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Pain, POTS & "Panic Attacks"

Updated: Apr 19



Attention Please! Panic attacks without panic in POTS and chronic pain


Panic attacks are a tricky subject. While they are absolutely a real experience that people have, defining what they are, and why people get them, isn't easy. The situation gets even more complicated when we consider how it works itself out in clinical practice and individual patient experiences for people with POTS and chronic pain.

In this article we'll attempt to tackle


What is a Panic Attack?

Panic attacks are typically defined as being sudden intense episodes of fear/anxiety accompanied by severe physical symptoms, in the absence of any real danger.

Physical symptoms of panic attacks can include:

  • Rapid breathing

  • Shortness of breath

  • Hyperventilation

  • Tachycardia (fast heart rate)

  • Heart palpitations

  • Chest pain

  • Sweating

  • Chills

  • Nausea

  • Shaking

  • Headache

  • Numbness/tingling of the extremities

  • Dizziness

  • Fainting

It bears mentioning, that some individuals are told they are having a panic attack because they experience the physical symptoms, but the emotional distress isn't present. The individual experienced no precipitating episode of fear or anxiety. This arguably does not fit the true definition of a panic attack. See below for a discussion on this alternative version of a panic attack.


Who Should Treat Panic Attacks?

The variety of symptoms makes panic attacks difficult to manage because no individual specialist manages all of those symptoms. Holistic management requires a team of different healthcare providers to work together.

Mental health providers are specialists in the management of the psychological distress of fear and anxiety, but their training to manage the accompanying physical symptoms is often lacking. Medical providers may have training on some of the physical symptoms that pertain to their area of specialty practice, but their training on other specialties, and the psychological component is limited.

In the push to advance specialization, the healthcare education system trains providers to excel in one area of medicine. While this is great if you have a problem that lies within one specialty area (and has led to many medical advancements in the last 100 years), it is not ideal for people with conditions that affect multiple systems in the body.

The symptoms you can experience during a panic attack are in a wide range of specialties. To cover them all, you'd need a provider that is a cardiologist, pulmonologist, endocrinologist, gastroenterologist, and a neurologist at minimum. And let's not forget, the mental health providers because the key sign that is supposed to be associated with panic attacks is the fear/anxiety.

You're unlikely to find one provider that specializes in all of those things. As a result, panic attacks are a problem that don't get a lot of attention. Most medical providers will write them off as "not in my scope of practice" and move on to focus on other patients whose symptoms fit neatly into the box of their specialty. For example, while you may have chest pain, palpitations and a rapid heart rate, the cardiologist might say that the other symptoms like nausea are better treated by a GI specialist, or that it's an emotional problem and you need to see someone who works in mental health to manage your anxiety.


The Panic-less Panic Attack

To make matters more complicated, some people with POTS or chronic pain experience the physical symptoms of a panic attack, without the emotional panic. They weren't anxious about anything or fearful before the physiologic panic attack symptoms started. They often aren't anxious or fearful during the attack either. If anything, they often become annoyed about having a panic attack when they weren't even upset to begin with. They are then further frustrated when they seek medical attention, to be told they're having a panic attack, even though they didn't feel panic. This can leave them feeling like they aren't being listened to, or worse, that they are being told that their very real, physical symptoms are "all in their head".


Categorizing Panic Attacks

The Diagnostic Statistical Manual of Mental Disorders (DSM) divides panic attacks into two main categories of "expected panic attacks", where the fear that precipitates the attack is identifiable, and "unexpected panic attacks", where the fear/anxiety precipitating the attack is not clear. In both incidences however, panic/fear is present.

To effectively treat panic attacks, it may help to divide them into more categories:

  1. Irrational emotional anxiety, with physical symptoms.

  2. Rational emotional anxiety, with physical symptoms.

  3. Unidentifiable emotional anxiety, with physical symptoms.

  4. Physical symptoms, in the absence of emotional anxiety.

The first three categories are true to the definition of a panic attack consistent with the DSM. In the first category, a person might have fear about something specific that is not reasonable. The important part, however, is that the fear is present. If fears about irrational, or highly improbably occurrences are present (such as a fear that you will be struck by an asteroid and killed while reading this article, which is statistically highly improbable), then mental health providers are typically the best equipped to manage the panic attacks. While the physical symptoms that follow are real, the best treatments in medicine are aimed at the source of the problem, not the symptoms.

The second category is worthy of recognition and differentiation. Some individuals have fear and anxiety, because they have something legitimate to be afraid of. If, for example, you didn't study for an exam that will determine your ability to graduate college, or perhaps you received news that you have a terminal illness and you are unsure what will happen to your young children when you pass away, it would be appropriate and rational to have anxiety about your future. Here again, psychological stressors are the primary symptom generator of the physical symptoms. Therefore, the best treatments are most likely going to be lifestyle management to reduce the stressors if possible (such as proactively studying for your exam), and intervention from a mental health provider to help you cope with the psychological stress, if the circumstances cannot be altered (a terminal illness diagnosis).

