For most of us, feelings of anxiety or panic are generally occasional, mild and brief – normal responses to being worried or scared. I never thought of myself as a person who was prone to experience anxiety or panic – until I survived a heart attack. I can now tell you quite confidently that there are few things in life that are more anxiety-producing than being in the middle of a frickety-frackin’ heart attack. . .
During this heart attack, I had two particularly terrifying cardiac episodes on a 5-hour flight returning to the west coast after my mother’s 80th birthday weekend. But at no time did I call the flight attendant over for help. I didn’t want to be one of those passengers who force the plane to turn around due to a medical emergency!
Besides, I already knew that it wasn’t my heart. A man with the letters MD after his name had told me so quite clearly earlier in the Emergency Department before he’d sent me home with an acid reflux misdiagnosis – despite my textbook Hollywood Heart Attack symptoms.
I survived that flight, and I did go back to Emergency when I returned home, this time to a correct diagnosis after a different ER doc called in a cardiologist (“You have significant heart disease!”)
But five months later, despite feeling very reluctant to walk onto a plane ever again, I found myself flying east to the wide open cornfields of Minnesota to attend the WomenHeart Science & Leadership patient advocacy training. Only the thought that I was en route to the world-famous Mayo Clinic propelled me onboard that plane, heel marks scuffing behind me all the way.
It was on that flight that I got a taste of what a panic attack might feel like. But I wasn’t even sure what it was at first.
Several minutes into the first leg of the trip to Minneapolis, I started sweating and shaking as I slowly realized that there didn’t seem to be enough oxygenated air circulating on our plane. The air felt too thin! I could hardly breathe. Something was not right.
But I could see the flight crew near me, acting normally, smiling, starting their beverage service, casually chatting with my fellow passengers. They seemed genuinely unconcerned that we were all going to die.
Of course, none of us died that day.
It turns out that this feeling of being smothered is apparently common during a panic attack, according to Canada’s Centre for Addiction and Mental Health (CAMH).
A panic attack is a type of anxiety disorder with sudden feelings of intense fear or discomfort that usually peak within several minutes. Anybody can experience a panic attack, especially when feeling overwhelmed or overtired.
Within several minutes of my own episode on the plane (minutes that felt like hours at the time), I was finally breathing normally again (although an exhausted and sweat-stained wreck after this odd episode).
Panic attacks become more serious if you’re increasingly worried about having another attack, or if you’re afraid that something bad will happen because of a panic attack (e.g. having a heart attack). That’s how it can become a panic disorder.
These attacks often include stressful physical and cognitive symptoms as well as behavioural signs. Here are some as identified by the CAMH:
Physical symptoms can include:
- pounding heart
- trembling or shaking
- shortness of breath
- feelings of choking
- chest pain or discomfort
- dizziness or nausea
- sensations of heat or cold
- numbness or tingling
- feelings of unreality or being detached.
Cognitive symptoms can include thoughts such as:
- “I’m having a heart attack.”
- “I’m suffocating.”
- “I’m losing control.”
- “I’m going crazy.”
Behavioural signs can include:
- avoiding places where you have had anxiety symptoms in the past (e.g. a certain grocery store) or similar places (e.g. all grocery stores)
- avoiding strenuous activities (e.g., exercise)
- avoiding travel, malls, line-ups
By comparison, here are some basic but important differences(2) between the two conditions:
- Escalating chest pain (starts small and gradually increases over time)
- Pain, pressure, heaviness, fullness or aching (may come and go away)
- Pain in the substernal or left chest area
- Pain or discomfort that travels or radiates from the chest to other areas, such as one or both arms, abdomen, back, shoulders, neck, throat or jaw
- Discomfort that is brought on by exertion (although unstable angina may bring about pain without exertion)
- Chest pain that does not get worse when you press on the area.
- In 10% of women’s heart attacks, there are NO chest pain symptoms at all (3)
- Sharp or stabbing chest pain
- Chest pain that is fleeting
- Pain that is localized to one small area
- Pain that usually occurs at rest
- Pain that accompanies anxiety
- Pain that is relieved or worsened when you change positions
- Pain that can be reproduced or worsened by pressing over the area of pain
My deep reluctance to board that flight to Mayo (or – even worse, the return flight home five days later) was an example of behavioural avoidance.
