HealthyGamerGG - What Do You Do When You Have a Panic Attack

Episode Date: July 24, 2022

Dr. K dives into dealing with panic attacks, their mechanisms, their broader implications, and more! Support this podcast at — https://redcircle.com/healthygamergg/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy Learn more about your ad choices. Visit megaphone.fm/adchoices

What really impairs our function is not the original issue. It's the way that we adapt to the issue. We're going to talk a little bit about panic attacks. So if you all have seen Dr. Kay's Guide to Anxiety, you know that we have a video on panic attacks. But generally speaking, we talk a lot more about anxiety than panic attacks. So what I'd love to do today is to talk to you all a little bit about panic attacks. and a couple of key things about panic attacks, okay? So has anyone else been mostly fine their whole life,

then randomly got a panic attack as an adult, and haven't been the same since? Just wondering. I'm 25, and I used to be able to live a perfectly normal life. Then I had what I believe was my first panic attack two months ago. The first month was so hard I didn't want to leave the house at all. I struggled to even get out of bed. This month I'm getting better and slowly getting back.

to normal. My anxiety symptoms persist, muscle weakness, heavy arms and legs randomly, and I get blood rushing to my head for no apparent reason. I'm not even sure if it is anxiety, but it's been two months and I'm still alive. I'm having trouble believing my symptoms are just anxiety. I also find it hard to believe anxiety and panic like this could onset at my age. So this is a really important post because, and the reason we're talking about panic attacks is because there's a lot of stuff that people don't understand about panic attacks. The first is that we assume that panic attacks and anxiety are related. Right. So there's sort of this idea that like, okay, if I have panic attacks, I should go see a psychiatrist. It's a mental health issue. If it's a mental health issue,

that must mean that it involves my mind. And this is what confuses a lot of people who have panic attacks because they assume that the origin of the panic attack is mental in nature. And then as you start, the more perplexing thing is that sometimes, like, you know, you'll see something like this where people are like, I'm not even sure if it's anxiety because I'm not even anxious particularly. Like, I don't have any particular fears. It's like a random, like I'm living a perfectly normal life and then suddenly I had a panic attack. And then I have all these weird crap going on with my physical body.

And like, it just doesn't feel mental. It doesn't feel like anxiety. And so what I'd love to do today is talk to you all a little bit about how that is absolutely what a panic attack and panic disorder is like. So the first thing to understand is that panic attacks are a symptom. They're not a diagnosis. So it's kind of like fever, right? So this is another example of a symptom.

So what causes fever? Well, COVID could cause fever. cancer could cause fever, you know, strep infection could cause fever, pneumonia could cause fever, staff infection in the skin could cause fever, all kinds of things can cause fever. It's a symptom. Now, the most common source of panic attacks is a diagnosis called panic disorder. Now, a diagnosis is like an etiology, so it's like a source of a problem. So if we take a diagnosis like COVID infection, this is going to create fever. it's going to create shortness of breath.

It's going to create maybe changes on your x-ray. It's going to create, you know, runny nose. So it's like a constellation of symptoms that all are caused by one thing. Now, the interesting thing is that pneumonia can also cause all of these changes, right? And you can have a COVID-related pneumonia. So that gets a little bit more complicated. But do you all sort of get how, oh, whoops, let me move this, do you all sort of get how there's a difference between a symptom and a diagnosis? And there are a couple of key features

to the diagnosis of panic disorder, which a lot of people don't really realize, but it's actually quite elucidating. So when someone has a panic attack, what is the primary experience of the panic attack? So the first thing to understand about the primary experience of the panic attack is that it's predominantly physiologic. So people oftentimes have elevated heart rate, so their heart is beating super fast. They'll have difficulty breathing, so they'll get shortness of breath. They'll have nausea. They'll get sweaty.