The third category is where things get tricky. Clinically, this category can serve as a catch all for otherwise unexplained panic attacks. The individual experiences fear and anxiety, seemingly about nothing at all. If the fear is non-specific, then working with a mental health provider to determine if there are repressed fears, or a generalized anxiety disorder is at play would be appropriate.

The fourth category, however, is not widely acknowledged in medical research. The panic attack without panic. These individuals are not psychologically stressed, and therefore we must consider the possibility that something else is causing their symptoms. While it may look like a panic attack, there is no emotional panic.

In a rushed healthcare system where doctors are pressed for time, they don't often have the ability to stop and question if there may actually be a physiologic trigger for the "panic attack". It is easier to simply make the diagnosis, claim it is outside their scope of practice, and move on to their next patient. Arguably, this isn't intentional insensitivity on the part of the healthcare provider, it is what they have been trained to do. They are taught to refer out to other specialists to manage things that are not within their specialty. In this case, they refer to mental health providers to manage panic attacks and believe that is the best thing they can do to help their patients.


Theories For The Panic-less Attack

The key to understanding the phenomenon of the panic-less panic attack (or what may be best called, a physiologic panic attack) however, may lie in a better understanding of patients with Postural Orthostatic Tachycardia Syndrome (POTS). In POTS, the body has a hard time getting blood where it needs to go efficiently. As a result patients can experience a variety of symptoms such as dizziness, fainting, and rapid heart beat as the body frantically tries to move the blood to tissues that need it. While that is not an exhaustive list of POTS symptoms, it's enough to draw some basic parallels.

The tricky part about POTS is that this all happens on the inside of the body. It's an invisible process to the naked eye. If we were to give a more physical representation, consider for a moment that someone was holding your head underwater.

If you are unable to breathe, your body would go into a state of emotional and physical panic in response to the threat of being unable to obtain the oxygen that your body needs to survive. While this analogy is a dramatic case, living with POTS may not be so different. It just happens on a slower timeline. Perhaps your head is being held under water periodically; not enough to kill you, but often enough that you aren't quite getting as much oxygen as you need.

If the body is unable to circulate blood to the tissues effectively, then a chronic state of somewhat decreased oxygenation may set in. The body has enough oxygen to live, but not enough to thrive. A person may feel fatigued, and like they have decreased energy. They could feel lightheaded if their brain isn't getting enough oxygen. They may develop exercise intolerance. Their brain might also feel foggy and sluggish because it doesn't have enough nutrients to work at optimal speed. All of these symptoms are common in people with POTS.

Perhaps the panic-less panic attack is better described as a physiologic panic attack. The body enters a state of panic due to a prolonged physiological distress, rather than an emotional distress.

A second potential cause can be best understood through the lens of chronic pain. Pain serves as the body's alarm system; it's job is to tell you about danger. (See Hurt vs. Harm & Car Alarms: Interpreting Chronic Pain)

For some however, the alarm system malfunctions. It begins to either sound the alarm, disproportionately to the level of danger present, or even in the absence of any observable tissue damage that doctors can see. That may mean that we simply lack the medical advancement to identify the cause of the symptoms. It may also mean that there is a problem in our nervous systems' ability to sense and interpret information correctly (a software problem, rather than a hardware problem).

Regardless of if the tissue damage is visible, the effects of the alarm are real. If someone pulls the fire alarm in a building, it doesn't really matter if there is a fire or not. When people hear the sound, they will move towards the exits accordingly, and fire trucks will arrive on the scene. Your body is no different. If it believes that it is in danger, it will begin responding accordingly.

If you are unable to resolve that danger because doctors are unsure how to treat the problem, your body can become frustrated. Just like a baby will initially cry softly, and escalate in volume until its parent responds, the body may decide it needs to do more to get your attention.

This might also explain why symptoms escalate into a "panic attack" without any perceivable emotional panic. The body may simply be trying to get more attention in hopes of getting its needs met. In order to effectively unravel these mysteries, it may be time that the mental health community and the medical community come together to search for the true causes of panic attacks, and to what extent they are emotionally and/or physiologically mediated.

In closing, it's important to remember that these are theories, not facts. These are plausible suggestions for why a panic attack might occur without emotional panic, but there is not at present any research available to confirm that these theories are true. More study is needed, but for that to occur, there must first be recognition in the medical community that what may best be termed a "panic-less attack" or a "physiologic panic attack" is in fact a legitimate medical condition.



Disclaimers: This article is intended for educational purposes and is not intended to serve as or replace individual medical advice from a healthcare provider. If you are seeking personalized medical advice, please contact our office to schedule an appointment with a licensed medical provider.

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