From Panic to Panic Disorder
In my previous articles on panic, I discussed the nature of panic attacks and described what causes them, as well as what you can do to stay out of the panic feedback loop. In this article, I will explain how panic attacks become part of panic disorder. This is important because panic attacks themselves can happen without significantly impacting your life, but panic disorder can lead to restricted living.
What is Panic Disorder?
Panic Disorder is a mental health diagnosis that is given when several symptoms are present. Panic attacks are actually one of those symptoms, but panic attacks by themselves do not represent a psychological disorder. In fact, panic attacks can be present in other anxiety disorders such as phobias, in depression, or even without the presence of any diagnosable disorder.
For some people, panic attacks occur and then the sufferer goes about his or her life, and may or may not ever have another attack. Sometimes attacks are isolated and occur years apart. But oftentimes, a panic attack will lead to significant changes in a person’s life, and the diagnosis of panic disorder can be made.
The following are a list of symptoms that are central to the diagnosis:
- Sudden and repeated panic attacks of intense anxiety and fear
- A feeling of being out of control, or a fear of death or impending doom during a panic attack
- Intense worry about when the next panic attack will happen
- Fear or avoidance of places where panic attacks have occurred in the past
As you may see from these symptoms, the disorder is basically the reaction to the panic, not the panic itself. The bottom two symptoms are at the core of panic disorder and are central to what causes panic attacks to turn into something bigger that can interfere with your life. But what determines why this happens?
If you watched my first two articles, you heard me describe the panic feedback loop. It is this very phenomenon, on a broader level, that is responsible for turning panic attacks into panic disorder. The feedback loop is similar to a vortex. You want to stay on the outside of the vortex to prevent getting pulled in.
Here is one definition of a vortex from the English dictionary:
A dangerous or bad situation in which you become more and more involved and from which you cannot escape.
Here’s why this happens. Once a panic attack occurs, our fear of it and our assessment of its meaning and significance can lead us to fear that another one will happen. We start to think something like this: “That was awful. I sure hope that never happens again”. We become preoccupied with the idea that it could happen again. We then start to plan what we need to do in order to keep it from ever happening again.
That sounds wise, right? It felt horrible and confusing, like nothing you had experienced before. Why wouldn’t you try to keep it from happening again? True, that may seem to make sense, but it is not the most helpful strategy.
I remember my first panic attack when I was in my early 20’s. I didn’t know what was happening, but I started to feel very strange. I thought perhaps I had eaten something poisonous or accidentally ingested some kind of drug. My friend was with me at the time and reassuringly told me that it seemed like I was having a panic attack. That was helpful because I knew what was happening, and within an hour, the symptoms subsided. I didn’t think too much of it after that.
Until later that week while I was sitting in a college class at Arizona State University. I started feeling some sensations in my body that instantly reminded me of the attack. My mind quickly jumped back to the experience of the first attack, and I started to worry that I would have a panic attack in the class. On top of that, I imagined the feeling of embarrassment if I had to leave in the middle of the lecture. You see, some people wouldn’t be phased by that but I never was one to draw attention to myself.
This happened several times, each time I felt quite anxious but did not have a full-blown attack. However, I spent lots of time imagining that I might, and how embarrassing it would be if I had to leave.
This led to my decision to sit in the back of the class at the end of the row so that if I did have to leave it would be easy and nobody would notice. What I did not know then, even though I was studying psychology, was that I had made a choice that would provide a temporary sense of relief but that would do nothing to help with the panic. Nope. It made it worse without me even knowing it.
You see, I had just told myself that I would not be ok if I had anxious feelings in class. As you recall, the belief that anxiety and panic are not tolerable actually reinforces the anxiety. This starts to become a bigger and bigger problem that you will do more and more to avoid. Each time you do avoid it, you unknowingly make the fear stronger. This is where it becomes a vortex.
So if this is happening to you, please understand that it is not your fault and does not mean that you are weak or somehow foolish. As I explained, this was also me. Wanting to avoid something uncomfortable is simply human nature. The main job of your brain is survival, so it becomes preoccupied with this imagined potential danger. But if we know this and understand more about it, we can guide our brains and ourselves in a different direction.
It’s important right now that you remember not to judge yourself for this. Practice being kind to yourself about it, because the judgment and self-criticism only serve to make you feel worse. Believe me, I’ve seen it in so many of my clients. This can lead to isolation and depression.
So instead of judging and blaming, let’s look more closely at why panic attacks lead to panic disorder. It’s actually very clear and very simple. I’m going to cover some key concepts that explain this progression.
One is our mental assessment or Interpretation of what panic means. We assess the panic attack as something bad that might lead to a problematic outcome. Often we think that we have to leave a situation if we feel panicky. Many people associate this with embarrassment, “what will they think of me”. Or perhaps “what if I fainted, or vomited?”
