Panic Disorder

The short version: Panic disorder is a tendency to suffer from disabling panic attacks. These attacks are feedback loops associated with unusual bodily sensations, probably relating to a tendency for the brain’s oxygen management system to suffer false alarms and believe you are suffocating. Panic disorder usually gets better on its own, but patients don’t always want to wait the months or years this can take. SSRIs are an effective pharmaceutical treatment for panic disorder; CBT is an effective psychotherapeutic one.

The long version:

1. What is panic disorder?

To vastly oversimplify: panic disorder is a false alarm in the brain’s suffocation detection system, plus a series of feedback loops that make the false alarm worse and prevent it from being fixed.

I realize this isn’t the standard explanation given in textbooks. But it’s a theory Professor Donald Klein proposed in Archives of General Psychiatry in 1992, it’s been supported by many experiments since then, it makes sense of various otherwise-inexplicable phenomena, and I think it should be better-known than it is. Also, when I explain it to patients with panic disorder, they usually feel better and recover more quickly, because part of the problem with panic attacks is a feeling of helplessness and not knowing what’s going on. I believe Professor Klein explained what was going on back in 1992 and that it’s worth explaining his model to the public.

Your brain has a collection of cells called the “central chemoreceptor” that checks the level of carbon dioxide in the blood. If there’s too much carbon dioxide, the central chemoreceptor tries to get you to breathe harder. If for some reason this doesn’t work, the chemoreceptor activates a “suffocation alarm”, telling the rest of your brain that you’re suffocating and it should drop everything else and try to solve this problem. If you’ve ever been in a situation where you’ve been low on air, you know what this feels like. Sudden, extreme panic. The feeling of suffocating (not really like any other feeling, very unpleasant), and the replacement of normal breathing with desperate gasping. Increased circulatory activity in case oxygenated blood just isn’t isn’t reaching your brain properly – that means fast, pounding heartbeat. A desire to get out of whatever situation you’re in and run outside (if you’re suffocating, probably the situation you’re in is some kind of cave or fire or something with no air supply). These are most of the symptoms of panic attacks, with the remainder being explained by general sympathetic activation.

Making people breathe air artificially enhanced to have extra CO2 can provoke panic attacks. This effect is stronger in relatives of people with panic disorder, even those who have never had the condition themselves, suggesting that they have genes for being more sensitive to carbon dioxide and the possibility of suffocation. Some of the genes involved in carbon dioxide sensing seem to predispose for panic disorder, although the studies involved are preliminary and should be confirmed with more modern genetic research tools.

(not-so-fun fact: scientists first discovered the central chemoreceptor by investigating a condition called Ondine’s Curse, where patients with certain kinds of neurological damage lose their natural drive to breathe: they could still breathe by consciously choosing to do so, but the moment they forgot, they would suffocate. Obviously this condition is extremely fatal; if nothing else, sufferers will die upon falling asleep. Panic disorder is a sort of opposite of Ondine’s Curse; Curse patients don’t feel like they’re suffocating even if they are; panic disorder patients feel like they’re suffocating even when they’re not).

Exactly how this overactive suffocation alarm produces panic attacks is a little murkier, but here’s one possible model: at some point, the normal ebb and flow of weird sensations in the body passes the threshold for setting off an oversensitive suffocation alarm. The suffocation alarm sounds a weak signal, which causes bodily sensations to become more deranged – eg faster heart rate, higher sympathetic activation. The suffocation alarm incorrectly interprets its own downstream effects as further evidence of suffocation (“there’s a fast heart rate, something must be really wrong!”) and sounds a stronger signal. This intensifies in a vicious cycle: stronger suffocation alarm means more deranged bodily signals means stronger suffocation alarm.

What are these deranged bodily sensations and how do we stop them? Probably there are many of them, and the central chemoreceptor takes inputs from all sorts of other bodily systems before deciding how much you are suffocating. One unusually ironic one that’s gotten a lot of attention is hypocapnia – not having enough carbon dioxide. Because the false suffocation alarm provokes hyperventilation (increased breathing, gasping for air), by the middle of a panic attack, patients usually have much too much oxygen, and much too little carbon dioxide, in their blood. This causes its own set of problems, and the chemoreceptor is totally incapable of distinguishing the problems of too little carbon dioxide from the problems of too much carbon dioxide, so it just notices things are getting worse and tries to make you breathe even harder (I don’t understand why evolution let this system get this stupid, but here we are). This is probably why deliberate attempts to decrease oxygenation (eg breathing into a paper bag) seem to help panic attacks. They might also work by giving the brain an “explanation” for its otherwise confusing sensations. When the suffocation alarm goes off, higher brain centers are able to think “Yeah, of course she’s got too much carbon dioxide, she’s breathing into a paper bag”, and then it doesn’t panic as much as it would otherwise.

