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The Case Of The Suffocating Woman

[Content warning: panic, suffocation]

I.

I recently presented this case at a conference and I figured you guys might want to hear it too. Various details have been obfuscated or changed around to protect confidentiality of the people involved.

A 20-something year old woman comes into the emergency room complaining that she can’t breathe. The emergency doctors note that she’s breathing perfectly normally. She says okay, fine, she’s breathing normally now, but she’s certain she’s about to suffocate. She’s having constant panic attacks, gasping for breath, feels like she can’t get any air into her lungs, been awake 96 hours straight because she’s afraid she’ll stop breathing in her sleep. She accepts voluntary admission to the psychiatric unit with a diagnosis of panic disorder.

We take a full history in the psych ward and there’s not much of interest. She’s never had any psychiatric conditions in the past. She’s never used any psychiatric medication. She’s never had any serious diseases. One month ago, she gave birth to a healthy baby girl, and she’s been very busy with all the new baby-related issues, but she doesn’t think it’s stressed her out unreasonably much.

We start her on an SSRI with (as usual) little immediate effect. On the ward, she continues to have panic attacks, which look like her gasping for breath and being utterly convinced that she is about to die; these last from a few minutes to a few hours. In between these she’s reasonable and cooperative but still very worried about her breathing. There are no other psychiatric symptoms. She isn’t delusional – when we tell her that our tests show her breathing is fine, she’s willing to admit we’re probably right – she just feels on a gut level like she can’t breathe. I’m still not really sure what’s going on.

So at this point, I do what any good psychiatrist would: I Google “how do you treat a patient who thinks she’s suffocating?” And I stumble onto one of the first convincing explanations I’ve ever seen of the pathophysiology of a psychiatric disorder.

II.

Panic disorder is a DSM-approved psychiatric condition affecting about 3% of the population. It’s marked by “panic attacks”, short (minutes to hours) episodes where patients experience extreme terror, increased heart rate, gasping for breath, feeling of impending doom, choking, chest pain, faintness, et cetera. These episodes can happen either after a particular stressor (for example, a claustrophobic patient getting stuck in a small room) or randomly for no reason at all when everything is fine. In a few cases, they even happen when patients are asleep and they wake up halfway through. The attacks rise to the level of a full disorder when they interfere with daily life – for example, a patient can’t do her job because she’s afraid of having panic attacks while engaged in sensitive activities like driving.

The standard model of panic disorder involves somatosensory feedback loops. Your body is always monitoring itself to make sure that nothing’s wrong. Any major organ dysfunction is going to produce a variety of abnormalities – pain, blockage of normal activities like digestion and circulation, change in chemical composition of the blood, etc. If your body notices enough of these things, it’ll go into alarm mode and activate the stress response – increased heart rate, sweating, etc – to make sure you’re sufficiently concerned.

In the feedback model of panic disorder, this response begins too early and recurses too heavily. So maybe you have an itch on your back. Your body notices this unusual sensation and falsely interprets it as the sort of abnormality that might indicate major dysfunction. It increases heart rate, starts sweating, et cetera. Then, because it’s stupid, it notices the increased heart rate and the sweating that it just caused, and decides this is definitely the sort of abnormality that indicates major dysfunction, and there’s nothing to do except activate even more stress response, which of course it interprets as even more organ dysfunction, and so on. At some point your body just maxes out on its stress response, your heart is beating as fast as it can possibly go and your brain is full of as many terror-related chemicals as you can produce on short notice, and then after a while of that it plateaus and returns to normal. So panic disorder sufferers are people who are overly prone to have the stress response, and overly prone to interpret their own stress response as further evidence of dysfunction.

This is probably part genetic and part learned – I have a panic disorder patient who has a bunch of really bad allergies, whose body would shut down in horrifying ways every time he accidentally ate a crumb of the wrong thing, and this seems to have “sensitized” him into having panic attacks; that is, his body has learned that worrying sensations often foretell a health crisis, and lowered its threshold accordingly to the point where random noise can easily set it off. I’ve done a lot of work with this guy, but none of it has been “just ignore your panic attacks, you’ll be fine”. His body knows what it’s doing, and we’ve got to work from a position of respecting it while also teaching it not to be quite so overzealous.

So this is where my understanding of panic disorder stood until I Googled “how do you treat a patient who thinks she’s suffocating?” and came across Donald Klein’s theory of panic as false suffocation alarm. You might want to read the full paper, as it’s got far too many fascinating things to list here, including a theory of sighing. But I’ll try to go over the basics.

Klein is a professor of psychiatry who studies the delightful field of “experimental panicogens”, ie chemicals that cause panic attacks if you inject them in someone. These include lactate, bicarbonate, and carbon dioxide, all of which naturally occur in the body under conditions of decreased respiration.

But this is actually confusing. All of these chemicals naturally occur in the body under conditions of decreased respiration. But they don’t cause panic attacks then. During exercise, for example, your body has much higher oxygen demand but (no matter how much you pant while running) only a little bit higher oxygen supply, so at the muscle level you don’t have enough oxygen and start forming lactate. But exercise doesn’t make people panic. Even deliberately holding your breath doesn’t make you panic, although it’s about the fastest way possible to increase levels of those chemicals. So it looks like your body is actively predicting how much lactate/bicarbonate/CO2 you should have, and only getting concerned if there’s more than it expects.

So Klein theorized that the brain has a “suffocation alarm”, which does some pretty complicated calculations to determine whether you’re suffocating or not. Its inputs are anything from blood CO2 level to very high-level cognitions like noticing that you’re in space and your spacesuit just ruptured. If, after considering all of this, and taking into account confounding factors like whether you’re exercising or voluntarily holding your breath, it decides that you’re suffocating, it activates your body’s natural suffocation response.

And the body’s natural suffocation response seems a lot like panic attacks. Increased heart rate? Check. Gasping for breath? Check. Feeling of impending doom? Check. Choking? Check. Chest pain? Check. Faintness? Check. Some of this makes more sense if you remember that the brain works on Bayesian process combining top-down and bottom-up information, so that your brain can predict that “suffocation implies choking” just as easily as “choking implies suffocation”.

A quick digression into medieval French mythology. Once upon a time there was a nymph named Ondine whose lover was unfaithful to her, as so often happens in mythology and in France. She placed a very creative curse on him: she cursed him not to be able to breathe automatically. He freaked out and kept trying to remember to breathe in, now breathe out, now breathe in, now breathe out, but at some point he had to fall asleep, at which point he stopped breathing and died.

