Sleep panic attacks

Mellman TA, Uhde TW (1989) Sleep panic attacks new clinical findings and theoretical implications. Am J Psychiatry 146 1204-1207... 

Labbate LA, Pollack MH, Otto MW, Langenauer S, Rosenbaum JF (1994) Sleep panic attacks an association with childhood anxiety and adult psychopathology. Biol Psychiatry 36 57-60... 

Social anxiety disorder is related to panic disorder in that panic attacks often accompany the symptoms. However, social anxiety patients only have panic attacks in particular social situations the attacks do not occur spontaneously when the patient is alone or sleeping. 

There has been a report of two patients with treatment-resistant PD who responded to treatment with olanzapine added to ongoing treatment with clonazepam (2 mg per day), ketazolam (30 mg per day), and venlafaxine (150 mg per day). The first patient was started on 7.5 mg at bedtime, and 2 weeks later he was much calmer and sleeping well. Olanzapine was increased to 12.5 mg per day, and venlafaxine was replaced with nefazodone up to 60 mg per day. Over the next few weeks, he improved progressively and clonazepam and ketazolam were discontinued. After 4 months, he was free from panic attacks and left his home alone. The second patient had 10 mg olanzapine daily added to ongoing treatment with 75 mg per day amitriptyline and 10 mg per day diazepam. After 2.5 months, she was being given olanzapine and had started going out on her own (126). 

Acute anxiety states panic attacks generalized anxiety disorder insomnia and other sleep disorders relaxation of skeletal muscle anesthesia (adjunctive) seizure disorders... 

A panic attack usually lasts from 5 to 30 minutes, with the symptoms peaking at about 10 minutes, but attacks have been reported to last for hours. A person must have at least 4 of the 13 symptoms listed in Table 9—6 for an episode to be classified as a panic attack. Panic attacks may occur during sleep, in which case they are known as nocturnal panic attacks. These attacks may wake the person from sleep but are otherwise similar in symptoms to daytime panic attacks. A majority of patients with panic disorder will experience nocturnal panic, but only a few patients describe having the majority of their panic attacks at night. 

Posttraumatic stress disorder (PTSD) is another anxiety disorder that can be characterized by attacks of anxiety or panic, but it is notably different from panic disorder or social phobia in that the initial anxiety or panic attack is in response to a real threat (being raped, for example) and subsequent attacks are usually linked to memories, thoughts, or flashbacks of the original trauma. The lifetime incidence of PTSD is about 1%. Patients have disturbed sleep and frequent sleep complaints. Comorbidities with other psychiatric disorders, especially depression and drug and alcohol abuse, are the rule rather than the exception. The DSM-IV diagnostic criteria are given in Table 9—11. 

BZDs such as chlordiazepoxide (Librium) or diazepam (Valium) may be prescribed to treat anxiety, seizures, acute stress reactions, and panic attacks, or to alleviate the side effects of drug or alcohol withdrawal. Those BZDs with a more sedating effect, such as estazo-lam (ProSom) or triazolam (Halcion), may be prescribed for short-term treatment of sleep disorders. However, the newer generation of non-BZD agents—zolpidem (Ambi-en) and (Sonata)—are less potentially addictive hypnotic drugs than the BZDs. 

CBT is an effective treatment for panic disorder, and has shown long-term efficacy [ 115]. CBT for panic disorder usually aims at preventing panic attacks and avoidance behaviors. However, there is a lack of data on the effect of CBT on nocturnal panic attacks. Sleep hygiene education and other CBT to reduce sleep-related worries and anxiety can be applied to avoid elevation of anxiety associated with sleep and to avoid maladaptive sleep-related behaviors that may further exacerbate sleep problems. 

Edlund MJ, McNamara ME, Millman RP (1991) Sleep apnea and panic attacks. Compr... 

Anxiety disorder (generalized anxiety disorder, panic disorder with panic attacks during sleep, post-traumatic stress disorder)... 

