Vegetative crisis (panic attack) - the first symptoms and treatment of a patient in this condition

A panic attack
is an inexplicable, painful attack of severe anxiety for the patient, accompanied by causeless fear, combined with various vegetative (somatic) symptoms.

Some [ specify

] Russian-speaking doctors use outdated terms “vegetative crisis”, “sympathoadrenal crisis”, “cardioneurosis”, “VSD (vegetative-vascular dystonia) with a crisis course”, “NCD (neurocirculatory dystonia)”, which reflect ideas about disorders of the autonomic nervous system and are not included in the ICD. depending on the leading symptom. “Panic disorder” (episodic paroxysmal anxiety), in turn, as an independent disease has worldwide recognition and is included in the International Classification of Diseases, 10th revision. According to ICD-10, a characteristic feature of panic disorder is “recurrent attacks of severe anxiety (panic) that are not limited to any particular situation or set of circumstances and, therefore, are unpredictable” [1]. At the same time, the presence of panic attacks does not necessarily mean that the patient has a panic disorder. Panic attacks can be symptoms of pheochromocytoma, somatoform dysfunctions, phobias, depressive disorders, post-traumatic stress disorder, endocrinological diseases, heart diseases, mitochondrial diseases, etc., or occur as a result of taking any medications (for example, Erespal). In the International Classification of Diseases, Eleventh Revision (ICD-11), panic attack has appeared as a separate symptom (code MB23.HMB23.H) and is included in the category of “symptoms or signs associated with appearance or behavior.”

To identify the severity of panic attacks, the Panic Disorder Severity Scale is used. This scale is also used in the form of a self-esteem questionnaire as a test for panic attacks[2][3].

Story

The word "panic" comes from the ancient Greek word panikos, named after the ancient Greek god Pan. According to mythology, Pan had a frightening appearance (he had horns and goat legs), he lived in the forest and had a habit of unexpectedly appearing before travelers, causing them great fear.

Image of Pan, 340-320 BC. e.

The ancient Greek philosopher Plato, in the dialogue “Timaeus,” suggested that the difficulty breathing characteristic of a panic attack is associated with an imaginary phenomenon called “wandering of the uterus.” (see Woman's uterus) in a woman's body: “in women, that part of them that is called the uterus, or womb, is nothing more than a beast that has settled inside them, filled with childbearing lust; when this beast is in season, and has not had a chance to conceive for a long time, it goes into a rage, roams throughout the body, constricts the respiratory tract and does not allow the woman to breathe.”

The ancient Greek physician Hippocrates associated anxiety symptoms with the theory of temperament, which depends on the ratio of 4 elements in the body (blood, lymph, black and yellow bile). Hippocrates explained the symptoms of anxiety as a state of melancholy (the spilling of “black bile”).

This idea of ​​the connection between anxiety and melancholy (that is, a depressive state) was preserved in medicine until the 17th century. For example, the English scientist Robert Burton in his book “The Anatomy of Melancholy” described the symptoms of a panic attack in a state of melancholy and identified the main sources of fear:

• fear of death
• fear of losing a loved one;
• paranoid anxiety;
• hypochondria;
• agoraphobia;
• claustrophobia;
• acrophobia;
• fear of events that will happen in the future;
• fear of public speaking.

Until the beginning of the 19th century, panic symptoms were considered a disease of the corresponding organs: for example, heart rhythm disturbances were considered a heart disease. For this reason, anxiety symptoms were treated by general practitioners rather than psychiatrists. In the mid-19th century, a connection between panic symptoms and psychological factors was established. Their study and treatment has become one of the areas of psychiatry. During this period, panic disorder was considered one of the manifestations of neurasthenia. Sigmund Freud was the first to suggest that panic disorder is not always associated with neurasthenia; he proposed a separate term “Angstneurose” to refer to anxiety disorders. At the beginning of the 20th century, it became widespread that panic attacks were associated, among other things, with hereditary factors.

