Disease Panic

Origin of the word "Panic" 
It is from the Greek "panikon" whose meaning fright or dread repetitive. In Greek mythology the god Pan, who had horns and goat feet, excited with his appearance in the horror shepherds and peasants. Thus the word has in our language the meaning of fear or dread violent and repetitive.In Athens, have been erected on the Acropolis a temple to the God Pan, next to the Agora, the market square where the popular assembly met to discuss the problems of the city, and then derived the term agoraphobia, used in psychiatry and has meaning as the fear of open spaces. 
Synonymy 
Disorder, Disease, Syndrome, Panic Disorder. 
Introduction 
Panic Disorder (PD) is a clinical entity recently and was once called neurasthenia or cardiocirculatory disease of the heart of the soldier ( "irritable heart" designation given by Da Costa in 1860 during the American Civil War), although the first description of the symptomatology has been made by Freud, who classified as anxious neurosis. Until 1980, there was grouped under the heading of "anxiety neurosis" and now this same group was divided into Disease Panic and Anxiety Disorder or Acute Generalized. 
The clinical differences, which is why the derived subdivision of the group of acute anxiety reactions and TP, lie in the fact that the factors generating the first are motivated by external agents that threaten a clear and consistent individual's life such as disaster crashes in planes, trains, vehicles, fires in theaters and movies among others. 
In the disorder that triggers the "panic attack" outside agents often is absent and the threat is within the patient's own (endogenous). Both disorders is accompanied by great stimulus autonomic nervous system characterized by dry mouth, rapid heartbeat, palpitations, paleness, sweating and shortness of breath. This set of events describes what is called "alarm reaction" adapting the organism to situations of flight, fight or imminent danger. These findings constitute the basic elements for cogitena possibility that we are facing a patient with PD. 
The TP is a frequent cause of demand for psychiatrists and psychotherapists and is considered a disease of modernity linked to day stress. It is a real condition (some label as freshness) and disabling symptoms due to their extremely unpleasant. Only those suffering from PD is that he appreciates the intensity of their symptoms. 
The Big Problem 
This is due largely to the lack of TP by general practitioners (not psychiatrists) which determines the delay in diagnosis of the case and the consequent development of undesirable complications. 
The vast majority of patients because the prevalence of symptoms related to the cardiovascular system are treated in emergency rooms for clinical cardiology and / or cardiologists and treated with drugs that are not able to block the "crisis or panic attacks." As the crisis came in, without which patients observe improvement, leads to insecurity and despair. Examinations are often held without reaching a conclusive diagnosis and symptoms attributed to general situations as fatigue, nervousness, weakness or phrases such as "Mr (a) have nothing." 
Etiology (cause) 
Are considered possible 3 basic assumptions: 
• hyperactivity or dysfunction of systems related to neurotransmitters (chemicals responsible for transmitting nerve signaling between cells) related brain with various elements of early warning systems, reaction and defense of the central nervous system (CNS). 
• change is not well established in the CNS sensitivity to sudden changes in pH and CO2 concentrations intracerebral and / or hypersensitivity of postsynaptic receptors (distal zone of contact between two nerve cells), 5 hydroxytryptamine involved in the brain aversive system. 
• genetic 
Epidemiology 
Research in the United States show that for every 1000 individuals about 1 to 3 are affected by TP. 
In Brazil, unfortunately, the statistics are inconclusive. 
It occurs mainly in young adults aged between 20 and 45 years of both sexes, with a predominance of females in a 3:1 ratio. In this age group patients are in the fullness of their potential to work and make the disease are generated disastrous consequences facing both the professional and social. 
Diagnostic Criteria of PD 
The diagnosis is based on the following criteria on the Diagnostic and Statistical of Mental Disorders (DSM-IV) American Psychiatric Association: 
Recurrent panic attacks and unexpected. Criteria for Panic Attack: 
A short period of intense fear or discomfort in which 4 or more of the following symptoms appear abruptly and peak in about 10 minutes. 
• sweating 
• palpitations and tachycardia (rapid heartbeat) 
• trembling or shaking 
• feeling short of breath or smothering 
• feeling of choking 
• nausea or abdominal discomfort 
• feeling of instability, vertigo, dizziness or fainting 
• feeling of unreality (derealization) or depersonalization (estardistante itself) 
• fear of dying 
• fear of losing control of the situation or go crazy 
• paresthesia (sensation of tingling or anesthesia) 
• chills or hot flashes 
At least one of the attacks have been followed for 1 month or more than one or more of the following conditions: 
• persistent fear of having another attack 
• concern about the implications of the attack or its consequences (ie, loss of control, having a heart attack, going crazy) 
• a significant change in behavior related to attacks 
The Panic Attack is not due to the direct physiological effects desubstâncias (drug or drugs) and alcohol, yohimbine, cocaine, crack cocaine, caffeine, ecstasy or other general medical condition (hyperthyroidism, pheochromocytoma, etc ...) 
The attacks should not be a consequence of another mental illness, such as Social Phobia (exposure to social situations that generate fear), Specific Phobia (fear of flying, lift, etc. ...), Obsessive-Compulsive Disorder, Post-traumatic or Separation. 
The Attack and the TP 
We should note that there are diagnostic criteria for classifying a patient as suffering from PD and they should be well established. An episode of panic attack alone does not meet the conditions necessary for the diagnosis of PD. The symptoms that characterize the attack must be recurrent and not precipitated by an external event or situation. 
