Authored by Giulio Perrotta
Abstract
Starting from the definition of “panic attacks”, we proceeded to list all the forms often mistaken for this disorder, such as anxiety attack, anxiety and terror, using the noso graphic descriptions contained in DSM-V, with particular attention to clinical, neurobiological and therapeutic profiles, concluding the analysis of the possible strategies to be used to finalize the resolutions to the problems deriving from the disorder in question.Introduction
Introductory and contextual aspects about the “anxiety” category
The definition of anxiety is not unequivocal in the literature
(Rachman, 2004), although the descriptive characteristics are well
circumscribed and easily identifiable. The American Psychiatric
Association, on the definition of anxiety, describes anxiety as:<<(...)
the anticipated anticipation of a future danger or negative event,
accompanied by feelings of dysphoria or physical symptoms of
tension. The elements exposed to risk may belong both to the
internal world and to the external world (...)>> (APA, 1994).
Similarly, in the Italian Treaty of Psychiatry, precisely in reference
to the definition of anxiety, it is referred to as:<<(...) an emotional
state with an unpleasant content, associated with a condition
of alarm and fear that arises in the absence of danger real and
which, however, is disproportionate to any triggering stimuli (...)>>
(Perugi-oni, 2002).
However, the idea that it consists of: <<(...) a psychophysical
state characterized by a feeling of apprehension, uncertainty, fear
and alarm towards events towards which the subject feels helpless
and / or is univocal helpless. It involves a psychic and somatic
involvement, associating itself with biological modifications, and
involving different systems, among which: neuro-transmittitorial,
immune, neuroendocrine (...)>> (Guccione, 2018).
<<(...) It represents an essential emotion for the correct
functioning of our organism in response to external or internal
stimuli, allowing a functional adaptation to environmental
demands. The related manifestations of anxiety have a prevalence,
in the general population, of 2-4%, a value that rises to 20% in
the non-psychotic psychiatric population. The feeling of anxiety,
as well as, in an extremely polymorphous way, is felt by every
human being, is characterized by a vague, widespread and
unpleasant sense of apprehension, often accompanied by somatic
symptoms autonomous species (palpitations, tachycardia,
tremors, hyperhidrosis, etc.), but also from psychic symptoms
and behavioral manifestations (...)>> (Damiani, 2017). Therefore,
anxiety is necessary for the development of one’s existence; it
becomes the source of a morbid condition if the management of
it becomes uncontrollable, to the point of undergoing a negative
change in one’s lifestyle.
<<(...) Anxiety is innate and is part of human nature. It is the
normal response of our body that prepares to face what it perceives
as a danger. We have the feeling of being vulnerable, even if
sometimes we do not understand for sure why. When our ancestors
faced the threat of ferocious animals or hostile peoples, the changes
that took place in their bodies prepared them for struggle or flight.
Nowadays the dangers are of a completely different nature, but faced with a situation that frightens us, or that we perceive as
threatening, the same changes occur in us at the time. When anxiety
is moderate it can be useful, because it puts us on the alert in the face
of a difficult situation allowing us to react quickly. It can become a
real problem when it is excessive compared to the situation we are
facing or lasts too long, to the point that doing the simplest thing
can become a huge effort (...)>> (Lavaggi, 2018).
Another study then focused on the identification of the main
constructs that cognitive theory associates with anxiety. In detail:
<<(...) the psychopathological constructs of anxiety are:
1) Disproportionate fear of harm and tendency to negative
predictions or catastrophic thought, definable as the tendency
on the part of the subject anxious to foresee a wider range of
negative consequences than to non-anxious subjects starting
from everyday situations and to conceiving the danger inherent
in these negative possibilities as essentially unavoidable,
irresistible and irreparable.
2) Fear of error or pathological perfectionism, definable as
the tendency to emphasize rather the errors and imperfections
present in the tasks performed than the positive results, and
to fear and foresee that these imperfections inevitably lead to
negative and catastrophic consequences.
3) Intolerance of uncertainty, definable as the tendency
to think of not being able to emotionally bear the fact of not
knowing perfectly all the possible future scenarios and events, of
not being able to bear the doubt that among the possible future
events there may be some negative ones , even if this possibility
is very low, or to fear that, if there are negative possibilities
in a certain scenario, these will be those that inevitably or
tendentially occur (of course the negative developments are
then feared because of point 1.
4) Negative self-assessment, definable as the tendency
to predict catastrophic scenarios deriving directly from a
negative evaluation both of one’s own practical skills (negative
performance self-assessment) and of one’s capacity for
emotional self-control and recovery in situations of difficulty
and stress (negative self-assessment of weakness, fragility.
5) Need for control, definable as the strenuous pursuit
and search by the anxious subject of the illusion of absolute
certainty that he can prevent all the negative possibilities
that he himself continually feared and foreseen in rumination
through continuous monitoring and manipulation some
aspects and parameters of external and/or internal reality (e.g
weight, food and/or fat in eating disorders, intrusive thoughts
or external order in obsessive compulsive disorder, etc.).
In our hypothesis, the tendency to control constitutes the
above-mentioned and terminal level of the hierarchical architecture
of anxiety. This means that we believe that at the bottom of every
anxious state there is always ideally the final belief that things tend
to go wrong and that a high degree of knowledge and control of
reality is necessary to prevent things from going wrong. The other
constructs (fear of damage, fear of error, negative self-assessment
and fear of uncertainty) are subordinate and not all always present,
at least from the theoretical point of view. Fear of damage and
negative self-assessment are the most general ones. It is difficult
to say, at present, whether they are organized hierarchically or
refer to different areas. Hypothetically it could be assumed that the
negative self-assessment is feared because it would lead to damage,
and therefore the fear of harm is the terminal belief. Likewise, one
might think that it is the negative self-assessment of the central
belief that fear of harm is only a predicate. Or one might consider
that the two concepts are two different dimensions of a single
construct, and therefore they are mutually non-hierarchical in
relation (...)>> (Sassaroli-Ruggiero, 2002).
