Anxiety and Panic Attacks In Emphysema/ Chronic Obstructive Pulmonary Diseases (COPD) | Vijai P. Sharma, Ph.D., psychologist
Chapter 3Anxiety and Panic Problems in Medical Patients
Unique Features of Anxiety and Panic Condition in Medical patientsAnxiety and panic attacks can occur in medical patients who may or may not have had any history of anxiety disorder/s. A severe and chronic illness itself is a major stressor and may often create significant levels of anxiety. Particularly vulnerable to anxiety and panic attacks are people suffering from such medical conditions as asthma, chronic obstructive pulmonary disease, heart disease, severe pain and medical obesity. Some of these patients might have had an underlying anxiety disorder, which could become worse with fears of possible death and disability due to their medical condition. Others may develop an anxiety problem as their medical condition worsens. During a panic attack, you might think you were having a heart attack, lung collapse, stroke or some other form of medical crisis. Symptoms such as pounding heart, out-of-control breathing or sweating can be caused by exacerbation of the medical condition or the anxiety associated with the medical condition. However, when symptom seem obviously ominous and physical, it is difficult to imagine that they might be anxiety related or caused by the mind rather than the body. To illustrate the difficulty in differentiating between heart attack and panic attack, let's review guidelines of The American Heart Association and American Psychiatric Association, respectively. The American Heart Association (AHA), among others, lists the following warning signals of a heart attack:
According to the American Psychiatric Association (APA), a panic attack is diagnosed by the presence of at least four of the following symptoms:
Let's now compare AHA's heart attack warning signs and APA's Panic attack symptoms in one glance. Make sure you understand this is not a complete list of all the warning signs of heart attack. There may be other significant warning signs of heart attack but these are the ones that AHA provides in their short list. If you suspect any problem with your heart function, consult your doctor. Do not use this as a reference for suspecting or ruling out heart problem. (Go to the next page)
Note that many warning signs of heart attack are similar to the symptoms of a panic attack. Therefore, it is best to get a thorough medical examination as recommended by your doctor so you would know if there is anything medically wrong with your heart or if you were having panic attacks. One lady who has had congestive heart failure and also experiences panic attacks has found her own way to tell which is which. Write your thoughts here how you can tell when you are having a panic attack or experiencing an exacerbation of your medical condition? Make sure you discuss this with your doctor. Your doctor may advise you how to tell one apart from the other. Research shows that a majority of people with healthy hearts can occasionally experience heart irregularity such as skipped beat, heart pounding, racing or palpitations. However, people who are prone to panic attacks react with an overwhelming sense of fear to even relatively harmless heart sensations. At such times, they may misinterpret abnormal physical sensations as virtually a matter of life and death. There is no relationship between panic attacks and heart disease except that a few symptoms of both can feel alike. After the first panic attack/s some people develop intense fear that they already have had or are headed for a future heart attack. They become hyper vigilant (sort of "paranoid," as we colloquially say) trying to detect any signs of heart disease. It is normal for the heart rate to increase when we experience emotional excitement, stress or fatigue. But, most people don't focus on it or view it as anything serious. But panic-prone people get scared thinking they are having a heart attack. Mere thought of having a heart attack triggers emergency response in the brain, heart, lungs and other vital organs pushing the rest of the body into a panic state. What I want to emphasize here is this: Many people who do not suffer from panic attacks also experience cardiac "events" such as heart palpitations or heart racing without regarding them as ominous signs of something terrible. They don't get alarmed and don't view them as warning signs of a heart attack, stroke or some other life threatening illness. Since anxiety can mimic major medical symptoms, it creates an additional "burden" for medical patients. They must learn to differentiate between a real medical crisis and an anxiety attack. Even healthy people have a hard time differentiating between the two. When panic attacks first begin to occur, even healthy individuals suspecting a heart attack may rush to the hospital emergency room. Only after being medically cleared and assured there is nothing wrong with their heart, they begin to realize that the problem is not with their heart or lungs but it has to do with panic attacks. People who have heart or lung disease along with anxiety and panic attacks always have to figure out whether the symptoms