Panic Disorder

Photo by: Tero Vesalainen / Shutterstock.com

Photo by: Tero Vesalainen / Shutterstock.com

Panic Attack Symptoms

A panic attack is an abrupt surge of fear or acute discomfort. It includes severe physical symptoms that escalate very quickly (usually within a few minutes).

The physical symptoms may include racing heart, clammy palms, shaking, dry mouth, shortness of breath, sweating, chest pain, dizziness, nausea, numbness or tingling sensations, and feelings of unreality or detachment.

The thoughts usually include a fear of dying, going crazy, losing control, or some other imminent catastrophe.

Although a person may have a panic attack when they are already anxious, oftentimes a panic attack starts seemingly out of nowhere, when one is in a perfectly calm state.

Some panic attacks are predictable and may happen when a person has to face a situation or trigger that usually causes high anxiety. Other panic episodes may come out of the blue. A person may even wake up to a panic attack at night (these are called nocturnal panic attacks).

‘Panic attack’ and ‘panic disorder’ are terms that are often used interchangeably. But they are not the same. The difference between the two is very important as it determines the course of the treatment.

How Long Do Panic Attacks Last

Panic attacks usually don't last very long. But they feel excruciatingly long, so people often overestimate how long their attacks last. The attacks develop and reach their peak extremely quickly, after which the symptoms start to subside.

Most panic attacks last up to 30 minutes. What often leads to the confusion about the duration of panic attacks is the question of what is considered to be the onset of an attack. Panic attacks, by definition, develop abruptly - within minutes. But when they develop from an already anxious state, the anxious state that preceded the attack does not count toward the time of the attack.

Another factor leading to the discrepancy in the perceived length of the attacks is related to what people do during the attack. Sometimes, a person will try very hard to calm down by breathing, distracting themselves, trying to relax, etc. This often leads to temporary relief of the symptoms but a subsequent increase of the symptoms. As counter-intuitive as it sounds, just "riding out" an attack without doing anything about it will lead to shorter attacks.

Panic Attack vs. Anxiety

Anxiety is usually related to a fear of a negative outcome or worry. It can develop relatively quickly or slowly.

Panic, however, comes seemingly out of nowhere and strikes rapidly. It is accompanied by severe, intense fear.

Panic Attack vs. Panic Disorder

‘Panic attack’ and ‘panic disorder’ are terms that are often used interchangeably. But they are not the same. The difference between the two is very important as it determines the course of the treatment.

You may experience numerous panic attacks without developing a panic disorder.

Panic attacks frequently happen in the context of a psychological disorder (Social Anxiety, Phobia, Illness Anxiety, Generalized Anxiety Disorder (GAD), Obsessive Compulsive Disorder (OCD), trauma, etc.). These attacks are related to the fear associated with the underlying disorder (a fear of a social situation, a specific object, acquiring a deadly disease, something bad happening in the future, etc.)

In these cases, a person usually will not meet the criteria for a panic disorder. It is then important to treat the underlying disorder (as opposed to panic).

For a panic disorder diagnosis to be established:

- A person must experience recurrent, unexpected panic attacks.

- At least one of the attacks must be followed by over one month of persistent worry that another attack will happen, and about its catastrophic consequences (having a heart attack or a stroke, losing control, going crazy, etc.).

Beware of treatment plans that focus on anxiety reduction and attempts to get rid of your unpleasant physical symptoms.

- A person must develop maladaptive safety and avoidance strategies aimed to prevent the dreaded next attack from happening. These strategies typically involve avoidance of situations or monitoring bodily sensations that are associated with the attacks.

- The attacks and the safety and avoidance strategies are not better explained by the presence of another psychological disorder.

Diagnosis of a Panic Disorder

The first important task in diagnosing a panic disorder is to rule out a medical condition by visiting your doctor. Many people come to treatment after visiting an ER a few times with what seemed, and felt, like a heart attack. After cardiovascular (and respiratory, endocrine, etc.) disorders are ruled out, the person is usually referred to counselling.

After ruling out the physical causes, it is important to see a psychologist or other mental health professional for a proper differential diagnosis.

Agoraphobia

Agoraphobia is a fear of and attempts to avoid some of the following situations:

- Using public transport (cars, buses, subways, planes)

- Being in either open or enclosed spaces

- Standing in line

- Being in a crowd

- Being outside of the home alone

The fear is caused by the thought of the inability to escape the above situations in case of a panic attack. As you can see, even though agoraphobia can be diagnosed as a separate disorder, it is related to the fear of having a panic attack and, therefore, it is often diagnosed as secondary to a panic disorder.

In extreme cases of agoraphobia, the person may become completely homebound.

Managing Panic Attacks and Popular Strategies that Don’t Work

There is an important difference between short-term, in-the-moment management (trying to get rid) of panic attacks and the treatment of panic disorder. In some ways they are, as strange as it sounds, the opposite of one another.

We need to demystify panic in order to perform the counterintuitive strategies that are required to overcome it and to gather the courage to get rid of avoidance and safety behaviors.

