Panic Disorders
What is Panic? and Why Do People Panic?
In this entry I return to the age-old question of anxiety.
I want to discuss Panic Disorders, for one, because it is the most common question I hear from clients. The phenomenon of panic frequently is the impetus that brings clients into therapy. Anxiety or fear is tolerable, but panic is not. People fear the experience of panic because it inherently means “loss of control” and no one wants to lose control, especially when it is unpredictable.
What is the experience of panic?
Mary Has a Panic Attack:
I remember, it was about 10 years ago, I was traveling to New York. While there, I hailed a cab because I was trying to get to the airport. As I settled into the back seat, I remember it was in the afternoon, I noticed the car seemed unusually hot, dirty and the space was tight and confining. The driver's seat was so far back it was almost crushing me. I could smell the sweaty cab driver. I also sensed my heart beating faster, I started to perspire all over and then I felt light-headed. I wanted to take off my sweater because I was profusely sweating, but my arms seemed frozen.
Suddenly, I couldn't breathe and I felt this crushing pain in my chest. My vision seemed to narrow. I was sure something was terribly wrong. That’s when I had the thought that I was going to die. I thought, “How could I die, I’m in good health, only 38 years old?”
I sat there, suffering and feeling like a wet mop. My hair was wet from sweat. Then all of a sudden the driver stopped, turned, and said we had arrived. I remember he asked me if I could hear him, if I was alright. I said I was OK and after a few minutes, I dragged myself out of the car, the driver gave me my suitcase. My palms were sweaty, I was embarrassed, I thought everyone was looking at me. I took the suitcase and left. I recall I didn’t leave the driver a tip or anything. He deserved a tip, I was just too upset and disoriented to pull out my money satchel. I was still shaking and I wondered if I could make the flight home.
I sat down, started taking some deep breaths, got a bottle of water and drank the whole bottle almost in one gulp. Soon, I was feeling well enough to go through the check-in at the airport. I was glad there was a delay so I could regain my composure and return home.
When I got home I called my primary care physician and made an appointment for what I said was either anxiety or a heart attack. The physician ultimately ordered a complete physical and also a stress test and at the end of all of this was convinced I wasn’t having a heart attack. But, I do remember her saying, “I think you may have had a panic attack. Is anything in you life bothering you?”
I haven’t had anything like that again, but now I’m constantly afraid that I’m going to have another attack so I’ve started carrying a bottle of Xanax with me wherever I go. It’s kind of my security blanket in case another situation like that happens.
What is Anxiety?
I start again with anxiety because, after all, anxiety is at the root of Panic Attack.
The dictionary defines anxiety as: “A feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome.”
Of all the symptoms that bring a client to counseling, anxiety, by far, is the most common reason.
What is it about anxiety that makes it such a problematic symptom?
There are several reasons anxiety is perhaps the most compelling symptom for coming into therapy
Anxiety is exceedingly uncomfortable
Anxiety tends to remind us that we are mortal. That we will die.
Anxiety causes physiological problems and this is threatening to health.
Anxiety comes on very quickly, it catches us by surprise.
Anxiety is usually attached to conflict and conflict is the root cause of emotional turbulence.
Anxiety is difficult if not impossible to control at the time that it occurs.
Anxiety is unpredictable, we could feel OK at one moment and anxious at another.
If there is an emotional state to put a person in help-seeking moder, anxiety will do it. It is symptom frequently a symptom of something deeper in the psyche. Usually associated with conflict. Anxiety symptoms can be treated in and of themselves, through behavioral and cognitive reframing, and this will move it into the background. But, if the conflict remains, anxiety is likely to re-occur. Anxiety generally is a manifestation of conflict unexpressed. A person in a conflicted state feels nearly constant emotional turmoil. Although turmoil can be managed, it requires psychic energy to keep it in check. The anxious person has difficulty resting, feeling content, never at peace with ones self. Getting at the conflict is the best way to resolve it, but this takes time and usually effort on the part of the individual. We are all very good at putting things off, so many people live lives in a kind of quiet desperation.
