Disorders at which the manifestation of anxiety is the main symptom and is not limited to any particular external situation. Depressive and obsessive symptoms may also be present and even some elements of phobic anxiety, provided that they are undoubtedly secondary and less severe.

Panic disorder [episodic paroxysmal anxiety]

The characteristic feature of the disorder is the recurrent attacks of a sharply expressed anxiety (panic), which are not limited to any particular situation or complex of circumstances and, therefore, unpredictable. As with other disturbing disorders, the main symptoms includes a sudden appearance of heartbeats, pain for the sternum, a feeling of suffocation, nausea and a sense of unreality (depersonalization or delinealization). In addition, as a secondary phenomenon is often praised to die, lose control of oneself or go crazy. Panic disorder should not be used as the main diagnosis, if the patient had a depressive disorder at the beginning of a panic attack. In this case, the attack of panic is most likely, is secondary in relation to depression.

Panic (OE):

• attack
• state

Excluded: panic disorder with agoraphobia (F40.0)

Generalized anxiety disorder

Anxiety, which is common and sustainable, but not limited or predominantly caused by some kind of special circumstances (that is, freely floating, or "free-floating"). Dominant symptoms changeable, but include complaints about stable nervousness, fear, muscle tension, sweating, feeling of madness, trembling, dizziness and discomfort in the epigastric area. Often expressed fear of an accident or illness, which, according to the patient, expect him or his relatives in the near future.

Anxious (OE):

• reaction
• state

Neurosis anxiety

Mixed anxious and depressive disorder

tU rubric should be used in the case when anxiety is also present, and depression, but none of these states is prevalent, and the degree of severity of their symptoms does not allow when considering everyone to put a separate diagnosis. If symptoms and anxiety, and depression are so pronounced that they allow you to put a separate diagnosis of each of these disorders, both diagnoses should be encoded, and in this case this heading should not be used.

Anxious depression (light or unstable)

3740 0

A. Re-manifestable panic attacks of sudden, overgrown anxiety and somatic discomfort, arising, as a rule, spontaneously and not related to specific situations (objects) or a real threat to life.

B. Panic attack reaches a maximum for 10 minutes and can continue usually no more than an hour.

B. Panic disorder is not due to another mental disorder, somatic and neurological diseases.

G. Between attacks The condition should be relatively free from disturbing symptoms (although an alarming waiting for an attack is usual).

D. must be present during the panic attack of at least 4 of the following most common symptoms:
1) rapid heartbeat;
2) a sense of air shortness;
3) a feeling of suffocation;
4) dizziness;
5) sweating;
6) tremor, "inner trembling";
7) Burning, pre-perspective condition;
8) discomfort or chest pain;
9) nausea or other gastrointestinal symptoms;
10) paresthesia;
11) chills or tide of blood to face;
12) a sense of removal, separation from themselves (depersonalization) and a sense of remoteness, unreality (dealerialization);
13) fear of death;
14) Fear of loss of self-control, the fear of going crazy.

Clinical picture of PA can vary significantly,
In this regard, they allocate varieties of PA:
a) on the representation of symptoms:
. large (deployed) pa - 4 symptoms and more
. Small (symptomatic poor) - less than 4 symptoms.

Large attacks arise less often than small (1 time / month - week), and small can occur to several times a day.
b) by the severity of certain components:
. Vegetative (typical) - with the predominance of somategoetatic disorders and non-differency of phobias;
. hyperventive - with leading hyperventive disorders, reinforced breathing, reflexian apnea, paresthesias, pain in muscles related to respiratory alkalosis;
. Phobic - secondary phobias prevail in the structure of PA over vegetative symptoms, but are still not sufficient for the criteria of an alarm-phobic disorder. Occur when the joining of fear in situations, potentially dangerous, according to the patient, for the emergence of attacks;
. Affective- with depressive and obsessive symptoms or dysforial experiences;
. Deconsonizational and delaimal.

Numerous surveys, in combination with the ineffectiveness of treatment, strengthen their conviction in the seriousness of their condition, generate a negative attitude towards individual doctors and disbelief in medicine as a whole. If we consider that psychotherapy is not performed with patients or generally, psychotherapy is not explained, the essence of the symptoms that persist or often recurrent, the development of a patient of the hypochondriacity becomes quite explained, the search for numerous doctors, social deadaption.

The most frequent and clinically significant manifestation of vegetative dysfunction on the side of the bronchopulmonary system is the so-called hyperventive syndrome (DHW), characterized by a violation of the respiratory pattern in the form of inadequate metabolism of ventilation, accompanied by various clinical symptoms. The main pathogenetic mechanism of manifestations of hyperventilation syndrome is the alveolar and arterial hypocria, which itself does not necessarily cause symptoms, and manifests itself with individual sensitivity and impaired adaptation to chronic hypocrine.

The key to the diagnosis of DHW is the complaints of the patient who often put a doctor in a dead end that is not aware of such violations.

Basic clinical manifestation DHW is respiratory discomfort in the form of a sense of dissatisfaction with a breath, which patients describe as shortness of breath, a shortage of air and even suffocations. These sensations are usually enhanced in stuffy rooms, from close clothes. Bad tolerability of stuffed premises are peculiar to such patients.

They are characterized by frequent sighs and yawns, noted by the patients themselves or their surrounding. A constant desire to make deep breaths leads to the development of hypocris, which is accompanied by dizziness, suddenly coming weakness, fainted states, sometimes convulsions. Such symptoms can be involuntarily reproduced during the auscultation of patients, especially if the doctor underestimates and does not take into account the possibility of the presence of a DHW in a patient.

At the same time, with a clinical examination of the patient, physicians use a simple provocative sample with hyperventilation, offering a patient to make some quick and deep breaths, after which patients note the appearance of the above symptoms. Typically, patients suspected lung disease ( bronchial asthma, chronical bronchitis) or cardiovascular pathology, which entails the conduct of unjustified and non-informative surveys. Appointed at the same time drug treatment (nitrates, bronchopholics, etc.), as a rule, turns out to be ineffective.

