What are panic attacks

A panic attack is defined as a sudden onset of strong feelings of fear. The common symptoms accompanying panic attacks include:

- Increased heart rate, or palpitations

- Sweating

- Shaking or trembling

- Discomfort or pain in the chest

- Nausea or abdominal distress

- Fear of going crazy

- Fear of dying

When panic attacks continue to reoccur, a diagnosis of panic disorder can be made. As one can never anticipate when a panic attack may occur, a significant number of individuals who experience panic attacks may develop avoidance or fear of situations where they would feel unsafe should they experience a panic attack. This fear is termed as agoraphobia, a fear of crowds or public places.

Panic attacks in Singapore

The prevalence of panic attacks in Singapore is unknown. However, a large-scale study on the prevalence of panic attacks in United States revealed lifetime prevalence estimates of 22.7% for isolated panic attacks and 3.7% for panic disorders (Kessler et al., 2006). Another 0.8% of the population may develop agoraphobia following a panic attack, and another 1.1% are estimated to develop panic disorder with agoraphobia.

Panic attack or medical condition

In the article discussed here, Meuret, Kroll and Ritz (2017) reviews current evidence of the comorbidity between panic disorders and other medical conditions, and discuss its implications for treatments.

The authors pointed out that unlike other anxiety disorders, such as generalized anxiety disorder and social phobia, the anxiety and fear in panic disorders are directed to one’s own bodily symptoms. They also noted that panic attacks possess high comorbidity rates with medical conditions, such as irritable bowel syndrome (IBS) and diabetes, and reviewed potential pathways underlying the two-way association between panic disorder and these medical conditions.

1) Panic attack and asthma

Reviews on panic disorder and asthma revealed a comorbidity rate between 6.5% to 24% in adults, and 0.6% to 4.7% in children. Asthma in childhood has also been found to be a risk factor for the development of panic attacks later in life.

Asthma may develop into a panic disorder through misinterpretation of asthmatic symptoms, such as catastrophizing when one feels breathless. Asthmatics are also more likely to lead an inactive lifestyle, and be at risk for obesity. In these individuals, physical exertion may increase sympathetic activation associated with panic disorders. Asthma attacks may also trigger hyperventilation, increasing the likelihood of panic.

2) Panic attack and cardiovascular illnesses

Illnesses that involve the heart or its blood vessels, such as myocardinal infarction (more popularly known as heart attacks), stroke, heart failure, and heart arrhythmia are classified as cardiovascular illnesses. Unsurprisingly, cardiovascular symptoms present the highest cause of distress in individuals with panic disorder. Cardiovascular illnesses are associated with subsequent anxiety, including panic attacks. For example, patients who are diagnosed with hypertension are 13% more likely than experience panic attacks compared to healthy controls. Seldenrijk and colleagues (2015) also found that individuals experiencing panic disorders are more two times more likely to develop a subsequent cardiovascular illness.

The review highlighted that medication for panic disorder can increase the risk of cardiovascular illness by activating the stress hormones in the hypothalamus-pituitary adrenal (HPA) and sympatho-adrenomedullary systems. Both these systems may potentially affect the cardiovascular system, immune regulation, metabolism, and inflammation, which may manifest in the form of a cardiovascular illness.

The diagnosis of a cardiovascular illness may cause significant stress to an individual, increasing the risk of developing panic attacks. Experiencing the symptoms of a cardiovasular illness may lead the individual to harbor catastrophic thoughts, and develop a fear of dying. Patients of cardiovascular illnesses also tend to develop a sedentary lifestyle thereafter, and thus, are more likely to experience the symptoms of panic attack at lower levels of activity.

3) Panic attack and irritable bowel syndrome

Irritable bowel syndrome (ISB) is a disorder involving the large intestine. The symptoms of IBS include abdominal pain, constipation or diarrhea, gas and bloating. Research on the prevalence of panic disorder in patients with IBS found prevalence rate between 3.8-31%. Conversely, up to 37% of individuals with panic disorder also suffer from IBS.

More research is needed to understand the neurobiological link between the brain and the digestive symptom. Panic disorders and IBS possess common symptoms of anticipatory anxiety, abdominal discomfort and nausea. In addition, individuals suffering from IBS have been found to engage in catastrophizing and somatization, which are associated with the severity of IBS.

Abnormal pain perception is a common characteristic of individuals with IBS and panic disorder. Activation of the HPA axis and the sympatho-adrenomedullary systems may also affect intestinal motility, microbial composition in the digestive system, fluid secretion and intestinal epithelial permeability. These are some predisposing factors in the development of IBS. IBS patients have also been found to be hypervigilant in detecting physical symptoms. This hypervigilence increases risk of interpreting somatic symptoms in a catastrophic manner, potentially leading to panic disorders.

4) Panic attack and diabetes

The prevalence of panic disorder range between 1.3-8.9% in patients with diabetes. However, individuals diagnosed with panic disorders are only slightly more likely to have diabetes compared to a control sample.

The frequent hypoglycemic episodes in diabetes, where the blood sugar decreases to below healthy levels, is hypothesized as the most likely mechanism between panic attacks in individuals with diabetes. The symptoms of hypoglycemia, such as shakiness, palpitations, and sweating, mirror that of panic episodes. This may lead to the conditioned fear responses seem in panic disorder.

Treatment for panic attack: Implications

Given the high comorbidity between panic disorders and other medical conditions, healthcare providers may take steps to explore the presence of more than one condition when assessing patients. The authors pointed out that once healthcare providers have established the presence of an anxiety disorder, they tend to overlook the presence of a cardiovascular illness, and vice versa. Hence, more comprehensive testing was recommended.

Treatment options will also have to consider the risk of exacerbating another condition. For example, the use of beta-adrenergic bronchodilators to treat asthma may lead to side effects that may develop or exacerbate the symptoms of panic disorders. Interceptive exposure exercises, including voluntary hyperventilation in cognitive behaviour therapy (CBT) may lead to complications in client with asthma due to the possibility of bronchoconstriction.

Benefit of therapy for panic disorder

Certain components of therapy for panic disorder may provide benefits for medical conditions as well. For example, deep breathing techniques to reduce hyperventilation is not only beneficial for the symptoms of panic attacks, but also for managing asthma. Anxiety and stress management exercises may also reduce the emotional toll experienced by patients with cardiovascular diseases.

References.

Kessler, R. C., Chiu, W. T., Jin, R., Ruscio, A. M., Shear, K., & Walters, E. E. (2006). The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Archives of general psychiatry, 63(4), 415-424.

Meuret, A. E., Kroll, J., & Ritz, T. (2017). Panic Disorder Comorbidity with Medical Conditions and Treatment Implications. Annual Review of Clinical Psychology, 13, 209-240.