So when people discovered a condition that limits the ability to breathe automatically, some very imaginative doctor named the condition Ondine’s Curse (some much less imaginative doctors provided its alternate name, central hypoventilation syndrome). People with Ondine’s curse don’t exactly not breathe automatically. But if for some reason they stop breathing, they don’t notice. Needless to say, this condition is very, very fatal. The usual method of death is that somebody stops breathing at night (ie sleep apnea, very common among the ordinary population, but not immediately dangerous since your body notices the problem and makes you start breathing again) and just never starts again.

Klein says that this proves the existence of the suffocation alarm: Ondine’s Curse is an underactive suffocation alarm – and thus the opposite of panic disorder, which is an overactive suffocation alarm. In Ondine’s Curse, patients don’t feel like they’re suffocating even when they are; in panic disorder, patients feel like they’re suffocating even when they’re not.

This picture has since gotten some pretty powerful confirmation, like the discovery that panic disorder is associated with ACCN2, a gene involved in carbon dioxide detection in the amygdala. If you’re looking for something that causes you to panic when you’re suffocating, a carbon dioxide detector in the amygdala is a pretty impressive fit.

I don’t think this is necessarily a replacement for the somatosensory feedback loop theory. I think it ties into it pretty nicely. The suffocation alarm is one of the many monitors watching the body and seeing whether something is dysfunctional, maybe the most important such monitor. It goes through some kind of Bayesian learning process to constantly have a prior probability of suffocation and update with incoming evidence. Let me give two examples.

First, my patient with the bad allergies. Every time he eats the wrong thing, he goes into anaphylactic shock, which prevents respiration and brings him to the edge of suffocating. His suffocation alarm becomes sensitized to this condition, increases its prior probability of suffocation, and so drops its threshold so low that it can be set off by random noise.

Second, claustrophobics. There’s a clear analogy between being crammed into a tiny space, and suffocating – think of people who are buried alive. For claustrophobics, for some reason that link is especially strong, and just being in an elevator is enough to set off their suffocation alarm and start a panic attack. Now, why agoraphobics get panic attacks I’m not sure. Maybe fear makes them feel woozy and hyperventilate, and the suffocation alarm treats wooziness and hyperventilation as signs of suffocation and then gets stuck in a feedback loop? I don’t know.

III.

Bandelow et al find that you’re about a hundred times more likely to develop a new case of panic disorder during the postpartum period than usual.

This can be contrasted with two equally marked trends. Panic attacks decrease markedly during pregnancy, and disappear entirely during childbirth. This last is really remarkable. People get panic attacks at any conceivable time. When they’re driving, when they’re walking, when they’re tired, when they’re asleep. Just not, apparently, when they’re giving birth. Childbirth is one of the scariest things you can imagine, your body’s getting all sorts of painful sensations it’s never felt before, and it’s a very dangerous period in terms of increased mortality risk. But in terms of panic attack, it’s one of the rare times when you are truly and completely protected.

Maternal And Fetal Acid-Base Chemistry: A Major Determinant Of Perinatal Outcomes notes that:

There is a substantial reduction in the partial pressure of carbon dioxide in pregnancy…this fall is found to reach a mean level of 30-32 mmHg and is associated with a 21% increase in oxygen uptake. The physiological hyperventilation of pregnancy is due to the hormonal effect of progesterone on the respiratory center.

In other words, you’re breathing more, you have more blood oxygen, you have less blood CO2, and you’re further away from suffocation. This nicely matches the observation that there’s fewer panic attacks.

According to Klein, “There is a period of extreme hyperventilation during delivery, which drops the blood carbon dioxide to the minimum recorded under nonpathological conditions”. This explains the extreme protective effect of labor against panic disorder, despite labor’s seeming panic-inducing properties. When your CO2 is that low, even an oversensitive suffocation alarm is very far from a position where it might be set off.

(source)

Then you give birth, and progesterone – the hormone that was increasing respiratory drive – falls off a cliff. Your body, which for nine months has been doing very nicely with far more oxygen than it could ever need, suddenly finds itself breathing much less than usual and having a normal CO2/oxygen balance. This explains the hundredfold increased risk of developing panic disorder! Somebody who’s previously never had any reason to think they’re suffocating finds themselves with much less air than they expect (though still the physiologically correct amount of air they need), and if they’ve got any sensitivity at all, their suffocation alarm interprets this as possible suffocation and freaks out.

This can go one of two directions: either it eventually fully readjusts to your new position and becomes comfortable with a merely normal level of oxygen. Or the constant panic and suffocation feelings sensitize it – the same way that my allergy patient’s constant anaphylaxis sensitized him – the alarm develops a higher prior on suffocation and a lower threshold, and the patient gets a chronic panic disorder.

The reason my patient was so interesting was that she was kind of in the middle of this process and had what must have been unusually good introspective ability. Instead of saying “I feel panic”, she said “I feel like I’m suffocating”. This is pretty interesting. It’s like a heart attack patient coming in, and instead of saying “I feel chest pain”, they say “I feel like I have a thrombus in my left coronary artery”. You’re like “Huh, good job”.

So I explained all of this to her, and since she didn’t know I used Google I probably looked very smart. I told her that she wasn’t suffocating, that this was a natural albeit unusual side effect of childbirth, and that with luck it would go away soon. I told her if it didn’t go away soon then she might develop panic disorder, which was unfortunate, but that there were lots of good therapies for panic disorder which she would be able to try. This calmed her down a lot and we were able to send her home with some benzodiazepines for acute exacerbation and some SSRIs which she would stay on for a while to see if they helped. She’s scheduled to see an outpatient psychiatrist for followup and hopefully he will monitor her panic attacks to see if they eventually get better.

IV.

I realize that case reports are usually supposed to include a part where the doctor does something interesting and heroic and tries an experimental new medication that saves the day. And I realize there wasn’t much of that here. But I think that in psychiatry, a good explanation can sometimes be half the battle.

Consider Schachter and Singer (1962). They injected patients with adrenaline (a drug which among other things makes people physiologically agitated) or a placebo. Half the patients were told that the drug would make them agitated. The other half were told it was just some test drug to improve their eyesight. Then a confederate came and did some annoying stuff, and they monitored how angry the patients got. The patients who knew that the drug was supposed to make them angry got less angry than the ones who didn’t. The researchers theorized that both groups experienced physiological changes related to anger, but the patients who knew it was because of the drug sort of mentally adjusted for them, and the ones who didn’t took them seriously and interpreted them as their own emotion.

We can think of this as the brain making a statistical calculation to try to figure out its own level of anger. It has a certain prior. It gets certain evidence, like the body’s physiological state and how annoying the confederate is being. And it controls for certain confounders, like being injected with an arousal-inducing drug. Eventually it makes its best guess, and that’s how angry you feel.

