Don’t Panic! Understanding Panic Attacks and How to Stop Fighting Them

One of the most common symptoms in psychiatry is the terrifying, infuriating, embarrassing panic attack. Panic is not a diagnosis, and panic attacks (also called anxiety attacks) can occur in a lot of different psychiatric conditions. They can also occur in people without anxiety disorders due to medical disorders, drug intoxication or side effect, or during a traumatic event.

So not everyone who has a panic attack has Panic Disorder, which is a psychiatric condition that falls under a group of disorders called Anxiety Disorders. Other anxiety disorders that can cause panic attacks are phobias (like people with a severe fear of snakes might have a panic attack when they run across a snake while hiking) or Post-Traumatic Stress Disorder (like someone with PTSD after being mugged might have a panic attack when they go back to the same neighborhood where they were attacked). Some people with performance anxiety (a form of Social Anxiety Disorder) get panic attacks before a concert or public speaking.

The DMS-5 describes a panic attack as a sudden episode of intense fear or discomfort accompanied by at least 4 of these symptoms:

• Palpitations, pounding heart, or accelerated heart rate

• Sweating

• Trembling or shaking

• Shortness of breath or feeling like you’re being smothered

• Feeling like you’re choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Feeling dizzy, unsteady, lightheaded, or faint

• Chills or a flush of heat

• Paresthesias (numbness or tingling, often in the fingers and toes or around the mouth)

• Derealization (feeling like you or the world isn’t real) or Depersonalization (feeling like you’re detached from your body and watching what’s happening, or that you’re separated from the world by a bubble or a distance)

• Fear of losing control or going crazy

• Fear of dying (sometimes because you think you’re having a heart attack or a stroke)

Classic panic attacks start pretty suddenly, have their peak of intensity within 5-10 minutes, and then start to subside. Sometimes people cry, or their face and neck get red. What is particularly noticeable to me is the feeling of urgency. Panic attacks make people feel like they have to do something, now – get out of the store, stop driving, get to an emergency room – and it’s really hard for them to just sit still and wait out the panic attack, even if they have had them before.

One of my patients went to the emergency room thirty times before he was finally convinced that a psychiatrist might be able to help him get better. Every single time, he believed he was having a heart attack and needed emergency treatment. He was in his early 20s and had already been completely evaluated by a cardiologist who reassured him that his heart was fine, but when had another episode of chest pain and shortness of breath and feeling like he was going to pass out, he was sure this time it was a heart attack, and he’d call 911 again.

Other patients really suffer in silence. They just start to avoid situations where they have had a panic attack, or might have a panic attack. In some patients this leads to Agoraphobia, the name for the disorder where people are so afraid they might be anxious that they don’t leave home unless it’s with a trusted person and to a relatively familiar environment, or it’s an emergency.

It’s also possible to have Agoraphobia even without panic attacks –the fear of leaving home or possibly having anxiety when away from a safe place keeps people stuck at home. Many of these people never seek psychiatric attention and just live quietly in isolation. The availability of grocery delivery and online ordering of almost anything makes it even less likely that these people will get the care they need – psychiatric or general health care.

Once you have had unprovoked (“out of the blue”) panic attacks, and have been avoiding places or things that might cause anxiety attacks for at least a month, you have Panic Disorder. Officially, this means your doctor considered and excluded other causes for panic attacks, like phobias or PTSD or OCD, but also medical causes like drugs (caffeine, stimulants like Ritalin or Adderall or cocaine, steroids, and others) and medical conditions like hyperthyroidism or pheochromocytoma. We especially want to think about hormone transitions like starting to menstruate, pregnancy, postpartum, and perimenopause, since these transitions can sometimes trigger anxiety and/or panic attacks.

Sometimes the first panic attack occurs in an obviously traumatic or stressful situation. But sometimes it occurs out of the blue. Patients (and doctors) often look hard for the reason why, believing that understanding the meaning behind someone’s anxiety will help resolve the anxiety. Sometimes that’s true, particularly when the anxiety attacks occurred in the context of trauma.

More often, once panic attacks start, they can just happen anytime. Searching for the “why” is less productive than making a plan for how to manage them when they occur, and deciding not to let them keep you from living a good life and doing what you want to do.

