anticipatory anxiety

• n.

• 予期不安
• 予期神経症

WordNet

1. (psychiatry) a relatively permanent state of worry and nervousness occurring in a variety of mental disorders, usually accompanied by compulsive behavior or attacks of panic (同)anxiousness
2. a vague unpleasant emotion that is experienced in anticipation of some (usually ill-defined) misfortune
3. in anticipation (同)prevenient
4. one who anticipates (同)anticipant

PrepTutorEJDIC

1. 〈U〉(…についての)『心配』,不安,気がかり《+『about(for)』+『名』》 / 〈C〉心配事,心配の種 / 〈U〉《話》『切望』,熱望;〈C〉切望する事(物)
2. 予想の,予測の / 見越しての / (文法)先行の

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/02/08 18:09:42」(JST)

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For other uses, see Panic attack (disambiguation).

Panic attack
Classification and external resources
A person who is experiencing a panic attack, being calmed down and reassured by another person.
ICD-10	F41.0
ICD-9	300.01
MeSH	D016584

Panic attacks are periods of intense fear or apprehension that are of sudden onset and of variable duration from minutes to hours. Panic attacks usually begin abruptly, may reach a peak within 10 to 20 minutes, but may continue for hours in some cases. Panic attacks usually subside on their own over the next several hours.^{[citation needed]} Often, those afflicted will experience significant anticipatory anxiety and limited symptom attacks in between attacks, in situations where attacks have previously occurred.^{[citation needed]} The effects of a panic attack vary. Some, notably first-time sufferers, may call for emergency services. Many who experience a panic attack, mostly for the first time, fear they are having a heart attack or a nervous breakdown. Common psychological themes associated with panic attacks include the fears of impending death or loss of sanity; depersonalisation is relatively common.

Panic attacks are of acute onset, although acute debilitation (generally severe) may be followed by a period of residually impaired psychological functioning. Experiencing a panic attack has been said to be one of the most intensely frightening, upsetting, and uncomfortable experiences of a person's life and may take days to initially recover from. Repeated panic attacks are considered a symptom of panic disorder. Screening tools such as the Panic Disorder Severity Scale can be used to detect possible cases of disorder, and suggest the need for a formal diagnostic assessment.

Description

Sufferers of panic attacks often report a fear of dying or heart attack, flashing vision, faintness or nausea, numbness throughout the body, heavy breathing and hyperventilation, or loss of bodily control. Some people also suffer from tunnel vision, mostly due to blood flow leaving the head to more critical parts of the body in defense. At least four of these symptoms must be present for a person to be considered having a full blown panic attack.^{[citation needed]} These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the sympathetic "fight-or-flight response") in which the hormone which causes this response is released in significant amounts. This response floods the body with hormones, particularly epinephrine (adrenaline), that aid it in defending against harm.

A panic attack is a response of the sympathetic nervous system (SNS). The most common symptoms may include trembling, dyspnea (shortness of breath), heart palpitations, chest pain (or chest tightness), hot flashes, cold flashes, burning sensations (particularly in the facial or neck area), sweating, nausea, dizziness (or slight vertigo), light-headedness, hyperventilation, paresthesias (tingling sensations), sensations of choking or smothering, difficulty moving and derealization. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety, and forms a positive feedback loop.

Often, the onset of shortness of breath and chest pain are the predominant symptoms; the sufferer incorrectly appraises this as a sign or symptom of a heart attack. This can result in the person experiencing a panic attack seeking treatment in an emergency room. However, since chest pain and shortness of breath are indeed hallmark symptoms of cardiovascular illnesses, including unstable angina and myocardial infarction (heart attack), especially in a person whose mental health status and heart health status are not known, attributing these pains to simple anxiety and not (also) a physical condition is a diagnosis of exclusion (other conditions must be ruled out first) until an electrocardiogram and a mental health assessment have been carried out.

Panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature. They are often experienced in conjunction with anxiety disorders and other psychological conditions, although panic attacks are not usually indicative of a mental disorder.