Differential Diagnosis 
If the diagnostic criteria are met there is great possibility that we are dealing with a case of TP, but how many signs and symptoms overlap with those of other organic diseases and psychiatric conditions, implies the need to establish the differential diagnosis: 
1. Organic Disease 
a. hyperthyroidism and hypothyroidism 
b. hiperpatireoidismo 
c. mitral valve prolapse 
d. arrhythmias 
e. coronary 
f epilepsy (especially temporal lobe) 
g. pheochromocytoma 
h. hypoglycemia 
i. labyrinthitis, neurological injuries 
j. abstinence from alcohol and / or other drugs 
To be assessed these diseases is extremely important clinical history and clinical evaluation, as well as become necessary laboratory tests (blood glucose, hormones, ácidovanil-mandelic acid, etc. ...), graphic (ECG, exercise test, Holter, EEG baseline with photo stimulation, hyperventilation, sleep deprivation and sleep, etc ...) and imaging (CT, MRI, echocardiography, etc. ...). 
SPECT (Single Photon Emission Computed Tomography), to take atualmenterealizado studies (scintigraphy as the regional cerebral blood flow, marked with radioactive contrast) has reveladoassimetria (right> left) in the lobostemporais gyrus and in the orbitofrontal cortex of the pre prefrontal dospacientes PD patients. 
Another important fact is that about 36 to 40% of patients with PD have associated mitral valve prolapse, revealed on echocardiography. 
2. Psychiatric Disorders 
• generalized anxiety 
• depression 
• depersonalization 
• somatoform 
• schizophrenia 
• character 
Complications and Interferences socio-economic and family 
The complications of repeated panic attacks induce excessive spending by patients with medical and laboratory tests, often dispensable. Away from work, absences, inability to accept promotion (for fear of assuming greater responsibility), and even resignations are situations in everyday life of these patients, especially if the TP is not diagnosed early and is accompanied by agoraphobia (fear of going places public and open). Adding to these facts there is a gradual economic deterioration. 
Socially, the successive refusals to invitations generate clearance and loss of social contacts. 
With regard to family relationship, the patient initially receives the care of relatives more closely involved. After several "pilgrimages" to doctors' offices, where the tests repeatedly show no palpable disease, family members adopt an attitude of encouragement for the patient to get out of the crisis. However, over time, this same patient becomes a target of criticisms paid not only the family but also friends who, unfortunately, only serve to exacerbate the situation. 
The development of agoraphobia occurs because patients come to the end of suffering another attack of panic where the previous one has already happened (theater or cinema for example). 
It should also be remembered as "anticipatory anxiety" (I'll have crisenovamente?) Reported by patients in performing complex tasks that simple as I take your car and drive to work. 
If the diagnosis and effective treatment are not established early greater isolation and the tendency not to leave. Iose weight is frequently observed. 
Treatment TP 
The primary factor in the initiation of treatment is effective blocking attacks or reduction in the frequency and intensity through the use of drugs and in this way (without the suffering the attacks) to allow other treatments. 
It is necessary to establish a good doctor-patient relationship, a therapeutic relationship and information. The knowledge by patients of their disease, evolution, possible side effects of drugs, the need for continued use of medication (dosage adjustment able to block attacks teráque be done) by the time required for the control of symptoms is imperative. Adverse effects of medications should be informed that there is no reason for frustration or guilt in close relationships. 
A. Drug Panic 
Although little known, but known to be effective, the mechanism of action of these drugs appear to exert their effects through actions at times seemingly antagonistic at the level of brain neurotransmitter systems, especially the noradrenergic and serotonin (neurotransmitters). The drugs increase the transmission of these substances anível brain as well as the decrease of its uptake. 
No treatment is known to use drugs that block the panic attacks as benzodiazepines, tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors deserotonina and selective serotonin and norepinephrine. 
Benzodiazepines: alprazolam and clonazepam 
Tricyclic antidepressants (TCAs): imipramine, clorimipramina, amitriptyline, nortriptyline 
Inhibitors of monoamine oxidase (MAO) inhibitors: tranylcypromine, moclobemide 
Inhibitors Selective serotonin reuptake inhibitors: sertraline, fluoxetine, paroxetine, fluvoxamine and citalopram 
Selective serotonin reuptake inhibitors of serotonin and norepinephrine: venlafaxine 
All medicines must be prescribed by doctors because they have efeitoscolaterais. 
There is considerable controversy about the time needed for maintenance treatment. Most authors admit to be the ideal duration between 6 months and two years later with the gradual withdrawal of the drugs and review whether the panic attacks recur. Although these criteria adopted the relapse rate after discontinuation of the drug varies between 20 and 50%. 
The patient should be informed that the onset of symptom improvement may take several weeks and depends on the adjustment of doses required to block the attacks, as well as its faithful adherence to therapy. This should be very clear to the patient to the patient with PD do not be anxious or depressed with the expectation of immediate improvement. 
B. Psychotherapeutic 
It is also of fundamental importance. Aims at maintaining adherence to therapy and guidance for the development and combat-related complications. The cognitive-behavioral techniques seem seras more effective in this direction, including increasing the response to drug treatment. 
As the panic attacks to succeed the patient develops hypochondria, phobias associated directly or indirectly with the circumstances in which the crisis has had, at baseline and anticipatory anxiety, agoraphobia, self-deprecation, depression, demoralization, alcoholism or drug usoabusivo. Any combination is possible and is independent of the characteristics although they are dependent on the severity and frequency of crises, as well as delay in diagnosis. The patient should be encouraged gradually (after the attacks blocked pharmacologically) to deal with places or situations where the attack by going this way and gaining self-confidence to face their adversities.