Do Panic Attacks Really Come Out of the Blue?

Stressful life events can cause an increase in panic attacks over time.

Posted Apr 25, 2016

 Flickr, "Fight or Flight? Flight!" by Saul Adereth, CC by 2.0
Source: Source: Flickr, "Fight or Flight? Flight!" by Saul Adereth, CC by 2.0

Panic disorder (PD) can be a severe, highly disabling and debilitating psychiatric condition. It is fairly common.

Panic attacks are basically attacks of extreme anxiety accompanied by a variety of physical symptoms, which I will describe in a moment. People experiencing them for the first time often think they are having a heart attack, because the symptoms of panic attacks mimic those of a myocardial infarction. Some of these folks go the emergency room multiple times. When they get there, the doctors do an EKG and blood tests looking for evidence that the patient is indeed having a heart attack, and lo and behold, all the tests come back completely normal.

In the days before ER docs became familiar with the disorder, patients would be basically told that their symptoms were all in their heads and sent home. The patient would be flummoxed. The physical symptoms are of such intensity that patients would come to the correct conclusion that something physical must have happened.

Panic attack symptoms may include palpitations (pounding heartbeat), increased heart rate, sweating, tremulousness, shortness of breath, choking, chest pain, dizziness or lightheadedness, nausea and abdominal distress, a sense that everything is unreal, fear of losing control or going crazy, fear of dying, numbness, tingling, chills, and hot flushes. Symptoms can last for a few minutes or for a few hours.

When people have recurring panic attacks, they are said to have panic disorder and are at high risk of developing a psychological reaction called agoraphobia. This byproduct of panic attacks is more common in women with the disorder than men for unknown reasons.

In any event, people with agoraphobia become fearful of being trapped and avoid crowds (malls, supermarkets, theaters, sporting events, and even church), elevators and other tight spaces, lines, and driving distances or over bridges. Sometimes sufferers become fearful of ever going outside the house alone, and in severe cases they may become completely housebound.

Fortunately, when PD is not accompanied by chronic repetitive interpersonal dysfunction, a personality disorder, or frequent self-destructive behavior, it is usually easily treatable with a combination of medication, breathing techniques, and cognitive-behavioral therapy techniques. The latter include systematic desensitization to crowds and driving, and challenging the patients' tendency to engage in so-called catastrophizing (worrying about unlikely worst-case scenarios) and shoulding all over themselves (berating themselves because they "should be like x and y and/or have done z"). 

However, PD often is frequently accompanied by these other issues.

The diagnostic criteria for panic disorder in the DSM-5 specify that the panic attacks must be "unexpected." That characterization is the main subject of this post because I believe it is misleading.

But first, I would like to point out that all of the listed physical panic symptoms can also be experienced as part of a rage reaction. Rage attacks are most often seen in patients with borderline personality disorder (BPD), a high percentage of whom also have panic attacks. In fact, studies show that 40 percent of women with BPD have panic disorder as well.

Surprisingly, the physiology of a rage attack is identical to those of a panic attack. The individual's cognitive processes (thoughts and evaluation of the symptoms and what may have triggered them) during an attack may be the only thing which distinguishes them.

That this should be the case is not surprising. Both panic and rage attacks are a manifestation of the primitive fight, flight, or freeze response present in most mammals. A fight response would lead to rage, and a flight or freeze response might result from panic.

Indeed, it seems that people who have panic disorder have a genetic disturbance of this fight, flight, or freeze mechanism that causes it to go off, and keep going off, even after any threatening stimulus is no longer present. An important, self-protective physiological phenomenon may have gone haywire.

Unlike panic attacks, which are supposedly unexpected and not necessarily triggered by any specific environmental stimulus, rage attacks are usually thought to be triggered by specific environmental events. If an individual has recurrent rage attacks that seem to be unexpected, spontaneous, and untriggered, then a completely different diagnostic label is usually applied to them by psychiatrists: intermittent explosive disorder.

I have never seen a single case of this in over 40 years that could not be better explained by another diagnosis. The judgment that a rage response is "out of proportion" to an environmental stimulus is usually based on the evaluator's lack of knowledge about a patient's prior experiences which determine why the patient finds something upsetting.

To summarize, for panic disorder, as opposed to the occasional panic attack, the conventional psychiatric wisdom is that they occur “out of the blue” rather than as responses to environmental threats. If they only occur in the presence of one or more specific environmental threats, say snakes, then the person is diagnosed with a specific phobia instead of panic disorder — a snake phobia in this case.

Panic disorder might be considered a prime example of something that would pit "biological" psychiatrists against psychotherapists. In people who suffer from panic disorder, the attacks do seem to come out of nowhere. Sufferers can be sitting quietly in their house doing almost nothing when one comes on. They can even be jolted awake from them in the middle of the night, without having had a nightmare. A tendency to have panic attacks tends to run in families, so clearly some people are more genetically prone to get them than others.

So does this mean that panic disorder is purely and entirely a brain disease? Is its classification as an anxiety disorder incorrect? Does it have nothing to do with chronic stressors?

In my opinion, the answer to all three of these questions is a resounding "no." People who are prone to the disorder do indeed seem to have a problem with the internal regulation of their flight or flight mechanism, to be sure, but environmental factors do, in my clinical experience, determine whether such a person has an occasional attack or has a lot of them.

The idea that, because panic attacks are not necessarily preceded by a specific environmental event, then therefore there are no specific triggers is a remnant of an old, nonsensical cognitive-behavior therapy theoretical chestnut. In animals, fear reactions are in fact usually immediately preceded by an environmental trigger. But people do not function on the same level as rats in cages.

But if attacks happen without a fearful stimulus being present, how is this possible? My theory is that people who are genetically prone to them will start to have them when they are chronically anxious. Whenever they are on guard, on edge, walking on eggshells, or disturbed about something, they then can have a panic at any time during the whole period they feel that way. Why they happen at any particular time remains a mystery.

A study from 2011 by Moitra and others (Journal of Affective Disorders, 2011 Nov; 134[1-3]: 373–376) adds a lot of credence to this opinion. The study results showed that, instead of an immediate reaction, stressful life events (SLEs) in patients with PD can cause a gradual, but steady, increase in panic symptoms over time.

The investigators noted that they expected to find that panic symptoms would spike immediately after a stressful event and then taper off, but this was not the case. In an analysis of more than 400 patients with PD from the Harvard/Brown Anxiety Research Program study, panic symptoms worsened progressively over three months after participants experienced specific SLEs, including such events as serious family discord or being fired.

I find that many patients with panic disorder are in the middle of ongoing repetitive dysfunctional family interactions. If the doctor does not specifically ask about them, patients are unlikely to bring them up. In these cases, just medicating them without a psychotherapy referral for the underlying problems (not just the symptoms) should be considered a gross disservice to the patient.