stem from anxiety or from their medical condition. It gets even more complicated. Sometimes, it's not just the anxiety or the medical condition, it is a combination of both and each one aids and abets the other. One lady who had a history of congestive heart failure and also suffered from depression and panic attacks explained how she can tell when it is her heart or a panic attack. She said the following: "My anxiety when panic attack is coming is much more severe. When my heart is acting up and I should be more panicky about it, but I have some anxiety and worry but it is nothing like a panic attack. When it is the heart problem, I take my Nitro(glycerine) and I feel better. But if it is a panic attack, Nitro won't make a difference." Isn't it fascinating? She has worked out her own technique to tell the difference between a panic attack and a heart episode. Another lady who had asthma and also suffered from panic attacks explains how she tells her asthma episode apart from a panic attack: "When I am having an asthma attack, I forget how to breathe. I have to remind myself how to breathe. Then I know it's time to take my inhaler. I take a breath and slowly let it out. I take another breath and slowly let it out. Soon, I begin to see some relief. When it is not my asthma, I feel jittery. I can take a breath and let it out and I am still smothering. So I know it is not my asthma, it is my anxiety attack." You will experience at least some ongoing anxiety when you suffer from a major medical condition. But it is important that the anxiety remain in control and proportionate to the seriousness of the situation. A disproportionate mental reaction would increase breathing discomfort and shortness of breath. Realistic anxiety is beneficial because it prompts us to take the required action but excessive anxiety helps nothing; it only complicates the medical condition. Mother Nature has built into us a "suffocation alarm system" so that we don't go on suffocating to the point of death. This suffocation alarm is important for our survival. Consider the case of babies who die in their sleep, perhaps without a scream or a cry. Perhaps their suffocation alarm system failed or had never developed. Without such an alarm system, we may not recognize the need to get away from a toxic environment even when the pollution reaches a dangerous level. As the saying goes, "forewarned is forearmed." Spontaneous panic attacks," or "panic attacks with sudden onset" as they are often called, come like a bolt out of the blue. Patients are not thinking of any anxious or worrying thoughts to cause a panic attack. In fact, they may be resting and thinking about a harmless, everyday event, and then a panic attack may "spontaneously" appear. Their heart suddenly races, breathing goes haywire, the body shakes, they sweat like their body is on fire, legs feel weak and crumbling, and other menacing symptoms shake and rattle the body. Such symptoms occur even when there is not such an ominous cause for terror. After the attack, one asks oneself, "I wasn't panicking about anything! Why did I have a panic attack?" The individual suspects he or she was having a heart attack but medical tests just failed to identify it. Some when find out there is nothing wrong with their heart begin to worry even more. They begin to think something along these lines, "The Doctors told me there was nothing wrong with my heart but I had severe chest pains and my heart was in my mouth. If my heart is okay, does it mean my head is not? Am I going crazy?" No you are not! You are having a perfectly normal reaction because you have not been explained much about the panic attacks. Panic attacks can mimic medical symptoms such as chest pains, heart palpitations, breathlessness and many other symptoms. Start saying something helpful to yourself such as, "It's a false alarm. I should try to stay calm!" Breathlessness and tightness of chest and throat can make you feel you are going to suffocate and die, or cause damage to your internal organs. But tell yourself, it is caused by anxiety that can produce all those symptoms. If the body's alarm system is messed up, it can go off even when there is no real danger. Think of your house alarm. Sometimes, house alarms go off even by slight smoke when you are cooking. Picture this: The house is not on fire but the alarm has gone off. If you don't know it was a false alarm, you might panic and rush to try to put out the fire or you might run out in a frenzy to save your life. Likewise, the body and brain can sometime act on a false alarm as if it's the real alarm. To continue with the analogy, some patients with heart or lung problems may receive a false alarm because of the presence of "smoke," that is, there is a problem but that heart or breathing problem is not a matter of life and death. A Breathing Disorder Such as COPD Can Resemble a Lot Like Panic DisorderThe two major symptoms found in almost all panic attacks are heart palpitation (heart goes "thump, thump") and dyspnea (shortness of breath). Shortness of breath, painful breathing, can set off a false suffocation alarm. In some cases, even a moderate change in heartbeat and breathing can trigger the alarm. After