Panic Attacks: What Can You Do If Nothing Stops Them?
Is it rational to expect therapy that depends on reason to work under stress?
Posted Sep 24, 2019
Cognitive Behavioral Therapy (CBT) has been called the "gold standard" treatment for panic disorder. How is this statement justified when only one panic sufferer in six treated with CBT becomes panic-free?
Frontiers In Psychiatry says, "For CBT the evidence is less robust than often portrayed." Some research finds CBT produces results that are not significantly superior to control group results or placebo treatment.
CBT is based on the notion that panic is caused by irrational thoughts, Too many irrational thoughts can release enough stress hormones that the sympathetic nervous system pushes the person into a panic. But, if the aim is to prevent this excessive up-regulation, why ignore the parasympathetic system that opposes the sympathetic system. If fully activated, the parasympathetic system can completely override the sympathetic system and stop it from revving us up.
The rational way to end panic is not rational thinking. Few can do that. The rational approach is to activate the system that can stop the up-regulation that leads to panic.
To Understand Regulation, Consider Your Car
Your car has an accelerator pedal. When pressed, it sends gas into the engine to rev it up. The accelerator pedal is like the amygdala. When triggered, the amygdala releases stress hormones that cause the sympathetic system to rev us up.
Your car also has a brake pedal. When pressed, it slows the car down. The parasympathetic system acts as a brake. When activated, it overrides the sympathetic system and slows the brain and body down.
A driver ordinarily presses only one pedal at a time. But in the brain can—and often should—operate the accelerator and the brake at the same time. Why? Because the brain's gas pedal has a lag. Once stress hormones are released, they continue revving the person up until they “burn off.” It's like your car continuing to accelerate after you have taken your foot off the accelerator pedal.
That's a frightening prospect. If the brakes aren't good, it's terrifying. That's what panic is all about. When panic takes place, it is not our revving up a system that's at fault. It is working just as it is supposed to. The problem is our emotional braking system. The system that is supposed to calm us down isn't working. Instead of fixing the faulty brakes, CBT tries to fix what isn't broken.
When a thought about something dangerous enters the mind, the amygdala does not recognize it as just a thought. In a “knee-jerk” reaction to the image of danger, the amygdala releases stress hormones. The hormones cause the sympathetic nervous system to rev the person up. That's the "fight or flight" response.
The same stress hormones activate our high-level thinking (executive function). Stress hormones are its cue to figure out what the amygdala is reacting to, determine whether it is or is not a threat, and decide what—if anything—needs to be done. But if stress hormones rise too high, Executive Function gets overwhelmed.
The Parasympathetic Nervous System to the Rescue
A series of thoughts about danger can trigger one release of stress hormones after another. If stress hormones levels rise too high, Executive Function shuts down unless the stress hormone effects are counteracted by parasympathetic system activity. In your car, the brake pedal can override the accelerator pedal.
For example, if you plant your left foot solidly on the brake, even if you press on the gas pedal with your right foot, the car goes nowhere. In a car, the brake pedal can override the gas pedal. The same is true in the mind when the parasympathetic nervous system is fully activated.
Let's look at what happens if the parasympathetic nervous system doesn't step in and protect the Executive Function from excessive stress hormones.
- Scenario One: The amygdala reacts to an actual threat. The parasympathetic nervous system does not step in. Fully overwhelmed, the executive function cannot deal with the threat rationally for a few minutes. Without the protection of the parasympathetic nervous system, the person is at risk until the stress hormones burn off.
- Scenario Two: The amygdala reacts to an imagined threat. The parasympathetic nervous system does not neutralize the effects of the stress hormones. Partially overwhelmed, executive function is unable to recognize that the threat is not real. Feelings caused by up-regulation (rapid heart rate, breathing rate, tension, etc.) are associated with danger, more in some persons than in others depending upon previous experience. These feelings mislead the person to believe danger exists. With executive function disabled by stress hormones, the person cannot decide what to do. The person stays anxious, or worse, goes into a panic.
Without the protection of the parasympathetic nervous system, rational thinking—exactly what CBT depends on—may be impossible. Attempting to reverse hyper-arousal with reason alone is like trying to lift yourself by your bootstraps.
Though the parasympathetic nervous system exists at birth, an infant cannot self-activate it. For down-regulation to occur, a caregiver must activate the infant’s parasympathetic nervous system. Research by Stephen Porges finds it is activated by social engagement.
When we are with other people, we unconsciously send and receive signals. These signals are unconsciously processed. If the caregiver's signals are calm and benign, the parasympathetic nervous system is activated by
- The caregiver's soft, non-judgmental facial expression
- The quality of the caregiver's voice
- The caregiver's touch
If a child’s parasympathetic nervous system is activated consistently enough in response to the release of stress hormones, the child’s parasympathetic nervous system becomes programmed to self-activate when stress hormones are released.
Unfortunately, insecurely attached children, believed to be approximately 40 percent, are unlikely to develop programming that activates the parasympathetic nervous system in response to stress hormone release. Recent research indicates that if a caregiver yells at a child or otherwise frightens the child during formative years the child will not develop secure attachment, and the programming that is supposed to be developed may not develop.
Anxiety is not well-regulated, and as an adult, the person may develop a generalized anxiety disorder or panic disorder.
If stress hormones get a head start, rational thinking shuts down. The answer is to program the parasympathetic nervous system to step in when needed. Info on how to do that is detailed in Panic Free: The 10-Day Program to End Panic, Anxiety, and Claustrophobia (click on title to read a sample free).
My book, Panic Free: The 10-Day Program to End Panic, Anxiety, and Claustrophobia provides step-by-step instructions.