A Primer on Panic Attacks
Photo by Andrey Metelev on Unsplash
Close to 1 out of every 3 people have experienced a panic attack at least once in their lives (Brown & Cash, 1990) meaning that about 2 billion people alive right now have had or will have a panic attack. A much smaller but still substantial number of people will go on to develop panic disorder, a condition in which they have frequent panic attacks.
So what exactly is a panic attack?
A panic attack is a combination of a wide range of body sensations and specific high intensity catastrophic thinking. Panic symptoms include cardiovascular sensations of rapid heart rate, a pounding heart, flipping/flapping chest sensations. It also includes shortness of breath, trouble breathing, tightness in the chest. Gastro-intestinal symptoms are common as well including nausea and stomach distress. But the catastrophic panic thinking seems to be the most common set of symptoms: a sense that you are about to go crazy, lose your mind, feeling like you are going to die, feeling that you are going to lose control of your body.
A panic attack happens quickly and usually dissipates in about 20-40 minutes (Taylor 2000). Dissipates is a complex term. Just like a hurricane can dissipate into heavy thundershowers, for some people the panic dissipates into high anxiety. For others exhaustion follows and believe it or not, for some people panic dissipates and they move on and have a good day (yes that happens).
Harm, danger and Losing control
Feeling panic almost always includes a sense of danger that harm is about to happen - harm could be in the form of physical harm like a heart attack, social harm, like something really embarrassing happening to you in a public space, but perhaps at the heart of panic is a fear of losing control. This turns out to be the most common symptom in a panic attack: a sense or a belief that you are about to lose control. Sensing that you are about to lose control includes thinking that you are going crazy, or about to act impulsively and do something embarrassing or terrible. It can include fearing that you are losing control over your body. Fears of fainting, uncontrolled vomiting or defecating are some of the possibilities.
When we panic, the ability to regulate control over ourselves can become or can appear difficult. When we panic, we might feel like our body and/or mind are starting to mutiny and is charting a course in directions we DO NOT want to go in. This can have the effect of amplifying our panic.
Why does a panic attack end?
Panic attacks seem to last from 20-40 minutes (Taylor, 2000; Radomsky, Rachman & Hammond, 2001). Why do panic attacks typically slow down considerably or end? Why don’t they last for extended durations? The answer is less than clear. Some researchers speculate that our bodies are just not capable of sustaining a long duration panic attack. Other times, we engage in actions that decrease the intensity of the experience. Typically, when we panic we focus on escaping the situation. Or, someone might be with us who coaches us through the panic. Or our bodies just get exhausted and run out of steam. Lastly, sometimes panic subsides because at some point while staying in the situation, the body/mind assesses that this is not a threatening situation.
A wayward stress response
The usual symptoms of panic bear some similarities to what has been called “the stress response”, originally coined by Hans Selye, later adapted to “fight or flight” by Walter Cannon. When our bodies launch a stress response or fight or flight, our body is prepping to physically mobilize. Much of this prep work is triggered and regulated via nerves in the autonomic nervous system and via the endocrine system by chemical messengers like adrenalin, noradrenaline and cortisol. The resulting effects include rapid breathing, increases in heart rate and contractility, increases in blood pressure, redirecting of blood to our skeletal muscles.
In panic, cardiovascular related symptoms are extremely common - specifically elevated heart rate and perceived heart palpitations. Palpitation includes rapidly beating, irregular beating or pounding heart sensations (Taylor 2000). This is probably why a number of people can get confused about whether they are having a panic attack or a heart attack. Could panic attacks be a fight or flight response that is triggered either out of the blue or in situations that don’t really warrant a fight of flight response? It seems like panic at least mimics a fight or flight response in some ways. This aspect of panic is picked up on in David Barlow’s model of panic attacks that I will describe in a little bit.