People who are not heart patients but who do suffer with anxiety or panic often believe that they are having a frightening heart attack.
Even when chest pain symptoms subside, and have not resulted in a heart attack at all, the fear that another horrible episode will happen often remains, and worse, the fear that this time it just might be a real heart attack.
This threat feels as real to a person experiencing anxiety or panic symptoms as my sudden inability to breathe enough oxygenated air on that plane felt to me at the time. It wasn’t real, of course. There was in reality plenty of clean safe air in the plane’s ventilation system, but it sure felt (temporarily) real to me.
As Dr. David Katerndahl wrote in his comprehensive literature review on chest pain in people with panic disorders:(1)
” Compared to patients with ischemic heart disease, those with normal cardiac angiogram tests have similar levels of pain and psychosocial stress, and use similar coping strategies.
“Thus, although certain atypical features may suggest panic disorder, many of the characteristics classically associated with coronary artery disease are common in patients with panic disorder or anxiety.”
Even if a person with such conditions finds that taking nitroglycerin works to relieve symptoms (nitro is a heart drug that helps to relax and dilate a heart patient’s coronary arteries to relieve the chest pain of angina), that relief itself is, ironically, not always a sign that the pain is heart-related at all, warns Dr. Katerendahl.
That’s because nitro also seems to help reduce the pain of esophageal spasm, a condition that is experienced by some people living with anxiety and panic disorders, and the kind of chest pain easily mistaken for cardiac pain. He cites studies, in fact, suggesting that nitro helps to relieve chest pain in up to two-thirds of these non-cardiac patients.
Many people living with anxiety or panic disorders have been to the Emergency Department, often more than once, convinced that their racing hearts, shortness of breath or chest pain mean they’re having a heart attack. Almost always, they are not.
Some studies suggest that one-quarter of all patients who seek medical care for chest pain actually have panic disorder.(2)
Trying to reduce the frightening symptoms of anxiety or panic is key to calming those responses. Cognitive Behavioural Therapy (CBT) is widely considered the most effective method of talk therapy to help calm them. An important part of CBT is helping people to identify, question and correct their tendencies to overestimate danger, and their perceived inability to cope with danger.
Psychotherapist Dr. Elvira Aletta is the author of the eBook 7 Rules for Living Well with Chronic Illness, and also a person who experienced her first severe panic attack as a child. One of the many helpful coping tools she describes on her helpful blog, Explore What’s Next, is to begin early interventions when she gets even a whiff that a panic attack may be starting:
“Don’t wait until the panic already has a hold. Most of us can tell when one is building up. Have a strategic list of things to do when the panic monster tries to get in your head.
“Put things on the list that will engage all five senses. My list included deep breathing, telling my husband how I was feeling and just talk, play with my dog or my children, take a hot shower, play some music (didn’t matter what) and dance, keep breathing, use aromatherapy by putting a bit of essential oil on a tissue and breathing the scent in, or watch a favorite old movie with happy associations.”
The topics of panic, anxiety and depression often come up in heart patient support groups because of the inherent emotional, mental and spiritual upset that’s part of so many cardiac events.
Yet mental health issues like anxiety, panic or depression are rarely even mentioned to heart patients in most hospital discharge instructions. See also: When are cardiologists going to start talking about depression?
Although almost half of female heart patients report suffering from significant mental health issues, for example, fewer than 10% are appropriately identified and treated. All heart patient should be told before hospital discharge that these issues – situational depression, anxiety or panic – are common, usually temporary and almost always treatable.
NOTE FROM CAROLYN: I wrote much more about the link between heart disease and mental health issues in Chapter 5 of my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the JHUP code HTWN to save 30% off the list price when you order).
1. Katerndahl, David A. “Chest pain and its importance in patients with panic disorder: an updated literature review.” Primary Care Companion to the Journal of Clinical Psychiatry, Vol. 10,5 (2008): 376-83.
2. Huffman, Jeff C. et al. “Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management.” Primary Care Companion to the Journal of Clinical Psychiatry vol. 4,2 (2002): 54-62.
Q: How were you able to tell that your heart attack was not panic or anxiety?
The CAMH provides a free online program called My Anxiety Plan (MAP) that introduces adults to six key stages in reducing symptoms (there’s also one for kids/teenagers).