The most effective form of therapy for panic attacks is Cognitive-Behavioral Therapy (CBT). Good CBT therapists have had specialized training in understanding and addressing anxiety in a way that helps you change the way you think about anxiety, and then change your behavior. My favorite type of CBT is called Acceptance & Commitment Therapy (ACT).

The big change is moving from just wanting the anxiety to go away and never come back to accepting that anxiety is not under your control, but your behavior is something you can choose. Here’s a typical clinical example. Sophie is a 25-year-old teacher. She has always been on the anxious side, very conscientious, plans ahead and tries to be prepared. Over the last few months, she started to have panic attacks that last about 15 minutes. At first, they happened when she was getting ready for school on Sunday nights or Monday mornings. She knew things were stressful at school and blamed that, so she tried to relax and tell herself there was nothing wrong. But then they started to happen during the school day. She was petrified that her students would notice and she’d lose control of her classroom. She’d feel tongue-tied, dry mouth, shaky, sweaty. She’d try to direct them to do some independent work while she got some water and sat down at her desk. But what if this meant she couldn’t be a teacher anymore? What if someone complained? What if they thought she was mentally unstable? Could she be fired? Or worse, what if she was mentally unstable? What if they had to call an ambulance and take her to a hospital? No parent would want her to teach their children. Her career would be over.

All these thoughts would cycle through her head while she was having the physical symptoms of the panic attack. It took everything she had not to run down the hallway and tell the principal she was ill and needed to leave. But her mom had also had panic attacks, so she knew what they were. How could she get them to stop?

We used a two-prong strategy. First, I educated her about panic attacks and panic disorder. It turns out that while panic attacks may feel different in different people, they usually follow the same cycle in an individual person. I had her write out the sequence of what she noticed and thought as her panic attacks started, continued, and ended. We figured out that they usually lasted 10-15 minutes. Then I taught her two simple physical strategies: Diaphragmatic Breathing (DBr), and Progressive Muscle Relaxation (PMR). The goal was for her to practice these techniques three times a day when she wasn’t having a panic attack, and then to start using DBr as soon as she felt a panic attack start. If the situation permitted, she could use PMR as well.

This was her strategy. When she noticed a panic attack start:

1. NAME IT. Inside her head or out loud, she would say, “Dang, it’s another panic attack. I can feel myself getting shaky, dry mouth, sweaty. I know what this is.”

2. ACCEPT IT. Instead of fighting it off, she’d say, “Okay anxiety, if you need to give me a panic attack, go ahead. I know what this is, it usually takes about 15 minutes, and I’m just going to wait it out and then get back to teaching (or driving or shopping or whatever she was doing).

3. BREATHE. She would start her DBr practice: counting to ten slowly while breathing in through her nose, counting to ten slowly while breathing out through her mouth, trying not to lift her shoulders, feeling her lower chest and abdomen push out as her diaphragm moved down and the lowest parts of her lungs filled up with air.

4. STOP AVOIDING. Anxiety would tell her she needed to escape: get out of the classroom, out of the store, whatever. Sophie would accept that feeling but not act on it. “Okay brain, I can’t control this anxiety, but I can choose to stay right here and let it wash over me.” If she was with a supportive person, she might let them know that she was having an anxiety attack and it would probably take 10-15 minutes to pass. If she was alone, she might look at the clock and remind herself that it would pass, and try to distract herself in the meantime. If she was teaching, she’d take a sip of water, keep breathing, and sit down if needed.

5. REGROUP. As the anxiety thoughts and sensations subsided, she got back to whatever she was doing when the panic attack hit. She would remind herself that this was the usual pattern, and she’d waited out another one successfully.

Once she had the pattern down, she gained more confidence. She started to notice that as soon as she felt like a panic attack was starting, she could go right to acceptance, start diaphragmatic breathing, and remind her brain that she wasn’t going to stop what she was doing or leave. Often instead of getting a panic attack, she would feel the shakiness and anxiety start to subside within a few minutes, and she felt more hopeful. She also felt more comfortable going to school in the morning, knowing she was prepared if a panic attack hit. And she told a few friends that she sometimes had panic attacks, but that she knew how to manage them. That helped her feel less weird and helpless. And over the next few months, the panic attacks became less frequent and eventually stopped.