Probably it is actually much more complicated than this. The part I always stress with my patients is that panic attacks are a specific type of false alarm. They don’t mean anything is actually going wrong. They’re happening for a very specific reason: your body thinks you are suffocating, and is trying to give you a level of freaked-out-ness appropriate to that situation. Many patients, if they concentrate closely enough on the sensations of panic, are able to explicitly perceive them as the feeling of suffocating. This can paradoxically be reassuring – if you’re in a normal well-ventilated place, you know you’re not suffocating and you can understand the false-alarm nature of the scary feelings.

2. What is the usual prognosis of panic disorder?

I can’t back this up with formal studies, but I’ve found people with panic disorder fall into three groups.

The smallest group is people who have had it ever since they were old enough to notice, have it consistently all the time, and will probably continue having it unless something changes. This situation seems pretty rare.

A somewhat larger group is people who have it when other problems get really bad. Depressed people who get panic attacks during the worst parts of their depression (and never once their depressive episode is over). Anxious people who get it during a stressful life event that makes them extra-anxious. My guess is that depression, anxiety, and so on activate the sympathetic nervous system in a way that the chemoreceptor interprets as a little bit of extra evidence of suffocation. With this “bonus”, it’s much more common for other small fluctuations to get over the threshold, set it off, and precipitate a panic attack. These people will stop having panic attacks once their anxiety or depression gets better.

The largest group are people who never had panic attacks until [incident], then [incident] gave them a very bad panic attack, and ever since [incident] they’ve continued to have panic attacks regularly. Sometimes [incident] is a traumatic event, sometimes it’s a random panic attack that came completely out of nowhere, but most often it involves using recreational drugs (even usually-considered-harmless drugs like small amounts of alcohol, marijuana, or LSD). Probably these drugs created weird internal sensations that confused their chemoreceptor, and their chemoreceptor decided to err on the side of caution and set off a suffocation alarm. Whatever the [incident], it “kindled” a temporary tendency toward panic attacks (if you’ve read the section on predictive coding, it produced some evidence that suffocation is common in the environment leading to a high prior on suffocation that has to be unlearned). The good news is you’ll unlearn this prior with time. This group of people tend to have very frequent panic attacks just after [incident], gradually declining in frequency and severity over the course of a few months to a year, and eventually recover completely. Sometimes there will be another incident some time in the future that will start the process over again, sometimes there won’t be.

Panic attacks often go away on their own, especially if an underlying cause is resolved. When they don’t, treatment is usually effective. Patients usually don’t feel like they have an effectively-treatable condition in the middle of a panic attack, but psychiatry’s track record here is usually pretty good.

3. What pharmacological treatments work for panic disorder?

There are two goals here. The first is an acute treatment you can take when you’re having a panic attack and want it to stop right now. The second is a maintenance treatment you can take to prevent panic attacks from happening at all.

The most common acute treatment is Xanax (alprazolam). This stops panic attacks pretty effectively. Its main downside is that it’s potentially addictive, but in practice people rarely get addicted if they take it 2-3x/week or less, so this is a good choice for people whose panic attacks are less frequent than that. If someone’s panic attacks are more frequent than that and they want something they can still take long term, my second-line choice is Vistaril (hydroxyzine). This is still pretty good but it can sometimes make people sleepy, which is annoying if they have a panic attack in the middle of the day.

A secondary downside to all acute treatments for panic attacks is that some people worry it inhibits the learning process. That is, part of treating panic disorder is convincing your lizard brain that panic attacks aren’t as scary as it thinks, breaking the feedback loop where panic causes worse panic and so on. But if you always take medication as soon as you start feeling a panic attack, then you never get a chance to habituate to the state of being in a panic attack.

I am pretty liberal on this one; I think part of the process of learning not to be scared of a panic attack is knowing that you could stop it if you wanted to. Somebody who knows they have a medication that could help them at any time, but who’s going to try to sit through the panic attack to get “the full experience”, is in a much safer and better place to learn something than the person who’s freaking out because they’re stuck in a panic attack they can’t control. Also, a lot of people’s panic attacks will go away on their own, or with the help of maintenance medication, after a while anyway. So I usually try to get somebody stabilized on an acute medication that works for them first, and then once they feel like things are in control, talk about whether they might want to try experiencing the panic attacks so they can habituate. Often the problem is mostly solved by then in any case and we don’t have to worry about that.

The usual dose for Xanax for panic attacks is 0.5 mg; if you’re a bigger person, or your attacks are unusually bad, or that doesn’t work, you can go up to 1.0 mg. If it takes too long to work, you can crush it into a powder and let it sit under your tongue until it gets absorbed by the blood vessels there, which will make it work faster than forcing it to go through your stomach and digestive tract. The usual dose of Vistaril is 25 – 50 mg, same story.

The most common maintenance treatment is antidepressants. For some reason, almost all antidepressants (except maybe Wellbutrin) treat panic attacks pretty much in proportion to how well they treat depression. As with depression, start with SSRIs. I’ve never had any panic attack patients need to go further than this, but in theory you would probably escalate to tricyclics or MAOIs if this didn’t work. Anxiolytics like buspirone and pregabalin should probably work too, but realistically SSRIs are really good for this and it rarely requires getting fancy.