In the same way, the suffocation monitor is taking all of its evidence about suffocation – from very low-level stuff like how much CO2 is in the blood to very high-level stuff like what situation you seem to be in – and then adjusting for confounders like whether you’re exercising. And I wonder whether telling a patient “You’re not actually suffocating, your panic comes from a known physiologic process and here are the hormones that control it” is the equivalent of telling them “You’re not really angry, your agitation comes from us giving you a drug that’s known to produce agitation”. It tells the suffocation alarm computer that this is a confounder to be controlled for rather than evidence on which to update.

I can’t claim to really understand this at a level where it makes sense to me. There are a lot of things that very directly increase CO2 but don’t increase panic, or vice versa. Hyperventilation can either cause or prevent panic depending on the situation. There seems to be something going on where the suffocation monitor controls for some things but not others, but this is an obvious cop-out that allows me to avoid making real predictions or narrowing hypothesis-space.

For example, this theory would seem to predict that waterboarding shouldn’t work. After all, its whole deal is artificially inducing the feeling of suffocation in a situation where the victim presumably knows that the interrogators aren’t going to let him suffocate. You would think that eventually the alarm realizes that “is being waterboarded” is a confounder to control for, but this doesn’t seem to be true.

(on the other hand, the inability to condition yourself seems relevant here. It seems like the brain might be not be controlling for whether something is reasonable, but only for whether something is produced by yourself. So maybe exercise counts because it’s under your control, but waterboarding doesn’t count because it isn’t. I wonder if anyone has ever tried letting someone waterboard themselves and giving them the on-off switch for the waterboarding device. Was Hitchens’ experience close enough to this to count? Why would this be different from letting someone hold their breath, which doesn’t produce the same level of panic?)

But overall I find Klein’s evidence pretty convincing and feel like this must be at least part of the story. And I think that giving this kind of explanation to somebody can comfort them, reassure them, and (maybe) even improve their condition.

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158 Responses to The Case Of The Suffocating Woman

  1. habu71 says:

    Very interesting. Recalling the reasoning in your Thin Air post, are sailors serving on submarines more likely to get panic attacks? Are many sailors excluded from service on subs because they get panic attacks? I have been told by a couple former nuclear submariners that ~ once a week the O2 level in the sub is raised for a few hours while they clean. It would be really interesting if there were a significant decrease in the amount of panic attacks seen during these periods of time.

    • bean says:

      I think any answers on that are going to be heavily confounded by the sorts of people who are able to stand being crammed into a tube under the ocean with a bunch of other people. Claustrophobia, for instance, will be totally unknown in that population because claustrophobes will wash out.
      I met a man once who had been in submarines. He said that in 1947, when he joined the navy, the test for submarine school was being put in a 21″ torpedo tube for a couple of hours. If you didn’t panic, you went to submarine school. They don’t do exactly that any more, but something similar is still in use.

      • Dissonant Cognizance says:

        Former submariner here, and I think you’re right. You could compare the rate of panic attacks on submarines while surfaced versus submerged, but I suspect the base rate is simply too low to come to any conclusion.

        I certainly never heard of a panic attack for any reason while on the boat, but I did know someone who panicked in the flood trainer, which prompted a chat with the sub school chaplain. He recommended a tour of an actual submarine, specifically lying in a rack for a while. Panic attack recurred, student diagnosed with claustrophobia and mustered into the surface fleet. Submarines in general contain probably every panic trigger there is (unless you’re agoraphobic, I guess), in an environment with ten times atmospheric CO2 concentration, so the training process seems to filter out anyone with a too-sensitive panic system before they get too far in.

  2. Unnamed says:

    Is it standard to give a room CO2 monitor to people with panic disorder, or to give them advice about keeping windows open, etc.?

    • masharpe says:

      Related question: are panic attacks more common in poorly-ventilated rooms?

    • zorbathut says:

      My wife, who had panic attacks for a while, says that she doesn’t believe a CO2 monitor would help at all. However, she did get a finger blood o2 saturation monitor, and kept it next to her bed; she’d put it on mid-panic-attack to reassure her that her blood was fine. That actually did help.

      It’s not entirely clear how this extends to the general population – she’s a nurse-in-training and is experienced with trusting these kinds of devices. But it may be worth a shot, given how inexpensive they are.

      At this point, her panic attacks have basically stopped. It’s unclear if this is due to a life stress reduction or due to her brain finally figuring out that there was no reason to panic in the middle of the night.

      • Unnamed says:

        I was thinking of using a CO2 monitor so that you can consistently keep the room CO2 levels low, which will help keep your blood CO2 levels low, which could cause you to get fewer panic attacks.

        It looks like you are thinking of a separate use case, which is looking at the monitor after a panic attack has started in order to tell the internal sensor that things are fine.

        • John Schilling says:

          I was thinking of using a CO2 monitor so that you can consistently keep the room CO2 levels low, which will help keep your blood CO2 levels low,

          Unlikely. Better than 90% of the CO2 in your lungs and your blood is generated by your own metabolism; if you are having problems (physical or psychological) in any environment this side of a submarine, you’ll almost certainly have the same problems even inhaling 100.00% CO2-free air.

  3. Fossegrimen says:

    re: Waterboarding:

    You can train yourself to resist waterboarding in “friendly” situations, i.e. special forces training and such where you know that killing you is not allowed. Not so much when captured by the Taliban and just drowning you is totally an option. This should tie in nicely with the rest of the post?

    • andhishorse says:

      I would guess that there is also some limitation to the extent to which complex (in human terms) explanations can reassure you on an instinctual level. “This is a result of an adjustment after 9+ months of weird bodily function” seems sort of intuitive, as does “this is because of the weird thing I was very recently injected with”. The explanation of “these people hate me and want to hurt me but not kill me because they want information” seems less so because it relies on a rather specific prediction about another human’s very calculated mental state.

    • Besserwisser says:

      My thesis would be that your brain knows they aren’t going to let you up until you start to shown signs of suffocation, so you show signs of suffocation instead of just drowning.

    • wintermute92 says:

      It does seem relevant that voluntary exercise is common and basically never proceeds to suffocation, but waterboarding is both highly contextual and can proceed to real suffocation. Even on a higher-cognition, frontal-lobe level, “the Taliban is making me feel like I can’t breathe” seems to offer a decently high risk of “and I’m actually going to die”.

    • Mengsk says:

      I could be incorrect here, but my understanding of waterboarding is that you are actually having some amount of liquid dripped into your nasal cavity, which your body really, really doesn’t take well to. It basically replicates the part of drowning where your sinuses get flooded with liquid, but not the part where water fills your lungs (which, at the end of day, is the part of drowning that actually kills you). It’s the same feeling you get if you a somersault underwater without holding your nose. The important difference is that, when you’re being waterboarded, you aren’t given an opportunity to clear your sinuses out.

