Wednesday, July 13, 2011

Do Panic Attacks Really Come "Out of the Blue?"

Panic disorder (PD) can be a severe, highly disabling and debilitating psychiatric condition. Thankfully, it is usually easily treatable with a combination of medication and a cognitive-behavioral technique known as cognitive restructuring, which I will not describe here.
Panic attacks are basically attacks of extreme anxiety accompanied by a variety of physical symptoms which I will describe in a moment. People experiencing them for the first time often think they are having a heart attack, because the symptoms of panic attacks mimic those of a myocardial infarction. They often go the emergency room multiple times. When they get there, the doctors do an EKG and blood tests that would be evidence that the patient was indeed having a heart attack, and lo and behold, all the tests would come back completely normal.
In the days before ER docs became familiar with the disorder, patients would be basically told that their symptoms were all in their head and sent home. The patient would be flumoxed. The physical symptoms are of such intensity and acuity that patients would come to the correct conclusion that something physical must have happened.
Panic attack symptoms include palpitations (pounding heartbeat), increased heart rate, sweating, tremulousness, shortness of breath, choking, chest pain, dizzyness or lightheadedness, nausea and abdominal distress, a sense that everything is unreal, fear of losing control or going crazy, fear of dying, numbness, tingling, chills, and hot flushes. Symptoms can last for a few minutes or for a few hours.
Hyperventilation, or breathing too fast, may trigger many of these symptoms, but not all panic attack sufferers hyperventilate. They still get a lot of the same symptoms. Nothing physical going on? What claptrap!!
When people have recurring panic attacks, they are said to have panic disorder, and are at high risk of developing a psychological reaction called agorophobia. This byproduct of panics is more common in women with the disorder than men for unknown reasons. In any event, people with agorophobia become fearful of being trapped and avoid crowds (malls, supermarkets, theaters, sporting events and even church), elevators and other tight spaces, lines, and driving, especially distances or over bridges. Sometimes sufferers become fearful of going outside the house alone, and in severe cases they become completely housebound.

The diagnostic criteria for panic disorder is defined in the DSM-IV-TR are:

Recurrent unexpected panic attacks and:
• The attacks are not due to the direct physiological effects of a substance (such as drug of abuse or a medication), or another general medical condition.
•The attacks are not better accounted for by another mental disorder, such as social phobia (such as occurring on exposure to feared social situations), specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder or separation anxiety disorder.

I italicized the "unexpected" criteria because that is the main subject of this post. But first, I would like to point out that all of the listed physical panic symptoms can also be experienced as part of a rage reaction. Rage attacks are most often seen in patients with borderline personality disorder, a high percentage of whom also have panic attacks.

In fact, the physiology and symptoms of a rage attack are identical to those of a panic attack. The individual's cognitive processes (thoughts and evaluation of the symptoms and what may have triggered them) during an attack may be the only phenomena which distinguish them.

That this should be the case is not surprising. Both panic and rage attacks are a manifestation of the primitive fight, flight, or freeze response in all animals. A fight response would lead to rage, and a flight or freeze response might result from panic. Indeed, it seems that people who have panic disorder have a disturbance of this fight, flight or freeze mechanism that causes it to go off and keep going off even after any threatening stimulus is no longer present. An important, self-protective physiological phenomenon may have gone haywire.

In humans, the ability to think might help an individual to decide whether to run or to fight in the presence of a potentially dangerous or threatening stimulus.

To make a diagnosis of panic disorder, the DSM requires that the individual with panic attacks experience them as unexpected, spontaneous, and uncued. That is, there does not seem to be an environmental event that triggers the attacks.

Rage attacks, on the other hand, are usually thought to be triggered by specific environmental events. If an individual has recurrent rage attacks which seem to be unexpected, spontaneous, and uncued, then a completely different diagnostic label is usually applied to them by psychiatrists: intermittent explosive disorder. I have never seen a case in over 30 years that could not be better explained by another diagnosis.

To summarize, for panic disorder, as opposed to the occasional panic attack, the conventional psychiatric wisdom is that they occur “out of the blue” rather than as responses to environmental threats. If they only occur in the presence of one or more specific environmental threats, say snakes, then the person is diagnosed with a specific phobia instead of panic disorder - a snake phobia in this case.

One caveat is that the idea of panic attacks being "unexpected" refers to the absence of a specific stimulus, not to whether or not the presence of a feared stimulus is expected to be present. If, for example, a snake phobic "unexpectedly" comes across a snake on a hike and has an attack, this would not qualify under the "unexpected" rubric of panic disorder.