In the 50s of the 20th century, drugs for the treatment of panic attacks (monoamine oxidase inhibitors, tricyclic antidepressants and benzodiazepines) appeared. Later, the effectiveness of SSRI antidepressants for the treatment of this disorder was proven.

In 1980, the diagnosis of panic disorder was introduced and was first mentioned in the DSM-III Diagnostic and Statistical Manual of Mental Disorders as a separate psychiatric diagnosis. In DSM-III-R (1987), agoraphobia was no longer a separate diagnosis, but was considered a consequence of panic disorder. The latter was divided into 2 types:

• panic disorder with agoraphobia;
• panic disorder without agoraphobia.

In addition, emphasis was placed on the importance of not only panic symptoms during an attack, but also phobic fear about the possible occurrence of new attacks. DSM-IV (1992) retained the previous definition of panic attack, but stated that panic symptoms may occur in disorders that do not meet clinical criteria for panic disorder. A division of three types of panic attacks has also been added:

• spontaneous attack;
• situational attack (due to agoraphobia);
• an attack caused by a specific phobia.

In the DSM-5 (2013), panic disorder and agoraphobia were classified into different categories[4].

Diagnostic methods

Determining the presence of a vegetative crisis is quite difficult even for an experienced specialist. To confirm the diagnosis, a comprehensive diagnosis is necessary, which includes a medical examination, assessment of reflex functions, ECG, pulse check, blood pressure, etc. Only after receiving the results can we make assumptions about the presence of a vegetative crisis in the patient. The disease can be accurately diagnosed only when the attack is over by excluding the following ailments and conditions:

• cardiac dysfunction - requires 24-hour cardiac monitoring, stress ECG, and cardiac ultrasound;
• stroke, brain tumors - CT and MRI are required;
• vascular crisis - encephalography and CT are performed;
• bronchial asthma – it is necessary to carry out breathing tests and skin tests to determine allergies;
• internal blood loss - you need an ultrasound of the peritoneal and pelvic organs;
• hypertensive vegetative crisis - CT or MRI is performed;
• mental disorders - examined by a psychiatrist.

When all of the listed pathologies are excluded and it is determined that the peak of the crisis occurs 10 minutes after the onset, and in addition an anxious feeling or deep-seated fear appears, the patient is diagnosed with a vegetative-vascular crisis.

In some cases, a similar diagnosis is given to children. The cause of this phenomenon may be psychological trauma or stress. As a rule, the development of a vegetative crisis in childhood is caused by quarrels in the family.

Symptoms

A panic attack is characterized by an attack of fear, panic or anxiety and/or a feeling of internal tension in combination with four or more of the following symptoms associated with panic:

1. Rapid pulse.
2. Sweating.
3. Chills, tremors, feeling of internal trembling.
4. Feeling of lack of air, shortness of breath.
5. Choking or difficulty breathing.
6. Nausea or abdominal discomfort.
7. Feeling dizzy, unsteady, lightheaded, or lightheaded.
8. Feeling of derealization, depersonalization.
9. Fear of going crazy or doing something uncontrollable.
10. Fear of death.
11. Feeling of numbness or tingling (paresthesia) in the extremities.
12. Insomnia.
13. Confusion of thoughts (decreased voluntary thinking).

There are other symptoms not included in the list: abdominal pain, fever, stool upset, frequent urination, sensation of a lump in the throat, gait disturbance, visual or hearing impairment, cramps in the arms or legs, motor dysfunction, high blood pressure.

Possible consequences

The vegetative crisis itself does not cause harm to health, but if attacks occur frequently, this is fraught with serious consequences. The patient begins to suffer from numerous phobias: fear of dying, being in a confined space, etc. Due to frequent attacks, heart function may be impaired, and sudden changes in blood pressure may develop. In addition, problems with the digestive organs and nerves may appear.