Panic attacks and panic disorder
I wrote earlier that about 1 in 3 people will have at least 1 panic attack in their lives. Stressful life events, interpersonal conflicts, hormonal changes, substance use can all trigger a panic attack. In my life, I’ve had about three panic attacks spaced out over some 30 years; rare but very memorable. I don’t qualify as having panic disorder, a diagnosis that requires recurring panic attacks combined with frequent worrying about having a panic attack. It turns out most people who have had panic attacks do NOT have panic disorder. In fact, only 2-4% of people have a lifetime prevalence of panic disorder (Weissman, Bland, Canino, 1997). If you don’t believe me, check out the National Institute of Mental Health’s page on panic disorder.
How do panic attacks become recurrent?
Appraisals
If 30% of people have had at least one panic attack, why do only 2-4% of people have panic disorder? In 1986, David Clark laid out the catastrophic misinterpretation model of panic disorder (You can read more about this in my essay on panic treatment) . In this model, a person who has an “enduring tendency” to interpret body sensations as dangerous, specifically that certain body sensations a sign of “immediately impending physical or mental disaster” is going to be more likely to eventually deal with repeated panic attacks. The process works as follows - there is an external or internal trigger. An external trigger is something like a crowded baseball stadium or being stuck in rush hour traffic. An internal trigger might be something like feeling a sudden sense of dizziness. Next, the person interprets these triggers as threatening-like it could signal something bad is about to happen. This leads to an increase in anxiety, which then causes a spike in internal body sensations like increased breathing, increased heart rate. Next, this then is interpreted as a sign of high impending danger (“I’m going to die”, “I’m going to lose it”, “I’m going to pass out”, “I’m going to have a heart attack”) which lights the fuse and the panic rocket takes flight.
Fear, appraisals and conditioning
David Barlow (1988) speculated a different, but similar model of panic. To Barlow, a panic attack is an alarm triggering a mobilization to escape RIGHT NOW! Unfortunately this alarm is going off in a situation that does not seem to be immediately dangerous. This initial spontaneous false panic alarm can initially go off during times of interpersonal stress, life change, biological or hormonal changes, changes in sleep or diet. There are a subset of people that are vulnerable to become anxious and repetitively think about and plan ways to avoid having another panic attack. Through repeated avoidance or repeated anxiety about panic, individuals develop “learned false alarms”, typically triggered by body sensations, specific thoughts or images in their minds, specific external environments. Barlow’s model, unlike Clark’s, includes but doesn’t require a specific appraisal of “oh boy this feeling is really bad!” Barlow states that panic can be learned automatically without conscious appraisal. The way this learning happens is through how our bodies learn to acquire fear, through classical “Pavlovian” conditioning and reinforcement or “operant” learning. Volumes have been written on these, but I will quickly describe them in the context of panic. In classical conditioning, previously neutral or benign situations, thoughts or body states (a shopping mall, an image of a roller coaster, a sense of stomach tightness) become conditioned triggers for a panic response. In reinforcement learning, avoiding a feared situation (not going to a shopping mall, mentally replacing the image of a roller coaster with a cute puppy dog, not wearing tight clothing to avoid a feeling stomach tightness) reinforce (or teach) our bodies to produce relief while also teaching our bodies that typically benign things like a shopping mall, an image of a roller coaster, a sense of stomach tightness should trigger a conditioned panic response.
Barlow’s model was an initial attempt to integrate pathways leading to panic disorder that were conscious and also “subconscious” (or more accurately nonconscious). We can become afraid and panic through these nonconscious processes. Panic disorder can be thought of as a conditioned, learned fear response through both conscious declarative memory pathways that involve cognitive monitoring, interpretations and appraisals, but also through nonconscious pathways of associative learning (Bouton et al, 2001). Over time, people start to develop stronger fears of panic attacks and also tend to avoid situations that may trigger a panic attacks. There is considerable evidence that treatments that focus on catastrophic misappraisals and reducing repeated avoidance can go a long way to reducing the frequency and intensity of panic.