As I review all of the diagnoses of people who have entered therapy, Generalized Anxiety Disorder, which is designated by DSM as: (GAD) DSM-5 300.02 or in the ICD-11 classification system as: (F41.1), is, by far, the most common. One could argue that almost everyone, at some time or another, experiences anxiety symptoms. I have experienced them myself many times over the course of my own life and they are not pleasant or easy.
Clients diagnosed with GAD may make statements like: “I was always a worrier: I feel keyed up and unable to relax. This unease will go for days and days, sometimes I feel keyed up constantly.” “I’m having trouble sleeping, I’m waking in the middle of the night, unable to fall back asleep.” “Doctor, my concentration is the problem, I can’t focus, read, or even work on the computer. Do I have ADHD?” Clients with GAD will anticipate worst-case situations, and when this happens it impairs all aspects of every-day life.
Who wouldn’t seek help from a therapist if they were experiencing these kinds of symptoms.
For Diagnostic purposes, all of the features I list below was be present in order to make a valid diagnosis of GAD:
Excessive anxiety and worry, occurring more days than not for at least 6 months, concerning a number of events;
Difficulty controlling general worry;
Worry are associated with at least three of the following six symptoms:
Restlessness, feeling keyed up or on edge.
Being easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
Anxiety, worry or physical symptoms cause clinically significant distress or impairment in important areas of functioning.
The disturbance is not due to the physiological effects of a substance or medical condition.
The disturbance is not better explained by another medical disorder.
How is Panic Related to Anxiety?
Let’s begin defining panic as it appears in the dictionary: A sudden overwhelming fear, with or without cause, that produces hysterical or irrational behavior, and that often spreads quickly through a group of persons or animals.
There are some key words that are essential for identifying panic from simple anxiety. These words are: “sudden” “overwhelming” “hysterical or irrational behavior” “spreads quickly” “persons or animals”
PANIC=ANXIETY
Panic is a specialized case of anxiety. I want to take these words that are distinctive for panic, one-by-one, and expand on them because these words are critical to understanding how Panic works and how Panic differs from Anxiety. I note again that panic is a subset of anxiety. That is, you cannot have panic without anxiety, but you can have anxiety without panic.
Panic is Sudden
Panic is sudden or all at once. It is associated with an immediate and marked physiological response that once started cannot be stopped until it runs its course. This means, if you experience a true panic attack, you will experience it from beginning to end and you are at the mercy of this powerful physiological response until it completes its physiological process. Few people understand this feature of panic, and even fewer know how to weather something that is this unexpected, usually brief (I mean lasting a few minutes to about an hour), usually strong, and generally leaving the person worn out or otherwise fatigued afterwards. Think of panic as a kind of emotional seizure.
Overwhelming
Panic doesn’t just impact one aspect of your physiology. It affects everything. It causes your body to sweat, it interferes with cognition, it impacts your balance, even at times your own consciousness. Think again about a grand mal seizure which impacts, in this case, only your brain, but the seizure affects your whole body: SEIZURE: “A sudden attack or convulsion characterized by generalized muscle spasms and loss of consciousness.”
Hysterical or Irrational Behavior
During panic the inclination is to freeze, then plan an escape. A profound awareness that “something is wrong” sets in. Symptoms appear during this awareness period such as racing heart rate, tingling fingers, numbness in hands, feeling overheated, sweating. In panic, the progression is fast and intense, so intense at times that it overwhelms the body. It is at this time that people think irrational thoughts: “I could be dying.” “My life is in imminent danger.” “Someone or something is chasing me.” “Something has got ahold of me.” The mind almost lashes out as a way to move you as fast as possible to escape or get out of the situation. The body does not want to stay at this level of heightened arousal very long. Being hysterical is experiencing: “emotionally charged thoughts that seem excessive and out of control.”