They'll get muscle tension or shakes. So it's a very physical thing. It feels like something is wrong with you physically. And what this actually does is this. results in a sense of impending doom. So when people, when someone has a panic attack, instead of asking them, what are your deep, dark fears? Instead of approaching it psychologically, oftentimes what I'll ask him is like, did it feel

like you were straight up going to die? Did it absolutely, like, did you feel like you were going to die? And like the world was like ending? And then they'll oftentimes, if they have a real panic attack, they'll say yes. Whereas if it's more like, you know, anxiety related oddly enough, that may not actually be a panic attack. So this is the first thing to understand. If you've got a panic attack,

is it's very physiologic in nature. Okay? So now that we know that, what we're going to do is talk a little bit about panic disorder, and then what we're going to do is look at some of the mechanisms through which this happens, and then we're going to tell you all what to do about it. Okay?

So the interesting thing about panic disorder is that in order to be diagnosed with panic disorder, you need one really important feature. and that is adjusting your behavior or a persistent fear of future panic attacks. So this is really important to understand. Oftentimes what causes us problems in life, what really impairs our function, is not the original issue. It's the way that we adapt to the issue. and what we see in panic disorder is not just the panic attack.

What really cripples people in panic disorder is not actually the panic attack. It's the fear of the future panic attack. So a good example of this is something that people call agoraphobia. What is agoraphobia? It's fear of leaving the house, fear of going outside. This is truly what's debilitating about panic disorder. It's not the panic attack itself. It's the fact that what will.

happen if I have a panic attack at work? What will happen if I have a panic attack at the movies? So what people end up doing is they stop going to the movies. They stop going to work. Right? You don't even have to be necessarily agoraphobic, like even if you're okay with like going to the grocery store and leaving the house and you enjoy going for walks. But what I tend to to find people at panic disorder is that they come up with like contingency plans for if they have a panic attack. So it's like, okay, I'm willing to go to a restaurant, but like only a restaurant that has three stalls in the bathroom. And I'll be like, why do you need to go to a restaurant that has three stalls in the bathroom? They're like, well, I recognize that oftentimes one stall may be

occupied. And in some cases, like, you know, if one stall is occupied and someone else goes in, the second stall will be occupied. But I absolutely need access to a bathroom stall if I have a panic attack because I need to hunker down for like 20 minutes there. So the only restaurants I'll go to are the ones that have three stalls. Or I need some kind of safe escape. This is really common for people have panic disorder. They need to know how to get out of a situation if they have a panic attack. Okay. So the key thing here is that if we look at like a lot of what causes us problems, it's not the original insult. It's the consequences of the insult or the adaptation. We also see this, for example, in like the dating world, right? So if I have a bad experience with a particular person,

I can generalize things about that person. So I can generalize things about their gender. Oh, this gender can't be trusted. This gender is cruel. I can generalize things about the race or their ethnicity. I'll never date this race or ethnic of a person again or this kind of ethnicity again because all of the people of that race or ethnicity are like this. It's not just the original problem in the date, it's the adaptation that we make to our negative experience, which actually causes us problems. So a key feature of panic disorder is actually adjusting your behavior or a persistent fear of future panic attacks. Okay. Now what we're going to do is talk a little bit about the mechanisms of panic attacks. And this will also set us up for what you can do about

panic attacks. So, the first thing to understand is that we tend to get signals. So these are things like heart rate, blood pressure, sweatiness, nausea, shortness of breath, things like this. We get these physiologic signals. And then our brain is trying to interpret these signals. Because it's like, if I'm just like, if I'm 25 years old and I'm healthy, and I just, every organ in my body starts like getting messed up. Like my heart is pounding in my chest. I can't

breathe. I feel like vomiting. I'm shaking. It's like what on earth is going on? Then what happens is there's an interpretation. And then there's a conclusion. I'm dying. And then what there is is based on that traumatic experience, there's an adaptation. Does that make sense? Now if we look at things like therapy, like psychotherapy, psychotherapy really works here and potentially here, but it doesn't actually work here, oftentimes. So let's try to understand a little bit about what we know about this right here and what we can do about that.