The “pathological” anxiety (Massaro, 2011), therefore, can
manifest itself in many ways:
1. Distressing and stressful thoughts and sensations.
2. Physical symptoms, such as cardiovascular symptoms
(tachycardia, palpitations, extrasystolia, arrhythmia, pain
or discomfort in the chest, hypertension or pressure drops,
fainting), respiratory (breathlessness, choking sensation,
sensation of a lump in the throat, asthma), gastrointestinal
(nausea, gastritis, gastroesophageal reflux, diarrhea, irritable
bowel syndrome), neuromuscular (shaking sensation tremor,
stiffness, paresthesia, contractures, muscle tension, weakness
and fatigue), neurological (vertigo, feeling of “empty head” or
light, feeling of heeling, trembling and flushing), dermatological
(hives, redness or pallor of the face, hyperhidrosis) and urinary
(sudden urge to urinate and pollachiuria).
3. Altered behaviors, such as agitation, increase/decrease
appetite and avoidance of certain situations.
In summary, when physiological anxiety becomes an abnormal
reaction to a normal alarm situation, it then takes on the pathological
appearance of one of the anxiety disorders described in the DSM-V
and which we will see in the next section. To be straightforward,
physiological anxiety is the sensation of not being able to pass a
university exam; the pathological version consists in the choice not
to present ourselves at the exam session, despite the fact that there
is an intense study of several months behind.
“Healthy” anxiety, however, must also be distinguished from
other feelings, often confused in the common jargon in terms of
terminology. We are talking about fear, anguish, phobia, panic, fear,
terror and stress. Let’s start with fear: <<(...) anxiety is distinguished
from fear because of the lack of a specific and recognizable stimulus
that evokes the answer. This difference is underlined by several
authors, including Nisita and Petracca, who describe anxiety as
“(...) an emotion that anticipates the danger in the absence of a
clearly identified object” (2002). Colombo (2001) defines anxiety
in a timely manner as an objectless fear, and Rachman (2004),
differentiates anxiety from fear, describing the former as a state
of increased vigilance and the latter as a consequent emergency
reaction to trigger factors (...)>>.
Fear can therefore be defined as that primordial feeling,
present in every mammal, which allows automatic evaluation of a
potential threat or danger so perceived, while anxiety is, instead, a
more complex response system involving cognitive and emotional
factors, behavioral and physiological. On this basis, it seems
correct to state that anxiety and fear are physiological and normal
responses in all individuals. Not surprisingly, several studies of
cognitive neuroscience (Kandle, 2018) have shown beyond any
doubt that anxiety states arise from an abnormal control of fear; in
particular, starting from the assumption that anxiety is an adaptive
state, anxiety disorders have a genetic component and that the
anxious disorders are different in intensity, time course and specific
symptomatology, the researchers have concluded, also thanks to
the use of images of neurovisualization (fMRI), which in the states
of fear and anxiety, are called into question the neural circuits that
originate in the amygdala; indeed, the activation of the amygdala
was recorded in response to the presentation of a stimulus that
induces fear, not consciously perceived.
Anguish is the extreme opposite of peace, the fifth extreme
essence of dysfunctional anxiety, where the invasiveness, the
restlessness and the sense of catastrophe seen and perceived, from
a psychodynamic point of view, from the Ego, such as to undermine
the ego’s ability to control and manage the pressures of the Superego
and the id, consisting of a painful emotional state in which there
were processes of discharge, capable of creating symptoms (Freud,
1925). From this description we derive the general definition,
which embodies it in the sense of frustration and psychophysical
malaise, a prelude to various pathologies, precisely because this
condition remains for a long time, in a subtle and constant way.
In the clinic, we tend to distinguish the “situational or transitory”
form (due to a specific circumstance) from the “existential or
chronic” form (due to the lack of processing and maturation of
the triggering condition). The phobia is the pathological condition
that is generated as a result of specific fear and is determined by
a situation that is not really dangerous (or at least less dangerous
than the subject feels); this because the phobia, unlike fear, is not
proportional to the risk to which one is aware of being exposed or
believed to be exposed. Fear degenerates deeply, thus provoking
unjustified anxiety.
The fear is simply: <<(...) the state of mind of those who fear
can occur a harmful, painful or unpleasant event. It arises when
a situation that suggests a pleasant effect, joins the possibility
of suffering. One is afraid when the hypothesis that the expected
pleasure may not occur is considered, however the hope is still
present that pleasure comes and covers the thoughts of different
and painful hypotheses. It’s the case of a person who waits for the
beloved/or an appointment. A minimum delay ignites the fear
that the pleasure (loved one) may not arrive, together with the
frustration and sorrow (pain) that will ensue. When the person
arrives, a smile of contentment covers the previous fear (...)>>
(Aruta, 2018).Terror, by contrast: <<(...) is even more serious than panic.
In terror, the muscles are paralyzed, the fight / flight reaction is
entirely inhibited. It arises in extreme danger or pain situations.
It is said: “frozen / petrified” by terror. The body deactivates any
sensation coming from the periphery to limit the body’s sensitivity
in the agony that precedes death. It is a withdrawal inward, as in
a state of shock. The breath remains paralyzed in the exhalation
phase. Terror can precede fainting, in this case life is maintained
by the neuro-vegetative system through unconscious processes. If
the terror persists for a long period of time, the depersonalization,
dissociation of the ego perceived by the bodily processes (...)>>
(Aruta, 2018). It can occur both on a conscious level and during the
night hours (e.g Night terror).
And finally, the stress. A term widely used in popular jargon
to indicate a state of nervousness and low-level anxiety, often
connected to the family or work environment. In the literature,
stress is universally regarded as the nonspecific psychophysical
response of the organism to every request made on it (Selye, 1974,
1976). Based on the duration of the stressful event it is possible
to distinguish two categories of stress: if the stimulus occurs only
once and has a limited duration, it is called “acute stress”; if instead
the source of stress persists over time, the expression “chronic
stress” is used.
