PathophysiologyPresentationPanic Attacks

Edvard Munch – The Scream

By Jannine Holmes

There can never be enough facts...

• It is estimated that 1 in 4 adults suffer from anxiety related illness compared to the 1 in 6 adults that suffer mental illness in general in the UK.

• Mental illness is the largest single cause of disability in the country costing £77 billion a year.

• Mixed general anxiety and depression disorder is the most common mental illness.

• Women are more likely to suffer anxiety related illness than men.• one and a half percent of the population of the world, the

number afflicted with an anxiety or panic disorder is 88,726,749. Almost 89 MILLION people

What is Anxiety?

• A permanent state of worry• A psychological event with physiological symptoms.• Fear: It is one of the most powerful emotions. It has a very

strong effect on your mind and body. It tells you what to do in emergencies like a fire, or being attacked.

• Fear can also kick in when you’re faced with non-dangerous situations, like exams, public speaking, PATHOPHYSIOLOGY PRESENTATIONS, a new job, or even a party. It’s a natural response to a perceived threat.

When does anxiety become Panic?

• Anxiety is a generalised term for the specific condition• However anxiety almost never stays anxiety.• It forms into other conditions when not treated or recognised early.• Panic Attacks is one of those conditions.• Panic attacks can occur for no reason whatsoever• The first time a person has a panic attack they will think they are

dying...Literally!• It is extremely terrifying for the person in question• People often feel like they are having a heart attack• Panic attacks occur out of the blue and can strike wherever and

whenever.• It is estimated that everyone at some point in their life will experience a

panic attack whether mild or severe.

What is a panic attack?

• A panic attack is an exaggeration of the body’s normal response to fear.

• A panic attack is a fluctuation of several physical symptoms.

• It is your body gearing up for a fight or flight situation• It is unprovoked

Fight Flight

What would you do........

Physiological symptoms of Panic Attacks

• Fast heart rate (120-275bpm)• Hyperventilating (breathing faster than normal)• Palpitations• Feeling sick • Chest pains • Headaches • Dry mouth• Sweating• Diarrhoea• Dizziness• Pseudo paralysis - pronounced loss of muscular strength and control without true

paralysis. Severe panic attacks sometimes cause pseudo paralysis to a degree where ability to walk, stand or sit upright may not be possible for the duration of the attack.

Here’s the science step by step....because your worth it!

• The Endocrine system plays a big part in anxiety related panic attacks due to the hormones and neurotransmitters that are involved.

• In particular the Hypothalamus, pituitary and adrenal glands.• The Autonomic Sympathetic system plays a huge part in panic attacks due to

the physiological symptoms experienced when the flight or flight response is triggered.

• The hypothalamus is located in the lower central part of the brain, no bigger than the size of an almond

• The pituitary gland is located at the base of the brain below the hypothalamus and is no bigger than a pea.

• The Adrenals are located on the top of kidneys, • the inner part being the medulla and the • outer part being the cortex.

More Science...

• The brain and spinal cord makes up the central nervous system.

• The rest of the body is served by the peripheral nervous system, a network of nerves that feeds into the spine relaying signals between the brain, muscles, skin and organs.

• They both work together consciously and unconsciously.• The peripheral nervous system breaks down into 2 sub

divisions known as the somatic system which sends sensory information to your brain and muscles.

• Then we have the autonomic system that connects to the parts of the body that operate unconsciously i.e. the heart, intestines, muscles of the stomach.

Can there ever be enough science.....

• The Autonomic system also has 2 divisions known as The sympathetic and parasympathetic system

• Both have extraordinary functions, as I am sure, we all remember from physiology that the parasympathetic and sympathetic systems do not work at the same time

• I will explain in detail how the Sympathetic system plays a very important part in panic attacks.

• But first here are some of the neurotransmitters and hormones that play a primary role in Panic attacks.

“I guess I could use a little social interaction”

serotoninEpinephrine

Dopamine

Acetylcholine

Adrenal GlandPituitary Gland

What do they all do????

Norepinephrine

details...details...

• The Hypothalamus sends hormones to the pituitary Gland• The anterior pituitary gland takes messages from the brain via the

hypothalamus and uses these messages to produce hormones that affect many parts of the body, the hormones in question are ACTH (Adrenocorticotrophic hormone ) this stimulates the adrenal glands to produce cortisol.

• The Adrenal glands also produce Adrenaline and Noradrenaline

• Acetylcholine, the first transmitter to be discovered, it is the neurotransmitter released by stimulation of the vagus nerve which alters heart muscle contractions and gastrointestinal muscle contraction it also plays a part in REM...dream sleep...not shiny happy people!

• Serotonin also known as 5-HT is concentrated in the neurons in a part of the brain called the raphe nucleus it is involved in sensory perception, temperature regulation, control of mood, appetite and the induction of sleep .

• Gaba or gamma-amino butyric acid is the most abundant inhibitory neurotransmitter in the brain although it is an amino acid it is still a neurotransmitter that helps induce sleep and relaxation, Anxiety is regulated by Gaba.