So there are a couple of really interesting things. The first is that we know that there's an interesting hypothesis. that we have a suffocation reflex. So when we start to suffocate, so if someone's like choking me or like I'm drowning or something like that, there's a reflex, a very strong survival mechanism that activates. And we have this kind of suffocation reflex. So the suffocation reflex is going to activate,

cause all kinds of changes to our amygdala, also cause physiological changes, like adrenaline rush. And then this in turn will lead to things like heart rate, increased respiratory rate, right? Shortness of breath, all that kind of stuff. Now, the interesting thing about the amygdala, so this is our fear center of the brain,

is that the amygdala also has an apnic response. So apnea is the cessation of breathing. So when we're very, very scared, right? I don't know if you all have ever seen like videos of like animals on the hunt or whatever. When we're terrified, what happens to our breathing? We freeze. So what activation of the amygdala can do is actually make, like, alter our respiratory rate

and actually make us stop breathing, which in turn will increase our CO2 and will cause a hyperventilation consistent with a panic attack. So what's going on in a panic attack? I suspect, so there's a data to support this, but we don't really know 100%. That a panic attack is actually physiologic in origin. And what you actually get is an inappropriate activation of your suffocation reflex. So sometimes something happens and like this reflex, this survival reflex turns on without it's supposed to be turned on. And so then we get this adrenaline rush that explains all these symptoms.

we also get activation of the amygdala, which gives us a sense of fear, right, which then turns into these thoughts like I'm dying, and then also triggers this whole cascade, which affects our respiratory rate, which in turn ends up affecting this. And by the way, this all the way goes back over here, and then we get our panic attack. Does that make sense? So the key thing to understand if you've got panic attacks is like oftentimes people think, and panic attacks think I'm dying or something's fundamentally wrong with me. And arguably, I mean, obviously if you're having a panic attack, there is something going on that's not supposed to be going on. But instead of having cancer or impending doom or things like that, chances are it's actually

just a misactivation of certain parts of your brain. That's the theory that I think has the best support behind it and also is consistent with what people actually experience. Okay? So in a sense, like, you'll be okay. But there's also treatment for this. Okay? So what should you do if you have a panic attack?

What do? The first thing. is that if you're actually having a panic attack, and if it's your first panic attack, I think it's completely appropriate to seek emergency medical services. This is completely appropriate. So in the U.S., you can actually call 911,

you can go to the emergency room. This is important to understand. So a panic attack, generally speaking, is not going to kill you. But emergency medical services are not just for things that are going to kill. you. Emergency medical services are for things that we don't know if this is going to kill us or not.

Does that make sense? Like, it's not your job as someone who's experiencing a panic attack to be able to differentiate between a cardiac arrhythmia, which could absolutely be lethal, and a panic attack. So I'm not trying to, you know, stress you all out here. What I'm saying is that if this is your first panic attack and you really don't know what's going on, or if you have another one, and you've never gotten diagnosed or something like that, you should absolutely seek emergency medical services. Because the important thing here, we'll get to this in a second.

And let's say the panic attack has passed and you didn't seek emergency services. What should you do the next day, the next couple days, things like that? You should absolutely seek a medical evaluation. And why do I say a medical evaluation instead of a psychiatric evaluation? So this is one of the things that I think is unfortunate

about the way that we train therapists is you may say, I'm having a panic attack, I need to go see a therapist. The problem is that there are all kinds of things that can cause these symptoms. And while a panic attack may be the most likely, there could be things like cardiac arrhythmias. So a cardiac arrhythmia is irregular activity of the heart, irregular electrical activity of the heart. And these can be transient. So you can get a heart that starts beating very, very fast when it's, you're going to

it's not supposed to, or when it beats or beats not properly. So it's kind of like, you know, the way that our heart beats, so our heart is kind of shaped like this, and it's filled with blood. And then what it starts doing is actually like it contracts from the bottom. And then it contracts higher and then it contracts higher. So that if you think about it, if I'm squeezing something from the bottom and the opening is at the top, what I'm actually going to do is facilitate. the flow out. But if I start squeezing from the top, that's not going to help things, you know,

blood leave the heart. It's actually going to push it downward. And then I start squeezing from the bottom and then like the heart doesn't empty appropriately. So arrhythmias can cause all kinds of weird things like this. There are also issues, for example, with thyroid. So if you're hyperthyroid, you can sort of get symptoms of a panic attack pretty easily sometimes. So the key thing for, the key reason for medical evaluation is that there may be medical causes to your quote unquote panic attack. That's why you need to go see a medical professional. And unfortunately, I have seen cases where people will go to therapists. The therapist, you know, if you're like a licensed clinical social worker, like,

