Vladimir Bostanov, PhD

(The article was printed in the hOUR THERAPY bulletin in 2024)

A single young man wakes up in the middle of night, feeling immensely sick, sensing that he is in grave danger. Something very bad is happening with his body. He is feeling nauseous, shaky and dizzy, sweating profusely, his heart pounding. The whole experience has a sinister, dreamlike quality, like a nightmare, although he knows he is awake. He thinks he might be dying.

He stands up only to find he is very unstable on his trembling feet. Struggling to keep his balance, he goes to the bathroom and looks in the mirror. The reflected image confirms his darkest suspicions. He sees a face with yellow-grayish skin and black circles around feverish eyes. A cold, rational voice in his head comments: "Well, at least one vital organ system is failing. Maybe the kidneys, or the liver, or the lungs... Maybe this is the end.". Then, he makes a very important decision: he will not call an ambulance, he will not call his father or his sister. He just pulls out the key from the lock of the apartment door, so that it would not have to be broken in the event of his death, and he goes back to bed.

Waking up in the morning, still alive, but also still feeling profoundly sick, he packs a small bag with some clothes, underwear, a toothbrush, and all else needed for spending a long time in hospital, and goes to a medical clinic for a thorough physical examination. To his amazement, it does not show any anomalies in any physiological function. His GP is less puzzled. "Have you also visited a psychiatrist?", he asks. In the psychiatrist's office, the mystery is finally solved. "Have you had a lot of stress recently?", she asks. "At work, maybe?". Sure, there has been a lot going on in the office lately, but he has already endured such times in the past. He is a high achiever, well-trained, experienced, and pretty resilient. "Something in the family then?". Yes. He lost his mother a month ago to brain cancer. "I think, you had a panic attack", concludes the psychiatrist.

What is a panic attack?

Approximately, one in eight people experience at least one panic attack in the course of their life (women are at twice greater risk than men). The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), defines a panic attack as:

"An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or 'going crazy.'
13. Fear of dying."

The World Health Organization's International Classification of Diseases, tenth Revision (ICD-10) provides a very similar definition. However, one or even a few panic attacks, are not necessarily seen as a problem. ICD-10 sets minimal severity and recurrence requirements as diagnostic criteria for panic disorder, while DSM-5 goes even further, leaving the possibility of repeated panic attacks that do not constitute a disorder, if at least one additional criterion is not met. These additional symptoms and features are critical for understanding the significance of panic attacks for a person's mental health. While panic attacks are usually short-lived, it is the chronic stress due to changes in one's, mood, emotions, perceptions, thoughts and behavior between the panic attacks that causes the most suffering. Furthermore, some of these changes are also instrumental in causing, maintaining and perpetuating the panic attacks. For these reasons, "clinically significant distress impairment in social, occupational, or other important areas of functioning" is required by DSM-5 as an additional diagnostic criterion for most mental disorders in general and for anxiety disorders in particular.

Types of panic attacks

An important feature of panic attacks is whether they are expected or unexpected. Repeated, unexpected panic attacks can be a symptom of a panic disorder, if they are followed by "persistent concern or worry about additional panic attacks or their consequences, or by a significant maladaptive change in one's behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)" (DSM-5). On the other hand, if panic attacks only occur in a certain type of situations — and are thus expected — they may be a symptom of another mental disorder. Such specific, feared situations may be, for example: being in public, or in open or enclosed spaces in agoraphobia; social situations in social phobia; intense worry in generalized anxiety disorder. Furthermore, panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders). And, to reiterate, they can even occur outside any disorder if they do not cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning" (DSM-5).

Causes of panic attacks

We have seen that, while panic attacks constitute the defining symptom of panic disorder, they also can be experienced by people suffering from other anxiety or depressive disorders. Moreover, about 80% of the people with panic disorder have also at least one other mental disorder — usually anxiety and/or depression — in the course of their life. But what makes us vulnerable to these emotional disorders? A major, non-specific factor is our tendency to experience a variety of negative emotions across a variety of situations. It is believed that 30-50% of such negative temperament is predetermined genetically, while the rest is acquired, i.e. learned, mostly from our parents, but also through other (negative) experiences in childhood. Secondary factors influence whether these negative emotions take the shape of anxiety or depression (or both), and whether the anxiety is expressed as constant worries, or as intense fear of specific situations (or both). In the case of panic attacks, one such specific factor is the "fear of fear", or more precisely the fear of the bodily manifestations of anxiety and fear.

How does this fear of fear work? If a person interprets a normal physiological response to physical or emotional stress, (e.g. accelerated heart rate, sweating, shortness of breath, dizziness, etc.) as a possible medical symptom, this person gets scared. But the (normal) physiological expression of fear produces more of these same "symptoms", and possibly even new ones, which in turn frightens the person experiencing them even more, and so on. This vicious cycle is responsible for the rapid increase of fear to a maximum level — which is panic. Through the traumatic experience of the initial panic attack (possibly amplified by previous experience of respiratory or other serious disease in childhood), this person learnes to interpret even small changes in nervous arousal as health/life-threatening. The learning process may be unconscious: a strong, automatic fear response is established by the association between the initial weak arousal and the following full-blown panic attack. But it can also have a powerful cognitive component: developing firm wrong beliefs about normal physiological reactions — that they are bad, dangerous and health/life-threatening.

