Episode 6: This is Panic Disorder

00:00:01

Annette: Hi, Dr. McIntosh. This is Annette. I’m sorry to call you, but there’s something wrong. I’d wake up at night. My heart would be pounding so hard against my chest and it was racing so hard that I thought I was having a heart attack.

00:00:24

Dr. Diane McIntosh: A racing pounding heart. Pressure in your chest that feels like you’re having a heart attack. Sudden uncontrollable, unexpected peaks of terror. This is a panic attack, but for Annette, it was just the start of a journey into the unknown world of panic. So let’s dig deeper into what panic is its causes, how it’s diagnosed, and the best way to approach treatment.

I’m Dr. Diane McIntosh and you’re listening to PSYCHEDUP. On this show, each episode will focus on one mental illness.

Today it’s panic attacks and panic disorder. As a psychiatrist, I want anyone experiencing any of these illnesses to be able to hear these stories and know there is a path ahead. My goal is to educate, de- stigmatize and inspire. Welcome to PSYCHEDUP.

Anxiety is pretty ubiquitous. We all have experienced anxiety, but sometimes it’s kind of challenging to figure out what is normal worry and what is pathological anxiety. I tend to think about it like this: say there’s a barking dog and it’s charging at us with its teeth bared. Being afraid of that dog, that’s normal. Our brain innately knows that dog could hurt us. Seeing and hearing an angry dog racing towards us triggers the fear center of our brain, the amygdala, which recognizes this is an emergency and kicks into action, starting a series of brain events that helps us to react quickly and effectively to the danger. It’s called the fight or flight response. The amygdala reacts to the fear by increasing our heart rate, increasing our blood pressure, moving blood to where it’s needed most, fueling our muscles to react. Our senses become more acute so we can focus on the danger and take evasive of action.

When we’re facing a threatening situation, the amygdala provokes our brain to release cortisol, which helps us to manage the situation and get back to normal as quickly as possible. But pathological anxiety is different. It’s fear gone wrong because it’s fear of something that’s vague. It’s imprecise or unknown. Pathological anxiety includes all of the same brain structures and brain chemicals as normal fear, but when it becomes chronic, the amygdala is constantly screaming, “This is an emergency,” even when it’s not an emergency. Eventually the cortisol that used to be able to help get the brain back to normal starts to damage the brain, harming and even destroying brain cells. This is Annette. I think we can learn a lot about panic from her.

00:03:10

Annette: The first time I had, which what I realized now to be a panic attack, was during the year that my brother had been between being diagnosed and when he passed away. This was my younger brother. He and I were very close and he was diagnosed when he was 43 with stage four colorectal cancer. It just tipped everything upside down, and my reaction to that was, “Okay, we’ve got to stay strong. I got to stay strong. The family is devastated, but we have to stay positive. Let’s just carry on,” and that’s what I did, except I’d wake up at night, my heart would be pounding so hard against my chest and it was racing so hard that I thought I was having a heart attack. I thought my whole issue was I can’t sleep. Once I can sleep, I’ll be fine again. But I couldn’t sleep. In my mind and my anxiety because it had gone amok. I was convinced I was going to die.

00:04:27

Dr. Diane McIntosh: It was awful. These panic or anxiety attacks are sudden, intense and terrifying experiences. So terrifying in fact that they’re commonly associated with thoughts, like I’m going to die, I’m going crazy, and like Annette, I’m having a heart attack. This fear of imminent death is not surprising because panic attacks are also associated with physical symptoms that can mimic serious health problems like a racing heart or chest pain or shortness of breath just to name a few. The fear associated with panic surges really quickly, peaks in a matter of minutes and then slowly resolves over time. I’ve had patients who told me they had panic attacks that last for days. Really, that’s not a panic attack. That’s a very high level of sustained anxiety because that panic attack is defined by a very sudden peak of terror, usually peaking within 10 minutes and then slowly coming down the other side. However, the impact of panic, that can definitely linger sometimes for days, sometimes much longer.

