What If I Have a Heart Attack?
George suddenly experienced excruciating chest pain one day at work. Never having experienced such symptoms before, he was rushed to the hospital. After testing to evaluate for a heart attack, the doctor concluded that his heart was fine and that he had an anxiety attack. When asked about stressors, George reported that he was under some deadlines at work and that some family problems were weighing on his mind. Although he understood that he didn't have a heart attack, he became worried that the doctor may not have been thorough enough and that maybe he would still have a heart attack. He became obsessed about any minor pain that occurred in his chest which exacerbated his anxiety and stress.  As a result, he continued to have panic attacks.

What If I Lose Control?
Francine had similar symptoms while she was driving. After she visited her doctor, she understood that she had experienced a panic attack. However, she became concerned about having another panic attack. "What if I have a panic attack and lose control of the car while driving?" Predictably, she began to experience increased anxiety especially related to driving and started to have panic attacks whenever she got in her car. She began to avoid driving completely and was diagnosed with agoraphobia.

What If I Feel This Again?
Sandy was overwhelmed with her initial symptoms of dizziness, lightheadedness, and visual disturbance. She was diagnosed with anxiety and although she knew she wasn't in any danger physically, she was fearful of having the symptoms. "I can't stand to feel that way! It's awful and I can't focus on my work." Again, the worry about feeling anxious created more anxiety leading to more attacks. Eventually, she was diagnosed with panic disorder.

What Is A Panic or Anxiety Attack?
A panic attack is a sudden onslaught of symptoms in which a person feels overwhelmed and out-of-control. The symptoms vary for each individual. However, common symptoms include rapid breathing, chest pain, dizziness, trembling, muscle tension, and stomach upset. These symptoms are often accompanied by fear of harm such as having a heart attack, fear of losing control, fear of experiencing symptoms and feeling bad, fear of going crazy, or fear of what people might think.

People often wonder what is the difference between an anxiety attack or panic attack. Often these terms are used interchangeably. However, some people will refer to a panic attck when their symptoms are more intense and out-of-control. Anxiety usually refers to symptoms that don't reach the level of an "attack."

Why Does Panic and Anxiety Occur?
Anxiety is a normal process of the body that people experience for a variety of reasons. Most commonly, if we are in danger our body needs to prepare to deal with whatever may be threatening us.

For instance, as you are driving on the highway, the car in front of you spins out of control. For you to handle the threat, your body needs to react quickly. To do this, your brain tells certain systems of your body to be activated and other systems to shut down.
 
1) AUTONOMIC NERVOUS SYSTEM ACTIVATION
This activation of the autonomic nervous system causes andrenalin to be released which speeds up your reaction time. This also causes the symptoms of rapid breathing, feelings of agitation, and restlessness.

2) PREPARATION TO REACT
In addition, your muscles tense to prepare you to react quickly. This creates the pain many people experience especially in their neck, shoulders and chest.

3) SYSTEM SHUTDOWN
Your body will shut down unnecessary systems to prepare to react. You really don't need to be digesting your last meal while you're trying to avoid an accident. However, because the digestive system is shut down people may experience gastrointestinal symptoms such as stomach upset, diarrhea, or constipation.

4) FOCUS ON THREAT
Also, the brain needs to focus on the immediate danger in front of you so it shuts down the peripheral vision which causes the tunnel vision many people experience. is a normal process. In fact, even panic is normal. Most of us will experience a spontaneous panic attack some time in our life. These panic attacks may be due to stress or some physical condition such as sleep deprivation, hormonal imbalance, or asthma. Most people don't worry about the panic attack itself. They focus on dealing with the condition signaled by the panic attack. However, some people become worried about the panic attack itself, start focusing on it, and as a result, create additional panic attacks. This is similar to a computer program getting stuck in a feedback loop: A causes B causes C which causes A again (which causes B and so on). In other words, the initial symptoms of the panic causes the person to worry. The worry is then perceived as a threat which, as I indicated earlier, can cause a panic attack. Therefore, the person becomes stuck in this cycle. When that occurs it is known as Panic Disorder.

Is Panic Dangerous?
Because a panic attack feels awful many people assume that it is dangerous or could create a dangerous situation. I will discuss the most common concerns that people have related to panic attacks.

1) FEAR OF HEART ATTACK
Symptoms of panic include many symptoms that occur when people have heart attacks such as chest pain, rapid breathing or shortness of breath, nausea, dizziness, cold sweat. Therefore, many people assume they are experiencing a heart attack. If it is the first panic attack, it is critical that the person be examined by a doctor to determine the diagnosis. However, if the doctor indicates that the person does not have heart disease, then the individual can safely assume that they are experiencing a panic attack.

