This article was originally published on the Brigham HealthHub blog

Contributor: Gabe Gruner, LICSW, psychotherapist at the Psychiatry Outpatient Clinic at Brigham and Women’s Hospital.

About 10 to 33 percent of people will experience at least one panic attack this year. Even if you’ve never had a panic attack, you probably know what they are like. A pounding heart, sweating, trembling, dizziness, chills.

Only 2.7 percent of people who experience a panic attack in a given year will meet the criteria for panic disorder, which is a type of anxiety disorder characterized by recurrent and often unexpected panic attacks.

An individual with panic disorder also worries about experiencing future panic attacks. In other words, panic disorder is the fear of panic attacks, or the fear of fear. Such anticipatory fear can cause significant distress and negatively impact an individual’s daily life.

How panic differs from anxiety

Panic and anxiety are often used interchangeably, but they refer to different events. Instances of panic are short-lived and intense. They usually last less than 10 minutes because the body can’t stay in such an aroused state for extended periods of time.

A panic attack activates our fight-or-flight response that helps prepare our body to protect us from real or perceived threats. However, panic attacks can occur with or without a threat. Anything from watching a scary movie to exercising to consuming excessive caffeine can trigger the physical changes that may lead to a panic attack.

On the other hand, anxiety is a more future-oriented emotion and usually results from thinking or imagining a negative occurrence in the future. Anxiety can be long-lasting, with a lower level of arousal in the body.

“Anxiety and panic are interrelated, and both contribute to panic disorder,” says Gabe Gruner, LICSW, a psychotherapist at the Psychiatry Outpatient Clinic at Brigham and Women’s Hospital.

Gruner specializes in obsessive compulsive disorder (OCD) and other anxiety disorders. “The anxiety part of the disorder involves worrying about future panic attacks,” he says. “A person with panic disorder may think, ‘When will my next panic attack occur? What will happen?’ They’re anxious about the panic attack, even when they’re not having it.”

The low-level of arousal that comes from anxiety about future panic attacks can trigger an actual panic attack. When you start to worry about panicking during an important meeting, for instance, this anxiety can spur a fear response (fast heart rate, sweaty palms) that can domino into a panic attack. People with panic disorder can find themselves caught in a vicious, self-fulfilling cycle.

About one third of people with panic disorder will show symptoms of agoraphobia, the fear of public or enclosed places where escape might be difficult. People with panic disorder show signs of agoraphobia when they begin to avoid situations that they associate with panic or anxiety. An individual with agoraphobia might be afraid to visit the supermarket, ride an elevator or train, or even leave their house.

Anxiety sensitivity is a risk factor for panic disorder

Most people experience some level of nervousness before a date or a presentation. In fact, it would probably feel strange if you delivered a presentation to your colleagues and didn’t experience an increase in heart rate. But why do some people have panic attacks while others experience only subtle arousal?

“The underlying mechanism that drives panic disorder is called anxiety sensitivity, a phenomenon where an individual becomes afraid of their bodily sensations,” explains Gruner.

When people have high anxiety sensitivity, they can mistake natural bodily sensations as harmful physical health symptoms, and this can lead to more anxiety and trigger panic attacks. For instance, a person’s increased heart rate might cause them to worry about an impending heart attack. A feeling of losing control might make them afraid that they are mentally unstable, or “losing their mind,” so to speak.

Most psychologists agree that anxiety sensitivity is not hereditary, but rather learned from personal experiences. “Your mind and body learn to respond to internal changes as if they were a threat,” says Gruner.

The process of learning to fear bodily sensations is called interoceptive conditioning. During the day, we all experience natural physiological changes. It’s possible to condition oneself to be overly sensitive to even slight bodily changes, such as a natural increase in heart rate, so that panic attacks become a conditioned response to these changes.

“Some people can experience nocturnal panic attacks for this reason, even without having a nightmare. It appears as if there’s no trigger, but the trigger is these slight body changes,” says Gruner.

Fortunately, anxiety sensitivity is highly treatable and can be greatly improved through certain types of therapy.

The factors that can lead to panic disorder
The following three factors contribute to interoceptive conditioning, higher anxiety sensitivity and development of panic disorder.