Anxiety Sensitivity
A key trait-like contributor to a panic attack turning into panic disorder is something called anxiety sensitivity. This is pretty similar to what Clark described as an “enduring tendency” to interpret body sensations as dangerous. Anxiety sensitivity refers a tendency to feel anxious when experiencing body sensations that we typically associate with fight or flight. These sensations include increased heart rate, rapid breathing, sweating, muscle trembling, as well as other unpleasant feelings like gastro-intestinal distress. Taylor suggests anxiety sensitivity would be more aptly called “arousal sensitivity” (2000, pg 37). People with low anxiety or arousal sensitivity are likely to interpret sensations like increased heart rate or feeling dizzy as unpleasant but harmless; in contrast people with high anxiety sensitivity tend to view these sensations as closely linked to death, insanity or social humiliation. Thus although many people experience panic attacks, those that have anxiety/arousal sensitivity are much more likely to develop panic disorder. Prospective research studies bear this out: a sample of 404 college aged adults without any current anxiety disorder were followed for 2 years. Individuals who had above average anxiety sensitivity scores (above the median), had a 2.5 time higher risk of developing panic disorder than those who had below average scores (Schmidt, et al, 2006).
“People have noisy bodies” Taylor (2000) asserts and goes on to describe that in studies with healthy participants, 6-21% of people report experiencing nausea, dizziness, chest pain, dyspnea, palpitations and/or trembling over the span of the last week. Taylor and other psychologists have drawn the conclusion that these symptoms are infrequent but typical in human experience. Are people vulnerable to panic more physically reactive? Studies examining heart rate, breathing rates and using procedures designed to trigger body reactions have not shown that people with panic have greater physiological reactions (Taylor 2000). Nor does it seem clear that people with panic have better capabilities at sensing changes in internal body state. What does seem clear is that people with panic disorder consistently avoid triggering situations and sensations and also misinterpret specific bodily feelings as catastrophic.
Other factors that can trigger panic
Interpersonal Conflict. A number of people with panic disorder have described the onset of frequent panic attacks to occur during a time when they feel a loss of or a lack of control in their interpersonal relationships (Williams et al, 1997).
Emotion mislabeling. Individuals who develop panic disorder can label a very broad, perhaps too broad range of bodily feelings and emotions as signs of anxiety (Williams et al, 2000). Mislabeling is a common problem in people with chronic anxiety. And beyond mislabeling other emotions as anxiety, Zeitlin and McNally (1993) found that people with panic disorder have trouble with recognizing and labelling emotional experience in general. As therapists we encourage people to feel what they feel; we validate their emotions. But part of our job is also to help explore initial interpretations about what we are feeling - is it anxiety or is it anger? Or is it sadness? Or all of it? Helping our clients acquaint themselves with the emotional experience may help reduce the misinterpretations and misappraisals that happen with panic.
References
Barlow 1988. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. Link to a more recent edition.
Bouton et al, 2001. A modern learning theory perspective on panic disorder
Brown & Cash, 1990. The phenomenon of nonclinical panic: Parameters of panic, fear, and avoidance
Chambless & Goldstein, 1981. Book Chapter in M. Mavissakalian & D. Barlow (Eds.), /Phobia: Psychological and pharmacological treatment/(pp. 103-144). New York: Guilford.
Clark, 1986. A cognitive approach to panic
Craske, Sanderson and Barlow, 1987. The relationships among panic, fear, and avoidance
Radomsky, Rachman & Hammond, 2002. Panic termination and the post-panic period
Schmidt et al 2006. Anxiety sensitivity: Prospective prediction of panic attacks and Axis I pathology
Taylor 2000. Understanding and Treating Panic Disorder: Cognitive-Behavioural Approaches. Link to the Book
Treating Panic: Why it all started in the 80's
The 1980’s were the beginning of the “glory years” of cognitive-behavior therapy (CBT), in my humble opinion. After slow and steady advances in conceptualizing and treating panic, in the 1980’s, our understanding of panic really came together, especially in the CBT world. To understand modern approaches to treating panic, I’m going to walk you through some of the classic CBT texts on panic to show you how CBT researchers and practitioners developed the rationales and approaches that are now so commonly used. The foundational texts were written in the 80’s and as you may or not know, I love the 80s. So I am going to pepper this text with a few non sequitur references to that great time.