you don't regularly order lab tests for your patients, right? Like you don't, you're not taught how to interpret lab tests. So hopefully what happens is a good therapist will say, by the way, have you gotten a medical evaluation? Why don't you talk to your primary care? physician or GP, and then, like, we can work on the panic stuff, but let's just make sure that it's not medical in origin. So a good therapist will do that. But you should get a medical evaluation, because the key thing here is I've had some patients with panic attacks who will, like, find a medical cause. And once we find a medical cause, they'll, like, fix the medical cause. So they'll start medication or maybe even have a procedure or something like that. And then

their panic attacks are, like, literally cured. Like, done. Never panic attack. for the rest of your life. You're fixed. So that's what's really important about getting medical evaluations, even if you have something like a panic attack. Now, a couple of other things to consider. So let's talk about psychotherapy. So this is where I think psychotherapy and medication

are equally effective, generally speaking. So if you look at effect sizes that compare the improvement from psychotherapy and medication, they tend to be about the same. So one isn't better than the other. But if we look at how psychotherapy works, I personally find psychotherapy to be very effective, especially at this adaptation step. So it's not just the panic attack itself.

It's the way that I have to account for the panic attack, that the way I adapt to it, the way that I maladapt to my panic attacks, the way that my panic attacks start controlling my life because I'm afraid of the panic attack. That is where psychotherapy can really, really do a lot of good work. because it can help you reclaim your life. It can help you notice what these adaptations are. It can help you conquer some of those maladaptations and hopefully start to live a pretty healthy life.

The other interesting thing is that psychotherapy, depending on what kind of psychotherapy you can do, you can stop this cognitive process of interpretation. So when I feel these signals, my mind interprets those signals and makes me conclude that I'm dying. And then this conclusion that I'm dying is going to create all kinds of other effects.

So stopping that interpretation can be very, very useful. Sort of understanding and coming to appreciate, oh, this is just a panic attack. It's my suffocation reflex inappropriately activating. It's amygdala hyperreactivity. I actually don't have too much to worry about. And interestingly enough, I know it sounds kind of weird. Can you just tell yourself that?

And that's where the therapy sort of helps you train skills to avoid cognitive mistakes. And it can help, absolutely. So there are medications for panic disorder. This is where, you know, a lot of people think and hope and unfortunately still prescribe things like benzodiazepines. And benzodiazepines can be effective for treating an individual panic attack. So things like Xanax or Alprazolam or Clonopin or Clonazepam. These are the benzodiazepine class of medications. They're basically work on the same receptors as alcohol can be highly addictive in habit forming.

These are not actually the best first-line treatment. The best first-line treatment is actually SSRIs or SNRIs. These are selective serotonin re-uptake. inhibitors, serotonin, norapinephrine re-uptake inhibitors. So these are medications that are also in the antidepressant class, and they seem to be pretty effective. Now, the interesting thing is a lot of people talk about breathing. So let's talk about breathing for a second.

So I'm a big fan of breathing. I teach a lot of brain I am. I'm all into like, oh, I'm Dr. Kay, and I love meditation and like, oh, like, let's learn meditation. Meditation is effective at reducing symptoms of panic disorder, by the way. The problem is that if you look at studies, if you look at meta-analyses of studies for breath training for panic disorder or panic attacks, it turns out that the evidence is average. It's not up, it's not down, it's kind of in the middle. So breathing, a lot of people may think that, so I personally have a certain interpretations of the literature, but if you look at it on the whole, breath training does not seem

to be a consistently effective intervention for panic attacks, which oftentimes is very confusing for people because when they have panic attacks, the vision that you have is someone breathing into a paper bag, right? So I personally still use breathing techniques for people who have panic disorder and panic attacks. I personally think that the problem with the research is that they'll call things breathing technique or breath training. But if you've studied things like Brown I.M. or Chi Gong or real yogic meditation breath techniques, you'll realize that they're wildly different. Right. So not all breath techniques are appropriate for panic attacks. The problem is that there's no uniformity in terms of what they call breath training.