      Given that, I think saying that you can acclimate to being waterboarded because you know that you’re not in danger of actually drowning is sort of like saying you don’t need anesthetic when undergoing surgery because you know that your body is being cut open in the context of a beneficent medical procedure.

      • Fossegrimen says:

        Right, sorry for my short drive-by comment the yesterday, I was pressed for time.

        By the term „you can“, I was intending the colloquial meaning of „it is possible“, not „everyone can“. Even with my sample size of one, this interpretation is still valid.

        My experience with waterboarding is from about 30 years ago when I was „captured“ by the „enemy“ and subjected to six days of sleep deprivation, moderate hypothermia, starvation and waterboarding. I also learned, much to my surprise that the Geneva convention only applies to enemy soldiers.

        I suspect, but do not know that my experience with waterboarding was not made easier by the fact that I started out with bad enough aquaphobia that I had elevated heart rate in the shower. On the other hand, being used to mild water-induced panic may have preconditioned me to intense water-induced panic, I don’t know. Anyway, there were a couple things that definitely did make it easier to tolerate;

        * We knew that it would not go on for ever as our training had a fixed end date.
        * We could stop it at any time by saying the words „I’m out“ after which we would be given warm clothes, transport to the airport and a ticket home.

        Only one of the 14 in my troop did, so I assume the other 12 had similar experiences to mine. (the total dropout rate of the course were around 70%, but most of it was during the first couple weeks and this was at the end when only the already severely mentally deficient remained.)

        What I didn’t learn to control was the heart rate or the adrenaline surge, but breathing can be consciously controlled and the general sense of fear diminished rather rapidly after the first couple sessions. It is similar (in kind though not really in magnitude) to how you can keep going at the end of a marathon even though your muscles are begging you to stop. It also taught me how to exert the same control over my aquaphobia so that I can go snorkelling now, even if 10 minutes of snorkelling is a bloody good cardio workout due to the elevated heart rate.

        Incidentally and somewhat OT, but possibly of interest:
        When it comes to being tortured, I’d actually prefer waterboarding to sleep deprivation and hypothermia, mostly because the hallucinations become rather intense after a few days. I guess I was lucky because I got the Easter-bunny-as-designed-by-Google-deep-dream taunting me with apple pie. Some guys who got creatures from the nether regions frequented the company psychiatrist for years afterwards.

        In fact, when these days I do things that require that I sleep minimally, I keep a lookout for my friend the Easter-bunny because his appearance means my mind is no longer trustworthy and it’s time for a nap.

  4. K says:

    Interesting.

    Some observations from scuba diving, which seem especially relevant to the last part. There’s a piece of equipment that some high level divers use called a rebreather, which, as the name suggests, recycles exhaled air for you to breath (making it much more efficient for expensive gases than traditional SCUBA equipment). It has a filtration system to scrub out exhaled CO2 and a computer system that monitors CO2 levels in the gas you’re being fed. If this system fucks up, you need to switch to a backup gas supply, which involves removing your mouthpiece and replacing it with another mouth piece connected to the backup system.

    One of the main symptoms of a CO2 spike in divers is panic. It turns out that there are few things a panicking diver wants to do less than remove the mouthpiece feeding them air, even when they have the backup in their hand and they will only have to hold their breath for a moment while switching. This leads to people staying on the faulty air source far, far too long, even when they know that they should be switching. If they’re lucky they just give themselves a headache, if not, they pass out and drown.

    I saw a pro diver give a talk once where he described an experiment that he did in the lab (i.e. not in the water), where he put guys on these breathing systems on a treadmill, got them walking, and then removed the filtration system. The dudes knew that this was what was going to happen. The little alarm light goes on, the participant knows he needs to switch gas supplies, and one participant… doesn’t do it. The guy in charge is looking the participant in the face, under completely controlled conditions *in a room full of breathable air*, giving him the signal to switch gas sources, and the participant is looking right back at him, slightly bugeyed, not doing it. Eventually he (very gently) switches mouth pieces for the participant, the guy’s CO2 levels come back down, and they have a conversation where the guy says yes, he understood, he knew he had to switch, but he just couldn’t bring himself to take the mouthpiece out. Not under 50 feet of water in the ocean. In a *room*.

    This seems to tell against awareness of the situation and personal control being sufficient. The participant wasn’t in control of when the filtration system came out or his CO2 spike, but he knew that it was going to happen, what it was going to feel like, and that all he needed to do was switch mouth pieces while standing in a room full of air to end it – and he couldn’t do it. This was doubly terrifying to me since we don’t generally identify changing mouthpieces as a particularly stressful process for divers (in comparison to say, removing your mask, which both activates your dive reflex, making you feel like you can’t breathe, and effectively blinds you).

    What’s interesting to me is that you can drill divers at this level to do all kinds of technically challenging things while panicking, and we do, quite successfully. I’ve panicked due to suffocation on a dive and done exactly the right series of things to address it, but none of those things was removing my mouthpiece. You’re not at all capable of complex thought in that moment – you need to have been drilled beforehand, extensively, on what you’ll need to do. In this sense I don’t think it’s the same as being angry – you can still think when you’re angry, albeit not as clearly. You can learn to *function* while panicking, but I doubt people engage in the kind of reflection you’re describing with the adrenaline experiment. I think they can undertake tasks, though, provided those tasks aren’t anything (like removing a mouthpiece) that will increase their stress even further.

    • Scott Alexander says:

      That’s really interesting; thanks.

    • And there’s this (the guy from Smarter Every Day testing what it’s like to have altitude sickness and getting gradually deprived of oxygen to the point that he doesn’t realize he needs to put his oxygen mask back on).

      I don’t know why, but something about him saying “I don’t want to die” while smiling and doing nothing to put his mask back on is just horrifying.

      Oxygen deprivation. Not even once.

      (The interesting thing here, though, is that he wasn’t panicking. Maybe because his brain was oxygen-deprived, but not carbon dioxide-overloaded, which failed to trip his suffocation instinct?)

      • wintermute92 says:

        (The interesting thing here, though, is that he wasn’t panicking. Maybe because his brain was oxygen-deprived, but not carbon dioxide-overloaded, which failed to trip his suffocation instinct?)

        Possibly relevant – humans are terrible at identifying low O2 situations. Shallow water blackouts happen when we drop CO2 levels without raising O2, and so just keep swimming underwater until we run out of of O2. People regularly die in volcanic areas because they walk into depressions full of denser-than-air, non-CO2 gasses and suffocate without ever noticing. There are stories of whole chains of people going to rescue previous victims of this and passing out next to them, because no one was capable of realizing they were dying.

