When you have panic disorder, the panic attacks are unexpected and come out of nowhere. You can be sitting in your chair, resting in your bed, or walking, when suddenly and unprovoked, a panic attack takes hold. There are no apparent triggers- you just have an unexpected panic attack.
These unexpected panic attacks then lead to anticipatory anxiety about having the next panic attack. The worry about having another panic attack can be so debilitating that it takes hold of you so that you can’t do anything else. Soon, you start avoiding places or situations due to the fear that you may have a panic attack there or that no help may be available. And this anticipatory anxiety about having another panic attack seems to make future panic attacks worse!
So this all starts with the unexpected panic attacks. The unprovoked panic attacks are caused by malfunctioning in the fear circuit based on the amygdala. The fear circuit malfunctions on an intermittent, unexpected, and catastrophic manner, leading to the panic attacks. Exacerbating this malfunction is the ongoing activation of the worry circuit located on the CSTC (cortico-striatal-thalamic-cortical) circuit. So the intermittent and catastrophic malfunctioning of the fear circuit leading to unexpected panic attacks is exacerbated and perpetuated by the malfunctioning in the worry circuit, where you are having anticipatory anxiety about when the next panic attack will occur. So it seems that worrying about the next panic attack only serves to kindle future panic attacks.
Thus, knowing the neurobiology of panic attacks can help to optimize the treatment for it. The intermittent and catastrophic malfunctioning of the fear circuit requires medications to help quell the severe panic attacks. After the panic attacks are successfully treated with medications, then the work continues with the anticipatory anxiety and the avoidant behaviors which contribute to the overactive fear circuit. So besides medications, the second part of treatment involves thinking more adaptive thoughts, and not engaging in avoidant behaviors.
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