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Fear Factor

By Greg Rienzi
Nearly a quarter of Americans will suffer a panic attack. A smaller number will spend years terrified about when and where the next one will hit.

Annie L. never particularly liked driving, especially on highways and bridges. But she accepted it as part of adult life. One day in early 2018, though, her relationship with the road changed drastically. On her way to visit family on Maryland’s Eastern Shore, Annie approached the Chesapeake Bay Bridge. Her two children, ages 4 and 18 months, sat in back. She was tired, and worried more than usual about crossing the 4.3-mile-long, dual-span bridge, notorious for its low railings. Then it started. She felt dizzy and lightheaded. Next came the numbness. She barely felt her hands grip the wheel or her feet touch the pedals. Her heart raced. In her mind, she pictured driving across the bridge in the wrong direction, or losing control of her car and hurtling over the edge into the cold, open water some 200 feet below.

“I wanted to scream,” says Annie, who chose not to use her real name to protect her privacy. “Then I started talking to myself: ‘You’ll be fine once you get over the bridge. Just drive.’” She managed to get across, driving just under the speed limit. But the return trip days later was worse. Approaching the bridge, Annie could barely focus. The numbness returned, as did the pounding heart and nightmarish scenarios. As the bridge came into view, she pulled over to the shoulder and sat there until the state police showed up.

“I was crying, clutching the wheel,” she says. “They offered to drive behind me to help me across, but I couldn’t go any farther. I just kept saying, ‘No, I can’t,’ to them.” Ultimately the state police called for a tow truck to transport her car over the bridge. Annie and her children rode along in the police car.

As she would later discover, Annie had suffered a textbook panic attack, a sudden and unexpected feeling of intense fear and impending doom, often accompanied by rapid heartbeat, shortness of breath, chills, dizziness, chest pain, sweating, and trembling.

According to a Harvard Medical School survey published in the journal Archives of General Psychiatry, roughly 23 percent of people experience a panic attack at some point during their lives. Clinically speaking, a panic attack entails at least four symptoms within a short period of time, typically under a minute. One moment you’re fine, the next, the walls are closing in and your mind is reaching for the worst-case scenario. The symptoms are so severe, you feel like you’re having a heart attack or simply losing all control.

Certain places or situations can trigger a panic attack, like being on a plane or about to give a speech. Anxiety experts say you’re most prone to one when you’re in a situation you feel you can’t escape from. But they can also wake you from sleep. Panic attacks often happen without warning. They often first emerge in your late 20s. They can occur at a time of stress or change, like getting married, starting a new job, or losing a loved one. But the moment comes and goes, and as frightening and upsetting as the attack can be, you get on with your life.

However, a smaller number of people, 3 percent of the population, go on to develop a more enduring form of anxiety, called panic disorder. For people such as Annie, panic attacks are recurrent, often causing them to live with persistent worry that another attack might happen at any moment. In Annie’s case, the trigger for most of her anxiety is the thought of driving on bridges, highways, or any major arteries. To cope, in the days and weeks after her initial panic attack, she drove less and had her husband take the wheel. When she did have to drive, she opted for alternate routes over back roads. Her work commute had taken 15 minutes; after the panic attacks, it took 40.

A panic attack entails at least four symptoms within a short period of time, typically under a minute. One moment you’re fine, the next, the walls are closing in and your mind is reaching for the worst-case scenario.

Una McCann, a professor of psychiatry and medical director of the Anxiety Disorders Clinic at the Johns Hopkins Bayview Medical Center, says that for people with panic disorder, their minds tend to go to the worst possible scenario. If you’re driving, you’re going to get into a horrific accident. If you’re giving a talk, you’re going to forget your lines and the audience will mock you. If your heart rate quickens, you’re having a heart attack.

“In response, people avoid any place or situation that they fear might lead to another panic attack, and are unable to escape from,” McCann says. “For these individuals, the world becomes smaller and smaller, and it’s really quite debilitating.”

For Susan T., the threat of panic attacks held her hostage for nearly 25 years. Now 64, Susan was 29 when she had her first. At the time, she lived in Boston, the mother of three young children, ages 6, 2, and 1. She had just finished putting the kids to bed and lain down on the couch to relax when she suddenly felt her heart race and then skip a beat. She felt dizzy. Something was wrong. She calmed herself down, but the feelings returned a week later. Again, out of the blue, with no discernible trigger.

