What happens during a panic attack in a patient with anxiety disorders and respiratory disease?

What Happens During a Panic Attack

A panic attack is an abrupt surge of intense fear or discomfort that peaks within 10 minutes, characterized by at least four physical and cognitive symptoms including palpitations, shortness of breath, chest pain, sweating, trembling, dizziness, feelings of choking or smothering, fear of dying, and fear of losing control. 1, 2

Core Clinical Features

Physical Manifestations

• Cardiovascular symptoms include palpitations, pounding heart, accelerated heart rate, chest pain or discomfort 2, 3
• Respiratory symptoms include shortness of breath, sensations of smothering, and feelings of choking 2, 1
• Neurological symptoms include trembling or shaking, dizziness, feeling unsteady, lightheaded or faint, and paresthesias (numbness or tingling) 2, 4
• Autonomic symptoms include sweating, chills or hot flushes 2, 3
• Gastrointestinal symptoms include nausea or abdominal distress 2

Cognitive and Psychological Features

• Fear of dying is a prominent cognitive symptom 2, 4
• Fear of losing control or "going mad" occurs during the attack 2, 4
• Derealization (feelings of unreality) or depersonalization (being detached from oneself) are dissociative symptoms 2
• The feeling of anxiety may actually recede into the background, with somatic symptoms dominating the presentation 4

Critical Distinction in Patients with Respiratory Disease

Overlapping Symptomatology

• Dyspnea in panic attacks manifests as "air hunger," "suffocating," "smothering," "cannot get enough air," and "breath does not go in all the way" 1
• These descriptors cluster together in panic disorder patients and overlap significantly with respiratory disease presentations 1
• Panic disorder is more common in patients with COPD than in the general population 1

Pathophysiological Mechanisms Unique to Panic

• Hyperventilation occurs both chronically and acutely in anxiety disorders, producing respiratory alkalosis rather than the metabolic acidosis seen in true respiratory compromise 5
• Patients with panic disorder demonstrate hypersensitivity to carbon dioxide, with CO2 inhalation capable of inducing panic attacks in susceptible individuals 5
• The mechanism involves excessive ventilatory drive or impaired perception of achieved ventilation even in the absence of reduced ventilatory capacity 1

Diagnostic Pitfalls in Patients with Comorbid Respiratory Disease

Medical Mimics That Must Be Excluded

• Thyroid disorders (particularly hyperthyroidism) produce anxiety, palpitations, shortness of breath, and increased perspiration that overlap with panic symptoms 1
• Cardiac arrhythmias can present identically to panic attacks 1
• Hypoglycemia and caffeine excess must be ruled out 1

Key Distinguishing Features

• Trigger pattern: Panic attacks are characterized by recurrent unexpected episodes, not solely triggered by respiratory exertion 2
• Temporal pattern: Symptoms develop abruptly and reach peak within 10 minutes, unlike the gradual worsening typical of respiratory decompensation 2, 3
• Response pattern: Panic symptoms often improve with reassurance and breathing techniques, while true respiratory compromise does not 1

Clinical Consequences and Complications

Immediate Sequelae

• Patients frequently present to non-psychiatric physicians with primarily somatic symptoms, leading to extensive cardiac and pulmonary workup 4, 6
• Up to one-third of patients with atypical chest pain and normal coronary angiograms have unrecognized panic disorder 6

Long-term Impact

• Agoraphobia develops as patients avoid situations where panic attacks occurred or where escape would be difficult 2, 6
• Increased prevalence of alcohol abuse occurs as patients self-medicate 4
• Depression is a common comorbidity 4
• Suicidal attempts are particularly concerning, with panic disorder associated with increased suicidal behavior 4

Assessment Approach in Patients with Respiratory Disease

Screening Strategy

• Use validated screening instruments rather than relying solely on clinical impression 1
• Assess for specific concerns including risk of harm to self or others, severe anxiety or agitation, presence of psychosis or confusion 1

Diagnostic Confirmation

• Medical and substance-induced causes must be diagnosed and treated first 1
• Confirmation requires meeting DSM-5 criteria: recurrent unexpected panic attacks plus at least one month of concern about additional attacks, worry about implications, or significant behavioral change 2
• Distinguish from normal anxiety responses which are developmentally appropriate and do not cause clinically significant distress or functional impairment 1

Critical Clinical Caveat

• Never dismiss symptoms because spirometry or other pulmonary function tests are normal - dyspnea predicts mortality more strongly than FEV1 in many conditions 7
• The presence of documented respiratory disease does not exclude panic disorder, as the two frequently coexist 1, 8