Chapter 4

The "Anatomy" and "Physiology" of a Panic attack

• How Does a Panic Attack Start and Escalate
• Anxiety, Panic Attacks Feed on Breath, Body and Thought Discomfort
• Self-Help Exercise
• Tips for Panic Control

How Does a Panic Attack Start and Escalate

Since many panic attacks occur suddenly, that is without prior warning and without an identifiable cause you may feel totally at loss in trying to make sense of it. In this section, we will discuss how these symptoms are interconnected and the mechanisms that escalate symptoms to a full blown panic attack.

Hopefully, when you understand how a panic attack starts and escalates, you may be able to forestall the onset or modify the intensity of the symptoms and as you acquire further knowledge and skills in this area, you may be able to stop them altogether.

Breath dysregulation may be the major reason for setting off the emergency alarm or let's say, our "panic button." A panic attack is nothing but the body's emergency system at work! The emergency system that is swung into action by an alarm (often false alarm) set off by your brain.

Breathing involves both brain and lungs. You hear a lot about the lungs, airways, air sacs, diaphragm, ribcage etc. in connection with breathing, but you rarely hear about the central and critical role your brain plays in monitoring and regulating breath. Let's call it the "central respiratory control system."

It can't be any other way! Breathing is absolutely essential for our survival, hence it has got to be under the control of the "higher ups," your brain. Your brain is constantly monitoring the oxygen (O2) and carbon dioxide (CO2) levels and the ratio between the two.

If the O2-CO2 levels and their ratio ever go outside "acceptable range," the brain will give distress signals or set off the emergency alarm. The higher order brain, also called the "thinking brain" or our "mind" may also get involved in modifying or magnifying the problem depending on perception, interpretation and other thoughts related to the breathing episode.

Recurrent panic attacks may be defined as a "dysfunction of the central respiratory control system." That dysfunction may be temporary or permanent. The areas of brain involved in monitoring and protecting the airways from acute respiratory danger (e.g. suffocation) become over sensitized and react inappropriately.

Breathing being a major cause of panic attacks makes it particularly tricky for heart and lung patients. We will discuss that aspect later. For now, let's continue to explore the mechanisms of how the central respiratory control system may begin to overreact and trigger emergency response even though there may not be a real emergency.

Here are three popular theories prevalent in psychological literature regarding panic attack and central respiratory control dysfunction:

Brain Suffocation Alarm Theory: Brain is constantly reading oxygen and carbon dioxide levels to protect you from suffocation. When O2- CO2 levels get to the unacceptable level, brain sounds the emergency alarm. Emergency operation, that is, the body's fight-flight operation swings into action releasing adrenaline, accelerating heart and lung activity, creating hot flashes, cold chills, and hundreds of other changes that prepare us to fight or flee. That emergency operation, also known as "fight flight' reflex, is what we experience in a "panic attack."

It constantly samples our blood to be sure that we are breathing well and nontoxic air. If there is a problem, our brain alarm wants us to run away from the dangerous situation With COPD, even small changes in the air such as odors, pollutions, pollens, sudden temperature changes, emotional excitement, acting as if in a hurry can trigger false suffocation alarms.

Hyperventilation and Hyperinflation Theory: Some people tend to mildly hyperventilate a lot of times. I call it "over breathing." Over breathing can create unacceptable levels of O2-CO2 ratio. When O2- CO2 levels get to the unacceptable level, the body's emergency system takes over, resulting in a panic attack. Over-breathing causes the lungs to hyper inflate, which means that the lungs are not able to get rid of the excess air they are taking in. Since all the old and stale air doesn't get out of the lungs, there is very little room for the fresh air to get in. In such condition, one tries even harder to take in more air. As a result, a person feels out of breath. They are unable to catch their breath or feel "hungry" for air. Panic sets in.

Catastrophic Theory: Here we rise beyond the territory of the brain and enter the corridors of the mind. Note that thoughts can trigger fight-flight reflex. Theory says that when you think such catastrophic thoughts as, "I may never be able to catch my breath and die" or, "I might be having a heart attack and I might not make it to the hospital." Such catastrophic thoughts can signal the brain of an impending danger and set off the body's emergency alarm system.

These theories offer us some insight into how body, breath and mind interact in a "crisis" to trigger a panic attack. However, quite often, the perceived crisis is not always a real crisis, but an exaggerated view of uncomfortable body sensations further confounded by our catastrophic thoughts.

Write, which of the above three (3) theories make sense to you or applies in your case?
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Anxiety, Panic Attacks Feed on Breath, Body and Thought Discomfort

In light of the above theories, namely, suffocation-, hyperventilation and/or hyperinflation and Catastrophic threat theories, we can now list the various panic attack symptoms in three categories: 1) Breath-related discomfort. 2) Uncomfortable bodily sensations 3) Catastrophic thoughts

Let us review the thirteen (13) symptoms of a panic attack as per the psychiatric manual (DSM IV) and note how 13 panic attack symptoms fit into in the above three categories.