What followed were nearly two years of medical testing. Doctors tested her for adrenal disorders, thyroid disease, and heart arrhythmia. She was put on beta blockers, used to treat high blood pressure and heart problems. “Nobody even suggested panic attacks at first because my heart rate was so elevated when I came in,” she says. “And in my mind, I was sure my issue was physical.”

Susan didn’t know where and when the next panic attack would strike. She had one on a plane. One driving on a bridge. One on the subway. She began to avoid travel for fear of having another attack in public.

In 1986, Susan went to the then director of the Anxiety Disorders Clinic at Johns Hopkins, Rudolf Hoehn-Saric, who diagnosed her with panic disorder. A pioneer in his field, Hoehn-Saric prescribed a daily antidepressant and a benzodiazepine to treat actual attacks.

“I finally believed someone when they told me it could be a panic attack because after all these years of them testing for A, B, and C, I was still alive,” Susan says with a laugh. “I gave up a lot because of my panic attacks. Career- wise, I never really had one. I would cancel appointments. The thought of doing anything that pushed me beyond getting through the day, just any sort of challenge or project beyond taking care of my kids, just seemed too big. I couldn’t escape this feeling of fear hovering over me.”

According to McCann, many of her patients confuse “normal anxiety” with panic attacks. Imagine you’re getting ready to talk in front of a crowd of 500 people. You might sweat, and maybe your heart rate speeds up. “You might just be nervous, and these are normal reactions,” McCann says. “With public speaking, this nervous anticipatory phase is often slow and gradual. But with a panic attack, there’s both an intensity of symptoms and a short time threshold.”

Joseph Bienvenu, a psychiatrist and a co-director of the Anxiety Disorders Clinic at Johns Hopkins Hospital, says another common misconception is that if you have a panic attack associated with a phobia, you may also have panic disorder. It is true that people with phobias often suffer panic attacks, but it’s in response to a specific stimulus, he explains. “A person with a fear of dogs might have a panic attack when they see a German shepherd running toward them, but they’re not generally living in worry of having a panic attack. In panic disorder, they are afraid of the attack itself.”

Generally, a panic attack starts with one symptom and then cascades into multiple ones. You feel your heart beating louder or faster, then might come a feeling of dizziness, numbness, and what psychiatrists call automatic thoughts such as, “I’m having a stroke,” “I can’t get any air,” or “I’m going to crash my car.” The initial symptom, coupled with the thoughts, stimulates adrenaline, and the symptoms worsen. Physically speaking, panic attacks are caused by a massive outpouring of norepinephrine—a hormone related to the fight-or-flight response—as the body’s sympathetic nervous system goes into overdrive. An attack typically lasts just a few minutes and no longer than an hour—a body can tolerate only so much strain, and the rush of norepinephrine and adrenaline subsides.

McCann says we’ve long understood the underlying physiology of a panic attack, but the tricky part is discerning the cognition, the fearful thoughts that are leading to these symptoms. “You’re not being attacked by a tiger, but you’re having the physical symptoms you would expect to have if you were,” she says. “So, what set you off? That is what I try to find out.”

“You’re not being attacked by a tiger, but you’re having the physical symptoms you would expect to have if you were.”

We now know that psychological stress can trigger anxiety and panic attacks, as can biochemical factors such as caffeine and elevated levels of lactic acid in the blood, which can be caused by alcohol use, low blood sugar, or prolonged exercise. In scientific studies of panic disorder patients, severe panic attacks were induced simply by giving people injections of lactate. Sleep deprivation also makes people more vulnerable.

Experts say that attacks tend to occur in people who often overthink, overanalyze, and dramatize. It’s also more common in women than men, as is the case with most anxiety disorders and depression, perhaps related to hormonal differences. There’s also an emerging field of thought that genetics might play a role.

“We’re not sure, but perhaps certain people are more sensitive to negative emotions and stress, and this is part of our DNA,” Bienvenu says. “People with panic disorder tend to be incredibly sensitive to physical symptoms of any sort.”

When first meeting with a patient who has had one or more panic attacks, McCann tries to determine whether the attack is associated with another anxiety disorder, such as obsessive-compulsive disorder. She says it’s also important to determine the frequency of attacks. What was the setting? Was there a traumatic experience that occurred shortly prior to the first panic attack?

Treatment traditionally involves cognitive behavioral therapy and medications, the only two evidence-based options. The type of therapy differs depending on the underlying cause. Bienvenu says he tries to understand what the situation was, and what the patient was thinking just before the event.

“[Attacks] can be caused by the brain,” he says. “In studies, even when we block certain symptoms with beta blockers, people with panic disorder will still report surges of fear. It’s not just the brain responding to the body.”

