Chest Pain - Panic Attacks/Panic Disorder

Dr. Naresh Vadlamani, Chief Consultant Psychiatrist

"All of a sudden, I felt afraid and feared that something bad was going to happen to me as if I was going to die for no reason at all. I was having chest pain, my heart was beating faster and I had difficulty in breathing, I felt giddy and thought I was going to die." I immediately wanted to go to the hospital-emergency. From then on, I was afraid to be alone or was afraid of travelling. I started avoiding places, food, rooms or even travel after that attack.

What are the symptoms of a panic attack?

As described above, the symptoms of a panic attack appear suddenly, without any apparent cause. They may include

• Racing or pounding heartbeat
• Chest pains
• Stomach discomfort
• Dizziness, light headedness, nausea
• Difficulty in Breathing, a sense of feeling smothered
• Tingling or numbness in the hands
• Flushes or chills
• Dreamlike sensations or perceptual distortions
• Terror: a sense that something unimaginably horrible is about to occur and one is powerless to prevent it
• Fear of losing control and doing something embarrassing
• Fear of dying

A panic attack typically lasts for several minutes and is one of the most distressing conditions that a person can experience. Most who have one attack will have others. When someone has repeated attacks, or feels severe anxiety about having another attack, he or she is said to have panic disorder.

What are panic attacks?

Panic attacks may be symptoms of an anxiety disorder. These attacks are a serious health problem in this country. At least 1.7% of adult Indians, or about 12 million people, will have panic attacks at some time in their lives. The symptom is strikingly different from other types of anxiety in that panic attacks are so very sudden and often unexpected, appear to be unprovoked, and are often disabling.
Panic attacks can occur at any time, even during sleep. An attack generally peaks within 10 minutes, but some symptoms may last much longer.
Once someone has had a panic attack, for example, while driving, shopping in a crowded store, or riding in an elevator, he or she may develop irrational fears, called phobias, about these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where the individual with panic disorder may be unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. Thus, panic disorder can have as serious an impact on a person's daily life as other major illnesses, unless the individual receives effective treatment.

Are panic attacks serious?

No, panic attacks are never life threatening. But yes, panic attacks are real and emotionally disabling, but they can be controlled with specific treatments. Because of the disturbing symptoms that accompany panic attacks, they may be mistaken for heart disease or some other life-threatening medical illness. People frequently go to hospital emergency rooms when they are having a panic attack, and extensive medical tests may be performed to rule out these other conditions.
Medical professionals generally attempt to reassure the panic attack patient that he or she is not in great danger. But these efforts at reassurance can sometimes add to the patient's difficulties: If the doctors use expressions such as "nothing serious," "all in your head," or "nothing to worry about," this may give the incorrect impression that there is no real problem and that treatment is not possible or necessary. Its is like going to a doctor for cough and all the doctors says is don’t cough which sounds ridiculous. The point is that while panic attacks can certainly be serious, it is not life threatening.

How to Identify Panic Disorder

Please remember that only a trained doctor or a psychiatrist can diagnose a panic disorder. There are certain signs you may already be aware of, though.
One study found that people sometimes see 10 or more doctors before being properly diagnosed, and that only one out of four people with the disorder receive the treatment they need. That's why it's important to know what the symptoms are, and to make sure you get the right help.
Many people experience occasional panic attacks, and if you have had one or two such attacks, there probably isn't any reason to worry. The key symptom of panic disorder is the persistent fear of having future panic attacks. If you suffer from repeated (four or more) panic attacks, and especially if you have had a panic attack and are in continued fear of having another, these are signs that you should consider finding a psychiatrist who can treat panic or anxiety disorders.

What causes panic attacks?

The body's normal "alarm system," the set of mental and physical mechanisms that allows a person to respond to a threat, tends to be triggered unnecessarily, when there is no danger. This triggering is brought about by changes in the neurochemicals in certain parts of the brain especially the temporal lobe and the amygdala. Panic disorder has been found to run in families, and this may mean that inheritance (genes) plays a strong role in determining who will get it. However, many people who have no family history of the disorder also develop it. Often, the first attacks are triggered by physical illnesses or a major life stressful event.

Can People with Panic Disorder lead normal lives?

