Panic attack

by Carolyn Thomas ♥ @HeartSisters

For most of us, feelings of anxiety or panic are occasional, mild and brief – the body’s 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. . . . .

I had a heart attack that featured, among many other scary bits, two particularly terrifying cardiac episodes during a 5-hour flight returning to the west coast after my mother’s 80th birthday weekend. I knew that something was terribly wrong with me even before I boarded that big plane, 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! And after all, I’d already been sent away from Emergency recently by a man with the letters M.D. after his name who had confidently misdiagnosed my severe symptoms (“You’re in the right demographic for acid reflux!”)

*NOTE FROM CAROLYN: In the immortal words of my late Dad, “Do NOT do what I do! Do what I say!”

Five months after I survived that flight, I found myself once again on a big plane – this time, flying east to attend the WomenHeart Science & Leadership patient advocacy training at Mayo Clinic in the fall of 2008. The last time I’d been onboard a plane, terrifying things had happened to me. I was feeling extremely nervous about walking onto that aircraft. Only the thought that Mayo is chock-a-block full of cardiologists (who would know what to do if I had another cardiac event this time) propelled me onboard that plane, heel marks scuffed 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 Rochester, Minnesota, I started sweating 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, 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 minutes. Anybody can experience a panic attack, especially when feeling stressed or overtired. I had never had one before that flight in 2008 – ever.

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 identified by the CAMH:

Physical symptoms can include:

pounding heart
sweating
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

My deep reluctance to board that big plane to Mayo (or – even worse, the return flight home four days later) was an example of behavioural avoidance. I’m sometimes asked if I feel better about flying these days. Since that Mayo Clinic flight in 2008, I’ve taken only two other return flights: the first was another trip to Mayo, and the next was to my mother’s funeral. Any future flight that is less important than attending my mother’s funeral is now of zero interest to me. Oddly enough, I don’t have the same reaction at all to flying by helicopter (a relatively common 35-minute commuter hop over to Vancouver from my island home) and I have been uneventfully flown there and back several times to speak at medical conferences. I didn’t, after all, have a heart attack on a helicopter. . .

But sometimes, behavioural avoidance triggered by a panic attack isn’t just about occasional or rare experiences like flying, but can severely disrupt everyday life (e.g. loud noises, exercise, crowds, confrontation, work deadlines, family illness, etc.) That’s when strategies for managing these responses – and knowing the difference between symptoms caused by panic and those caused by a heart attack – can be important to know in advance.

Here are some basic differences(1) that might help you:

HEART ATTACK

Escalating chest pain (may start small and gradually increase 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 at least 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

People who are not heart patients but who do suffer with anxiety or panic often believe that they are having a massive 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 belief in my inability to breathe enough oxygenated air on that plane felt to me at the time. It was NOT 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.”

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 a panic disorder.(2)

Strategies to reduce the frightening symptoms of anxiety or panic are 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. I wish I’d had her list of these tips when I was on that plane heading to Mayo in 2008!

“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.”

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 is linked to surviving a cardiac event.

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 new-onset 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.

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?

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 (BOOK SALE! Use their code HTWN to save 30% off the list price when you order).