Panic Attack

By Dr. Cheryl Lane, PhD

Everyone experiences a feeling of panic from time to time, whether it’s due to a “close call” while driving on a busy freeway or the sudden realization that the oven wasn’t turned off before leaving the house. However, while those situations can certainly cause your heart to race, they’re a normal response to a potentially dangerous or threatening situation and don’t meet the criteria for a panic attack – at least not in the clinical sense.

Panic attacks involve the experience of intense fear or significant discomfort. They start suddenly and usually last for just a few minutes. Panic attacks may be triggered by something specific (e.g. seeing a spider or getting into a crowded elevator) or occur “out of the blue”, with no specific trigger. They must be accompanied by at least 4 symptoms that are somatic (e.g. sweating, shaking) and / or cognitive (e.g. a fear of losing control) in nature.

Panic attack triggers

In many instances, panic attacks do not occur in response to a real threat or imminent danger. Rather, the trigger (if one is present) is the irrational perception of a threat or danger. For example, someone who suffers from arachnophobia is typically terrified of all spiders – not just unusually large spiders (e.g. tarantulas) or ones that are truly dangerous, such as the brown recluse. Many people with this phobia will also respond with significant anxiety to a picture of a spider. In other words, the threat or danger isn’t real, but the mere thought or image can still trigger a panic attack.

Panic attacks are a primary symptom of panic disorder, and a very common symptom of social phobia and specific phobias. Individuals with other anxiety disorders, such as Posttraumatic Stress Disorder (PTSD), Acute Stress Disorder, and Obsessive-Compulsive Disorder (OCD), also often experience panic attacks. They may also occur in the context of other psychiatric disorders such as Major Depressive Disorder and various psychotic disorders.

Individuals who suffer from frequent panic attacks often go out of their way to avoid situations or things that may trigger one. This avoidant behavior can significantly interfere with their lives. For example, someone who experiences a panic attack every time he/she has to fly may avoid any job that involves a lot of travel. Individuals who have severe panic attacks in social situations may become reclusive.

Panic attacks can also wreak havoc in other ways. Individuals who experience them frequently may begin to fear that they’re “going crazy”, or that they’re emotionally weak or mentally deficient in some way. They may start to worry that they have a serious medical condition that hasn’t yet been diagnosed – despite a thorough medical workup and reassurance from their doctor.

Symptoms of Panic Attacks

As mentioned above, symptoms of panic attacks are somatic and cognitive. While some people experience just a few symptoms, others may experience the entire gamut. It’s not uncommon to confuse a panic attack with a heart attack. However, unlike heart attacks, panic attacks are not dangerous or life-threatening.

Somatic symptoms may include:

• Pounding or racing heart; heart palpitations
• Shallow, rapid breathing (hyperventilation); the feeling that you can’t breathe
• The sensation that you’re choking
• Chest pain, tightness, or heaviness
• Nausea or knots in the stomach
• Quivering or shaking
• Sweating
• Dizziness, lightheadedness, feeling faint or unsteady
• Chills or hot flashes
• Tingling or numbness
• Cognitive symptoms may include:
• The fear that you’re dying
• The fear that you’re losing your mind, “going crazy”, or losing control
• Feeling as if you’re in a dream or outside of your body (depersonalization) or that nothing around you is real (derealization)

Types of Panic Attacks

There are actually three different types of panic attacks, according to the DSM (Diagnostic and Statistical Manual of Mental Disorders):

1. Unexpected (uncued)
2. Situationally bound (cued)
3. Situationally predisposed

An unexpected or uncued panic attack occurs “out of nowhere” or spontaneously. There wasn’t a specific thing or situation that triggered the attack.

Situationally bound, or cued, panic attacks occur as an immediate response to a specific thing or situation. The attack may be in response to direct exposure to the feared object or situation (e.g. seeing a dog, getting on a plane) or in anticipation of it (e.g. while waiting to board the airplane).

Situationally predisposed panic attacks often occur in response to the feared situation or thing, but not always and not always right away (e.g. the attack may occur half an hour after exposure).

Risk Factors for Panic Attacks

Individuals who have a higher risk for panic attacks include those who have:

• An anxiety disorder or other psychiatric disorder
• A family history of panic disorder, other anxiety disorders, or panic attacks
• Parents who were anxious or overprotective
• A history of abuse or trauma in childhood
• Witnessed or personally experienced something traumatic, such as combat, a tragic accident, an assault, or a natural disaster
• A loved one who is seriously ill or who has died recently
• A high level of stress in their life
• Had a recent major life transition
• A passive, avoidant, or anxious personality growing up

What causes panic attacks?

No one knows exactly why some people have panic attacks and others don’t. They are likely due to a combination of factors including genetics, biology, environmental influences, learned behavior, and maladaptive thought processes.

Treatment for panic attacks

The treatment for panic attacks may vary somewhat depending on the context in which they occur. Treatment can be very beneficial in terms of reducing the symptoms and learning to prevent the attacks from manifesting in the first place. Treatment often involves a combination of medication and psychotherapy.

Medication

Antidepressant medications, such as SSRIs (selective serotonin reuptake inhibitors), can be beneficial in terms of reducing the severity of symptoms when they do occur, decreasing their frequency, and also preventing them altogether. Benzodiazepines (e.g. Xanax®) can be used for immediate relief of symptoms once a panic attack starts. However, due to the high risk for addiction, benzodiazepines should be for short-term use only. Medication may be necessary if you are significantly impaired. It can help you feel good enough to participate in therapy.

One of the primary drawbacks of medication is that both antidepressants and benzodiazepines have the potential to trigger symptoms of anxiety.

Psychotherapy

Psychotherapy is generally regarded as the most effective treatment for anyone who is suffering from panic attacks. This is because therapy gets to the root of the problem. With the right type of therapy and a skilled therapist, panic attacks can be overcome altogether in many cases.

Cognitive behavioral therapy (CBT) is generally regarded as one of the most effective types of therapy for panic attacks. Exposure therapy (which is part of CBT) can be very effective for panic attacks caused by specific things or situations.

Meditation, relaxation techniques, yoga, and regular exercise can also be very beneficial for anyone who suffers from panic attacks.