A Primer into Panic Disorder

Panic disorder is a type of anxiety disorder that is characterized by 1) reoccurring panic attacks that are unexpected (they come out of the blue) and 2) worries about additional panic attacks and/or changing behaviours to avoid more panic attacks.

Simply put, people with panic disorder are very afraid of panic attacks and what they could mean (“am I having a heart attack?”), and begin to change their lives in very significant ways to make sure that they don’t have any more panic attacks. Panic disorder can really limit a person’s life because in some cases, they may even begin to not want to leave their home in case they get a panic attack.

What are panic attacks?

Panic attacks are abrupt rushes of anxiety that reaches a peak within minutes and typically last around 15 to 20 minutes. They can be expected (because of something anxiety provoking – e.g., being stressed about an important exam) or unexpected. To meet criteria for a panic attack, you need to experience at least 4 of the 13 symptoms found below:

1. Heart palpitations; racing heart

2. Sweating

3. Trembling or shaking

4. Shortness of breath or difficulty breathing

5. Feeling of choking

6. Chest pain or discomfort

7. Feeling dizzy, unsteady, or faint

8. Derealization or depersonalization (feelings of unreality or detached from oneself)

9. Nausea or abdominal distress

10. Fear of losing control or ‘going crazy’

11. Fear of dying

12. Tingling or numbness in parts of the body

13. Chills or hot flushes Having panic attacks doesn’t necessarily mean you have Panic Disorder. Some people can brush it off and not worry about panic attacks. However, others become much more concerned about panic symptoms (like heart-racing, difficulty breathing) and begin to have catastrophic thoughts, which can create a pretty vicious cycle.

A diagram charting panic attacks
A simple diagram to understand how panic attacks happen and how they are maintained in panic disorder

The Vicious Cycle of Panic Attacks

1. Notice sensations that could be perceived as the beginning of a panic attack (e.g., heart-racing, trembling, feeling hot flushes)

2. Becoming anxious that this could lead to a panic attack or something worse (like a heart attack)

3. Thoughts, such as “I’m going to have a panic attack”, “I can’t handle this” begin to ramp up

4. Physical symptoms become stronger because of the anxiety and thoughts

5. Cycle continues and becomes stronger until a panic attack occurs

6. Avoidant behaviours (e.g., not going outside; taking anxiety medication) maintains fear

A Cognitive-Behavioural Approach to Dealing with Panic Attacks

CBT therapists typically intervene in two ways: cognitive strategies and behavioural strategies. Cognitive strategies target some of the scary thoughts we have when it comes to panic attacks as a way to evaluate these thoughts to see if they are true. Behavioural strategies include types of exposures to reduce our fears to the physical symptoms and recognize that they are actually relatively harmless. We’ll talk about each one in turn:

Countering Panic Thoughts to Reduce Catastrophizing

The symptoms experienced in panic attacks are the physiological responses associated with anxiety. In that sense, panic disorder is in essence a fear of anxiety symptoms itself (that fight-or-flight response). Unfortunately, this creates a vicious cycle that’s hard to break. One way to do so is through countering our catastrophic thoughts when we are experiencing panic symptoms.

One thing that is important to recognize is that the symptoms of anxiety are scary but they are not life-threatening. Oftentimes, anxiety symptoms can make us feel like something is dreadfully wrong. In reality, you are likely going to just feel very uncomfortable for a period of time. Moreover, anxiety is a heightened state – we cannot exist forever in this state and eventually the parasympathetic nervous system (the system that brings you down from anxiety to rest) will take hold. Therefore, panic attacks are 1) not life-threatening and 2) not permanent. This will be important to remember when you are countering some of the scary thoughts that come out when you feel like a panic attack is coming up.

Beyond these two points, other thoughts you can use to counter catastrophic thoughts would be to remind yourself of examples where you have handled panic attacks and gotten through them. Draw from your previous experiences where you’ve struggled but got through to the other side!

Examples I’ve heard from previous patients include:

– “It was very uncomfortable, but I was able to take a few minutes to breath. I then went to finish up my grocery shopping and went home.”

– “I reminded myself that it would eventually go away and it wasn’t life-threateninng. And after 10 minutes or so, it subsided enough for me to go about my day.”

Remember to use real-world detailed examples to support your countering! The more specific examples you have regarding your resilience during panic attacks, the better.

So an example of an anxious thought might be “I will panic if I don’t get out of here. I won’t be able to handle it and freak out” whereas an alternative thought could be “I am just having anxiety sensations and they are not dangerous. I have felt this way before and I have been able to ride it out. The symptoms will pass very soon”. As you can see, the way that we interpret symptoms of anxiety can drastically change how we feel.

Girl holding hands on chest
For some people, a racing heart might mean love. For people with panic disorder, a racing heart might mean a panic attack (or worse)
Photo by Giulia Bertelli on Unsplash

Interoceptive Exposure to Reduce Fear of Panic Symptoms

When we are afraid of something, exposures are a great way to recognize that 1) something is less dangerous than we think and 2) that we can cope with a scary situation better than we think. In panic disorder, we are afraid of symptoms of anxiety. Therefore, interoceptive (perception of sensations in our body) exposures is an evidence-based strategy that is effective in treating panic disorder (Deacon et al., 2013). The point is to exposure ourselves to panic symptoms in a controlled environment to develop resistance to these feelings of discomfort. Examples can include:

– breathing through a straw

– doing jumping jacks for 30 seconds

– being in a small and dark room for a period of time

– jogging in place for a minute

– moving your head up and down 30 times

– spin in a circle while standing for 10 seconds

– stare at an optical illusion

When engaging in an exposure, pick an activity that is challenging but manageable. Give yourself time to let the anxiety reduce without engaging in avoidance behaviours (e.g., stopping the exercise early, taking medication). Control your breathing and use the countering strategies to support the exposure. Be a scientist and carefully assess your anxiety before, during, and after the exposure. Write down learned lessons.

If you’re interested in completing an exposure, check out this post on creating an exposure hierarchy!

Summary

  • Panic disorder requires 1) recurrent, unexpected panic attacks 2) being afraid of more panic attacks and/or changing behaviours to avoid more panic attacks
  • In panic disorder, there is a fear of internal anxiety symptoms (e.g., racing heart, difficulty breathing)
  • Fear of these symptoms and avoidance behaviours lead to more panic attacks and maintains anxiety
  • Countering and interoceptive exposures are two evidence-based CBT techniques for panic disorder

I hope this post was helpful in understanding a little more on panic disorder and evidence-based strategies to manage panic attacks and make them a little less scary!

If you’re interested in learning more about different anxiety disorders, see this post about six common anxiety disorders.

Best wishes,

P

Featured image: Photo by Andrey Metelev on Unsplash