all, shortness of breath or any type of breathing discomfort raises a possibility in our minds that we may not be able to breathe at all! During a panic attack, one might rush to a window and throw it open in an attempt to fill their lungs with air. We all want to breathe. We all can panic if we are unable to breathe. Severe and continued breathlessness can cause smothering sensations. Panic disorder is one of the most common psychiatric disorders in COPD. Note that not all COPD patients have panic attacks and not all panic attack patients have heart or lung problems. People who are highly anxious or tense can also have changes in their heart rate and breathing. Sometimes the suffocation alarm may be falsely activated by even moderate changes in the breathing and heart rate. Patient education regarding anxiety and panic attacks, breathing training and medication can provide significant relief. It helps to stay calm and in control even when symptoms are severe. There are helpful techniques, and you can learn them in order to calm down and exercise reasonable control. More to come on our biological emergency alarm system later! Write down how you can tell when it is your anxiety or panic attack and when it is a symptom caused by your medical condition: Psychiatric Perspective on Anxiety and Panic attacks"Anxiety," "anxiety attacks," or "panic attacks." So far I have been using these words interchangeably. But psychiatrically speaking there is a difference between the two. Anxiety is a "catch-all" term referring to the tension or stress a person experiences in the presence of an actual or anticipated threat. Anxiety can be severe, moderate or mild. There are many people who experience low-grade anxiety all the time and are unable to relax. In common parlance, we often refer to them as "worry warts." Only some of them experience panic attacks. I have constructed my own anxiety checklist, which I have been using and continually modifying for the last 15 years or so at my clinic with anxiety and panic attack patients. In this checklist, there are 43 symptoms that cover a wide spectrum of anxiety complaints. You can see Dr. Sharma's Anxiety Checklist at the end of this fle. But, only 13 out of the 43 symptoms on my Anxiety Checklist fall in the category of panic attacks. Those 13 symptoms are classified as symptoms of a panic attack according to the Diagnostic and Statistical Manual IV of Mental Disorders, briefly referred to as DSM IV. According to DSM IV, you have a "panic attack" when you experience at least 4 out of the 13 symptoms, which may gradually or suddenly escalate to the level of a full blown panic attack. Panic attacks with sudden onset rapidly build to a peak and are accompanied by an overwhelming sense of fear. Panic attacks with "sudden onset" or without sudden onset typically last for a few minutes. They peak out anywhere between 5 to 15 minutes. But, in some circumstances they can last even an hour or two. It can be a scary experience when you have no inkling of a panic attack coming, and you suddenly experience such symptoms as heart pounding, panting and shaking and trembling like a train is running towards you from a blind corner. If you experience fewer than four symptoms, some clinicians would refer to it as a "limited-symptom panic attack." "Anxiety attack" is not a DSM IV term. When one has some of the panic symptoms but they don't meet the criteria of a panic attack, we refer to them as "anxiety attacks." I don't believe there is a precise definition of an "anxiety attack" upon which we all can agree. Thirteen (13) Symptoms of a Panic Attack according to the Psychiatric manual (DSM IV)
According to the psychiatric manual (DSM IV) a person must experience at least 4 out of 13 symptoms to meet the criteria of "panic attack" "Fear of dying" and "fear of losing control or going crazy," refer to one's thought process at the time. But the remaining 11 symptoms consist of uncomfortable and unpleasant bodily sensations. No wonder they APPEAR as a medical crisis on hand. Yet, in many cases, panic attack symptoms occur even though there is no medical basis for the symptoms. If you are a medical patient and have panic attacks, you can train yourself to "smell" a panic attack coming without anxiety and can even take measures to "nip it in the bud." Dr. Sharma's Anxiety checklist In the next page, we provide Dr. Sharma's Anxiety Checklist. It was adapted from the psychiatric manual (DSM IV) and several other anxiety checklists. The first thirteen symptoms of panic attack are also included in this checklist. It is a comprehensive list of anxiety symptoms but not exhaustive. You may have some or most of the symptoms listed here. You may also have some which are not listed here. You can rate each symptom you have as "none" "mild" "moderate" or "severe." Name Date DR. SHARMA'S ANXIETY CHECKLIST
(Adapted from DSM-IV, Beck, Burns Anxiety Inventories) Please rate each symptom by putting (x) mark to indicate how bothered ("none", "mild", "moderate", or "severe") you have been by these symptoms in the past 2 weeks, including today.
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Dr. Vijai Sharma
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