Fear of developing another attack can affect personal characteristics. Often such people try to communicate less with others, which is why they become withdrawn, and sometimes they may develop inappropriate behavior.

Clinical picture

The intensity of the main criterion for a panic attack (anxiety attacks) can vary widely: from a pronounced state of panic to a feeling of internal tension. In the latter case, when the vegetative (somatic) component comes to the fore, they speak of a “non-insurance” panic attack, or “panic without panic”. Attacks with a low level of emotional manifestations are more common in therapeutic and neurological practice. Also, the level of fear in attacks decreases as the disease progresses.

The duration of attacks can vary from several minutes to several hours, averaging 15-30 minutes. The frequency of attacks ranges from several per day to once a month. Most patients report spontaneous (unprovoked) attacks. However, active questioning makes it possible to identify, along with spontaneous attacks, also situational attacks that occur in potentially “threatening” situations. Such situations may be using transport, being in a crowd or confined space, the need to leave your own home, some stressful situations, etc.

A person encountering this condition for the first time becomes very frightened and begins to think about some serious disease of the heart, endocrine or nervous systems, or digestion, and may call an ambulance.

The patient’s interpretation of a panic attack as a manifestation of some physical disease leads to frequent visits to the doctor, multiple consultations with specialists in various fields (cardiologists, neurologists, endocrinologists, gastroenterologists, therapists), unjustified diagnostic tests and creates in the patient the impression of the complexity and uniqueness of his disease. Paying significant attention and accumulated misconceptions of the patient about the essence of the disease lead to the formation of hypochondriacal symptoms that contribute to the aggravation of the disease.

Internists, as a rule, do not find organic pathology and recommend visiting a psychotherapist. With the personal interest of the doctor, there are cases of overdiagnosis and prescription of treatment based on a false diagnosis. At the same time, sedative, vascular and metabolic drugs are often prescribed with an unreliable evidence base and unpredictable effects. In the most positive case, there are general recommendations related to lifestyle changes: rest more, play sports, don’t be overloaded with work, avoid stress, switch gears. There are often banal and formulaic prescriptions: take herbal sedatives (valerian, motherwort).

In most cases, panic attacks are not limited to one attack. The first episodes leave an indelible mark on the patient’s memory. This leads to the appearance of the anxiety syndrome of “waiting” for an attack, which, in turn, perpetuates the repetition of attacks. Repeating attacks in similar situations (transport, being in a crowd, etc.) contributes to the formation of restrictive behavior, that is, avoidance of places and situations that potentially lead to the development of panic attacks. Anxiety about the possible development of an attack in a certain place (situation) and avoidance of this place (situation) is defined by the term “agoraphobia.” The increase in agoraphobic symptoms leads to social maladjustment of the patient. Because of fear, patients may be unable to leave home and remain alone, dooming themselves to house arrest. The presence of agoraphobia in panic disorder indicates a more severe illness, entails a worse prognosis and requires special treatment tactics. Reactive depression can also join in, which also aggravates the course of the disease, especially if the patient cannot understand for a long time what exactly is happening to him, does not find help, support, and does not receive relief.

In terms of age categories, studies have shown that panic attacks are most common in people aged 25 to 64 years, but are more prevalent among 25 to 44 year olds. Sometimes panic attacks can occur against the background of endocrine instability in adolescence. The rarest cases occur in the group aged 65 years and older. In older patients, panic attacks have much less symptoms. A paroxysm may contain from two to four symptoms. At the same time, emotional components are most often well expressed. Sometimes the manifestation of panic attacks in old age can be a relapse or exacerbation of panic attacks that began at a young age[5].

What is a vegetative crisis, how is it classified?

A vegetative crisis is an extreme form of expression of VSD (vegetative-vascular dystonia), which is characterized by a disorder of the nervous system. In the International System of Classification of Diseases (ICD), this pathology is coded F 41.0.

