Understanding Panic Attacks

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Q. My uncle has been recently diagnosed with panic anxiety disorder. Can this just come on at the age of 45 for no apparent reason, and can you pass out during a panic attack? Also, his heart rate goes up really high, to 170 then down to 30. Is that diagnosis correct?

A. Panic anxiety attacks can be scary for the people suffering from them, as well as for their friends and loved ones. No doubt your uncle is very worried and fearful given his irregular heart rate and his passing out. So, a question we try to figure out is this: Is the anticipation of a medical problem triggering his anxiety, or is his panic anxiety bringing on symptoms such as his rapid heart rate? Kind of like "Which event came first?"

Let me explain. It is not unusual for a person affected with a chronic medical problem to have some degree of anxiety regarding his or her condition, such as a preoccupation about when and if it will reoccur. Some of these health concerns include asthma attacks, mitral valve prolapse, hypoglycemia, thyroid disease, substance abuse, depression, seizure disorders and chest pain.

On the other hand, when a person has panic anxiety disorder, he typically has had two or more panic attacks plus other symptoms, which I’ll explain more later. During these panic attacks, a patient’s breathing becomes rapid, his heart rate increases, and he can become lightheaded and feel like he will pass out.

With the brief information you gave about your uncle, I think it would be unusual for a panic anxiety disorder to rocket his heart rate up to 170, slow it down to 30, then cause him to pass out. I'm not saying he doesn't have some degree of panic anxiety, but I am concerned a medical condition is at its root. I would encourage a re-evaluation by his primary care physician or cardiologist. For instance, your uncle may be experiencing an irregular heart rhythm, which in turn is triggering his anxiety. Sometimes a second look is helpful.

But, before I sign off, I’d like to give more information about panic anxiety disorder. To help a patient with anxiety, we need to figure out the pattern for his attacks. Because this requires detective work, we need as much information as the patient can give us in order to figure out the cause of the problem.

In general, panic attacks seem to occur in three patterns:

Situational: For example, getting on elevators triggers them.
Random: A person could be having a good day and from out of nowhere symptoms occur.
Reminder events: A situation where the person has had prior panic attacks, but they don’t always occur (for example, being in a crowded area).

Panic attacks tend to start quickly, last 10-30 minutes and bring intense fear or discomfort. Everyone is different and may experience a wide range of symptoms. But to be called a panic attack, the episodes usually have at least four of the following:

A rapid heart beat (tachycardia), palpitations
A feeling of imminent danger or dying
Abdominal discomfort, nausea or cramping
The need to immediately escape
A sense of things being unreal
A choking feeling
Shortness of breath
A fear of losing control or going crazy
Dizziness or lightheadedness
Trembling or weakness
Sweating
Hot and cold flashes
Chest pains or discomfort
Tingling or numbness.

Panic attacks can happen with other types of anxiety such as phobias and post-traumatic stress disorder. Even if you do not have an anxiety disorder, many people experience a panic attack at some time in their lives. While it is scary to have that happen to you, a diagnosis of panic disorder is not made unless a person experiences at least two of these unexpected and sudden panic attacks, as well as a month or longer occurrence of one of the following:

Worrying about another attack
Worrying about the cause of the attack (heart problems)
Changing behaviors to avoid another attack (for example, sitting by an open door so you can “get out” whenever you need to).

If panic disorder is to occur, it usually shows itself somewhere between the teenage years and the 30s. However, it can begin earlier or later. It is more common in women than in men. Some people have frequent panic attacks, while others may have few, if any reoccurrence. The main thing is this: If you have anxiety, please get checked by a physician or mental-health specialist skilled at helping people with this problem.

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Robert Danoff, D.O., M.S., is a family physician and program director of The Family Practice Residency, as well as the combined Family Practice/Emergency Medicine Residency programs at Frankford Hospitals, Jefferson Health System, Philadelphia, Pa. He is the medical correspondent for CN8, The Comcast Network, a regular contributor to Discovery Health Online and a contributing writer to The New York Times Special Features. (Read his full bio.)