But first, let’s start in antiquity. Around 2000 years ago, around the “0080’s”, Epictetus, the Greek Stoic, when faced with racing, disturbing thoughts, advised us to say to that thought: “Impression, wait for me a little. Let me see who you are and what you represent. Let me test you”*. We learn by testing things out, by investigating, by becoming familiar with that which we fear. In the 8th century the monk Shantideva wrote a crucial Buddhist text called The Guide to the Bodhisattva’s Way of Life and in it he produced a similar sentiment as Epictetus in an even more pithy form by stating “everything is made easier through acquaintance”. At the heart of treating panic, and honestly treating all anxiety struggles, is acquainting with that which is feared.
Treatment of panic involves four major parts. The first part is education about emotions, thoughts and thinking and behaviors related to panic and the panic cycle. The second part involves working on cognition - reappraising the beliefs and ways of thinking that transmute body sensation anxiety into a panic attack. The third is interoceptive exposure - engaging with body sensations that you fear may cause panic. The fourth major part is real world exposures - engaging in environments that you fear may cause panic.
Cognitive-behavior therapy (CBT) has a history of relying on clinical and cognitive neuroscience and behavioral clinical trials to develop and test treatment approaches. Early outcomes from clinical trials have indicated that the fundamental strategies to treat panic involve: teaching individuals about the cycle of anxiety and panic, breath work, cognitive reframing, and relaxation exercises. But perhaps the most important treatment strategy is directly connecting with that which you fear. In clinical terms, we call this exposure therapy (I prefer the term “engagement” rather than exposure, but I’ll save that for another post). There are two general categories of exposure therapies - in vivo and interoceptive. In vivo exposure is just another way of saying engaging “in the real world” rather than while sitting in a therapy office. If your panic attacks tend to happen when you go to shopping malls or movie theaters, then treatment involves progressively working your way up to going to shopping malls to go to the Wherehouse to buy a “compact disc” of Freddy Mercury and Queen’s new album or a movie theater to see Ferris Beuller or Pretty in Pink (sneaky 80’s references). Interoceptive exposure refers to deliberately inducing in a progressive manner, unpleasant sensations (rapid heart rate for example) that might be related to triggering panic.
Education
Education, often called psychoeducation, is a primary treatment tool in all psychotherapy, but it is particularly important in CBT. Education about panic involves learning about anxiety on multiple levels - cognitive, emotionally, behaviorally, physically/biologically and also situationally. In CBT, psychoeducation often involves some discussion of the basics of learning. How do we learn to fear things and how do we learn to not fear things?
Reworking Beliefs and ways of thinking
Clark’s cognitive model of panic (1986) introduced a central term in the conceptualization of panic that emphasized cognition, or “thinking” in the development and in the treatment of panic. Clark emphasized that an essential piece in the cycle in of panic is a misappraisal of the meaning of a body sensation as being “catastrophic”. Clark starts by saying that panic can be induced physiologically through things like infusions of lactate or isoproterenol, inhalation of carbon dioxide or through voluntary hyperventilating. Clark then notes that these things rarely produce panic in people who do not have any history of panic attacks. He then suggests that it may not be the substances or activities themselves that induce panic symptoms, but the way the person psychologically interprets the meanings and implications of the symptoms they feel when intaking these substances or engaging in these activities. Clark states that some individuals tend to interpret unpleasant body sensations (dizziness, palpitations, shortness of breath) as having considerably more ominous or dangerous meanings that they actually do. Next, these folks intentionally or unintentionally engage in behaviors that amplify anxiety. Typically these behaviors include hyperventilating, repeating overthinking and focusing on symptoms of anxiety. This then loops back to the misinterpretation of the danger of these symptoms which then circles back to the “igniting” behaviors. This looping then leads to panic. What made Clark’s model so compelling at the time was the primacy of the interpretation of these bodily sensations as being catastrophic. This gave CBT therapists an “intervention point” - to focus on helping individuals become aware of these interpretations and then helping their clients re-interpret the meanings of these symptoms. Before this, psychotherapists tended to focus exclusively on helping clients seek insight into interpersonal relationships and early childhood as a treatment approach for treating panic. It’s hard to not over emphasize how revolutionary this way of thinking was for treating panic disorder.
