What is the Difference between Panic and Anxiety?

Panic and anxiety share similar symptomology and can co-exist. Anxiety involves thoughts (e.g., ruminations, worrying too much or unable to stop worrying) and actions (e.g., avoidance, safety behaviors) that are amenable to change. Anxiety builds up over time with symptoms such as muscle tension, restlessness, excessive worry, irritability, difficulty focusing, and sleep problems.  

Panic involves frequent panic attacks (e.g., can be expected or out of the blue), followed by worry about having another panic attack, losing control, or “going crazy.”  Panic is acute, intense, and often lasts just a few minutes, but can be extremely uncomfortable and frightening. It may feel like losing control, having a heart attack, and fear of dying. Once a panic attack has occurred, the fear of another panic attack is present and drives future panic attacks. Panic is more sudden and overwhelming than anxiety. It can result in significant changes in behavior (e.g., avoiding situation that trigger panic). Therefore, panic can lead to agoraphobia (e.g., fear of open spaces, leaving safe spaces like home) or at least some curtailing of activities that results in limitations – a very small world with which to get one’s need and wants met. Triggers for panic are not always obvious (e.g., visual auditory, gustatory, olfactory stimuli, a tone of voice, physical proximity, etc.). Once the brain gets the message that a threat is present (real, imagined, or predicted) the nervous system will take appropriate action to manage the perceived threat.  There is no stopping this once it gets started, but it does have a predictable beginning middle and end (i.e., Rise, Peak, Fall), if worry thoughts don’t take hold. To prevent a prolonged panic response, learn to stay out of your head during the panic attack. In other words, “Don’t add fuel to the fire!” (e.g., worry, “What ifs…?”). This is no easy task.  Remember, panic is the body’s normal response to a perceived threat and is NOT dangerous.

Symptoms of panic can vary greatly but often involve a struggle to breathe, feeling dizzy, nauseous, increased heart rate or palpitations, urge to use the toilet, light-headed/faint/tingling and feeling numb. The key is learning to identify symptoms sooner so you can intervene early and effectively.

Anxiety, like all moods, has associated thoughts that filter our view of ourselves, others, and the world (e.g., consider grey rather than rose colored glasses). The goal is to recognize we are wearing anxious lenses and over-ride this manner of thinking to be more honest, adaptive, and aligned with our true selves. Remember, struggle is a part of life and can motivate us to make difficult changes in our own best interest. We also learn from struggle and can develop empathy and compassion as a result. The difference between “Helpful Concern” and “Unhelpful Worry” is the meaning and predictions we make about it.

Where Does Panic Come From?

While there is no single know cause of panic attacks, there are many factors that influence its development. Like many traits, there is some basis for a genetic component (panic is more common if you have a first-degree relative who experiences panic). Psychological factors that contribute to panic include chronic stress, learning early in life that internal physical sensations are worrying and should be paid close attention to, being encouraged to rest and recover at the first sign of a different physical sensation, having another existing mental health issue (e.g., depression, OCD, PTSD, phobias, GAD, and social anxiety), having a strong internal focus, hypervigilant to changes in the body, and a low opinion of self-worth. Environmental factors include experiencing a recent loss, facing a major stressful life event job loss, moving, relationship turmoil, weddings (even eustress adds to the cumulative burden), and having a physical illness.

How is Panic Treated?

So why can’t we ‘just’ stop thinking panic thoughts? While the goal is to regain confidence in ourselves and redirect our thinking, this is much easier said than done. It is important to keep in mind that once the brain detects a threat (real, perceived or predicted) and triggered the fight-or-flight system, it has to run its course preparing you for “battle.” Therefore, you will need to learn how to self-soothe, distract, remove barriers to success, elicit support, and choose more balanced and adaptive thoughts about the situation to recover from panic.

Before a diagnosis of panic disorder can be made, it is important to rule-out another health diagnoses that can look like panic (e.g., heart or thyroid problems, substance use, or another mental health condition that better accounts for the symptoms). Additionally, symptom clusters only reach the threshold for diagnosis if they significantly disrupt your life (e.g., relationships, work, health).