• Biological vulnerability. A genetic predisposition to certain personality styles, such as negative affect, contributes to the development of anxiety.
• Psychological vulnerability. Early developmental experiences can make certain individuals more likely to experience anxiety, especially if they grew up in controlled environments without opportunities to explore threatening situations.
• A specific psychological experience. A negative experience with an illness may cause a person to fear certain symptoms associated with that condition. Also, an individual may fear an illness if a family member modeled the illness as something to fear.

Gruner says that panic disorder often starts with an unexpected panic attack that surprises the person. They might have a panic attack while driving, in a parking lot, on a plane—somewhere where it could have severe consequences to have a panic attack and also where the attack seems unwarranted based on the situation.

“The first panic attack can be very disconcerting, and then an individual can fear that it may happen again,” says Gruner.

If you think you have panic disorder, self-educate and seek professional help

Many individuals with panic disorder realize they have the disorder after a trip to the emergency room (ER), as panic attack symptoms can easily be mistaken for a heart attack or stroke. An ER can only offer short-term relief or provide a referral to mental health services.

Many people who are concerned about panic disorder visit their primary care provider (PCP). Unfortunately, according to Gruner, PCPs can sometimes mistreat panic disorder by prescribing benzodiazepines, such as lorazepam (Ativan) or klonopin (Clonazepam). However, current research shows that ‘benzos’ are a counterproductive long-term treatment approach.

“Benzodiazepines can reduce your anxiety in the short-term, but people can become dependent on them to the point where they don’t feel safe without it. They usually attribute progress to the benzo, so it can make treatment progress difficult,” says Gruner.

Gruner advises individuals to be wary if their PCP prescribes benzodiazepines. “There is increased awareness among PCPs now with the problem of prescribing benzos to people with panic disorder, but it’s not perfect,” says Gruner. “So, it’s worth educating yourself about effective treatment before meeting with your PCP.”

Ideally, a PCP would recommend a therapist or psychiatrist. A cognitive behavioral therapist who has experience with anxiety disorders is an ideal choice.

Cognitive Behavioral Therapy is 70 to 90 percent effective as a treatment for panic disorder

Panic disorder is one of the most treatable anxiety disorders. The prevailing treatment is cognitive behavioral therapy (CBT). A new offshoot of CBT, known as Acceptance and Commitment Therapy (ACT), has also been found effective in treating panic disorder. Psychologist Steven Hayes developed ACT in part as a way to treat his own panic disorder. This form of therapy uses acceptance and mindfulness techniques to change how you relate to your physical sensations of anxiety and anxiety itself.

“CBT is an incredibly effective treatment for panic disorder. Seventy to ninety percent of people who undergo CBT will get better,” says Gruner.

A key part of CBT in treating panic is a method called interoceptive exposure, in which the person deliberately confronts the unpleasant physical sensations that are causing anxiety. People become more sensitive to these sensations because they fear and avoid them, so facing the sensations and learning that they are not dangerous can lower anxiety sensitivity.

CBT sessions are usually conducted on a weekly basis and last for around 12 to 16 sessions. The treatment tends to show long-lasting results, and relapse is uncommon.

Selective serotonin reuptake inhibitors (SSRIs) are also often used to treat depression and anxiety disorders, with or without CBT. These drugs can be effective, but CBT has been found to be a longer-lasting treatment than SSRIs.

Therapy isn’t always covered by insurance. Because of this, people with panic disorder can live with a highly treatable disorder and not know how to treat it. If you’re in this situation, visit such websites as Anxiety and Depression Association of America, Association for Behavioral and Cognitive Therapies, or Association for Contextual and Behavioral Science to find self-help materials or tools to help find a therapist.

What do I do if I’m having a panic attack?

With or without panic disorder, panic attacks are common. And there’s a big misconception around dealing with them, Gruner explains.

“The most common advice people hear when they’re experiencing a panic attack is to take deep breaths, think positively, and try to calm down,” he says.

However, trying to control anxiety in these ways can backfire. Struggling to prevent a panic attack can have a paradoxical effect and actually cause a panic attack.

During a panic attack, a person should do the counterintuitive thing: let go of control and allow the panic attack to run its course.

It can also be useful to remind yourself that you can’t die from a panic attack, and that it’s your body’s normal, natural reaction, which is not dangerous.