Breath related discomfort
Shortness of breath or smothering
Feeling of choking
Dizziness or lightheadedness or fainting feeling

Uncomfortable bodily sensations
Palpitations, pounding heart, or accelerated heart rate
Chest pain or discomfort
Sweating (not due to heat or exertion)
Trembling or shaking (extremities or the insides)
Numbness or tingling sensations (parts of body or whole body)
Chills or hot flashes (parts of body or whole body)
Nausea or abdominal distress
Feeling of unreality or of detached from self.

Catastrophic thoughts
Fear of losing control or going crazy (e.g. "I am losing my mind!")
Fear of dying (e.g. I won't make it to the hospital!"

Many cognitive therapists believe panic attacks occur because of our highly exaggerated response to breathing discomfort and unpleasant bodily sensations, and due to the catastrophic thoughts that cross our mind at that time.

Please go to the next page to the Self-Help Exercise and identify which ones do you think might be playing a part in your anxiety/panic attacks!

Self-Help Exercise

Out of three ( 3) "Breath Related Discomforts listed above," which ones do you have?
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Out of eight (8) "Uncomfortable Bodily Sensations," listed above, which ones do you have?
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Out of two (2) "Catastrophic Thoughts," listed above, which ones do you have?
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Tips For Panic Control

WHAT SHOULD YOU DO FOR YOUR PANIC ATTACKS?

Learn to work with your body's defense system, often called, "emergency/rescue system" or "fight-flight" response. It's true that panic symptoms are an enormous nuisance, but still their purpose is to ensure our survival! Thank your body it is doing what it's supposed to do but it's operating in the over drive and receiving false signals.

Understand your body's defense system, honor it and try to work with it. With that attitude of mind, you might just be able to counter such catastrophic thoughts as, "Am I losing my mind?" or, "I have lost total control over my body!" and superimpose assuring and calming thoughts such as, "This will be lot better as I calm down and do my pursed-lip breathing," or "This too shall pass. It can pass when I focus on exhaling and relaxing."

Note I didn't suggest that you try to "avoid" or "not think" catastrophic thoughts, I am asking you to "counter" the catastrophic thoughts and "superimpose" more helpful thoughts. This technique is different from the more common advice you might receive such as, "Don't think those morbid thoughts!"

Why should you counter catastrophic thoughts? Because, those thoughts can produce massive fear, and trigger or aggravate the fight-flight response.

Some would say, "Well, those are just thoughts. Thoughts come and go. Why do I need to do anything about them?" The problem is that thoughts are also physical in nature. Thoughts release real chemicals and hormones and thus have a real effect on the body, breath and mind.

Watch those negative thoughts. Remember most people tend to think negative and worrisome thoughts over and over again, but they don't do the same thing with positive and encouraging thoughts!

Thoughts can be as real as real things. For example, one doesn't have to actually see a tiger; just the thought of meeting a tiger in the lonely woods can trigger a real fight-flight response. The thought of a tiger attacking you or your tiger-like boss attacking you can set off your emergency alarm.

Some don't believe they had any thoughts before they panicked, "I wasn't thinking of anything, it (panic attack) just came out of the blue."

By understanding and cooperating with the body's defense system, you can modify the symptoms of a panic attack.

Suppose you SUDDENLY notice rapid breathing, chest heaving up and down, hot flashes and heart racing. But it might not have been so sudden. Your anxiety or concern might have been building up all day below your level of awareness. Perhaps, you were worried all day about your more-than-usual wheezing or tightness in the chest you noticed that morning. As you noticed it, maybe thoughts crossed your mind about a possible flare up of COPD symptoms or pneumonia. As the pneumonia thought crossed your mind, perhaps you saw a "flash" in the mind's eye of being in the ICU of your local hospital.

And, from that point on, to continue with the example, perhaps your breathing speeded a little, heartbeat quickened and chest tightened. You took all that on the chin without making a big deal of it, until the panic symptoms loudly knocked on the door and the "emergency alarm" went off.

Not being aware of the relationship between your anxious thoughts and rapid breathing, you might feel you've lost all control over yourself. The adrenaline "rush," the fuel for the "fight-flight motor" wants you to flee but you can't because someone is right there in the room. You don't want to look like you're doing something "crazy" right in front of your house guest. You become more tense up and ever more breathless!

This takes you right to the panic state and you start hyperventilating. You begin to think catastrophic thoughts such as, "My breathing could get out of control, "I am going crazy" "I'm losing control (or losing my mind)" or "I won't make it to the hospital!" can increase the anxiety severely.

Now, the panic attack has reached the "Point of No Return" and you experience a full- blown panic attack.

Logical Explanation of Specific Symptoms

Here is the explanation of how and why these symptoms take place:

Shortness of breath or rapid breathing is intended by nature to help us run or fight (notice when runners run or fighters fight, they are breathing rapidly). The heart beats fast and strong because it's the heart's job to rush the blood to the arms and legs. After all, we need our arms and legs to run or to fight.

Reason you feel lightheaded, faintish or dizzy is because the blood is being diverted from the head and rushed to the peripheries, that is, your arms and legs.

