It could happen on the freeway or in a business meeting, in a shopping mall or sitting in front of the television. It has no regard to race or gender. It is a sudden and intense physical sensation coupled with outright fear that leads people to think: I am having a heart attack. I am dying. Feeling as if their lives are in danger, they rush to an emergency room, only to have a doctor tell them there is nothing physically wrong with them. Instead, they are sent home with a telephone number for a psychiatrist.
They are called panic attacks and they afflict an estimated 1 million to 3 million Americans. Researchers believe the attacks are a psychological condition which causes the brain's warning system to start firing off danger signals, making the sufferer believe something is terribly wrong with his or her body.
Symptoms include "feeling like you are going to have a heart attack, feeling like you going to faint, that you are going to get sick, be nauseated, that you are going to stop breathing, (or) that are you are going to choke," explained Scott Granite, a licensed clinical social worker with the Palo Alto Medical Foundation who leads a 10-week therapy group for people who suffer from the attacks.
People "may certainly go to the emergency room. I have met a number of people who have," said Granite. The attacks "feel very real. It is just that there is nothing physically dangerous going on. But, it certainly feels that way."
And, as scary as the attacks themselves are, the side effects can be equally as frightening. Once people realize they have a mental, and not a physical condition, depression and anxiety often set in. "One of the most common symptoms is people feeling they are going crazy," Granite said.
The intensity of the attacks can have debilitating effects on people. "Once it has started happening, then every little thing can become a stimulus to trigger (an attack)," said Dr. Javaid Sheikh, director of geriatric psychiatry at Stanford's School of Medicine. He has been studying panic disorders for 11 years.
"People start avoiding certain situations (because) they are afraid that (they) will trigger panic attacks," he said. For example, fear of driving on the freeway "is a major thing which happens all the time... those kinds of things start accumulating." In extreme cases a person may start avoiding so many perceived triggers that agoraphobia can develop, a condition in which people fear leaving the safety of their homes.
The causes of panic attacks, while not perfectly known, are becoming clearer. The panic attack mechanisms in the brain, which appear to be closely related to some of the mechanisms behind certain kinds of depression, may revolve around a chemical imbalance. There is also evidence that a genetic tendency may exist toward having attacks.
"Because of this chemical abnormality," Sheikh said, "at some point . . . typically early 20s or late teens, for whatever reason, (sufferers) brains are ready to start developing panic attacks." But "there needs to be not only biological imbalance, but . . . a psychological trigger."
The most common trigger, researchers believe, is stress: either a build-up of stress over a period of time, or a sudden traumatic stress, like losing a spouse.
Panic attacks do not just occur in early adulthood though, but can occur at any stage of life. Sheikh is currently studying a group of people, who did not have an attack before the age of 55.
If ignored, even everyday sources of stress, like driving in rush hour traffic, may turn out to be damaging. Granite likens the dangers of ignored daily stress to a rain barrel which fills drop by drop. "Sooner or later your body tells you 'time is up.' You have ignored this stuff for too long, and then the stress comes out as panic."
A typical person susceptible to stress might be someone working 60 or 70 hours a week while eating improperly and not exercising, Granite said. Another common type is the person who has a hard time expressing feelings, especially anger or frustration.
A major complication in the whole process is that for many people, once the attacks begin, they are too ashamed or embarrassed to seek treatment. This is especially true of men, who in the past were thought to be relatively immune from panic attacks. In fact the condition was sometimes referred to as 'housewife's disease,' because until recently women were diagnosed at twice the rate of men. Today, Sheikh said, the ratio between men and women who suffer from panic attacks is fairly even.
The good news is that panic attacks are highly treatable, and Sheikh predicts they will become even more so. "Panic attacks are going to become one of the most treatable conditions in psychiatry, along with depression," he said, "you can treat them very effectively."
The two primary forms of treatment, which often are combined, are drug therapy, which helps stabilize brain chemistry, and cognitive behavior therapy, which teaches people to be aware of their thought processes and coping skills. Drug therapy is especially helpful for people who are in such a state of distress that the lessons of behavior therapy are muted. The medication can bring about a respite or at least a lessening of the attacks.
"We believe that a psychological approach can affect brain chemistry," said Sheikh. "People can learn coping skills . . . and they can go, for example, and drive on the freeway. If they can cope with that, (then) that practice and learning effect can change brain chemistry."
Granite, who practices cognitive behavior therapy, agrees. "It is interesting because I think it has been medically proven that cognitive behavior therapy really can make for some of the same chemical changes in the brain as medication, and that is pretty remarkable."
Regardless of the final form of treatment, both Granite and Sheikh agree that the first step a person should take is to see their regular physician. "You really need to see your doctor," said Granite. "Because one of the things that all therapists need to be careful about is to make sure that there is not a medical problem. None of us wants to treat someone for panic attacks and find out that somebody in fact has heart disease."
And Granite says people should have a positive realization that they will get better with treatment. "In reality, people have a much greater ability to cope than they ever give themselves credit for."