• Cortisol - the body's chief stress fighting hormone produced by the adrenal gland. Cortisol is high during periods of stress and low when relaxing. A decrease in cortisol is associated with increase in serotonin and dopamine. Heightened levels of cortisol are associated with muscle tension and sweating.

• Catecholamine's a family of Monoamines:• Epinephrine and Norepinephrine also known as adrenaline and

noradrenaline these hormones are released by the Adrenal Medulla, the amounts of the hormone secreted are not equal, usually about 80% of adrenaline and 20% of noradrenaline, these hormones play a huge part in the fight or flight response.

• Dopamine is needed to produce epinephrine and norepinephrine, it is a neurotransmitter that is essential for survival orientated behaviour.

Back to the sympathetic nervous system

• During physical or emotional stress the sympathetic system dominates the parasympathetic system

• The flight or fight response has been triggered..your body is ready to do what ever it takes to survive..how incredible is that!

This mouse clearly has not read the basic fight or flight survival guide

The why’s and wherefore’s• What takes place when the sympathetic system is activated?• Pupils dilate = To let in more light so you can see where to run

(tunnel vision)• Inhibited flow of saliva = The sympathetic system has stopped the

production of saliva resulting in a dry mouth• Fast heartbeat = The sympathetic system does this to increase

blood flow..you need to run...you need oxygen in those muscles...waste products are also eliminated. Paleness in the face, fingers and toes is because there is a tightening of blood vessels, you are less likely to bleed to death if a digit is bitten off, pins/needles numbness and tingling are also felt.

• The lungs Dilate = This is so you can take in more Oxygen..breathing is faster and at a lesser depth...it supplies the tissues..ready for action.

Sympathy Continued...• Inhibits excretion of faeces and other waste = blood is taken away from

the digestive area and used for the muscles and heart, however the term “ I s**t myself” is an expression used widely when placed in a situation of fright, this is literal as before the escape takes place, the body eliminates all waste products whether you can reach the bush or not!

• Glycogen into glucose = When your blood sugar is low, your heart has to make more of an effort to get enough glucose to your brain, your heart has enough to do, so your brain will trigger Adrenaline into releasing glucose from the liver so it can think and react immediately when it needs too.

• Secretion of Adrenaline and Noradrenaline = Adrenaline increases the heart and breathing rate. Noradrenaline maintains blood pressure, adrenals are responsible for the release of cortisol which affects the release of glucose from the liver giving the energy to run.

The sympathetic Nervous System

Diagnosis• Only if symptoms of panic attacks re-occur will a G.P investigate• When other physical findings are negative• An overactive thyroid can cause similar symptoms to panic attacks • Blood tests - this is done to check hormones, vitamin and mineral levels and to

rule our other medical causes.• A CT scan or EEG of the head will be performed to rule out possible brain tumours

as the cause of the attacks.• Psychological testing – these are done to assess the level of anxiety, this is usually

done by asking the patient questions or filling out a questionnaire, this method is not always reliable as it is based on the testimony of the patient on that day.

• Sleep Study – sleep deprivation can be the cause of panic attacks, sleep apnoea can increase stress levels.

• Neurotransmitter testing – This is done by testing the level of hormone in the urine, especially those that are released by the kidneys, if identified medication can be prescribed for the particular deficiency i.e. SSRI’S are helpful for increasing serotonin.

Treatment...• Panic attacks can be treated successfully• The main aim is to reduce the number of panic attacks a person has and to reduce

symptoms• 2 types of treatments available are :1. Psychological therapy ( talking therapies, cognitive behavioural therapy)2. Medication• Cognitive behavioural therapy (cbt) is a talking therapy, a therapist will discuss

your life, behavioural patterns you have adapted, also most importantly your reactions to every day life and situations you avoid, your negative thoughts also play a huge part in cbt as it is these that fuel the panic. You will then turn this around and look logically at what is happening, homework is set with the aim for the patient to acquire knowledge of the subject which in turn helps confirm the non life threatening situation which then eases the anxiety.

• This is a short term treatment based on a number of sessions usually around 6-12, it is estimated that over half of panic attack sufferers receiving this treatment will benefit from it and recover.

Treatment cont...• There is a vast amount of medication available to Panic attack sufferers but yet it is

found to be the least effective on it’s own• G.p’s will generally start a course of anti-depressants as these usually contain

neurotransmitter replicates such as: SSRI’s (Selective Serotonin Re-uptake Inhibitors) these are said to increase levels of

serotonin so are the most common of the anti – depressants prescribed. However if you look at the side effects of the drug, they mimic symptoms of panic attacks therefore giving no relief whatsoever, the patient then loses confidence with the drug and stops taking it.

o Side effects include: Nausea, dizziness, dry mouth, palpitations, feeling agitated and insomnia.

Tricyclic Anti-depressants work in a similar way to SSRI’s, they replicate serotonin and noradrenaline, these drugs are said to have a feel good factor, lifting the mood. This type of drug also has a wide range of side effects, although not as severe as SSRI’s.