I wish I could tell you that Panic Disorder is curable. In some people, panic attacks never come back. But in many people, even after many years, a random panic attack pops up and scares them before they remember the old familiar thoughts and physical symptoms. Don’t panic! Research shows that patients who have learned to manage their panic attacks without sedating medications can usually restart their old cognitive-behavioral strategies quickly, and not have to suffer from a severe episode of panic attacks again. So don’t panic about panic attacks – accept them and commit to learning how to manage them! And if you need some DIY help, check out these books:

https://www.amazon.com/Get-Your-Mind-Into-Life/dp/1572244259

https://www.amazon.com/Panic-Attacks-Workbook-Program-Beating/dp/1569754152

https://www.amazon.com/Anxiety-Cure-Kids-Parents-Children/dp/0471263613

Distinguishing Bipolar Disorder: Is it Type 1 or 2?

One of the most interesting challenges in psychiatry is trying to identify patients with bipolar disorder as early as possible. Because many patients experience major depression first, before they have an episode of hypomania or mania, they may be treated with antidepressants. Unfortunately, antidepressants may not be any help at all for bipolar depression. Worse, antidepressants sometimes make people with bipolar disorder feel worse. They can make the brain zing up to a manic episode, or a hypomanic episode, or an agitated “mixed state.” 

So first we need to understand the basic varieties of bipolar disorder: Bipolar 1 and Bipolar 2. This is a very simplified discussion. For much more info, read Dr Francis Mondimore’s book called Bipolar Disorder, or my upcoming book The Essential Guide to Bipolar 2 Disorder: Master Your Moods, Create the Life You Want. I promise to put a discount code on the blog as soon as it’s ready!

Here’s the tricky part. In Major Depressive Disorder, patients have recurring episodes of major depression. In Bipolar Disorder, patients have episodes of mania or hypomania, and they have episodes of major depression. Bipolar means two poles of mood, energy, and cognitive speed: up and down. So until someone recognizes the mania or hypomania “up” part, we might misdiagnose someone with Major Depressive Disorder (sometimes called “unipolar depression”) when they are actually having a major depressive episode as part of Bipolar Disorder (“bipolar depression”). 

An episode of major depression has the same symptoms whether someone has Major Depressive Disorder or Bipolar Disorder. The difference is that someone with Bipolar Disorder will also have episodes of mania (in Bipolar 1 Disorder) or hypomania (in Bipolar 2 Disorder). So how do we diagnose mania or hypomania

Patients who have manic episodes can be stable and look completely healthy and normal for years. They may have had an episode of major depression, or they might not have ever had one. Then, over days or weeks, they develop elevated energy, decreased need for sleep, and grandiosity, usually with psychotic features (delusions or hallucinations), that is way out the realm of normal behavior for anyone. Everyone notices, and it causes big problems. We diagnose Bipolar 1 Disorder. 

In the DSM-5, mania is a period with these symptoms most of the time, most every day: 

• Abnormally and persistently elevated, expansive, or irritable mood

• And persistently goal-directed behavior or energy

lasting at least a week, or any duration if hospitalization is necessary. It’s severe enough to cause “marked impairment” in school/work, social activities, or relationships; requires hospitalization to prevent harm to self or others; or there are psychotic features. Often mania causes all of these. 

During mania, the person has at least three of these symptoms which are a noticeable change from usual behavior and occur “to a significant degree”: 

• Inflated self-esteem or grandiosity

• Decreased need for sleep (like feeling rested after only three hours of sleep)

• More talkative than usual, or pressure to keep talking

• Flight of ideas or the subjective experience that thoughts are racing

• Distractibility

• Increase in goal-directed activity (socially, at work or school, or sexually) or “psychomotor agitation”

• Excessive involvement activities with a high potential for painful consequences (like shopping sprees, sexual impulsivity, foolish business investments)