Often, respiratory disorders are accompanied by cardiac symptoms (cardialgia, rhythm disorders), a sense of anxiety and fear, other manifestations of vegetative dysfunction, which aggravates the conviction of the patient in the presence of severe disease, sharply enhance the alarm-phobic symptoms

V.Tashlykov, D.V. Kovpak

The right medical name of panic attacks is "episodic paroxysmal anxiety." Panic attacks The code for the ICD 10 has F41.0. Disorder refer to the subsection of other alarming disorders of the neurotic subsection associated with stress and somatoforms. And he, in turn, refers to a section with mental disorders and behavior disorders. The full path to the section, where the panic attack is assigned to the ICD 10, - V: F00-F99: F40-F48: F41: F41.0. It should be noted that the disorder can be observed autonomously, but may be a secondary phenomenon in depressive disorder. Separately, one should select panic attacks in agoraphobia that have their own F40.0 code. In this case, PA is a form of expression of basic neurosis.

The duration of the bosic attack depends on several factors

Answer the question of how much the panic attack lasts exactly possible is not possible. The fact is that they are associated with primary and secondary signs. The latter refers to the effect of depersonalization and delaimalization, other subsequent experiences - the fear of die, go crazy, just fall into fainting, which can pursue the patient for a long time after completing the attack. Directly critical moment can be quite short - 10-20 minutes. However, its completion does not mean that the attack will not arise again, after a very short period of time.

In some patients, some of the somatic symptoms can be maintained for a long time after the attack. For example, after the panic attack headache or the pain in the heart area is saved. It also worsens the state and contributes to the development of many parallel neurosis. In this context, it is not so important how much the panic attack lasts in itself, and we need to keep on the general worsening of the patient's life.

Attacks that are denoted by the code F41.0 do not have a clear dependence on the circumstances. Attack can be overtaken anywhere and at any time. If someone had a panic attack after a meal, then a person can bind the disorder itself precisely with the welcome. But this is an illusion ... Tomorrow, the attack can occur completely in another place and under other circumstances.

A long time for PA was trying to explain the vegetaryous dystonia. However, being a common descriptive designation of a number of somatic diseases, IT cannot be an explanation, since we would try to explain some psychosomatic diseases by others. Operate the nature of the appearance of PA, just the case when they are associated with depression or agoraphobia. Both, in their endogenous forms, is a psyche disorder that is generated by some internal conflict. Most often, he can be expressed by the words about distrust. A person loses his confidence in his own body, to himself as a subject capable of living.

Even if the duration of the panic attack is small, some symptoms remain after the attack

So, in one patient, 28 years old panic attacks arose immediately after the death of the father, whom he loved very much. But the point is not that such an impact has provided stress. The guy suddenly met with death, with the fact that the person just smiled and made plans for the future, and after an hour it was not. Of course, he thought that he could die too at any moment. A powerful mental protest led the psyche to provoke this very death, which he was so afraid. But not in the form of suicide, but in the form of somatic - pain in the field of heart, rapid heartbeat, difficulty breathing. Reached the ridiculous. The young man was so afraid that she would now fall, which fell in advance. From this it covered shame. He locked in four walls without any agoraphobia.

Yoga on the contrary

The complexity of such situations is that the patient understands that he needs to change his attitude towards death and life issues, but another part does not want to do this. It is actually a dyewoman - it's not fantasy.

Pro suffering from this disorder can be said that they are some yoga on the contrary. Those are able to control their heart and breathing, biological processes in the body to achieve certain purposes. Thus, they implement their potential, strive for samadhi or enlightenment, pay attention to their health. In this case, the psyche force is mainly used. Here the power is exactly the same, but released on the arbitrary of fate.

Like a car with a sleeping driver. These people do not even think that something happens to their body. The heart actually beats very often, the hands are trembling, there is plenty of sweating. All the time how much the attack attack lasts patients are convinced that it makes no sense to make sure. When the doctor becomes counting the pulse, then will also detect 120 beats per minute. However, there are no signs of the disease of the cardiovascular system. All this makes the psyche of man. If you ask the patient to cause the same thing in his will, then he will not succeed.

Yoga classes help a person change his attitude to life and death issues

In addition to the main, additional symptoms may also be observed. For example, do not hurry with distrust of the girl, who believes that it is due to the panic attacks. In that way, to lose weight the patient can actually, only the reason for the attacks and weight loss is the same - mental disorder. This is not attacks something cause. They are only one of the forms of expressing internal conflict. Panic attack and weight loss are connected just like any body change in any neurosis or psychosis.

Treatment of panic attacks

PA treatment can be only integrated. The basis of its medication scheme is quite difficult to develop. The allocation of PA in the autonomous unit is fully justified, but does not mean that panic attacks with the code F41.0 on the ICD 10 Take place with people without internal conflicts perfectly. We can only talk about that earlier acute symptoms Not observed.

Currently it is assumed that almost the main form of psychotherapy in this case is the one that is based on a cognitive approach. Nothing in principle, in principle, against this direction, it should still be noted that this is not the only efficient way of work. A good positive effect can give bodily-oriented psychotherapy.

True, the very direction of the physician is a little shy, because it was initially associated with such concepts as bioenergy, which in science did not receive any official reinforcement. However, many methods and exercises are mainly working with breathing, give good positive results and for prevention and during attacks. No less effective should be the approach of existential psychology.

The assurance of the patients is that nothing happens to them that no one else from the panic attack can be and fairly, but does not have a special effect. First, it is still not entirely true. The physical sensations are quite concrete. Secondly, mental disorders are a medical problem, which is very even happening and not all patients, unfortunately, remain alive. Therefore, you need to start not with the assurance of people in the fact that they are all invented, but with the explanation of the nature of disorders. Even if you came up, how to be now?

1. It is understood that the psyche disorder is something that creates discomfort, but has its own positive functions. In any case, it is corrected.
2. Work with attacks. For example, learn to manage your condition with breathing exercises.
3. To understand what role this panic is playing in life. Fear can stop from something, saying that in life something is wrong.
4. Learn to pass through fear, be able to ignore it.

You need to learn to overcome your fear

As for medicines, their main role is to bring a person to the state when psychotherapy will be the most effective. Sometimes you can do without them. The duration of neurosis of this type can stretch for more than a year. But you do not need to lean very much. If, for example, someone has an agoraphobia with panic attacks, he cannot leave his apartment, then the quality of life will certainly be terrible. Medicines together with psychotherapy are able to bring a patient from the "black strip" in just a month. Everything else, he, depending on the situation, can continue to take drugs and only occasionally visit the psychotherapist.