Furthermore, according to the nature, the stressor (stressful
events) is distinguished in distress, as an event that lowers the
immune defenses (correlating it to frustration and anxiety),
and eustress, which is an event that fosters greater vitality. The
generally perceived symptoms depend on the triggering event but
can be summarized in physical-somatic (headache, abdominal pain,
muscle pain, sensory disturbances, sexual disorders), emotional
(tension, anxiety, unhappiness, restlessness), behavioral (feeding
impaired sleep disorders, anger, substance abuse) and cognitive
impairment (memory and attention deficit, difficulty in problem
solving and agitation).
Definition and clinical contexts of panic disorder
<< (…) Panic is an abnormal and uncontrolled reaction to
an initially neutral or mildly stressful situation. If, therefore,
pathological anxiety, in most cases, is due to the limits that we
impose ourselves for some form of fear, and the anguish is the result
of a false Self, of an identity that does not belong to us but that
we consider ours and that we do not recognize as false, the panic
attack is the clinical manifestation of the result of a long-standing
anxiety, to which we have never left space for the elaboration and
that, in a moment often of apparent banality or serenity, while the
ego’s defenses are at a minimum, it hits the victim by paralyzing
her. It is not by chance that the main symptoms of a panic attack,
according to the DSM-5 (which classifies it as an anxiety disorder)
are: palpitations, cardiopalmos, or tachycardia, sweating, fine
tremors or great tremors, dyspnoea or suffocation, feeling of
asphyxiation (lack of air), chest pain or discomfort, abdominal
discomfort, discomfort, instability, lightheaded or fainting,
derealization (feeling of unreality) or depersonalization (being
detached from oneself), fear of losing control or going crazy, fear
of dying, paresthesia (sensations of numbness or tingling), chills or
hot flashes. From the panic attack, which single episode, however,
should be distinguished the real panic disorder, or the simultaneous
presence of multiple, unexpected and recurrent panic attacks and at
least one of the attacks must have been preceded by the persistent
worry of having other attacks or concerns about the implications
of the attack or its consequences (e.g losing control, having a heart
attack, “going crazy”) or significant alteration of the behavior
related to the attacks. The presence or absence of agoraphobia then
represents a specification. (…)>> [1].
<< (…) The experience of anguish frightens, a strong sense of
air hunger and a “crazy” heart that makes death seem imminent,
even without a direct connection with dramatic episodes. This is
an experience that from the very beginning debases and conditions
life, lived with a profound sense of insecurity and shame, with
the terror that can be repeated. Although unpleasant (sometimes
extreme), panic attacks are not dangerous. (…) The panic attack,
therefore, is the most acute and intense form of anxiety and has the
characteristics of a crisis that is consumed in about ten minutes.
In general, those who have experienced one or more panic attacks
tend to develop fear and worry that the panic attack may occur
again and concern about the consequences of the panic attack itself
(e.g fear that with the occurrence of a series of panic attacks you can
go crazy, lose control, risk a heart attack, etc.); consequently there
is a tendency to avoid all a series of situations that are considered
by the person as “at risk of panic attack” (e.g avoiding places where
panic attacks have already occurred, avoiding places where it is
difficult to disengage or go out and be able to return to familiar
places, implement behavior aimed at protecting yourself from a
possible panic attack, for example when you are away from home
try to park very close to reach your vehicle as soon as possible in
the case in in which the person should be ill, or in any case take
“safety measures” if the panic attack occurs).
The most widespread protective behaviors turn out to be carry
with you drugs for anxiety; move only in areas where medical
facilities are present; leave home only if accompanied by trusted
persons; always keep the emergency exits under control. In general,
the person tends to avoid all the situations or places that he
considers “anxious”, in which the person considers that it is difficult
to find an “escape” or to receive help in the event of a panic attack.
These “avoidances”, if extended to different areas and situations of
daily life, are very disabling and constricting for the person who
lives them, so much so as to compromise the quality of life: often
the fear that develops with respect to the panic attack forces many
people who do not drive, for example, for fear that a panic attack
occurs while driving and therefore lose control in such a situation,
the person arrives at this point to compromise their autonomy;
or, again, many people who live in very large urban centers who
manage to avoid using public transport, such as the underground, so
they will have problems moving around and reaching “important”
places such as their workplace, school or even worse, social life
is compromised (there is a tendency to renounce meeting friends
or in general to leave home, often the person feels shame for the
consequences that the panic attack may have or fears that other
people might notice it) . Among the most widespread “avoidance
behavior” are do not use a car, bus, subway, train or plane; not to
attend closed places (e.g cinema); do not move away from areas
considered safe (e.g home); do not make physical efforts.
Panic attacks can also be classified on the basis of the conditions
in which they occur, i.e. dependent on situations and those that
occur spontaneously; the latter occur unexpectedly, while those
dependent on the situations occur at precise environmental
conditions (e.g staying in crowded places, in the elevator, on the
underground, in the car, in places where it is difficult to disengage,
etc.), or between these, those generated by internal stimuli (e.g
physical sensations such as the acceleration of the heartbeat, the
sensation of a lump in the throat, assessing that he is blushing in the
face, etc.) often interpreted as anticipatory signs of anxiety and/or
‘panic attack, or the person may start to think that the cause is within
himself and to have thoughts like: “I’m about to faint!”, “I’m going to
have a heart attack!”, “I’ll lose control of myself! “,” I’ll go crazy! “,”
Oh God, I’m going to die!”. Panic attacks can also be classified on
the basis of the conditions in which they occur, i.e. situations that
occur spontaneously; the latter occur unexpectedly, while those are
dependent on situations such as staying in crowded places, in the
elevator, in the underground, in the car, in places where it is difficult
to disengage, etc.), or between these, those generated by internal
stimuli (e.g physical sensations such as the acceleration of the
heartbeat, the sensation of a lump in the throat, assessment that is
blushing in the face, etc.) “I am going to have a heart attack!”, “I’ll go
to have a heart attack!”, “I’ll lose control of myself!”, “I’ll go crazy!”,
“OH God, I’m going to die!”.
