If you’ve ever had a panic attack, you are well aware of what a terrifying experience it can be – and if you have a panic disorder, you understand how this condition can negatively impact virtually every part of your life.
One of the many challenges clinicians face in effectively treating panic disorder is understanding the neurobiology of panic attacks.
Where does panic begin in the brain?
How does the initial signal lead to a full-blown attack?
In January 2024, experts with the Salk Institute announced a significant step toward answering these questions. The Salk Institute study, which appeared in the journal Nature Neuroscience, identified a neural pathway researchers believe could hold the key to more effective treatment for panic disorder.
What is Panic Disorder?
Before we delve into the Salk Institute study, let’s take a moment to review what, exactly, we’re talking about when we discuss panic attacks and panic disorder.
Panic disorder is a type of anxiety disorder. It’s characterized by recurrent panic attacks, which are unpredictable waves of intense fear accompanied by distressing physical symptoms.
As established in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following symptoms are characteristic of a panic attack:
- Heart palpitations
- Chest pain
- Excessive perspiration
- Shaking or trembling
- Inability to catch their breath
- Sense of being choked or smothered
- Nausea or other types of abdominal distress
- Dizziness or lightheadedness
- Hot flashes or chills
- Numbness or tingling, typically in the hands and feet
- Derealization or depersonalization
- Fear that they are “going crazy”
- Fear that they may be about to die
It’s difficult to overstate the emotional impact of these experiences. Although panic attacks are relatively short, on average, lasting just a few minutes, during a panic attack a person may literally believe that they’ve lost control of their mind or are about to die.
Adding to this distress is the unpredictable nature of panic attacks. They can occur at any time, often with no apparent external trigger.
Fear of having a panic attack in front of other people can cause some individuals to make drastic behavioral or lifestyle changes, which in turn can negatively impact their job performance, relationships, and overall quality of life.
The Neural Pathway of Panic
Many prior studies on the neurobiology of panic attacks and panic disorder focused on the amygdala. Research efforts using functional magnetic resonance imaging (fMRI), positron emission tomography (PET), and other technologies have observed increased activity in the amygdala during panic attacks.
However, as lead author Sung Han said in a news release on the Salk Institute’s website, his team research based their research on the hypothesis that panic attacks likely start in another part of the brain:
“Previously, we thought the amygdala, known as the brain’s fear center, was mainly responsible – but even people who have damage to their amygdala can still experience panic attacks, so we knew we needed to look elsewhere. Now, we’ve found a specific brain circuit outside of the amygdala that is linked to panic attacks and could inspire new panic disorder treatments that differ from current available panic disorder medications that typically target the brain’s serotonin system.”
Using the rodent model, Han’s team focused on the lateral parabrachial nucleus (PBL), located in the brain stem. This area, which connects the brain with the spinal cord, is also responsible for functions such as heart rate, respiration, body temperature, and the sleep/wake cycle.
Looking closer at the PBL, Han and his colleagues discovered that this region produces substances called pituitary adenylate cyclase-activating polypeptides (PACAPs), which the news release describe as “the master regulator of stress responses.”
When the researchers induced panic-like responses in the rodents, they observed the following:
- Activation of neurons in the PBL that produce PACAPs.
- PACAP messengers dispatched to the dorsal raphe.
- In the dorsal raphe, the PACAP messengers stimulated specialized receptor neurons.
- The activated receptor neurons produced behavioral and physical symptoms related to panic in the rodents.
The Salk Institute research may also help experts better understand the difference between panic disorder and various stress-related conditions, such as posttraumatic stress disorder (PTSD) and certain other anxiety disorders.
Specific experiences or memories often trigger the symptoms of disorders such as specific phobia, social anxiety disorder, and PTSD. Panic attacks, on the other hand, can occur without any clear external or internal trigger.
Han explained that his team identified a neurobiological difference between these conditions that involves the amygdala:
“We found that the activity of PACAP-producing neurons in the brain’s parabrachial nucleus is inhibited during anxiety conditions and traumatic memory events – the mouse’s amygdala actually directly inhibits those neurons. Because anxiety seems to be operating conversely to the panic brain circuit, it would be interesting to look at the interaction between anxiety and panic.”
If additional research confirms the connection between the lateral parabrachial nucleus and panic responses in humans, this could lead to the development of new pharmacological solutions for people who suffer from panic attacks.
Current Treatment Options for Panic Disorder
The Salk Institute research suggests clinicians may one day employ highly specialized pharmaceuticals to minimize risk of continued panic attacks in patients with panic disorder. However, such a development may be decades away.
Today, a variety of medications and therapies can mitigate the negative impact of panic attacks and empower patients to manage their symptoms.
The specific elements in a treatment plan depend on several factors, including the frequency and intensity of their panic attacks, the level of disruption they cause, and the presence of co-occurring mental or behavioral health disorders.
Prescription medications for panic disorder treatment may include:
Benzodiazepines:
- Xanax (alprazolam)
- Klonopin (clonazepam)
Selective serotonin reuptake inhibitors (SSRIs):
- Zoloft (sertraline) and Paxil (paroxetine)
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Effexor (venlafaxine)
Benzodiazepines are classified as anxiolytics, typically prescribed to people who have anxiety disorders. Physicians also prescribe benzodiazepines to treat insomnia, seizures, and alcohol withdrawal syndrome.
SSRIs and SNRIs are primarily antidepressants. But they can also help people who have PTSD, bulimia, bipolar disorder, premenstrual dysphoric disorder, obsessive-compulsive disorder, and several anxiety disorders.
The therapeutic component of treatment for panic disorder may include the following:
- Cognitive-behavioral therapy (CBT)
- Exposure therapy
- Panic-focused psychodynamic psychotherapy (PFPP)
- Dialectical behavior therapy (DBT)
If panic disorder originates in untreated trauma, clinicians often use a technique called eye movement desensitization and reprocessing (EMDR).
Several reputable organizations, including the American Psychiatric Association (APA) and the UK National Institute for Health Care Excellence (NICE), endorse CBT as an effective first-line form of therapy for panic disorder:
- CBT is based in part on the view that many psychological problems result from unhealthy ways of thinking and maladaptive learned behavior patterns.
- CBT is a short-term, goal-focused approach designed to help patients recognize self-defeating patterns and replace them with productive ways of thinking and acting.
- For panic disorder patients, CBT sessions may focus on facing their fears, managing panic symptoms, and employing effective self-soothing techniques.
Find Treatment for Panic Disorder in Southern California
If you or someone in your life experiences acute symptoms of panic disorder or another complex mental health disorder, Crownview Psychiatric Institute can help.
Our mental health treatment center in Oceanside, California, provides comprehensive, personalized services in a dynamic, community-like environment. We offer an array of evidence-based therapies, focused life- and work-skills education, innovative adjunct services, and wraparound support.
We’re committed to helping each patient rediscover their innate strengths and capabilities. But more importantly, we help patients remember they’re unique individuals worthy of dignity and respect.
To learn more about how we can help you or your loved one, please visit our Contact page or call us today.
Gianna Melendez
Jodie Dahl, CpHT