However, some people still worry that the panic attack could cause a heart attack. This is not possible (except in the movies). The reason for this is that anxiety and panic is a normal process of the body as I said earlier. It is the arousal of the autonomic nervous system also know as the "flight or fight response." This system is a beneficial part of the body meant to help us. It is activated if we are threatened and need to react quickly such as by running or fighting back. Therefore, it cannot harm us. That would be like saying that the normal process of breathing which is meant to help us could actually harm us. It can't. And neither can the arousal of the autonomic nervous system.

Now, there is some evidence that long-term (over years) arousal of the autonomic nervous system can contribute to heart disease. However, this is through a different process. What occurs is that during this arousal, the stress hormone cortisol is released. Cortisol is meant to help us cope with stress. But under the condition of chronic stress where too much is in our system over time, it will lead to the build up of fat around the middle of our body. As you may know, this particular fat has been indicated to be a risk factor with heart disease. Again, however, if you do not have heart disease, a panic attack cannot trigger a heart attack.

2) FEAR OF GOING CRAZY
Another fear that people have is that a panic attack will cause them to go crazy. Certainly, panic is very disorienting and it may be hard to focus and concentrate so it may feel as if you are losing your mind. However, that can't happen. And again, the reason is because panic is a normal system of the body. Anything normal cannot cause a person to lose their mind.

The only time that a person can "lose their mind" with panic is if they already have a mental condition that causes them to lose touch with reality. Even then, it can only be a trigger for an underlying condition. For example, if a person has schizophrenia or bipolar disorder. However, there would be other signs of these conditions. Therefore, if you have seen a physician or psychologist and you have not been diagnosed with these types of mental conditions, panic cannot cause you to go crazy.

3) FEAR OF LOSING CONTROL
Many people who have recurring panic fear that it will cause them to lose control. For example, they fear that if they are driving they will suddenly lose control and not be able to drive. Then, they become fearful that the panic will cause them to have an accident.

This is certainly not true and for a very interesting reason. Remember, earlier I said that panic is to help us prepare to handle a threat. Therefore, while our autonomic nervous system is aroused we are in a heightened state of preparation and are more ready to react quickly to a problem. We are able to think and respond. In my 20 years treating panic and anxiety and doing driving exposures with clients, I have never once seen or heard of any of them unable to at least pull the car over to the side of the road. No one has ever just taken their hands off the steering wheel and had an accident. I am not concerned about riding in a car with someone who is having a panic attack because I don't believe I am in danger (unless they are just a bad driver, in general).

4) FEAR OF FAINTING
Another fear that people experience due to the symptoms of lightheadedness and dizziness is that they will faint and the fainting will cause a dangerous situations. However, this does not occur because panic causes an increase in blood pressure (one of those symptoms to help us prepare for threat) but fainting is most typically caused by low blood pressure.

However, one caveat to this is that if a person already has a fainting condition, a panic attack may trigger a faint. Even  in this case it is not typical due to the rise in blood pressure. However, again, if a physician has given you a clean bill of health and you have never fainted previously due to another condition, a panic attack will not cause you to faint.

Medical Conditions That Mimic or Involve Anxiety
Due to the non-specific nature of panic symptoms, it is important to obtain a complete physical and an accurate diagnosis from a physician prior to  assuming that the experience was a panic attack. Many other conditions may have similar symptoms making it necessary to rule-out these other conditions prior to treating for panic. Some of the common conditions include heart disease, high blood pressure, asthma, hyperthyroidism, hormonal imbalance,  and sleep apnea. However, other conditions that I have seen which created or triggered anxiety/panic include Meniere's disease, hiatal hernia, GERD, diabetes, and even the common cold.

Also, certain medications or the use of drugs or alcohol can cause panic. A common cold medication that has pseudoephidrine in it can trigger anxiety in susceptible individuals. Overuse of products with caffeine can stimulate anxiety. For instance, most people can develop heart palpitations with 1000mg of caffeine or the equivalent of about six cups of regular coffee.

In addition, a person may have both an anxiety disorder and a medical condition. In that case, the medical condition may exacerbate or trigger the panic. Therefore, a person may require treatment for both.

However, it is important to note that once medical conditions have been ruled-out and/or treated by a physician, it can be assumed that the individual can be safely treated for an anxiety condition.

What Is Panic Disorder? What Is Agoraphobia?
Panic Disorder is when an individual has recurring panic attacks and has developed a dread of having additional attacks. Panic disorder has often been referred to as "the fear of fear" but more accurately it is the fear of having the symptoms that occur with anxiety/panic.

If the individual begins to avoid situations due to the possibility of having a panic attack they may be diagnosed with agoraphobia as well. This avoidance may cause the individual to have serious limitations in their life including not being able to work, not being able to drive, and sometimes, not being able to leave their home.