Signs and symptoms

Diagnostic criteria

DSM-5 Diagnostic Criteria for Panic Attack: A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within minutes:

• Palpitations, and/or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or being smothered
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress

• Feeling dizzy, unsteady, lightheaded, or faint
• De-realization (feelings of unreality) or depersonalization (being detached from oneself)
• Fear of losing control or going insane
• Sense of impending death
• Paresthesias (numbness or tingling sensations)
• Chills or hot flashes

In DSM-5, culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Part or all of these symptoms can be found in the presence of a Pheochromocytoma.

Causes

• 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. The onset of panic disorder usually occurs in early adulthood, although it may appear at any age. It occurs more frequently in women and often in people with above average intelligence. 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 correlated with panic attacks.
• Biological causes — obsessive compulsive disorder, post traumatic stress disorder, hypoglycemia, hyperthyroidism, Wilson's disease, mitral valve prolapse, pheochromocytoma, and inner ear disturbances (labyrinthitis). Parasitic infection can cause psychiatric symptoms.
• 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 and, as seen below, stimulants such as caffeine or nicotine, 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 who 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 frequently present in those that are afflicted with panic attacks.
• Medications — Sometimes, panic attacks may be a listed side effect of medications such as 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 excessive 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. Examples of this include college, work, or deployment. See PTSD
• 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 nonpharmacological means.
• Chronic and/or serious illness — Cardiac conditions that can cause sudden death such as long QT syndrome; catecholaminergic polymorphic ventricular tachycardia 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. However, people in this group often experience multiple and unavoidable hospitalisations; in people with these types of diagnoses, it can be difficult to differentiate between symptoms of a panic attack versus cardiac symptoms without an electrocardiogram.

Pathophysiology

While the various symptoms of a panic attack may cause the person to feel that their body is failing, it is in fact protecting itself from harm. The various symptoms of a panic attack can be understood as follows. First, there is frequently (but not always) the sudden onset of fear with little provoking stimulus. This leads to a release of adrenaline (epinephrine) which brings about the so-called fight-or-flight response wherein the person's body prepares for strenuous physical activity. This leads to an increased heart rate (tachycardia), rapid breathing (hyperventilation) which may be perceived as shortness of breath (dyspnea), and sweating (which increases grip and aids heat loss). Because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon dioxide levels in the lungs and then in the blood. This leads to shifts in blood pH (respiratory alkalosis or hypocapnia), which in turn can lead to many other symptoms, such as tingling or numbness, dizziness, burning and lightheadedness. Moreover, the release of adrenaline during a panic attack causes vasoconstriction resulting in slightly less blood flow to the head which causes dizziness and lightheadedness. A panic attack can cause blood sugar to be drawn away from the brain and towards the major muscles. It is also possible for the person experiencing such an attack to feel as though they are unable to catch their breath, and they begin to take deeper breaths, which also acts to decrease carbon dioxide levels in the blood.

Classification

Agoraphobia

Main article: Agoraphobia

Agoraphobia is an anxiety disorder which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape. Panic attacks are commonly linked to agoraphobia and the fear of not being able to escape a bad situation. As the result, severe sufferers of agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place". The word "agoraphobia" is an English adoption of the Greek words agora (αγορά) and phobos (φόβος). The term "agora" refers to the place where ancient Greeks used to gather and talk about issues of the city, so it basically applies to any or all public places; however the essence of agoraphobia is a fear of panic attacks especially if they occur in public as the victim may feel like he or she has no escape. In the case of agoraphobia caused by social phobia or social anxiety, sufferers may be very embarrassed by having a panic attack publicly in the first place. This translation is the reason for the common misconception that agoraphobia is a fear of open spaces, and is not clinically accurate. Agoraphobia, as described in this manner, is actually a symptom professionals check for when making a diagnosis of panic disorder. Other syndromes like obsessive compulsive disorder or post traumatic stress disorder and Social Anxiety Disorder can also cause agoraphobia; basically any irrational fear that keeps one from going outside can cause the syndrome.

People who have had a panic attack in certain situations may develop irrational fears, called phobias, of these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with panic disorder are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. This can be one of the most harmful side-effects of panic disorder as it can prevent sufferers from seeking treatment in the first place.

