Understanding Panic Attacks

Health Professional

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.

How does our body and mind create a system that amplifies our anxiety so rapidly? The answer to this question is complicated. Yet one answer is that a panic attack has two components: mental anguish and physical duress that play off of one another in a fast forward positive feedback loop. Once upon a time we thought of the rapid breathing and quick heart rate as physiologic symptoms or consequences of the mental anguish associated with a panic attack. We now know that these two components, the mental and physiologic feed off of one another. Anxiety leads to rapid breathing, which in turn increases anxiety. This results in still more rapid breathing and heart rate, and so on. The good news concerning this feedback loop is that it is possible to intervene by attacking either the anxiety component or physiologic component - or both.

The options available for treatment will be discussed in a future blog. They include breathing exercises and techniques, cognitive behavioral therapy, dealing with underlying conflicts and anxieties, as well as pharmacological intervention. Most of these treatments take into account the physiology that we have discussed as central to the treatment. Both the rapid time course, as well as the connection between mind and body is important concepts in understanding and treating panic disorder.