Panic attacks are sudden episodes of intense fear followed by cognitive and somatic symptoms such as losing breath, increased heart rate, and having a numb feeling in your hands. Panic disorder is a mental disorder defined by recurring panic attacks that become chronic, and a constant fear that the attack might occur again. People experiencing this disorder have the tendency to adopt maladaptive behaviors such as avoidance of certain places, people, or situations to prevent the attacks to occur.

The article structure:

1. What is it?
2. Biological Markers
3. Coping With Panic Attacks

‍

What is it?

Let’s begin by looking at panic attacks: intense, sudden episodes that trigger extreme psychological reactions such as fear in the face of no real danger [1].  When such an event occurs, people have the feeling of losing control, they feel dizzy, experience shortness of breath, and increased heart rate. Usually, they come with intense negative thoughts of death - people might think they are experiencing a heart attack due to the rapid heart rate and hot flashes. Indeed, studies showed that panic attacks are positively correlated with heart rate variability (HRV), a key feature of cardiovascular diseases, but not with heart attacks per se. The panic symptoms typically reach their peak after 10 minutes, and they can last up to hours. If the panic attacks are recurrent, it is advised to seek a doctor that can further decide to redirect the patient to a psychologist or psychiatrist, as the panic attacks can signal Panic disorder.

Now, let’s look more closely at the disorder. Panic disorder is a mental and behavioral disorder present mostly in people with intense anxiety, and is characterized by recurrent panic attacks [1]. The panic disorder comes with the concern about the panic attacks themselves - it is a vicious circle (see image 1). Because of this, individuals adopt maladaptive strategies to avoid triggering situations, and location, or even physical exercise.

‍

Panic attacks can be divided into expected (as a response to a fearful situation/object/person) and unexpected (when they happen for no reason). This is an important aspect for diagnosis, which is given also in cases where there is actually, no apparent reason or phobia for panic. Moreover, the disturbance “should not be explained by other mental disorders, other medical conditions, or substance use”.

The following sings and/or symptoms as presented in DSM-5 [1]:

• Palpitations, pounding heart, or accelerated heart rate.
• Sweating.
• Trembling or shaking.
• Sensations of shortness of breath or smothering.
• Feelings of choking.
• Chest pain or discomfort.
• Nausea or abdominal distress.
• Feeling dizzy, unsteady, light-headed, or faint.
• Chills or heat sensations.
• Paresthesias (numbness or tingling sensations).
• Derealization (feelings of unreality) or depersonalization (being detached from oneself).
• Fear of losing control or “going crazy.”
• Fear of dying.
  

→ It’s important to distinguish a panic attack from a panic disorder: it may happen from time to time to experience a panic attack, but this is no indicator of the panic disorder.

Biological Markers

Panic attacks might be the result of our biological construction. People are built to respond to danger in order to avoid it - in dangerous situations, such as a direct attack, the amygdala is activated and cortisol, the stress hormone, is secreted to act as a warning that danger is approaching. However, even in a normal everyday-life situation, our body may have a similar reaction. Why?

The hypothalamic–pituitary–adrenal (HPA) axis is a major endocrine system that regulates stress responses and dictates how people adapt to the environment and cope with stress [3]. In the past, it was assumed that panic attacks were the result of a mis-regulation of the HPA [6]. However, studies have shown inconsistent results: some patients reported higher cortisol levels in panic attack days as compared with attack-free days, [2,6] and other people showed only marginal HPA axis activation during spontaneous panic attacks. Several studies have shown a clear distinction between PD patients and the control group in terms of cortisol levels, whereas other studies have shown no difference between the two groups. The inconclusive results suggest that cortisol secretion is not, alone, a reliable indicator of panic attacks.

Nowadays, new efforts are put into classifying mental disorders based on biological markers [3]. Structural changes in the volume of the amygdala, hippocampus, parahippocampal gyri, and brainstem nuclei have been observed in people with PD.  Additionally, increased cerebral blood flow in the left occipital cortex, lower serotonin (5-TH) plasma levels, and a significant association between hyperactivation of the NE system (noradrenaline), anxiety, and somatic symptoms in people suffering from PD have been observed. (These patterns differ from normal populations). The aberrant respiratory pattern (i.e. hyperventilation) [7] and the heart rate variability (HRV) are also seen as biomarkers for PD. Heart rate variability (HRV) is positively correlated with panic attacks for both clinical and non-clinical samples.