In fact, it happens to experience anxiety and fear as these are
“legitimate”, “normal” emotions, in the sense that in everyday life
situations are experienced that justify the emotion of anxiety or
fear that one experiences: e.g, a student before examination test
anxiety; before a job interview you experience anxiety; waiting
for the results of a clinical examination arouses anxiety; etc. in
this sense anxiety has an important function, like all the other
emotions that one experiences, which is that of signaling that one
of our aims is threatened or compromised; for example, if we are
crossing a road and we see a vehicle that comes to meet us at high
speed without slowing down as it approaches, we estimate that it
would be dangerous for our own life, we feel fear and run to save
ourselves; therefore anxiety and fear are emotions that generally
indicate a danger for one of our important purpose or objectives.
This means that there is a “normal”, and therefore healthy,
anxiety that is experienced in circumstances in which it is generally
legitimate to experience anxiety, since an important purpose is at
stake for the person and anxiety is felt because the person considers
that this purpose could be compromised (in the previous examples,
the student has the purpose of passing the exam; the young person
of the interview to pass it and get the job; the patient who waits
for the results hopes for the success of the same), and an anxiety
“ pathological “, which differs from the first in that it is excessive
compared to a real danger (e.g thinking of dying or having a heart
attack if you experience anxiety, feeling anxious about being on a means
of transport, in the meaning that in such cases the situations
are not “really dangerous” to justify the reaction of intense anxiety).
Pathological anxiety is therefore excessive compared to a
real danger, it is characterized by “avoidance” behaviors, that is
to avoid certain situations considered risky for the panic attack,
this condition generally compromises the quality of life, as the
person who he suffers from it tends to limit activities and habits
that he faced calmly before he felt ill. All of this generates a sense of
frustration and dissatisfaction with one’s life. Anxiety has a series
of both cognitive symptoms (listlessness, instability, skidding,
mental confusion, feeling of unreality, fear of dying, going crazy,
losing control) and physical (nausea, abdominal pain, sweating,
palpitations, discomfort or pain in the chest, etc.); the physical
symptoms manifest themselves consequently to the physiological
changes produced by the adrenaline that enters the bloodstream,
as anxiety and fear signal a danger and therefore prepare us
physically for a “attack-escape” type reaction (e.g of the machine
that we comes against). The anxiety considered pathological is the
one that triggers an attack-flight-like reaction, but which does not
correspond to a real danger. (…)>> [2].
Although therefore they are unpleasant (and sometimes
devastating), panic attacks are not dangerous for life, as much for
the conduct of a serene and harmonious social and personal life,
even if the feeling of imminent death appears real and concrete.
In other cases, these anxiety disorders and depression can coexist
(co-morbidities), or depression may arise first and the signs and
symptoms of anxiety disorders may occur later. Determining
whether these attacks are so severe as to be a disorder is a decision
that depends on numerous variables and the doctors diverge in
making the diagnosis. The diagnosis of a specific anxiety disorder is
largely based on its characteristic signs and symptoms.
A family history of anxiety disorders (except post-traumatic
stress disorder) is helpful, as many individuals seem to inherit a
predisposition to the same anxiety disorders from which their
family members suffer, as well as a general vulnerability to other
anxiety disorders. <<(…) Usually, panic disorder is also associated
with social anxiety disorder or social phobia, as a pathological
condition of discomfort and marked fear that an individual
experiences in social situations in which there is the possibility of
being judged by others, for fear of being embarrassed , to appear
ridiculous or incapable and be humiliated in front of others. The
typical symptoms are:
a) Marked fear or anxiety related to one or more social
situations in which the individual is exposed to the possible
judgment of others, such as being observed or performing in
front of others.
b) The individual fears that he will act in such a way as to be
criticized or manifest anxiety symptoms that will be negatively
evaluated.
c) Feared social situations almost invariably cause fear or
anxiety.
d) Social situations are avoided or endured with intense fear
or anxiety.
e) Fear or anxiety are disproportionate to the real threat
posed by the social situation and the socio-cultural context.
f) Fear, anxiety or avoidance are persistent and typically last
6 months or more.
(…) Again, we can find this disorder also associated with
agoraphobia, a condition in which the affected subject tries to avoid
public places or unfamiliar places, has difficulty leaving home and
traveling. The severity of anxiety and avoidant behaviors are variable;
Agoraphobia is one of the most debilitating anxiety manifestations,
as those who suffer from it often become completely dependent on
their home walls or are forced to leave home only when they are
accompanied. The object of agoraphobia can be to leave home, enter
shops, public places, travel alone on buses, trains or planes; panic
attacks can relate to the fear of collapsing or being left without help
in public, or derive from the lack of an immediate emergency exit
(one of the key features of agoraphobic situations). The fear of the
social consequences of a panic crisis due to agoraphobia often itself
becomes a further cause of emotional difficulty. The fear of leaving
the home and relating to the outside world shows a difficulty
in dealing with events, people, new and unknown situations,
without that “protection”, in this case represented by the family
environment, where the individual he does not risk immersing
himself in the anonymity of the chaotic crowd. Depending on the
personal history of each individual, the connection to his habits and
daily safety, his level of risk acceptance and relational uncertainty,
the meaning assumed by this phobia will be peculiar and therefore
it will be up to the psychotherapist to evaluate the type of care to be
taken. In the absence of therapy, agoraphobia can become chronic,
although usually with a fluctuating clinical course.