The classification of vegetative crises is carried out according to several types, which is determined by the severity of the disease and the totality of the existing symptoms.

Depending on the severity of the course, a vegetative crisis can be:

• light – lasts a maximum of half an hour. Accompanied by minor but characteristic violations;
• medium – lasts about an hour. This form is characterized by multiple somatic disorders with the further formation of asthenia (neuropsychic weakness), which persists throughout the day;
• severe – lasting more than an hour. The appearance of various disorders is noted, accompanied by various paroxysms and the subsequent development of asthenia, which persists for several days.

In modern medicine, vegetative crises are also divided into 4 types in accordance with the symptoms that appear. According to this classification they are:

• sympathetic-adrenaline. Manifested by severe anxiety, discomfort in the heart, rapid pulse and high blood pressure;
• vagoinsular. The patient feels his heart sink, then notes the onset of weakness, lack of air, and a decrease in blood pressure;
• vegetative-vestibular. In this case, the person complains of dizziness, vomiting, which appears with a sudden change in posture: turning the head, bending over and other movements;
• hyperventilating. Manifests itself in the form of rapid breathing, increased blood pressure, dizziness, and muscle tone.

The occurrence of any vegetative crisis is acute and unexpected for a person. Sometimes it can appear at night. But such a phenomenon is not dangerous and does not threaten the patient’s life. Although at first glance the clinical picture is quite scary, the attacks always stop, so you should not be afraid of them.

Genetic predisposition

Currently, the genetic aspects of panic attacks are less studied than the genetics of disorders such as schizophrenia, bipolar disorder, major depressive disorder and autism. This is due, in particular, to the fact that panic attacks can occur with a significant number of diseases of a very different nature. In addition, there is no consensus on where the line between a panic attack and normal fear lies. It has now been established that an individual's risk of developing panic attacks is 5-10 times higher than the population average if his sibling has this disorder. In identical twins, the correlation between the risk of panic attacks reaches 100%, and in fraternal twins - up to 50%. In females, inheritance is more pronounced (up to 96%) than in males (21%)[6].

Preventive actions

There is no specific prevention that will help prevent the formation of the disease. Although there are recommendations on how to help the body quickly overcome attacks. To do this you will need:

• maintaining a healthy lifestyle, giving up alcohol;
• in the moments between attacks, you can take folk remedies that have a sedative effect (valerian, peony, motherwort in the form of tincture);
• Periodically visit a psychiatrist to develop stress resistance.

If you wish, you can overcome an attack of vegetative crisis. However, this will require strict adherence to your doctor's advice. Timely therapy is a serious prerequisite for eliminating the problem.

To undergo diagnostics and prescribe a course of treatment, contact our medical (formerly NDC) on Gakkelevskaya 33. Click the “SIGN UP” button, get advice from our specialists and come to us. We will help you cope with the disease.

Treatment

Panic disorder can be effectively treated with a variety of interventions, including psychological treatments and medication, with the strongest evidence suggesting that cognitive behavioral therapy has the most comprehensive and long-lasting effects when combined with the use of selective serotonin reuptake inhibitors. According to other data (a meta-analysis published in 1989, authors - RA Gould, MW Otto, etc.), cognitive behavioral therapy has a higher effect rate in comparison with pharmacological treatment and combination treatment (that is, psychopharmacology in combination with psychotherapy)[7].

Subsequent research by Barbara Milrod and her colleagues suggests that psychoanalytic therapy may be effective in reducing panic attacks, but these results should be taken with caution. Although the results obtained from treatments that include cognitive behavioral therapy and selective serotonin reuptake inhibitors are supported by many studies and meta-analyses, the psychoanalytic research results obtained by Barbara Milrod are not supported. The scientific validity of the psychoanalytic approach for the treatment of panic disorder has not yet been proven. In particular, the mechanisms by which psychoanalysis reduces panic are unclear, whereas cognitive behavioral therapy has a clear conceptual framework that can be applied to panic.