Interoceptive Exposure
At almost the same time, another blockbuster paper came out written by David Barlow and his team and included exposure therapy into panic treatment (Barlow et al 1989). His team’s approach integrated Beck and Emory’s approach to treating anxiety by focusing on re-evaluating on cognitive appraisals, predictions and prescriptions about self, handling anxiety and anxiety-triggering situations. They emphasized teaching clients to use tools like analyzing faulty logic, reattribution and reframing, exploring alternative beliefs, practicing decatastrophizing, and using hypothesis testing in anxiety triggering situations. All bedrock strategies in CBT.
But Barlow also speculated that panic attacks were a learned response conditioned automatically through associative or Pavlovian conditioning and operant conditioning. Simply put, in the process of living life and having distressing experiences at times, benign or mild body sensations (like dry mouth, mild dizziness, stomach tightness) and/or external stimuli like a busy crowd at a mall become paired with a danger signal + panic response. Over time, these body sensations become a conditioned trigger for panic. For example, imagine you are at Starcourt mall (or in my case, the Glendale Galleria), walking to Hot Dog on a Stick to get their giant fresh lemonade (sneaky 80’s references) and you feel flush or dizzy. Why do you feel this way? Because it happens sometimes. You get up too quick, you are little dehydrated, or maybe you are just prone to mild dizziness. But automatically, you start to feel anxious because that sensation might remind you of a panic attack you had. The anxiety builds, you might even start focusing on “what if I have a panic attack right here right now in from of all these people? This could escalate into a full blown panic attack, or you might leave the mall to prevent a panic attack. This pattern of behavior strengthens the relationship between the sensations, the mall and a panic response.
Barlow and colleagues emphasized repeated exposure to these benign physical sensations that arise early on before a full blown panic attack develops as a way to help the body “relearn” that these sensations are normal and do not need to trigger a panic attack. These techniques involved “bringing on” specific physical sensations related to panic - like hyperventilating for 30-60 seconds to bring on rapid breathing or doing jumping jacks to bring on a sensation of elevated heart rate. They coined the term interoceptive exposure as a technique in which the therapist leads the client through a set of exercises meant to stimulate these physical sensations. By repeatedly practicing engagement with these sensations, clients begin to learn to break the chain linking these sensations to the onset of panic.
There are a variety of exercises that fall under the umbrella of interoceptive exposures and cover intentionally produced body experiences such as dizziness, shortness of breath and rapid heart rate. Lee and colleagues (2006) broke down these exercises into four categories: neurological, gastrointestinal, cardiorespiratory and dissociative. In his book on panic disorder (Taylor 2000) Steven Taylor compiled a list of 17 exercises such as spinning around while standing up with arms stretched for 1min, breathing through a narrow straw without breathing through your nose for 2 min, etc. These exercises are typically of a short duration and are practiced in session 2-3x during a session and then practiced at home 3-5x a week. Before engaging in these exercises, a client is asked what their beliefs are about triggering these sensations (I will not be able to handle it, I will be anxious for a long time afterwards, etc). Then by deliberately engaging in the triggering behavior, the client gets to experience an “expectancy violation” - i.e. the bad event either didn’t happen, or was less intense than expected, or was very intense yet the client learned to manage them. This produces new associations and new ways of thinking about the triggered sensations either automatically or through debriefing conversations with the therapist.
Real world Exposure
Reintegrating into triggering situations is the last major aspect of panic treatment. Where do people experience panic? In their bedrooms? In their cars? In restaurants? How can we help people work on getting back to being in these situations?
Real world exposures are conducted via a road map - a hierarchical listing of situations ranked in increasing distress intensity, with the most triggering situations listed at the top and the least triggering situations at the bottom. Therapist and client work together and start at the middle or lower middle of the list. Either in session or as homework the client practices being in those situations. Real world exposures are challenging - there are alot of variables at play. But they can be very helpful to clients. Therapists who work within the Acceptance and Commitment Therapy (ACT) framework of CBT prefer to scrap the hierarchy of feared situations and instead develop a listing of desired behaviors (going to a movie, taking a flight somewhere) and creating a roadmap to help the client engage these behaviors in those situations and not avoid being in situations they want to be in. ACT therapists emphasize that the most important factor in real world engagement is the desirability of being in the situation (“it’s important to me”) rather than the degree of distress the situation might trigger.