(…) Agoraphobic, panic and social anxiety disorders can evolve
over time into a true personality disorder called “avoidance of
personality disorder”(…). Those suffering from social anxiety
disorder could experience panic attacks, very intense anxiety crises
that peak in a short time and are accompanied by the fear of going
crazy, losing control or dying. In social phobia, panic attacks always
occur on the occasion of social situations where others’ judgment
is feared, thus differentiating themselves from the panic disorder
in which the sudden and unexpected attacks are not necessarily
linked to interpersonal contexts. In generalized anxiety disorder,
the anxious state is constant and, unlike the social anxiety disorder,
also present in contexts that are not linked to the judgment of
others. In major depressive disorder, the individual may fear the
negative judgment of others because they feel devalued and not
worthy of approval and appreciation, while in the condition of
social anxiety the fear of a bad evaluation by others is linked to the
belief that their behavior are inadequate or your appearance and
anxious symptoms are a cause for ridicule.
If the reason for the concern is linked solely and exclusively
to a shame related to one’s physical appearance or to a particular
of one’s body, one speaks of a disorder of body dysmorphism and not of
social anxiety disorder. There are no delusional ideas in this
disorder, and most individuals with social anxiety have a good
judgment about their beliefs or know that they are disproportionate
to reality. Social anxiety and communication deficits are common in
the autism spectrum disorder. However, those suffering from social
anxiety disorder have an initial impairment in these areas in the
cognitive phase, unknown people and places, which disappears if
they can become familiar. Finally, in the avoidance of personality
disorder there are common characteristics with the social anxiety
disorder. In avoidance disorders, avoidance is usually more
pronounced and extended than social anxiety and has lasted much
longer; however, avoidant personality disorder and social anxiety
disorder often occur together. (…)>> [2].
After the first panic attack, there are factors that maintain
and feed the problem, hindering the solution: sensitivity to
anxiety; effect of inconsistency with the emotion experienced;
disinformation; disillusioned beliefs and expectations; missed or
attempted solutions; protective and/or avoiding behavior [2]. The
difference between “panic attack” and “panic attack disorder” is
fundamental: in fact, if in the first case we are talking about one or
more rare and sporadic episodes, following a specific stress event, in
the second case we are talking instead of a real disorder, structured
and disabling, which has as its object the panic attack, defined as a
sudden and intense episode with fearful and uncontrolled psychophysical
manifestations [3].
Etiology and neural correlates in panic disorder
The etiopathology has not yet been fully clarified; what emerges
from recent studies is the implication of both neurophysiological
causes and psychological causes; therefore, the condition is
necessarily multifactorial [4-7]. From a physiological point of view,
all thoughts and feelings can be conceived as resulting from brain
electrochemical processes (in a 2004 study it was discovered that
three brain areas, anterior cingulate, posterior cingulate and and in
raphe), showed serotonin values lower than 1/3 of the minimum
physiological standard); however, this says little about the complex
interactions between neurotransmitters and neuromodulators in
the brain, as well as about anxiety and the normal and pathological
state of alarm.
From a psychological point of view, however, panic attacks and
panic disorder are considered a response to environmental stressors,
such as the interruption of a significant relationship or exposure
to a potentially lethal disaster. Even certain physiopathological
factors, such as hyperthyroidism, asthma, immune and allergic
dysfunctions, use of narcotic and alcoholic substances, but also as
lactic acid, sodium bicarbonate, carbon dioxide and caffeine, can
aggravate the precarious and vulnerable body chemistry, inducing
the anxiogenic state and therefore the onset of panic crisis, up to an
actual epileptic attack (in subjects already predisposed).
Many researches have led to the hypothesis that a defective
or exaggerated transmission within a circuit that includes the
hippocampus, various amygdaloid nuclei, the periaquedottal
gray substance, the medial pre-vertebral cortex and the cingulate
nucleus, various hypothalamic nuclei, the parabrachial nucleus,
the core of the solitary tract, the locus coeruleus and the sensory
part of the thalamus, may be responsible for the symptoms of panic
attacks. Recently, it seems to me that the frontal and insular cortices
are beyond the limbic system. In summary, therefore, the brain
structures of the prefrontal cortex, the cingulate, the insular and
the amygdala-hippocampus complex are involved.
Clinical strategies for the management of the pathological conditions
Having ascertained that the disorder in question derives from
a dysfunction that has biological and psychological connotations,
pharmacological and behavioral therapy are the only tools able
to face, manage and overcome the panic attack, both acute and
chronic. From a pharmacological point of view, the best choice
appears to be oriented towards the prescription of anxiolytics
and antidepressants (especially those that have an anxiolytic
efficacy), in order to prevent or reduce the anticipatory anxiety,
phobic avoidance and the frequency and intensity of panic
attacks. Numerous classes of antidepressants, including tricyclics,
monoamine oxidase inhibitors, selective serotonin reuptake
inhibitors, atypical antidepressants, are fully effective; compared to
antidepressants, instead, the choice will fall on a specific drug based
on the duration of the treatment and the risk of recurrence, so as
to intervene also on the intensity of the attacks. Benzodiazepines,
however, have a faster effect than antidepressants (often a few
minutes) but are more likely to induce physical dependence and
side effects, such as drowsiness, ataxia and memory problems.
They are therefore useful for symptomatic treatment and need but
are not suitable for prolonged use. An important aspect concerns
the question linked to drug dependence and dose ineffectiveness
if the administration time is prolonged. All aspects to be evaluated
during the interview with the psychiatrist, on a case by case basis
[8].
The “Mayo clinic” protocols provide for the use of these product
classes [9]:
i. “Selective serotonin reuptake inhibitors” (SSRIs).
Generally safe with a low risk of serious side effects, SSRI
antidepressants are typically recommended as the first choice
of medications to treat panic attacks. SSRIs approved by the
Food and Drug Administration (FDA) for the treatment of panic
disorder include fluoxetine (Prozac), paroxetine (Paxil, Pexeva)
and sertraline (Zoloft).
ii. “Serotonin and norepinephrine reuptake inhibitors”
(SNRIs). These medications are another class of antidepressants.