Some special nutrition for panic attacks or additional procedures usually depend on individual preferences.

Panic attacks Participated in the international classification of diseases of the tenth revision ( mKB-10.). This directory is necessary as a single registry of diseases for doctors of all specializations.

Panic attack is placed in a section with mental disorders and behavior disorders (V, F00-F99). Subsection: Neurotic, associated with stress and

somatoform disorders (F40-F48): Other alarm disorders (F41): Panic disorder [episodic paroxysmal anxiety] (F41.0).

Thus, the full way to panic attacks on the ICD-10 looks like this: V: F00-F99: F40-F48: F41: F41.0.

The definition of panic attack or disorder in the ICD-10 sounds as follows (I give it literally): a characteristic feature of the disorder is the recurrent attacks of a sharply expressed anxiety (panic) that are not limited to any particular situation or complex of circumstances and, therefore, unpredictable. As with other disturbing disorders, the main symptoms includes a sudden appearance of heartbeats, pain for the sternum, a feeling of suffocation, nausea and a sense of unreality (depersonalization or delinealization). In addition, as a secondary phenomenon is often praised to die, lose control of oneself or go crazy. Panic disorder should not be used as the main diagnosis, if the patient had a depressive disorder at the beginning of a panic attack. In this case, the attack of panic is most likely, is secondary in relation to depression. Exception: Panic disorder with agoraphobia (F40.0).

As you can see, the panic attack on the ICD-10 may not only be isolated, but to include agoraphobia or depression.

Agorafobia (F40.0)

A fairly well-defined group of phobias, which includes fear of going out of the house, enter shops, fear of crowds and public places, fear alone to travel by train, by bus, plane. Panic disorder is an ordinary feature of episodes and in the past, and in the present. In addition, depressive and obsessive symptoms and social phobias are often present as an additional characteristic. Often the avoidance of phobic situations is often expressed, and the persons suffering from agoraphobia do not have great concern, as they are able to avoid these "dangers."

Depressive episode (F32.0)

In the lungs, medium or severe typical cases of depressive episodes in the patient, a reduced mood is noted, reducing the energeticness and the fall in activity. Reduced the ability to rejoice, enjoy, wondering, focus. The usual is pronounced fatigue even after the minimum effort. Usually sleep and reduced appetite. Self-assessment and self-confidence are almost always reduced, even with light forms of the disease. Often there are thoughts about their own guilt and uselessness. The reduced mood, a little changing day of day, does not depend on the circumstances and may be accompanied by so-called somatic symptoms, such as loss of interest in the surrounding and loss of sensations that make fun, awakening in the morning a few hours earlier than usual time, strengthening depression in the morning, expressed Psychomotor inhibition, anxiety, loss of appetite, weight loss and a decrease in libido. Depending on the number and severity of the symptoms, the depressive episode can be classified as light, moderately pronounced and heavy.

As a rule, when working with a panic attack, all the possibilities of its appearance and flow are considered at the primary conversation.

Other alarm disorders (F41)

Disorders at which the manifestation of anxiety is the main symptom and is not limited to any particular external situation. Depressive and obsessive symptoms may also be present and even some elements of phobic anxiety, provided that they are undoubtedly secondary and less severe.

The characteristic feature of the disorder is the recurrent attacks of a sharply expressed anxiety (panic), which are not limited to any particular situation or complex of circumstances and, therefore, unpredictable. As with other disturbing disorders, the main symptoms includes a sudden appearance of heartbeats, pain for the sternum, a feeling of suffocation, nausea and a sense of unreality (depersonalization or delinealization). In addition, as a secondary phenomenon is often praised to die, lose control of oneself or go crazy. Panic disorder should not be used as the main diagnosis, if the patient had a depressive disorder at the beginning of a panic attack. In this case, the attack of panic is most likely, is secondary in relation to depression.

Panic (OE):

• attack
• state

Excluded: Panic disorder with agoraphobia (F40.0)

Anxiety, which is common and sustainable, but not limited or predominantly caused by some kind of special circumstances (i.e., freely floating, or "free-floating"). Dominant symptoms changeable, but include complaints about stable nervousness, fear, muscle tension, sweating, feeling of madness, trembling, dizziness and discomfort in the epigastric area. Often expressed fear of an accident or illness, which, according to the patient, expect him or his relatives in the near future.

Anxious (OE):

• reaction

tU rubric should be used in the case when anxiety is also present, and depression, but none of these states is prevalent, and the degree of severity of their symptoms does not allow when considering everyone to put a separate diagnosis. If symptoms and anxiety, and depression are so pronounced that they allow you to put a separate diagnosis of each of these disorders, both diagnoses should be encoded, and in this case this heading should not be used.

Anxious depression (light or unstable)

The symptoms of anxiety are combined with the features of other disorders classified under the F42-F48 headings. At the same time, the degree of severity of symptoms of these disorders is not so heavy so that it is possible to diagnose if they are considered separately.

Panic disorder (episodic paroxysmal anxiety)

Definition and general information [edit]

Anxiety is known to everyone. Many experience it daily due to tense or dangerous work, permanent changes in life. Anxiety is a signal of threatening changes in the body or the outside world, and in this regard, it plays an adaptive role; However, if it is expressed excessively, then, on the contrary, interferes with normal life. A slight feeling of anxiety may occur not only when dangerous, but in general, with any changes and unexpected events. Anxiety is a sense of tension, expectations, discomfort, accompanied by some typical objective signs (rapid breathing, muscle tension, trembling, etc.). The most familiar state that occurs when the hazard appears and manifests the sweating of palms, nervous tremble, heartbeat. Another typical example is constantly concerned people, tense, pale, with an ever murred forehead. The common manifestations of the alarming states include obsessive images, thoughts and memories, nightmares, constant alertness, disturbed awareness of themselves or environment (depersonalization, dealealization).

