The body has a set of physiological responses to danger: the pupils dilate, respiration deepens, heart rate and blood pressure rise, muscles tense for action. The gastro-intestinal system reacts also. This complicated physical response is called the “fight or flight” reaction. The body is preparing to confront the danger or to run away. When a perceived danger is not immediately apparent, but this reaction occurs nevertheless, the affected person is having a panic attack. The physical response itself seems to be the danger. As the panicky person focuses on these seemingly extraordinary physical symptoms, they become more exaggerated; and he/she becomes still more frightened. There is the sense of these symptoms spiraling out of control. Sometimes one or another aspect of this emergency response predominates. Some people concentrate on their dry mouth, and they become aware of trouble swallowing. They may feel that there is a lump in their throat. Because the ancient Greeks noticed that this condition occurred mostly in women, they called it globus hystericus, which refers to a wandering uterus. They thought the uterus wandered up into the throat where it obstructed swallowing.
Sometimes the panicky person concentrates on breathing. The heightened respiration of the fight or flight reaction is experienced subjectively as a shortness of breath. Trying to get a deep breath, he/she overbreathes. This is a common phenomenon. People who are not anxious will overbreathe if they try purposely to breathe normally. We seem to think we need to breathe more than we actually do. Overbreathing is called hyperventilation. There are some physiological consequences to overbreathing. First, the carbon dioxide level in the body drops. Since dissolved CO2 is an acid, the acid-base balance in the blood changes, which, in turn, affects the ionization of calcium. If hyperventilation persists for a long enough period of time, the affected person can develop a temporary tetany, secondary to the changes in calcium. This state is manifested first by tingling in the fingers and lips and then by contractions of the hands and wrists. Finally, a wobbly feeling may appear. This complicated phenomenon is scary, but is reversible and not dangerous. It can persist for hours, or even longer. In order to prevent the consequences of hyperventilation, patients are often instructed to breath into a paper bag. Re-breathing the air previously exhaled maintains a proper level of carbon dioxide. I don’t recommend this procedure to a panicky person. It makes that person feel that recovery is something that needs to be managed actively when the truth is the condition is self-limiting. And no one can breathe into a paper bag without looking ridiculous. Although it is conceivable that someone can hyperventilate to the point of passing out, I have never seen that happen—except one time.
I was drafted into the army as a psychiatrist. I served in Germany. Occasionally, like all the other medical personnel, I had to cover the emergency room. One evening, I heard a growing clamor from the hallway leading to the emergency room. Soon there appeared a group of gesticulating men and women, crying out from time to time. There were four or five adults and a young girl who was, I guessed, about sixteen. When they calmed down after a while, they told a story about the girl passing out over and over again at a softball game. They were ushered into a small examining room, where I went to talk to them. While I talked to the still semi-hysterical adults, I watched the young girl, who was sitting on an examining table. She was breathing just as fast as she could. Imagine yourself breathing as deeply as you can and as fast as you can. That is what she was doing. I listened to her family’s story and watched her. Finally, I went over to her and asked why she was doing this.
There are a number of medical conditions that cause breathing difficulties: asthma, anaphylactic shock, obstructions of one sort or another, metabolic alkalosis, and so on. But it was obvious that she was breathing comfortably, but just as fast as she could, purposely.
She ignored me. And then she fell back on the examining table and passed out. Her family started to scream. The appearance of the young woman took on an extraordinary aspect: she stopped breathing. If you didn’t know better, you would have thought she was dead. No breathing. But her pulse when I took it was regular and normal.
There are two centers in the brain that control breathing. The more sensitive one responds to carbon dioxide. A rise in CO2 in the body causes deeper breathing. There is also an area sensitive to the oxygen level in the body. The lower the level the more urgency is felt to breathe. The two centers work together to control the level of breathing, unconsciously. But when there is a very low level of carbon dioxide in the blood and a high level of oxygen, there is no impetus to breathe! That is what was happening to this young girl. After a few moments, her breathing started up again, first shallow breathing and then more normal, whereupon she woke up. I tried again to get her attention, but she ignored me. She immediately started hyperventilating again as hard as she could. And the family started to scream again.
Adolescent girls, for reasons that are not really understood, tend sometimes to develop hysterical (psychosomatic) symptoms. In the past, there were occasions when groups of girls in school together fainted one after the other, or began to throw up—with no discernible cause. And over the next few days, they would be joined by others. In a different setting some adolescent girls have been seen to throw things about the room surreptitiously and pretend that a poltergeist in present. These behaviors, thankfully, do not happen very frequently. And I had never seen a girl like this who was obviously doing this hyperventilation trick for the effect it was having on her family.
When she had passed out again, I ushered the family out of the room. When they had gone, I picked the young woman up and placed her on the floor, where she wouldn’t hurt herself if she kept this behavior up. I know how this sounds, unfeeling, and perhaps unprofessional; but it had the effect of isolating her, which was required, and doing it safely. And then I closed the door and left her alone. About twenty minutes later a very angry young woman came out of the room and, after arguing with her family for ten or fifteen minutes, she left with the others.
If you hyperventilate as part of a panic attack, I would like to assure you that you will not stop breathing. You have to overbreathe purposely to get into this state, as hard as you can. Otherwise, you can’t get there from here. © Fredric Neuman2012 Follow Dr. Neuman’s blog at fredricneumanmd.com/blog