Panic attacks are terrible, and terrible in a very particular way. On paper, recognizing panic attacks and Panic Disorder is straightforward. In practice, “having a panic attack” means different things to different people. Panic occurs in various situations, likely as a product of distinct mechanisms, all serving a deeply unpleasant but useful end. It’s a bit like throwing up.
When asked about panic, some people try hard to get to yes. “Hmmm…well, I really freak out sometimes...” It shouldn’t be hard to recall a panic attack! Feeling especially stressed and overwhelmed is worth addressing, but the colloquial anxiety attack fits better here.
The traditional idea of panic involves hyperventilation, palpitations, a choking sensation, impending doom, and an urge to flee. This probably originated as an ancient “suffocation alarm.” Attacks are induced by high blood carbon dioxide and lactate, while confined places, implying constricted breathing, are a classic cause.
Of course, sometimes people really are suffocating! In ICUs, people on breathing support must wean from the ventilator, with resulting air hunger. In late pregnancy, the uterus compresses the diaphragm and lungs. In general, panic is more common in any lung pathology. Despite the DSM recognizing this distinction, physiologic panic is often dubbed a disorder.
But people with panic disorder tend to notice and over-interpret all bodily sensations, and attacks are also triggered by palpitations, dizziness, or nausea. The gut hormone cholecystokinin reliably induces panic. Think of phobias toward blood and vomit, plus the overlap of panic disorder with illness anxiety. This all hangs together as part of the body-scanning interoceptive nervous system, with internal panic as an over-amplified but generic error signal.
On the other hand, there’s plenty of external panic. Causes include genuine danger like wild animals or assault, PTSD from combat or car crashes, and phobias of snakes or dogs. We should probably just call this fear! Speaking of which, the HPA cortisol stress axis is activated by fear but not panic attacks.
Finally, some panic represents separation distress. Imagine a three year old stranded in the aisle of a grocery store: they call out, cry, tremble, and hyperventilate. Childhood separation anxiety is a risk factor for adult panic disorder, especially with agoraphobia (fear of markets…). Insecure attachment often goes with panic, and bereavement is a common time for first attacks. Panksepp used “PANIC/GRIEF” to denote his separation distress system: activation induces animals to stay in place and call out with chirping, crying, or drunken texting. This makes a lot of sense if the goal is reunion with a loved one, and very little sense as a response to suffocation or predators.
A plausible link here is endogenous opioids, which regulate both respiration and separation anxiety. Think how opiates simultaneously suppress breathing and induce warm bliss. It’s tempting to extend the idea of opioid dysregulation from panic disorder to certain types of depression, psychosomatic pain, and the labile attachment of borderline personality, a common mechanism for conditions that often occur together.
Fascinating and really useful concise summary.
I developed a form of "anxiety" disorder that went from near-panic (mostly physiological symptoms, generally breathing and dizziness connected, often exercise-triggered) to bog standard health anxiety/minor phobia like fixations (and most certainly oversensitivity to internal body clues that I'd not even notice few months prior) to generalized sense of somewhat melancholy doom accompanied by intrusive thoughts of atrocities that didn't affect me personally (so closer to "OCD like" patterns). All as a result of moderately traumatic bereavement in middle age -- there has been a morbid fascination in observing my brain breaking (metaphorically) and then sort of but not quite (yet) reassembling itself.
So, why not to call ALL of that "inappropriate fear (threat detection) reaction" seems like a very valid point on the one hand -- but finer gradation of "panic" also make much sense (the only real full on panic attack with clammy skin and other clinical symptoms I have ever had was long time before my breakdown, completely random, one off, and purely physiological -- I was 100% sure that I wasn't dying while all my symptoms were screaming that I was -- very surreal experience).