A Primer on Panic Attacks
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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