Typical hazard reactions are the type of fighting and escape. The latter are rather diverse and include not only the response of avoidance (the desire does not fall into the threatening situation) and running off (the desire to exit the threatening situation without the struggle with the most dangerous), but also others, less common and worse. These include stupor and self-deception. Both in animals and in humans they can be purely external (an example of talking - a fixed attached animal, self-deception - a child hiding his head under a blanket in a dark room), but a person more often takes the nature of psychological protection (see ch. 1, p . I). In this case, they are manifested by various forms of distortion of reality, displacement, displacement and even dissociative disorders (see ch. 3, p. I.A.); The last more often develop when a person feels powerless before the threat or it comes from someone from loved ones. All this - methods of subconscious "ostrich" protection (by the way, in fact, the ostrich at the time of danger does not hide the head in the ground, but listens to it).

Anxiety arising from real external danger should be distinguished from natural fear. Anxiety in this case is called an exaggerated reaction that does not correspond to the degree of threat. In addition, anxiety develops when the source of danger is unclear or unknown. An example may be anxiety arising in response to a conditional stimulus, whose relationship with the most danger (with unconditional stimulus) is ousted or forgotten. Anxiety is also developing when a person feels helpless in the face of danger.

Anxiety is situational and endogenous, parole or continuous, most often - short-term. When it becomes so pronounced that it begins to interfere with life, an alarming disorder is diagnosed.

Based on clinical practice, the results of clinical trials and epidemiological data began to distinguish between anxiety as a reaction or a temporary state and permanent anxiety as a feature of the individual or manifestation of mental disorder. This made it possible to develop diagnostic criteria for alarming disorders, investigate their prevalence, clinical picture and social significance.

The incidence during the year is 1-2%. Women are 2-4 times more often. Most studies have revealed genetic predisposition. The average age of the beginning is 25 years; Approximately 75% of cases by 30 years, the picture of the disease is fully consistent with the diagnostic criteria.

Etiology and pathogenesis [edit]

Panic disorder is described as a separate disease about 20 years ago. Its main feature is panic attacks. These attacks arise spontaneously, without visible connection with external stimuli ("like a thunder among the clear sky"), last 5-30 minutes and are accompanied by a sense of panic horror. The spontaneity of panic attacks is recognized not by all: careful missing often helps to identify hidden provoking factors, missed during the hasty or incomplete collection of anamnesis. Horror with panic attacks may be so strong that disorientation, depersonalization and other psychotic phenomena arise. Patients are afraid to suffocate, go crazy, die. Secondary changes in the type of target reactions are often developed (see ch. 25, paragraph (i). Some are trying to prevent attacks with alcohol and psychotropic drugs.

The attacks often occur when patients are constrained in freedom of movement or believe that they cannot get help. They are rapidly under constant stress. Approximately 30% of patients with attacks occur in a dream when the level of carbon dioxide in the blood increases; In these cases, the patient wakes up in a state of panic.

Clinical manifestations [edit]

Panic disorder (episodic paroxysmal anxiety): diagnostics [edit]

Diagnostic criteria for panic disorders are presented in Table. 25.7. Additional symptoms should appear mainly during attacks. Panic attacks should not be secondary to any other disease.

Differential diagnosis [edit]

In most patients with panic disorder, attacks may be provoked by the introduction of sodium lactate, doxappara or isoprenaline V / B, caffeine or yohimbin inside, smoking marijuana or inhalation CO 2 at a concentration above 4-5%. Some of these samples are used to diagnose.

Panic disorder (episodic paroxysmal anxiety): treatment [edit]

1) Antidepressants. Highly efficient is imipramine, Mao inhibitors (phenlaylzine) and inhibitors of serotonin reverse seizure (fluoxetine, serralin, etc.). These funds prevent panic attacks, but do not stop them. Doses vary; Sometimes there is enough 2.5-5 mg / day fluoxetine or 10 mg / day imipramine inside, but more often to achieve the effect requires long-term treatment (sometimes up to 6 weeks). Side effects develop more often than when using benzodiazepines.

2) Benzodiazepines - preparations of choice both to reduce expectation alarm and to relieve panic seizures. The dose is chosen empirically. First, prescribe the minimum (taking into account the age, gender, weight and previously conducted treatment) dose. Then it is raised every few days until the effect or appearance of side effects. In the latter case, for a while, the dose is not raised or even reduced. Drowsiness and other sedative effects arising at the beginning of treatment, then often disappear; Apparently, this is due to the development of psychological adaptation or tolerance. In most cases, it is possible to pick up such a dose at which the effect is good, and the side effects are minimal.

Recently, alprazolam is widely used and investigated. In controlled tests, its high efficiency is shown to reduce the frequency and severity of panic attacks, reduce the anxiety of expectation and responses of avoidance. Currently, Alprazolam is the only benzodiazepine approved by the FDA with panic disorder. At the same time, there is evidence that clonezepams, diazepams, lorazepam and other benzodiazepines may be equally effective.

The available data allows you to control the treatment of alprazolam by measuring its serum concentration. With an average concentration of less than 20 ng / ml effect, there is almost no effect, and at a concentration of 20-40 ng / ml in most cases there is a distinct improvement in the overall state and a decrease in individual symptoms of anxiety. Some data indicate that in order to relieve spontaneous and provoked seizures, the serum concentration of alprazolam should exceed 40 ng / ml, but these data are not confirmed. An increase in the dose of alprazolam per 1 mg / day leads to an increase in its serum concentration of about 10 ng / ml. Thus, when taking alprazolem in a dose of 1 mg 3 times a day, a stationary concentration of about 30 mg / ml is achieved, which corresponds to the therapeutic level.

For other benzodiazepines, quantitative relationships between the dose (or serum concentration) and the effect are not yet established. Exemplary serum concentration ranges corresponding to conventional therapeutic doses, the following: diazepam - 300-1000 ng / ml (diazepam itself and the same concentration of desmethyldiazepam); Clossepat - 600-1500 ng / ml (desmethyldiazepama); Lorazepam - 20-80 ng / ml. In many situations, the definition of these indicators can be very useful. Thus, the ineffectiveness of treatment may be due to the individual resistance to the drug (in this case, its serum concentration will correspond to therapeutic) and its accelerated metabolism or disruption of medical prescriptions (plasma concentration will be reduced). The measurement of serum concentration of the drug also makes it possible to determine whether side effects (for example, fatigue) treatment or the disease itself are determined.