Spreads Quickly
Panic spreads quickly, in fact, a defining feature of a panic attack is its suddenness. The instantaneous feature of panic makes the disorder susceptible to anticipatory fear. People will do all kinds of things to “avoid” even the possibility of panic. Mostly, because panic is so uncomfortable, so disruptive, so punishing, that even the thought that one “might” experience a panic attack is enough, by itself, to trigger a panic attack.
Persons or Animals
All animals panic or show a panic response to grave threat. You’ve seen this if your pet cat, Fluffy, is frightened. Panic as when the animal “plays dead” or “becomes immobile.” Panic is an ultimate method to ward off threat (it’s akin to a human black out during).
In the 1920’s, Walter Cannon, a Harvard Professor of Physiology, coined the idea of a “fight or flight response.” Experimenting with laboratory mice, Cannon discovered that when faced with threat, mice engaged a specific brain mechanism (involving the excretion of adrenaline) that bypassed higher-order processes over a pronounced physiological response. Something akin to pulling a biological fire alarm to set off a cascade of immediate reactions. The consequence is a general discharge of the sympathetic nervous system, priming the animal to fight or flee.
Below is a causal model descriptive of panic. This looks like a complex picture, but there are important components in this model that highlight unique features of panic.
The only direct pathway to panic is through “body sensations” or biological processes. Early life events (far left) don’t directly cause panic, it is the body appraisal of an early life event that causes panic. This is why people commonly report. “I was just crossing the street and all of a sudden I’m hit with panic.” Panic, as this picture portrays, is an intra-psychic process that occurs when a person is in a state of turmoil. Sometimes the person is aware of this turmoil, and sometimes not.
Panic doesn’t need to have an anxiety build-up, but it is frequently stimulated by an acute stressor (someone comes after you with a knife. This is a stressor that could cause panic). When you see someone with a knife (you perceive the knife as a threat - bodily sensation), then you have a behavior response (panic). There is really no need for appraisal in this case.
With appraisal you might see that the knife is a “pocket knife” and you might appraise the person as cleaning under his fingernails versus attacking you with a pocket knife, then you would not likely experience panic at seeing a knife. Unless, of course, you’ve had a previous trauma with a knife, then appraisal could be blocked or shattered and the move from biological to behavioral would be without appraisal. In this case, it wouldn’t matter what kind of a knife it was or why you are seeing it, the knife is enough of a trigger to cause a panic attack.
The Physiology of a Panic Attack
What happens to you psychologically when you experience a panic attack?
This diagram is a good outline of the panic process as it unfolds. The focus of this diagram is when long-term stress or worries in an anxious mind with a reactive physiology triggers a panic attack. The first active step is when there is a misinterpretation that something is very wrong, which immediately escalates to a flight-fight response where the brains begins to secretes hormones such as adrenaline (and secondarily cortisol). The feeling of panic is almost instantaneous and this feeling, itself, can stimulate a further acceleration of stress hormones. As this is happening, there is no place to run or escape, and no obvious threat of harm, but still, the feeling intensifies (seemingly out of control) until the anxious state itself becomes the source of fear. The spiral builds quickly from this rapid feedback loop, happening in seconds, so before the person is conscious of it, the stress feelings (light headedness, blurred or muted vision, rapid heartrate, and so forth) have already started overtaking the body and since there is no way for the person to run or slough off these hormones it starts to overwhelm the individual with symptoms.
Panic attack is still, fundamentally, a subjective experience. It is different from the experience of free-floating anxiety primarily due to its intensity and suddenness, otherwise it would be no different than experiencing a worry or anxious state. The same biological processes are in play regardless if it is Generalized Anxiety or Panic. But, people really fear panic. It seems a life-threatening condition as it occurs. This is why many people misjudge (or misperceive) panic attacks as “heart attacks” or “stroke” even though the actual process of these cardiovascular diseases are different and ultimately not lethally harmful to the body. Losing consciousness is the worst-possible end-state in panic attack. This is terrifying enough, however, to cause people to feel great anticipatory fear of a panic attack once they have first experienced it.
