Panic Disorder 411
Recovery From Panic Disorder
What Causes Panic Disorder - Text
My name is Renault Purefoy, and in this video, I'll present my
understanding of how panic disorder develops that comes from over
20 years of work with people with various anxiety disorders. In a
second companion video, I'll outline the approach I developed
that can allow you to overcome panic disorder and return to a
normal life. "Overcoming Anxiety"
During the first session with a client, I would usually begin by asking, "Why do you think you developed this condition?" The vast majority would then give a vague answer such as, "It's a chemical imbalance." "It's a mental disorder," or simply, "I'm not sure." It was rare to find someone who had a clear understanding of what caused their condition, even though most had read about panic disorder and seen at least one professional, more often, several. While understanding the causes of panic disorder does not in itself change anything, it is the first step to making the changes and learning the skills needed to return to a normal life.
In order to understand how panic disorder develops, it's necessary to first look at a number of factors that can play a role in its development. We'll begin by looking at the fight or flight response. Like all of your body responses, the various anxiety related symptoms people experience are controlled by your nervous system.
Somatic and Autonomic Nervous Systems
Now the nervous system leading to the various parts of your body is usually divided into two basic parts—the voluntary nervous system and the autonomic nervous system. The voluntary nervous system is also called the somatic system and controls movements and sensations you normally are aware of. It connects the brain to the muscles that control movement as well as your various senses. Information from your eyes, ears, and other senses go to the brain through these nerves. Actions you wish to take, such as raising your arm or walking, are then controlled through this system.
Autonomic Nervous System - Sympathetic and Parasympathetic Divisions
The autonomic nervous system controls functions in your body that you are normally not aware of. It is composed of all the nerves that connect your brain to your involuntary muscles, such as your heart and the muscles in your lungs, the muscles in your stomach and intestines, as well as the nerves connecting your brain to your internal organs and glands. This system controls all the autonomic activities that occur in your body, such as digestion, breathing, and glandular activity. The autonomic nervous system is itself divided into the sympathetic and parasympathetic divisions. The sympathetic division is responsible for what is commonly referred to as the fight or flight response, and is designed to activate the body quickly and prepare it to fight or flee from danger. When the danger has passed, the parasympathetic division quiets the body and returns it to normal functioning.
Sympathetic Division → Perception of Danger
Now, when the perception of danger triggers the sympathetic division, it suspends all non-essential activity in the body and increases activity in any system necessary to either fight or flee from an external physical threat. This involves many complex reactions in the body. Some of the most noticeable changes that take place include the following:
– An accelerated heartbeat, along with deeper and more rapid breathing to ensure a large supply of oxygen.
– Increased muscle tension to prepare the muscles for any upcoming action.
– A cold sweat that prepares the body for the warm sweat of intense muscular activity.
– The constriction of the peripheral blood vessels near the surface of the body. This raises blood pressure and is the basis for the blanching with fear that is sometimes seen.
– Shivering and raising of hairs to conserve heat and protect the body from the increased threat of cold caused by the constriction of the peripheral blood vessels
– Dilation of the pupils to permit a better view of threatening dangers. This is, also, why eyes are sometimes said to be wide with fear.
– Suspension of digestive activity to provide additional blood for the motor muscles. It is, also, what causes the dry mouth often associated with anxiety.
– A tendency to void the bladder and the bowels to free up the body for more strenuous activity.
– Finally, there is a suppression of the immune system and pain response. This prevents swelling and discomfort, which could interfere with a quick escape. This is, also, why people sometimes injure themselves when angry, afraid, or excited, but only notice it later.
When you look at this list, you see all of the common symptoms associated with anxiety and panic attacks. When they occur during a panic attack, they're simply normal reactions being triggered when there is no real danger. Let me repeat this. They are simply normal reactions being triggered when there is no real danger. While they may seem frightening, there is nothing dangerous about them.