The duration of the treatment of benzodiazepines with panic disorder and the neurosis alarm depends on the course of the disease. If the attacks are provoked by known factors, and between the attacks the condition is satisfactory, then benzodiazepines can be assigned only as needed. With constant symptoms, long-term therapy may be required. Unfortunately, it is not yet established how long the continuing treatment of benzodiazepines should be. In most controlled test, therapy was carried out no more than a month, as it is necessary to assign one placebo for a larger period of inhumanly. However, individual long-term tests are still available, and they show that the anxiolytic effect of some benzodiazepines is preserved for 2-6 months. Additional proof is the results of controlled tests of the abolition of benzodiazepines: replacement of these means after long-term use on placebo often led to exacerbation or by abstinence syndrome (see ch. 25, paragraph iv.g.2.z). Finally, observations of patients who stopped receiving benzodiazepines, point to high frequency Exacerbations Even with a gradual decline in the dose.

Sometimes, a panic disorder and anxiety neurosis proceeds practically without remission, and in these cases constant therapy is often required. The FDA in its recommendations indicates that the use of benzodiazepines more than 4 months in a row is not studied and that during long-term therapy it is necessary to periodically assess the need for its continuation (this last recommendation is important not only with medical, but also from a legal point of view). In most cases, breaks are needed in the treatment of benzodiazepines. Every 4 months or more should be trying to gradually reduce the dose. In some patients, it is possible to completely cancel the drug, and others have an exacerbation, requiring the resumption of treatment. Periodic breaks in treatment can help reveal patients with constant anxiety, but a good effect of benzodiazepines; It is especially shown long therapy. Currently, the selection criteria for such patients are not defined, and it is not known what their share among all patients with disturbing disorders.

Side effects of benzodiazepines. Since 1960, benzodiazepines have become extremely widespread all over the world. Preparations of other groups are used in disturbing disorders less often; Their side effects are discussed in other chapters.

The side effects of any medicinal product must be distinguished from reactions arising against the background of its reception, but not necessitated directly, and from the symptoms of the disease itself.

Benzodiazepine derivatives act on GABA receptors associated with chlorine channels. Since GABA is a braking mediator, benzodiazepines have a nonspecific depressing, or sedative, effect on the central nervous system. It is the most frequent and predictable side effect Benzodiazepines. Its severity and duration after the administration of a single dose of benzodiazepine depends on this dose and, accordingly, on the concentration of the drug in the brain tissue and the degree of employment of receptors.

- A sedative effect can be manifested fatigue, lethargy or drowsiness. There is also disturbances of the concentration of attention, maintaining wakefulness and visual accommodation, slowdiness of thinking, ataxia, a malfunction of equilibrium. In a psychophysiological study, you can reveal a slowdown in the reaction, a decrease in the speed of execution of tasks and a violation of coordination of movements.

- fixing amnesia, apparently, is also due to the non-specific oppression of the CNS. There may be violations of both memorization and storage of new information. Usually, amnesia is characterized by anterograde - patients partially or completely forget what happened for some time after the next reception of the drug.

All these effects are temporary, reversible and disappeared after the abolition of the drug and its removal from the brain tissue. There are no clear data on the fact that the ability to cause a sedative effect is different from different benzodiazepines. In some studies, it is shown that drowsiness occurs more often in the treatment of benzodiazepines accumulating in the body with large T 1/2. At enough long use The sedative effect decreases due to tolerance due to apparently, the desensitization of receptors. In this case, an anxiolytic effect does not weaken.

Paradoxical effects of benzodiazepines have recently been given clearly excessive attention in the media. Very rarely when taking benzodiazepines, instead of calm, irritability and alentability are marked. It is possible that this action is not always true paradoxical: some sick alarm can be a mechanism for deterring the malice, and then the elimination of anxiety leads to the discharge of the malice. This effect is investigated mainly in psychological work with a quantitative measurement of the level of malice or hostility by testing. However, on the basis of these research, it is impossible to assume that benzodiazepines can cause astocal behavior in the form of threats, aggression, etc. There are also no scientific confirmations indicating that benzodiazepines can lead to violations of consciousness, impulsiveness, delusion, hallucinations , depersonalization and other psychotic phenomena.

Benzodiazepine cancellation syndromes are deterioration after the cessation of their reception. From a clinical point of view, it is important to distinguish three different cancellation syndrome.

1) Since with panic disorder and neurosis, alarm, as well as in insomnia (see ch. 21), benzodiazepines provide only symptomatic relief, after their cancellation in most cases an aggravation occurs (the former symptoms are resumed). It is usually not developing immediately, although it may come very quickly.

2) Rickest syndrome is also the resumption of symptoms, but in reinforced form. Typical examples are ricochetic anxiety and insomnia, especially after the abolition of a short-acting benzodiazepines, the ricochet syndrome lasts only a few days and can be replaced by exacerbation. It is important that it is not due to physical addiction.

Prevention [edit]

Other [edit]

Sources (links) [edit]

1. Harney, D. S., Woods, S. W. Benzodiazepine Treatment of Panic Disorder: A COMPARISON OF ALPRAZOLAM AND LORAZEPAM, J. CLIN. Psychiatry 50: 418-423, 1989.

2. Ciraulo, D. A., Antal, E. J., et al. The Relationship of Alprazolam Dose to Steady-State Plasma Concentrations. J. Clin. Psychopharmacol. 10: 27-32, 1990.

3. Cowley, D. S. Alcohol Abuse, Substance Abuse, and Panic Disorder. Am. J. Med. 92 (Suppl. Ia): 41S-48S, 1992.

4. Croft-Jeffreys, C., Wilkinson, G. Estimated Costs of Neurotic Disorder In UK General Practice 1985. Psychol. MED 19: 549-558, 1989.

5. Cross-National Collaborative Panic Study, Second Phase Investigators. Drug Treatment of Panic Disorder: Comparative Efficacy of Alprazolam, Imipramine, and Placebo. Br. J. Psychiatry 160: 191-202, 1992.

6. CURRAN, H. V. BENZODIAZEPINES, MEMORY AND MOOD: A REVIEW. Psychopharmacology 105: 1-8, 1991.

7. DAGER, S. R., ROY-BYRNE, P., ET AL. Long-Term Outcome of Panic States During Double-Blind Treatment and After Withdrawal of Alprazolam and Placebo. Ann. Clin, Psychiatry 4: 251-258, 1992.