The answer to this is a resounding YES -- if they receive treatment.
Panic disorder is highly treatable, with a variety of available therapies. These treatments are extremely effective. Once treated, panic disorder doesn't lead to any permanent complications.

Side Effects of Panic Disorder

Without treatment, panic disorder can have very serious consequences.
The immediate danger with panic disorder is that it can often lead to a phobia.
Many people with panic disorder show 'situational avoidance' associated with their panic attacks. For example, if one has an attack while driving, they then start to avoid driving. In worst case scenarios, people with panic disorder develop agoraphobia -- fear of going outdoors -- because they believe that by staying inside, they can avoid all situations that might provoke an attack, or where they might not be able to get help. The fear of an attack is so debilitating, they prefer to spend their lives locked inside their homes.
Even if one doesn't develop these extreme phobias, their quality of life can be severely damaged by untreated panic disorder. A recent study showed that people who suffer from panic disorder:

• Are more prone to alcohol and other drug abuse
• Have greater risk of attempting suicide
• Spend more time in hospital emergency rooms
• Spend less time on hobbies, sports and other satisfying activities
• Tend to be financially dependent on others
• Report feeling emotionally and physically less healthy than non-sufferers
• Are afraid of going more than a few miles away from home

Panic disorders can also have economic effects. For example, a recent study cited the case of a woman who gave up a Rs.10,00,000 a year job that required travel for one close to home that only paid Rs.1,40,000 a year. Other sufferers have reported losing their jobs and having to rely on public assistance or family members.

What is the treatment for panic attacks?

Thanks to research, there are a variety of treatments available, including several effective medications, and specific forms of psychotherapy. In terms of medications, SSRI's have been proved to be useful to treat panic disorder. Examples of such medications include sertraline, venlafaxine, citalopram and escitalopram. It is common to use sedatives and anxiolytics which should be avoided. Medications from the betablockers (for example, proponolol) are sometimes used to treat the physical symptoms associated with a panic attack. However, as anything that is ingested carries risk of side effects, it is important to work closely with the prescribing psychiatrist to decide whether medication treatment is an appropriate intervention and if so, which medication should be administered.
The psychotherapy component of treatment for panic disorders is equally as important as medication treatment. In fact, research shows that the combination of medication and psychotherapy treatment for panic disorder is more effective than either intervention alone. To address anxiety, cognitive behavioral therapy is widely accepted as an effective form of psychotherapy. That form of therapy seeks to help those with panic disorder identify and decrease the irrational thoughts and behaviors that reinforce panic symptoms. Behavioral techniques that are often used to decrease anxiety include relaxation techniques and gradually increasing exposure to situations that may have previously increased anxiety in the individual.
Improvement is usually noticed in a fairly short period of time, about two to four weeks. Thus, appropriate treatment for panic disorder can prevent panic attacks or at least substantially reduce their severity and frequency, bringing significant relief to 70 to 90% of people with panic disorder.
There are also things that people with panic disorder can do to help make treatment more effective. Since substances like caffeine and alcohol can worsen panic attacks, those things should be avoided. It may be worth engaging in aerobic exercise and stress management techniques like deep breathing and yoga, as those activities have been found to help decrease the frequency and severity of panic attacks. All these can be used with the medications and psychotherapy.
In addition, people with panic disorder may need treatment for other emotional problems. Depression has often been associated with panic disorder, as have alcohol and drug abuse. Recent research also suggests that suicide attempts are more frequent in people with panic disorder. Fortunately, these problems associated with panic disorder can be overcome effectively, just like panic disorder itself.
Tragically, many people with panic attacks do not seek or receive treatment or get misdirected by doctors themselves!!!!

What happens if panic attacks are not treated?

Panic attacks tend to continue for months or years. While it typically begins in young adulthood, in some people the symptoms may arise earlier or later in life. If left untreated, it may worsen to the point where the person's life is seriously affected by panic attacks and by attempts to avoid or conceal them. In fact, many people have had problems with friends and family or lost jobs while struggling to cope with panic attacks. There may be periods of spontaneous improvement in the attacks, but it does not usually go away unless the person receives treatments designed specifically to help people with panic attacks.