For example, a classic example of mania would be a philosophy graduate student who got increasingly fascinated by mathematical symbols. He began writing a new graduate thesis, unifying mathematical theorems with space travel and nanoparticles, with so many ideas and so much energy that he didn’t need to sleep for three days. He began posting long tirades on the internet regarding his belief that he was a new incarnation of Mahatma Gandhi, and then that he was the recipient of the Nobel Peace Prize for the unification of all humanity. His friends became increasingly alarmed after they realized he wasn’t just being funny, he was serious. As he got increasingly angry and agitated that no one was listening to him, he quickly shifted to a very dark mood state and became paranoid, believing that Special Forces military personnel had targeted him. Ultimately he had to be involuntarily hospitalized before he took action in “self-defense.” He was treated with lithium and an antipsychotic, and his symptoms resolved over several weeks. Eventually, the antipsychotic was tapered off. He was well for about ten years on lithium until a similar manic episode occurred after he had become a professor.  

So manic episodes are dramatically out of the ordinary. When someone is manic, everyone (other than the patient, who usually lacks insight that they are ill during the manic episode) agrees that the patient is really sick, and they get identified. Bipolar 1 Disorder is fairly straightforward to diagnose. It affects about 1% of the population, and occurs equally in men and women. We have a lot of good treatments for manic episodes that can help people get stabilized, usually within a few weeks and sometimes within days. 

In Bipolar 2 Disorder, patients do not ever have a manic episode. However, they have episodes of hypomania. “Hypo” means “less than,” so hypomania is less than mania but has higher than normal mood, energy level, and cognitive speed. The duration may only last four days, and there are no psychotic features. The other symptoms like grandiosity, distractibility, and excessive goal-directed activity are the same as in mania, but they are not severe enough to cause “marked impairment” in social or school/work functioning, and hospitalization is not necessary. The real problem in Bipolar 2 Disorder is usually long episodes of major depression.

For example, I think of a patient who worked part-time as a doctor and had two young kids. She came to see me after feeling burned out and depressed for almost a year. She felt exhausted all the time, and she had a really hard time getting up in the morning to get her kids ready for the day even if she went to bed early. Sometimes she was late for work even though she was a very conscientious person, which made her feel guilty and like she was failing as a mom and as a doctor.  It was harder to concentrate at work than it used to be. In fact, it was harder to do everything, even shop for groceries or do the laundry. She was starting to think she should just give up medicine, but she had no confidence that she could do a good job as a stay-at-home mom. She was more irritable with her husband and got easily frustrated with normal toddler behavior and sometimes yelled at her kids, which also made her feel guilty. She was nervous about taking medication, but felt so bad that she was willing to try an antidepressant.

What really frustrated her was that she used to feel great. Not just good, but great. She won honors in college for a senior thesis she wrote in five days. It just flowed, and she kept writing and didn’t even need to sleep much those days because everything just seemed clear and made sense. When she was in medical school, she aced rotations that other people struggled with, like surgery – she did fine even though she had to get up by 430am to get to the hospital almost every day. She liked the fast pace and the pressure to make decisions fast. That’s what got her into emergency medicine. But now? It was like moving through molasses. No energy, no spark, no flow. 

For most people, hypomania feels great. People can often think faster, better, and more creatively. They might start new projects and make new social or professional connections. Energy and libido go up, need for sleep goes down, but they can still work well. One of my patients was a businessman who could tell he was hypomanic because he’d walk into a complicated business negotiation and be able to see exactly how to manage everyone – and he was right! 

But as a hypomania progresses often patients start to get impatient. Why can’t everyone else keep up with them? Sometimes they get really irritable or hostile when people aren’t willing to go along with their brilliant ideas or risks. Then there’s often a fast crash down into a bad depression lasts a long time. Many Bipolar 2 patients first seek treatment during depression, and they may not remember feeling amazing for a few days, a few months before. Or they may not even recognize their hypomania as an abnormal mood state – they just know that sometimes they finally feel good after months of feeling depressed. 

But when I can get an accurate history, or when I see the hypomania myself, I can diagnose Bipolar 2 Disorder. This affects 2-5% of the population. Women are affected about twice as often as men (just like Major Depressive Disorder). Unfortunately, we have fewer good treatments for bipolar depression than for mania. Our best options are starting a mood stabilizer like lithium or lamotrigine for long-term stability, and often an atypical antipsychotic medication (even though the patient is not psychotic) that has been FDA-approved for bipolar depression.