8. Dietch, J. T., Jennings, R. K. Aggressive Dyscontrol in Patients Treated with Benzodiazepines. J. Clin. Psychiatry 49: 184-188, 1988.

9. FRIED, R. THE HYPERVENTILATION SYNDROME. Baltimore: Johns Hopkins, 1987.

10. Ghoneim, M. M., Mewaldt, S. P. Benzodiazepines and Human Memory: A Review. Anesthesiology 72: 926-938, 1990.

Panic disorder MKB-10

The main feature is repeated seizures of severe alarm (panic) that are not limited to a certain situation or circumstances and therefore unpredictable. As with other alarming disorders, the dominant symptoms vary from different patients, but the generals of unexpected heartbeat, chest pain, a feeling of suffocation, dizziness and a sense of unreality (depersonalization or delinealization) are common. The secondary fear of death, loss of self-control or madness is also almost inevitable. Usually attacks continue only minutes, although at times and longer; Their frequency and course of disorder are quite variable. In panic attack, patients often experience sharply growing fear and vegetative symptoms that lead to the fact that the patients hurriedly leave the place where there are. If this occurs in a specific situation, for example, in a bus or in a crowd, the patient may subsequently avoid this situation. Similarly. Frequent and unpredictable panic attacks cause fear to remain alone or appear in crowded places. Panic attack often leads to the constant fear of the emergence of another attack.

Diagnostic instructions:

In this classification, the panic attack arising in the established phobic situation is considered an expression of the gravity of phobia, which in diagnostics should be taken into account in the first place. Panic disorder should be diagnosed as a primary diagnosis only in the absence of any of the phobias in F 40.-.

For a reliable diagnosis, it is necessary that several heavy attacks of vegetative anxiety occurred over the period of about 1 month:

a) under circumstances that are not related to an objective threat;

b) attacks should not be limited to known or predictable situations;

c) between attacks the state must be relatively free from alarming symptoms (although anti-anti-alarm is usual).

Differential diagnosis:

Panic disorder must be distinguished from panic attacks. Arising as part of the established phobic disorders, as already noted. Panic attacks can be secondary to depressive disorders, especially in men, and if the criteria for depressive disorder are also detected, the panic disorder should not be established as a primary diagnosis.

Turn on:

Excluded:

panic disorder with agoraphobia (F 40.01).

www.psychiatry.ru.

Panic attacks. And how to get rid of them (Elena Skibo)

Hello, panically afraid and other readers of the book. I am practicing psychotherapy for almost 20 years, over the past 7 years there have been a lot of patients with a diagnosis of "Panic attacks". I want to tell you about panic attacks, and if you understand what I explained, and do some clear, accessible recommendations, then get rid of panic attacks. The result of psychotherapy: "I understood! I know what to do!". Warranties - 100%, if fully implemented recommendations.

• Knowledge

PA, definition, symptoms, ICD-10. Reactive depression. Atypical panic attacks

"Panic (from the Greek Panikon is scoreless horror) is a psychological state caused by the threatening impact of external conditions and expressed in a sense of acute fear, covering a person, an uncontrolled and uncontrolled desire to avoid a dangerous situation."

"Anxiety is a negatively painted emotion, expressing the feeling of uncertainty, waiting for negative events, hard-determined premonitions. Strong spiritual excitement, anxiety, confusion. The signal of the upcoming danger. Unlike the causes of fear, the reasons for the alarm are usually not realized, but it prevents human participation in potentially harmful behavior or encourages him to increase the probability of prosperous event of events. "

International Classification of Diseases-10

"The main feature is repeated seizures of severe alarm (panic) that are not limited to a certain situation or circumstances and therefore unpredictable. As with other alarming disorders, the dominant symptoms vary from different patients, but the common heartbeat, chest pain, a feeling of suffocation, dizziness and a sense of unrealism (depersonalization or delinealization) are common. The secondary fear of death, self-control or madness loss is also almost inevitable. Usually attacks continue only minutes, although at times and longer; Their frequency and course of disorder are quite variable. In panic attack, patients often experience sharply growing fear and vegetative symptoms that lead to the fact that the patients hurriedly leave the place where there are. If this occurs in a specific situation, for example, in a bus or in a crowd, the patient may subsequently avoid this situation. Similarly, frequent and unpredictable panic attacks cause fear to remain one or appear in crowded places. Panic attack often leads to the constant fear of the emergence of another attack.

In this classification, the panic attack arising in the established phobic situation is considered an expression of the gravity of phobia, which in diagnostics should be taken into account in the first place. Panic disorder should be diagnosed as a primary diagnosis only in the absence of any of the phobias in F40.-.

For a reliable diagnosis, it is necessary that several heavy attacks of vegetative anxiety occurred over the period of about 1 month:

a) under circumstances that are not related to an objective threat;

b) attacks should not be limited to known or predictable situations;

c) between attacks the state must be relatively free from alarming symptoms (although anti-anti-alarm is usual).

Panic disorder must be distinguished from panic attacks arising as part of the established phobic disorders, as already noted. Panic attacks can be secondary to depressive disorders, especially in men, and if the criteria for depressive disorder are also detected, the panic disorder should not be established as a primary diagnosis.

On the duration of the reactive state In a modern classification - "disorders associated with stress and impaired adaptation", allocate short-term (no more than 1 month) and prolonged (from 1-2 months to 2 years) depressive reactions.

Attack of acute alarm (panic) is accompanied by unpleasant physical sensations and psychological discomfort:

Heartbeat, rapid pulse, interruptions in the heart.

Pain or discomfort in the left half of the chest.

Feeling of lack of air, breathing, shortness of breath.

Sweating, tingling or numbness in hand and legs.

Chills, tremor, feeling of the inner trembling.

Nausea, discomfort in the stomach.

Feeling of dizziness or pre-corrupt state.

Fear to go crazy or commit an uncontrollable act.

The feeling of the unreality of what is happening.

As the panic disorder is weighted, the following changes occur: single seizures are moving into more frequent. New symptoms appear - a constant fear of health, the formation of avoiding behavior (a person ceases to go outside, ride in transport, reduces performance), planning each of his step, based on the fact that the attack can begin at any time.