        We literally don’t have a sensor for it, we just don’t react at all unless we higher-cognition our way to “I’m not thinking clearly, must be oxygen deprivation”. Which, of course, is tough during oxygen deprivation.

        • Randy M says:

          Which is how people die in N2 tanks, despite it being a harmless gas. Excess CO2 is what is monitored biologically, not, as you say, low O2.

          • Schibes says:

            On a related note: Asphyxiation via N2 gas is on its way to becoming the trendy new capital punishment method of the 21st century. Alabama appears set this week to become the second state to approve its use, joining the (somewhat disturbingly, IMO) execution-happy state of Oklahoma in endorsing the practice.

        • A grad student in a lab I used to work at died in a helium 3 spill. If you’re working with cryogenic liquids like that be careful.

          • John Schilling says:

            Is it a sign of my evil mad scientist nature that my first instinct is to wonder how much an asphyxiation’s worth of 3He costs?

            “No, you fools, you can’t autopsy the victim! We have to outgas him first! Igor, get me the Giant Bell Jar! No, wait, that was Igor…”

          • bean says:

            I didn’t think there was that much He3 on the planet, much less in one place.

          • Eric Rall says:

            According to wikipedia, “US industrial demand for helium-3 reached a peak of 70,000 liters (approximately 8 kg) per year in 2008. Price at auction, historically about $100/liter, reached as high as $2000/liter.”

            He3 is a biproduct of nuclear weapons maintenance: tritium manufactured (by exposing Li6 to neutron flux from fission reactors) for nukes needs to be periodically bled off and filtered because it decays into He3. And when demand outstrips supply from that source, they can make more by just making extra tritium and storing it until it decays.

            He3 is also a component (up to about 0.5%) of naturally occurring terrestrial helium (mostly recovered as a byproduct of natural gas extraction). It’s not currently separated out in bulk, but it doesn’t sound like it’s far from being economically viable to do so. There’s also something like 37,000 tonnes of He3 in the atmosphere, but I suspect that’s a long ways from being viable to extract.

        • Machina ex Deus says:

          We literally don’t have a sensor for it…

          There is an interesting exception: people with emphysema can tell when they’re not getting enough oxygen (as opposed to not getting rid of enough carbon dioxide).

          • as1018 says:

            Emphysema is complicated.
            Someone with emphysema has the usual drive to breathe when CO2 levels drop but when they have chronically elevated CO2 the respiration control has a shift to be more responsive to O2. If blood oxygen increases too rapidly, they can lose the hypoxic drive and this can depress their respiration. This can be a real problem. I had a patient with emphysema and every time she felt any discomfort, she would increase her oxygen from her tank. I would check on her her and it would be flowing at insanely high levels and I thought she was having a reduced respiratory drive from this but it was impossible to manage because whenever the exam ended, she went back to doing what she wanted. Unfortunately, she died suddenly one night and I have always wondered if the problems controlling the oxygen was contributory.

    • stevenj says:

      How does this relate to the standard buddy breathing exercise?
      It’s been a long time since I had scuba training, but in the exercise, you take the regulator out of your mouth and give it to your buddy who is out of air.
      It’s difficult, and easy to panic while doing, but with practice and trust you can do it underwater.
      (And for these reasons, it’s an absolute last resort for out-of-air emergencies.
      There are lots of better ways to handle it.)

      This seems inconsistent with the experiment you describe.
      Maybe the results would be different in the experiment if the participants attempted it multiple times.

      • Nornagest says:

        When I was getting my SCUBA license, I didn’t have any trouble with the buddy-breathing drills — by that point I’d gotten used to controlling my breathing, so gently exhaling into the water for a few seconds was no big deal. It also helps that you’ll usually have had some practice doing it in about three feet of water, and only graduate to doing it nine or ten meters down once you have it down cold.

        But I did have quite a bit of trouble with the drills for clearing a flooded mask, especially the ones where you take the mask off completely and you have to recover and clear it. Realistically this should have presented less risk — you still have the regulator in and you can breathe through your mouth. But as soon as I took the mask off, my vision went to hell and my nose partially flooded with water, and the first couple times I tried it I was absolutely convinced that the next breath I took was going to be seawater rather than compressed air. Pretty similar to waterboarding, now that I think about it.

        I did eventually get over it, but that was probably the scariest thing in the whole training program. (The second scariest was ascending from 9 meters without air.)

      • Virbie says:

        > How does this relate to the standard buddy breathing exercise?

        I was thinking of this too. I got my SCUBA license about a year ago and didn’t recall having any difficulty with that exercise. This despite the fact that, if anything, I’m more prone to shortness of breath in real life (due to anxiety). Even once I got in the habit of controlling my breathing underwater, I used way more oxygen than everyone else did.

        I think the difference might be that the subject was on a treadmill, so already in a situation in which he was breathing more heavily than normal. This is consistent with the difficulty of removing a rebreather _once blood CO2 has started spiking_.

        • wintermute92 says:

          Yeah. As I understand it, buddy breathing drills start when everyone is happy and low-CO2, which implies nice rational decisions that keep CO2 levels from every getting high.

          Notably, the stories I’ve heard of real, crisis buddy-breathing involve the share-r having to forcibly guide the share-ee on what to do. I always attributed that to the share-ee being less experienced (it’s how they got in trouble, and also why they panic), but I’m not sure that’s right – some incidents like cut hoses aren’t about experience at all.

          It seems plausible that real buddy breathing does involve a freakout by the person with the broken regulator, who gets guided by the non-panicked person until they settle down.

          • Virbie says:

            > Yeah. As I understand it, buddy breathing drills start when everyone is happy and low-CO2, which implies nice rational decisions that keep CO2 levels from every getting high.

            I don’t recall the instructor taking any particular care to ensure this: it just came at a natural point in the course (which was only three days, so there wasn’t a lot of wiggle room).

            > Notably, the stories I’ve heard of real, crisis buddy-breathing involve the share-r having to forcibly guide the share-ee on what to do. I always attributed that to the share-ee being less experienced (it’s how they got in trouble, and also why they panic), but I’m not sure that’s right – some incidents like cut hoses aren’t about experience at all.

            My instructor told me almost the opposite: I asked him why you give your buddy your primary and then switch to your secondary instead of giving him the secondary directly: he told me it was because the majority of the time, the share-ee who’s run out of air underwater just swims over and snatches the primary out of the sharer’s mouth in a panic, so the drills try to hew as close to the real-life situation as possible. I don’t know if that’s tru though.