There is some indication that real world exposures are useful, but are NOT as essential to successful treatment as interoceptive exposures. Craske and colleagues (2006) compared interoceptive exposure treatment versus interoceptive + real world exposure treatment and found that the reductions in panic attacks were similar for both groups. Alessandro Pompoli and Toshi Furukawa (2017) published a review of 72 studies with a total 4064 patients with panic disorder. In their statistical review of these studies, Pompoli and Furukawa found that interoceptive exposure treatment had better outcomes than real world exposure treatment.
So, if you are getting treatment for panic, one take home message is that doing interoceptive exposures is very helpful and that doing real world exposures may be helpful, but you need to do the interoceptive exposures as well.
What about breath work or muscle relaxation? It works, people like it, but it doesn’t work as well as exposure.
Remember 5-4-3-2-1 breathing? Google panic treatment and you will find lots of write ups about how to do it. It seems like a reasonable idea that teaching people to slow their breath or to relax would be a useful technique for helping people with panic. Early treatment studies done in Barlow’s lab compared relaxation training versus cognitive therapy + exposure training (Barlow 1989) and found that both were clinically helpful in reducing panic attacks. But they noticed that cognitive training + exposure therapy group had a larger number of people reporting having zero panic attacks in the period after treatment was complete. Plus, a 2 year follow up study with the same sample found that the benefits of relaxation training did not hold up well over time, but the benefits of cognitive training + exposure training held up remarkably well and actually improved over time (Craske et al, 1991). This framed relaxation techniques as helpful but limited. These studies were ground breaking at the time but had very small sample sizes. Since those studies, many, many clinical trials seem to indicate the same thing. In the review analysis done by Pompoli and Furukawa (2017) examining 72 separate studies on panic disorder treatments, they found some interesting results on breathing retraining and muscle relaxation. They concluded that education, cognitive training and exposure therapy, specifically interoceptive exposure, were the best CBT strategies to use in terms of symptom reduction and remission rates and that muscle relaxation and breath focused strategies were the “least helpful” strategies for treating panic attacks. Yet they found that study participants liked having breathing retraining exercises to practice. So breath work helps, but not as much as you’d think, but people like doing them. So about 30 years after Barlow and Craske’s initial small pilot study findings on treating panic have held strong. Sorry to sound repetitive, but it will really help to do the interoceptive exposures. Don’t skimp on them!
The take home message
The 1980’s gave us the Showtime Lakers, Prince, Madonna, and fabulous fashion (remember Kajagoogoo and Spandau Ballet?). It also gave us the foundations of CBT based panic treatment and in the ensuing years, through a number of clinical trials and basic science studies have spelled out the important components of treatment. Psychoeducation, reworking how you interpret body sensations that are unpleasant and associated with panic, and interoceptive and real world exposures. Each component involves learning - learning about how our body learns to react with panic and perpetuate avoidance behaviors that strengthen the panic cycle (Barlow 1989), learning about the roles of cognitive appraisal in the panic cycle and how to work on it in treatment (Clark, 1986) and how engaging in exercises that trigger body sensations associated with panic helps our body learn new ways to handle these sensation instead of trying to escape or avoid them.
References
Alessandro Pompoli et al 2017. Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis
Barlow 1989. Behavioral treatment of panic disorder
Clark, 1986. A cognitive approach to panic
Craske, Brown & Barlow 1991. Behavioral treatment of panic disorder: A two-year follow-up -
Craske, DeCola, Sachs, Pontillo Panic control treatment for agoraphobia
Taylor 2000. Understanding and Treating Panic Disorder: Cognitive-Behavioural Approaches. Link to the Book
* I read the Epictetus quote was in an excellent book by Donald Robertson called The Philosophy of Cognitive-Behavioural Therapy.