Panic disorder might be considered a prime example of something that would pit "biological" psychiatrists against psychotherapists. In people who suffer from panic disorder, the attacks do seem to come out of nowhere. They can be sitting quietly in their house doing almost nothing when one comes on. They can even be jolted awake from them in the middle of the night, without having had a nightmare. A tendency to have panic attacks tends to run in families, so clearly some people are more genetically prone to get them than others.

So does this mean that panic disorder is purely and entirely a brain disease? Is its classification as an anxiety disorder incorrect? Does it have nothing to do with chronic stressors?

In my opinion, the answer to all three questions is a resounding no. People who are prone to the disorder do indeed seem to have to have a problem with the internal regulation of their flight or flight mechanism, to be sure, but environmental factors do, in my clinical experience, determine whether such a person has an occasional attack or has a lot of them.

But if attacks happen without a fearful stimulus being present, how is this possible? My theory is thatpeople who are genetically prone to them will start to have them when they are chronically anxious. Whenever they are on guard, on edge, walking on eggshells, or disturbed about something, they then can have a panic at any time during the whole period they feel that way. Why they happen at any particular time remains a mystery.

Now comes a study which adds a lot of credence to the opinion I have formed over the years (Ethan Moitra et al, Journal of Affective Disorders, in press). The study results show that, instead of an immediate reaction, stressful life events (SLEs) in patients with PD can cause a gradual, but steady, increase in panic symptoms over time.

The investigators note they expected to find that panic symptoms would spike immediately after a stressful event and then taper off, but this was not the case. In analysis of more than 400 patients with PD from the Harvard/Brown Anxiety Research Program (HARP) study, panic symptoms worsened progressively over 3 months after participants experienced specific SLEs, including serious family discord or being fired.

What this study tells clinicians is that they need to be aware that, although people may have an immediate reaction, be vigilant in keeping track of how patients are doing over the next few months after the event, and perhaps even longer," according to lead author Dr. Moitra quoted in a Medscape article.

So most patients with panic disorder, even if the symptoms are extremely well controlled with medications as they often are, should also be offered psychotherapy to learn better coping skills to handle the stressors they are experiencing. Otherwise, they will most likely never be able to get off the medication. Not offering or referring for therapy in these cases is disgraceful.

I almost always find that anyone who seems to be experiencing any long term, ongoing anxiety symptoms and/or unhappiness is usually in the middle of ongoing repetitive dysfunctional family interactions. If the doctor does not specifically ask about them, the patients is unlikely to bring them up.


  1. In my experience, panic attacks are commonly triggered by frustration/anger that is forgotten once anxiety about the bodily symptoms takes hold.

  2. Do the rage attacks of BPDs also point somehow to a genetic weakness in regulating the f/f/f response? And it seems they are beyond their control as well. You talk about their ability of being able to "turn their behavior off or on"", but probably not in this respect. Am I right?

  3. Anonymous,

    When anyone goes into a complete rage (many "rage" episodes of people with BPD are feigned, but many are not), I think they have a relative lack of control. BPD's are no different. They do seem to have a lower threshold for going into a rage (I've witnessed real ones, and believe me, you do not want to be around), but whether this is purely genetic or a conditioned response or a combination of the two is not really known.

    My opinion is that most of it is not purely genetic but is conditioned, but it's very hard to prove one way or the other.

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  5. "In people who suffer from panic disorder, the attacks do seem to come out of nowhere."

    I think you would find elevated levels of serotonin and estrogen in a person who suffers genuine "Panic Disorder". Elevated serotonin in the brain is a major cause of anxiety, panic and general psychological problems. Estrogen promotes the production of Serotonin in the intestine (Where 90% of serotonin is made). It baffles me that is isn't common knowledge in the medical world but thats dogmatism for you!
    Cyproheptadine, a first generation anti histamine also has anti serotonin effects and has been clearly shown to reduce anxiety.

    If you were to test free blood serotonin in any person that was suffering "Panic Disorder" you will almost always find elevated serotonin.

  6. I would not think that I would be considered as having Panic Disorder, as the panic attacks that I have experienced happen so infrequently that it is hard to identify as being just that. With that said I have experienced them on several occasions throughout my life with no seeming instigation. Which is terrifying. I really would like to know the actual process you body goes through to create the symptoms. For example I understand that stress can manifest itself physically but what is happening inside of your brain to develop these undeniable and terrifying physical reactions.

    1. Hi Unknown,

      Like most of what goes on in the brain, the most complex object in the known universe, there are a lot of guesses but nobody knows for sure. It seems like the body's "fight or flight" mechanism suddenly goes off when it shouldn't.