          • thedufer says:

            @Virbie

            The thing you’re describing is not the same thing as the rest of this thread. Buddy breathing is an exercise that has been phased out of scuba training, in which two people share a single valve. Nowadays we just attach a secondary valve to every tank. The modern procedure obviously is a lot less panic-inducing – the person who is recovering from an out-of-air situation no longer has to catch their breath while simultaneously not depriving their partner.

      • K says:

        Good question. We make tech divers buddy breathe in stressful situations, as part as stress testing (ie in an active attempt to induce panic). In your open water course you do it with your mask on, in the pool, facing each other, not going anywhere. Sure, no problem.

        In tech training you do it with your mask off, following a line side by side. I’ve panicked during that exercise (turns out I’m not made for cave diving). Buddy breathing in a genuine emergency is pretty unlikely to go well unless both divers, the receiver especially, have very cool heads.

      • K says:

        (Follow up to previous comment, can’t edit on my phone. )

        As I said to Scott above, to do anything well while panicking you need to have drilled it extensively before hand. If I were ever going to do buddy breathing, I’d want it to be with someone who’d practiced it a lot under minimal stress – not someone who did it once on their open water course. I’m sure people do it successfully without that training, but I imagine a lot of people do just panic and bolt for the surface.

        • Virbie says:

          Oh I agree, I was perhaps reading a little more into “standard buddy-breathing exercise” as referring specifically to why the open-water course situation isn’t more intense. We did it on the ocean floor, but I didn’t feel particularly worried at any point. I can’t imagine I’d feel the same in an actual emergency without an instructor 5 feet away from me.

      • thedufer says:

        I mentioned this downthread, but it’s worth noting that buddy breathing exercises have been phased out. Instead they just assume you’ll have a modern setup with two valves, so you can hand your partner an extra one if they’re out of air.

  5. elliot teperman says:

    Another anecdote to add to the pile: when I learnt the physiological reason why you get nauseous when you’re drunk and lying down, it made me less nauseous.

    I was also thinking a relevant theory could be that understanding the reasons why a process occurs in our body engages pre-frontal thinking. Same reason why articulating you are feeling an emotion, helps to regulate that emotion.

    • publiusvarinius says:

      Another anecdote to add to the pile: when I learnt the physiological reason why you get nauseous when you’re drunk and lying down, it made me less nauseous.

      Could this be one of the universal human experiences that I’m missing? I get drunk fairly often, but I don’t think I ever experienced nausea while lying down. In fact, I consider lying in bed straight after going home from the pub a fairly pleasant experience.

      • gbdub says:

        You’ve never gotten “the spins”? It’s not quite nausea directly, more a general dizziness that gets much much worse if you lay down and close your eyes. It feels like the room is spinning. Which really sucks when you’re super tired (it’s late and you’re drink) but can’t go to sleep because closing your eyes makes you want to hurl.

        What’s bad for me is that my threshold of “drunk enough to get the spins if I lay down” is noticeably lower than my threshold of “actually feeling sick while standing”, making it harder to avoid.

        • HeelBearCub says:

          If I’m that drunk (it’s been quite a while), I just go with it and go ahead and hurl.

          Then I drink at least 32 oz. of water, take some naproxen sodium and go to bed again.

        • Ryan Beren says:

          Oh, interesting. I’ve always enjoyed that sensation a great deal. I like to imagine I’m doing backflips.

      • Evan Þ says:

        Interesting! I’ve never been drunk, but when I’m sick or when I’ve overeaten, lying down generally makes me feel more nauseous. Might this be linked?

        • wintermute92 says:

          Probably not? On overeating at least, heartburn and similar issues are made mechanically worse by lying down. The valve at the ‘top’ of your stomach suddenly moves to the ‘side’, and is pressed on by food and acid. It’s one of those remarkably mechanistic health issues.

  6. hinewaccount says:

    Two thoughts:

    One, did you consider prescribing progesterone to your patient, with the intention to taper dosage down over time and avoid the end-of-pregnancy cliff? I’m assuming that the pregnancy was one of the details you didn’t change, because the story about how progesterone affects respiration is sort of key. Progesterone-only pills have been used for birth control for quite a while and (if the US is anything like the UK) she wouldn’t even need a prescription to get at them, but it wouln’t hurt if she had an Official Doctorly Recommendation to be taking them.

    Two, regarding waterboarding and the SCUBA mouthpiece-switching comment versus holding your breath: holding your breath without having a panic attack is something that’s likely to have been very useful in the ancestral environment, so it’s not surprising that there’d be some adaptation for it; switching mouthpieces is a much more recent thing, so if the brain’s wired-in heuristics are failing it doesn’t necessarily sink the hypothesis. Waterboarding is a trickier case, since drowning *is* something in the ancestral environment that we’d expect adaptation to, but I guess the panic response is always a good idea once you’re actually inhaling water (as opposed to deliberately holding your breath).

    • as1018 says:

      As a family practice physician, I also think the treatment with progesterone would be beneficial. I also was wondering how much of a work up the emergency room did before sending her to psychiatry. A post partum woman could be showering emboli to the lungs and this would give similar symptoms and would be a horrible thing to miss.

      • sconn says:

        I have heard some good things about postpartum progesterone supplementation. First, progesterone crashes very fast after birth; and second, breastfeeding may keep it very low as well. I know in my case low progesterone has resulted in cyclic depression and heavy periods, both of which suck, and a friend of mine who takes progesterone was like “you need to go on this! it will totally help both these conditions!”

        I never did it, for complicated reasons, but I may do so this time if I experience the same problems.

      • Garrett says:

        I volunteer in EMS and have done clinical rotations in the ER. Anybody coming in and complaining of some kind of difficulty breathing is going to get put on a pulse oximeter at the least, and possibly have a blood gas or end-tidal capnography done as well.

        • as1018 says:

          A blood gas won’t necessarily identify a pulmonary embolism but it would identify if there has been one that was serious enough to cause low oxygen. A D-dimer would do this better than just looking at oxygen levels. I would like to believe that this would be checked but I have seen patients designated as “psychiatric” early in their ER visit, then being shuttled to psych without a complete medical work up.

    • Nancy Lebovitz says:

      One important difference between holding your breath and being waterboarded– if you decide to stop holding your breath, you start breathing immediately. If you have water in your airway, you need to clear it out before you can breathe properly.

      • hinewaccount says:

        Makes sense. I think the idea I’m groping towards is that, until the progress of civilisation had advanced to the point where waterboarding was invented, water in the respiratory tract was a very, very reliable sign that something was very, very wrong. No matter how under-control our ancestors might have *thought* the situation was, the evolutionarily best response for them was to thrash and struggle and do something, anything; acting as if they believed that if they didn’t, they were going to die. (Which they probably were.) And that describes the panic response pretty well!

