Panic attacks and fear - they are different things

There is some compelling evidence coming from neurological and other studies that show that panic attacks and anxiety or fear are different. Part of the problem is that once an individual has had one episode of a panic attack they can begin to fear the onset of another attack, which often exacerbates the problem.

Research findings

A study (American Journal of Psychiatry 1991; 148:361-364) conducted by Russell, Kushner, Beitman and Bartels at the University of Missouri, Columbia School of Medicine in1991 tested a group of patients who were having panic attacks for symptoms of anxiety and fear. They were surprised to discover that not one of the individuals who were having panic attacks presented symptoms of anxiety. As a result of this and a number of similar studies panic attacks are known as 'Non-fearful Panic Disorder' by professionals.

When examined using fMRI scans, panic attacks activate pathways that are similar to those activated during anxiety or fear related episodes. In the early days of MRI scans it was thought that panic disorders and fear / anxiety had exactly the same pathways. However recently (2008 onwards) studies at my own university (University of Oxford) have shown that whilst they do at first look remarkably similar in that the same regions (especially the thalamus and amygdelea) are involved, there are significant differences in the neuronal pathways within these regions.

This really shouldn't have come as a surprise as the experience of a panic attack, when compared with anxiety or fear, are obviously different.

Panic attacks - what they are

The main symptoms of a panic attack are (sufferers may get any combination or all of these):

1. Panic attacks are noted particularly for the unexpected and sudden nature of their onset. They arrive very suddenly.
2. There is no or little warning and unlike fear and anxiety, they don't appear to be associated with any external stimuli or event. In other words they appear impossible to predict, there doesn't appear to be a pattern to them or anything that 'sets them off'. Suffers report that they just strike anywhere any time. Including during sleep, when people can wake up having an attack.
   
3. Heart palpitations, frequently causing the sufferer to believe that they may have or be having a heart attack, or that their heart will burst or stop.
4. Going red and getting suddenly uncomfortably hot, or 'burning up'; alternatively others report feeling very cold, particularly in the extremities - the feet or hands.
5. Clammy hands or sweaty.
   
6. Feeling dizzy, faint or weak.
7. Shortness of breath or hyperventilation
8. Nausea or abdominal discomfort
9. Paresthesias of hands and feet (numbness, prickling or tingling sensations)
10. Depersonalisation and Derealisation (feeling strangely detached and like things aren't real)
11. Chocking or severe constriction of the through - a feeling of suffocation.

One of the major distinguishing characteristics (and most worrying for the victim) of a panic attack is that they strike without warning, at any time. They aren't normally associated with a trigger. So for example sufferers usually report shock when they have had their first attack because they were doing something mundane or 'normal' when the attack occurred. Additionally the apparently random, sudden and debilitating nature of a panic attack often results in the sufferer living in dread and fear of another episode. This exacerbates the situation. Especially when a second attack occurs. As soon as the victim realises what is happening the second attack is often worse.

Fear, nervousness and anxiety - What they are

The first thing to note about fear is that nerves and anxieties are usually considered to be less intense but component levels of fear. The next thing to note is that fear, nerves and anxiety are almost always linked or associated with some (usually) external stimulus like flying, an exam, public speaking or spiders for example, which is not usually the case with panic attacks. As such, the individual is normally, (but not always) conciously aware of the associated stimulus. In other words the person usually knows what is 'causing' the fear. This is not the case with panic attacks which don't normally appear to be associated with the immediate surroundings.

The onset of a fear response usually has degrees or levels. So that if the stimulus, say doing a presentation, is some distance away the level of fear or anxiety experienced is less than if the stimulus is imminent or in very close proximity.

Panic Attacks are feared

As mentioned at the head of the article, once an individual has had a panic attack, because of the sudden and apparently random nature of the attack, they then often begin to fear another attack. This fear actually makes the situation worse and can increase the frequency of attacks.

The differences between panic and fear

The major distinctions between fear and a panic attack are:

	Panic Attack	Fear
Warning	No warning	Usually preceded by anxiety or 'nerves' or proximity of associated stimulus.
Speed	Strikes suddenly	Usually has a bit of a build up unless surprised by something
Association	Appears to have no association / pattern - just happen anywhere, anytime.	Normally associated with something - speaking in public or spiders for example. Discernable pattern (usually)
When	Anytime including during 'no dream' as well as dream sleep	Always associated - so anytime and during dream sleep only
Duration	From a few minutes to 30 mins: average 4 - 15 minutes	Can last for sustained periods
Who	Anyone - about 5 - 7% of population have one at sometime in their life. However typical profile: Female (approx 70:30 female:male) 19 - 47 (Peak early 20's) Stressed (usually within 3 months of a stress event/change)	Anyone - Every normal functioning human will feel fear at some time in their lives.
Pathway	Similar but significantly different to fear	Fear, nervousness and anxiety share the same neural pathways

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