The SNRI venlafaxine (Effexor XR) is FDA approved for the
treatment of panic disorder.
iii. “Benzodiazepines”. These sedatives are central nervous
system depressants. Benzodiazepines approved by the FDA for
the treatment of panic disorder include alprazolam (Xanax) and
clonazepam (Klonopin). Benzodiazepines are generally used
only on a short-term basis because they can be habit-forming, causing mental or physical dependence. These medications are
not a good choice if you’ve had problems with alcohol or drug
use. They can also interact with other drugs, causing dangerous
side effects.
Genetic susceptibility, functional alterations of brain structures,
the neutrophic factor and the level of inflammation are further
possible causes or contributory causes of resistance to drug therapy
and therefore of delay in healing [10]. From a psychotherapeutic
point of view [11], the cognitive-behavioral approach has proved to
be widely shared and effective with respect to the problems related
to the disorder in question. Therefore, various techniques such as
exposure, guided breathing, imaginary verbal strategies, Acceptance
and Commitment Therapy (ACT), Eye Movement Desensitization
and Reprocessing (EMDR), autogenic training and yoga are strongly
recommended. According to Beck’s cognitive-behavioral model
(2013) it is not the situation itself that is frightening, but the way
we interpret it.
Therefore, events do not cause what we feel, but the way we
see them and manage them, through our thoughts. This treatment
therefore involves helping the patient in a series of steps: paying
attention to what one feels, even at the level of bodily sensations,
at a given moment; identify which are the thoughts related to
the emotion, one’s internal dialogue; to practice questioning
dysfunctional thoughts and beliefs; replace dysfunctional thoughts
and beliefs with thoughts closer to reality and more useful for
achieving one’s goals; stop avoiding using behavioral techniques
such as enteroceptive and in vivo exposure; prevent relapses.
In recent years, however, other therapeutic hypotheses have
come into being, such as group therapies (among these, Andrews
suggests the use of his seven-point protocol: psychoeducation,
panic monitoring, anxiety management techniques, cognitive
restructuring, exposure gradual to situations, gradual exposure
to physical sensations, relapse prevention) and self-help
interventions; again, two other specific protocols for the resolution
of this disorder: a) the first, with a psychodynamic approach; the
second, with a short strategic approach.
The first protocol [12], conceived by Massimo Fagioli, is based
on the assumption that the ego is formed from the moment a
human being comes into the world and with it is formed at birth
an image of Self which, not yet being identity, it needs continuous
confirmation in the relationship with the reference adults, so that
it can develop in a valid way and in parallel with the material wellbeing
deriving from being nourished and heated. In the newborn,
the valid relationship with the mother promotes physiological
development, improving over time its ability to see both physical
and mental, to the point of acquiring certainty and awareness of
oneself, of others and of the world, thus realizing the development
of a “true” self”.
If the relationship dynamics do not take place in a physiological
way, there is the risk of an initially deficient and then pathological
evolution of the self-image, which does not allow the newborn
to fully realize its human potential. If the mother is attentive and
caring for the needs of the newborn but is unable to grasp the needs
of internal living and reactions to the world, we can assume that the
child will feel confirmed with respect to his own physical reality,
but not in his psychic reality. The child, not yet certain of himself,
will tend to make a split between mind and body, which at weaning
will evolve in a pathological sense as a split between the conscious
mind and the unconscious mind. Conscious reality, no longer having
an unconscious internal guide, will forge itself on what comes from
the outside: thoughts, rules, stereotypes, developing over time a
rational modality detached from its own internal sense.
A process that actively contributes to the development of a “false
self”. The second pathological trait of panic disorder, the alexithymic
typology, derives precisely from the split between mind and body
which leads to considering only the needs of the body, gradually
eliminating the attention towards non-material internal reality
and this is why many Patients treated for panic attacks report an
absence of dream activity. The psychotherapeutic relationship, with
particular reference to group psychotherapy, allows the patient to
increase vitality through the interhuman relationship and with it to
realize his own image as a human being. He will therefore be able
to make the “false self” disappear and to find again that own reality
of affection, curiosity and desire for knowledge that will allow him
to complete the partial development of the first year of life and to
consolidate a certain identity of self and autonomy, therefore able
to continue to evolve throughout life.
The second protocol [13], of short strategic matrix, is based
on the studies of over thirty years; the whole procedure is based
on four fundamental steps, in order to disrupt the pathogenic
perceptive-reactive system of the disorder suffered by the patient.
From a “strategic” point of view, the effective intervention on
anxiety and panic disorders is based on changing the perception of
threatening reality. In fact, if one intervenes at a solely symptomatic
level, the risk of relapse is very high or even certain. The strategic
approach focuses attention on “how” the problem works and is
maintained in the present and on which dysfunctional strategies
(the “attempted solutions” codes) are implemented to address it.
The person is guided through experiences guided by the therapist
to build those individual abilities and abilities that allow to manage
the problem to overcome it effectively and definitively [14-16].
<<(…) “The subterfuges of hope are just as ineffective as the
arguments of reason “(Cioran, 1993) when the heart beats wildly,
the breath becomes labored, the body seems to be crossed by a
high voltage electric current and the mind runs fast, looking for
a solution to those sensations that one cannot explain. The need
for help and protection, as well as the attempt to escape from the
situation that you just want to stop, prevent any attempt to be able
to control yourself and your reactions. Then, suddenly, everything
ends, leaving the same feeling of devastation produced by a
tsunami, in this psychological case. Until the next time. We have
just taken four steps in crippling fear; the one that terrifies, the
one that annihilates. But how can it happen that from a natural fear
one can arrive at structuring a real disturbance, which the person
cannot get rid of? Fear, as our natural endowment, comes before and
after everything, pushing us to act anticipating the same mind,
with speed and precision. At the same time, precisely because of
the described characteristics, when it attacks us, it devastates
everything else and the reason is wrecked, the fear exceeds itself
and from a great resource becomes limit; becomes panic.