A 47-year-old woman with an 8-year history of nocturnal panic attacks and a recent history of major depression had a poor response to SSRIs and instead took a 0.1% tincture of St. John s wort. After 10 days she noted racing and distorted thoughts, increased irritability, hostility, aggressive behavior, and a reduced need for sleep. After discontinuing the herbal treatment, her symptoms resolved within 2 days. 

The patient has physical symptoms and behaviors suggestive of medical and psychiatric disorders, such as fatigue, concentration and cognitive difficulties, confusion, memory impairment, sleep and appetite disturbance, panic attacks, and ritualistic behaviors. 

The essential feature of this condition is chronic anxiety and worry. To the nonsufferer the focus of the worry often seems to be trivial, e.g. getting the housework done or being late for appointments, but to the patient it is insurmountable. The anxiety is often associated with other symptoms, which include restlessness, difficulty in concentrating, irritability, muscle tension and sleep disturbance. The course of the disorder is typically chronic with exacerbations at times of stress and is often associated with depression. Its chronic nature with worsening at times of stress helps to distinguish GAD from anxiety in the form of episodic panic attacks with associated anticipatory anxiety (panic disorder). Hyperthyroidism and caffeinism should also be excluded. 

Anxiety disorders may cause patients to complain about their sleep, cither because there is a reduction in sleep continuity or because normal periods of nocturnal waking arc somehow less well tolerated. Nocturnal panic attacks can make patients fearful of going off lo sleep... 

Much more common are such sjmptoms as confusion (13% of cases), depression (9% of cases, often requiring antidepressant drugs), and sleep disturbances (20% of cases). Vivid hallucinations are common. Psychotic sjmptoms appear to be more common when enzyme inhibitors are used or anticholinergic drugs given. Panic attacks seem to occur in some 20% of cases during the off phases of an off/on cycle (38). 

Panic disorder begins with the eruption of full-blown panic attacks—many of which (as mentioned earlier) occur "out of the blue" in low- or no-stress situations. Some individuals with panic disorder suffer from relatively infrequent attacks (a few per month) in more severe cases, attacks can occur several times a day and oftentimes even during sleep. The noradrenergic hypothesis holds that the intense, recurring attacks are caused by hypersensitive neurons in the LC or a dysfunction in the natural braking mechanism in the LC nerve cells or both (see figure 7-F). 

Mindy is a stylishly dressed, 25-year-old art director who is seeking treatment for panic attacks that have occurred with increasing frequency over the past year, often two or three times a day. These attacks begin with a sudden intense wave of horrible fear that seems to come out of nowhere, sometimes during the day, sometimes waking her from sleep. She... 

Although the etiology of autism is not understood, the defining or core symptoms of autistic disorder are considered to be impaired social interaction, impaired verbal and nonverbal communication, and restrictive, repetitive patterns of behavior. In addition, most patients with a primary diagnosis of autism exhibit other neurological or psychiatric symptoms, which may include seizures, sleep disorders, anxiety, panic attacks, attention deficit/hyperactivity, self-injury, and cognitive impairment (Simonoff et ah, 2008). It is not known to what extent these comorbidities reflect the primary pathology of autism and to what extent they represent unrelated vulnerabilities that are exacerbated by the impaired social interaction and communication that is characteristic of the disorder. 

Anxiety can be defined as a sense of apprehensive expectation. In reasonable amounts and at appropriate times, anxiety is helpful (e.g., anxiety before an examination may cause a student to initiate an appropriate study plan). Too much anxiety, however, can be deleterious. Anxiety can be considered pathological when it is either completely inappropriate to the situation or is in excess of what the situation normally should call for. An example of the former is nocturnal panic attacks—episodes of extreme anxiety that arise out of one of the most physiologically quiet times of the day, stage lll/IV sleep (64). An example of the latter is specific phobias—for example, an irrational fear to venture outside of one s home. 

The hormone melatonin induces sleep, but serotonin is involved in dreaming both are produced in the pineal gland. If the brain has low serotonin levels, dreaming will not occur. Serotonin is also important in learning, memory, and mood. It is deficient in the brains of depressed patients. Serotonin deficiency can result in an inability to fall asleep at night, panic attacks, loss of concentration, and thoughts of suicide or attempted suicide. 

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