In such situations, doctors neurologists, cardiologists, therapists put diagnoses:

"Vegeth-vascular dystonia" (VD);

"Anxious syndrome" or "anxious-depressive syndrome".

Diagnosis "Vegetoe Vascular Distonia" Describes somatic malfunctions in the vegetative nervous system. That is, the root of the problem is physiological disorders, and psychological problems arise later, as a result of this.

Diagnosis "Panic disorder" In the international classifier of diseases of the 10th publication is located in the column "Mental disorders and disorders of behavior". Which means: in the treatment of panic attacks, it is necessary to pay primarily a psyche, not physiology.

Intergreacy period for panic attacks It may proceed from several hours to several years. It is characterized by the following symptoms:

Permanent expectation of a new panic attack.

Hiking for doctors and carrying out a multitude of surveys.

Frequent repetitive thoughts about what happened, constant talk about their problems.

Search on the Internet information on panic attacks, visiting forums, "Zhoi's discharge".

Avoiding situations that can cause a panic attack attack, a change in the overall pattern of behavior, a change in lifestyle, restrictions on many activities.

Increased attention to their bodily signals.

The presence of drugs that can help buy an apparatus for measuring blood pressure, constant control of blood pressure.

The fear of the accumulation of people (transport, crowd).

Fear of open space or fear of closed spaces.

Fear of the fact that the attack can arise at any moment.

Gradual formation of depression.

Reactive depression - violation of the emotional sphere, which arises as a consequence of some serious stressful situation.

Among the most frequent reasons for reactive depression: the death of a loved one, a gap with a loved one, divorce, bankruptcy, financial collapse, loss of work, trial, large conflict at work, serious material losses, dismissal, sharp lifestyle change, moving, somatic disease, surgical intervention etc.

Symptoms of reactive depression:

Consistently reduced mood;

Loss of appetite and, as a result, weight loss;

Pessimistic attitude to life;

Inhibition in movements and mental reactions;

Headaches, malfunctions in breathing and other vegetative violations;

Constant concentration of consciousness on the accomplished event;

Deep despair, fear, thoughts about death.

Poslisiness to panic attacks.

Pathological education in childhood;

Features of functioning nervous system, temperament;

Personal characteristics (imperativeness, impressionability, impulsiveness, vulnerability, leaning to fixation on experiences);

Demonstrative and exteroidal accentuation of character;

Features of the hormonal background, disease of the endocrine system.

Atypical Panic Attack attack . A person may not experience the emotions of fear, anxiety; Such panic attacks are called "panic without panic", or "non-pershent panic attacks."

Manifested by the following symptoms:

Feeling of irritation (longing, depression, hopelessness);

Local pains (headaches, pain in the heart, abdomen, backs);

Feeling "Coma in the throat";

Feeling of weakness in hands or legs;

Violation of vision or hearing;

Nausea or vomiting.

After the first attack or the next attack of fear, a person goes to the hospital, turning first to the therapist, cardiologist, a gastroenterologist or a neurologist. It rarely gets to a psychiatrist prescribing neuroleptics, antidepressants, tranquilizers, from which the effect if it happens, then insignificant and short. Preparations are mostly devastating symptom, reduce the anxiety, but they do not eliminate the main cause of fear. And at best, doctors recommend to visit the psychotherapist, and at worst they treat non-existent diseases or bred hands and give "banal" recommendations: more relaxing, play sports, not nervous, drink vitamins, Valerian or Novopaalsit.

Treatment of panic attacks - the task of a psychotherapist, to which a person usually falls immediately, after the development of depression and deterioration of the quality of life. The earlier person in this case turn to a psychotherapist, the faster and easier will be treated.

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Only the memory of the experienced attack of panic is already alarming in a person who collided with him. And it is not surprising: after all, panic attacks are like "death in miniature." People who survived such noted "as if the body and the mind are disconnected," often in this situation in humans have some channels of information perception and communication with the outside world are closed, and it remains one for one with his fear. With all the wishes of others, a person suffers from panic attack just does not hear them, most often does not even respond to appeals.

Where does this state arise, and how to help him?

Feeling of fear or anxiety is familiar to any of us. With a sharp fright, heartbeat and breathing are rapidly, a feeling of dryness in the mouth appears - this is how the body is preparing to instantly respond to danger, and to protect themselves - if it takes. In a state of anxiety, sweating appears, sometimes pallor, nervous trembling. These processes, regardless of human consciousness, manages the autonomic nervous system. Thus, the human body has been helped by many centuries to avoid real danger or act as effectively in any stressful situation.

It is clear that the alarm and fear accompany our lives throughout its entire, and even help us - in the case when they are justified. But there are such conditions when anxiety from an ally turns into an enemy, and becomes a leading symptom that, on the contrary, prevents a person to act successfully in the surrounding world. Such cases, specialists are defined as alarming disorders, which include panic attacks.

What is behind the terminology

Terms "Panic Attack" and "Panic Disorder" are recognized at the world level, and included in International Classification Diseases of the 10th revision (ICD 10).

MKB 10 defines these terms as follows:

• Panic attack is an inexplicable, painful for a patient's attack of poor well-being, accompanied by fear or anxiety in combination with various vegetative (somatic) symptoms (cipher on ICD 10 F 41.0).
• Panic disorder is a mental disorder characterized by spontaneous emergence of panic attacks from several times a year to several times a day and the expectation of their occurrence (cipher on the ICD 10 F.41.041.0).

However, to determine such states, the doctors on the territory of the post-Soviet space still use other terms: "vegetative crisis", "cardioneeremosis", "sympathetic crisis", "Vegeta dystonia with crisis flow", "Neurocirculatory dystonia". It helps to understand that the roots of the problem still lie in the field of disorders of the vegetative nervous system.

Basic symptoms or signs of panic attack

These include: dizziness, pallor, numbness of limbs, sweating, elevated arterial pressure, Breathing difficulty, rapid pulse, nausea, perception disorder, chills, pain in the left side of the chest.

From the usual feeling of anxiety, this state is obviously different and the degree of severity, and the main thing - the lack of visible reasons for its occurrence.

Such attacks may occur in any situations, but most often occur in various public places, transport, as well as in closed spaces. Nevertheless, there is no visible reasons for panic - the life and health of a person or his loved ones at this moment does not threaten.