        I should be more suspicious of evopsych just-so stories, though. Does this theory predict anything else? What are some other situations where pre-modern humans would’ve had to respond urgently to stimuli that are reliable indicators of threats to life or limb? Fire leaps to mind, but the existence of fire-eaters and other performers suggests that there isn’t the same unconditional panic response, so maybe the theory’s wrong…

        • martinw says:

          The average mammal is probably a lot more likely to end up submerged in water at some point during their life, than to be caught in a fire. So it makes sense that there would be a stronger evolutionary pressure to develop an instinctive response to drowning than to being burnt.

          Also, panicking and trashing wildly is quite unlikely to be an effective response to a fire, but it might be your best last chance if you’re drowning.

          Finally, note that when a fire-eater does his job correctly, he won’t actually get burnt by the flame. Just as a decent swimmer won’t normally panic as soon as they touch the water, but only when they breathe water into their respiratory tract.

  7. Broseph says:

    As a kid I was once sorta waterboarded. I can confirm that it is a uniquely horrible experience. The worst thing about it is the feeling of moisture hitting your airways. I’m sure it also kicks into gear some sort of tactile reflex. Because I felt much more panic then times I’ve been suffocated or strangled, as part of martial arts classes.

  8. Enkidum says:

    I’m confused as to why you think the theory predicts waterboarding shouldn’t work. Seems to me that that is like saying that rules of perspective in pictures shouldn’t work after you know how to draw. Isn’t it a general rule that automatic processes are virtually unaffected by conscious thoughts?

    • beleester says:

      Because this seems to be a case where knowing what will happen does overrule the automatic system. Exercising makes you expect a shortage of oxygen, and your suffocation alarm becomes less sensitive, and you don’t panic. Having really terrible allergies puts you on the lookout for breathing problems, and you panic more.

      So why doesn’t knowing that your oxygen shortage is because of waterboarding make you panic less?

      • Enkidum says:

        I don’t think conscious deliberation enters into either of the examples you gave. Presumably whatever shortness-of-breath detectors are involved in these decisions are calibrated to account for the current state of exercise. And having repeated breathing problems presumably changes the threshold of these detectors.

        This strikes me as a fairly impenetrable mechanism.

        • Also, I have observed that panic is generally incompatible with being already physically exhausted. I wonder if any doctor has recommended screaming into a pillow at full force and doing 50 push-ups in a row (or as many as can be done before collapsing) to deal with panic attacks.

          It seems to me like the worst part of a panic attack is the feeling that one urgently needs to do something, but the brain doesn’t know what needs to be done, so people just stand there paralyzed without any feeling of resolution.

          Whereas, even if you do some sort of vigorous activity that is exerting, it can kind of fool your brain into thinking that at least you are doing SOMETHING about the distressing situation, and thus the situation must be under control, even if the thing you are doing is nonsensical (like push-ups, or sprinting) and doesn’t actually do anything to address a real threat.

          • Spookykou says:

            It seems to me like the worst part of a panic attack is the feeling that one urgently needs to do something, but the brain doesn’t know what needs to be done, so people just stand there paralyzed without any feeling of resolution.

            I have never heard somebody describe a panic attack this way before, and always assumed that I have never had a panic attack. However a medication I took briefly(I don’t remember the name) caused me to experience almost exactly that. I suddenly started shaking uncontrollably, I was playing a game at the time and I had to remove my hands from the keyboard and mouse. My heart was racing and I couldn’t focus my thoughts at all, after maybe a minute of this I got up from my chair and ran to my bedroom where I started violently whaling away at my mattress for several minutes until I was exhausted/calmed down(I don’t really know why I thought to do that, I just needed desperately to do something). I stopped taking the medication shortly after(it kept happening), I described it simply as ‘extreme restlessness’ to my doctor who didn’t really comment on it, and just asked if I wanted to change medications. I had never considered this a panic attack though, because it seemed to me that anger, not fear, best described the emotion I was feeling at the time(which might explain the hitting?).

            So the point of all this is just personal curiosity, Is what I described normally considered a panic attack, or did I experience something else?

          • greenshackle says:

            Spookykou: it doesn’t sound like a panic attack to me. The defining feature of a panic attack is extreme fear. Fear of imminent death, usually.

            It sounds like what happens to me when I take too much caffeine. I become restless, fidgety, cannot focus, and feel extremely irritable. Was the medication a stimulant by any chance? An amphetamine or something?

          • Seth says:

            “The defining feature of a panic attack is extreme fear.”
            Frequently, but not necessarily. I have had a few panic attacks featuring accelerated heart rate, light-headedness, hyperventilation, shaking, tingling, and slight nausea, without the intense fear. They were just intensely unpleasant physiological responses to a stressor. (First time might have been a little terrifying if I hadn’t quickly recognized it for what it was.)

          • Cadie says:

            Anecdotally, when I’m doing some kind of vigorous activity, I don’t get panic attacks, even though I get them frequently when I’m not. In fact it got to the point where I had to switch positions at one of my jobs to reduce their frequency. The one I switched to was the one I was hired to do in the first place, so it was fine.

            If I’m zipping around the kitchen and sending out an order every two minutes… no problem. If I’m having to stand around waiting at the cash register with people upset with me and so on because someone else is taking too long, it can trigger an attack quickly. I recently made the connection between “under stress and physically very active = fine, under stress and not physically active = NOT fine.”

            And now seeing this post and the comments, maybe it’s not a nutty quirk. Maybe there’s some physiological basis for it. When stress hormones are rising but I’ve been moving fast in a hot room for 30 minutes straight, my brain goes “Duh, it’s 100 degrees and you’re doing the equivalent of a workout. Situation normal.” If there’s nothing physically obvious, that override doesn’t happen.

          • Spookykou says:

            I honestly don’t remember exactly, I have been on several different antidepressants without much luck and I believe this medication was an off label solution. I know it wasn’t amphetamines as I have been trying to get those for a long time with no successes.

          • TheEternallyPerplexed says:

            It may be more than exhaustion. Bercelly postulated that trembling was a stress-release mechanism and developed a sequence of exercises to trigger trembling in specific muscle groups.

      • vV_Vv says:

        Exercising makes you expect a shortage of oxygen, and your suffocation alarm becomes less sensitive, and you don’t panic.

        The calibration of the suffocation alarm for the oxygen and CO2 levels experienced during high physical activity may well depend on some archaic innate mechanism, possibly evolved in our air breathing fish ancestors, that does not require much conscious thought.

    • gbdub says:

      But he also gives two examples of automatic responses that apparently are mediated by conscious thought: the patient, who got better once she had an explanation, and the adrenaline-injected patients who got less agitated when they were told the drug was agitation inducing.