Benzodiazepines can also be used for panic attacks. The term "anxiolytic" has become almost synonymous with benzodiazepines because these compounds have been drugs of choice for stress-related anxiety for nearly 40 years.

Lifestyle change

Caffeine may cause or worsen panic anxiety. When you quit caffeine and other drugs, your anxiety may temporarily increase.

Intensified and regulated aerobic exercise, such as running, has been shown to have a positive effect in combating panic anxiety. There is evidence that this effect correlates with the release of exercise-induced endorphins and a subsequent decrease in levels of the stress hormone cortisol.

It remains possible that the increased breathing rate during aerobic exercise will cause panic symptoms to manifest or worsen. This increase in breathing rate can lead to hyperventilation and hyperventilation syndrome, which mimics the symptoms of a heart attack by causing a panic attack. Muscle relaxation techniques are helpful for some people. Although muscle relaxation has been found to be less effective than cognitive behavioral therapy in controlled trials, many people still find at least temporary relief with this technique.

Breathing exercises

In the vast majority of cases, hyperventilation occurs, exacerbating the consequences of a panic attack. Retraining breathing exercises help balance oxygen and CO2 levels in the blood.

Movement of the diaphragm during breathing

David D. Burns recommends breathing exercises for those who suffer from anxiety. One of these exercises is “5-2-5”. Using your stomach (or diaphragm) rather than your chest, inhale (feel your stomach rise rather than chest expand) for five seconds. When the maximum point of inhalation is reached, hold your breath for two seconds. Then exhale slowly for five seconds. Repeat this cycle twice and then breathe “normally” for five cycles (1 cycle = 1 inhalation + 1 exhalation). The key is to focus on your breathing and relax your heart rate. Regular diaphragmatic breathing can be achieved by expanding the exhalation through counting or humming.

Why does a vegetative crisis develop?

At present, the sources of this problem have not been fully investigated. Although some factors have been identified that can provoke the onset of a vegetative crisis. These include:

• tendency at the genetic level;
• hormonal imbalances (menopause, pregnancy, abortion);
• frequent stress, mental disorders (death of a loved one, difficulties with work or personal life);
• endocrinological pathologies;
• disturbances in the functions of the central nervous system;
• heavy physical activity;
• alcohol addiction;
• long-term treatment with potent drugs.

Scientists and psychotherapists have created a general description of subjects predisposed to this disease. Representatives of the weaker sex are more susceptible to vegetative crisis, who are characterized by the presence of:

• artistry;
• instability of thoughts;
• inclinations to dramatize any situation;
• constant expectation of troubles, fear of them;
• inadequate response to criticism;
• constant desire to improve your own figure.

It is precisely such people who are prone to developing unreasonable panic attacks, in which there is a feeling of anxiety and fear. Moreover, somatic symptoms are pronounced.

Notes

1. ICD-10: F41.0 - Panic disorder
2. Shear MK, Brown TA, Barlow DH, Money R, Sholomskas DE, Woods SW et al.
   Multicenter collaborative panic disorder severity scale (English) // American Journal of Psychiatry: journal. - 1997. - Vol. 154, no. 11. - P. 1571-1575. - doi:10.1176/ajp.154.11.1571. - PMID 9356566.
3. Panic Disorder Severity Scale - Self Report Form
4. Nardi AE, Freire RC, 2021, p. 2-7.
5. Autonomic disorders: Clinic, treatment, diagnosis. / Ed. A. M. Veina. - M.: Medical Information Agency, 2000. - 752 p.
6. Nardi AE, Freire RC, 2021, p. 162.
7. Kholmogorova A. B., Garanyan N. G., Nikitina I. V., Pugovkina O. D.
   Scientific research into the process of psychotherapy and its effectiveness: the current state of the problem. Part 1 // Social and clinical psychiatry. - 2009. - T. XIX, No. 3. - P. 92-100.