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.
Amygdala
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
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.
Drugs
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.
Stress
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.
Self-Perception
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.
Anticipatory Anxiety
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↑