00:05:37

Annette: I was powerless to get up or wake my husband up and say, “I think I need to go to the hospital.” There was almost a part of me that was kind of like, I’m tired and I’m so overwhelmed right now that maybe if I do have a heart attack, it’s okay. And I mean, that’s how flawed your thinking becomes.

00:06:00

Dr. Diane McIntosh: Thankfully, Annette was not having a heart attack, but she did have panic attacks and while she made it through that night, the symptoms kept coming.

00:06:08

Annette: It became to the point where physically I started to break down. Even just standing, I know it’s hard to understand this perhaps if you haven’t experienced it, but it became to the point where I was exhausted, so exhausted that even taking a shower became this huge thing. I would crawl to my bathroom and it would take me an hour to shower just because it was like I had no energy whatsoever in my body. Other times it would be like I had a live wire in my body and I would just be so wired, is the word I just kept using. So I would walk and I would go and I would have a two-hour walk, and I’m not talking like a walk where you’re sauntering, I’m almost running because it’s like I’m trying to outrun this feeling. It was so uncomfortable and it was just like my whole body was vibrating. So I would seem to swing between the two things.

00:07:19

Dr. Diane McIntosh: But still, she tried to be strong.

00:07:22

Annette: You may think that what is wrong with my brain, and apparently that’s a part of it. When you experience anxiety and depression, your cognitive abilities are also compromised. And that scared me, and I just thought that if I ignored things and if I just got up every day and powered through, I would get to the other side and this would all go away. And eventually what happens is if you don’t address it, it is not going away and it just becomes a tipping point. And that’s what happened to me. I went to work and I couldn’t figure out how to turn on my laptop and I just sat there and I just broke down.

00:08:13

Dr. Diane McIntosh: Panic attacks can happen to anyone, but they usually occur in association with a psychiatric disorder. Maybe it’s PTSD, substance use disorder, or very commonly, with depression. Panic attacks can also happen in association with physical disorders, especially ones that affect your breathing or your heart rate or your balance. Panic disorder is an anxiety disorder that includes panic attacks, but the attacks must be recurrent and unexpected. That means that they come completely out of the blue. You could be relaxing, watching TV or even sleeping. Nothing scary is happening and suddenly you’re in a full panic.

And remember when I mentioned the impact of panic that it can definitely linger? Well, that’s what happens with panic disorder. After the panic attack fades away, the person is left with a persistent fear that they’ll have another panic attack or they’ll be afraid of the potential consequences of another attack. That leads to a whole host of issues. So how do we treat panic? Let’s dig in.

So as always, I’m here with my friend and colleague Dr. Randy Mackoff. Randy is a PhD psychologist and an expert in talk therapy while I, as a psychiatrist, tend to focus on prescribing medications for mental illness. Randy, thank you for being here.

00:09:38

Dr. Randy Mackoff: Well, thank you for having me here, Diane.

00:09:40

Dr. Diane McIntosh: So let’s dive into panic disorder. You also have a lot of experience treating patients who are struggling with panic attacks or panic disorder. What approach do you take if someone comes in and says, “I’ve got panic. I’m panicking. I have repeated panic attacks.”?

00:09:58

Dr. Randy Mackoff: Panic is one of those disorders that people often hide for a while, just like many disorders, because they really feel, and I hate to use the term, but this comes from the patients, that they’re going crazy, and it just doesn’t make sense because it comes out of nowhere and there’s a bit of embarrassment that many of my patients have experienced with this. So the person comes in and they’re talking about something that happened to them and their reaction to it. Their heart starts to pound. They felt like they were choking. They felt like they were outside their body. They felt that they were having a heart attack. They went to the emergency department because they were sure that they were dying, and the emergency department often they’ll say, “You just have panic,” which is very dismissive, and they send the person home and then they come into my office saying that the emergency room doc said I just have panic. What do I do with this?