The next thing to look at are the brain circuits that manage fear. One of the key parts of the brain for processing danger are two very complex almond- shaped structures on either side of the brain called the amygdala. When you experience something fearful or unpleasant, the amygdala give this memory an emotional stamp of danger. That is why an amygdala is located next to each of the hippocampus, the structures that actually form your memories.
When you encounter this fearful situation again, an immediate fear response is triggered that activates the fight or flight response and draws your attention to whatever activated the response. For example, it you are reading a book and hear glass breaking, your attention shifts immediately from your reading to the sound because it has been associated with danger. In fact, a key feature of the amygdala is that they are designed to overreact to possible signs of danger. For example, a person living where there are poisonous snakes will quickly learn to associate snakes with danger. The amygdala will then immediately trigger the fight or flight response when anything that might be a snake is perceived. After all, if you are walking in the woods, it is better to mistake a stick for a snake than to mistake a snake for a stick.
Keep in mind that this all occurs very quickly at an unconscious level. This circuitry allows you to react to danger quickly without the need to consciously think about what is occurring. Unfortunately, events and objects that pose no threat can become associated with danger and trigger a fear response when you encounter them. This unconscious interpretation of harmless everyday situations as dangerous plays a major role in many anxiety related problems.
Common Personality Traits: Perfectionism & Need For Approval
Next, let's look at two personality traits common to people with panic disorder: perfectionism and an excessive need for approval. Before going on, let me stress that like all traits, these exist across the spectrum. In the case of perfectionism, at the extreme high end is the person who refuses to accept any standards short of perfection and becomes obsessed with flaws and errors. On the other side of the spectrum is the person who is careless and shows no interest in doing things well.
Obviously, the healthy place to be is somewhere between these two extremes. In fact, there's a wide range between these two extremes with some people who are comfortable with less exactness, and others who are more meticulous and like to strive for excellence. Both of these can lead happy and successful lives. The point of all this is that people whose perfectionism is interfering with their lives do not need to rid themselves of the trait. Indeed, part of it was probably something they were born with. However, they can learn to soften it so it becomes an asset rather than a liability.
The second trait commonly found in people with panic disorder is an excessive need for approval. This is often referred to as a fear of rejection. Like perfectionism, it exists across a spectrum. If your need for approval is excessive, even mild disapproval can devastate you and interfere with relationships. On the opposite end of the approval spectrum is not caring at all what others think. Extreme examples are sociopaths who have no ability to empathize or form close relationships. Wanting the other person to like you is essential for healthy relationships. At the same time, a healthy person is able to tolerate the day to day disapproval we all experience.
So with both these traits, the goal is not to eliminate perfectionism or the need for approval. Instead, if they are exaggerated, the goal is to reduce them to a healthy level. Early childhood experiences are another factor that can play a role in the development of panic disorder. It's common for people with panic disorder to have a background that caused them to develop a self-image in which they believed they were inadequate in some way or that something was wrong with them. This sense of inadequacy may go away in early adulthood, but often re-emerges when panic disorder develops and confirms that they are broken, different, or don't measure up in some important way. While there are many things that can cause this, a few common examples include physical, sexual, or mental abuse. Overly critical parents, an anxious parental role model or the presence of substance abuse in the family.
Sensitive Reactive Bodies
The final thing to consider before putting all this together is how people with panic disorder often have highly reactive bodies that respond more intensely to environmental stimuli such as noise, odors, medications, or temperature variations. This is an inherited trait like eye or hair color.
Like all human traits, this type of sensitivity has a positive and a negative side. On the positive side, people with this type of body tend to be more aware of their surroundings because more information is coming into the brain. They, also, tend to be more intuitive and sensitive to the reactions of others. In fact, this trait is often what others like best about them. It helps people with this characteristic to listen and empathize better as well as notice when something is wrong in another person. People with a less sensitive body tend to miss the subtle, nonverbal messages of others.
