Panic Disorder

Dr. Moses Appel (Edited by Matthew Shields)

Michael was riding the subway to work when his heart suddenly began racing. He felt lightheaded, his hands were shaking, and he was sweating profusely. He tried to take deep breaths, but it felt like he couldn't get enough air. His thoughts spiraled quickly: ‘Am I having a heart attack? Am I dying?’  The train car felt like it was closing in on him. He had the overwhelming urge to escape, but there was nowhere to go. At the same time, it almost felt like he was watching himself struggle rather than experiencing the panic attack directly. 

He got off at the next stop and stumbled onto the platform. His legs felt like jelly, and the world around him seemed distorted, like he was watching it through a thick fog. After a few minutes, the symptoms subsided—but the experience left him shaken and terrified, just as it had the last time Michael had a panic attack.

Michael, a lawyer by trade and president of his community's shul (synagogue) also happens to have panic disorder. In this blog, we'll discuss the diagnostic criteria for panic disorder, explain how it's much more prevalent than people seem to think, and address some of the ways the field addresses panic disorder. 

Before we get into panic disorder, we need to discuss briefly what a panic attack is, as people can experience panic attacks—and often do—without developing panic disorder. However, it's important to note that to reach the diagnosis of panic disorder, you must be experiencing panic attacks.

So, what is a panic attack?

A panic attack is an abrupt surge of intense fear or intense discomfort with four of the following symptoms being present:

• Palpitations, pounding heart, accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations of shortness of breath

• Feelings of choking

• Chest pain

• Nausea

• Feeling dizzy or faint

• Experiencing chills or heat sensations

• Tingling sensations

• Feelings of derealization or depersonalization—feeling as if things are unreal or detached from yourself. This symptom is very hard to describe if you haven't experienced it. In the example I presented at the beginning, remember how Michael felt like he was almost watching a movie of himself? That's the way many of my patients have explained their panic attacks to me. 

• Fear of losing control or going crazy

• Fear of dying

So, if you have an abrupt surge of intense feelings, with at least four of these symptoms present it's likely you're experiencing a panic attack.

Remember that experiencing panic attacks does not necessarily mean that someone has panic disorder. Someone can experience a standalone panic attack and not be diagnosed with any psychological condition. Further, panic attacks can be linked to clinical disorders other than panic disorder. For example, someone can have Social Anxiety Disorder with panic attacks. A helpful way to think about panic attacks is that they could be a specifier for disorders other than panic disorder, like Social Anxiety Disorder with panic attacks, or they can be tied to a panic disorder diagnosis.

The first criterion for a panic disorder diagnosis is the experience of recurrent—which means at least two—unexpected panic attacks. "Unexpected" means it seems as if the panic attack came out of the blue. In the example above, Michael was riding the subway to his law firm; hardly an activity he expected would induce a panic attack. Of course, with the help of hindsight, people who struggle with panic attacks might be able to guess what may have caused it, but during the attack, they're unable to do so.

What's an example of a panic attack that wouldn't qualify as "unexpected?" Imagine you're terrified of needles. When you're at the doctor's office and feel a panic attack before you're about to get a shot, that would not be considered unexpected—since you know that needles trigger intense anxiety in you. But, if you're minding your own business at the mall–a place without any previously known triggers– and all of a sudden you're experiencing a panic attack, that's considered "unexpected."

Additionally, as it relates to panic disorder, after experiencing these unexpected panic attacks, you constantly face worries like: ‘When is the next panic attack going to come? Does this mean I'm going crazy? Am I losing control? Am I going to be having a heart attack?’ Basically, if you're constantly worried about the consequences of your panic attacks, that's a marker for panic disorder. In fact, Panic Disorder is often referred to as “fear of fear” because what the person fears, are the fear symptoms themselves.

Similarly, If you're not worried about having another one, but you've changed your behavior in such a way to avoid panic attacks—because you're staying home all day or changing your routine in order to avoid the possibility of experiencing a panic attack—that's another criterion for panic disorder.

As mentioned earlier, panic disorder is much more common than people realize. Let's talk about some statistics:

• The lifetime prevalence of a panic attack is approximately 35%. So, a significant portion of the population—about a third, maybe even more than that­—experience having at least one panic attack at some point in their life. If you're hanging out with your two best friends, it's statistically more likely than not that at least one of you will experience a panic attack over your lifetime. 

• Panic disorder is less common, with a lifetime prevalence of around 5%. In other words, only one in twenty will meet the criteria for panic disorder at some point in their lives. 

• Interestingly, the prevalence of panic disorder is quite low in people younger than 14. For whatever reason, we don't see panic disorder much in children.

• Women are much more likely than men to have panic disorder. In fact, the Female-to-male ratio is 2:1; women are twice as likely to have panic disorder as compared to their male counterparts.

• Unfortunately, 25% of people with panic disorder report experiencing concurrent suicidal thoughts. We can easily see how distressing this disorder truly is. 

So, what therapy options do people have to treat their panic disorder? In my practice, we primarily utilize Cognitive Behavioral Therapy (CBT). We’ll start with a general CBT conceptualization, then apply it to panic disorder. To learn more about CBT, check out my video here. 

The main slogan for Cognitive Behavioral Therapy is that what we think and do affects how we feel. When it comes to panic disorder, that doesn't change.  Thoughts and behaviors affect and impact those with the disorder. Therefore, if we work to change our thoughts and behaviors, it will likely bring us a measure of relief from panic disorder.

