Hope is faith holding out its hand in the dark.  -George Iles

Thursday, July 30, 2009

Triggers and Causes of Panic Attacks

▪ Long-term, predisposing causes — Heredity. Panic disorder has been found to run in families, and this may mean that inheritance plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it. Various twin studies where one identical twin has an anxiety disorder have reported an incidence ranging from 31 to 88 percent of the other twin also having an anxiety disorder diagnosis. Environmental factors such as an overly cautious view of the world expressed by parents and cumulative stress over time have been found to be causes.

▪ Biological causes — obsessive compulsive disorder, post traumatic stress disorder, hypoglycemia, hyperthyroidism, Wilson's disease, mitral valve prolapse, pheochromocytoma and inner ear disturbances (labyrinthitis). Vitamin B deficiency from inadequate diet or caused by periodic depletion due to parasitic infection from tapeworm can be a trigger of anxiety attacks.

▪ Phobias — People will often experience panic attacks as a direct result of exposure to a phobic object or situation.

▪ Short-term triggering causes — Significant personal loss, including an emotional attachment to a romantic partner, life transitions, significant life change, stimulants such as caffeine or nicotine, or other drugs such as marijuana and psilocybin, can act as triggers.

▪ Maintaining causes — Avoidance of panic provoking situations or environments, anxious/negative self-talk ("what-if" thinking), mistaken beliefs ("these symptoms are harmful and/or dangerous"), withheld feelings, lack of assertiveness.

▪ Lack of assertiveness — A growing body of evidence supports the idea that those that suffer from panic attacks engage in a passive style of communication or interactions with others. This communication style, while polite and respectful, is also characteristically un-assertive. This un-assertive way of communicating seems to contribute to panic attacks while being consistently present in those that are afflicted with panic attacks.

▪ Medications — Sometimes panic attacks may be a listed side effect of medications such as Ritalin (methylphenidate) or even fluoroquinolone type antibiotics. These may be a temporary side effect, only occurring when a patient first starts a medication, or could continue occurring even after the patient is accustomed to the drug, which likely would warrant a medication change in either dosage, or type of drug. Nearly the entire SSRI class of antidepressants can cause increased anxiety in the beginning of use. It is not uncommon for inexperienced users to have panic attacks while weaning on or off the medication, especially ones prone to anxiety.

▪ Alcohol, medication or drug withdrawal — Various substances both prescribed and unprescribed can cause panic attacks to develop as part of their withdrawal syndrome or rebound effect. Alcohol withdrawal and benzodiazepine withdrawal are the most well known to cause these effects as a rebound withdrawal symptom of their tranquillising properties.

▪ Hyperventilation syndrome — Breathing from the chest may cause overbreathing, exhaling excess carbon dioxide in relation to the amount of oxygen in one's bloodstream. Hyperventilation syndrome can cause respiratory alkalosis and hypocapnia. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms including rapid heart beat, dizziness, and lightheadedness which can trigger panic attacks.

▪ Situationally bound panic attacks — Associating certain situations with panic attacks, due to experiencing one in that particular situation, can create a cognitive or behavioral predisposition to having panic attacks in certain situations (situationally bound panic attacks). It is a form of classical conditioning. 

▪ Pharmacological triggers — Certain chemical substances, mainly stimulants but also certain depressants, can either contribute pharmacologically to a constellation of provocations, and thus trigger a panic attack or even a panic disorder, or directly induce one. This includes caffeine, amphetamine, alcohol and many more. Some sufferers of panic attacks also report phobias of specific drugs or chemicals, that thus have a merely psychosomatic effect, thereby functioning as drug-triggers by non-pharmacological means.

▪ Chronic and/or serious illness — Cardiac conditions that can cause sudden death such as Long QT syndrome; CPVT or Wolff-Parkinson-White syndrome can also result in panic attacks. This is particularly difficult to manage as the anxiety relates to events that may occur such as cardiac arrest, or if an Implantable cardioverter-defibrillator is in situ, the possibility of having a shock delivered. It can be difficult for someone with a cardiac condition to distinguish between symptoms of cardiac dysfunction and symptoms of anxiety. In CPVT, anxiety itself can and does trigger arrythmia.Current management of panic attacks secondary to cardiac conditions appears to rely heavily on Benzodiazepines; Selective serotonin reuptake inhibitors and/or Cognitive Behavioural Therapy. Although often this group of people experience multiple and unavoidable hospitalisations as without an electrocardiogram it can be difficult to differentiate between symptoms of panic attack and cardiac symptoms in those with these types of diagnosis.

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