Anxiety Disorders cont., / Panic Attacks, Panic Disorder

This is a continuation of yesterday’s post – Diagnosis and Management of Anxiety Disorders, by Charles Shelton, Doctor of Osteopathy. Dr Shelton is a national speaker on the visiting speakers bureau of Wyeth Pharmaceuticals. He is also on the speakers bureaus of GlaxoSmithKline; Pfizer Inc; Cephalon, Inc; and Bristol-Myers Squibb Company. Dr Shelton is also on the CNS advisory panels of Pfizer Inc and Elan Pharmaceuticals.

I’m using this article for reference because Dr. Shelton is obviously thoroughly embedded in the “Big Pharma” industry. I’m not concerned here with the wildly predatory “business” model of pharmaceuticals, but with the “drugs” that are “recommended” for treatment. Drug manufacturers are more conservative about which medications should – should not be prescribed for specific conditions than are many prescribers! Instructions and warnings are included with medications, which are so “legally protective” that reading them is often skipped – by prescribers! They go by what the drug sales rep. tells them; it’s an incredibly careless system; a crap shoot that depends on the integrity of your prescriber.

I’m not giving “medical advice” but clarifying some pitfalls in the “game” of American healthcare, based on a lifetime of experience with the “mental” healthcare system.

WARNING: Your prescriber may be ignorant of drug “chemistry” – side effects, conflicts between different drugs when taken together, or may simply be “pill happy” – the “try this” scenario of passing out pharmaceutical samples and adding more, more, more drugs. Do not trust a “randomly-assigned” prescriber – always read the side effects and other warnings: ask THE PHARMACIST about the drug’s potential for harm and any other concerns.

Back to the article:

“In general, individuals with PD may see up to ten practitioners before a correct diagnosis is made, have continuous increases in health care utilization spanning 10 years before diagnosis, and have a 5 to 8 times greater likelihood of being high users of health care.”

Now that’s a great confidence-producing set of statistics! What arrogance to claim that this dismal record indicates “expert” knowledge on the part of the psychology-psychiatry-therapy healthcare system.

Panic Attacks

Figure 1. Agents used in pharmacotherapy for panic disorder.

As discussed, panic attacks, defined as discrete periods of sudden symptom onset usually peaking in 10 minutes, can occur with most anxiety disorders.

The DSM-IV-TR criteria for panic attack are as follows: palpitations, pounding heart, or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath or smothering; feeling of choking; chest pain or discomfort; nausea or abdominal distress; feeling dizzy, unsteady, lightheaded, or faint; derealization (feelings of unreality) or depersonalization (being detached); fear of losing control or going crazy; fear of dying; paresthesias; chills or hot flushes; one or more unexpected panic attacks. (?)

A “PA” is a single event; it may have one of many “causes” and occur only once or infrequently. To be a disorder, it must meet criteria below. One attack does not constitute a disorder. It is always a good idea to be checked out by a MEDICAL doctor first, to rule out a physical condition before consulting a “therapist” of unknown quality.

Panic disorder: at least 1 month of worry, including change in cognition or behavior;     presence or absence of agoraphobia; or attacks not accounted for by another mental disorder, or general medical condition. That’s pretty vague! It’s obvious HOW EASY it is for a “potential patient or client” to meet the requirements and to be diagnosed – a real profit bonus for “assembly line” type therapists and clinics!

Panic attacks must be differentiated from PD. Panic disorder as defined by the DSM-IV-TR includes: recurrent unexpected panic attacks; and at least one of the attacks has been followed by 1 month (or more) of one or more of the following:

persistent concern about having additional attacks; worry about the implications of the attacks or their consequences (eg, losing control, having a heart attack, going crazy); or a significant change in behavior related to the attacks.

In general, individuals with PD may see up to ten practitioners before a correct diagnosis is made, have continuous increases in health care utilization spanning 10 years before diagnosis, and have a 5 to 8 times greater likelihood of being high users of health care.

Now that’s a great confidence-producing set of statistics! What arrogance to claim that this dismal record indicates “expert” knowledge on the part of the healthcare system.


What really is a “panic attack”? It’s the activation of the “fight, flight or freeze” response. 

Myriad papers and articles about panic attacks are fairly repetitive:

1. There is no “real danger” present in the environment (at the time of that attack) that would justify the “extreme or “over” reaction.

2. Therefore, the PA is an abnormal event. The trigger is a memory of a prior experience with similar conditions (crowds, etc) that has “taken over” the response by the fight, flight freeze system. “Phobia”.

