Panic and the defence cascade

In panic disorder, the involuntary autonomic physical sensations of the adrenalin response have been misinterpreted by the body as being a sign of imminent threat. From a physiological perspective, the amygdala in the limbic system has learned, through conditioning, that these physical sensations of arousal are a threat that needs an active fear cascade defence. Therefore, the amygdala sends the alarm to the hypothalamus (just like an over-sensitive smoke alarm going off when classical there is no real fire, just burning toast or dust!) whenever internal (body sensations/ thoughts) or external (situations/places) triggers occur. As a learned response, this can be over-learned, through exposure and habituation, which teaches the body the alarm is not required for these symptoms. As these triggers cause arousal, the threat is always imminent and an active defence response initiated (fight or flight). Right at the time they are experiencing the trigger, be it a place, a physical sensation, a thought - even about something in the future - the threat (arousal symptoms) is right there when the fear response is initiated by the amygdala. In literal terms, panic disorder is a fear of fear. These triggers can be any situations that bring on the physical symptoms of the arousal response. These could be busy, crowded places; of previous panic attacks, or also neutral activities and situations that bring on physical sensations that are also part of the arousal response symptoms, like exercise, sex or even walking up stairs, as these increase heart rate, or other physical body changes that happen in arousal such as sweating or a dry mouth.

Understandably, the person begins to avoid things that trigger feeling this way as much as possible. They may also try to escape from these situations if they begin to have symptoms and cannot avoid them, or may do things to make them go down more quickly. People with panic disorder have a range of safety seeking behaviours that they add to their behaviour feel ‘safer’ in these situations. These are done initially to help with the unpleasant physical symptoms they experience, such as carrying water for a dry mouth, taking someone out with them, adapting when they go, listen to music on headphones, walk at the edge of busy streets, use a stick to walk or a trolley in supermarkets to manage feeling unsteady or carrying emergency numbers as just some examples. They may use alcohol to feel able to face situations, or carry around herbal or prescribed medications ‘just in case’. Other patients may avoid alcohol, coffee or similar substances as they bring on their symptoms. People may also use more covert and subtle safety seeking behaviours to divert their attention away from their symptoms and distract themselves, for example humming or trying to think about other things.

Asking about what they do and gathering specific examples is very important as these things may otherwise negatively impact on exposure exercises or can be contra-indicated with exposure and habituation (such as use of benzodiazepines or beta-blockers). It also helps with hierarchy creation. For every safety behaviour gathered, the associated autonomic symptom that it brings relief from should be linked and checked and what they think would happen if they did not do the safety behaviour asked.

These adaptations to behaviour serve to maintain the panic disorder, with the reason for not panicking attributed to this. They backfire as then become part of the pattern and also block over learning that the fear response was not required from taking place.