Panic disorder

Main article: Panic disorder

People who have repeated, persistent attacks or feel severe anxiety about having another attack are said to have panic disorder. Panic disorder is strikingly different from other types of anxiety disorders in that panic attacks are often sudden and unprovoked.

Treatment

Panic disorder can be effectively treated with a variety of interventions including psychological therapies and medication with the evidence that cognitive behavioral therapy has the longest duration of effect, followed by specific selective serotonin reuptake inhibitors. However, subsequent research by Barbara Milrod and her colleagues has shown that psychoanalytic psychotherapy is equally effective in relieving panic attacks as behavioral approaches and has fewer relapses. A psychoanalytic approach that identifies actual but dissociated causes of panic reactions may lead to rapid disappearance of symptoms.

The term anxiolytic has become nearly synonymous with the benzodiazepines because these compounds have been for almost 40 years the drugs of choice for stress-related anxiety. Low doses of complete-agonist benzodiazepines alleviate anxiety, agitation, and fear by their actions on receptors located in the amygdala, orbitofrontal cortex, and insula. Administration of benzodiazepines during a panic attack may result in complete relief from symptoms in as little as ten or fifteen minutes. Benzodiazepines do not treat the source of the underlying fear but rather offer rapid-onset relief from the immediate symptoms.

Breathing exercises

In the great majority of cases hyperventilation is involved so that re-establishing an evenly measured diaphragmatic breathing pattern is appropriate, effective and rapid way to stop the attack. Regular breathing helps to rebalance the oxygen and CO₂ levels in the blood.

David D. Burns recommends breathing exercises for those suffering from anxiety. One such breathing exercise is a 5-2-5 count. Using the stomach (or diaphragm) - and not the chest - you inhale (feel your stomach come out, as opposed to your chest expanding) for 5 seconds. As you reach the maximal point at inhalation, hold your breath for 2 seconds. Then slowly exhale, over 5 seconds. Repeat this cycle twice, and then breathe 'normally' for 5 cycles (1 cycle = 1 inhale + 1 exhale). The point is to focus on the breathing, and relax the heart-rate. Regular diaphragmatic breathing may also be achieved by extending the outbreath either by counting or even humming.

Although breathing into a paper bag was a common traditional recommendation for attempting short-term treatment of the symptoms of an acute panic attack, it has more recently been criticized as inferior to measured breathing, even potentially worsening the panic attack, and possibly reducing needed blood oxygen. While the paper bag technique increases needed carbon dioxide and so reduces symptoms, it may at the same time excessively lower oxygen levels in the blood stream. To make matters worse, several studies now show a link between panic attacks and the abrupt increase in CO₂ from the paper bag method, so that use of the paper bag method itself may worsen feelings of panic in patients who might otherwise use measured breathing techniques with success.

Psychotherapies

According to the American Psychological Association, "most specialists agree that a combination of cognitive and behavioral therapies are the best treatment for panic disorder. Medication might also be appropriate in some cases". The first part of therapy is largely informational; many people are greatly helped by simply understanding exactly what panic disorder is, and how many others suffer from it. Many people who suffer from panic disorder are worried that their panic attacks mean they are 'going crazy' or that the panic might induce a heart attack. Cognitive restructuring helps people replace those thoughts with more realistic, positive ways of viewing the attacks.

In deeper level psychoanalytic approaches, in particular object relations theory, panic attacks are frequently associated with splitting (psychology), paranoid-schizoid and depressive positions, and paranoid anxiety. They are often found comorbid with borderline personality disorder and child sexual abuse. Paranoid anxiety may reach the level of a persecutory anxiety state.

Meditation may also be helpful in the treatment of panic disorders.

Dietary changes

Caffeine may cause or exacerbate panic anxiety. Anxiety can temporarily increase during withdrawal from caffeine and other various drugs.

Prognosis

Limited symptom attack

Many people being treated for panic attacks begin to experience limited symptom attacks. These panic attacks are less comprehensive, with fewer than 4 bodily symptoms being experienced.