Other clues that someone with long depressions may actually have Bipolar 2? Many have a family history of bipolar 1 or 2 disorder. Many have what we call “reverse vegetative symptoms” – unlike a classic melancholic depression where someone loses their appetite and can’t sleep, many bipolar depressions cause patients to eat more than normal and need more sleep than normal. Earlier age of first depression may be a sign of bipolar disorder. And if someone who has taken several antidepressants and they haven’t helped, or if they caused severe irritability, agitation, or insomnia, I’m going to worry about the possibility of bipolar 2 disorder. 

My goal is to get patients into remission, meaning they no longer meet criteria for a manic/hypomanic episode or a major depressive episode. They still have Bipolar Disorder, but it’s not currently impairing their function at school or work, and they can have good relationships with people and enjoy their lives. Sometimes it takes a lot of trial and error to find the right combination of medications and to help patients develop healthy strategies for sleep, activity, and not using drugs or overusing alcohol. That’s what my book will describe in a lot more detail. Coming soon!

Any patients described are composites of true patients with all identifying details changed, so that privacy is protected. I’m so excited to share with you the fascinating, never boring world of adult psychiatry. Please share the blog with others, and feel free to follow me on Twitter @LeslieWalkerMD.

Welcome

Welcome to Brain Blossom! After years of procrastinating, it’s finally time to launch a blog for patients, families, therapists, clinicians, and anyone else who wants to learn more about how a psychiatrist thinks, why I do what I do, and how amazing (and sometimes terrifying) our brains can be.

Why the title? Well, I’m a psychiatrist, and I originally trained in neuroscience. I weave back and forth between the brain, the mind, the heart, and the soul. I believe that one of my spiritual gifts is the capacity to see patients as they could be, as they will be someday. Patients often come to see me for the first time when they are despondent, anxious, overwhelmed, burned out, guilty, or paranoid. My job is to create a safe space for them to be honest about how bad they feel right now. 

Then my job is to express hope, often for patients and families who feel hopeless. And if I do my job well, I can give them a glimpse of what we’re shooting for: remission. Restoration. A new sense of purpose. Clarity. An understanding of their true self, separate from anxiety or depression or paranoia or repetitive behaviors that are killing them. To me, this process is like a flower blossoming. The flower was there, sometimes just a bud, but needed a safe place, the right soil, nutrients, sun, rain, nurturing care, sometimes other parts of the garden like bees or shade from other plants or some cross-pollination. As we put those other factors in place, over time, the flower is able to blossom and grow into the beautiful potential that was always there. 

As a psychiatrist for adults, many of my patients have already worked with other doctors or psychotherapists. Sometimes I’m the first mental health specialist they have seen. Either way, part of my job is to help them understand different conditions they experience. I need to teach the language of the brain, the vocabulary of the mind, the variety of different psychiatric conditions and treatments and symptoms. I also need to make sure I listen very carefully to my patients. Are we speaking the same language? When they describe how they feel, or what they think, am I correctly understanding them? Can I accurately connect their descriptions to my clinical understanding, to make sure we are in agreement about what’s going on inside them? 

You can see why so much of psychiatry involves language. But words alone aren’t enough. There is something powerful about being in the presence of someone who trusts you enough to be honest about their most private thoughts, feelings, and experiences. So I must also be extremely careful to maintain my patients’ privacy. I must be gentle and respectful of their beliefs and values, particularly if they differ from my own. I can encourage patients towards healthier behaviors, but I can’t force anyone to do anything. Most of what I do involves collaboration: working together to figure out the first step, the next step, and the next. Blossoming, growing, changing. 

This blog will tackle some challenging topics. Bipolar disorder. Panic attacks. Psychiatric treatment during pregnancy and postpartum. New treatments for major depression, like ketamine and transcranial magnetic stimulation. And that’s just the first four weeks! But I hope you will find this a useful source of information not just for details about conditions and treatments, but for learning how one particular psychiatrist – me!- thinks and feels as she works to help a variety of patients. Any patients described will be composites of true patients with all identifying details changed, so that privacy is protected. But I’m so excited to share with you the fascinating, never boring world of adult psychiatry. Please share the blog with others, and feel free to follow me on Twitter @LeslieWalkerMD.