Read Something Interesting About Anxiety/Panic Disorder From A Doc

[tednlou2]

I was searching for some answers on anxiety and came across this response from a doctor.  I thought it was interesting.  Actually, thought it was very interesting, and thought how nice to have a doc respond in such detail.  Perhaps I'll save why I was searching for this for another thread, as it would get really long.

A doc responds to a question about perceived physical problems:

To the issue that seems more overwhelming to you, let me speak a few minutes about panic disorder. I want to discuss it purely from a physiological standpoint and see if we can better explain some of your symptoms and refrain from trying to hang a label around your neck of some type.

First of all, realize that physical symptoms do not necessarily equate with physical disease. It is both an innate characteristic and prominent social training that causes humans to make this direct connection. So it stands to reason that when unfamiliar symptoms arise, apprehension is quite intense that it's related to some as yet unidentified physical disorder or disease and more likely a serious one. The continuation of the rather unpredictable course of symptoms can begin to errode a person's self-confidence and well-being such that a low-level fearfulness predominates the thought processes. There is oftentimes vigilence to autonomic functions such as heartbeat, heart rate and respiration that can extend to other other body functions for signs of trouble or any departure from what they know to be normal.

This sort of mental feedback can introduce something known as a fight or flight response, wherein the nervous system goes on high alert. It's important to understand that this response is an entirely normal function under the right circumstances and is controlled by the sympathetic and parasympathetic nervous system. You can sort of think of the sympathetic nervous system as the gas pedal, accelerating the heart and respiration, increasing awareness and visual acuity, decreasing GI functions and generally preparing the body to either fend off a threat or run from it.

Think of the parasympathetic nervous system as the brakes, lowering heart rate and respiration, returning cognitive vigilence and visual acuity to more base-level functioning and increasing GI motility and peristalsis. In general, the parasympathetic drives induce physiological attenuation of the excitatory phases caused by the sympathetic nervous system. Again, under the right circumstances, these changes are entirely normal.

Now, let's employ a real-life example to illustrate how these two systems work in concert to create physiological changes. Let's suppose that you're at the movies and you become engrossed in the visual effects and impact of the film that is designed to invoke emotion of some type. Let's further use the context wherein these effects cause fear. As tension mounts in the movie scene, we can begin to experience apprehension of some climactic event about to unfold. The respiration is increased, together with heart rate and unknown to most folks at the time, systolic blood pressure. Auditory senses are also increased and we become further affected by the pause in sound or single monotones that we are accustomed to associating with mounting tension on the movie screen.

Suddenly, the threshold event occurs and we are momentarily jolted by the surprise and unpredictability. The heart begins racing and may even skip a beat or two, respiration becomes shallow and rapid, even irregular, the stomach may experience a sinking feeling that is associated with adrenal surge, tingling sensations rush through the body and tightness is sensed in the throat of some persons and because our senses are highly stimulated, we absorb the full emotional impact. Realize that the body responds with lightning fast changes because the brain interprets the situation to represent danger, regardless of whether it's real or not. The description of the events outlined above are associated with sympathetic nervous response.

Once the threshold passes and folks stop screaming or gasping, the brain senses from visual and other feedback that the fear has passed. So the heart suddenly slows down and in the case where a rapid change in blood pressure occurs, it can sometimes fall too low. In fact, in some cases people have been known to feel faint or actually pass out momentarily as a result of this rapid change. Understand at this point that when blood pressure falls too quickly, there are sensors in the large arteries in your neck that send signals to the cardiac center of the brain and tells the heart to quickly increase its force so that blood pressure is returned to normal. You sense this as pounding heart. Increased cardiac force is one of the quickest ways for the body to restore normal blood pressure.

The body also increases GI function and some people on rare occasion have been known to lose continence. This event has often been characterized in a more crasse and descriptive jargon.

