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Breathing difficulties summarized in excellent details the major symptoms and usual presentation of panic attacks, panic disorder and agoraphobia. This is a leading cause of emergency department evaluations and referrals for cardiology assessment on the one hand and for psychiatric evaluation on the other. It is an unpleasant and often alarming condition and these attacks can be disabling, but if appropriate evaluations do not find another medical disorder, current treatments can bring relief in 90 per cent or more of cases. Panic attacks and panic disorder are classified among the anxiety disorders and managed with treatments appropriate for anxiety, but it is particularly important not just to prescribe a medication like Valium or Xanax.

Panic disorder is the recurrence of panic attacks, accompanied by what are called anticipatory attacks, periods of worry about the unpredictable recurrence of the attacks and the implications of having them.

Panic attacks are characterized by the sudden onset of intense anxiety symptoms that peak within 10 minutes and then subside.

The diagnosis requires four or more of the following: sensations of shortness of breath or smothering; palpitations, pounding heart or rapid heart rate; a feeling of choking; chest pain or discomfort, sweating; shaking or trembling; nausea or abdominal distress; dizziness, unsteadiness, lightheadedness or faintness, feelings of being detached or outside oneself (depersonalization) or a sense of unreality (derealization); fear of dying, going crazy or losing control of oneself; numbness or tingling (paresthesias); or hot flushes or chills.

The World Health Organization estimated in 2000 that about 320 men and 650 women out of 100,000 people had panic disorder in North America, with essentially similar rates in other parts of the world. About a third of people with panic disorder also have agoraphobia, which is the intense fear of being in open spaces, where something bad may happen and help may not be available or may not arrive in time. For many years, agoraphobia was required for the diagnosis of panic disorder, and the unwillingness and eventual inability to go out is one of the most disabling features of panic disorder; it is now recognized that many people have panic attacks without agoraphobia, at least initially, and that agoraphobia may develop over time as a reaction to the fear of having panic attacks.

Although panic attacks are part of the spectrum of anxiety disorders, they are different from anxiety attacks. Anxiety itself is an unpleasant state of mental turmoil and nervous behavior on account of the dread of anticipated bad things happening, and anxiety symptoms like shortness of breath, increased heart rate, tension, irritability and fatigue can be present at low to moderate intensity for long periods, with intermittent attacks during periods of increased worry. Anxiety attacks are less intense and overwhelming than panic attacks, and are usually more focused on dread and anticipation, but are longer-lasting and symptoms rise and fall rather than occurring in a sudden severe burst. An old clinical saw is that if you worry that you are going to die eventually you may have anxiety attacks, but if you think that you are going to die right now, then you have panic attacks.

The cause of panic attacks is not known, but there is evidence of abnormality in parts of the limbic system, a pathway that connects parts of the frontal and temporal lobes that are involved in memory, emotion and arousal. One of the chemical transmitters there is GABA or gamma-aminobutyric acid, which is an inhibiting or calming transmitter, and a deficiency in level or effect may cause the amygdala, an almond-shaped nucleus of cells deep inside the temporal lobe, to become overactive and to activate the "fight or flight" response that it regulates. The "fight or flight" response involves most of the symptoms of panic attacks, which may represent the occurrence of the body's normal response to immediate danger without any immediate danger being present.

Carbon dioxide in the blood is another factor involved in panic attacks, and is related to the shortness of breath and urge to breathe that people often feel in the attacks, and to the hyperventilation that frequently goes along with anxiety and panic. Low levels of carbon dioxide pressure in the blood, which are seen with hyperventilation, are also associated with panic disorder, and it has been suggested that there is a "suffocation alarm system" that monitors oxygen and carbon dioxide levels in the blood and that it is oversensitive in anxiety disorders and goes off in panic attacks. In other words, it may not be the changes in body sensations that trigger the respiratory abnormalities, but rather the breathing changes that cause the abnormal bodily sensations.

The appropriate tests have been done; it is often necessary to exclude a heart attack during a panic attack or in between a series of them. A chest X-ray will eliminate the more remote possibility of collapsed lung or pneumonia, and low blood sugar, anemia and thyroid overactivity need to be considered as causes. The other symptoms of panic described above can be elicited by a primary-care or emergency department physician, and it is appropriate to inquire about stress, depression, sleep and sleep deprivation and alcohol, caffeine, nicotine, stimulant drugs like amphetamine or sedatives like the benzodiazepines, use or withdrawal from which can cause these symptoms. A family history of depression or anxiety disorder is also an important clue.

Treatment may be as simple as trying to do without caffeine for a week or do, cutting down or cutting out alcohol or stopping smoking if that is an issue. Prescription drugs like stimulants for attention deficit or benzodiazepines for various reasons should be stopped, and if any other drugs are being taken these attacks are a sign that this should be dealt with. Cognitive Behavioral Therapy , which teaches people to recognize and defuse the abnormal patterns of thinking and reaction that contribute to panic, may help 85 to 90 per cent of patients. Interoceptive therapy involves simulating the symptoms of panic attacks by hyperventilation, breath holding, spinning in a chair, running in place and body tensing, then working on reorganizing thought processes and anxious thoughts so as not to react to these bodily sensations with panic; it is reported to have a success rate of 87 per cent. These techniques are often combined with the newer antidepressants that increase levels of serotonin or norepinephrine in the brain such as Prozac or Zoloft, particularly for people with agoraphobia. Benzodiazpines like Valium or Xanax are usually not recommended because of the development of tolerance and dependence, and because people may find them too easy to overuse or stop them and experience withdrawal; the long-acting benzodiazepine clonazepam is sometimes useful for severe panic attacks. Some simple natural approaches are also safe, inexpensive and easy to try at home, including herbal medications like chamomile, lavender, valerian or skullcap, B-complex vitamins and nutrititional supplements like calcium and magnesium and over-the-counter homeopathic remedies like aconite, belladonna, pulsatilla and sepia.

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