Managing Panic/Anxiety
1) MEDICATION
Since most people see their physician first for panic and anxiety, most people are treated with medication. Although medication can be effective and requires little effort, cognitive behavioral therapy (CBT) is just as effective, has a lower drop-out rate due to the lack of side-effects, and has a lower relapse rate (Mitte, 2005; Olatunji et al, 2008; Smits et al, 2008). In other words, people who take medication may need to stay on medication to manage the symptoms whereas CBT teaches skills that, once learned, do not need the ongoing intervention of the therapist to continue the benefit.

2) EDUCATION
The first thing that people with anxiety and panic need is proper education about panic attacks and their mechanism. They need to understand as described above that panic and anxiety cannot harm them. This is the first step of the cognitive therapy which involves changing how people think.

3) ANXIETY REDUCTION SKILLS
People with anxiety and panic need to learn that they have methods available that help them to reduce and control the symptoms they experience. Various methods include slow breathing, muscle relaxation, meditative relaxation, mindfulness practice, and Qi Gong and other movement types of relaxaton such as yoga (read: Why Are Meditative Relaxation and Mindulness Important?).

These methods take practice when the person is not feeling anxious otherwise they may not be very effective. For instance, if someone tries to deep breathe during a panic attack and they have never practiced the breathing at any other time, it is not likely to work.

4) CHALLENGE THE IRRATIONAL FEARS
Using the education about panic, the individual needs to challege the irrational beliefs they have about the panic symptoms. For example, if they fear the panic is a heart attack, they need to remind themselves that they have been examined by a physician who has determined that this experience is anxiety. And they may need to repeat this as often as necessary until they believe it. Cognitive restructuring requires repetition to be effective (read: How Do We Change Irrational Thinking?).

Eventually, to control anxiety the individual needs to develop the belief, "So what if I panic? It's just unpleasant. It can't hurt me." When I have clients that get to the point where they tell the anxiety "Bring it on! You don't scare me" I know we're at the end of therapy. Because once somebody truly feels that way, we typically see a reduction in the intensity and frequency of the panic/anxiety symptoms typically to a normal level. Since it is normal to have anxiety or an occasional panic, I would not expect to completely eliminate the symptoms.

4) Panic Assistance Audio
To create the above belief, an individual needs to develop a tolerance for the anxiety symptoms. I see treatment for panic as two-fold: developing tolerance for the symptoms and developing self-confidence in the ability to reduce the symptoms. To help clients learn how to develop tolerance I created a Panic Assistance Audio (download free) that coaches an individual through the panic while challenging the irrational fears of the panic.

This audio can be used whenever you feel high anxiety or panicky. However, this audio is particularly designed to assist people when they are doing exposures (see below) to the anxiety situations.

4) INTEROCEPTIVE DECONDITIONING
Interoceptive deconditioning is a fancy (and almost scary) psychological term referring to a method to reduce the fear to the anxiety symptoms. Although I will describe this method, it is important to do this only with therapeutic support because if it is not done correctly it can have the opposite effect intended and actually increase intensity or frequency of panic.

This method involves artificially creating the physical symptoms of anxiety. This can be done for some people just by thinking about having a panic attack. For others, it can be created by deliberately hyperventilating, spinning around in circles, or cardio exercise. Typically this method involves a gradual desensitization. For instance, we start with creating a low level of anxiety and as the person develops tolerance as well as the anxiety management skills we increase the anxiety level until they are able to tolerate the panic level.

This method of treatment is conducted under very controlled circumstances and from my experience due to the training process people are ready when it is time to confront the panic because they have already learned tolerance of the symptoms and have confidence in their ability to manage the symptoms. We never move to the next level of anxiety until they are ready to do so.

5) EXPOSURES
Exposure therapy involves confronting the situations that trigger the panic. In fact, interoceptive deconditioning just described is a type of exposure therapy.  Other exposure therapy is utilized when a person may be avoiding situations due to fear of having a panic attack such as people who have agoraphobia. For example, someone may be avoiding driving. Exposure therapy to driving would be to gradually introduce the person to the feared situation while having them use the previously learned tools to manage the anxiety and challenge the thinking. Depending on the level of fear sometimes this involves the therapist assisting the individual. Which is why I have been with many clients when they are having a panic attack while driving. The therapist may need to coach the person while they face their fear. However, as soon as practical, it is important that the therapeutic support is withdrawn so the individual can rely on him or herself.

REFERENCES
Mitte, K. (2005). Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: a comparison with pharmacotherapy. Psychological Bulletin, 131, 785-795.

Olatunji, B., Cisler, J.M., and Deacon, B.J. (2008). Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings. Psychiatric Clinics of North America, 33, 557-577.

Smits, J.A., Berry, A.C., Tart, C.D., and Powers, M.B. (2008). The efficacy of cognitive-behavioral interventions for reducing anxiety sensitivity: a meta-analytic review. Behavioral Research and Therapy, 46, 1047-1054.