Okay, so now you see how the body typically responds to circumstances where fear is detected and the fight or flight response causes physiological changes to occur. It is of interesting note that all during these changes, no one contemplates whether these vast changes in physiology might represent symptoms of an underlying disease. In fact, people even openly discuss them as commonplace, describing the consequence as something to the effect of "my heart skipped a beat!" or "my heart was pounding out of my chest!" or "I couldn't get my breath!" and a long, descriptive list of other exclamations used to represent what we all know to be normal physiological reactions to something that frightened us.

Now what about the case where no external event exists, such as the climax in the movie film, to make the direct connection between what we sense as the body makes these changes in upregulation and down-regulation? Well, realize that almost without exception, the description you are providing with respect to symptoms that have you so concerned about underlying disease, are actually the very same physiological responses occuring during a fearful event like the example we've discussed. Only in the latter case, your mind does not make any rational connection such that it appears normal to you and thus, people affected in such a manner begin resorting to irrational thoughts and questions about all the odd and abnormal sensations occurring that in the absence of a reasonable connection, must now be associated with disease of some kind.

The fact that people can't seem to get that long, inspirational breath has to do with several body functions that are affected by the nervous system and you also need to realize that most often, the changes are more dramatic on the parasympathetic side because it feels like things are shutting down, ie heart palpitations, lowered respiration, increased GI function(which can increase motility and cause air or gas to become trapped in the lumen of the intestines and place pressure on the diaphragm, which you sense as a catch or swelling under the lower edge of the ribcage. In other words, the diaphragm can't draw down as far without a sensation of pressure and people who sense this, struggle to overcome it and feel as though they can't get enough air. They may even forcibly yawn to try and cause a deep breath to occur). Understand that there is a main nerve, the vagus nerve, which innervates the heart, lungs, larnyx (tightness in the throat) and the GI tract which responds as part of the parasympathetic nervous system to make all these changes at once.

When the parasympathetic drives begin to compensate, the muscles at the larnyx can be affected due to vagus nerve response and people feel as though their throat is closing off. It is actually only muscle stimulation that yields this effect, but fear and panic causes the person to struggle even harder to get a deep breath. This sensation is known as Globus Hystericus and is quite common in persons with panic.

All of these sensations and changes occurring at once cause fear that something is going terribly wrong and the person feels the urge to run for safety. Thoughts begin to race, which only provides further escalation of the fear that consequently drives the nervous system to respond in a more intensified manner. At some point, a panic threshold can occur that represents a sort of release from a struggle to maintain one's composure of the event and physical collapse is almost imminent.

The problem for many people is that physicians tend to avoid such a lengthy discourse due to obvious time constraints and simply characterize the symptoms as due to anxiety.

Most people who receive such an answer flatly deny that it's due to mere anxiety, and they're right. What you are sensing is caused by a step beyond anxiety, but does not represent situational anxiety of the caliber that is recognized by most people.

What you actually have is a somatic or physical response which exceeds the normal realm of situational anxiety. It is a chronic stimulation of factors related to the nervous system that produce changes which you are misinterpreting as symptoms of disease. All tests for an underlying cause will be negative because diagnostic algorithms are based upon actual markers of disease.

The reason is that the same nervous system network is used in both cases to produce physiological changes, both in instances where underlying disease can be the cause or in your case where it is nothing more than the stimulation of the nervous system itself occurs. Also realize that true disease is more than just stimulation of certain nervous system functions and real symptoms of actual disease are confirmed based upon the company they keep. In other words, certain symptoms in the absence of others is insufficient for association with disease.

My suggestion at this point is to relax. I've reviewed your constellation of symptoms and while I won't echo the comments of your healthcare professionals, I will tell you that I do not believe your symptomatology to be associated with disease. You'll be just fine.

Best regards,

J Cottle, MD

Modified to add link:

http://forums.bettermedicine.com/showthread.php/36841-cant-beathe-pressure-behind-ribs-heart-palipitations