Panic as a psychological disorder is a modern diagnostic
category, although the characteristic reaction as a response to
conditions of extreme threat, namely the defined “panic-fear”, is the
most archaic of emotions. The WHO (World Health Organization),
in 2000, defined panic disorder as the most important existing
disease, affecting 20% of the population. From a nosographic
perspective, in the DSM (Diagnostic and Statistical Manual of Mental
Disorders), panic attacks were contradictorily included within the
category of anxiety disorders. While, from an operational point of
view, it turns out that it is not anxiety that triggers fear, but it is fear
that triggers the physiological reaction of anxiety, which sharpens
more and more with the rise of perception of individual threat,
transforming itself thus from functional mechanism of activation to
loss of control.
Following this logic, if the activation of anxiety is an effect
of the perception of internal or external stimuli to the organism,
the privileged ways of care become the management and
transformation of perceptions that trigger the subject’s reactions
in moments of crisis, while the classification of panic attacks
among anxiety disorders leads to a distortion of the observation
and evaluation of the disorder, indicating as an adequate solution
the pharmacological inhibitory therapy of anxiety itself. It is no
coincidence that the first false positive in the diagnosis of panic is
represented precisely by the generalized anxiety disorder, where
in reality there is no total loss of control typical of panic; the alarm
status is constant, with an increase in the physiological parameters,
which do not reach tilt however.
From the etiological point of view, despite the really rigorous
methodology to understand how a pathology works is represented
by the type of therapeutic solution able to solve it, most of the
times the perspective remains the traditional one that seeks in the
past the causes of the present problem. However, during a panic
attack, the person is terrified of his own feelings of fear against
the threatening stimulus that he will try to fight, as we will see, in
this way increasing them; the effect therefore turns into a cause.
Therapeutic change can only occur within the present dynamic of
problem persistence, thus acting on the way in which the individual
perceives threatening stimuli and, reacting to them, instead of
managing them functionally, is overwhelmed. The focus of the
study is the interaction of the organism with its reality, to which
it responds by modifying it and being modified. Panic is defined
by many as the most extreme form of fear that, if below a certain
threshold it represents a resource that allows alerting the body
to dangerous situations, above this limit becomes pathological.
There are different situations in which the thrill of fear envelops
the person in his coils, but the functioning structure of the vicious
circle that creates and maintains fear itself, until it becomes panic,
is similar.
By analyzing the most usual reactions to a perception of intense
fear, some constant redundancies are observed in different people
and situations:
a) The attempt to avoid or shun what scares, which makes
one feel less and less able to face that monster that assumes
ever more gigantic proportions in the mind of those who are
afraid.
b) The search for help and protection, which at the same time
makes you feel safe, but then, even if we succeed, it will only
be a swab that will take effect until next time. This is because
there is a kind of delegation to the other in facing the fear that,
being an individual perception, can be exorcised only and only
by those who hear it.
c) The failed attempt to keep one’s physiological reactions
under control, which paradoxically loses control, so we get even
more agitated.
The repetition over time of this type of interaction
increases the perception of fear leading to an exasperation of
the physiological parameters that are activated naturally in the
presence of threatening stimuli, up to the explosion of the panic.
If, on the contrary, we succeed in interrupting these dysfunctional
interactions, fear falls within the limits of functionality [14-16].
This last statement was precisely the hypothesis from which
Giorgio Nardone and his collaborators took the first steps for the
development of specific intervention protocols: if the avoidance, the
request for help and the attempted bankruptcy control are really
what turns a fear reaction into a panic, so letting a person suffering
from this disorder interrupt such response scripts should lead to
the extinction of the disorder itself. In 1987 the first application of
a specific therapeutic protocol for panic attacks with agoraphobia
was carried out, based on a strategic sequence of therapeutic
stratagems that created the planned random events, which led the
subjects first to experience the corrective emotional experience, for
then being gradually exposed to the feared situations, touching the
newly acquired capacities with hand.
The first research-intervention published in 1988 (Nardone,
1988) represented the cornerstone of all the work on panic
developed in the following decades to date, demonstrating its
extraordinary efficacy and therapeutic efficiency in breaking
the rigidity of the phobic perceptive-reactive system obsessive
dysfunctional. Currently, the therapeutic treatment developed,
and thus tested and proven, represents the “best practice” in
the treatment of panic attacks, responding to all the established
criteria to be able to evaluate, from an epistemological and
empirical point of view, the scientific validity and application of
a therapeutic intervention model. Specifically: - the therapeutic
changes obtained are maintained over time, with the possibility
of repercussions of the disorder reduced to a minimum; to test
this, the experimental studies conducted with a control group
and randomized samples, the video recordings of the therapeutic
processes, and the comparison with other therapeutic techniques,
i.e. both qualitative and quantitative assessments (efficacy); the
therapeutic strategy produces results in reasonably short times,
months and not years, otherwise the change could be the effect
of fortuitous events (efficiency); therapeutic techniques and their
processualism can replicate the results on different subjects that
present the same pathology (replicability); - during the application,
the effects of each single therapeutic maneuver can be predicted
within the entire sequence of the model (predictability);the model
and all its techniques are constantly taught and transmitted to other
colleagues so that they can achieve similar results (transmissibility)
by applying them.
Initially, the unlocking maneuvers acted by blocking the
request for help and protection through a restructuring aimed at
creating a greater fear that inhibited the present one, resuming the
observation that a greater fear puts in the cornering, and those who
hear it often pull out a winning courage even in the most adverse
conditions. To act on avoidant behavior, a series of suggestive
prescriptions were created that could distract the subject during
exposure to the feared situations (counter-avoidances), such as the
prescription of the pirouette and that of the apple (Nardone, 1993;
2003). Finally, to interrupt the attempt to suppress their reactions,
the “logbook” was devised, a sort of apparent monitoring of panic
episodes, but in reality, aimed at producing emotional detachment.
