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Panic Attacks

by Mike on June 30, 2008

A panic attack is a sudden surge of overwhelming fear that comes without warning and without any obvious reason. It is far more intense than the feeling of being “stressed out” that most people experience. 

Symptoms include a pounding heart, sweating, shortness of breath or a feeling of choking, feelings of unreality and the fear of going crazy or dying. In addition to these and other symptoms, a panic attack is marked by 

  • occurring suddenly, without any warning and without any way to stop it
  • the level of fear is way out of proportion to the actual situation, and is often completely unrelated
  • it passes in a few minutes, however, repeated attacks can continue to recur for hours

Panic attacks affect from 9.1 million to 17 million people in the United States. Women are up to three times as likely to have panic attacks as men.

While the exact causes of panic attacks are not known, a great deal of research is being done on the subject. Prominent among the suspected causes are inappropriate activities of the amygdala part of the brain; the actions of serotonin, a brain chemical; and learned responses to stressors.

Long-term treatment for panic attacks is the same as for Panic Disorder. Treatment while a panic attack is happening include relaxation and breathing techniques.

What is the criteria for diagnosis of a panic attack?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association lists the following criteria for a panic attack: (1)

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

1. palpitations, pounding heart, or accelerated heart rate

2. sweating

3. trembling or shaking

4. sensations of shortness of breath or smothering

5. feeling of choking

6. chest pain or discomfort

7. nausea or abdominal distress

8. feeling dizzy, unsteady, lightheaded, or faint

9. derealization (feelings of unreality) or depersonalization (being detached from oneself)

10. fear of losing control or going crazy

11. fear of dying

12. paresthesias (numbness or tingling sensations)

13. chills or hot flushes

Panic attacks reach a crescendo within ten minutes and typically last fifteen minutes. However, they may recur rapidly, and once the symptoms abate, a severely anxious state may not remit for several hours.

In contrast to the criteria for diagnosis above, a Limited-Symptom Attack is a panic attack that meets all criteria for a “full-blown” panic attack, but has fewer than four of the listed symptoms. These are very common in people with Panic Disorder, though they do happen to people without Panic Disorder. Limited-Symptom Attacks have a lifetime prevalence of about two percent, so their significance to Panic Disorder remains uncertain. Full-blown panic attacks are generally associated with a greater likelihood of Panic Disorder.(2)

What is the prevalence of panic attacks?

Lifetime prevalence of panic attack estimates range from 3 to 5.6 percent of the American population — from 9.1 million to 17 million people. Compare these numbers to the estimated prevalence for Panic Disorder of 1.5 to 5 percent, or 4.6 million to 15.2 million Americans.(3)  The difference is 1.8 million to 4.5 million people who have panic attacks but do not have Panic Disorder. 

The American Psychological Association estimates that one in seventy-five people experience panic attacks. They say that some people see ten or more doctors before they are properly diagnosed, and that only one out of four people receive treatment.(4) One study found that panic attack sufferers used healthcare services, such as physicians, emergency rooms and psychiatric services, more than any other psychiatric diagnosis.(5) 

Women are up to three times as likely to be affected with panic attacks as men. They have double the rate of recurrence of panic attacks after a reduction in the severity of attacks or a temporary disappearance of symptoms of the condition. Low education status is connected with a higher incidence of panic attacks. The incidence is generally lower in people who work, are married, and who do not live alone.(6)

The most common age of onset of panic attacks is the mid-teens and early adulthood. However, they may begin at any time, with the maximum risk being between the ages of 25 to 44 years.(7)

Why does it take so long to diagnose panic attacks?

As stated above, many panic attack sufferers see ten or more doctors before they are properly diagnosed. Panic attacks mimic a number of physical conditions, so many physicians perform extensive medical check-ups as they unsuccessfully evaluate one after another possible physical causes for the attacks.

These include heart problems such as cardiac arrhythmia and mitral valve prolapse; pulmonary disorders like asthma, hypoxia and embolism; endocrine disorders such as thyroid disease and hypoglycemia; seizures due to epilepsy or Parkinson’s disease; substance-related effects due to caffeine, cocaine, alcohol and drug withdrawal, and barbiturates; and other physical maladies.

Due to the prolonged attempts of physicians to diagnose a person’s complaints and the helplessness associated with panic attacks, many are at a particular risk of developing depression. As many as thirty percent of those suffering Panic Disorder develop major depression during or after the onset of panic attacks. (8)

Despite the necessity of a full medical assessment of a patient’s physical condition to rule out physical causes for the attacks, a complete psychological assessment is also required as a part of the diagnostic process. This is often not done until all other routes to diagnosis are exhausted.

