Panic

Panic attacks are intensely physical. Your heart slams. Breathing stops working properly, and the harder you try to breathe the worse it gets. Your hands and face go numb or start to tingle, the room takes on an unreal quality, you are drenched or freezing or both, your legs will not hold you. It builds to its worst within minutes, which is fast enough to feel like something catastrophic is happening to your body rather than something psychological.

A great many people meet their first panic attack in an emergency room. The cardiac workup comes back clean, they are told it was anxiety, and they leave with the unsettling combination of relief and disbelief — because what happened did not feel like a mood.

Panic disorder involves recurrent, unexpected panic attacks and the fear of having more of them. It is treatable, and treatment is unusually specific: the goal is not simply to feel less anxious, but to change what happens when the body produces the sensations that have come to mean danger.

The fear of the next one

The fear of the next panic attack, of losing control, is a key feature of panic disorder — and it is what turns isolated attacks into a condition that organizes a life.

After a few, you begin scanning. A flutter in your chest gets checked against the last time. A slightly light head on a warm afternoon becomes a question. This is the loop that keeps panic disorder running: heightened attention to bodily sensation makes sensation more noticeable, noticing it produces alarm, alarm produces adrenaline, and adrenaline produces exactly the sensations you were afraid of. The attack arrives having been assembled out of the fear of it.

Then the avoidance starts, and it is rarely a decision. You take the surface streets because of the one on the freeway. You sit near the door. You stop going to the supermarket at busy times, then stop going alone, then find that the list of manageable places has quietly shrunk to four. When fear and avoidance spread across situations like this, agoraphobia can develop. It is not simply a fear of open spaces, but a fear of being somewhere escape might be difficult or help might not be available if panic or other incapacitating symptoms occur.

What treatment involves

Panic responds well to treatment, and the treatment is specific rather than general anxiety management.

Cognitive Behavioral Therapy for panic works on the interpretation first: the moment where a racing heart is read as a cardiac event, or unreality as the onset of madness. Those readings are what convert a surge of physical sensation into terror, and they can be examined and tested.

The distinctive piece is interoceptive exposure, which sounds alarming and is the part that works. You deliberately bring on the sensations you fear — spinning in a chair, running in place, or other exercises chosen to reproduce particular sensations — in session, on purpose, until a pounding heart or dizziness stops functioning as an emergency signal. You are not being taught to prevent the sensations. You are finding out, repeatedly, that they are survivable and that they subside on their own.

Breathing work has a place and a caveat. Learning not to over-breathe genuinely helps. Used as a rescue technique deployed at the first flicker of a symptom, though, it can become another form of avoidance and keep the belief in danger alive.

Medication is effective for many people and is worth discussing with a prescriber. One issue to discuss is the use of fast-acting sedating medication during exposure treatment: when medication becomes something a person feels they must take in order to face a feared situation, it can sometimes complicate the learning exposure is meant to produce.

What to look for in a therapist

Treatment for panic usually works on the physical sensations directly — bringing on the racing heart, the breathlessness, the dizziness on purpose, so the body stops reading them as danger. It sounds counterintuitive and it’s the part that tends to help most. Worth knowing that going in, so it doesn’t come as a surprise.

Avoidance usually needs its own plan. Attacks are what bring most people in, but if travel, driving, or leaving the house have narrowed, that’s often what’s cost more, and it doesn’t always resolve just because the attacks ease.

And it’s worth getting the medical question settled once, properly. Chest pain or other new or concerning physical symptoms deserve appropriate medical evaluation. Once a medical cause has been adequately ruled out, repeated testing can become reassurance-seeking: it provides temporary relief while keeping alive the question of whether the next sensation might be dangerous. This is familiar ground for therapists who work with panic.