The journey of therapy for panic disorder starts with psychoeducation, which is just a fancy way of saying the therapist provides the patient with information related to their disorder in a way that's comprehensive but also digestible to the majority of patients who don't read the DSM for fun. 

It's vital that the therapist explain what makes panic disorder distinct from individual panic attacks. I tell my patients that panic disorder is often referred to as "fear of fear" because what the person is afraid of are the panicky and fearful symptoms. They’re so scared of it that they end up triggering the fear, in a way. By explaining the disorder in this way, patients both understand what panic disorder is and feel validation for the pain panic disorder has caused them. 

Also crucial is that the patient understands the cycle of events relating to panic disorder. Here's a typical breakdown of panic disorder: 

1. Someone experiences a panic attack

2. As a result, they feel physical arousal and worry about another attack

3. They then become hypervigilant—constantly checking in with their body: “Am I okay? Am I feeling faint?”

4. After that, they may catastrophically misinterpret small physical sensations, like: “Oh no, it's starting again.”

5. And boom—another panic attack occurs

Patients must know that our bodies are designed to fluctuate. At some points throughout the day, you may feel an increase in your heart rate, a little weaker or stronger, or dizzy for a moment. But as long as you ignore the symptom and it doesn't keep coming back, you're fine. In panic disorder, people become hypervigilant. The more vigilant they are, the more likely it is to become a full-blown panic attack, so the key is avoiding being too vigilant. 

Here's a good psychoeducation example of hypervigilance making things worse: Two women are walking in the woods. One is warned about a bear in the area. The other is not. The one who knows about the bear is constantly on the lookout. She interprets rustling in the woods as danger. She's hypersensitive to any indications of a bear and might avoid the woods altogether. The other woman goes about her hike, taking in the nature. The first woman exemplifies what happens to people with panic disorder when they've had a panic attack—they become alert to everything, and ordinary sensations feel dangerous.

Another part of psychoeducation is discussing the body's fight-or-flight response. Our body has a built-in system to protect us from danger, where, when the body detects danger, it prepares to either fight or flee. This then triggers the physiological sensations experienced during a panic attack. And while it seems like these symptoms only produce needless suffering, each of them are actually there to protect us, not hurt us.

For example, blurry vision might result from your pupils expanding their visual field, whereas dry mouth happens because the body shuts down digestion to redirect energy. These aren't signs of harm—they're signs of protection. The more patients understand the biological factors behind their panic attacks, the less daunting they become. 

These responses would be helpful if a bear really was approaching, as you'd need to either run or fight. Your sympathetic nervous system kicks in and causes all those sensations—a racing heart, shortness of breath, etc. It's less helpful in non-life-threatening situations. Instead of misinterpreting these sensations as danger cues, we want patients to learn to reinterpret them as a false alarm, and nothing more. I always tell my patients to repeat the slogan “not dangerous, just uncomfortable!”

To better understand panic attacks, it helps to distinguish between two parts of the autonomic nervous system: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The SNS is what activates the fight-or-flight response, increasing heart rate, blood pressure, and respiration to prepare your body for immediate action. Conversely, the PNS functions to calm the body down, slowing heart rate and lowering blood pressure, promoting rest and digestion. Fainting is caused by a significant drop in blood pressure or heart rate—a response associated with the PNS, not the SNS. Therefore, fainting is very unlikely during a typical panic attack, as panic attacks activate the SNS, not the PNS. However, there is one notable exception: individuals with a blood-injection-injury phobia frequently experience fainting when confronted by their phobia. This is because this specific type of phobia uniquely triggers the parasympathetic system, causing a sudden drop in blood pressure and potentially leading to fainting. Importantly, even if fainting does occur, it is not dangerous by itself—although there's a risk of injury if one collapses and hits their head.

Now that we’ve covered psychoeducation, we move into cognitive and behavioral skills. Here are a few of the most common techniques: 

• Cognitive restructuring: Identify distorted thoughts (e.g., “I'm dying”) and replace them with more true ones (e.g., “This is a false alarm, not a heart attack”).

• Behavioral experiments: If a person thinks, “If I skip breakfast, I’ll faint,” we test that. Have them skip breakfast and observe what happens. Either they won’t panic—or they will, and survive, which is equally informative.

• Panic attack record: Patients record the symptoms they typically experience and rate severity. This helps determine which exposures to focus on, and getting more data is empowering in itself. 

• Interoceptive exposures: Here, we intentionally induce feared sensations, such as spinning in a chair to feel dizzy or breathing through a straw to feel breathless. With repetition, these sensations become less scary.

To summarize:

• Panic attacks are fairly common and not inherently dangerous

• Panic attacks are experienced by 35% of the population at some point in their lives, and panic disorder has a lifetime prevalence of 5%.

• Treatment includes psychoeducation, cognitive restructuring (“not dangerous, just uncomfortable”), and situational and interoceptive exposures.

• Therapists should tailor therapy to match the patient’s values and symptoms.

Disclaimer: All characters and scenarios in this post are entirely fictional. This content is intended for informational purposes only and is not a substitute for professional therapy or treatment from a licensed mental health provider. To contact Dr. Appel, please email office@ADOPsychologyCenter.com.