It is not unusual to experience only one or two symptoms at a time, such as vibrations in their legs, or shortness of breath, or an intense wave of heat traveling up their bodies which is not similar to hot flashes due to estrogen shortage. Some symptoms, such as vibrations in the legs are sufficiently different from any normal sensation that they clearly indicate panic disorder. Other symptoms on the list can occur in people who may or may not have panic disorder. Panic disorder does not require four or more symptoms to all be present at the same time. Causeless panic and racing heartbeat are sufficient to indicate a panic attack.

References

Notes

UpToDate Contents

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• 1. 緩和ケアにおける不安の概要 overview of anxiety in palliative care
• 2. Approach to treating generalized anxiety disorder in adults
• 3. 死別および悲嘆：臨床的特徴 grief and bereavement in adults clinical features
• 4. Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis
• 5. Social anxiety disorder in adults: Epidemiology, clinical manifestations, and diagnosis

English Journal

• Consequences of anticipatory processing on cognitive symptoms of social anxiety.

• Mills AC1, Grant DM, Judah MR, Lechner WV.
• Anxiety, stress, and coping.Anxiety Stress Coping.2014 Jul;27(4):394-409. doi: 10.1080/10615806.2013.866229. Epub 2013 Dec 16.
• Anticipatory processing is an anxious style of repetitive negative thought associated with social anxiety (SA) that was proposed by Clark and Wells. Considerable research has examined factors of Clark and Wells' cognitive model of SA (e.g. attention, interpretation), but few studies have examined an
• PMID 24245523

• Sustained anxiety increases amygdala-dorsomedial prefrontal coupling: a mechanism for maintaining an anxious state in healthy adults.

• Vytal KE, Overstreet C, Charney DR, Robinson OJ, Grillon C.
• Journal of psychiatry & neuroscience : JPN.J Psychiatry Neurosci.2014 Jun 3;39(4):130145. doi: 10.1503/jpn.130145. [Epub ahead of print]
• BACKGROUND: Neuroimaging research has traditionally explored fear and anxiety in response to discrete threat cues (e.g., during fear conditioning). However, anxiety is a sustained aversive state that can persist in the absence of discrete threats. Little is known about mechanisms that maintain anxie
• PMID 24886788

• Electrical neuroimaging reveals content-specific effects of threat in primary visual cortex and fronto-parietal attentional networks.

• Rossi V1, Pourtois G2.
• NeuroImage.Neuroimage.2014 May 2. pii: S1053-8119(14)00344-9. doi: 10.1016/j.neuroimage.2014.04.064. [Epub ahead of print]
• Whereas effects of anticipatory anxiety on attention are usually assumed to remain largely undifferentiated, discrepant findings in the literature suggest that, depending on its content and causes, different modulatory effects on attention control and early sensory processing may arise. Using electr
• PMID 24793834

Japanese Journal

• Amygdala Response During Anticipatory Anxiety in Patients with Tension-type Headache

• The Showa University Journal of Medical Sciences 27(1), 39-48, 2015
• NAID 130005096785

• 高年初産の母親の産後1か月間におけるソーシャルサポートの体験

• 母性衛生 55(2), 369-377, 2014-07
• NAID 110009839050

• 新規制吐剤の使用開始前後における外来がん患者の予期性悪心の検討

• 医療薬学 40(3), 165-173, 2014
• NAID 130004894850

Related Links

• What Is Anticipatory Anxiety? - Anxiety Disorders Center ...

Anticipatory anxiety can occur when you're worried about confronting something that has scared you in the past. Learn how to overcome this anxiety issue. ... Rego describes anticipatory anxiety symptoms as “feeling ...

• Anticipatory anxiety - Anxiety UK

Anticipatory anxiety is where a person experiences increased levels of anxiety by thinking about an event or situation in the future. Rather than being a s

Related Pictures

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★リンクテーブル★

リンク元	「予期不安」
関連記事	「anxiety」「anticipatory」

「予期不安」

　　[★]

英

anticipatory anxiety, expectation anxiety

関

不安

「anxiety」

　　[★]

• n.

• 心配、不安、懸念
• 悩みの種、心配事
• 望み、切望、渇望
• (医)不安神経症

　 　 　

「anticipatory」

　　[★]

• adj.

• 予測的な

関

predictive, predictively