So not only do we fear the panic itself, but we come to associate it with fears about the outcome of having the attack. We worry we would not be able to escape or we would be embarrassed in doing so. Although we often have no confirmation that this is true. Our minds are very good at coming up with the worst-case scenarios. But as you might realize, this only makes you feel more anxious.
Another major contributor is that we start to become “hypervigilant” to any signs that we might have a panic attack. This means that we are highly focused and scanning our body for any signs of panic. We can be hypervigilant with our body sensations as well as external triggers that might bring on the panic. Again, it’s a function of the brain to look out for danger in order to maximize survival. So hypervigilance can actually just be seen as a misguided attempt from our brain to keep us alive.
If we do notice a sign we will immediately have those thoughts that get us sucked into the feedback loop. So we become more sensitive to sensations of panic. We are like an over-sensitive smoke detector that will go off if we light a candle. When we are hypervigilant and we find the possible trigger, it sets off a chain reaction.
What is wrong with being hypervigilant? Well, it is actually helpful if we are in a dangerous situation. We would need to be on guard and to seek out signs of possible danger in order to protect ourselves and to react quickly.
But most of us don’t live in this type of situation. When applied to daily life, hypervigilance is a problem because it narrows our focus to things that are potentially bad. It prevents us from seeing more of our experience, especially things that are good. It also takes away the energy and focus that we could direct toward living our lives. Hypervigilance also keeps us wary of normal sensations and circumstances that are typically neutral, and that can be an endless number of sensations.
Another major concept in the progression from an occasional panic attack to panic disorder is avoidance. We will naturally avoid certain things in our outer and inner environments that tend to trigger our anxiety symptoms. For example, coffee, hangovers, exercise, being hot, standing up too fast and getting dizzy, are all things that can remind us of panic and are commonly avoided by panic sufferers. For instance, you might decide not to exercise or avoid outdoor concerts because you might feel hot or flushed.
I remember planes were a big issue for me. For years, I carried a Xanax with me on trips. It got to the point that I considered avoiding my trips because of it and I know of many people whose lives are limited because of this.
We will avoid things that might make us feel anxious and might lead to a panic attack. That doesn’t sound like a bad idea but actually causes problems.
Do you see the trap here? If we avoid these things we are not living our lives to their fullest. This pattern of avoidance feeds off of itself and is self-reinforcing. The more we avoid, the more we will continue to avoid.
We keep pulling back in our lives because we don’t want to feel panic. The panic starts to dominate. Instead of focusing on things that we care about we focus on how to prevent ourselves from experiencing panic symptoms.
This process where avoidance makes the panic worse is fueled by something called negative reinforcement. It is a form of learning in which we increase behaviors that result in the removal of an unwanted stimulus. It occurs all the time and often without our awareness.
In the case of panic, our acts of avoidance temporarily reduce our anxiety and gives us a false sense of safety. The relief we get from the reduction of anxiety then prompts us to increase the avoidance behavior. This phenomenon can spiral downward to the point where someone no longer leaves the house, a condition called “Agoraphobia”. It is not common but is an extreme example of the vortex of panic disorder, which is fueled by negative reinforcement.
The other problem is that this spiral interacts with our perceptions of ourselves, our beliefs about our lives, and who we are. It can lead us to come up with a narrative about how we operate in the world.
For instance, “I am a person who can not ride on airplanes and who, therefore, is limited in my achievements or ability to explore the world”.
Panic disorder can also lead to depression because of many of the things I have talked about today. It leads to a sense of helplessness and hopelessness and the idea that we just can’t handle things. The world is too much for us. This is a false narrative.
Safety behaviors are behaviors that make us feel that we can not handle panic. For instance, a person that accompanies us everywhere, or medications.
For example, carrying around Xanax just to feel secure. Again, this was me at one point. I would tell myself that if I got anxious I would be ok as long as I had my Xanax. This interfered with my ability to believe that the anxiety was acceptable and that I could tolerate it. If I have Xanax I am ok, if I don’t I’m in big trouble.
But if this sounds like you, I’m not asking you to give up this safety net right now. I’m not trying to say you should never use meds. This is a complex topic and I don’t want to simplify. Sometimes meds help you to do the work that you need to get better. My point is that we should be careful to resort to them or to over-rely on them as a long-term solution. In my program, I will help you work toward letting go of them.
Thank you again for joining me. The purpose of this information was not to scare you about what could happen, but to educate you. I believe that knowledge is one of the keys to psychological freedom.
Panic attacks feel awful, there’s just no getting around it. However, knowledge is power. The good news is that there are a number of ways that you can learn to reduce your panic symptoms and the cycle that is involved.
In my online community, Hello Panic, I focus on educating people about panic so it is no longer the monster in the dark. In a twist that goes against instinct and much of our medical model, I believe that what actually changes panic for good is to stop fighting it. Rather, we can benefit from getting to know it, and by saying “hello” to panic.
Best wishes to you on your panic journey, and I hope to hear from you soon!