Circadian Rhythm Disruption in Panic
Disruption of Circadian Rhythms pre-disposes people to anxiety and panic attack.
As mammals, human beings are tied to circadium rhythms which is our internal biological clock. More precisely, circadium rhythms are internal bodily manifestations of the solar day. We are at our healthiest, even at a molecular level, when our body can sleep and our brain is allowed to reset itself on a normal 24-hour light-dark cycle pattern. Recent science has argued that we have a master clock to the entire body mediated through a brain structure labelled the hypothalamus (I discuss this in greater detail in the Seasonal Affective Disorder entry).
In the pre-technology age, people were exposed to minimal light at night and full light at day. In the 21st Century, especially in 1st World Societies, this, of course, is no longer the case. Continuous light exposure at night disrupts these circadian patterns. This phenomenon has given rise to a number of unintended negative consequences. Seasonal affective disorder in which mood oscillates between dysthymia during the short day lengths of winter and euthymia during the long summer days is just one. With sleep disrupted, all kinds of mental health disorders proliferate. Major depression is one with the formal label SAD (or seasonal affective disorder). Generalized anxiety, and susceptibility to panic are high on the list of issues that are linked to circadium rhythm disruption.
I raise this point here because finding ways for individuals with panic attacks to reset a regular day and night routine appears critical in the long-term recovery from panic attack disease. I will discuss this issue further in the treatment section of this entry.
Measuring Panic Attacks
There are published instruments, surveys, checklists, and tests that assess clients who experience symptoms of panic attack. I’ve copied the “Severity for Panic Disorder” test from the American Psychological Association public domain test registry. It is a short and clear instrument that highlights the precursory and ongoing symptoms of panic. It doesn’t delve into the reasons a person is experiencing panic, but it does identify the main symptoms of panic attack. There is also a scoring formula I’ve copied below so that you can score yourself. There are no norms, per se. on this test, but an average score above 5 (summed items and averaged) would be indicative of a panic disorder and would probably need additional testing and treatment.
Severity Measure for Panic Disorder (American Psychological Association)
The following questions ask about thoughts, feelings, and behaviors about panic attacks. A panic attack is an episode of intense fear that sometimes comes out of the blue (for no apparent reason). The symptoms of a panic attack include: a racing heart, shortness of breath, dizziness, sweating, and fear of losing control or dying. Please select one item for each question below:
1 Felt moments of sudden terror, fear, or fright, sometimes out of the blue (i.e., a panic attack)
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
2. Felt anxious, worried, or nervous about having more panic attacks.
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
3. Had thoughts of losing control, dying, going crazy, or other bad things happening because of panic attacks
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
4. Felt a racing heart, sweaty, trouble breathing, faint, or shaky
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
5. Felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
6. Avoided, or did not approach or enter, situations in which panic attacks might occur
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
7. Left situations early, or participated only minimally, because of panic attacks
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
8. spent a lot of time preparing for, or procrastinating about (putting off), situations in which panic attacks might occur
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
9. distracted myself to avoid thinking about panic attacks
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
10. needed help to cope with panic attacks (e.g., alcohol or medication, superstitious objects, other people).
0=Never
1=Occasionally
2=Half of the time
3=Most of the time
4=All of the time
Each item on the measure is rated on a 5-point scale (0=Never; 1=Occasionally; 2=Half of the time; 3=Most of the time, and 4=All of the time). The total score can range from 0 to 40, with higher scores indicating greater severity of panic disorder.
The raw scores on the 10 items should be summed to obtain a total raw score. In addition, the clinician is asked to calculate and use the average total score. The average total score reduces the overall score to a 5-point scale, which allows the clinician to think of the severity of the individual’s panic disorder in terms of none (0), mild (1), moderate (2), severe (3), or extreme (4).