Coping With Panic Attacks :)

Panic attacks are more of a natural alarm system that signals the body that a danger is approaching. Thus the body enters fight or flight mode that in short term can be very useful in responding to the danger [8]. However, when no physical or real danger exists, activating this defense can lead to a lot of frustration or/and the belief that these situations can be actually harmful. So, people might have the tendency to isolate and expose themselves less to social functions. Interesting, panic attacks can lead to Agoraphobia.

Therefore, the first step in coping with the symptoms is to understand your mind and body. Start with a journal where you can write down the symptoms you experience and the catastrophic thoughts you have in relation to that symptom. For example:

• Symptom: Shortness of breath.
• Catastrophic Misinterpretation: I will choke to death

Write this for every symptom and every time the misinterpretation changes.

Now that everything is on paper, it is advised to try to challenge these misinterpretations so that, with time, they translate to healthier responses.

You can challenge this by asking yourself:

• The last time when I experienced this symptom and the intrusive thought appeared, did the misinterpreted scenario actually happen?
• If the scenario did not happen, what makes me think it will happen this time?
• What would I say to a friend who experiences panic attacks? Tell that to yourself !

Another method to cope with attacks is distracting yourself by grounding [8].

Best way to do it is to focus on your immediate surroundings through your senses: what can you see, hear, smell and touch? This method helps  you get out of your head and focus on what is real. Another distraction technique is to imagine yourself in a safe space, such as your holiday home or your favorite park.

Breathing techniques can be used as well - sit upright and try to control your breathing. Keep your hands on your chest and stomach while you breathe using the 4-7-8 rule: inhale with your nose for 4 seconds, hold for 7 seconds then exhale for 8 seconds.

Adopt a set of safety behaviors - if you feel that the panic attack can cause vomiting, then carry a bag with you. This will give you a sense of safety. In the same journal where you keep track of your symptoms and misinterpretation, you could also make a list of safety behaviors in response to the symptoms.

Finally, it is important not only to cope with the disorder but also to try to “cure” it by gradually exposing yourself to uncomfortable situations [8]. Try to resist a little longer each time to prove to your brain that there is no real danger indeed. Keep track of your improvements or setbacks.

As a final note, it is necessary to understand that progress is not a straight line and that there can be setbacks. Despite all, I encourage you to continue with the coping mechanisms. Exercise often and develop a habit of keeping a journal <3

‍

Interesting Video:

What a Panic Attack feels like: Milli’s Story https://www.beyondblue.org.au/the-facts/anxiety/types-of-anxiety/panic-disorder

‍

References:

1. American Psychiatric Association, D. S., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5). Washington, DC: American psychiatric association.

‍

2. Bandelow, B., Wedekind, D., Pauls, J., Broocks, A., Hajak, G. ½., & Rï¿ ½, E. (2000). Salivary cortisol in panic attacks. American Journal of Psychiatry, 157(3), 454-456.

‍

3. Bandelow, B., Baldwin, D., Abelli, M., Altamura, C., Dell’Osso, B., Domschke, K., ... & Riederer, P. (2016). Biological markers for anxiety disorders, OCD and PTSD–a consensus statement. Part I: neuroimaging and genetics. The World Journal of Biological Psychiatry, 17(5), 321-365.

‍

4. Cosci, F., & Mansueto, G. (2019). Biological and clinical markers in panic disorder. Psychiatry Investigation, 16(1), 27.

‍

5. Hillebrand, S., Gast, K. B., de Mutsert, R., Swenne, C. A., Jukema, J. W., Middeldorp, S., ... & Dekkers, O. M. (2013). Heart rate variability and first cardiovascular event in populations without known cardiovascular disease: meta-analysis and dose–response meta-regression. Europace, 15(5), 742-749.

‍

6. Ising, M., Hohne, N., Siebertz, A., Parchmann, A. M., Erhardt, A., & Keck, M. (2012). Stress response regulation in panic disorder. Current pharmaceutical design, 18(35), 5675-5684.

‍

7. Perna, G., Caldirola, D., & Bellodi, L. (2004). Panic disorder: from respiration to the homeostatic brain. Acta Neuropsychiatrica, 16(2), 57-67.

‍

8. Young, C., Hunte, A., Newell, J., & Valian, P. (2011). Coping with panic. Cambridgeshire and Peterborough NHS Foundation Trust, ed. Improving Access to Psychological Therapies, 4, 27-28.

‍