People with reactive bodies often are also more emotionally reactive in both a positive an negative way. They can be the life of the party as well as more visibly upset than others when something bad happens. A simple way to understand the negative side of this biological trait is to imagine a house where the electrical wiring is inadequate. The electrical system works fine as long as it is not overburdened, but when too many electrical appliances operate at the same time, the electrical system is overloaded and circuit breakers begin to trip. In a similar manner, it's easier for a person with a reactive body to experience an exaggerated fight or flight response when overburdened with mental, physical, or emotional stress. Again, keep in mind that this is a normal variation. Just as people vary in height and eye color, people's nervous systems vary in their reactivity. There is nothing abnormal or dangerous about it. Let me repeat this essential point. Having a sensitive body is a normal variation. There is nothing abnormal or dangerous about it.
Now, let's put all of this together and see how panic disorder develops. One thing that everyone with panic disorder has in common is an initial panic attack that seemed to occur for no apparent reason.
Take, for example, Brian who experienced his first panic attack while he was at work. One day, he was going through his normal routine when suddenly his heart started to pound, and he found it difficult to breathe. The sensations lasted only ten minutes, but left him shaky and frightened for the rest of the day. Like most people, Brian attributed the physical symptoms to an unknown physical illness and left work to seek a diagnosis from a physician. At the doctors office, Brian was told that he was fine, and that the symptoms were just nerves.
Before going on with Brian's story, let's look at five factors that can cause this initial panic attack. For any particular person only one may be present or several may combine to produce the initial panic attack. I've already discussed the genetic component that is often present—a reactive body. This inherited reactivity often interacts with an x-factor stress to produce the initial panic attack.
Unfortunately, once panic disorder develops, the person with a sensitive body finds his or her body becoming even more reactive. In addition, a person with a less reactive body may find that it becomes over-reactive after a period of prolonged anxiety. It's similar to the way in which a person is more emotionally reactive when sick or tired.
The good news is that once a person learns how to manage and reduce the symptoms of anxiety, this reactivity will slowly return to the level it was prior to the development of panic disorder. When recalling the time just before the first panic attack occurred, people often recall a number of factors that were producing a high level of physical, mental, or emotional stress. Unfortunately, prior to the onset of panic disorder, they are often out of touch with their bodies and don't realize how stressed they are. After the initial panic attack, they become overly focused on their bodies. Because they are not aware of how stressed they are, they continue to try to do all of the things they usually do and often expect to be as effective as they usually are.
In essence, their first panic attack was really just a stress response. This is what Brian's doctor meant when he said his first attack was just nerves. Unfortunately, Brian didn't really understand what this meant, and the doctor didn't explain it to him or give him any guidelines on how to manage his stress more effectively.
Hyperventilation refers to breathing more rapidly or more deeply than is necessary. In fact, the first major panic attack for many people is actually a hyperventilation episode. For others, like Brian, hyperventilation accompanies most panic attacks and accounts for many of the distressing symptoms experienced. Many people have both the biological sensitivity already described and the tendency to hyperventilate. (Note: It is not clear if hyperventilation is a cause or a symptom of a panic attack. Approximately 50% of patients with panic disorder manifest hyperventilation as a symptom.)
The initial panic attacks that some people experience are triggered by a medical condition. There are many medical conditions that can produce one or more of the symptoms commonly associated with anxiety. Illnesses that are life-threatening or that produce unpleasant symptoms can also cause so much anxiety that they begin to trigger panic attacks.
For example, one source reports that about 14% of cardiac patients suffer from panic disorder. It's easy to see how a cardiac patient can become overly focused on his or her body and begin to become frightened by normal body reactions, which in turn, triggers the fight or flight response. The more alarmed this person becomes, the stronger the response.
Finally, many medications and recreational drugs can cause symptoms characteristic of a panic attack. It's important to note that not everyone who has a panic attack will develop panic disorder. One of the keys to developing this problem is how you think about your symptoms.
Returning to our example of Brian, you can see that Brian's initial panic attack was the result of several things interacting. First, he had three of the previous factors: a reactive body, stress, and hyperventilation.
When Brian recalled the time just before his initial panic attack at work, he remembered that he had been going to school full-time and working at a tiring job, had recently broken up with his fiancee, and had recently experienced the death of his father. His first panic attack had actually simply been a stress reaction. Brian didn't understand this.