What are the symptoms of a panic attack?

Panic attacks are by their nature subjective experiences, and like all subjective experiences, are open to the interpretation and description of the sufferer. Aside from the symptoms listed above from the DSM-IV criteria for diagnosis, Wikipedia has an informal compiled list of symptoms grouped under the physical, mental, emotional and perceptual headings: (9)

Physical

  • A sensation of adrenaline going through your entire body
  • Sweating
  • Shortness of breath (dyspnea)
  • Stomach Problems (spastic colon)
  • Racing or pounding heartbeat or palpitations
  • Chest pain
  • Dizziness or vertigo
  • Headache
  • Lightheadedness
  • Nausea or stomach pains
  • Hyperventilation
  • Choking or smothering sensations
  • Hot flashes
  • Cold flashes
  • Tingling or numbness in the hands, face, feet or mouth (paresthesia)
  • Feelings of “crawly,” “itchy,” or “cringy” skin sensations.
  • Burning sensations
  • Trembling or shaking
  • Feeling of claustrophobia
  • Feeling like the body is shutting down and/or dying
  • Tremors in the legs and thighs
  • Tingling spine
  • Feeling like one is experiencing a heart attack
  • Exhaustion
  • Muscle spasms
  • Feeling of physical weakness or limpness of the body
  • Grinding teeth or tensing other muscles repeatedly or for prolonged periods of time
  • Temporary blindness
  • Sizzling or ringing in ears

Mental

  • Intense and/or frightening realizations of reality
  • Loss of the ability to react logically to stimuli
  • Loss of cognitive ability in general
  • Racing thoughts (often based on fear)
  • Irrational thoughts
  • Loud internal dialogue
  • Feeling like nothing is real
  • Feeling of impending doom
  • Feeling of “going crazy”
  • Feeling out of control
  • Feeling like no one understands what is happening
  • Vision is somewhat impaired (eyes may feel like they are shaking.)
  • Feeling like you are going to die any second
  • Avoidance behavior
  • Agoraphobia

Emotional

  • Terror, or a sense that something unimaginably horrible is about to occur and one is powerless to prevent it
  • Fear that the panic is a symptom of a serious illness
  • Fear that the panic will not subside
  • Fear of losing control
  • Fear of death
  • Fear of living
  • Fear of going crazy
  • Flashbacks to earlier panic trigger
  • Intense “scared” feeling
  • Fear of failure

Perceptual

  • Tunnel vision
  • Heightened senses
  • The apparent slowing down or speeding up of time
  • Dream-like sensation or perceptual distortion (derealization)
  • Dissociation, or the perception that one is not connected to the body or is disconnected from space and time (depersonalization)
  • Feeling of loss of free will, as if acting entirely automatically without control

What are the causes of panic attacks?

Many of the causes of panic attacks are virtually the same as those for Panic Disorder (please see Panic Disorder in the Information sidebar). The following discusses causes specific to panic attacks. But causes are not the same as triggers for panic attacks, so triggers are covered in a separate section.

Like Panic Disorder, it is not known exactly what causes panic attacks or why some people are more susceptible than others. There are some who believe that the causes are entirely in the brain and body, and there are others that reject this to say that the causes lie mostly in a person’s environment and their reaction to it. 

Medical and psychiatric researchers are actively seeking the root causes of panic attacks in the body, brain and genes, and they are discovering some intriguing hints. Most center around the parts of the brain called the amygdala and locus ceruleus, and the neurotransmitter serotonin.

Other researchers are working on how a person’s past and present environment cause them to react to it with panic attacks. 

Most psychologists and psychiatrists believe that panic attacks are related to both human anatomy and psychology. The interplay between inherited genetics, brain chemistry, a person’s past and present environment is what causes a panic attack.

Biological Causes of Panic Attacks

Researchers recently have been intensively studying the role of the brain’s amygdala region in panic attacks. The amygdala is a small, almond-shaped group of neurons located deep within the brain. It performs a primary role in the processing and memory of emotional reactions. Among its functions is to trigger the “fight or flight” response, which prepares the body for dealing with a perceived danger or a stressful event. It is believed that in panic attacks, a hyper-inflated “fight or flight” response is the cause of the great fear of imminent danger in panic attacks. This sends adrenaline streaming through the body, producing many of the symptoms listed as diagnostic criteria by the DVM-IV.

