I had my first Panic Attack (PA) during the second semester of my junior year of college. It seemed to come out of nowhere and hit me like a freight train. This began a multiple year struggle with Panic and Generalized Anxiety Disorder (PD and GAD respectively)*. My episodes of panic involved a feeling of impending doom. I felt that I was going to die. I was paralyzed with fear. There was no apparent instigating event.
From that point forward, I was preoccupied with when the next attack would occur. I socialized less and stopped venturing far from my residence. My ability to focus while in class and study were greatly diminished. As with many individuals who have been challenged with PD, I remember everything about my first episode: the time, place, what I was doing, who I was with. It’s as if it happened yesterday, but it occurred over 45 years ago!
What Are Panic Attacks And Why We Have Them?
In addition to being in control of our body’s homeostasis (the equilibrium of our vital bodily functions, e.g., heart rate, blood pressure, temperature, fluid balance), our brain’s other major role is to ensure our safety. Evolutionarily speaking, not remembering a life-threatening event does not bode well for the preservation of the species. So if the organism, us, either experiences or believes it is experiencing a life-threatening event, one of the brain’s protective functions is to neurologically imprint the event, that is, create a memory and ensure that it is never forgotten. This characteristic of PD, the imprinting of the initial event, is one of the most challenging issues confronting individuals working through this disorder.
Along with the feeling of impending doom, the most common physiological features associated with PD are tingling in extremities, sweaty palms, rapid heart rate and palpitations, breathlessness, lightheadedness, blurry vision, weakness in legs, muscle tension and nausea. Not everyone has the same constellation of symptoms, but most have several of these. I had all of them!
As mentioned in several of my previous blogs, the physiological symptoms of panic can be directly attributed to the body’s autonomic nervous system, specifically the sympathetic nervous system, which instigates what is commonly referred to as the “fight or flight” response. Common to all mammalian species, as well as many other earthly life forms, this response is built-in to our DNA and is part of our evolutionary survival mechanism. (See my “Lions and Tigers…” and “Physiology of Fear” blogs, as well as the “Stress Response” video by Stanford neurobiologist Robert Sapolsky.
The National Institute of health estimated 31.1% of U.S. adults experience an anxiety disorder at some time in their lives, and that an estimated 19.1% of U.S. adults had an anxiety disorder in the past year. Epidemiological studies have shown that anxiety disorders are the most common psychological disorders in the world and cause more impairment in social and occupational functioning than all other mental health disorders combined. A meta-analysis (a survey of a large group of studies) published in the Canadian Journal of Psychiatry in 2017, showed the mean age of onset of all anxiety disorders was 21.3 years of age. Separation anxiety disorder, specific phobia, and social phobia had their mean onset before the age of 15 years, whereas agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, panic disorder, and generalized anxiety disorder began, on average, between 21.1 and 34.9 years.
First episodes of panic often land people in an emergency room, a medical clinic or doctor’s office. Subsequently, searching for a cause of the event or events, individuals will often be seen by multiple physicians. Many individuals who experience a PA cannot identify any specific life event or circumstance as a cause, and while the physiology of panic and generalized anxiety is clearly linked to the over-activity of the sympathetic nervous system, the cause is less straightforward. Modern day research points to both genetic and environmental factors as contributing to an individual’s predisposition for developing a disorder. If an individual has a sibling or parent diagnosed with an anxiety or depressive disorder, there is an increased likelihood that they will be similarly diagnosed. Additionally, individuals, and especially children, exposed to trauma, stressful environments, chronic illness, and certain physical conditions (e.g., thyroid disorders) are at increased risk of developing an anxiety disorder.
There are many different therapies and associated techniques that can assist in the amelioration and cure of PD and GAD Over the past several decades, therapies that focus on both the psychological and physiological components of PD and GAD have proven to be the most effective. Of these, the most utilized are a constellation of therapies referred to as cognitive-behavioral. Of the therapies that fall under the cognitive-behavioral umbrella, the most widely utilized are, REBT, CBT, ACT, DBT, MBSR, and EMDR. These therapies utilize a wide range of techniques, including but not limited to, psychoeducation, mindfulness, exposure, thought disputation, progressive muscle relaxation, yoga, breath-work, meditation, sensory stimulation (light, sound, olfactory, tactile, etc.).
The ultimate goal of all cognitive-behavioral therapies is behavior change. Remember that “behavior” can be external, observable to others, or internal, such as thoughts and emotions. The core tenant of these therapies is that our thoughts, emotions, and behaviors all influence each other. Utilizing a variety of techniques, cognitive behavioral therapies work at confronting PD and GAD from all three angles. As an example, the therapist is likely to educate the client on the biological mechanisms underlying PD and GAD. Equipped with this knowledge, the client will be more apt to meet each subsequent episode with less fear, thereby reducing the emotional intensity of their experience. The therapist might assist the client in identifying thoughts and patterns of thinking that can play a role in triggering or exacerbating their PD and/or GAD. The therapist and client may also work on identifying and understanding the emotions that are associated with these thoughts, thereby reducing the likelihood that the client will engage in behaviors that are antithetical to their movement toward wellness (e.g., substance abuse, antisocial and other avoidance behaviors). Another cognitive-behavioral technique often utilized by therapists is exposure. This technique can take many forms, but all involve exposing the client to what they fear (e.g., leaving the safety of one’s home, recalling the physiological symptoms that are experienced during a PD). The goal of exposure is habituation (a decrease in reaction to the feared object) and ultimately extinction (complete cessation of symptoms by breaking the association between the feared object and the behavior).
Stress Reduction Techniques
Finally, therapists will most often teach the client stress-reduction techniques (muscle relaxation, breath work, meditation, etc.) to help moderate both the emotional and physical intensity of their experience. Cognitive-behavioral therapeutic approaches are considered to be very active, that is, the therapist provides the client with a great deal of information, feedback and instruction, and they work in collaboration to increase the client’s understanding of the underlying mechanisms and solutions to the presenting challenge. Additionally, the course of therapy is seen as relatively short when compared to that of other therapeutic interventions (e.g., psychodynamic, client-centered, existential). The bottom line, cognitive-behavioral therapeutic approaches have been clearly shown to be the most effective, and as a result, the intervention of choice for treating both PD and GAD.
In subsequent blogs I will further address the specifics of cognitive-behavioral therapies and delineate some of the differences and unique features of each. Meanwhile, if you have a few extra minutes, I highly recommend the article “Learning to Live with Anxiety” that can be found in the Resources section of my webpage.
* A single episode of panic does not constitute having PD. A diagnosis of PD is made when the first experience is then followed by either additional episodes, continued worry about experiencing another, and/or a change in one’s day-to-day behavior (often in an effort to avoid future episodes). Similarly, someone can have an episode of acute anxiety or experience intermittent episodes without being diagnosed with GAD.