The best therapy is one that addresses both the symptoms as well as resolving the underlying causes for more permanent relief.

Evidence-based treatment for panic includes:

• Psychotherapy: Cognitive Behavioral Therapy (CBT) identifies, understands, and changes the way we think and behave that perpetuate panic (e.g., “Non-home spaces are dangerous” vs. “Although leaving the home may be uncomfortable, it is not inherently a danger.”). You can ask yourself, “Is this the truth, the whole truth, and nothing but the truth that I’m in danger when away from home?” Remember, we initially think the way we feel, so when experiencing panic (a strong and uncomfortable sensation) fear will guide your thinking if you are unaware of the thinking errors that contribute to it. We must develop the capacity to challenge our initial appraisal, collect more information about the incident, and accept a second appraisal that includes over-riding the current emotional state. This is no easy task! Have you ever been stressed or anxious and have someone tell you “Just Relax”?  If so, then you understand how disempowering this recommendation is. Other therapy approaches include Mindfulness-Based Therapy (supports grounding in the present moment and gain greater awareness of your body and mind so you can recognize the signs and symptoms before they escalate, teaches you to “Ride the Wave of Panic” instead of being swept away by it), Psychodynamic Therapy (exploration of the past to find the roots of panic and resolve the underlying issues that contribute to panic), Acceptance and Commitment Therapy (ACT) (acceptance of  what it rather than fight the inevitable), and Exposure Therapy (gradually exposes you to the feared object or situation, moving from more safe to more risk as a means of building up your tolerance and reduce avoidance behaviors).
• Medications: Selective Serotonin Reuptake Inhibitors (SSRIs such as Prozac, Paxil, Zoloft); Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs such as Effexor); and Benzodiazepines (such as Xanax and Klonopin). Benzodiazepines are habit-forming and need to be limited to short-term use with acute symptoms. Benzodiazepines are meant to be used like pain relievers to manage pain while engaged in physical therapy for lasting results. Pain relievers like oxycodone are prescribed to manage the pain associate with physical therapy. Physical therapy is the treatment that will result in lasting recovery, so pain can’t cause avoidance of movement. Finally, beta-blockers such as propranolol and histamines like hydroxyzine can reduce the physical manifestations of anxiety and panic. Psychotherapy is like physical therapy in regard to last relief from the signs and symptoms of panic. Taking a medication to better manage panic and reduce avoiding is key to making psychotherapy attainable.
• Lifestyle: Stick to your treatment plan; join a support group; avoid caffeine, alcohol, smoking and recreational drugs; practice stress management and/or relaxation techniques; be physically active; and get sufficient sleep.

What is the Long-Term Outlook for Panic?

There are times when panic may be absent from one’s life for long periods of time only to reemerge during particularly stressful times. This will happen from time to time even with a good understanding of the drivers of panic, skill in addressing current episodes, rallying support, and preventative action. The key is to have a plan. First, determine the health behaviors and mindset you need to set yourself up for success every day. Next, figure out what interventions help calm or distract you and allow you to continue practicing your most adaptive thoughts when panic occurs despite your best efforts to prevent it. Finally, this is a living and evolving plan that changes as your needs change, so keep adjusting it to be the most current reflection of what you need to navigate the challenges of life with as much confidence and grace as possible.

EXAMPLE

Proactively: Setting your biological system up for stability and balance by focusing on adequate sleep, nutrition and exercise. Additionally, set up weekly assignment for exposure therapy, interoceptive exposure, practicing assertive communication skills, and other experiments and tasks to support emotional regulation. Medications such as SSRIs.

Self-Compassion: Take a self-compassion break…this is not easy work! “This is a moment of panic. Others also experience panic at times.  May I be gentle with myself while I get through this moment of suffering.”

Reactively: Diaphragmatic breathing, call a loved one or friend for support, read affirmations, distracting (e.g., ABC game, counting, music) and remind yourself this is your body preparing your physiology to act in your protection (not failing you). Medications such as propranolol, hydroxyzine, or benzodiazepine (e.g., Xanax). Use cognitive behavioral strategies to improve thoughts and actions to be as accurate and adaptive as possible.