Imagine that you are walking down a lonely street. It is dusk. The street lights have not yet come on. The only sound of traffic is blocks away. Suddenly, three young men come out from behind a stoop and silently begin walking over to you. They are carrying baseball bats. You look behind you and see another young man blocking your retreat. Before we imagine Superman swooping down and carrying you off to safety, consider how your body is reacting. You are, I am sure, experiencing the “fight or flight” reaction. That is: you are taking deep breaths, your muscles are tensing up, your heart rate and blood pressure are rising, your mouth is getting dry. Your whole body is preparing for a struggle. Your physical response to this acute stress is dramatic. A doctor who suddenly appears at your side next to the street light with a stethoscope, immediately notices all these physiological responses. Are you aware of all these various, striking changes in your body? Of course, not! The only thing you are paying attention to is the approach of these threatening young men. You are looking around desperately for a way to run away. Your pupils are dilated,( but only the doctor standing next to you , who is very perspicacious, notices this.) Luckily, you have spotted a machine gun propped up against a fire hydrant, and by an extraordinary effort manage to reach it before the young men have surrounded you, and before Superman has arrived finally, having been delayed by an encounter with an alien spaceship a few blocks away. It is fair to say, and accurate, that this whole episode has caused you to become panicky. But this is not a panic attack.

A panic attack typically occurs in situations where very little is going on. There is no obvious threat. Someone may be sitting quietly in a restaurant, or in a car. But the physical reaction is the same. The threat is perceived as different, however. There is no gang of hoodlums bearing down—or other life-threatening dangers such as running out of air while scuba diving or paddling in a leaky rowboat through an electrical storm. There is nothing to prepare for. There is nowhere to run, no paddle to row faster and faster, no machine gun lying about that must be grabbed hold of just in time. The threat the phobic person feels is from the panic attack itself. It is those physiological aspects of being frightened that are themselves frightening. One or another physical symptom might be especially worrisome. Some people who suffer from panic disorder are focused primarily on their heart rate, which seems to be going faster and faster, so that they worry about having a heart attack. Others can’t catch their breath, and they begin to hyperventilate. Still others complain of their legs feeling weak from muscular tension, and they worry about falling down. Since there is no external threat, there is no way of running away. Even so, they do run away, and if they feel trapped for one reason or another wherever they happen to be, they begin to avoid those places. They become phobic.

The psychological dimension to a panic attack is the sense that panicky persons have that pretty soon, if they don’t escape the phobic situation, they will lose control of themselves and do something embarrassing or dangerous, like screaming, falling to the ground, throwing up or soiling themselves. These things never happen.

Successful treatment requires that people with panic disorder stay in the phobic situation long enough to see that the panic attack resolves by itself in a matter usually of only minutes. After some time, some considerable time, sometimes, the patient becomes unafraid of these occasional attacks, which continue to happen from time to time, at increasing intervals, for reasons no one understands. Then they go away altogether.

I thought a particular woman was over this condition once and for all, when she came to my office saying she had another panic attack. This can happen, but I was surprised. I asked her to explain the circumstances

“It was on the highway,” she told me. “It was snowing, and suddenly I began to skid at 60 miles an hour; and all the old feelings came back.”

That was not a panic attack I told her, that was just plain panic. “You’re supposed to feel panicky when you’re skidding at high speed.” If she didn’t have a history of panic disorder, she would never have noticed her symptoms. She would have been concentrating on the road.

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