So it's basically, if you do something with the breath, does it help panic attacks? And the answer is, generally speaking, we can't conclude that the answer is yes. So it doesn't mean no. It just means that there's variable responses. And I suspect that's because of the way that you do breath training really matters. There's good breath training and there's bad breath training. The problem is that the people who are doing the breath training aren't experts in like yogic science and don't understand. They're just like, oh, like, it's a meditation technique and like, oh, like, let's just use it.

And it turns out that I don't think that that's very effective. So I personally will still teach this stuff, and I see good clinical effect sizes. But if you look at the whole of the literature, it turns out that breath training is like a plus minus kind of intervention. It doesn't seem to be as consistently effective as psychotherapy or medication. And part of the advantages of something like medication is that it's standardized, right? Like, it's standardized. Whereas things like breath training or not.

So mindfulness or meditation does help, so you can definitely do that. But this is where, you know, I hate to break it to you, but if you're having a true panic attack or you have true panic disorder, sometimes like later on we're going to talk about, you know, things that will offer answers in a different kind of way. So this isn't medical advice, but this is just to explain that based on if someone were to ask me a general question, if I have a panic attack, what should I do? I'd say, go see your doctor. And that may be like a little bit of a disappointing answer, but sometimes that's actually the right answer. Right? Like I think talking about cognitive patterns and talking about this meditation and that meditation, it can help you in this way and that way. And that's like all good. Like I'm not saying that there aren't additional things that you can do. But part of the part of what I learned in medical school is that some of this like new agey kind of even like meditation and stuff, which I'm a huge fan of like sometimes it just doesn't work as consistently as some of this other like Western medical stuff. And we could talk about yoga and some scars in the mind and focusing. and all this kind of good stuff, but sometimes what you really need to do

is, like, go to the emergency room. Sometimes what you really need to do is, like, go talk to a doctor and get your thyroid checked. And if you're honestly asking me, like, if I had a family member who had a panic attack, what would I do?

If they were having a panic attack, I would send them to the emergency room. If they told me, hey, I had a panic attack yesterday, what would I do? I would say, hey, you should go see a doctor and, like, get yourself,

like, physically checked out. And then, after that, you know, we can explore some of these things like psychotherapy and medication. And then if you want to, you can try breathing techniques and you can try meditation and mindfulness. But it's really important to understand that these things should not be a substitute for these

things. Now, if you don't want to put medications in your body, that's totally fine. Then by all means, go do psychotherapy. Questions. Yeah, so Heron and Robin is saying deep, deep breathing didn't really work for me. It just made me more nauseous. You know, it's really unfortunate, but like, that is sometimes people's experience, right? Is it possible to frequently experience singles but never had a panic attack?

Very possible. I mean, all kinds of stuff is possible. That's where, you know, and that's where the mechanism is kind of important, right? We don't know if it's like the suffocation reflex or there's some amount of amygdala hyperreactivity. So if someone is already using SSRIs, do they have a lesser chance of a panic attack? I would guess that the answer to that question is yes. Can a panic attack make you feel like you're having a heart attack, like big chest pain? Absolutely.

So isn't Bellow's Breath, Breath of Fire completely shallow? I've had great success with it. Yeah, so this is where there's a lot of nuance to the technique that we use. So let's talk about Bellow's Breath or Breath of Fire. So for those of y'all that don't know these techniques, they're in Dr. K's Guide. You may be able to find them on YouTube as well because I think we've taught both of those on stream before. So the key thing about Bellow's breath and breath of fire is that what you're actually doing is hyperventilate. to become hypocapnic.

So when you increase your respiratory rate, you drop your CO2 level. And when your CO2 level drops really, really low, what that forces your body to do, or not force, but what it sends your signals to your body to do is actually breathe slowly. So then it's like, wait a second, our CO2 level is too low. Let's slow down our respiratory rate to get our CO2 level back up. and as you have that physiologic suppression of the respiratory drive and your rate of breathing goes down, you're taking like two breaths a minute, three breaths a minute, that is incredibly relaxing.