Some researchers believe that there is a precursor over-activity in the part of the brain called the locus ceruleus. It is a nucleus in the brain stem involved in the physiological responses to the sleep-wake cycle, arousal, anxiety and fear.(10) Scientists speculate that people who have panic attacks unwittingly send alarms to the locus ceruleus via norepinephrine, a chemical messenger produced by the hippocampus. The locus ceruleus overreacts to the perceived danger and sends messages to the amygdala to trigger the “fight or flight” response.(11)

Research has also shown that there is a “fear network” in the brain that involves the amygdala, the hypothalamus, and the brainstem centers. This is called the Neuroanatomic Model of panic attack, and it suggests that panic attacks are mediated by this “fear network.” (12)

Other portions of the brain have been shown to have activity during a panic attack. According to a report by Fischer, a person having a PET scan had a panic attack which was recorded. She showed decreased activity in the right orbitofrontal, prelimbic, anterior cingulate, and anterior temporal cortices.(13)

Research is proceeding at a rapid rate, with new reports appearing seemingly every week. Other models of the causes of panic attack in the brain currently are:

Serotonin is a chemical in the brain believed to be involved in panic attacks. It effects were first discovered due to the positive effect SSRI antidepressant drugs had upon Panic Disorder. It is not understood in what way it is involved, however. Recent research is beginning to clarify the interaction between norepinephrine, another brain chemical, and serotonin, indicating that  serotonin may regulate norepinephrine in the locus ceruleus, thus providing the connection between the very beginning of a panic attack and its escalation by the locus ceruleus.(14)

It is also thought that the overproduction of the hormonal/adrenal glands may be a source of physical symptoms. Another adrenaline-related theory posits that there is a hypersensitivity in the brain to adrenaline pumped into the body by the amygdala’s “fight or flight” reaction to stress.

Lactate is suspected to cause symptoms of panic attacks due to the body’s metabolism being put out of balance by the chemical.

The false suffocation carbon dioxide hypothesis explains panic phenomena by hypersensitive brainstem receptors. This would explain the sensation of choking, not being able to breathe, or hyperventilation.

The Gamma-Aminobutyric (GABA) model suggests that receptors in the brain that normally would inhibit the escalation of a panic attack are not functioning properly. The difficulty in directly measuring activity at these receptors in the brain has hindered research.

Genetic research is continuing its effort to connect panic attacks to a specific genetic marker, but without a definitive success to date. Panic attacks have been shown to run in families, however.

Environmental Causes of Panic Attacks

Psychiatric researchers are working on how a person’s past and present environment causes them to have what is called (in Freudian terms) “a deficit in their stimulus barrier.”(15) The person seems to have a heightened sensitivity to the environment and reacts more strongly to the stimuli around them, such as words, noises, action, movement, smells and sights. This deficit makes these stimuli more difficult to shut out than it is for other people. Some feel that this heightened sensitivity brings on memories of helplessness and fear from early childhood.

There is also evidence that panic may be a learned response and that the attacks can be initiated in otherwise healthy people simply given the right set of circumstances. This is called the Learning Theory and has proceeded from research in Behavioral Therapy.

Often, the first attacks are triggered by physical illnesses, a major life stress, or perhaps medications that increase activity in the part of the brain involved in fear reactions. An increase in the frequency of panic attacks has been seen in some women during pregnancy. Study is going forward to list and investigate these suspected causes.

Predisposing Causes for Panic Attacks

Panic attacks, as well as Panic Disorder, tends to run in families. This may mean that genetic inheritance has a bearing on who will have them. About twenty to 25 percent of people experiencing panic attacks have close relatives with Panic Disorder. (16)

Having other Anxiety Disorders, such as Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Post Traumatic Stress Disorder, and Specific Phobias seem to predispose people to having panic attacks.

What are the triggers for panic attacks?

Psychologists group panic attacks into three types: unexpected, situationally bound, and situationally disposed.(17) Scientists do not know why one event or situation will trigger a panic attack in one person and not in another. Triggers are highly individualized and can only be given a general discussion.

Unexpected panic attacks occur spontaneously and for no clear reason. They might even occur when a person is relaxed or asleep. The reason for these is shrouded in mystery. Most scientists explain them based on the biological causes for panic attack discussed above.

Situationally bound panic attacks are consistently triggered by a specific situation, such as crossing a bridge or being in a crowded sports event. This type of panic attack almost always occurs immediately after one are exposed or anticipate being exposed to the feared situation. Avoidance of this type of triggering situation or event tends to build up over time. For example, a person might have a panic attack crossing a bridge, then start having a panic attack in busy traffic, then when riding or driving a car under any conditions.

Situationally predisposed panic attacks are similar to situationally bound panic attacks. They are triggered by a specific situation. However, the difference is that the attacks only sometimes occur. Another difference is that they don’t always occur immediately after exposure to the feared situation. For example, if a person’s trigger is public speaking, there are times when they can give a speech without having a panic attack and other times when the panic attack only starts after they have already been speaking for 15 minutes.