Beta Blockers are generally effective in reducing the symptoms of panic therefore reducing the overall anxiety, beta blockers work by reducing the heart rate and blood pressure, keeping the body in a happy state, giving the mind time to recover, if your not obsessing about your heart racing, you can concentrate on other things.

More drugs????• There are also side effects with beta blockers, not many but they can be

unpleasant• Cold Hands and feet, Dry mouth, dry skin, dizziness, general weakness and

fatigue• Beta blockers should be a short term solution as they are difficult to come

off and must be reduced little by little as adverse effects such as those similar to “cold turkey” could be experienced.

Beta - Blocker Tricyclic Anti-depressants SSRI’s

There’s more...

• The most important key factor in recovering from panic is exercise

• After-all the body has produced the adrenaline, it may as well be used correctly

• Exercise helps keep the heart healthy, provides nutrients around the body and muscles, it clears the mind.

• Exercise is proven to induce endorphins which are said to give the “feel good factor”

• Endorphins are found in the pituitary gland they are the bodies natural painkiller and stress reliever.

Diet and nutrition• What about Diet?

• The lack of essential vitamins like B6, B9, B12 and Vitamin-C can have an effect on the body and brain as they are needed to keep the internal environment particularly the nervous system, healthy.

• B Vitamins are water soluble so don’t stay in the body long, what the body does not use gets flushed away so constant intake of these vitamins is essential.B Vitamins can be found in food such as poultry, dairy, select vegetables, beef and breakfast cereals.

• Vitamin C is essential for proper functioning of the adrenal glands and general brain function, it is associated with reducing stress and anxiety.

• Lots of sugars and carbohydrates lead to increased insulin levels. High insulin tells the body to store what you just ate as fat, thereby dropping your blood sugar concentration. Your brain can burn only sugar, so it is deprived of food. Poor concentration and depression can result. Hypoglycaemia (low blood sugar) can lead to diabetes. Also, the low blood sugar make you hungry, which causes you to eat more sugar or carbohydrates, and the cycle is repeated. Insulin affects serotonin levels and many systems throughout the body, so try to stay away from sugar and carbs.

Other Causes of Panic...• Unstable blood sugar levels (hypoglycaemia) can be the result of poor eating habits, dieting

and fasting. • Over-breathing (hyperventilation) happens when you are under stress, though you may not

be aware of it. Your breathing becomes more rapid, in order to meet the body's demand for more oxygen for the muscles. As a result, you breathe out more carbon-dioxide than normal, which can bring on panic symptoms.

• Digestive problems, particularly food allergies, may be to blame. • Taking antidepressants, particularly the newer ones, may produce panic attacks, especially

at first. • Caffeine, cigarettes, alcohol, and certain street drugs (such as LSD, marijuana and cocaine)

can bring on a panic reaction. • Withdrawing from any drug that has a sedative effect, such as nicotine, alcohol and

tranquillisers, can do the same. • Some prescription medication, including some amphetamines, steroids, anti-asthma drugs,

and even nasal decongestants have been reported to increase anxiety. • Sometimes, problems with the way the brain works (known as organic brain dysfunction)

will cause balance, coordination and visual difficulties that make people very vulnerable to stress, and may contribute to agoraphobia.

• Being in chronic pain can be another cause of panic attacks, as can simple jet lag.

Last but not least....

Psychology!

Reference• http://www.ehow.com/about_5369635_testing-panic-disorder.html• http://www.nhs.uk/Conditions/Panic-disorder/Pages/Diagnosis.aspx• www.nhs.co.uk/anxiety• Images taken from Google• www.mentalhealth.org.uk• www.anxiety-and-depression-solutions.com• http://www.sciencedaily.com/articles/s/sympathetic_nervous_system.htm• http://www.nhs.uk/conditions/panic-disorder/Pages/Introduction.aspx• http://www.anxietypanicattack.com/• http://anxiety-panic.com/dictionary/en-dictc.htm• http://www.algy.com/anxiety/files/barlow.html• http://www.nomorepanic.co.uk/articles/symptoms/• http://www.dh.gov.uk/en/Healthcare/Mentalhealth/index.htm• ttp://www.nhs.uk/Conditions/Panic-disorder/Pages/Treatment.aspx• http://www.youtube.com/watch?v=Yt_IP93B2• http://www.dailymotion.com/video/xcez13_panic-attacks-what-is-anxiety-disor_techQE• http://www.patient.co.uk/health/Panic-Disorder-(Recurring-Panic-Attacks).htm• http://www.medicinenet.com/script/main/art.asp?articlekey=55001

• http://bvitamins.wordpress.com/vitamin-b12/• http://www.panicattackrecovery.com/vitamins_for_panic_attacks.html• http://www.youtube.com/watch?v=c_BgitzVKzw• http://www.youtube.com/watch?v=V08dWz5XNBA&feature=related

http://www.anxiety-and-depression solutions.com/insight_answers/gaba.php