INTRODUCTION:
Anxiety is a symptom of high frequency.
It is found in one in five patients in consultation with a general practitioner and in over a third of hospitalized patients in medical services. Very frequent, anxiety is also nonspecific. It is observed in many organic disorders and in most psychiatric disorders.
Its intensity is variable and may extend to paroxysm of anxiety attack, described by the name of “panic attack” in the classification of mental disorders in DSM-IV.
Based on the DSM-IV – which is limited to symptomatic description of mental disorders, but makes a useful identification criteria (symptoms) for the purpose of diagnosis and treatment – panic attack is described all of first as an isolated entity and in anxiety disorders, forms of “anxiétémaladie” in which it manifests itself.
DIAGNOSTIC:
How to distinguish pathological anxiety of normal anxiety?
Anxiety is a normal emotion in response to stress in daily life. Such anxiety, adapted to the context and lets face it, does not warrant any treatment.
Anxiety becomes pathological when it is a source of distress for the individual who does the most control. She then an impact on its ability to adapt because it causes inhibition and prevents face the situations of everyday life.
Panic Attack:
This term corresponds to the classical anxiety attack, paroxysmal anxiety, whose etymology (Latin angustia “narrow, narrow place”) emphasizes the physical component.
The panic attack is a discrete period of intense anxiety or discomfort, without any real danger, in which at least four of the following symptoms (Box 1) occurred abruptly.
Box 1. Symptoms of a panic attack (according to DSM-IV)
somatic symptoms
respiratory
Feeling “blown off e” or feeling of suffocation Chest pain or discomfort
throttle sensation
Cardiovascular
Palpitations, heartbeat or rapid heartbeat
neurological
Feeling dizzy, unsteady, light-headedness or
Feel faint
Paresthesias (numbness or tingling)
autonomic
– sweat
– Chills or hot flashes
muscle
Trembling or shaking
digestive
Nausea or abdominal discomfort
cognitive symptoms
Fear of losing self-control or going crazy
Fear of dying
Derealization (feelings of unreality) or depersonalization (being detached from oneself)
Attacks meeting the definition above, and with less than four somatic and cognitive symptoms are considered as the diagnostic criteria of DSM-IV as mildly symptomatic.
Somatic, uncontrollable symptoms usually dominate the table and can maintain the fear of having a cardiac or respiratory accident.
Cognitive symptoms testify to the fear of an imaginary danger ( “fear of going crazy,” “fear of death”). The presence of symptoms of derealization (feeling of strangeness of the surrounding world) and more rarely of depersonalization, loss of bodily limitations or even perceptual distortion (change in the intensity of sounds, distorted forms) increase the anxiety of the patient.
The panic attack reaches its peak in 10 minutes or less. It usually takes 20 to 30 minutes and rarely exceeds one hour.
The patient’s desire is to put an end to this painful experience. One can observe violent escape responses in order to find immediate relief or otherwise of prostrate attitudes.
DIAGNOSTIC APPROACH TO FACE PANIC ATTACK:
Search first organic cause:
Some organic pathologies can cause panic attacks. A physical examination is necessary to eliminate:
– Cardiovascular disease (angina, myocardial infarction, arrhythmia, pulmonary embolism);
– Respiratory disease (asthma, pneumonia);
– Endocrine pathology (hypoglycemia, hyperthyroidism, hyperparathyroidism, pheochromocytoma);
– Neurological disease (epilepsy, transient ischemic attack, tumor).
No diagnostic testing is systematic: laboratory tests, ECG, EEG, etc., are prescribed based on clinical examination.
Are systematically sought:
– Taking toxic: cocaine, amphetamines, ecstasy, cannabis, etc;
– Withdrawal: alcohol, opiates, barbiturates, benzodiazepines, etc.
Search a mood disorder or a psychotic disorder:
Among psychiatric disorders with anxiety in the foreground, it is important to seek a depressive or psychotic disorder that can make be marked hospitalization:
– Mood disorder: anxiety melancholy. In its favor, there is the notion of a break from the usual operation of the subject, the late age of onset of anxiety (> 35 years), the melancholy theme ( sadness to depression ), the change of the table in the day (morning asthenia, Vespers improvement) and potential personal or family history;
– Psychotic disorder: schizophrenia, brief psychotic disorder (acute delirium). Anxiety may be linked to the experience of depersonalization and delusional symptomatology or hallucinatory (risk of acting out hetero aggressive but mostly suicidal). Also think about any side effects of neuroleptics, for example, extrapyramidal crisis, very anxiety provoking.
