Panic Attacks: Symptoms and How to manage them?

Panic attack is characterized by intense fear and terror usually manifested in the form of debilitating physical symptoms. Panic attacks can be extremely distressing, especially when one is experiencing them multiple times every week. Onset of panic attack can be sudden or can first be triggered when a person is experiencing stress. Panic attacks can also result in agoraphobia; the fear of public spaces, not being able to step out of the comfort of home etc.

Contents of the Article

1. Symptoms and Diagnostic Guidelines of Panic Disorder

2. Prevalence of Panic Disorder

3. Causes of Panic Disorder

4. Understanding Panic Attacks: Cognitive Behavior Therapy Perspective

5. Maintenance of Panic Disorder: Cognitive Behavior Therapy Perspective

6. Catastrophic Misinterpretations

7. Treatment

8. Strategies That Help in Managing Panic Panic Attacks

Symptoms and Diagnostic Guidelines of Panic Disorder

Diagnostic Statistical Manual-V guidelines for panic disorder are as follows:

A. Recurrent unexpected panic attack. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes during which four or more of the following symptoms must be present:

1. Increased heart rate, palpitations, pounding heart

2. Sweating

3. Trembling or shaking

4. Shortness of breath

5. Feelings of Choking

6. Chest pain or discomfort

7. Nausea or abdominal discomfort

8. Feeling dizzy, unsteady, light-headed

9. Chills or heat sensations

10. Paresthesia (numbness or tingling sensations)

11. Derealization (feelings of unreality) and depersonalization (being detached from one-self).

12. Fear of losing control or going crazy

13. Fear of Dying

B. At least one of the attacks has been followed by 1 month or more of one or both of the following

1. Persistent concern or worry about panic attack or their consequences

2. A significant maladaptive change in behavior related to the attacks; such as avoidance of public spaces or unfamiliar situations or any other situation that they think might bring about a panic attack.

C. The disturbance is not attributable to the physiological effects of a substance.

D. The disturbance is not better explained by another mental health disorder.

Prevalence of panic disorder

In a cross-national study from high-, middle- and low-income countries, the life time prevalence of panic disorder was 13.2%. 66% of those who had panic attacks had recurrent panic attacks, although only 12.8% met DSM-V criteria for panic disorder. Recurrent panic attacks were associated with onset of other mental health disorders especially mood disorders, than one-time panic attack. Almost 80.4% of individuals with lifetime panic disorder also had lifetime comorbid mental health disorder. The age of onset of panic disorder was 32 years (Jonge, Roest, Lim, & Florescu, 2016). Of prevalence of panic disorder in India, there are not many studies done on a wider scale. In the one study done on 94 patients experiencing panic disorder, 69.8% of them experienced primary depression and simultaneous generalized anxiety disorder in individuals who experienced panic disorder with depression (Trivedi & Gupta, 2010). A study that aimed to see the prevalence and new incidence of PTSD, panic disorder, depression and anxiety, during COVID-19 among eleven countries including India, during the pandemic, observed that Indian respondents had the highest prevalence of PTSD and Panic Disorder (40.8% and 18.8% respectively) (Georgieva, et al., 2021).

Causes of Panic Disorder

Biological causes

• I will discuss the biomarkers of panic disorder. Biomarkers are characteristics that are observed through scientific objective measures, that indicate a pathology or a normal or non-pathological process. Structural changes in the volume of amygdala, hippocampus and brain stem nuclei are biomarkers of panic disorder. Increases or reduction in the volume of the above-mentioned areas and increased activation of amygdala and Hippocampus when exposed to fearful stimuli have also been observed in patients with panic disorder. Decreased left amygdala volume has also been associated with panic disorder. Patients with panic disorder also showed higher cerebral blood flow in the left occipital cortex (Cosci & Mansueto, 2019). An imbalance in neurotransmitters, such as serotonin is also known to be a biological marker of panic disorder. A study showed that serotonin levels in three main areas; anterior cingulate, posterior cingulate and raphe; were well below minimum standard (1/3rd lesser) (Perrotta, 2019).

• For a long time, HPA axis (Hypothalamic-Pituitary-Adrenal Axis) and its dysregulation has been associated with panic disorder. The HPA Axis regulates our physiological responses to stress and also result in how we might cope with stress or change our behavior to adapt to our environment. When a person goes through chronic stress, it can result in a dysregulation of the HPA axis and result in higher daily cortisol production. Although some studies have shown results that support this theory; the results have been inconsistent and inconclusive (Cosci & Mansueto, 2019).