In addition, his beliefs about himself told him that he should be strong and continue to do all the things he normally did even though he was experiencing major stress. He didn't understand that his initial symptoms were simply a very strong message that he was doing too much. Because of this, when his doctor said his symptoms were simply due to nerves, Brian began to think that this diagnosis was impossible and that there must be something terribly wrong with him that the doctor had missed.
Control & Inability To Recognize Stress In addition to these factors, Brian had a high need to be in control of himself to appear normal, and to avoid anything that might cause others to disapprove of him. This, coupled with his lack of awareness of how stressed he really was, caused him to worry that the mysterious and frightening symptoms would recur and again produce that terrible sense of being out of control. This fear caused Brian to become very aware of internal sensations such as his heartbeat and rate of breathing. This increased awareness of the body is called internalization or body scanning.
As Brian became more aware of his body, he began to imagine what might happen if the frightening sensations were to occur in various situations, a type of worry called negative anticipation or "what if" thinking. This combination of not understanding what had happened, internalization and negative anticipation caused the development of an anxiety/panic cycle, which can be diagrammed as follows: A normal body reaction occurs. In Brian's case, it was simply a response to stress causing him to hyperventilate. Because the reaction is not understood, it triggers fear, which activates the fight or flight response causing the frightening symptoms to increase. This is noticed and causes increased fear, which intensifies the body reactions, triggering a vicious circle of increasing intensity that we call a panic attack.
Thinking in terms of Brian's brain circuitry, we could say that the sensations associated with Brian's first panic attack, rapid heart beat, muscle tension, rapid breathing, lightheadedness, and so on had become stamped by his amygdala as signs of danger. Thus, whenever he experienced these symptoms, even when they were normal and at a very low level of intensity, they would trigger the fight or flight response. And his attention would immediately be drawn to them.
For example, when Brian walked up a flight of stairs shortly after the initial episode of frightening symptoms, he immediately noticed his increased heartbeat and increased rate of breathing. Instead of recognizing these sensations as normal reactions to walking up stairs, the fear response caused him to think, "Oh, my gosh. Here it comes again. This triggered the fight or flight response and intensified the physical reactions he was noticing. This series of reactions, in turn, increased his fear producing an even stronger fight or flight response. Within seconds, Brian had talked himself into a self-generated panic attack. (Note: Although, one's internal dialogue plays a large role in sustaining panic disorder, the mechanism that triggers panic attacks is not fully understood.)
As more and more normal situations were associated with danger, Brian began experiencing these self-generated panic attacks regularly and was now suffering from panic disorder. Brian eventually developed agoraphobia and often avoided situations, where he feared a panic attack might occur.
As Brian's world grew smaller, his tendency to use rigid thinking, need for control, and need for approval became more exaggerated. He was caught up in a series of vicious circles.
What separates individuals like Brian, who developed the anxiety/panic cycle, from those who don't is the way they think about their symptoms. While having a reactive body, a tendency to hyperventilate, a medical condition, or an adverse drug reaction can contribute to the development of an anxiety/panic cycle, the most important factor is the way a person thinks about his or her anxiety symptoms. People with several of the personality traits and childhood experiences described earlier are more likely to overreact to the initial symptoms, begin to watch their body carefully, and worry about what these symptoms mean and what might happen if they can't be controlled. In essence, anxiety becomes a sort of boogeyman that follows them around. They flee from any indication that this boogeyman is coming. Unfortunately, most of the symptoms they flee from are normal. They just don't understand this important point.
The good news is that the automatic responses and distorted thinking that develop with panic disorder can be reversed, and you can learn to lead a normal life once again. The specific program I use is outlined in the second companion video to this one. However, if you are suffering from panic disorder, take some time before you view it to write a simple explanation of why you developed panic disorder. Having a clear understanding of what causes your panic attacks is an essential first step in returning to a normal life.
