Panic is the pinnacle of fear—a surge of intense physical and emotional distress that often appears to arrive without warning. Your heart races, muscles tighten, and you may feel an urgent need to escape, even when no real threat is present.
At Midpoint Counseling, we know how overwhelming these experiences can be. Understanding how panic becomes a problem and what maintains it is important to learning how to break free. This guide will help you understand what panic disorder it, what causes it, and most importantly, how to treat it effectively.
QUICK FACTS
- Panic attacks are common and don’t necessarily mean having panic disorder.
- Avoidance is often used ineffectively as a strategy to reduce uncomfortable feelings.
- Building tolerance of uncertainty and uncomfortable feelings are important targets for improvement.
- Panic disorder is highly treatable.
A CLOSER LOOK AT PANIC
What is Panic Disorder?
Panic disorder is when you have recurrent, unexpected panic attacks. These waves of intense fear and discomfort reach their peak within minutes and must have at least four of the following symptoms:
Heart palpitations
Sweating
Trembling or shaking
Shortness of breath sensations
Feelings of choking
Chest pain or discomfort
Nausea or stomach distress
Feeling dizzy, lightheaded or faint
Chills or heat sensations
Numbness or tingling sensations
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying
Having a panic attack doesn't mean having panic disorder.
About 1 in 5 adults will experience a panic attack at some point in their lives.1
But for panic attacks to be considered “disordered,” the following must also be true:
Occurrence of more than one panic attack
Fear of having another attack
Misinterpreting the attacks as dangerous or life-threatening
Avoiding situations that might trigger another attack
Sensitivity to physical cues that start a chain reaction into panic
Symptoms lasting at least one month
About 4.8% of adults in the U.S. will be affected by panic disorder at some point.1
Most of the time it develops between one’s early 20s to early 30s, but it can be experienced at any stage of life.2
Most panic attacks last between 5 and 20 minutes, but our reactions to them can re-trigger a new panic attack before the last one ends. This can lead to the experience of having one long episode.
The number of attacks you have indicates the severity of the condition. Some people have them once or twice a month, while others have them several times a week.
If you’re in Washington state and have been struggling with panic attacks, reach out today for more info.
THE CONNECTION BETWEEN TWO HEALTH CONDITIONS
Panic Disorder with Agoraphobia
Agoraphobia is the fear having a panic attack or losing control in a public place where there’s no clear escape. This leads to a greater degree of restriction in daily life due to withdrawal from public spaces compared to panic disorder without agoraphobia.
Common surroundings that trigger panic related to agoraphobia include:
Public Spaces
- Stores
- Restaurants
- Theaters
- Churches
Travel
- Cars, buses, trains, or planes
- Over bridges or through tunnels
- Being far from home
- Traffic
Confined Spaces
- Crowds or standing in line
- Dentist or salon chairs
- Waiting rooms
Open Spaces
- Parks
- Fields
- Wide streets
THE SCIENCE BEHIND PANIC SYMPTOMS
Biological Factors in Panic Disorder
While no brain or body scan can diagnose panic disorder, they’ve given us a good look into underlying factors that affect thoughts and behavior. Some findings include:
Respiratory abnormalities causing more baseline hyperventilation compared to other anxiety disorders. This contributes to what’s called a “suffocation false alarm,” which activates the body’s stress response.3
Alterations in acid-sensing ion channels (ASICs) in the brain that stimulate neurons when acid is detected.4 Since CO2 acts like an acid in the body, the body can become more reactive to hyperventilation and exercise.
Differences in how the body processes lactic acid. This may partially explain why some people experience exercise-induced panic due to the buildup of lactic acid in the muscles.5
Variations in brainstem regions that lead to heightened nervous system activity.6
Physical illnesses that interfere with lung and heart function that induce anxiety-like sensations that can trigger panic.7
Brain chemistry and genetics influence panic, but they aren't it's only causes.
CONTEXTUAL INFLUENCES ON PANIC
Environmental Factors in Panic Disorder
Panic disorder often develops when the brain learns to associate internal sensations with external sources of danger. Over time, this can lead to hypervigilance, where your brain constantly scans for warning signs and reacts with panic in situations where it isn't necesssary.
Environmental factors that can affect this learning include:
Childhood upbringing
Stress in the family
Trauma history
Personal relationships
Ongoing periods of chronic stress
Significant life transitions
Personality development
The brain develops into your 20s, making it vulnerable to the effects of stress for a long time.8
But even if you’ve been affected by any of these factors, there are effective treatments to help change how your nervous system responds to challenging circumstances.
Midpoint Counseling provides in-person and virtual therapy for panic disorder. Contact us to learn how we can help.
EVIDENCE-BASED APPROACHES TO PANIC
3 Targets for Treating Panic Disorder
Three core targets are important to hit when dealing with panic disorder. These targets aren’t about reducing the experience of anxiety, but about helping you stop the underlying patterns of thought and behavior that maintain it.
People who aim for these targets are much more likely to regain the sense of flexibility in their lives that has been lost.
1. Build your tolerance of uncertainty.
The goal is flexibility that allows you to continue doing meaningful things without needing to have all the answers. When you don’t have this, life becomes about eliminating ambiguity, rigidly controlling situations, fixating on negative possibilities, and over-preparing to prevent their occurrence. Intolerance of uncertainty and overestimations of risk are at the heart of most issues with anxiety and why they’re so important to bring within healthy limits.