Physical and psychological causes of panic disorder work together to create triggers. Although initially attacks may come out of the blue, eventually the sufferer may actually help bring them on by responding to physical symptoms of an attack, leading to situationally bound and predisposed panic attacks. For example, if a person with panic disorder experiences a racing heartbeat caused by drinking coffee, exercising, or taking a certain medication, they might interpret this as a symptom of an attack and, because of their anxiety, actually bring on the attack. 

On the other hand, coffee, exercise, and certain medications sometimes do, in fact, cause panic attacks. One of the most frustrating things for the panic sufferer is never knowing how to isolate the different triggers of an attack. 

Stressful life events can trigger panic attacks, such as a recent loss or separation, a birth, death or job move. It is noted that pregnant women sometimes have panic attacks. Some researchers liken the “life stressor” to a thermostat: When stresses lower one’s resistance, the underlying physical predisposition kicks in and triggers an attack.

What are the side effects of panic attacks?

Without treatment, panic attacks can have very serious consequences. In short order, they can lead to a “full-blown” Panic Disorder (see the Panic Disorder reference) and then on to Agoraphobia.

The immediate danger of panic attacks is that they can quickly lead to a phobia. Because a person has suffered a panic attack in one situation, they may start avoiding similar situations. Many people experiencing panic attacks show “situational avoidance” associated with them. For example, if one has a panic attack in a crowded store, they may go on to avoid crowded parties, then any kind of gathering with a large number of people, and then decreasingly smaller numbers of people. The fear of an attack is so debilitating that the person eventually prefers to spend their life locked inside their home rather than face the triggering situations. By this point, the person likely has diagnosable Panic Disorder with Agoraphobia.

Even if these extreme phobias do not develop, one’s quality of life can be severely damaged by untreated panic attacks. A recent study showed that people who suffer from panic attacks: (18)

  • Are more prone to alcohol and other drug abuse
  • Have greater risk of attempting suicide
  • Spend more time in hospital emergency rooms
  • Spend less time on hobbies, sports and other satisfying activities
  • Tend to be financially dependent on others
  • Report feeling emotionally and physically less healthy than non-sufferers.
  • Are afraid of driving more than a few miles away from home

Panic attacks can have economic effects, as well. Some people give up jobs that require a situation they are avoiding, such as air travel or a crowded office, and have to take jobs earning much less. Others lose their jobs entirely and have to rely on public assistance or family members.

Are panic attacks dangerous?

Only if you faint and hit your head, or have one while driving, like I have. Otherwise, absolutely not.

Dr. David Carbonell, a popular author who writes about panic attacks, holds that panic attacks and Panic Disorder are a “trick” played on the unsuspecting sufferer. It tricks a person into thinking that a panic attack is hazardous to health. It makes them think that they are having a heart attack, or going insane, that their tremors and fainting puts them at death’s door. (19)

The only situation in which panic attacks can be dangerous is when they mimic and mask a real physical condition. For example, if one has undiagnosed heart disease and knows that their panic attacks mimic a heart attack, they may be less inclined to have a physical checkup.

What is the treatment for panic attacks?

The long-term treatment is the same as for Panic Disorder. Persons experiencing panic attacks are urged to seek treatment with a mental health care professional as soon as possible.

Short-term treatment mostly consists of taking care of the symptoms of the panic attack. There are many sources of suggestions, but they can be summarized as:

  • Gently reassure yourself that you are not dying or going crazy. Take deep breaths and repeat this to yourself mantra-like. 
  • Learn and recall the symptoms of panic attacks and one-by-one identify each one you are having, all the while reassuring yourself that the attack will only last a short while.
  • If you are concerned about not being able to breathe or you are choking, tell yourself that if you can talk, you can breathe. Relax your muscles and slow down your breathing. Take deep breaths, hold them and let them out slowly as if blowing out a candle.
  • For trembling and shaking, or numbness and tingling sensations, try shaking the arms and/or legs to help relax the muscles. Tell yourself that the tingling and numbness are caused by the body’s “fight or flight” reaction, which redirects blood to the lungs, brain and large muscles and away from the extremities.
  • If you are nauseated or feeling dizzy and faint, try to find a quiet place to sit down and put your head between your knees. Lacking that, seek something that you can steady yourself on, breathe deeply and relax your muscles.
  • Relax your muscles, particularly in the shoulders and neck. Become conscious of any tension that you may be feeling in your muscles. Then progressively tense and relax all the large muscle groups. For example, tighten the muscles in your left leg with a deep breath in, hold it, then release the muscles. Proceed with the right leg, then move up the body, one muscle group at a time.
  • If you are hyperventilating or over-breathing, hold your breath for as long as you comfortably can to prevent the dissipation of carbon dioxide. If you hold your breath for a period of between 10 and 15 seconds and repeat this a few times, it will be sufficient to calm hyperventilation quickly. Alternatively, breathe in and out of a paper bag, which causes you to inhale the carbon dioxide you exhaled. This may not be possible under some situations.
  • Slow down your breathing. This may be done by blowing out each breath through pursed lips as if blowing out a candle. Also, place your hands on your stomach to feel the rapidity of your breathing. 