• Researches have also indicated that, an exaggerated or a defective transmission in areas such as hippocampus, amygdala nuclei, sensory parts of the thalamus, cingulate nuclei, hypothalamic nuclei etc. are known to be responsible for panic disorder (Perrotta, 2019).

• Panic disorder is also known to run in families, individuals with a history of panic disorder in the family are at a higher risk and have a genetic predisposition towards panic disorder.

Psychological causes: Not many psychological causes are known or fully understood, but traumatic childhood experiences such a bereavement, abuse and major life stressors etc., are linked to panic disorder (National Health Service, 2020).

Understanding Panic Attacks: Cognitive Behavior Therapy Perspective

Cognitive Behavior Therapy posits that, although initial panic attack is out of the blue and in response to an external or internal stressor, subsequent panic attacks are maintained by catastrophic interpretations of the physical symptoms experienced during a panic attack. CBT aims to manage panic attacks by changing these catastrophic interpretations. Before we move on to understand the maintenance cycle, we must understand certain central concepts of CBT.

Cognitive Behavior Therapy holds that, certain maladaptive thoughts that we hold give rise to our disturbances. These maladaptive thoughts could be formed due to certain experiences an individual has faced in his/her life or because of certain expectations that significant people in their life have communicated to them. They can also form from certain direct words their significant others have used to describe them (words like disappointment, useless, bad, unlovable etc.). All these experiences influence the core beliefs, an individual forms about him/herself (I am unlovable, I am not good enough, I am ugly, I am useless, weak, disappointment) the world around them (the world is dangerous) and of others (people are bad, they can’t be trusted, people betray). Core beliefs are usually inflexible, held on to rigidly and we tend focus on things that fit with our core belief and leave out information that contradict them. Another important aspect is of negative automatic thoughts (NATs). These are automatic thoughts or images that pop into our heads, when they are triggered by a certain situation. For example: When a friend doesn’t text back, the immediate NAT that pops up are thoughts of them ignoring you, them hating you, thoughts that you have offended in some way and they are angry etc. These NATs are influenced by the core belief we hold of ourselves, others and the world.

Maintenance of Panic Disorder: CBT Perspective

CBT maintains that, after the initial panic attacks, the subsequent panic attacks are maintained by catastrophic interpretations of the physical symptoms. Because of these catastrophic interpretations they hold about the physical symptoms of panic attacks, therefore a person might overestimate or catastrophize the consequence of panic attacks as well. Another is also the overestimation of a likelihood of panic attack as well. The continuous fear of experiencing another attack, makes hypervigilant. Individuals who have experienced panic attacks, start paying excessive and close attention to changes in their body. They notice small cues and changes in their body, might believe they are experiencing a panic attack and the chain of anxiety producing thoughts follow (this cant be happening here, I am going to die, I will always be like this), increasingly causes worry, fear, anxiety and ultimately leads to a panic attack. Sometimes even normal changes in body, can be misinterpreted as the onset of panic attack, making panic attacks more likely to happen. For example: A person while walking fast, may notice that his breathing is shallow, heart beat rising and interpret it as onset of an attack, and the rest of the cognitions follow after that. The continuous fear, excessive attention to environment, internal cues, interpreting and catastrophizing symptoms ultimately leads to a panic attack. It works like a self-fulfilling prophecy

Fig.1 Showing the CBT perspective of the maintenance cycle of panic attacks.

Coming to the behavior aspect, just like cognitions add to the maintenance on panic disorder, certain behaviors also stop us from getting over our panic attacks. Behaviors such as avoidance of situations that they believe might trigger an attack, avoidance of public places where they might believe that escape is impossible or the practice of safety behaviors, help in maintaining panic disorder. This is one of the reasons why people with panic disorders develop agoraphobia as well. The reason individuals avoid is because it provides short term relief. But it also doesn’t provide the opportunity to grow and learn that, these symptoms are not dangerous. Avoidance blocks a person from overcoming their fears and hence, maintains it.

Next are safety behaviors, these are behaviors individuals do to manage their anxiety, when they are out of the comfort of their home or a place, they believe that might trigger a panic attack. These behaviors may look like, sitting next to the door, so that they can make a quick escape if they experience an attack. Or it might be a person who they might go with to feel safe or for help. The thought that even if something happens, I have help, can reduce the likelihood of a panic attack. How these behaviors work as maintenance, is that, when a person engages in safety behaviors, they are just coping while not realizing that, they don’t have anything to fear about in the first place. Again, these behaviors hinder a person from overcoming their fears and realizing that they are misinterpreting and overestimating the likelihood of a panic attack.

