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A Study of Physiological, Behavioral and Emotional Interlink in Panic Disorder

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A Study of Physiological, Behavioral and Emotional Interlink in Panic Disorder

Cathy Tsang-Feign

Brief Abstract

Over 3 million Americans are affected by panic disorder.  Neuroscientists suggest that the amygdale plays an important role in bringing about the symptoms of panic attack.  Panic attack can be a learned fear response, a genetic and physiologically disposed condition or influenced by one’s cognitive capability in coping with stress.  Cognitive behavior therapy proves to be the most effective treatment modality.  Studies indicate that patients with panic disorder will benefit from learning proper breathing techniques to pace themselves in managing the anxiety of possible panic attack.  A gradual process of regaining trust in their own body will allow them to overcome the panic disorder.


According to studies conducted by the National Institute of Mental Health (NIMH), more than 19 million adult Americans aged 18 to 54 suffer from anxiety disorders (NIMH, 2000).  Anxiety disorders include several clinical conditions: panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, phobias and generalized anxiety disorder.  Currently about 3 million Americans are affected by panic disorder.  Panic disorder can cause individuals to feel extreme fear, accompanied by intense physical symptoms which strike unexpectedly and repeatedly for no apparent reason.


Neuroscientists indicate that panic disorder is a response dictated by the autonomic nervous system.  The fight or flight reaction is a physical symptom in response to perceived danger.  Such a response is caused by the specific brain area and circuits called the amygdale, which triggers the anxiety and fear. The vital neurotransmitter acetylcholine is activated by negative emotions and passes signals through the spinal cord.  In turn, acetylcholine sends an alarm to the sympathetic nervous system to set off physical reactions in the body, such as palpations, hyperventilation, dizziness, dry mouth, and shortness of breath, as if the body were experiencing a real physical attack.  This ultimately brings on a full-blown panic attack.

Possible contributing factors of panic attack

A) Learned Fear Response

According to studies conducted by The National Institute of Mental Health, fearful experiences or traumas can condition a person to respond excessively to situations in which most people would not experience fear. This is a learned fear response (NIMH, 2000).  Such a behavioral response is triggered by imprinted memories, which bring the body to a state of hypervigilance with the help of adrenaline.  The fight or flight response and feelings of anxiety kick in and result in a panic attack for the sufferer.  In addition, the chronic worry about having another attack aggravates the person’s anxiety, which subsequently triggers further panic attacks.  The more a person experiences panic attacks, the more anxious they become and the likelihood of them experiencing another attack is increased.  Gradually panic attack sufferers feel their life is out of their control. 

B) Brain Functioning

            Recent research show that memories stored in the amygdale are relatively difficult to erase.  The negative memories resulting from panic attacks can be triggered over and over again as long as the panic disorder sufferer perceives certain experiences or situations as fearful or dangerous.  The physiological state will take on a life of its own to bring on the fight or flight response.  Therefore individuals who suffer from panic disorder need to learn to control the amygdale cognitively in order to bring the attack under control.

C) Cognitive factors toward stimuli

An individual’s way of processing information cognitively and their cognitive capability in anxiety provoking circumstances can be an indication of possible factors causing them to suffer from panic disorder.  Some people tend to view things negatively and perceive themselves often in a disadvantageous position, such as feelings of always having to fend for themselves alone or no one really caring about them.  They may tend to assess life events or situations with fear and worry.  Data from the National Institute of Mental Health shows that people who tend to be overly responsive to potentially threatening stimuli are more likely than others to experience panic attacks (NIMH, 2000).

D) Hormone Reaction

Studies conducted by B. Bandelow and his team claim that panic attacks are associated with abnormal levels of certain hormones.  Subjects experiencing panic attack show a low level of stress hormone cortisol in the saliva but overabundance of epinephrine and norepinephrine (Bandelow, Wedekind & Pauls, 2000).  This perhaps explains why individuals continue to feel anxious even after a panic attack.  At the same time, they tend to have higher than usual levels of corticotrophin releasing factor (CRF), which helps to bring on the stress response rapidly.  This also predisposes such people to panic attacks and leads them to become easily startled (Starkman, Cameron & Zelnik, 1990).

E) Cigarette Smoking and Neuroticism

Results from the Midlife Development in the United States Survey indicate that panic attacks are associated with a significantly higher likelihood of cigarette smoking.  At the same time, results of three separate multivariate logistic regression analyses—with neuroticism as the independent variable and the three indicator variables such as panic without smoking, smoking without panic, co-occurring panic and smoking—revealed that neuroticism was not significantly associated either with panic attacks without smoking or with cigarette smoking in the absence of panic attacks (Goodwin & Hamilton, 2002). Neuroticism was an independent predictor of the co-occurrence of cigarette smoking.  It became obvious that there is a symbiotic relationship between high neuroticism and likelihood of the co-occurrence of panic attacks and cigarette smoking.  In other words, the increase in neuroticism will increase the chance of panic attacks and cigarette smoking. 