It cannot be emphasized enough that if you are having panic attacks, you need to seek help as soon as possible. Panic attack treatment has one of the highest success rates of all mental health treatments. Panic attacks can rapidly escalate into Panic Disorder and Agoraphobia, and a quickly deteriorating quality of life if left untreated.

FOOTNOTES

(1) DSM-IV is the abbreviation for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, which is a publication of the American Psychiatric Association. It is a primary American source for mental health professionals that lists categories of mental disorders and the criteria for diagnosing them. It is used by clinicians and researchers, insurance companies, pharmaceutical companies and policy makers. The American Psychiatric Association has more information on the DSM-IV.

(2) Overcoming Anxiety. (2008). Panic Attack: Symptom, Treatment and Panic Cure. Retrieved Jun 30, 2008 from Overcoming Anxiety Web site:  http://www.overcominganxiety.org/panic-disorder/panic-attack.html

(3) Daniels, Colin Y. (2006). Panic Disorder. Retrieved Jun 30, 2008 from eMedicine Web site: http://www.emedicine.com/med/TOPIC1725.HTM

(4) American Psychological Association. (2008). Answers to Your Questions About Panic Disorder. Retrieved July 5, 2008 from American Psychological Association Web site: http://www.apa.org/topics/anxietyqanda.html

(5, 6, 7, 8.) BrainExplorer.org. (2008). Panic Disorder. Retrieved July 4, 2008 from BrainExplorer.org Web site: http://www.brainexplorer.org/brain_disorders/Focus_Panic_disorder.shtml

(9) Wikipedia. (2008). Panic attack. Retrieved June 28, 2008 from Wikipedia Web site: http://en.wikipedia.org/wiki/Panic_attack

(10) Psychology Today. (2006). Locus ceruleus and panic/anxiety. Retrieved July 7, 2008 from Psychology Today Web site: http://psychologytoday.psychtests.com/articles/mentalhealth/pd_lc.html

(11) Sichel, Mark. (2008). The Biochemistry of Panic. Retrieved July 4, 2008 from HealthyPlace.com Web site: http://www.healthyplace.com/Communities/Anxiety/causes_3.asp

(12) Daniels, Colin Y. (2006). Panic Disorder. Retrieved June 30, 2008 from eMedicine Web site: http://www.emedicine.com/med/TOPIC1725.HTM

(13) Fischer, Hakan. (1998). Brain correlates of an unexpected panic attack: a human positron emission tomographic study. Retrieved July 4, 2008 from ScienceDirect Web site: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T0G-3TDS03P-K&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=bed3713a2dd8cbd9df13d662b0b1806b

(14) Boyd, Mary Ann; Psychiatric Nursing: Contemporary Practice. Hagerstown, MD: Lippincott Williams & Wilkins. 2007.

(15) Yorke, Clifford. (1986). Reflections on the Problem of Psychic Trauma. Retrieved July 6, 2008 from Circumcision Reference Library Web site: http://www.cirp.org/library/psych/yorke/

(16) Sichel, Mark. (2008). op cit

(17) Smith, Melinda. (2006). Panic Attacks, Panic Disorder and Agoraphobia: Symptoms, Causes and Treatment. Retrieved July 6, 2008 from HelpGuide.org Web site: http://www.helpguide.org/mental/panic_disorder_anxiety_attack_symptom_treatment.htm

(18) American Psychological Association. (2008). op cit

(19) Carbonell, David.; Panic Attacks Workbook: A Guided Program for Beating the Panic Trick. Berkeley: Ulysses Press. 2004.

Further Reading:

Bourne, Edmund J.; The Anxiety & Phobia Workbook. Oakland, California: New Harbinger Publications. 1990. Fourth Edition, 2005.

Burns, David D. When Panic Attacks: The New, Drug-Free Anxiety Therapy That Can Change Your Life. New York: Morgan Road Books. 2006.

Ellis, Albert. How to Control Anxiety Before It Controls You. New York: Citadel Press. 2000.

Reviewed 12/05/08