Catastrophic Misinterpretations

There are four types of cognitive distortions that are associated with panic attacks:

1. Catastrophizing : Individuals who experience panic attacks, usually misinterpret their anxiety symptoms as dangerous. For example: I am feeling light headed, I might faint, or I am sweating profusely I might be experiencing a heart attack. When in reality, they are just experiencing symptoms of fight/flight response, because our brain has falsely perceived a threat in the environment and activated our sympathetic nervous system.

2. Emotional Reasoning: Emotional reasoning is another cognitive distortion, where individuals tend to believe things that have no real evidence base, but they still hold on to them because they feel like that and their emotions are the truth. We tend to think in line with our cognitive distortions, because our brains filter out information that is against these strong beliefs (Star,2021)

3. Overestimation of likelihood of panic attack: It’s the overestimation of the panic attack happening, that leads to individuals avoiding that particular situation or use safety behaviors. For example: I will definitely experience an attack if I go out or if I go walking etc. When individuals do have to face their fears, they might constantly be searching for threats or pay excessive attention to normal changes in their body, misinterpret them and end up having a panic attack.

4. Overestimation of the cost of panic attack: Thoughts like “Its going to be the worst if I have a panic attack now” or worries about what people will think about them, can lead to the overestimation. It could also be of the physical consequences that individuals falsely believe can also lead to this.

Individuals stuck in this cycle can often believe that, they are going crazy etc. It also leads to hopelessness, with thoughts such as he/she is always going to be like this, that they will suffer like this for the rest of their lives. This can lead to depression as well.

Treatment

Three line of treatment options are available:

1. Medication: Usually Anti-Depressants (SSRIs and SNRIs) and benzodiazepines are prescribed for individuals experiencing panic attacks.

• Selective Serotonin Reuptake Inhibitors (SSRIs) are usually prescribed as the first line of treatment. They are also one of the safe choices with low side effects. Prozac, Zoloft etc. are some of the SSRIs used. They help increase serotonin neurotransmitter in the brain, by the inhibition of reuptake; which is where the nerve endings of a neuron, take back the neurotransmitter it released. It is known to help in mood and sleep (Mayo Clinic, 2018).

• Serotonin and Norepinephrine Reuptake Inhibitors: Another anti-depressant, which is prescribed. It works the same way as SSRIs. It can help with reducing anxiety, mood and lessen panic attacks. The FDA (Food and Drug Administration) authorized the use of venlafaxine (Effexor XR) to treat panic disorder (Mayo Clinic, 2018).

• Benzodiazepines: These are CNS (central nervous system) depressants. They work by slowing down brain activity, which results in muscle relaxation and has a calming effect. These are sedatives, tend to have side effects, and habit-forming properties. Hence, they are usually used as short-term treatments and have harmful effects when used in certain drug combinations. They are used for insomnia, anxiety and panic attacks. Some common ones are Xanax and Clonazepam (Mayo Clinic, 2018).

2. Therapy: Usually Cognitive Behavior Therapy (CBT) is widely used and proven to deal with panic attacks. In severe cases a combination of medication and therapy works best. As discussed earlier, CBT views the maintenance of panic disorder, because of certain cognitive distortions and maladaptive behaviors. CBT helps in changing these thoughts and helping individuals realize that, these symptoms are not harmful, rather they are just changes caused during fight/flight mode. Giving them grounding and breathing techniques, helping them be aware of their maladaptive thoughts and helping them dispute them are ways that help. Once they break the factors that are maintaining panic attacks, the intensity and the likelihood of panic attacks are reduced.

3. Exposure Therapy: The behavioral aspects that maintain panic attacks is dealt with exposure therapy. The client is helped in understanding how avoidance and safety behaviors are maintaining panic by not giving him an opportunity to face and understand that the situation and the panic symptoms are not harmful. Goals are then formed to face the situations. Dealing with cognitions and disputing must be taught before exposure therapy is done. After realistic goal formation, the end goal is divided into smaller steps. These start from least anxiety causing to most anxiety causing. This is measured by SUDS (Subjective unit of distress scale). The client is helped in facing them, along with relaxation techniques. Each step is supposed to have a time limit exposure ranging from low to high. This helps the individual realize that, the symptoms they experience are not harmful, its possible to get over and control their intensity.