3. The PA is “illegitimate” given the benign circumstances that “actually” exist at the time of the PA.

4. The FFF system will shut down and return to “normal” in 10 minutes, so don’t “panic”!

5. Underlying these assumptions is the “belief” that the FFF response is an “animal thing” – that is, designed for wild environments and encounters between predator and prey. It’s “archaic” in essence; not suited to “modern life” but resurrected if a person is in “real danger” – a physical attack, natural disaster, an accident. Otherwise, the modern “environment” is safe, benign, non-threatening. HAH!

6. The descriptions are subtly judgmental: WOMEN are more likely to experience PA and anxiety than men, therefore the “cause” must be the unstable female psyche! (Hormones) Her system is “broken” – abnormal or damaged, which is a traditional view of “being female”.

Well! What does this indicate? Conditions that were “present” during a traumatic experience (example: a child being locked in a closet as punishment for “bad behavior” in a social situation) are not “imaginary” – confronting similar conditions (a crowded  event in which “good behavior” is a social requirement) are not imaginary: this is a normal fight, flight or freeze function. If a prey animal “survives” a predation event by the automatic physiological response of “OMG! I’m gonna die – run like Hell” OF COURSE it will “remember” the situation; it learns by the experience. If it simply “forgot” the experience, it probably would not survive for long. This is unconscious  processing: it’s the same in humans. These deep survival mechanisms did not go away because in our “imagination” we are no longer “truly animals” but live in wonderful cities and suburbs safe from natural consequences.

Why women? Because females are prey animals: females are “trapped” as the objects of sexual predation, violence and psychological imprisonment in “belief systems” that classify females as “lesser beings.” Females must repress “survival” behavior in order to survive.

Any child who has been traumatized by a single “life-threatening” event, or subjected to chronic abuse, is a candidate for ANXIETY which is the anticipation of both the horrible event reoccurring and the physical response of fight, flight or freeze, which is a frightening physical response. “Life and Death”

Telling a person who has a “panic attack” that it’s not real, or serious, or that it’s all in the mind, or that it will “go away” in ten minutes, or that they are being “a baby” or that they are weak, or are a “social embarrassment” is cruel. Saying these things in effect devalues the original trauma as “unimportant or imaginary” – telling him or her that they ARE CRAZY. This is stimulus for more anxiety and painful behavior.

Underlying the very high rates of “pathology” in American culture is the principle belief in, and unshakeable use of, punishment for any and all “social disobedience”  – from serious crime to the crime of simply being “a child.” Brutality, whether or not it’s physical or psychological, is held to be an “American Virtue”.

Researchers can fiddle with “the brain” AFTER THE FACT that the developing child brain has been compromised by maltreatment during pregnancy, premature birth, horrific medical intervention, abusive parents, malnourishment or neglect, or the prevalent (although denied) guidepost of spare the rod, spoil the child –  but this is madness: the origin of “disorder” is the diehard belief that brutality “toughens people” “produces superior individuals” especially males, and that life is a competition for “promoting one’s DNA”. This perversion means that only predators “win” –

Whoopee! More hypotheses, more studies, more verbiage, more funding, more denial that human on human predation causes damage to individuals, societies and the degeneration of Homo sapiens as a viable species.

A paper that flogs the obvious: Hyperventilation accompanies and exacerbates panic attacks.

Respir Physiol Neurobiol. 2009 May 30;167(1):133-43. doi: 10.1016/j.resp.2008.07.011. Epub 2008 Jul 25.

Panic disorder and control of breathing.


Anxiety disorders, particularly panic disorder (PD), are associated with respiratory abnormalities. PD consists of unexpected panic attacks (PA) with anxiety, fear and many autonomic and respiratory symptoms. There is a substantial body of literature demonstrating that stimulation of respiration is a common event in panic disorder patients during PA. A number of abnormalities in respiration, such as enhanced CO(2) sensitivity, have been detected in PD patients. As a result, some investigators advanced that there is a fundamental abnormality in the physiological mechanisms that control breathing in PD. Studies indicate that PD patients with dominant respiratory symptoms are particularly sensitive to respiratory tests compared with those who do not manifest dominant respiratory symptoms, possibly representing a distinct subtype. Accumulated evidence suggests that respiratory physiology remains normal in PD patients and that their tendency to hyperventilate and to react with panic to respiratory stimulants like CO(2) represents the triggering of a hypersensitive fear network. However, some recent evidences support the presence of subclinical abnormalities in respiration and other functions related to body homeostasis. The fear network, composed by the hippocampus, the medial prefrontal cortex, the amygdala and its brainstem projections, may be abnormally sensitive in PD patients. This theory might explain why both medication and psychosocial therapies are clearly effective. The evidence of abnormalities in several neurochemical systems might be just the expression of the complex interactions among brain circuits. Our aim was to review the relationship between respiration and panic disorder, addressing the respiratory subtype of panic disorder, the hyperventilation syndrome, the respiratory challenge tests, the current mechanistic concepts and the pharmacological implications.




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