Understanding Panic Attacks

Many of the questions that have come over this blog have been about the origin of, or the "why" of anxiety. In the last blog, we discussed panic disorder. Before we discuss the treatment of panic attacks, lets at some of the underlying physiologic phenomena that animate these attacks. Hopefully, doing so will help us understand something about anxiety in general.

The prevalence of panic disorder is between 1%-3%. Sensation of shortness of breath or choking, chest pain, vision changes and rapid heart rate are just some of the possible physical symptoms of a panic attack. To observers, panic attacks are at once scary and fascinating. To the patient, a panic attack is even scarier. The first panic attack often lands a person in emergency room - and for good reason. If you ever experience the feeling of unexplained shortness of breath, chest tightness or dizziness, you should go to the emergency room promptly as your condition can be cardiac in origin. In the case of a panic attack, however, a thorough workup is performed, and a person is often told that their experience was due to "anxiety." Yet, how can a mental health condition morph so rapidly into such a dramatic presentation?

Panic attacks are best thought of as dramatic, rapid spikes in anxiety that trigger a very rapid physical response. This is triggered by a built in human ability to "rev-up" our physical preparedness in response to fear (conscious or unconscious). Many of us, for example, have been "jarred" or "spooked". Have you ever walked around the corner while hiking, say, and seen something move? You might jump in fear, heart pounding. Cognitively, your mind feels safe when you realize that the moving rodent was really just an errant plastic bag blowing in the wind. Yet, even with this knowledge, your heart continues to pound even after you realize that the mischievous object is an inanimate household object that better belongs in the closet than on the trail. You try to extinguish this feeling and say to yourself "relax", but notice: the sensation of visceral fear remains and your heart continues to pound away.

This "fight or flight" design, and its modern day vestige of a "panic attack" is a holdover from evolutionary biology. We are built to jump, run and escape at the slightest roar of a saber-tooth tiger - and our heart and breathing respond accordingly. This mechanism includes increases of catecholamines, which includes nor-epinephrine and "adrenaline" in our central nervous system, is built to either fight for survival or flee from prey. If we were to graph this response, or the subjective feeling of anxiety during a panic attack on one axis, and put time on the other axis, we would see that it does not rise in a linear fashion, but in an exponential one. While dialing this down is very difficult, much neurobiological energy is devoted to its lightening fast assembly. Yet, if this speed of onset is beneficial in the bush, the same rapidity of onset is a mismatch for the demands of modern, civilized life.