To the Editor: In the Epidemiologic Catchment Area Program of the National Institute of Mental Health survey, panic attacks occurred in 28% to 63% of individuals with schizophrenia (1). Investigators have suggested that panic may be related in some way to paranoia (2, 3; unpublished report by Young et al., 1998). To further explore this intriguing connection, we report on a patient with self-described paranoid attacks.
Mr. A was a 42-year-old man who had had schizoaffective disorder since he was 22 years old; he had five hospitalizations for psychosis, depression, and suicidality. Early in his illness, he heard voices threatening to cut off his genitals. He became convinced that his neighbor wanted to shoot him, so he attempted suicide "to die before they could…torture me." Voices telling him that the Mafia was after him and that he was being watched and would be tortured continued episodically. Others sent their thoughts to him telepathically, he said. These symptoms were in good control on a regimen of clozapine, 200 mg/day, and lorazepam, 2 mg b.i.d., except when he had panic attacks.
Mr. A had panic attacks with severe anxiety, shortness of breath, choking, racing heart, sweating, dizziness, light-headedness, chest pains, a feeling that he might lose control or "blow up," and, occasionally, numbness and tingling. During these episodes, he had a return of paranoia, commonly reexperiencing the thoughts that his genitals would be cut off and that others were talking about him behind his back. He referred to these episodes as paranoid attacks.
Siris and colleagues (4) presented three patients with schizophrenia or schizoaffective disorder and panic, one of whom also described his panic-like attacks as paranoid attacks. Galynker and colleagues (5) described four patients in whom panic attacks were closely followed by, or coincided with, the development of psychotic symptoms.
What is the relationship between panic and paranoid attacks? Panic attacks appear to be sudden explosions of extreme anxiety, with a host of associated physiological components, including rapid heart rate and breathing, sweating, and the like. Panic attacks include a cognitive component, a feeling of dread attributed to a sense of impending catastrophe, loss of control, or "going crazy." These cognitive elements might be the mind elaborating while seeking to explain sudden, inexplicable fear. The paranoid thoughts expressed by a person with paranoid attacks likewise might represent the cognitive elaboration of a panic attack, the result of a mental search to attribute such danger to a suitably malevolent component of the environment. Perhaps panic and paranoia share some underlying biological substrate.
Are paranoid attacks the form that panic attacks take in certain psychotically vulnerable individuals? Other patients with schizophrenia have told us, when questioned, that they have paranoid attacks. The rate of panic episodes in schizophrenia may reflect the presence of such a process, because respondents responded affirmatively to the panic question on the National Institute of Mental Health Diagnostic Interview Schedule: "Have you ever had a spell or attack when all of a sudden you felt frightened, anxious, or very uneasy in situations when most people would not be afraid?" How common are they? This phenomenon deserves further consideration from several perspectives, including implications for etiology and treatment (3).