So first thing I do is I say, “Hey, look. This is panic attack and panic attack has a biological component to it that you’re not just making this up, but the first thing I’d like you to do is I’d like you to go see your physician and in a non- emergency situation, have a medical with your physician so they can rule out anything that could be contributing to this.” 99. 99% of the time what comes back is that there’s nothing medical that’s contributing to this. My thyroid’s good, my heart’s good, everything is really good, so let’s do the psychological work. So that’s where we then take off from there.

And because one of the things is that people really need reassurance that there is nothing that is going to kill them from this because what’s happening is that they’re going into an emergency mode without a threat being there. But here they may be driving over a bridge, they may be in a grocery store, and all of a sudden it’s like they’re being attacked physically or that there’s some real threat when the threat is happening from within, and they’re perceiving the world as being dangerous in some way without it being aware of the cognitions.

00:11:49

Dr. Diane McIntosh: Your brain is actually messing with you. It’s actually hijacking and creating this fear response, and you’re sometimes feeling like, “That was the scariest thing that ever happened to me in my life. I got to avoid that situation because if I ever go back to that grocery store or over that bridge,” or whatever situation that may have provoked the first or the second one, then that reinforces the fear. Then the grocery store does become scary. And I think that’s a lot of the work you do in CBT, in cognitive behavioral therapy, is trying to help the person to be able to go back into those environments that were so terrifying.

00:12:26

Dr. Randy Mackoff: Yeah, and really, I’m glad you brought up this idea of avoidance because what happens is avoidance starts to develop the illusion of safety. And so yes, if I don’t go to the grocery store, I won’t have a panic attack, but it’s not just the grocery store where the panic attack is taking place. And when they don’t go to the grocery store and they don’t have the panic attack, they then start to fill that in with some automatic thoughts that become that much more disabling and they start to develop a false sense of security based on, if I avoid this, I avoid that, until the world becomes very, very small. The person doesn’t want to leave their home. They don’t want to have social interactions. It’s difficult to go to work in some cases. And so panic can really grow as a result of avoidance.

00:13:10

Dr. Diane McIntosh: What do you tell your patients?

00:13:11

Dr. Randy Mackoff: The first thing, or maybe it’s the second thing, is to start recognizing that actually you’re not in a dangerous situation and that there’s lots of ways to escape from this without having to run away. For example, the person who is in the shopping center, when all of a sudden their heart starts to pound, they feel like they’re choking on things. Well, here’s something you can do. You can actually start to slow down your breathing. You can actually start to calm yourself. You can focus on other senses, what your feet feel on the ground, what the color is in the room, and then importantly, start to take control of your thoughts and understand, “Okay, this is me responding like there’s an emergency when there’s no emergency and I’m actually safe.” And in a therapeutic environment, teaching that and then having the people use that really can have a huge amount of benefit.

00:14:01

Dr. Diane McIntosh: Breathing is a good one because I don’t think you can actually have a full- blown panic attack if you are breathing. People have no idea that they are holding their breath, and I can see people sitting in front of me not breathing, and I can tell that they’re sort of escalating, feeling panic, and I’m saying, “You need to breathe.” And then what do they do? They deep- breathe and hold their breath so they’re not breathing still. So you have to continue to breathe in a regular pattern and people go… And I’m like, ” No, you’re not breathing. You have to keep breathing in order not to go down that panic path.” That’s a lot of psycho education that you have to spend time with people and walk them through.

00:14:45

Dr. Randy Mackoff: And one of the things I say, when you’re not breathing in a slow pattern way where you’re actually getting oxygen, what’s happening is the ratio of carbon dioxide to oxygen in your body is actually triggering your panic. And so because you’re getting short of that oxygen, you’re getting high in the carbon dioxide and this creates difficulties. And then with breathing, being able to calm and relax. So let the tension in your shoulders go, let your hands relax, let your face relax, which can be done quite quickly and can become a really effective tool in dealing with a panic.