Someone else is asking, so you're saying that the literature lacks technical specificity with brown I am 100%. That's a great way to put it. So we're starting to see this where now people are doing studies on something called cardioresum cardiac coherence breathing. Cardiac coherence breathing is not eshudi pranayam. They just call it a different thing. Right? And then they say, oh, cardiac coherence breathing is effective at all these kinds of things.

But then people will continue to say, oh, pranayem is like alternative medicine. Right? It's, and so I hope that we can sort of continue to move things in that direction where we test these different kinds of bronyam and start to see different, different, different physiologic effects and treatment benefits. So how do you help a friend who's having a panic attack in the moment? You get them to emergency medical services and make sure that it's not something more serious. What do I do if I'm at the point?

If I have agoraphobia already? Great question. That's why you need to see a therapist. Right? So the process of overcoming that agoraphobia is absolutely something that a therapist can help you with. So Shadow 7578 is asking if I feel like my heart is actually skisketing. skipping a beat and my breath gets heavy, but in 15 seconds I'm fine, is that a panic attack? So that's the kind of thing where, like, that you need a medical evaluation for that, right?

So here I am educating y'all about the specifics of panic attacks. But this is important to understand. If you have a particular constellation of stuff, I don't know what that is. Because in order to confidently answer that, I would actually need to do a medical evaluation on you, right? I would need to ask you a bunch of questions. Like, how often does it happen? What happens? What happens to your heart rate?

Let's check your... Like, in order to answer that question, I would check your thyroid. I would also potentially send you for, you know, a general practitioner evaluation, maybe get something like an EKG. I don't think EKG is super appropriate in that situation. My point is that the more specific your question is, hey, Dr. K, I have this constellation of weird things. What is it?

That's exactly why you should go see a medical doctor. because the information that you're giving me may not be the relevant information and figuring out what it is. That's why doctors ask a bunch of questions. So Marmalade is asking, would you agree that expiration is what makes breathing relaxing? I personally only feel better when I focus on breathing out instead of in. So it's not partially true. The key thing is that the length of exhalation, generally speaking, correlates with the degree of relaxation. So it's not just exhalation.

Chances are, since you're focusing on exhalation, what you're really doing is slowing down your exhalation. Because when you focus on your breathing, you tend to slow it down. And as you slow it down, chances are you start to feel more relaxed. Do I have a paper on cardiac coherence breathing? I mean, you can just search for it, but cardiac coherence, it's not about, so people will do studies like on particular conditions, right? Does that make sense? So there are, I mean, there may be papers on just straight cardiac coherence breathing, but usually what people are doing is it's like cardiac coherence breathing for PTSD,

if that makes sense. But I don't have a particular study on hand. Is there a difference between an anxiety attack and a panic attack? Are they synonymous? Anxiety attack is not a medical term. Panic attack is a medical term. So I generally think of them in the, common usage is synonymous.

When someone says, and that's why like, when someone says I had an anxiety attack, that's where I will assess them, right? So I'll do a clinical assessment. I'll ask them, what did you feel? When did it start? How long did it last? How do you feel now? Has it happened before?

And then I'll determine whether something called an anxiety attack was a true panic attack or not. Okay. Yeah. So Maluka is saying three years ago, I had a series of panic attacks and I didn't know what they were, now I'm kind of in fear of having another one. I think I should see a therapist for that. I think you should too.

Saco 5 is saying, I've only reached a no-mind state once now. I'm trying to reach it a second time. It's way harder. Any tips? Yeah. So the funny thing about meditation is the first no-mind state you reach is easier than the second. The second is actually the hardest.

The reason that the second no-mind state is harder than the first no-mind state is now you have an expectation of the no-mind state. And so since you're looking for the no-mind state, your mind remains active because it's wanting a no-mind state. Right. Does that make sense? It's like you stumble upon something. And so the reason it's easy to stumble on it the first time is because you have no expectation of it. Now that you have an expectation, that expectation exists within the mind and is like harder to let go. So what you have to do is stop looking for the no-mind state in meditation. And then you'll find it again.