F) Smaller Hippocampus

Imaging studies show that brain structure may be related to panic disorder.  Results show that there is a decreased volume of the hippocampus in patients with panic disorder (Campbell & MacQueen, 2004).   When individuals are confronted with fear, neuronal processes in the amygdale are extended, while the hippocampus shrinks with stress.  There is clear indication that chronic stress can cause degeneration of the hippocampus (Dolnak, 2006).  At the same time, research suggests that people who have a smaller hippocampus are more prone to panic attacks (Campbell & MacQueen, 2004).

G) Genetic Factors

Research on twins suggests that genetics can be an important factor causing some people to be at higher risk of suffering from panic attacks.  The genetic predisposition of family members passing on panic disorder is between ten and twenty percent (Chew, 2001).  In addition, studies conducted by researchers from Ohio State University indicate that panic disorder can be due to a biological malfunction.  They found that a specific gene, the 5HTT, which is responsible for regulating serotonin, is imbalanced in patients suffering from panic attacks.  The combination of genetic traits and the serotonin imbalance causes susceptible patients’ brains to take up serotonin more quickly.  This process leaves less serotonin available during stress and makes the person more likely to have panic attacks (Schmidt, 2000). 

Assessment techniques

The majority of panic attack sufferers try to assess their own condition prior to seeking professional help.  Their early episodes of panic attacks usually are mistaken by them as heart attacks; therefore they often check themselves into an emergency room for urgent care.  Usually this is their first step: self-assessment through physicians.  In most cases they are informed that they have a clean bill of physical health and often they are advised that their condition is likely anxiety disorder.  Then finally they may look into the psychological aspects of panic attacks.  To fit the diagnosis of panic disorder the initial panic attack lasts at least one month, with at least one the following symptoms and behaviors: 1) constant worry about having another panic attack between episodes; 2) constant worry about what caused the attack; or 3) behavioral changes related to the panic attack such as avoidance of places or situations.

An individual’s life situation or circumstances will provide a clear picture of what kind of stress he or she is under at the time of the first onset of a panic attack.  The personality and methods of handling his or her emotions in relation to stress are crucial.  Some people may simply suppress the intense emotions resulting from a stress-provoking situation.  They rationalize to themselves that they are not stressed or affected by the triggering incidents and yet they may be producing a great degree of physical reaction (Strohle, Holsboer & Rupprocht, 2002).  These behaviors may be changing the hormone balance and perception of the real situations, which together ultimately triggers the fight or flight responses.  Therefore in assessing panic disorder it is important to assess individual patterns of coping with stress, family history and coping mechanisms, the ways individuals resolve problems or issues that trouble them, any major changes in life recently such as change of job, divorce or break-up, death of a family member, and so on.  It is rather difficult to define panic disorder in a simplistic way.  It is a psychological disorder with symptoms manifested through behavioral and physiological aspects.  Therefore the assessment of such a condition requires a view of both aspects to get a clear and accurate picture of the condition of a patient.

 Mechanism of action of the causative agents

A panic attack triggers a false alarm to the body.  But the fight or flight response which is triggered is a built-in mechanism meant to protect life in case of threat in dangerous circumstances.  This adaptive function kicks in to cause immediate response for the sake of self-preservation. The sympathetic nervous system is responsible for releasing adrenaline and noradrenaline to cause such an action. The parasympathetic nervous system serves as a stabilizer to restore its function to the normal state after a period of time.  However, the sympathetic nervous system of individuals prone to anxiety and panic attacks tend to be triggered by false alarms.  The fight or flight response get activated in situations or circumstances that do not pose any genuine danger to the person.  Somehow the brain sets off the faulty message to the amygdale, which results in a panic reaction (Valencia, 1999).  At the same time there is also a malfunction in the parasympathetic nervous system which causes its inability to restore the body to a stable state after panic has been triggered.  Sufferers remain hyped up for hours or even days because there are high levels of free-floating adrenaline in the body that have not been burned off (Frederico, Garcia-Leal & Del-Ben, 2005).

Fight or flight is not an abnormal physiological state but a life saving mechanism.  However, when such a physical response is caused by psychological triggers which mimic a real life danger, it changes the actual function of the bodily mechanism.  Panic attack then becomes a psychological dysfunction and behavioral condition which defeats the normality of an individual’s physical health.  It disrupts a person’s daily life and mental state, and inhibits their movement due to fear of possibility of a panic attack episode.  In some cases people who suffer from panic attack believe they are suffering from a heart attack (Friedman, 2001).  Even if they are not outright having a heart attack, they fear that the symptoms of panic attack will somehow lead them to have a heart attack.  The fear of having yet another panic attack is intertwined in a sufferer’s mind and physical body.  In other words, an individual’s fear and anxiety of the possible panic episode actually causes their body to produce the symptoms of a panic attack.  Often they are trapped into the fear of more panic attacks more so than actually experiencing further attacks.

