Iris Publishers - Current Trends in Clinical & Medical Sciences (CTCMS)
Panic Disorder: Definitions, Contexts, Neural Correlates and Clinical Strategies
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].
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