One of the most common symptoms in psychiatry is the terrifying, infuriating, embarrassing panic attack. Panic is not a diagnosis, and panic attacks (also called anxiety attacks) can occur in a lot of different psychiatric conditions. They can also occur in people without anxiety disorders due to medical disorders, drug intoxication or side effect, or during a traumatic event.
So not everyone who has a panic attack has Panic Disorder, which is a psychiatric condition that falls under a group of disorders called Anxiety Disorders. Other anxiety disorders that can cause panic attacks are phobias (like people with a severe fear of snakes might have a panic attack when they run across a snake while hiking) or Post-Traumatic Stress Disorder (like someone with PTSD after being mugged might have a panic attack when they go back to the same neighborhood where they were attacked). Some people with performance anxiety (a form of Social Anxiety Disorder) get panic attacks before a concert or public speaking.
The DMS-5 describes a panic attack as a sudden episode of intense fear or discomfort accompanied by at least 4 of these symptoms:
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Shortness of breath or feeling like you’re being smothered
Feeling like you’re choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Chills or a flush of heat
Paresthesias (numbness or tingling, often in the fingers and toes or around the mouth)
Derealization (feeling like you or the world isn’t real) or Depersonalization (feeling like you’re detached from your body and watching what’s happening, or that you’re separated from the world by a bubble or a distance)
Fear of losing control or going crazy
Fear of dying (sometimes because you think you’re having a heart attack or a stroke)
Classic panic attacks start pretty suddenly, have their peak of intensity within 5-10 minutes, and then start to subside. Sometimes people cry, or their face and neck get red. What is particularly noticeable to me is the feeling of urgency. Panic attacks make people feel like they have to do something, now – get out of the store, stop driving, get to an emergency room – and it’s really hard for them to just sit still and wait out the panic attack, even if they have had them before.
One of my patients went to the emergency room thirty times before he was finally convinced that a psychiatrist might be able to help him get better. Every single time, he believed he was having a heart attack and needed emergency treatment. He was in his early 20s and had already been completely evaluated by a cardiologist who reassured him that his heart was fine, but when had another episode of chest pain and shortness of breath and feeling like he was going to pass out, he was sure this time it was a heart attack, and he’d call 911 again.
Other patients really suffer in silence. They just start to avoid situations where they have had a panic attack, or might have a panic attack. In some patients this leads to Agoraphobia, the name for the disorder where people are so afraid they might be anxious that they don’t leave home unless it’s with a trusted person and to a relatively familiar environment, or it’s an emergency.
It’s also possible to have Agoraphobia even without panic attacks –the fear of leaving home or possibly having anxiety when away from a safe place keeps people stuck at home. Many of these people never seek psychiatric attention and just live quietly in isolation. The availability of grocery delivery and online ordering of almost anything makes it even less likely that these people will get the care they need – psychiatric or general health care.
Once you have had unprovoked (“out of the blue”) panic attacks, and have been avoiding places or things that might cause anxiety attacks for at least a month, you have Panic Disorder. Officially, this means your doctor considered and excluded other causes for panic attacks, like phobias or PTSD or OCD, but also medical causes like drugs (caffeine, stimulants like Ritalin or Adderall or cocaine, steroids, and others) and medical conditions like hyperthyroidism or pheochromocytoma. We especially want to think about hormone transitions like starting to menstruate, pregnancy, postpartum, and perimenopause, since these transitions can sometimes trigger anxiety and/or panic attacks.
Sometimes the first panic attack occurs in an obviously traumatic or stressful situation. But sometimes it occurs out of the blue. Patients (and doctors) often look hard for the reason why, believing that understanding the meaning behind someone’s anxiety will help resolve the anxiety. Sometimes that’s true, particularly when the anxiety attacks occurred in the context of trauma.
More often, once panic attacks start, they can just happen anytime. Searching for the “why” is less productive than making a plan for how to manage them when they occur, and deciding not to let them keep you from living a good life and doing what you want to do.
The most effective form of therapy for panic attacks is Cognitive-Behavioral Therapy (CBT). Good CBT therapists have had specialized training in understanding and addressing anxiety in a way that helps you change the way you think about anxiety, and then change your behavior. My favorite type of CBT is called Acceptance & Commitment Therapy (ACT).