00:15:17

Dr. Diane McIntosh: I know you use exposure therapy with your patients. Can you talk a little about that?

00:15:28

Dr. Randy Mackoff: First of all is you’re teaching how to calm and how to think, and then you have the person visualize going to these situations and as they start to increase their anxiety, their tension, or start to go into a panic, then they’re able to use the skills that they’re learning in the session. Then once they are really good at it, then it’s about going into that environment and really using their visualization.

00:15:54

Dr. Diane McIntosh: What do you tell people? Well, I’m afraid if I go in, I’ll get in there and then I’ll be afraid and I’ll want to run away. What do you tell them?

00:16:00

Dr. Randy Mackoff: Yeah. Well, that’s where we go back to, that there’s nothing bad happening, but you’re reacting like something bad is happening. So there’s a lot of things that they’ve got to be prepared for. One is what happens if they do get a panic attack and someone comes up to them and says, “Is everything okay?” Then they feel very self-conscious. They think something is not okay. So we talk about that and how to be prepared for that and have to have one or two scripted lines to be able to respond to somebody who’s approaching them, and then we talk about the ways of managing it and we have the systematic desensitization for it. And if that’s not effective in the situation that how to deal with it in the situation, which is having those scripted lines, being able to stay with it, not filling it in with some automatic negative thoughts. This is the approach that I take. I know there’s a variety of different medications. Diane, what’s your medication approach?

00:16:44

Dr. Diane McIntosh: So with few exceptions, all anxiety disorders are treated with the same group of medications, the antidepressants. If things get really severe, people are really struggling, sometimes we add the antipsychotic medications. But antidepressants are extremely effective, most of them, the ones that impact serotonin can be extremely effective for all anxiety disorders including panic disorder. You brought up a really important point though, Randy, I want to make sure we don’t miss, which is panic disorder is very commonly comorbid with another disorder, other disorders, particularly depression. So if I meet a 40 or a 50-year-old who comes in with a first onset of panic attacks, always I’m looking for a depression diagnosis because that is unusual to start to have panic disorder in your 40s or 50s. Depression and panic often come together, and so you can feed two birds with one scone by treating with an antidepressant that both manages the anxiety symptoms as well as the depression symptoms.

I will point out that whenever you have an anxiety disorder, significant anxiety symptoms, that means the course of the disorder, the course of the depression is actually likely to be more serious. There’s a greater risk of being treatment- resistant. There’s a greater risk of having suicidal thoughts or completed suicide. So it’s really important when anxiety is present that it is identified and it often takes higher doses and can take a little bit longer for anxiety symptoms to respond compared to just having depression symptoms.

00:18:21

Dr. Randy Mackoff: Yeah, and that’s so important for people to know, especially the higher doses. So someone, them will come in and say, “Well, my family doctor has me on 15 milligrams of so-and-so, and actually my mood’s a little bit better, but my anxiety’s still really high.” So I’ll say, “Hey, look. Go back to your physician and talk about that because it may be that you need a higher doses of what you’re using to deal with the anxiety symptoms and perhaps deal with the panic.”

00:18:43

Dr. Diane McIntosh: I think people kind of poo-poo anxiety. The depression, that’s the dangerous one, but the anxiety is actually what increases suicide risk. It is awful to live with anxiety and it is harder to treat. So people think, “Well, my depression’s better, and my antidepressant, it must be for depression,” but in fact, we have to try to get rid of all of those anxiety symptoms because they make your brain vulnerable to having more anxiety symptoms, but also a relapse of your depression. So anxiety I take very seriously. And also of course, panic is absolutely awful and sometimes it’s very difficult when you have a huge amount of anxiety to get started on an antidepressant because people have what’s called ‘anxiety sensitivity’. Every side effect that could happen early on, headaches, a little bit of nausea, they think then that the antidepressant is making them sick or making them worse.