Some panic attack patients feel as if they are in a dream or that panic attack events are happening to someone else. This is called a state of dissociation. Anxiety can cause dissociation from the normal level of awareness. Such experiences also result from blood/oxygen being diverted from the brain.

Since you need the "fuel" for your "fight-flight engine," adrenaline is being pumped into the blood. Adrenaline is sheer energy which creates excess heat in the body. The heat can sometimes cause hot flashes all over the body or in parts of the body. Since blood is being diverted to some areas of the body, you may experience cold chills in other parts of the body. Sweating also serves an important function, so the body's engine doesn't get too heated. In a panic attack, you may start sweating which occurs to cool down your body after excessive heat has been generated in the system.

Trembling or shaking in the arms and legs, or numbness or tingling sensations in parts of the body or the whole body can result from oxygen-carbon dioxide imbalance and the nervous system firing off. I like to explain to myself that my engine is "racing" but the vehicle is not going anywhere. By that I mean, that all the chemicals and hormones, the "fuel" is rapidly pouring in to prepare me to fight or run but I am not actually fighting or running. I am just sitting there huffing and puffing.

If I were to actually run, I would view my rapid breathing, heart racing and leg shaking as very normal result of my running. Runners don't think they are having a panic attack. They are just running!

Experiences such as, "rubbery legs" "jelly legs' or "wobbly feeling" can result from expanded blood vessels in the legs. Legs are supplied with plenty of blood to make them extra efficient for fighting or fleeing.

The rumor (or fact) is that Elvis Presley, the king of the rock, invented the gyrating movements as part of his singing because his legs would constantly shake as a result of stage fright. Presley acted on the age old wisdom "when you can't fight them, join them." So, constant shaking and moving of the legs became a part of his rock music.

You might also experience 'butterflies,' upset tummy or even diarrhea. Anxious patients also commonly report the need for frequent urination which is not due to prostate or bladder problems. So, abdominal discomfort or urinary urgency are undoubtedly a nuisance but still a part of Mother Nature clever design! Think about it-Why would you want to carry "excess weight" when the house is on fire? You want to run out of the house as fast as you can.

In order to "travel light" or more appropriately "fighting fleeing operation, the body intends to empty the bowel and bladder during the emergency operation.

A scenario with better ending: Forestalling a panic attack!

Let's now draw a scenario with a better ending! Say, you had read the chapter on "Panic Attacks in Medical Patients," from this book. As a result, you know there is no real emergency though your body might FEEL it is an emergency. Were you to experience wheezing or chest tightness that morning, you would've halted or at least ameliorated those worrisome thoughts and focused on taking proactive steps such as checking your breathing function, blood pressure, pulse and oxygen level, and the recommended medication.

Say, you were still anxious during the day lest your symptoms escalate. As soon as you were to notice shallow breathing, accelerated heart rate or rapid breathing, you would've right away taken such corrective breathing measures as slowing down your breathing, pacing the breathing or doing pursed lip breathing before it could escalate to the point of hyperventilation.

To continue with the "happy-ending" example, instead of catastrophic thoughts, you would've given yourself positive messages such as, "My breathing is slowing down," or "I am going to calm down." Or "Pursed lip breathing will help me to get the excess air out of my lungs. I'll feel better in a short while!"

Thus, by recognizing the signs early on, you can nip a panic attack in the bud. When you try to regulate your breathing and change anxiety provoking thoughts as they show up, panic attack symptoms are less likely to escalate to the point of no return. As the saying goes, "A stitch in time saves nine," you might experience symptoms that are uncomfortable but you might just be able to avoid a full-blown panic attack.

At any rate, with practice as you get better in recognizing the symptoms pretty early on and bring your breathing to normal, panic attacks might become a thing of the past.

Note: When you acquire skills in slowing and normalizing your breathing and in changing your hot thoughts to cool thoughts, you may also be able to reduce the severity of your breathlessness.

Panic attack symptoms despite their unpleasantness are proof that your emergency system works!

Biologically speaking, panic symptoms perform a very vital function. Panic symptoms occur because the body is preparing itself to deal with an emergency. Therefore, panic symptoms show that the body is doing its job, even though in a bizarre way! It's weird to think that we should be grateful for having a fight-flight system in our body that gives us so much trouble. But the fight-flight system shows that our body and mind are working normally and logically. That is exactly how we are supposed to react in case of an emergency.

The problem is that once the alarm falsely goes off, it keeps going off. I like to draw the analogy of a house alarm. Suppose the two wires in the house smoke alarm come loose. They might start touching each other and accidentally setting off the alarm. For instance, you walk on the floor in your house that causes vibrations/tremors in the wall on which the house smoke alarm hangs. As a result of the vibrations, wires touch each other and the alarm goes off! We have to be able to tell when it's a false alarm. We must also learn to shut it off at will by using the techniques in the Chapter 8, "Calming the Breath, Mind and Body for Anxiety and Panic Control."

Continue to Chapter 5

Return to Chapter 3

Copyright 2008, Mind Publications 
Posted August 2008