Don’t Panic

Roger came to treatment because he was experiencing panic attacks that seemed to come out of nowhere.  Suddenly he would be overcome with a sense of impending doom and dread, had palpitations, chest pain, shortness of breath, sweating, dizziness.  The first two times he went to an emergency room thinking he was having a heart attack at the ripe old age of 31.  His discharge diagnosis from the emergency was the same both times:  panic attack.  The recommendation:  See a psychiatrist.

He was convinced that his panic was from the combined stress of hating his job and adjusting to his hyperactive first child who had just begun walking and creating chaos everywhere.  Although we investigated his assumptions carefully, this cause-effect hypothesis just didn’t seem to hold water.

His symptoms improved significantly with medication but he would still experience breakthrough panic attacks.  He began to chart his panic attacks, keeping a journal of where he was during an attack, what was going on in his life just prior, his diet, sleep – anything that could be relevant.  After examining a sufficient number of episodes, it was clear that there was no pattern.

In short, there was no identifiable pattern associated with his panic attacks until one day when he remarked that one of his panic attacks occurred at roughly the same time as a large earthquake in South America.  More out of amusement than anything else, we reviewed his journal and looked on a website that tracks earthquakes all over the world.  As it turns out, there are several small earthquakes on a daily basis.  Remarkably however, in reviewing his journal and the website, nearly all of his panic attacks occurred within 24 hours of a very major earthquake somewhere in the world.

So is Roger some type of human seismograph?  Can humans perceive earthquakes that occur very far away?  I have no idea.  But the story illustrates a more important point.

Not everything in our world follows a cause-effect pattern.  Many things are inexplicable and we may never understand why they occur.  And we are extremely uncomfortable with that realization.  We perceive things and have reactions to them, but cannot identify what we are perceiving.  In order to not feel “crazy,” we have a habit of attribution.  We are constantly attributing our thoughts and feelings to something because we cannot tolerate not knowing why.

Anxiety is a natural physiological process – a signal to us that we are perceiving some danger or threat.  Imagine how vulnerable we would be if we didn’t have this innate mechanism.  The lions would have eaten us up long ago.

However this natural and necessary mechanism can go awry and take on a life of its own, like with Roger.  He was experiencing the very uncomfortable signal in the absence of any identifiable danger or threat.  We now know that some individuals are genetically predisposed to a disconnect between the signal (i.e., the anxiety or panic) and the cause.  It is like a faulty fire alarm that goes off constantly when there is no fire.  Moreover, once you have one panic attack, your neurons become “primed” for another.  Essentially, that first panic attack lowers your threshold for panic so that it becomes a vicious cycle in which each panic attack predisposes you to have another.

When this goes on too long, it takes on a life of its own.  We make assumptions or attributions.  The panic attack happened in a bus; then we stop riding buses.  The next panic attack happened when we were sleep deprived; then we are so worried about getting enough sleep, we can’t fall asleep.  And so on…

Between the constant fear of another panic attack, and the many ways our life becomes limited and avoidant, we then become depressed.  Ironically, in some individuals who develop depression, the panic attacks disappear.  What a terrible trade-off, depression for panic attacks.

Research has clearly demonstrated the benefit of practicing relaxation techniques, particularly those involving breathing.  Deep, long abdominal breathing activates the parasympathetic nervous system (PNS) that counteracts the culprit behind the panic attacks – the sympathetic nervous system (SNS).  The mechanism here is that the panic attacks are associated with a release of adrenaline from the SNS.  But the adrenaline can be brought under control by an anecdote – acetylcholine – which is released by the PNS.

The literature also suggests the utility of cognitive-behavioral therapy (CBT) designed to change one’s thinking, calm the mind, and short-circuit the panic.  So if the panic-associated thought is, “I am going to die,” CBT trains one to recognize that dying is a catastrophic thought and thus a distortion of reality.  CBT is based on the adage, “Mind over Matter.”

Unfortunately in my experience relaxation techniques and CBT are inadequate interventions for panic.  In the midst of an attack, it is nearly impossible to have the presence of mind to analyze one’s thinking or to take control of one’s body through breathing.  There is no doubt that these interventions are effective, however they are not sufficiently reliable.

In most cases, at least initially when the problem is acute, the most effective and rapid treatment is medications.  It is crucial to intervene as soon as possible in order to short-circuit the process by which each panic attack predisposes to the next one.

Frequently individuals are prescribed benzodiazepines like Ativan (lorazepam) or Xanax (alprazolam), and usually by their primary care providers and not by a psychiatrist.  The reason panic is so frequently treated by primary care providers is because initially the problem presents as medical – ruling out heart disease, gastrointestinal disease, thyroid problems and other conditions.  These benzodiazepines provide immediate relief, however they are dependency forming and in the case of Xanax, even more addictive and quite dangerous in the long term.

There are other medication options that are not dependency forming and are quite effective.  It is also very important to remove other factors that are known to worsen panic such as alcohol, caffeine, tobacco, marijuana, other drugs as well as certain foods.  At the same time, aerobic exercise is extremely helpful.  It may seem counterintuitive to pursue relaxation exercises to slow the breathing and heartbeat while also engaging in an activity that increases respiration and heart rate like aerobic exercise.  However both are necessary to restore the balance between the active mode and the relaxation mode.

In the end, the priority is to stop the panic as soon as possible before one begins to avoid situations or limit activities arising from the fear that these will bring on another panic attack. And perhaps even more importantly, we need those alarms to alert us to real dangers, real fires.