several reasons:

• severe stressful situation;
• unbearable mental stress at work;
• cardiac or oncological diseases;
• peculiarities of upbringing - overprotection, strict control or perception of the child as the center of the universe;
• schizophrenia and other mental disorders;
• changes in hormonal levels - the onset of sexual activity, menstrual cycle disruption, pregnancy and childbirth, lactation, menopause;
• tendency towards hypochondria, suspiciousness;
• physical inactivity.

During a panic paroxysm, a woman experiences depersonalization and derealization, a feeling of impending disaster, motor disinhibition or stiffness. This condition is not an obstacle to pregnancy, but symptoms may intensify after the birth of the child.

Panic attacks often accompany postpartum depression, fears for the child, fears of being a bad mother, and general dissatisfaction with life arise. During menopause or menopause, there is an intense release of stress hormones, which provokes the disorder. The quality of life is deteriorating, the woman does not feel happy, she is constantly in nervous tension, waiting for the next PA. Often women do not realize what exactly is happening to them at this moment, and this is more frightening than the physiological symptoms.

Our patients turn to the doctor with complaints of an incurable disease. They don’t yet know what happened to them, but they believe that some kind of system has suffered a serious failure. We act openly. We immediately stipulate that panic attacks are treatable, they can and should be fought by learning self-regulation in difficult life situations.

How to cope with a panic attack with proper breathing

During panic attacks, the stress hormone adrenaline is released into the blood. One of the effects of its action is increased breathing - hyperventilation. Hyperventilation itself promotes the production of adrenaline, prolonging the panic attack.

Therefore, to prevent a panic attack, it is necessary to restore the breathing rhythm. But breathing exercises should also be done to prevent attacks. Thus, yogi breathing exercises normalize both the breathing rhythm and the gas composition of the blood. The system of breathing exercises in yoga is called Pranayama. It is based on developing the skills of holding your breath, which accumulates carbon dioxide in the blood and tissues. It affects the respiratory center, normalizes its functioning, reduces anxiety, fears, and dilates blood vessels.

Breathing techniques to help relieve a panic attack:

• If during an attack of fear there is a palpitation of the heart, a feeling of blood speeding up, you need to adjust your breathing. Stand or sit in the most comfortable position, relax your shoulder girdle, take deep breaths and smooth exhalations. When exhaling, you need to achieve the feeling that all the air has left the lungs;
• the second technique is 4 by 4 breathing. You need to sit in a comfortable position and relax your shoulder girdle. Start an internal account. For the first four numbers, take a smooth, deep breath, for the second four numbers, exhale the same way;
• After mastering the four-count breathing method, it is necessary to synchronize with the pulse beats. For four heart contractions you need to take a deep breath, for the next four contractions you need to exhale smoothly;
• An effective method for relieving panic attacks is to exhale into your palms or a paper bag. You need to take a deep breath through your nose, and then exhale forcefully into your palms or a paper bag so that carbon dioxide accumulates there. Then take a deep breath again. And carbon dioxide will enter the lungs, which will reduce the feeling of fear;
• if a panic attack is accompanied by depersonalization and derealization, then you need to place your palm on your bare stomach and focus on this feeling. You need to breathe with your abdominal muscles. Thoughts should be focused only on the feeling of the palm on the stomach and breathing.

Questions and answers

Have there been any cases of death due to PA in medicine?

No, the concept of PA implies a feeling of fear, as well as a number of other physiological changes. They are strong in intensity, but not so strong as to lead to the death of the body.

Who is more susceptible to the disease - men or women?

Individuals, regardless of gender or age, are prone to the disorder.

What mental disorders can cause the disorder?

At risk are schizophrenics, people diagnosed with bipolar affective disorder, manic-depressive psychosis, and various phobias.