Strategies That Help in Managing Panic Attacks

The following strategies help in dealing with a panic attack. To start off it is helpful to first notice the antecedent internal or external events that might trigger anxiety, which might then be followed by physiological symptoms. Notice them and the thoughts that follow, that might lead to a gradual increase of anxiety and ultimately lead to a panic attack. It is important and helpful to recognize them because, it is possible only in the beginning stages to help yourself calm down with breathing techniques or grounding techniques and dispute your thoughts. Doing this in the earlier stages, makes sure that anxiety doesn't escalate further; thereby avoiding a full-blown panic attack. It is much easier to do this in the beginning phases rather than later.

• Recognize that you are not in any physical danger, the symptoms of panic attacks are just like flight and fight symptoms, which do not immediately cause any physical harm to your body. It is not possible to faint or pass out, because your blood pressure increases during stress; rather than decrease (which is what happens when you faint). It does not also lead to a heart attack.

• When you feel like you are about to get a panic attack, first recognize that you are safe, if you are at home, you can go to a safe place at your home (maybe your bedroom) or if you are at a workplace or in a public space, you could try to sit down.

• Deep breathing techniques are something that can be really helpful, There are two breathing techniques you could try. When breathing if you see your chest rising, then you are shallow breathing, deep breathing involves the stomach rising. First is box breathing; where you breathe in for 4 seconds, hold for 4 seconds and exhale for 4 seconds. Second, is where you breathe in for 4 seconds, hold for 2 seconds and exhale for 6 seconds. Repeat until you feel relaxed.

• Grounding Technique is another one that helps, when experiencing intense anxiety like in a panic attack. It is also helpful, when people are experiencing flashbacks of traumatic events, like in PTSD. It helps us bring back to the here and now and grounds us in reality, where you are in a safe space. It involves the following:

- Acknowledge 5 things around you

- Acknowledge 4 things you can touch around you

- Acknowledge 3 things you can hear in your environment

- Acknowledge 2 things you can smell around you

- Acknowledge 1 thing you can taste

If your significant other, friend, relative or colleague is experiencing a panic attack, be there for them, remind them that they are in a safe place, everything is fine. All they need you to do is be there with them, quietly supporting them. When they are feeling better, you can ask them to do deep breathing and relax.

If you are experiencing panic attacks; they have been causing you significant distress and functional deficit in personal, professional and social lives, please seek help. One doesn’t have to suffer from panic attacks, it is possible to manage them. Help is available.

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references

Cosci, F., & Mansueto, G. (2019). Biological and Clinical Markers in Panic Disorder. Psychiatry Investigation, 27-36.

Georgieva, I., Lepping, P., Bozev, V., Lickiewicz, J., Pekara, J., Wikman, S., . . . Lantta, T. (2021). Prevalence, New Incidence, Course, and Risk Factors of PTSD, Depression, Anxiety, and Panic Disorder during the Covid-19 Pandemic in 11 Countries. Mental Health in Times of Pandemic: Protective and Risk Factors.

Jonge, P. D., Roest, A. M., Lim, C. C., & Florescu, S. (2016). Cross-national epidemiology of panic disorder and panic attacks in the world mental health surveys. Depression and Anxiety .

Mayo Clinic. (2018, May 4). Panic Attacks and Panic Disorder . Retrieved from Mayo Clinic:

https://www.mayoclinic.org/diseases-conditions/panic-attacks/diagnosis-treatment/drc-20376027#:~:text=SSRIs%20approved%20by%20the%20Food,are%20another%20class%20of%20antidepressants.

National Health Service. (2020, July 28). Panic disorder. Retrieved from National Health Service: https://www.nhs.uk/mental-health/conditions/panic-disorder/#:~:text=As%20with%20many%20mental%20health,family%20member%20with%20panic%20disorder

Perrotta, G. (2019). Panic Disorder: Definitions, Contexts, Neural Correlates and Clinical Strategies. Current Trends in Clinical & Medical Sciences.

Star, K. (2021, January 19). Emotional Reasoning and Panic Disorder. Retrieved from Verywell Mind: https://www.verywellmind.com/emotional-reasoning-and-panic-disorder-2584179#:~:text=Emotional%20reasoning%20is%20one%20type,we%20must%20be%20in%20danger.

Trivedi, J. K., & Gupta, P. K. (2010). An overview of Indian research in anxiety disorders. Journal of Indian Psychiatry , 210-218.