by Brenda Kijesky, LCMFT

While these symptoms may make you feel as if you’re going crazy, you are anything but crazy. You may think that you are the only one who experiences these feelings; however, you are far from alone.

“OMG, I’m dying!”

“I think I’m having a heart attack!”

“People probably think I’m crazy!”

“I’m afraid I’m going to pass out!”

“It’s happening again!”

“I can’t breathe!”

If you’ve ever experienced a panic attack, you know it can be a very distressing rush of extreme anxiety accompanied by uncomfortable physical sensations and negative thinking. So what exactly are panic attacks?  The DSM-V (a book that catalogs the criteria for mental health disorders) describes a panic attack as a discrete period of intense fear or discomfort, in which at least four of the following symptoms showed up abruptly and reached a peak within minutes:

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Choking feeling (tightness in throat)
  • Chest pain or discomfort (tightness or feeling a heavy weight)
  • Nausea or abdominal distress (churning stomach, need to use the toilet)
  • Feeling dizzy, unsteady, lightheaded, or faint (ringing in the ears)
  • Chills or heat sensations
  • Numbness or tingling sensations
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself – like you’re not connected to your body)
  • Fear of losing control or ‘going crazy’
  • Fear of dying (sense of dread or “doom”)

While these symptoms may make you feel as if you’re going crazy, you are anything but crazy. You may think that you are the only one who experiences these feelings; however, you are far from alone. Panic attacks are quite common – in a given year, about 11.2% of adults experience at least one panic attack. According to the National Institute of Mental Health (NIMH), 22.7% of U.S. adults will experience a panic attack in their lifetimes. Panic attacks commonly last anywhere from a couple minutes to 20 minutes; although in some rare instances, they may last up to a few hours.

Frequently, panic attacks start with an identifiable trigger.

Case Example: Jennifer

Jennifer is 32 years old and has been diagnosed with OCD. Her obsessions tend to evolve around perfection – wanting to do things perfectly and appear perfect to others. Jennifer’s job requires giving occasional presentations to her management team. When she has an upcoming presentation, she spends a significant amount of time re-checking her work and rehearsing because OCD tells her that it’s not okay to make a mistake or appear as if she doesn’t know everything. Before the presentation, she starts to feel anxious and notices uncomfortable sensations in her body – heart pounding, stomach churning, feeling light-headed – and views those symptoms as a sign that the presentation is going to go terribly, which will lead to panic, and, ultimately, the loss of her job. She engages with that fear by giving it a lot of attention, desperately trying to get it to go away, which triggers even more physical arousal and then, she panics! Her heart rate jumps through the roof, she feels like she can’t breathe, her mind becomes flooded with thoughts of going insane and dying.  She tells her boss she’s ill and someone has to cover for her.  The panic symptoms eventually subside, but now Jennifer believes that these presentations are something to be feared and avoided because they trigger panic attacks.

Panic Attacks or Panic Disorder?

Panic attacks can occur within a number of mental disorders, such as OCD, anxiety and related disorders, depressive disorders, trauma, bipolar disorders, impulse-control disorders, and substance-use disorders.  The case example above demonstrated how a panic attack might be triggered by an unhelpful response to anxiety and OCD. However, to meet criteria for Panic Disorder, panic attacks must be both recurrent and unexpected. Recurrent simply means more than one panic attack has occurred. Unexpected means there is no clear trigger for the panic attack, such as a feared social situation (like Jennifer’s) or a stimulus that feels inherently dangerous. In Panic Disorder, panic attacks may occur when you are comfortably relaxing at home, or even at night, waking you out of a sound sleep for no apparent reason. People with Panic Disorder also engage in persistent worry about future panic attacks and their consequences and engage in strategies to avoid situations that may trigger more attacks.

Why do I feel this way?