Antidepressants in the family of selective serotonin reuptake inhibitors, or SSRIs, are most commonly used to treat panic disorder. Anti-anxiety drugs like Valium and Xanax are less often prescribed because, while they can halt a panic attack, they can cause dependence and lose their effectiveness over time.

Bienvenu advises his patients that cognitive behavioral therapy takes a lot of work but has proved effective. A common technique is simple breathing retraining. When we start to feel anxious, our breath becomes short and shallow, a condition that could lead to hyperventilation. Bienvenu tells patients when they begin to feel anxious, to take deep breaths to fill the lungs. Another technique is cognitive restructuring. A therapist will help identify unhelpful automatic thoughts, such as ‘I’m having a heart attack,’ and redirect the mind to an alternative more positive feeling, like a funny joke or the image of a child.

An increasingly common therapy involves controlled exposure to symptoms and triggers during a time of low or no anxiety. For example, Bienvenu will have a patient run in place to elevate the heart rate. He might have a person stare at a lamp to temporarily blur their vision, or shake hands repeatedly to bring on a sense of numbness. The goal is to help the person both identify and tolerate the symptoms.

“Some people with panic disorder might even avoid exercising, as it brings about overlapping panic attack symptoms. But we want them to habituate to these sensations,” Bienvenu says. “It’s the symptoms without the anxiety. We first do these in the office, in a controlled environment, and then the patient does them on their own. The more they get used to feeling this way, the anxiety part will decrease.”

There’s also what is called real-world exposure, going to places that people have been avoiding, such as a train or a shopping mall. Bienvenue says his patients are often reluctant at first.

“I tell people it’s perfectly natural to be frightened by these attacks,” he says. “They do tend to scare the heck out of people. It’s natural to want to avoid one again. But the people who do best are the ones who address it as soon as possible and don’t develop a lifetime of avoidance.”

“It’s perfectly natural to be frightened by these attacks. It’s natural to want to avoid one again. But the people who do best are the ones who address it as soon as possible and don’t develop a lifetime of avoidance.”

In her case, Annie first went to a primary care physician, who referred her to a cardiologist. She also went to see an eye doctor, thinking perhaps a vision problem such as tunnel vision was the cause of her bridge anxiety. Ultimately, she saw a psychologist at Johns Hopkins Bayview, who prescribed a 12-week treatment that involved talking in detail about her anxiety and her symptoms, followed by progressive cognitive behavioral therapy. First she started chewing gum, especially when driving, and took up morning yoga and deep-breathing exercises. She was prescribed anti-anxiety medicine for a year. To help her better identify her symptoms, she started breathing through a straw to mimic her anxiety symptoms, such as breathlessness and a rapid heart rate. While driving, she would call her husband on her car’s Bluetooth when a symptom appeared, so he could help calm her down. She drove on the highways for a short period on days she felt “safe.” She also repeated a mantra of “I will be fine” when behind the wheel.

Today, Annie takes the highway for her commute to work. “But I still have some anxiety when I see a bridge,” she says. “My doctor wants me to keep working on it, and eventually I will have no anxiety at all. Hopefully, at the end of my program, I won’t need any pills, and I can drive like I used to.”

Susan continued with “talk” therapy and tried several relaxation programs. Those interventions, along with medications, mostly kept the panic attacks at bay, although the threat of them still kept her avoiding many activities. In 2008, following the death of several close friends and her father’s heart attack, Susan’s attacks resurfaced. Her new psychiatrist convinced her to try an SSRI. He also recommended exposure therapy, which she rejected, as the idea of inducing a panic attack was too frightening. Five years later, she gained the confidence to travel more, even fly. Today she can even drive over bridges without debilitating anxiety. Not only have the panic attacks disappeared but so has the anxiety about having one. “I have control over my life again,” she says.

car on bridge facing doom
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What are the symptoms of a panic attack?

Generally, if you have four or more panic attacks—and if you always worry about having another—you have panic disorder. An attack can last from a few minutes to an hour, or sometimes longer. Symptoms of a panic attack may include:

  • Sense of impending doom or danger
  • Pounding heart
  • Sweating
  • Trembling or shaking
  • Shortness of breath
  • Sense of choking
  • Nausea or belly pain
  • Dizziness or lightheadedness
  • Feeling unreal or disconnected from oneself
  • Fear of losing control
  • Fear of “going crazy” or dying
  • Numbness
  • Chills or hot flashes
  • Chest pain and other symptoms that mimic a heart attack

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