Breathing, relaxation, and grounding techniques can be very helpful in the moment. But if you truly want to overcome this debilitating condition, you need to seek a therapist specializing in exposure, which is a part of Cognitive Behavioral Therapy (CBT), as well as in Acceptance and Commitment Therapy (ACT). This treatment is very effective and has a high rate of success for panic disorder.

Beware of treatment plans that focus on anxiety reduction and attempts to get rid of your unpleasant physical symptoms. These may include:

- Distraction

- Positive thinking

- Deep breathing

- Relaxation

- Fidget toys or Silly Putty

- Closing your eyes

- Making sure to carry water with you and take sips if you feel the panic coming

- Picturing your happy/safe place

- Grounding techniques

- Counting

- Repeating a mantra

- Taking a benzodiazepine when you feel the symptoms approaching

If you have been in therapy, you may be surprised that the suggestions above are counter-indicative for the treatment of a panic disorder, as it is likely that these are exactly the techniques that were suggested by your therapist. Moreover, some of them may have even helped to prevent or stop an occasional panic attack.

So why, then, does the evidence-based treatment advise against using these techniques?

Evidence-Based Panic Disorder Treatment

You will work on radically changing your relationship with discomfort – whether it is caused by physical symptoms or thoughts. You will develop skills to help you give up the futile agenda of trying to get rid of unpleasant physical sensations. Instead, you will learn to take steps toward the life you want to live regardless of how you feel at the moment, and of the thoughts that pop up in your mind.

As mentioned in the previous section, it turns out that the very techniques that may temporarily help manage a panic attack may also maintain or even strengthen the panic disorder in the long run.

The reason for that is that panic attacks, as unpleasant as they are, are not dangerous. It’s just our sympathetic nervous system over-reacting to a benign physical symptom.

But people suffering from panic disorder are hyper-aware of these normal bodily sensations and tend to misinterpret them as dangerous. This misinterpretation leads to anxiety, and anxiety creates even more physical symptoms. This, in turn, leads to even greater catastrophizing.

It goes like this:

Physical symptom “Oh, no! I’m having a panic attack again!” anxiety more physical symptoms “This must be a heart attack” more anxiety, etc.

So, the person enters a vicious, rapidly escalating cycle of:

Sensation thought anxiety sensation thought anxiety, etc.

To make matters worse, the person then usually tries to do everything possible to prevent further attacks from happening. This includes attempts to avoid threatening situations and physical sensations.

Panic Disorder Cycle

Whenever avoiding a situation or a sensation is impossible, the person resorts to various safety strategies, such as always carrying water or anti-anxiety meds, trying to stay relaxed, monitoring their breathing, sitting close to the exit at the movies, avoiding highways or bridges, asking for reassurance, looking for distractions, seeking fresh air, etc.

These strategies further reinforce the belief that the physical symptoms are unbearable and dangerous. The person also usually feels better when avoiding or using safety strategies, but then he or she attributes this relief to the above strategies and never gets to find out that the panic attack would have subsided on its own. This keeps the panic disorder going.

Another pattern that maintains panic is monitoring the physical symptoms. This may include checking heart rate, pulse, and breathing, watching for signs of dizziness, or trying to swallow. This selective attention leads to hypervigilance and to more frequent and heightened experiences of the symptoms.

As you can see, these maladaptive attempts to control anxiety look very similar (identical?) to the strategies that are often used in therapy and are promoted in the media.

Main (Real) Treatment Steps

1. The treatment of a panic disorder always starts with teaching you, in detail, about how panic develops and how safety and avoidance behaviours, as well as selective attention/monitoring, keep the panic disorder going.

We need to demystify panic in order to perform the counterintuitive strategies that are required to overcome it, and to gather the courage to get rid of avoidance and safety behaviours.

2. The next step involves gradually getting rid of avoiding threatening situations. This takes a leap of faith, but also usually produces very empowering results as your world expands and you gain confidence.

3. Another vital step is giving up your safety behaviours. You can give them up progressively, or you can go cold turkey. Either way, you have to learn that you don’t need crutches to cope with normal bodily sensations.

4. Simultaneously with the steps above, you will work on radically changing your relationship with discomfort – whether it is caused by physical symptoms or thoughts. You will develop skills to help you give up the futile agenda of trying to get rid of unpleasant physical sensations. Instead, you will learn to take steps toward the life you want to live regardless of how you feel at the moment, and of the thoughts that pop up in your mind.

A good side effect of this step is that it is effortlessly transferrable to other areas of your life and makes it so much easier to move toward your life goals in all life domains.

5. Moreover, in line with all the above, the treatment will involve practicing voluntarily producing your symptoms.

Remember how we said that trying to get rid of a panic attack is the opposite of treating a panic disorder? When your goal is to get rid of the symptoms, you learn that they are dangerous and should be avoided at all costs. This learning feeds the panic.

But when you practice purposely being uncomfortable or even scared, you quickly learn that no catastrophe is taking place. These symptoms are unpleasant, but harmless. Diligently practicing these exercises quickly leads to breaking your vicious panic cycle.


Anna-Prudovski-blog-bio-picture.png

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.


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