2. Increase your tolerance for discomfort.
This refers to your personal threshold for being with uncomfortable physical sensations before interpreting them as bad and in need of elimination. The lower the threshold, the more fixated you’ll be on signals from your body and thoughts about risk, rather than building mastery over the situation that caused the trouble. This continues the cycle of avoidance in order to achieve short-term relief but ultimately maintains the panic disorder.
3. Strengthen your confidence in your abilities.
Difficulties navigating feelings of uncertainty and physical discomfort can naturally bring doubt to your abilities to cope. But with panic disorder, the idea is not to cope with your fear, but to deliberately allow and invite feeling fearful. This target is somewhat counterintuitive because it refers to a growing confidence in your ability to contain emotional and physical discomfort without resorting to unnecessary short-term coping strategies.
RELIEF STARTS WITH THE RIGHT SUPPORT
How Therapy Helps with Panic Disorder
Panic disorder can be tough to manage on your own! That’s where the help of a trained therapist comes in. While there are many approaches to these problems, some have more evidence supporting their efficacy than others.
CBT and ERP are currently considered the gold standards of treatment for panic disorder.
Cognitive Behavioral Therapy (CBT): Consists of scientifically informed interventions that address unhelpful beliefs, perceived inabilities to cope, and patterns of behavior that maintain panic.
Exposure and Response Prevention (ERP): A type of cognitive behavioral therapy that focuses on willingly facing triggering situations while refraining from doing whatever you would normally do to protect yourself from fear. This is done with the guidance of a mental health professional to engage in realistic tasks, with manageable steps, in a systematic way, and consistently over time.
Following these steps helps to gradually invite situations that trigger discomfort. It creates opportunities to associate feared situations with a lack of danger and a confidence in being with uncertainty and other uncomfortable feelings. This new learning is considered to inhibit old fearful thoughts to break free from unhelpful coping strategies.
SETTING THE RIGHT INTENTION FOR TREATMENT
The "Three Cs" of Exposure Therapy Success
To get the most from exposure work, focus on:
Calm: You have to be calm enough to pull it off. This doesn’t mean feeling completely calm, but rather not losing your edge due to catastrophic thinking or being unable to breathe.
Competent: You need the skill base to do it so that you know exactly what to do when the uncomfortable thoughts and feelings start to emerge.
Confident: You need to have some expectation of success. This involves preparation and coping ahead, role playing, rehearsing, and practicing.
GETTING THE MOST OUT OF EXPOSURE WORK
Maximize Learning from Exposure
The goal of ERP is not to eliminate anxiety, but to stay in the situation until fully violating your expectation of something intolerably bad happening.
Before each exposure, ask:
- What do you expect will happen?
- What do you expect this will feel like?
- How high do you think your distress will be?
- How well do you think you’re going to be able to manage that?
- Do you think you can tolerate that and choose to do this and still be standing at the end?
After each exposure, reflect:
- Did anything surprise you?
- What did you notice that you didn’t expect?
- What was your experience not acting on unnecessary avoidance?
- Did you notice a greater tolerance for uncertainty?
- What can you take from your experience in this situation that you can apply next time?
You cannot think your way out of panic disorder.
Exposure therapy creates opportunities to test your hypotheses about feared outcomes. This can't be done by simply thinking your way through it. You need to go and face what’s been avoided with a curious attitude and a willingness to learn through experience.
CREATING NEW MEMORIES OF SUCCESS
The Role of Learning in Panic Recovery
If you face a triggering situation prepared to have a positive experience, old memories can be changed! But the circuitry in your brain that holds the memory of the fearful experience must be activated to do so.
You have between 10 minutes and 6 hours to have a better, more successful experience.
This is the time during which memories appear to be less stable and more susceptible to change after they’ve been retrieved.9
This is how exposure treatments work. New memories of successful experiences become encoded with the original fear cue. The more healthy and successful behaviors are rehearsed, the more the brain reconsolidates memories as less dangerous and more manageable. But you have to have the right attitude of willingly moving toward the uncomfortable situation in order to learn something new, rather than willfully pushing away.
FINDING SUPPORT
Break Free from Panic
Breaking free from panic disorder means aiming for new targets. A new approach and a new mindset can help bring fear and anxiety that’s gotten out of hand back under healthy control. If you’ve been struggling with panic attacks and having a hard time doing the things you want to be doing, consider reaching out to us at Midpoint Counseling. We’re here to help you find greater balance and freedom from the overwhelming experiences of panic.
References:
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Klein D. F. (1993). False suffocation alarms, spontaneous panics, and related conditions. An integrative hypothesis. Archives of general psychiatry, 50(4), 306–317. https://doi.org/10.1001/archpsyc.1993.01820160076009
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Maddock R. J. (2001). The lactic acid response to alkalosis in panic disorder : an integrative review. The Journal of neuropsychiatry and clinical neurosciences, 13(1), 22–34. https://doi.org/10.1176/jnp.13.1.22
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Jason Peruchini, LMFT
Jason Peruchini is a licensed psychotherapist and anxiety treatment professional who helps people address issues in mental health to live better lives.