How to Treat Panic Attacks
I bring this point up because most of the people who experience panic attacks, in my experience, often don’t know what it is. On reflection, these people frequently have: a history of disrupted sleep, a period of time when their sleep-wake cycle was substantially altered (airline pilots, emergency room physicians, a job where they are working across international datelines and getting up or retiring early or late, etc.).
First Step in Treatment
In my practice, one rule of thumb for dealing with panic attacks is to encourage the client to:
Get back to a place (usually home) where you feel secure. This encourages the client to immediately reduce external stress (even routine stress)
Pharmacologically or behaviorally, engineer a few nights where you get “more than enough sleep.” The goal here is to reset your physiology after a panic attack
Start a temporary program of sleeping and waking on a regular schedule.
Further Steps in Treatment
Someone physiologically prone to panic attacks can be difficult to treat. For one, the individual is likely someone who has “learned,” for good or bad, that it is essential to be alert “all the time.” One might think that this could be due to a previous trauma or catastrophic event. This, in fact, may not be the case. Human beings don’t necessarily need to be directly exposed to a catastrophic personal even to feel traumatized or to train themselves to be alert 24/7. Think about movies that embed traumatic events into the storyline to entertain the audience. Who hasn’t screamed, flinched, closed their eyes to an exciting or scary movie.
In most instances, a therapist will not be able to train a person to be “less vigilant or aware.” This is likely an automatic or autonomic process and perceived as adaptive, so the next best thing is to teach a person about
Interpreting or misinterpreting bodily sensations associated with the “fight-
flight-freeze” response as dangerous. Believing that an increase in your
heart rate means that you are having a heart attack, would more likely than not be a misinterpretation especially if you are an otherwise health adult. Living in fear of
additional panic attacks is not desirable. People who do this avoid things that may trigger panic attacks. They go through life on the “lookout” for the next attack and constantly scanning for trigger body sensations.
I like this example:
Two hikers are going for a hike in the woods. One hiker runs into the park ranger, who warns her that a bear has been spotted in the woods. The other hiker does not receive this warning and continues on his way enjoying an afternoon hike. If he hears a rustling in the woods, he assumes that it is a squirrel or the wind. The hiker who was told about the bear, however, is very cautious and constantly on the lookout for the bear. She becomes sensitive to anything that suggests the bear is near (for example rustling in the woods) and might decide to avoid the woods altogether and not return to the park. This is what happens when someone is in an: “over-alerted” state of mind, you might find yourself always on the lookout for another panic attack. The panic attack is your bear, and the bear is ever present. Anything can make you feel nervous, which might lead to another panic attack. You might even start to avoid things that remind you of the attack (such as not looking at a Smoky the Bear) sign while in the Park.
Subtle but Meaningful Lifestyle Change
As a person learns more about panic disorder, what causes is, the process of the disorder, the fact that it is rarely a harmful process (it is generated by your body - fight-flight hormones are internal as the body’s way to defend against threat).
IMPORTANT POINT: The body knows how to shut down or shut off the panic process before you are damaged.
Again, this is learning to trust your body and your body’s ability to regulate itself even in the case of panic where it seems like your body is out of control and actually trying to harm you (your brain and mind). This way of thinking may seem ironic, but if you contemplate it deeper, the victim of panic attacks feels that her or his own body is the attacker (the bear so-to-speak)
Suggesting meaningful life changes will help the person with panic attacks:
A regular sleep-wake schedule.
Getting enough sleep.
Establishing a life-routine where overtaxing your physical/mental system occurs at a low frequency.
Working to eliminate sources of conflict in your life.
I mention only a few features of how I approach a person who wants to rid themselves of the cycle of panic attacks. What will follow is a discussion about the “philosophy of panic.”
ENTRY CONTINUES 1-13-2022