Why Am I Having Panic Attacks?

When someone comes to see me because they are having panic attacks, one of the first things I do is explain to them what a panic attack is.

What happens during a panic attack is that your brain makes a catastrophic misinterpretation of otherwise ordinary signals. Those signals come through the vagus nerve complex from your gut, heart, and lungs, although they can also come from your thoughts. Your brain may pick up on excitement, nervousness, being out of breath, an elevated heart rate, a release of adrenaline, or some other physical sensation and misinterpret it as evidence that you are under threat, that you are being attacked, or that something very bad is happening.

That activates the amygdala and sends the body into fight or flight. At that point, you are experiencing panic.

The Panic Response Happens Before Logic

The part of the brain involved in this process is very primitive. The amygdala and the rest of the limbic system evolved to respond instinctively to danger. It takes in information from our senses and allows us to act immediately, before the logical part of the brain has had time to assess what is actually going on.

That is extremely useful when there is an actual threat. We don't want to have to logically analyze whether we should jump out of the way of a moving car before our body responds. The system is designed to respond first and ask questions later.

The problem with a panic attack is that the alarm is being activated when there isn't an immediate threat.

This can happen for a number of reasons. It can happen because of trauma in the past. It can happen because someone has had a previous panic attack and has become hypervigilant for the next one. It can also happen because someone has inherited a predisposition to panic. There isn't one explanation that applies to everyone.

Why Panic Attacks Feel So Convincing

It is very common for people having panic attacks to believe that they are dying, having a heart attack or stroke, losing their mind, or losing control.

Even after someone has experienced a panic attack, been medically evaluated, and been told that their heart is fine, the next panic attack can convince them that this time is different. Between panic attacks, they know there is nothing physically wrong with them. In the middle of one, the fear tricks them into believing, “No, this time I'm actually dying.”

That doesn't mean they're crazy. The fear of dying, losing control, or losing one's mind is something that almost everyone who has regular panic attacks struggles with.

When Panic Attacks Become Panic Disorder

Panic attacks can develop into panic disorder when the fear of having another panic attack paradoxically begins to produce more panic attacks. After someone has experienced a frightening panic attack, they may become hypervigilant for signs that another one is beginning. They begin monitoring their heart rate, their breathing, sensations in their stomach, or other changes in their body.

The problem is that this hypervigilance itself creates anxiety and makes ordinary physical sensations seem more significant. The person notices a change in their breathing or heart rate, interprets it as the beginning of another panic attack, becomes frightened, and that fear produces more of the very sensations they were monitoring. The fear of another panic attack can therefore become part of what perpetuates the cycle.

Why Are You Having Panic Attacks?

Knowing how a panic attack happens is only part of the answer. I also want to understand why this particular person is having them.

Earlier in my career, when I first learned the catastrophic-misinterpretation model of panic, I made the mistake of assuming that treating the panic response itself was the answer. The conventional Cognitive Behavioral Therapy approach frequently uses something called interoceptive exposure. We deliberately reproduce some of the physical sensations associated with panic so that the brain can learn that the sensation itself isn't dangerous.

For example, if someone becomes frightened when they feel short of breath, we might deliberately produce that sensation. If dizziness triggers panic, we can deliberately produce dizziness. Interoceptive exposure can be very useful.

What I learned, however, was that it was often a mistake to jump immediately to the assumption that this was all the person needed.

When I put aside the immediate fix and simply engaged in good interviewing—getting to know the person and helping them talk about what was happening in their life—I often found emotional and situational conditions behind the panic attacks.

Sometimes Feeling Trapped Means You Feel Trapped

Someone may tell me that when they panic, they have an overwhelming feeling that they need to escape. As we begin talking about their life, we may discover that they really do want to escape.

Perhaps they feel trapped in a marriage they don't want to be in, but they have children, financial obligations, or are financially dependent on their spouse. Another person may be facing a decision where there is no easy answer. No matter what they choose, there will be a negative consequence.

They feel trapped because, in an important way, they are trapped.

That doesn't mean every panic attack has some hidden psychological meaning. It doesn't. Panic attacks can occur for many reasons. But before assuming that the entire problem is simply a brain that has learned to fear physical sensations, I want to know the person.

I want to know what is happening in their life now, and I also want some understanding of their history. Usually within the first few sessions, I ask for at least a brief narrative history of their life. Sometimes I tell people, “Just humor me. Tell me the story of your life.”

There may be nothing in the past that directly explains the panic attacks. Most of the time, however, there is something relevant. Either way, if I don't know your past, I don't really know you, and I may miss something important.

Treating Panic Attacks

The treatment depends on what we find.

For some people, interoceptive exposure and other Cognitive Behavioral Therapy interventions are very effective. We can teach the brain that an elevated heart rate, shortness of breath, dizziness, or a sensation in the stomach is simply a sensation and not evidence of catastrophe.

For other people, we need to address the trauma, emotional conflict, or life circumstances that are contributing to the panic. Sometimes, once people feel heard and understood, feel less trapped, or begin making meaningful movement in their lives, the panic attacks begin to resolve.