You can pick whichever individual SSRI you would normally pick for depression, use the same dose as in depression, and expect it to take the same amount of time to work as depression. Strange, huh? My guess is this has something to do with SSRIs’ ability to blunt emotions breaking the negative feedback loops involved in panic disorder, but I don’t have a really clear understanding here.

4. What psychotherapy works for panic disorder?

Most people benefit from a course of cognitive-behavioral therapy centered on exposure.

The cognitive-behavioral therapy teaches you things about panic attacks. You learn that they can’t actually hurt you. You learn some coping strategies for what to do when you’re having them (eg breathing exercises). You learn to recognize negative thoughts (“I’m never going to be able to deal with this”) and transform them into positive ones (“I’m gradually working on learning how to deal with this”).

Once the CBT has made you more able to deal with panic attacks, you start the exposure therapy, which is intended to make you stop having them. Exposure therapy works especially well if your panic attacks have a clear trigger, like socializing or going outside. You and your therapist work together to make an “exposure ladder”, starting with easier things and moving to harder things. For example, if someone had panic attacks upon being out in big crowds, their ladder might look like:

1. Go outside the house into my front yard
2. Go on a walk to the corner store and buy milk
3. Go to the big local supermarket and do a grocery run late at night when nobody’s there
4. Go to the big local supermarket and do a grocery run at midday when everybody’s there
5. Go to the shopping district and browse some of the stores
6. Go to a sports game at a packed stadium

The idea is: first you go outside the house into your front yard. You repeat this every day. Probably this will make you uncomfortable but not cause a panic attack. Or maybe it will make you have a mild panic attack, but you will use the techniques you learned in cognitive-behavioral therapy to not let it get to you as much. Your brain will learn that going into the front yard isn’t that scary, and after a while it will stop making you so uncomfortable. You will have “unlearned” a little bit of your fear of open places.

After going into your front yard barely causes any distress at all, you move on to the next phase, going on a walk to the corner store and buying milk. Again, this will make you uncomfortable – but given the unlearning you did in the last step, this is probably a small enough step forward that it won’t cause a panic attack either. You repeat this every day and after a while it stops making you so uncomfortable, and then you move on to the next step, and so on.

Some people make this work without a therapist’s help. This is great, but you want to be careful, because if you do the exposure too quickly, or without having done the part where you learn how to cope with panic attacks, then you can have very bad panic attacks during the exposure and accidentally make your brain further-learn that things are scary, instead of unlearning it. If you’re going to go this route, I strongly recommend David Burns’ book When Panic Attacks, which is a great guide to everything you need to know about panic disorder and how to plan an exposure therapy course for it.

Other psychotherapies might also work for panic disorder, but are less tested, and I know less about them.

5. What can I do when I’m having a panic attack?

If you’ve talked to your doctor and have a special medication for stopping panic attacks, like alprazolam or hydroxyzine, you may want to use that (see above for some considerations for why or why not).

If you’re trying to get through it without medications, different people will find different things are helpful. But here are some options you might want to try:

1. Do anything that causes strong bodily sensations other than the sensations of panic. Taking a very cold (or very hot) shower has worked for a lot of people.

2. Experiment with what you can and can’t do while having an attack. Most people having a panic attack assume they are completely incapacitated, can’t think straight, some people don’t even think they can walk. David Burns makes these people do jumping jacks, complicated mental math problems, and whatever else they say they’re not capable of. I’ve talked to patients who say they’re lying in bed because they think they can’t stand up without falling over, and made them go on walks around their house, which they are perfectly capable of. During a panic attack, your body is lying to you. Call its bluff. This will make you less afraid, less incapacitated, and it’s part of the process of learning to reinterpret your panicky feelings and eventually defuse them. Just don’t do anything where you could potentially seriously hurt yourself (like driving a car). You would probably be completely capable of driving safely, but I wouldn’t want you to freak out and decide to give up in the middle of the highway.

3. Exercise is a combination of strong bodily sensations and experimenting with what you’re capable of doing; predictably, it can be pretty helpful.

4. Do breathing exercises. I recommend learning the exercise before a panic attack so you’re ready when one happens; this one is pretty good; if you’re into yoga, you can also try nadi shodhana breath. My guess is that the actual features of the breathing exercise you’re doing matter less than the fact that you’re breathing mindfully (plus a little placebo effect).

5. A friend of mine swears that eating honey, especially letting it sit on their tongue and the roof of their mouth, reliably aborts their panic attacks. I don’t know if this is a sub-example of “anything that causes strong bodily sensations”, and I’ve never heard of anyone else trying this. If you try it, let me know.

6. Anything else I should do?

I want to recommend a second time David Burns’ book When Panic Attacks. Because panic attacks involve a feedback loop that passes through your thoughts and emotions around having a panic attack, understanding what they are is half the battle. This book gives you a better understand and has more good advice for dealing with them.