00:19:39

Dr. Randy Mackoff: Yeah, exactly. And you do experience that, “My stomach was upset, it was just making things worse and I just couldn’t stay with it.” And one of the ways of dealing with that is to really provide good information about what to expect when they start a medication and that this is just your body adjusting to things. And I always think of, Diane, you telling me, and I use this a lot with people, is that serotonin is being produced in your gut, and so your stomach is going to get upset because the serotonin is being changed, and that you’re going to adjust to and that it’s short-term and that when it’s given a lower dosage, that your body will adjust with it often with food. And to really check in with their GP about that and their pharmacist with that, and if they’re seeing a psychiatrist, that’s important.

00:20:18

Dr. Diane McIntosh: Again, with the psychoeducation. Again about preparing people for what to expect. Start low, go slow, but aim for all those symptoms to be gone, and what I say to my patients is when you’re really ill, when you’re cognitively impaired, you can’t get to the end of a newspaper article that you’re trying to read and remember what was at the beginning. That’s not the time to be in an intensive cognitive behavioral therapy program because you need to be able to attend, to listen, to learn. What’s your take on that?

00:20:51

Dr. Randy Mackoff: I’m in agreement with you. And not giving out information to reveal who anybody is, recently I had a phone call from a patient who has been suffering from depression and anxiety for a very long period and they stopped treatment with me and they went to see somebody else who said, “Look, you don’t need medication. We can do this purely through counseling.” I wasn’t in agreement. They’d already had depression on a number of occasions, so it was recurrent, there was a need to stay on this, the anxiety was evident they need to be on medication. They phoned me and they said, “I’m losing my mind. I can’t cope anymore and I’m in serious trouble.”

So my take here, and this is an extreme example, is, “Okay, first thing is you need to go to your family doctor if you can get in right away. If not, what I’d like you to do is I’d like you to go to the emergency department, and I want you to go to the emergency department. I want you to tell them both when you’re on medication, how much better you do, that you have a history of suffering from recurrent depression and that you’re having panic attacks, but you need to go in there and you need to get started on medication.”

So fortunately, they listened to what I said, and they went right away to the emergency department and they all of a sudden were reassured and now they’re very committed to staying with medication, and so also then being able to pursue the psychological interventions. But what I’m saying is that during that acute period, during that time where they were overwhelmed, they could have talked to me on the phone for hours, it would’ve changed nothing. I can reassure, I can calm that. Then they need to get in for the medication so that once the medication starts to work, we can then start approaching this from a psychological way.

00:22:23

Dr. Diane McIntosh: So I think what you’re saying, and just in a nutshell, is you’re saying I am the warm-up act for the psychologist, is that what I’m hearing?

00:22:31

Dr. Randy Mackoff: Oh, definitely, because the psychologist once again is doing the heavy lifting.

00:22:34

Dr. Diane McIntosh: Yes. Thank you, Randy.

00:22:38

Dr. Randy Mackoff: Thank you, Diane.

00:22:44

Dr. Diane McIntosh: So let’s go back to Annette. She knew she was in trouble, but no one knew what to do. She saw her doctor, she went to a clinic. She even tried the emergency room, but she wasn’t getting proper treatment and she wasn’t getting better.

00:22:57

Annette: I still was having difficulty walking, and all I wanted to do was just curl up in a ball that felt the most comfortable to me, to be in the fetal position.

00:23:10

Dr. Diane McIntosh: Desperate for answers, Annette and her husband kept at it, searching for help.

00:23:15

Annette: He could see where this was going, so he realized, okay, I needed something more. And so he reached out to a psychiatrist and fortunately that was the missing piece.

00:23:30

Dr. Diane McIntosh: Finally, Annette was diagnosed and started treatment.

00:23:33

Annette: So I had to try different types of medication and some did not work very well, some caused more issues, and then finally I found that did work.

00:23:46

Dr. Diane McIntosh: Annette also went to therapy. She worked through her brother’s death, and she also learned how to deal with all of her emotions.