The big change is moving from just wanting the anxiety to go away and never come back to accepting that anxiety is not under your control, but your behavior is something you can choose. Here’s a typical clinical example. Sophie is a 25-year-old teacher. She has always been on the anxious side, very conscientious, plans ahead and tries to be prepared. Over the last few months, she started to have panic attacks that last about 15 minutes. At first, they happened when she was getting ready for school on Sunday nights or Monday mornings. She knew things were stressful at school and blamed that, so she tried to relax and tell herself there was nothing wrong. But then they started to happen during the school day. She was petrified that her students would notice and she’d lose control of her classroom. She’d feel tongue-tied, dry mouth, shaky, sweaty. She’d try to direct them to do some independent work while she got some water and sat down at her desk. But what if this meant she couldn’t be a teacher anymore? What if someone complained? What if they thought she was mentally unstable? Could she be fired? Or worse, what if she was mentally unstable? What if they had to call an ambulance and take her to a hospital? No parent would want her to teach their children. Her career would be over.
All these thoughts would cycle through her head while she was having the physical symptoms of the panic attack. It took everything she had not to run down the hallway and tell the principal she was ill and needed to leave. But her mom had also had panic attacks, so she knew what they were. How could she get them to stop?
We used a two-prong strategy. First, I educated her about panic attacks and panic disorder. It turns out that while panic attacks may feel different in different people, they usually follow the same cycle in an individual person. I had her write out the sequence of what she noticed and thought as her panic attacks started, continued, and ended. We figured out that they usually lasted 10-15 minutes. Then I taught her two simple physical strategies: Diaphragmatic Breathing (DBr), and Progressive Muscle Relaxation (PMR). The goal was for her to practice these techniques three times a day when she wasn’t having a panic attack, and then to start using DBr as soon as she felt a panic attack start. If the situation permitted, she could use PMR as well.
This was her strategy. When she noticed a panic attack start:
NAME IT. Inside her head or out loud, she would say, “Dang, it’s another panic attack. I can feel myself getting shaky, dry mouth, sweaty. I know what this is.”
ACCEPT IT. Instead of fighting it off, she’d say, “Okay anxiety, if you need to give me a panic attack, go ahead. I know what this is, it usually takes about 15 minutes, and I’m just going to wait it out and then get back to teaching (or driving or shopping or whatever she was doing).
BREATHE. She would start her DBr practice: counting to ten slowly while breathing in through her nose, counting to ten slowly while breathing out through her mouth, trying not to lift her shoulders, feeling her lower chest and abdomen push out as her diaphragm moved down and the lowest parts of her lungs filled up with air.
STOP AVOIDING. Anxiety would tell her she needed to escape: get out of the classroom, out of the store, whatever. Sophie would accept that feeling but not act on it. “Okay brain, I can’t control this anxiety, but I can choose to stay right here and let it wash over me.” If she was with a supportive person, she might let them know that she was having an anxiety attack and it would probably take 10-15 minutes to pass. If she was alone, she might look at the clock and remind herself that it would pass, and try to distract herself in the meantime. If she was teaching, she’d take a sip of water, keep breathing, and sit down if needed.
REGROUP. As the anxiety thoughts and sensations subsided, she got back to whatever she was doing when the panic attack hit. She would remind herself that this was the usual pattern, and she’d waited out another one successfully.
Once she had the pattern down, she gained more confidence. She started to notice that as soon as she felt like a panic attack was starting, she could go right to acceptance, start diaphragmatic breathing, and remind her brain that she wasn’t going to stop what she was doing or leave. Often instead of getting a panic attack, she would feel the shakiness and anxiety start to subside within a few minutes, and she felt more hopeful. She also felt more comfortable going to school in the morning, knowing she was prepared if a panic attack hit. And she told a few friends that she sometimes had panic attacks, but that she knew how to manage them. That helped her feel less weird and helpless. And over the next few months, the panic attacks became less frequent and eventually stopped.
I wish I could tell you that Panic Disorder is curable. In some people, panic attacks never come back. But in many people, even after many years, a random panic attack pops up and scares them before they remember the old familiar thoughts and physical symptoms. Don’t panic! Research shows that patients who have learned to manage their panic attacks without sedating medications can usually restart their old cognitive-behavioral strategies quickly, and not have to suffer from a severe episode of panic attacks again. So don’t panic about panic attacks – accept them and commit to learning how to manage them! And if you need some DIY help, check out these books:
https://www.amazon.com/Get-Your-Mind-Into-Life/dp/1572244259
https://www.amazon.com/Panic-Attacks-Workbook-Program-Beating/dp/1569754152
https://www.amazon.com/Anxiety-Cure-Kids-Parents-Children/dp/0471263613