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The San Mateo CBT Clinic provides therapy for anxiety disorders in children, teens, and adults. Jonah Lakin PsyD is a licensed clinical psychologist specializing in Cognitive-Behavioral Therapy (CBT) for Obsessive-Compulsive Disorder (OCD), panic disorder, phobia, Generalized Anxiety Disorder (GAD),  social anxiety disorder/social phobia, agorophobia, emetophobia (fear of vomiting), illness anxiety disorder, trichotillomania (hair pulling), & excoriation (skin-picking).

San Mateo CBT Clinic blog about anxiety treatment

Anxiety Blog. Describes CBT principles involved in treatment for anxiety disorders in children and adults. Conditions discussed include: Obsessive-Compulsive Disorder (OCD), panic disorder, phobia, Generalized Anxiety Disorder (GAD),  social anxiety disorder/social phobia, agorophobia, emetophobia (fear of vomiting), illness anxiety disorder, trichotillomania (hair pulling), & excoriation (skin-picking).

Panic Attacks, Panic Disorder and Treatment

Jonah Lakin

Panic attacks are sudden surges of intense fear or discomfort that reach their peak intensity within a few minutes. This could happen when someone is already anxious, or when someone feels calm. Possible symptoms of a panic attack include: heart pounding, sweating, shaking, shortness of breath, feelings of choking, chest pain, nausea or stomach pain, dizziness/light-headedness, chills or feeling overheated, numbness/tingling, derealization/depersonalization, fear of going crazy or fear or dying. Panic disorder involves recurrent panic attacks, as well as fear of these attacks or a change in behavior related to them.  

Panic attacks and panic disorder are very treatable. To understand the treatment for panic disorder, you have to understand a bit about what panic attacks are. At their core, panic attacks are the result of an unusual type of phobia. Most phobias relate to things in the environment, like a phobia of dogs, germs, or darkness. In contrast, the phobia that causes panic attacks is a fear of sensations in one’s own body; in other words, people who have panic attacks are fearful of the physical symptoms of anxiety.  If you look at the list of symptoms of a panic attack above, you’ll notice that the overwhelming majority are physical symptoms of anxiety.

Nearly all of us has at one time or another felt anxious and noticed a rapid heart rate,  sweatiness, shortness of breath, or a tingling feeling in our fingers. If you don’t have panic disorder, you probably have noticed these symptoms and found them to be unpleasant, but also found that they go away after a little while. But if you have a fear of these symptoms, you can get stuck in a very nasty trap which turns these normal sensations into terrifying experiences. 

Imagine that you have a fear of a rapid heart rate, and you are sitting and watching TV. Suddenly, you notice your heart seems to be beating a little bit faster than normal. Maybe this is the result of feeling anxious, or maybe this is just the normal fluctuations that our bodies sometimes go through (our bodies aren’t perfect machines, so they often do all sorts of strange things!) Either way, because you are fearful of a rapid heart rate, the slight elevation in your heart rate will likely make you anxious. And what happens when you get anxious? Your heart pounds faster! So now your heart is pounding even faster, which makes you even more afraid, which of course makes your heart pound even faster, which makes you even more scared…As your heart seems to be pounding intensely, you begin to worry that you’re having a heart attack, or that you might die from heart failure. As you can see, the experience of anxiety escalates rapidly, causing a “sudden surge of intense fear,” a.k.a a panic attack. Thus, what started as a normal symptom of anxiety (or the normal “noise” of the body) turns into a terrifying experience wherein the heart seems to be pounding faster and harder and a person becomes fearful that they’ll have a heart attack and die. 

The same thing could happen with difficulty breathing. Let’s say you have a fear related to being unable to breathe. You sit down at work and notice it’s a bit hard to breathe. Maybe this is because you had to walk up a few flights of stairs to get to your desk, or you’re a little nervous about a meeting, or this is just more bodily noise.  Because you have a fear of being unable to breathe, this experience makes you anxious. Feeling anxious makes it harder to breathe, which makes you more anxious, which makes it even harder to breathe, which makes you even more terrified…

Not everyone with panic disorder has a fear of being unable to catch their breath or a fear of heart attacks, but the mechanism is usually the same. When a person has some fear of a physical sensation, and the sensation occurs, they feel afraid. That makes the sensation happen even more forcefully, which makes the person even more scared. This feedback loop intensifies very rapidly, causing a panic attack. This explains those last two symptoms of panic attacks that aren’t physical sensations; the rapid intensification of symptoms makes people feel afraid that they’re somehow going crazy, or that they might die from a heart attack, suffocation, or some other medical emergency related to the rapid changes in their body. 

So, how is panic disorder treated? If you’ve been reading my other blog posts, you already know that the treatment for phobias is exposure. If someone is afraid of dogs, we expose them to dogs; if someone is fearful of driving, we expose them to driving. If someone is fearful of rapid heart rate or difficulty breathing, we have to expose them to rapid heart rate or difficulty breathing.

Exposure to physical sensations is called interoceptive exposure. A classic interoceptive exposure exercise involves breathing through a tiny straw; this usually causes difficulty breathing. Another classic interoceptive exposure exercise involves running in place for one minute, which causes a rapid heart rate. As with all exposures, if people practice these exercises over and over and over again, they eventually learn that these stimuli (bodily sensations) aren’t dangerous, and the association between these sensations and anxiety is broken (which describes a process called classical extinction). 

As always, we have to eliminate safety behaviors for exposures to be effective. Safety behaviors are behaviors that people engage in when they feel anxious in order to make themselves feel safe (or less anxious). While safety behaviors are understandable responses to intense anxiety, they have the very unfortunate side effect of making exposure ineffective.

One of the most common safety behaviors for panic disorder is taking benzodiazepines such as Xanax or Valium. Because of the intense fear of having a panic attack, many people request to take these pills before completing exposure exercises. Unfortunately, if you practice exposures while taking these drugs, your fears of physical symptoms will never reduce, because you may attribute your safety to the drugs, not to the relative safety of temporarily having a rapid heart rate or difficulty breathing.

Another common safety behavior is to carry these drugs with you. Many people will say that they haven’t taken the pill in months, but always have one on them “just in case.” Carrying the pill makes them feel safe, and since panic attacks are so unpleasant, it’s a pretty understandable safety behavior. Nonetheless, to fully recover from panic disorder, people have to stop carrying these “just in case pills” with them so that they can see there is no danger in being out and about without them. Naturally, any decisions regarding medication should be made in consultation with a psychiatrist, and clients should never decide to start or stop these drugs without medical supervision. 

In summary, panic attacks are intense surges of anxiety that reach a peak within a few minutes, and are the result of phobias of physical symptoms of anxiety. The fear of these symptoms, combined with the fact that the symptoms are triggered by anxiety, makes for a vicious cycle in which normal physical sensations are turned into horrifying experiences. Panic attacks can be alleviated through repeated interoceptive exposure and the elimination of relevant safety behaviors.