00:23:53

Annette: There was a huge part of me that did not ask for help until I had to because I did not want anyone to see me as anything but strong, which of course, I came to realize, you are strong if you ask for help. You are strong if you let people in, and I had to learn that in a very hard way, but that has been probably the best thing. My relationships with people have become so much brighter and I’ve become so much closer and the connections have been tighter than they ever were before and never could have been, because I finally said, “I am not strong. I’m broken and I need help.”

00:24:48

Dr. Diane McIntosh: Those are some powerful words and it takes bravery to say them. I’s like to take a minute and expand on something that I think is really important in each episode. I call it my Shrink Wrap, if you will, and today it’s about stigma. When it comes to mental illness, we tend to think about stigma as something that lives out there in some small groups of uninformed individuals, but in reality, stigma lives everywhere, including in medicine and throughout the healthcare system. When you have a mental illness, you often carry shame and guilt and hopelessness. It’s just the nature of these disorders. But sadly, these feelings are compounded when the people in their lives stigmatize them. This happens when perhaps well- meaning, but uninformed family, friends or co- workers make comments that undermine the confidence of an individual who is already struggling. An aunt might announce, “You just need to pull up your socks,” or a co-worker might say, “You look fine to me.”

Whether it’s second-guessing our medical care or making offhand comments without any context or knowledge, stigma can cause irreparable harm. And then within medicine, as Randy mentioned earlier, an offhand comment by an ER nurse, “It’s just panic,” or a doctor you’re seeing one time for a pap smear who opines, “You’re on too many medications.” To a vulnerable individual who’s struggling to stay on their treatment and looking for any reason to stop, that’s a sure way to make it happen. 

Randy mentioned he might see someone for months before they feel comfortable enough to share what’s really going on. That’s because they’re afraid of what his reaction may be. We need to be really aware of the messages we’re sending and conscientious not to drive people who are already suffering deeper into their despair. All of my patients have faced stigma and most have shared stories of how that stigma was a barrier to their diagnosis and their treatment.

Stigma is what prevents a lot of people, including Annette, from asking for help in the first place. Because of the stigma around mental illness, no one wants to admit that they’re struggling mentally. I am here to remind everyone that mental health is health, and I hope anyone listening to this will hear from Annette, what a difference it made to ask for help. Strong, competent people sometimes need help. We all sometimes need help. To get it, you need to ask. During her struggles, Annette really worried at times that she was slipping through the cracks of an overwhelmed system, but she and her family stuck with it. She now considers herself one of the lucky ones because she did receive the help and support she needed.

00:27:36

Annette: I am doing, I don’t want to say ‘great’, because that was what I told people when I wasn’t. “How are you doing?” “Great.” I wasn’t. But I am doing great, but I also am doing great because it took several years and it took a lot of different tools to help me get here. I also know that the work is not done. I have to keep showing up, I have to keep doing the things that will keep me healthy. So I know that if I have an emotion now, and if I’m sad, I just say, “I’m feeling sad,” and I acknowledge it, or if I’m angry and I acknowledge that and I tell myself, “It’s okay, it’s okay. This is a hard thing you’re going through, or this is a sad thing.” I’m very protective of my sleep. I make sure I exercise, even if it’s just getting a walk. Yeah, I’m doing well, but I also know that none of us know what’s coming down the road, but I feel better equipped now to deal with those things, and I’ve learned a lot about myself, and I’ve had to get real with myself.

00:28:52

Dr. Diane McIntosh: A huge thanks to Annette for sharing her story with us. It takes courage to talk about such personal experiences, especially related to mental illness, and I hope her story encourages you if you’re struggling. You are not alone.

This is PSYCHEDUP, an original podcast from RAPIDS Health. If you know anyone who has panic attacks or panic disorder, or you love someone who does, please share this episode with them. And if you think you might have panic attacks, please reach out to your primary healthcare provider and ask for help. And if you like what you heard, please follow and rate the show. It helps other people who might need or want some guidance to find it. Until next time, I’m Dr. Diane McIntosh.