Question: I have always been somewhat anxious person struggling with anxiety. Recently, however, my symptoms of fear started unexpectedly when I was in a place where I was enjoying myself. My heart started racing; I felt shortness of breath, started sweating, and felt nauseas. I was scared that I would lose control and have no one close to me to help. Ever since, I have been avoiding walking up the stairs, hot drinks, and other activities that could bring on these sensations, and now I am becoming even more scared to do the things I used to enjoy. I have gone to my primary care doctor who reassured me that my heart is healthy. I am concerned to talk about this with people who might think I am crazy.

Sincerely,

Panicky

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Dear Panicky,

What you are describing seems to be indicative of a panic disorder, which is a sudden onset of physical symptoms of anxiety, plus a chronic fear of having panic attacks. People with panic tend to use avoidance as a way to “prevent” panic attacks from occurring – this avoidance is called agoraphobia. In your case, you’ve had a panic attack and you are avoiding activities that you worry might bring on these symptoms.

It is understandable that people with panic disorder want to avoid situations that may bring on panic symptoms, as this helps in the short term to feel less anxious. The problem is that in the long run, avoidance maintains the symptoms.

Cognitive Behavior Therapy (CBT) addresses this very issue. CBT utilizes (1) psychoeducation (presenting accurate information about panic disorder and agoraphobia), (2) cognitive restructuring, and (3) exposure to decrease severity and intensity of suffering. Here are some gleanings from each of these aspects of treatment.

1. Most people experience immediate relief when they simply learn about what panic is and is not. Panic symptoms are similar to sensations that get a person ready for an emergency. When a threat is perceived, energy is mobilized to systems that assist in fight or flight for self-protection. Energy that usually flows to the digestive system, immune system, and other systems are redirected to systems that may aid in self-protection such as the brain, the heart, breathing, and major muscles. This extra energy is adaptive and healthy because it assists us in getting out of danger and back to safety in case of a real emergency. In panic attacks, however, people experience a fight or flight response although they are not in a real emergency.
2. People tend to pay special attention to potential threats while not noticing evidence that may indicate that all is well. In cognitive restructuring, patients are encouraged to examine both the evidence for and against signals of danger. Since the panic response is adaptive, the goal is not to take it away but rather to examine both the evidence for threat and the evidence against threat to get a more balanced picture of what is actually happening in the moment. Additionally, since people tend to scan for threat while in the fight or flight state, they tend to turn their attention inward for signals of threat once external threats are ruled out.
3. Exposure addresses the discomfort experienced from the fight or flight response such as increased heart rate and hyperventilation. People who have experienced panic attack are often sensitive to the physical sensations associated with the fight or flight response. This sensitivity increases awareness of internal sensations that would otherwise not have been noticed. As a demonstration, stop for a moment now and scan your skin for an itch. Do so until you feel it. How much time did it take for you to notice the itch? Do you think you would have felt it should you have continued reading without actually looking for it? Being highly attuned to physical sensations and interpreting increased heart rate as a signal of danger fuels the threat response. With exposure treatment, the goal is to help people feel more comfortable with their internal sensations.

CBT is highly effective for treating panic disorder. In fact, over 90% of people with panic disorder respond to CBT, with decreased number and intensity of panic attacks, and better ability to tolerate internal sensations after treatment.

Feel free to reach out if you need assistance managing your panic symptoms. We are here to help!

All our best,

Center for Anxiety

David H. Rosmarin, Ph.D., ABPP, is an Assistant Professor in the Department of Psychiatry at Harvard Medical School, part-time, and a board certified clinical psychologist. He also directs the Center for Anxiety, which has offices in Manhattan, Brooklyn, Monsey, and Boston. Malky Berger, LMSW is a staff clinician at the Center for Anxiety’s Monsey office. She specializes in working with children, adolescents, and adults presenting with anxiety, depression, ADHD, and other mental health problems. She is also fluent in Yiddish.

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