Intervention techniques

Studies suggest that increased cognitive control over the amygdale shortcuts the false signals panic attack sufferers may trigger in the brain (Broocks, Bardelow & Koch, 2002).  Such action helps disrupt the reactive responses to situations that they perceive as imminent danger.  Cognitive-behavioral therapy has been proven to be the most effective intervention for panic disorder (Barlow & Craske, G., 1989). While patients need to cognitively learn about what panic attacks are all about, at the same time they have to adopt a new behavior pattern to deal with the physical responses during the attacks. Therefore, therapy should focus on practical and directive formats, helping patients to cope with the anxiety when it arises.  It is crucial to educate them about how the fight or flight mechanism works in the body and empower them to regain control over their body through their mind. 

At the same time patients must be provided with practical skills, such as proper breathing techniques and relaxation techniques, to enhance their control over the distorted physical sensations and calm themselves down in anxiety-provoking circumstances.  For people who experience panic attacks, proper breathing technique is crucial to master.  Through a better breathing pattern they can pace themselves and even bring down their anxiety level in stressful situations.

Panic attack sufferers must be helped to focus on positive actions to combat the recurring panic attacks by establishing a regular exercise routine (Barlow, H., 1988).  This will give them a channel to release stress which ultimately manifests through the body if not dealt with.

Sometimes medications are used to help patients to cope with the symptoms of panic attacks. These include beta blockers, tricyclics, benzodiazepines, MAOIs, and SSRIs.  However, from my own experience working with people with panic disorder, medication tends to suppress the symptoms only.  Once the medication is stopped the symptoms return.  Many people end up relying on medication for years to cope with the disorder without really overcoming the problem.  I would rather support patients to exhaust all other methods before falling back onto relying on medication.  If medication were to be prescribed it should only be used alongside psychotherapy at the beginning of treatment, and only for a very short time.  The length of time on medication should be carefully monitored.

Panic attacks require sufferers to understand, learn, cope and manage from their own experiences.  Providing them with knowledge of the illness and coaching them to new thinking and behavior patterns will help them to slowly regain confidence in taking charge of their body.  They have to learn to trust their body again and not be fearful that their body will give up on them.  Only time and practice will help them to rebuild their trust in their body and mind.


Bandelow, B., Wedekind, D. & Pauls, J. (2000). Salivary cortisol in panic attack. American Journal of Psychiatry, 157: 454-456.

Barlow, H. (1988). Anxiety and its disorders: the nature and treatment and treatment of anxiety and panic. New York: The Guilford Press.
Barlow, H. & Craske, G. (1989). Mastery of your anxiety and panic.  Manual available from the Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany NY 12203  

Broocks, A., Bardelow, B. & Koch, K. (2002). Smoking modulates neuroendocrine responses to ipsapirone in patients with panic disorder. Neuropsychopharmacology, 27: 270-278.

Campbell,  S. & MacQueen, G. (2004). The role of the hippocampus in the pathophysiology of major depression. Journal of Psychiatry in Neuroscience, 29: 417-426.

Chew, J. (2001), Panic Attacks; Why? How can we stop them?  Website:

Dolnak, D. (2006). Treating patients for comorbid depression, anxiety disorders and somatic illnesses.  Website:

Frederico, G., Garcia-Leal, C. & Del-Ben, C. (2005) . Does the panic attack activate the     hypothalamic-pituitary-adrenal axis? Annals of the Brazilian Academy of Sciences, 77: 477-491

Friedman, S. (2001). Anxiety and anxiety disorder.  website:

Goodwin, R. & Hamilton, S. (2002). Cigarette smoking and panic: the role of  neuroticism.     American Journal of Psychiatry 159: 1208-1213.

National Institute of Mental Health (NIMH) (2000). Anxiety disorder reseach at the National Institute of Mental Health. website:

Schmidt, N. (2000). Gene for panic attack. website:

Starkman, M., Cameron, O. & Zelnik, T.(1990) . Peripheral catecholamine levels and the symptoms of anxiety studies in patients with and without pheochromocytoma. Psychosomatic medicine, 52: 129-142.

Strohle, A., Holsboer, F. & Rupprocht, R. (2002). Increased ACTH concentrations associated with Cholecystokinin Tetrapeptide-induced panic attacks in patients with panic disorder. Neuropsychopharmacology 22: 251-256.

Valencia, A., Nardi, A. & Nascimento, W. (1999).  Carbon dioxide-induced panic attacks and short term clonazapan treatment. website: