Causes of Anxiety Attacks

Whole Psychiatry goes beyond traditional psychiatric approaches. Traditional psychiatry views the cause of an anxiety attack as due to an unconscious conflict, which is bubbling up into your conscious awareness. Since you don’t want to face the conflict (so the theory goes), you displace the fear onto something else. For example, lets say your father took you to the empire state building when you were 8 years old. At the time, you were unusually angry with, or very afraid of, your father for some reason-lets say he was drinking, an you smelled alcohol on his breath–but saying anything was way too risky as he might get angry with you, or even abandon you, or you were afraid he would fall over the side of the building, since he was so tipsy. You said nothing, and completely forgot about the event. Now, 20 years later, you are having a business lunch, at a nice restaurant overlooking a park, and you smell alcohol on your associate’s breath. Suddenly, you have a panic attack. Your body goes into hyper-arousal. The traditional approach, then, is psychotherapy, to uncover the source of the panic. In the last couple of decades specific types of therapy (cognitive behavioral therapy, exposure and response prevention) to deal with anxiety attacks.

More recently, it has been thought by biological psychiatrists that the causes of anxiety attacks lie in an instability of the brain circuitry which mediates the anxiety attack. This circuitry includes four brain centers or pathways (see figure): The Raphe Nucleus (activated with anticipatory anxiety-the fear of a panic attack), the solitary nucleus (monitors levels of carbon dioxide in the blood), the locus coeruleus (releases adrenalin), and the vagus nerve (bodily sensations from the heart, gut etc.).
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Various medications are commonly used to stabilize these aspects of the circuit, and for the most part psychiatrists now prescribe medications, such as the serotonin reuptake inhibitors (SSRI’s) fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), sertraline (Zoloft), and serotonin-norepinephrine reuptake inhibitors duloxetine (Cymbalta), venlafaxine (Effexor), desvenlafaxine (Pristiq), buspirone (Buspar), to combat all of the anxiety disorders. Specific medications work for specific aspects of anxiety disorders.

More Causes of Anxiety Attacks

Think of the anxiety attack/panic circuitry as a shock absorber in a car. We all drive down the road of life, and we experience bumps in the road. If we have great shock absorbers, we barely feel the bumps. If our shock absorbers are not in good condition, we feel the bumps more. If they are not working much at all, we can lose control of the car if we hit a large bump. Sometimes the bump in the road is just an illusion-its not really there-our senses fool us because we haven’t slept all night, or drank too much coffee– and we react as if it is there. We now know that the brain circuitry referred to above requires certain healthy conditions to exist so that it will function normally.

Whole psychiatry seeks to find out why the shock absorber is unstable, to get to the root of the problem and to fix the shock absorber-not to medicate it. We do this by examining all the parts and systems of the body that affect how the shock absorber works. We take into account the persons situation and circumstances, as well as their psychology too. This process involves looking at nutrition, hormones, digestion, immune function (infection, inflammation), detoxification, genetics, and energy and oxidative stress. After a careful history, physical, and testing, we can determine what needs correction. Very often, this process alone, or in combination with a time-limited therapy, will eliminate the anxiety attacks or other anxiety disorders without medication. When medication is needed, the doses are lower, and the number of medications are reduced. The Whole Psychiatry understanding of the causes of anxiety attacks and anxiety disorders in general includes most all of the above, but seeks to minimize medication, and even psychotherapy, until other causes of anxiety attacks are excluded.

Using the Whole Psychiatry approach many other causes of anxiety attacks have been uncovered. They include:

  • Gut problems (as we age we have more difficulty absorbing nutrients) such as intrinsic factor blocking antibodies, chronic use of antacids, bacterial overgrowth of the small intestine, malabsorption, etc.
  • B-vitamin deficiencies (often vitamin B-12, or folic acid)
  • Fairly common genetic mutations in COMT and MTHFR genes, which increase risk by changing how neurotransmitters are made and broken down
  • Immune System problems such as chronic infections (lyme disease, candida overgrowth), auto-immunity and inflammation
  • Hormonal problems such as hyperthyroidism, adrenal insufficiency or steroid use; hypoglycemia; premature ovarian failure and PMS
  • Tumors such as pheochromocytoma (adrenal gland tumor), or brain tumors
  • Drugs such as caffeine, stimulants, anti-depressants (usually in people with immune system problems), antacids, steroids, thyroid medications
  • Medications and therapy will fail to help with panic attacks or any anxiety disorder if any of the above are present.

Figure: Neural Circuits involved in Anxiety Attacks

Figure: Neural Circuits involved in Anxiety Attacks

Spontaneous Panic Cue-induced (phobic) Panic
Initial  symptoms Respiratory distress: breathlessness, chest discomfort, feelings of choking or suffocation Adrenalin response: rapid heart rate, lightheadedness, sweating, trembling
Brain nucleus involved Solitary nucleus (monitors CO2): suffocation alarm Locus coeruleus (responds to percieved danger with fight/flight response): separation alarm.
Vulnerable periods Relaxation, falling asleep, nondream  sleep, excercise Threatened separation from a relationship percieved as essential, from social group, and from life itself.
Naturally occurring human models Ondine’s curse (an inborn defect in serotonin neurons of the solitary nucleus: in these infants when breathing slows, the increased CO2 does not activate the suffocation alarm); infants with this disorder stop breathing when asleep– the opposite of and absence of panic. Separation of infant from mother
Psychotherapy type Education Cognitive and behavioral exposure therapy
Effective medications Tofranil, Anafranil, Prozac, Zoloft, Paxil, Luvox, Nardil, etc. Klonopin, Xanax, Nardil Inderal, Progesterone , etc.
Chemical inducers Lactic acid (exercise), CO2, bicarbonate, Isuprel (heart medication) Caffeine, Yocon (used for sexual dysfunction)
Anticipatory anxiety Yes Yes
Activation of hormonal axis No immediate activation;  activated later as disorder becomes chronic Immediate activation

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