Causes of problems and risk group

In general, the causes of panic attacks are still not fully defined by specialists. As a rule, the main reason is considered a long-term residence of a person in psychotrauming conditions, sometimes assume that this syndrome may occur and due to the experience of a single severe stress situation. However, such an explanation does not give a response, why not every person who fell by the will of the case into traumatic circumstances, facing a panic attack.

Once the root of the problem lies in the functioning of the autonomic nervous system, it is obvious and the causes of the occurrence of panic syndrome should be sought in its characteristics. For example, such a concept as temperament describes the properties of the human nervous system (strong or weak, stable or unstable).

Obviously, a sanguine has a strong and stable nervous system where the symptoms of panic may arise less frequently than melancholic, the owner of an unstable and weak nervous system.

The properties of the nervous system may partly be inherited (therefore, the risk of obtaining panic syndrome is much higher for those people who have similar cases among family members). In addition, the state of the hormonal background may have a significant impact on the work of the nervous system. Often, panic attacks arise against other somatic disorders (work of the heart, pancreas and thyroid gland). Also, the abuse of alcohol and the "hangover" condition (abstineent syndrome) can be one of the factors of the occurrence of panic attack.

The factors listed above describe the individual properties of the nervous system and human health status. However, there are statistical data according to which the symptoms of panic disorder occur in total in 5% of the population, and in women, the attacks of panic attacks occur 3 times more often than in men. In addition, the average age of patients facing this disease - from 20 to 40 years. And it is not surprising. Indeed, it is in this age interval that key events occur, which determine the further life of a person, and having extremely high significance for it.

Classification

Three types of panic attacks are separated on the basis of the features of their occurrence:

• Spontaneous panic attack. Manifests itself suddenly, in the absence of reasons and circumstances predisposing to its appearance
• Situational Panic Attack. Arises when experienced arising against the background of any particular psychotrauming situation, or due to the fact that a person expects such a situation
• Conditional situational panic attack. Its occurrence is preceded by the effect of any chemical or biological "catalyst" - the use of alcohol, violation of the hormonal background, etc.

In addition, based on the peculiarities of the panic attack itself, panic attacks are divided into 2 categories: typical and atypical.

A typical panic attack proceeds in a complex with cardiovascular symptoms (interruptions in the work of the heart, tachycardia, heart pain, increased blood pressure). Also among the symptoms of typical panic attacks are distinguished by suffocity, nausea, fear of death, dizziness, coats of cold or heat.

Atypical panic attack has other symptoms: muscle cramps, hearing impairment or vision, gait disruption, "com in throat", vomiting, loss of consciousness.

Despite the abundance of similar symptoms, it is possible to distinguish a panic attack on a disease of a somatic nature. Panic attacks are characterized by increasing symptoms and reaching their peak for a short time interval (from 5 minutes to 1 hour, as a rule, the average duration of the attack is about 20-40 minutes). In this case, the emergence of attacks always occurs suddenly. As for the gaps between the attacks, they differ significantly from each of the patients, and can be from several days to several years. However, in the period between the attacks of the patient is subject to depression: the surviving horror makes a person with a huge fear to expect his repetition.

Since panic attacks have symptoms, so similar with a number of somatic diseases, there is a need for high-quality diagnostics, which only a doctor can hold.

If you are faced with a similar attack - a consultation of the therapist, cardiologist and neurologist is needed. It is also worth a survey at the endocrinologist and psychiatrist. Perhaps the treatment of someone from these specialists will be necessary - a panic attack occurs against the background of an already existing somatic disorder. After experts excluded other diseases, or conducted a course of treatment on a somatic disease - then it is necessary to refer to profile specialists who work with panic attacks.

Ways of help

There are several methods of treating and rehabilitation of a person having a panic syndrome. In accordance with this, there are a number of specialists involved in this process (psychologists, psychiatrists, psychotherapists). It is important to understand that a psychologist or psychoanalyst, for example, has no right to treat the patient to medicinely or diagnose. However, it can help with identifying and studying deep problems leading to panic. After all, panic attacks, the reasons for which lie in the depths of the unconscious, are not always amenable to drug therapy. In turn, the psychiatrist has the right to treat the patient, to diagnose, prescribe medicines.

There are situations where without the use of drugs can not do. This becomes a necessity for those patients who appealed for help not immediately, or when the frequency of attacks is very high.

In general, all methods of treating panic attacks can be divided into 2 categories:

• Methods allowing to cope with the attack directly during its flow
• Methods to prevent attacks or reduce the frequency of their occurrence.

In addition, there are medical and non-drug treatment methods (the latter refers to work with a psychologist, hypnosis, intake of medicinal herbs, respiratory gymnastics, relaxing baths and massages, methods of autotraining and meditation, treatment with homeopathic agents, compliance with a certain mode).

Medical treatment with panic attacks:

• to relieve the attack at the time of its flow, benzodiazepines are usually prescribed (for example, valium, diazepam (Sibaz), nitrazepam, quasapam and a number of others). Some drugs of this group (for example, clonazepams) can be used as preventive tools when panic attacks - regular phenomenon
• for the treatment of the disease as a whole, and in order to prevent subsequent attacks, antidepressants are used (paroxetine, sertraline, fluoxetine, cipralex, anatherapy, paxyl). Already in the first days of reception of these drugs, a feeling of anxiety decreases, but the maximum effect is achieved in 2-3 weeks after the start of the course. The course of treatment with antidepressants is about two months. Anxiolitics were also widely used (Afobazole was considered one of the most efficient). Auxiliary drugs may include vitamins, or agents that improve cerebral circulation (for example, phenibut).

The disadvantages of drug treatment methods themselves are addicted to the drug and not high efficiency (symptoms completely disappear only in 50% of cases). Once again it is necessary to remind you that only a doctor is entitled to treat with medicines. In no case begin receiving drugs yourself or on the advice of friends or acquaintances.

Non-drug methods provide an effect only with long-term use, however, the sustainability of the result is higher. It should be noted that among non-drug methods there are such where without the help of a specialist you can not do (hypnosis, group or individual psychotherapy, homeopathy). But there are also people who can master and apply without difficulty in everyday life. Remember that treating panic disorder is much more difficult than carrying out timely prevention of its occurrence.