This, starting from the observation that, when the subject reacts
to the frightening situation driven by some reason or stimulus that
distracts him from it, he acts without thinking and, only afterwards,
he realizes what he has done successfully. Studies on the
neurophysiology of panic (Nardone, 2003, 2016) then highlighted
two fundamental processes that take place during a panic attack:
on the one hand, the phobic perception involves the limbic system
(amygdala, hippocampus, locus coeruleus, hypothalamus ...), that
reacts in thousandths of a second by immediately conveying a
response to the periphery, activating the “flight or fight” reaction,
(which is now “freezing”), thanks to the stimulation of the “freezing”,
autonomic nervous system, in particular of the sympathetic
section. On the other hand, after thousandths of seconds, the
sensation reaches the cortex, which is responsible for the conscious
evaluation of external stimuli and modulates voluntary behavior;
for the amygdala to respond to fear reactions, the medial prefrontal
cortex must be deactivated.
The problem emerges when the modern mind, therefore the
cortex, confuses the healthy mechanism described with something
dangerous, realizing itself out of its control, and what frightens
most begins to be no longer fear in itself, but the reaction of loss
control of the organism, which leads the reason to try to control,
and the more it tries to control the more it loses control, up to the
physiological tilt of the panic attack. It was therefore necessary to
introduce a technique capable of successfully intervening in panic
attacks in the absence of a real threatening source, or in those cases
in which the frightening threat does not come from outside, but
derives from having fear of the fear that triggers the paradoxical
escalation to the point of panic. Paradoxically, fear turns into a selffulfilling
prophecy without the need for any external triggering
situation. The technique of the “worst fantasy”, fruit of the constant
work of research-intervention in the field and of concrete examples
of success of the paradox in history. Think of the stoic courage of
Seneca who, condemned to kill himself by cutting his veins with
his own hands and having seen his wife suffer the same fate before
him, managed to overcome his fear by spending the period before
the execution, imagining all the fantasies most terrible about
that atrocious horror movie that would inevitably become the
protagonist.
Specifically, the technique consists of asking the person to
retire every day in a room where no one can disturb her and, getting
comfortable, will dim the lights and create a soft atmosphere. She
will set an alarm to sound half an hour later and in this half hour she
will begin to fall into all the worst fantasies compared to what could
happen to her. And, at this time, she will do whatever she wants to
do: if she feels like crying, she cries, if she screams from screaming,
if she gets her feet banged on the ground, she does it. When the
alarm goes off ... stop ... it’s all over; take off the alarm, go to wash
your face and go back to your usual day. So, the important thing is
that for the entire half-hour, whether or not he feels sick, he stays
there, sinking into all the worst fantasies that could happen. He
does all that he has to do, but when the alarm goes off ... stop ... it’s
all over. Detach the alarm clock, wash your face and return to your
usual day. So, half an hour of daily passion.
The results of the application of the paradoxical injunction to
panic (Frankl,1946) are extraordinary: patients induced to descend
into all possible worst fantasies with respect to panic, instead of
becoming frightened, relax, creating a counter-paradoxical effect
(Nardone, Balbi, 2008) with respect to the paradox of escalation
from fear to panic, up to sometimes falling asleep. After a rigorous
training, which sees the evolution of the technique from half an
hour to five minutes to five times a day when the person has to
make scheduled appointments to his fears to become familiar with
the experience for which the more he seeks the fear and less this
it will be presented, it comes to using the technique before doing
something feared (looking at fear in the face so that it becomes
courage) and when fear unexpectedly appears (touch the ghost
when it appears to make it fade).
In 2000, the evaluation study of 3482 treated cases, of which
over 70% suffered from panic attacks, showed a therapeutic
efficacy of 95% and with a duration of treatments reduced to seven
sessions. Since then, hundreds of thousands of cases have been
successfully treated, with average success rates in international
statistics exceeding 85%. But the most astonishing fact is that the
patients get rid of the invalidating disorder within 3-6 months and
that these results, as the follow-up measurements after the end
of the therapies show, are maintained over time in the absence of
relapses and symptom shifts.
This thanks to the application of an isomorphic logic to that
of the persistence of the problem, therefore non-ordinary, and to
a suggestive-persuasive form of communication. Fear, therefore,
if pushed, instead of shunned or repressed, becomes saturated
with its own excesses (Nardone,2016), becoming the most evident
demonstration of the fact that “There is no night that does not see
the day” (Nardone, 2003). (…)>> [13, 17-23].
Conclusion
From the latest studies a still rather fragmented picture
emerges with respect to the etiological certainties of panic disorder.
If compared to the therapies, the protocols are rather precise
and functional, operating between those of psychotherapeutic
matrix (the cognitive-behavioral approach and the short strategic
one) and the pharmacological ones (anxiolytics and SSRIs/SNRIs
antidepressants), the causes that trigger the disorder orientate
towards a multifactorial nature: genetic, psychophysiological, food
and environmental. In particular, neurobiology plays a fundamental
role, demonstrating which brain structures are involved: many
researches have led to hypothesis that a defective or exaggerated
transmission in a circuit that includes the hippocampus, various
amygdaloid nuclei, the periaquedottal gray substance, the medial
pre-vertebral cortex and the cingulate nucleus, various hypothalamic
nuclei, the parabrachial nucleus, the core of the solitary tract,
the locus coeruleus and the sensory part of the thalamus, may be
responsible for the symptoms of panic attacks. Recently, it seems
to me that the frontal and insular cortices are beyond the limbic
system. In summary: the brain structures of the prefrontal cortex,
the cingulate, the insular and the amygdala-hippocampus complex
are involved. Future research must necessarily be oriented towards
prevention and better management of symptoms, as despite great
efforts in this direction a good proportion of patients is drugresistant
(certainly due to genetic factors) or is still relapsing with
pathological symptoms.
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