The fear of fear is closely related to an important class of behaviors that represent both a symptom and a maintaining factor of the occurrence of panic attacks. This perpetuating factor is avoidance. People suffering from panic attacks try to prevent them from happening by avoiding both feared situations and the inner experience of anxiety and fear (experiential avoidance). Not only does such behavior cause a lot of suffering by the resulting "impairment in social, occupational, or other important areas of functioning" (DSM-5), but it also blocks and prevents new, therapeutic, learning experience. The person avoiding feared situations and inner experiences cannot learn that allowing and accepting them will not cause any physical or mental heath damage (e.g. having a heart attack, "going crazy"). Thus, the status quo is maintained and the panic attacks continue to occur.

Other factors that can trigger the occurrence of panic attacks are: current negative life events, chronic stress, and substance abuse. Chronic stress can be caused by a variety of circumstances including a physical illness, but also — as already mentioned — another mental disorder. Moreover, panic attacks can be directly induced by certain medical conditions and by many substances, including both legal and illegal drugs.

Therapy of panic

General measures and pharmacological treatment

The aforementioned causes for panic attacks also represent natural targets of therapeutic interventions. Adequate medical treatment of any acute or chronic physical illness causing substantial suffering can influence positively psychological symptoms including panic attacks. Substance abuse should be a priority target of any pharmacological and psychological treatment. If panic attacks appear to be a secondary symptom of another mental disorder, the latter should be addressed by therapeutic interventions.

Modern antidepressant medications like selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are pretty effective in the treatment of various emotional disorders, including anxiety and panic disorders. Unfortunately, however, their effect tends to last so long as patients continue to take them. Once they get off the medication, symptoms often come back. Psychotherapy, generally, produces more lasting effects, because clients learn new knowledge, attitudes and skills that help them change and thus overcome suffering.

Psychotherapy

The fear of fear and the resulting avoidance behaviors described above represent the main targets of modern cognitive behavioral therapy (CBT). The simplest cognitive intervention is psychoeducation. It does not even necessarily require a psychotherapist. It may already start in the emergency department where you landed after having called an ambulance, fearing for your life. A physician's reassurance — that you are not dying, you are not having a heart attack or a stroke, you are actually in good physical health, you have just had a panic attack — provides important first knowledge about what is happening. Further (online) research and reading can deepen your intellectual understanding of the phenomenon and thus challenge your belief that you are in grave danger. Such rational knowledge, however, is usually not enough to overcome the acquired irrational fears and to change the learned avoidance behaviors.

Further cognitive and behavioral treatment components facilitate learning at an experiential level. They are aimed at breaking the learned associations between normal, harmless physical arousal and feared consequences, the latter including both real panic and imagined physical/mental health damage. They necessarily include some kind of exposure to feared situations and experiences. Most of us have certainly heard that "you have to face your fears in order to overcome them". This is exactly what happens in therapy. You gradually learn to allow and accept feared situations and experiences. Learning by exposure may include purposefully triggering panic-like sensations by simple exercises like, for example, raising your heart rate and blood pressure by physical exertion; getting nauseous by spinning on an office chair; getting dizzy and nauseous by hastened breathing (hyperventilation) or spinning, etc. An inner attitude of radical acceptance during these and other exposure exercises is of critical importance. It is an active and willful stance which is very different from passive endurance. The cultivation of radical acceptance can be greatly facilitated by mindfulness training which has become a central component in the treatment of emotional disorders.

Other therapeutic approaches can also be effective in treating panic and anxiety. CBT, however, has been studied most extensively, and has provided the most systematic evidence for its efficacy (at least regarding the anxiety disorders).

Summary

Panic attacks can be normal reactions to acute or chronic stress. Returning to the case of the young man we presented in the introduction: this person never experienced another panic attack after the first one. He took a very active stance while it was happening by accepting his fate, whatever it may be, thus refusing to succumb to fear. The minimal psychoeducation provided by the psychiatrist, followed by a short pharmacological treatment, completed the job of preventing the panic from becoming a chronic debilitating disorder. Unfortunately, however, there are a lot of us who are not that lucky. We learn to fear the panic with its extremely unpleasant physical manifestations, and the anxiety becomes the master of our lives with all the destructive consequences for our relationships, career, well-being, etc. The good news for all of us who suffer from panic and/or other emotional disorders is that there are very effective therapeutic approaches that have proved successful in the treatment of these disorders. Such therapies have helped and continue helping a lot of people overcome their suffering caused by fear, and gain back their freedom and happiness.

References:

• American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition, text revision. Washington: American Psychiatric Association, 2022.
• World Health Organization. The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. World Health Organization, 1993.
• Barlow, David H., editor. Clinical handbook of psychological disorders: A step-by-step treatment manual, sixth edition. Guilford publications, 2021.