Search the context of the occurrence of a panic attack:
Unexpected panic attacks: Panic Disorder:
The patient does not associate the beginning of the panic attack to a specific triggering condition, which occurs unexpectedly. Panic disorder is characterized by so unexpected panic attacks, recurrent, intensity and frequency vary.Patients experience sooner or fear of recurrence, fear called “anticipatory anxiety” can become almost permanent and cause an avoidance behavior.
Panic attacks linked to a position and manifesting within anxiety disorders (DSM-IV):
Agoraphobia:
Panic disorder is often complicated by agoraphobia corresponding to the fear of being in places or situations where it might be difficult to escape or be rescued in case of occurrence of a panic attack ( for example, being in a crowd or on the contrary in the great outdoors or in confined places). Usually, such situations are avoided by the agoraphobic patients or require the presence of a companion.
Specific phobia and social phobia (social anxiety disorder):
A phobia is defined as an irrational fear of an object or situation not having in itself objectively threatening character. In addition agoraphobia, DSM-IV defines two types of phobic disorders:
– Specific phobia: the most common are phobias of animals, water, heights, blood, injections or aircraft;
– Social phobia is characterized by fear to feel humiliated or embarrassed in social situations of exposure to others (for example, talking, eating, drinking in public or talk to a third party).
The confrontation with a situation or a phobic object or a dreaded social situation causes almost invariably anxiety, which may take the form of a panic attack.
Obsessive Compulsive Disorder:
Obsessions are perceived as intrusive obsessive thoughts and inappropriate and that cause anxiety or significant distress (eg, fear of dirt, contamination, disease, permanent doubt, fear of a hetero-aggressive act or profane ).
Compulsions are deliberate and stereotypical acts whose objective is to neutralize the obsessive thoughts and soothe anxiety (eg washing rituals, audits).
A panic attack can occur with the waning of obsessive compulsive disorder, for example, on exposure to dirt in someone with an obsession with contamination.
State of post-traumatic stress:
A panic attack can result from the confrontation of the subject with a situation, an object or a person who promotes the reminiscence of a situation of extreme danger he faced before. For example, watching television report on a tsunami can trigger a panic attack with reliving the traumatic situation experienced.
Generalized anxiety disorder (GAD):
DSM-IV criteria for the diagnosis of
TAG, in current practice, are:
– 6 months at least;
– Severe anxiety / excessive worry, uncontrollable, chronic with permanent impression of nervousness, tension and physical symptoms cause significant distress;
– Anxiety and worries associated with some of the following symptoms:
– Motor tension fatigue, muscle tension, restlessness, or overexcitement
– Hypervigilance: difficulty concentrating, sleep disturbances, irritability, autonomic signs: cold and wet hands, dry mouth, sweating, nausea, diarrhea, urinary frequency,
– Difficulty swallowing or lump in the throat, tremor, twitching, pain,
– Muscle aches, irritable bowel syndrome, headache.
Comorbidity of GAD with panic attacks / panic disorder is common (it corresponds to the former “anxiety neurosis”).Thus, the distinction is sometimes difficult between the two diagnoses.
GAD can be a prodrome of panic disorder.
Attacks pauci-symptomatic panic are difficult to distinguish the fluctuations of generalized anxiety.
TREATMENT:
Panic Attack:
Psychological care:
In practice, at the same time that the diagnosis to reassure the patient and to play down the situation, you must:
– Remove the entourage which increases the anxiety of the patient;
– Establish a dialogue and a relationship of trust and conduct an assessment interview to clarify the circumstances of occurrence of the crisis, the development of the disorder, the social and environmental context, history;
– Perform a careful physical examination and practice if necessary diagnostic tests to rule out organic etiology and reassurance of physical integrity.
Medical treatment:
Beyond this reinsurance to which many patients are sensitive, it is often necessary to resort to drug treatment:
– First-line oral benzodiazepine whose dosage is adjusted according to the intensity of the symptoms and age of the patient (eg, Xanax® [0.25 to 0.50 mg]
Seresta® [10 to 50 mg]). If oral administration is difficult, we opt for intramuscular administration (eg Tranxène® [50 mg, ½ to 1 ampoule IM]);
– In the case of severe anxiety with agitation or aggression, we may use a sedative neuroleptic treatment (eg Loxapac® [25-50 mg orally or IM]).
Most often, the immediate management provides a sedated.
Hospitalization:
One is prompted to resort to hospitalization in case of panic attacks occurring in rapid succession or when suicidal thoughts are expressed. A brief hospitalization may help to better understand a diagnosis and guide to psychiatric care. Hospitalization is required in the presence of a severe depressive or delusional disorder. In the context of an anxiety disorder, acute care should lead to drug type of prevention strategies or psychotherapy and lifestyle.