Here is what Brian wrote: "I experienced physical discomfort due to my sensitive body and the stress I was experiencing. Because I didn't identify the source of my anxiety symptoms accurately at that time, I began watching my body and began to notice any sensation that resembled those that originally frightened me. I became trapped in the anxiety/panic cycle. As I work through these lessons, I will learn how to quiet these responses."
Additional examples can be found in my two books: "Anxiety, Phobias, & Panic," and "Overcoming Anxiety." These books expand on the overview presented here and include recommended activities at the end of each chapter to help you apply the ideas to your particular situation. Thank you for viewing my presentation. I hope it has helped you to understand panic disorder more fully and that this understanding helps you take another step on your road to recovery. Companion Video: "Overcoming Anxiety"
The video was written and presented by Reneau Peurifoy, a therapist, teacher, and author of several books. Please visit his channel for more information (Audio transcribed to text for educational and accessibility purposes.)
Understanding Panic Disorder by Michael Jackson Smith
A panic attack can strike anyone at any time. Most people
never experience an attack, and others may have only one or two
over the course of a lifetime. Someone who has a series of
attacks can be diagnosed with panic disorder, a debilitating
illness that can lead to a decreased ability to function in the
everyday world. Untreated panic disorder can lead to agoraphobia,
an extreme fear of open places and crowds. The phrase panic
attack (anxiety attack) has become a part of our vocabulary and
is used to describe any uncomfortable experience, unrelated to
the unbridled terror of a real panic attack.
Fear is an emotional response to danger. It is an innate survival mechanism that alerts the mind to take immediate action. The brain alerts the sympathetic nervous system to either fight or run in the face of perceived danger in the environment. Within an instant, physiological changes occur: the flow of adrenaline increases; the heart beats faster to pump blood to the muscles; and certain systems, like digestion, shut down to focus all of the body's energy to fight or to run. The reaction is commonly called the fight-or-flight response (also called hyperarousal, or the acute stress response).
If a tiger is springing from his rear haunches toward you, the fear response will instantly provide you with the energy that you need to grab your rifle and shoot him or to climb a tree faster than a monkey to the safety of the high branches. After the danger has passed, your body and mind return to their former state of equilibrium.
During a panic attack, the same fear mechanism that protects one from danger is evoked spontaneously. However, there is nothing to fight or any danger in the environment at all. The stimulus is not a tiger, but rather the spontaneous fear response itself that can spiral into additional attacks. Because it's not in the realm of human experience to be terrified for no reason, the sympathetic nervous system remains in hyperarousal. The parasympathetic nervous system (the rest and digest system) that would normally calm you after a real threat in the environment had passed is slow to respond.
People have said that having a panic attack is the most horrifying experience of a lifetime. It is so upsetting that repeated attacks result in the development of anticipatory anxiety, a secondary fear of having another attack. The intense distress of experiencing reoccurring panic attacks over a prolonged period of time will demand that one take action to escape the dreaded cycle of fear. Since the parasympathetic system is slow to respond when the source of the terror is internal, one will seek some alternative kind of relief.
The relief could be restricting one's activities by staying away from places that seem to induce panic attacks. Eventually, a person's comfort zone could become so limited that they become housebound. Agoraphobia severely limits a person's range of activity, and his ability to work and to care for himself. Others seek relief in drugs or alcohol.
The most immediate action one can take is to learn how to breathe correctly. Diaphragmatic breathing stimulates the vagus nerves, which evoke the calming effect of the parasympathetic nervous system.
Diaphragmatic Breathing Exercises and the Vagus Nerve
THE ROAD TO FORT WORTH by Michael Jackson Smith: Very little was known about panic disorder when I had my first panic attack. There was no help available to teach me how to assuage the attacks, but I discovered that alcohol would dissolve my fear instantly. My website contains the kind of information that would have been a tremendous help to me in the early days of my illness as I searched for solutions for the panic disorder, agoraphobia, and alcoholism that incapacitated me. My book is the story of my journey into recovery. Read Chapter 8 | Top of Page↑