Panic attacks are typically triggered by feared beliefs about uncomfortable physical sensations (i.e., heart pounding, stomach churning) or by conditions where one experiences these sensations (Clark, 1986). For example, you may notice yourself anticipating a panic attack if your stomach starts to churn before a job interview or if you feel jittery and have heart palpitations after drinking too much Red Bull the night before a big test. In some cases, a medical condition, hormonal change, or medication side effect can also trigger these symptoms.  People with Panic Disorder typically have strong beliefs and fears that the physical sensations associated with panic attacks will cause physical or mental harm (Chambless, Caputo, Bright, & Gallagher, 1984), (McNally & Lorenz, 1987); hence, the common belief that a racing heart may trigger a heart attack or “butterflies” in the stomach means you will definitely vomit. This may explain why a medication side effect such as nausea can appear to trigger panic attacks in some.  In other words, the automatic interpretation of the nausea may light up the panic center of the brain in a susceptible person.

People who have Panic Disorder are more likely than the general population to catastrophize the experience of uncomfortable physical anxiety symptoms (Clark et al., 1988), meaning they predict a negative future outcome that they assume cannot be coped with. For example, you may believe that you will never be able to go to work feeling this way and, therefore, you’ll have to be dependent on others for the rest of your life.  When the emotional brain senses a threat, it signals your nervous system to engage and keep you safe by giving you increased strength and speed. It’s basically an adrenaline rush. When the emotional brain senses that the perceived threat has passed, the anxiety comes down.  How this “rush” is interpreted can make a big difference.

The Truth About Your Attacks

  • Panic attacks are not dangerous.
  • Panic attacks will not make you go crazy.
  • Panic attacks will not cause heart attacks. They are just a sudden burst of intense energy that can feel extremely uncomfortable.
  • All panic attacks end! It is not physiologically possible for that feeling to continue forever because the body cannot sustain that level of energy usage for very long.

So, Fear of Panic Attacks Brings on Panic Attacks?!?

Panic attacks can feel extremely scary. Typically, it’s the concerns about what the physiological symptoms may mean, the concerns about social consequences (what other people would think of you), and/or the fears about “going crazy” that perpetuate the fear. The more the panic attacks occur, the more you fear having another attack, and that is what increases their frequency. The more you try to run away from a panic attack, the more it will chase you. What can feel the scariest is the sense of no longer having control during a panic attack. When experiencing a sense of danger/doom or fear of dying, escape feels like the only option.

The cycle may look something like this: You experience some kind of uncomfortable bodily sensation > you think, “Oh, I’m anxious!” > your body further responds to the belief that you are anxious and you experience more uncomfortable sensations > you start predicting what horrible thing will happen if you panic > you feel even more anxious > you notice more uncomfortable sensations > the cycle revs up and you have a panic attack!

Or this: You walk into the grocery store where you’ve experienced panic before and think, “What if I panic, again, and can’t go to the grocery store anymore?” > you notice physical symptoms of anxiety in response to that thought  > those sensations are your evidence that you are going to panic > you decide to stay close to the exit in case you need to escape > your body becomes more aroused > panic attack!

Avoidance is a Trap

The fear of panic often leads people to avoid things that are important to them, such as going out with friends, going to concerts, places of worship, exercise, etc. Sometimes, the avoidance behaviors become so pervasive that people stop engaging in essential daily activities such as going to work or running errands. Persistent avoidance of places that are associated with panic attacks may lead to a disorder called Agoraphobia (fear of being outside). It’s a myth that you can stop panic attacks simply by changing your environment. If you flee wherever you are when you are panicking, you may spare yourself short-term pain; however, you are reinforcing the belief that panic symptoms themselves are a threat, which will exacerbate the cycle.

But you don’t need to live your life in perpetual fear of the next attack.  By first understanding the common shared experience of panic attacks and how our instinctual urges to avoid them can perpetuate them, you now have the power to begin to demystify them.  What may seem uncontrollable and more powerful than you now can be overcome.

Part Two of this blog will discuss some of the effective therapeutic techniques for taking command of this treatable condition.

Brenda Kijesky, LCMFT is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.

References

Chambless, D.L., Caputo, G.C., Bright, P., & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52(6),1090-1097.

Clark, D.M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470.

 Clark D.M. et al. (1988) Tests of a Cognitive Theory of Panic. In: Hand I., Wittchen HU. (eds) Panic and Phobias 2. Springer, Berlin, Heidelberg

McNally, R.J., & Lorenz, M. (1987). Anxiety sensitivity in agoraphobics. Journal of Behavior Therapy and Experimental Psychiatry, 18(1), 3-11.