Anxiety disorders:
General measures:
An accompanying psychotherapeutic intervention at the first consultation, includes a listening and advice based on anxiety situations. It includes the explanation to the patient somatic symptoms of psychological origin and different treatments.
This approach helps to establish a relationship of trust between doctor and patient, based on a therapeutic alliance.
Of lifestyle changes (stop / decrease in alcohol and tobacco, coffee, regular physical exercise) are recommended.
Treatment includes psychotherapy in terms of accessibility and choice of the patient and / or drug treatment.
Regarding medication, the physician must inform the patient of their advantages and disadvantages: onset of action, side effects, possible signs of withdrawal and signs of rebound anxiety.
The objective of the management of anxiety disorders is symptomatic improvement, the reappearance of well-being and reduction of social disability.
The treatment of anxiety disorders is ambulatory, hospitalization is required in case of complication with depressive suicidal risk.
Psychotherapies:
Cognitive behavioral therapy:
These therapies are intended to clarify the circumstances of occurrence of the disorders, to identify irrational thoughts to evaluate and modify the reorganization of inappropriate attitudes.
They combine relaxation, repeated exposure to avoided situations and cognitive restructuring catastrophic interpretations worries overvalued. Cognitive behavioral therapies are as effective as drug treatments and represent an alternative to these treatments especially benzodiazepines. However, they are still difficult to access (insufficient number of trained therapists sometimes financial aspect).
Analytical type of psychotherapy:
An analytical type of psychotherapy aims to help patients who are in the process of identifying the underlying unconscious conflicts to conducted generating anxiety and clarify the early trauma of the first interpersonal experiences. Anxiety debilitating in some patients can be significantly improved especially when there are personality disorders.
Drug treatments:
Antidepressants and anti-anxiety drugs have demonstrated their interest in the treatment of anxiety disorders.
Antidepressants:
Antidepressants have obtained the authorization of the placing on the market (AMM) in the indication of anxiety disorders, and their dosages:
– Clomipramine (Anafranil): it is the tricyclic antidepressant oldest known in preventing panic attacks and in the treatment of obsessive compulsive disorder. The most common side effects of clomipramine are Anticholinergic: dry mouth, constipation, accommodation disorders, tachycardia, sweating, trouble urinating, etc. They are usually mild and yield to continued treatment;
– Reuptake inhibitors of serotonin (IRS): paroxetine (Deroxat®), fluvoxamine (Floxyfral®), fluoxetine (Prozac), escitalopram (Seroplex®), citalopram (Seropram®), sertraline (Zoloft);
– Serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor).
IRS and IRSN are used most often in first intention for their low anticholinergic effects and less toxicity in overdose.Their most common side effects are the beginning of treatment: gastrointestinal disorders, insomnia, somnolence and dizziness.
The anxiolytic effects of antidepressants start between the first and third week of treatment. They must be initiated at low dose and increased gradually at intervals of 1 week, depending on their effectiveness and tolerance, to the usual dose or maximum, varying topics. It advocates a period of 6 to 12 months asymptomatic before very gradually reduce the dosage.
Benzodiazepines:
Whatever their half-life benzodiazepines have rapid anxiolytic effect on somatic signs of anxiety. They expose to the risk of drowsiness at the beginning of treatment and dependence stopped. The gradual withdrawal of benzodiazepines is recommended even after short-term treatment. The maximum legal duration of treatment is 12 weeks, including gradual withdrawal. Ben zodiazépines are frequently associated in the beginning of antidepressant treatment until the maximum therapeutic effect of antidepressants reference is reached.
Buspirone (Buspar®):
Buspirone, which has a marketing authorization in the TAG has an anxiolytic effect on especially fickle psychic anxiety symptoms. Its onset of action up to 3 weeks. Adverse effects are dizziness and sedation. There are no withdrawal syndrome to stop or dependence.
Adjunctive therapy:
Moderate forms of anxiety may benefit from adjunctive:
– Hydroxyzine (Atarax®) has anticholinergic effects and sedation but little effect of dependency and rebound anxiety;
– Herbal medicine by Euphytose;
– Acupuncture.
CONCLUSION:
It should not underestimate the comorbidity of anxiety disorders with depression and addictions (alcohol in particular), to assess the risk of suicide and social isolation consecutive inhibition and avoidance behavior.
panic attacks anxiety disorders, the doctor will place in a prevention strategy, regularly reviews the drug treatment favoring as much as possible psychological treatments and relaxation techniques that seem to work best in the long term.