      Water boarding seems more acute, you’re less in control, and your captors are probably trying to deliberately increase your panic response, not let you calmly reason your way out of it.

      Or it could just be that ” unexpected moisture in my airway” is a much harder signal to ignore than “elevated heartrate” or “slight increase in blood CO2” (both of the latter occur frequently for benign reasons, the former not so much).

      • Enkidum says:

        Yeah, I’m probably leaning too hard on the cognitive impenetrability of this stuff. You can presumably do something, especially with repeated training (i.e. therapy) about this sort of thing.

  9. JASSCC says:

    Random completely unsupported thought from a completely unqualified kibbitzer:

    As a mechanism to cope if she started to feel the unpleasant sensation coming on, I wonder if it would help to do some mild exercise like by starting walking around her house.

    I ask because I have found that I’m never more aware of my respiratory system sort of doing its job and earning its keep than when I exercise. This might be tricky because really hard exercise can push it to a point where the respiratory system is working really hard to keep up and that might be perceived as struggling to breathe. But just taking a nice walk in a hilly area for a few minutes really gets the lungs going in a way that to me seems very obviously successful — you’re not at risk of suffocating when your lungs are breathing up a storm, as it were. I wonder if that would be reassuring to a person with this fear. Plus exercise is good for you, etc.

    My caveat is that I could see how this could backfire if the person overdid it or if I’m weird and other people don’t have the same subjective feeling. But perhaps it’s worth a try in a clinical setting like on a treadmill at the hospital. I imagine exercise is easy to prescribe.

    • sconn says:

      Exercise does seem to help a little. It’s hard to make myself do it though. I think “oh no I can’t get enough air, I MUST go lie down and rest!” And of course lying down and breathing deeply and slowly does help, because CO2 would go down in that case, but the second I get up it would get worse. However if I had already started hyperventilating, I would pace around the house to stop the dizziness, and the whole attack would fade. Adding more exercise into my daily schedule seemed to decrease the frequency of the attacks; I assumed it was because I was getting in better shape.

  10. tgb says:

    I’m a little leery of this hypothesis for the following reason: when I read that delivery suppresses panic attacks, I thought “Oh of course, it’s because delivery obviously induces all the usual stressors that lead to suffocation and panic attacks, but the body knows that’s going to happen and so suppresses the panic attack anyway.” But then I read that the opposite happened and was equally well-explained by the theory. So what can’t this explain?

  11. Deiseach says:

    After all, its whole deal is artificially inducing the feeling of suffocation in a situation where the victim presumably knows that the interrogators aren’t going to let him suffocate.

    If people are TORTURING YOU, I think it’s not unreasonable to believe they’re not going to be very careful with your health and life. Also, a panic attack is an imagined feeling of suffocation/heart beating too fast, as in your patient’s case the hospital runs tests and says “no, you are not having a real heart attack”. Being waterboarded is being really drowned.

    • Matt M says:

      Right. In a REAL torture situation, you presumably aren’t 100% sure that the torturers are going to be extra careful with your life.

      Conversely, as far as the “controlled experiments” go, I’m willing to take people’s word for it that it’s still the worst thing ever. But I would point out that for all the talk of “you can’t condition yourself for this,” the people who are probably the subject matter experts in this arena (the US military) still seem to deem it worthwhile to force their own people to experience it at least once. So they presumably think that, to at least some small extent, you can condition yourself for it.

      • Controls Freak says:

        There’s a possible middle-ground. It may not condition a person for the physiological/psychological experience of the actual event, but rather for moments around the event. It’s the worst feeling ever, and you know it’s going to be the worst feeling ever, but you’ve done it before. You’ve seen it done to a bunch of your friends. If that’s all they do, it won’t kill you.

        After a pouring, there is a time where the torturer wants you to think, “This is so horrible… and I might literally die, because it feels like I’m going to die. Maybe I should just tell them what I know.” Instead, in that moment, you’re thinking, “This is so horrible, but I won’t literally die unless they do other things.” That might not be enough to keep everyone from talking, but it might push around some marginal cases.

        My understanding is that a lot of torture methods are based on the idea that it’s not the pain or the immediate discomfort that really does the trick. It’s the credible threat that worse is to come, and that it can come at any point. The next time they pour, you might not come off the table… the next time they drag you out of your cell for a simulated execution, it might not be so simulated, etc. You better stop it now, before that happens.

  12. sconn says:

    Oh my gosh, I have this.

    I started having these breathing spells after having my third baby. It would sometimes happen when I was stressed, but sometimes when I wasn’t stressed at all. I’d get up out of my chair and suddenly OH NO CAN’T BREATHE! So I’d take big deep breaths trying to get more air, and instead of helping, I just felt dizzy. So I went to the doctor and they tested my breathing and it was fine. Lung capacity was fine, heart was fine, blood ox was fine so the doctor shrugged and said “Maybe it’s stress.” I said, “I have three kids, so I’m pretty stressed, but these attacks aren’t happening when I’m stressed, they happen when I change position or sometimes for no reason at all, like at night.” He said, “Well, you don’t LOOK stressed. Just try not to hyperventilate, continue with your normal activities, and come back if it doesn’t go away in a month.”

    It didn’t really go away, but I was able to keep from hyperventilating by consciously breathing slowly, so it wasn’t that huge of a deal. And then I got pregnant and it only happened maybe once that whole time.

    Fourth baby is two months old and I just had another spritz of attacks. Interestingly, this started on the first day of my second postpartum period, i.e. when progesterone has a big drop.

    I feel a LOT better hearing this information, as predicted.

  13. hollyluja says:

    Thank you for this!
    I’ve had panic attacks only during pregnancy. This last one (twins!) they gave me Buspar and tried to get me into a 5 week outpatient program for anxiety. I asked them to check my iron levels and they were very low – not surprisingly since your blood volume doubles in a twin pregnancy.
    I had five iron infusions and the panic attacks totally stopped. Of course iron transports oxygen in the blood and symptoms of anemia can look like panic.

    I’ve also meditated for years and I wonder if the training to breathe slowly and deeply wasn’t exactly the wrong thing to do while pregnant

    • sconn says:

      Huh, anemia was something I’ve also wondered if I had. I assumed that I wasn’t anemic because my blood oxygen was fine, but later someone told me that anemia does not affect blood oxygen readings. But I did have *extremely* heavy periods at the time due to low progesterone.

      Gah this stuff is complicated and it would have been REALLY HELPFUL if the doctor had done some of the thinking and research for me instead of just sending me home with a dose of “you’re probably fine.”

      • as1018 says:

        Anemia can have an effect on blood oxygenation but the hemoglobin needs to get fairly low to do so. The medical standard is to transfuse if hemoglobin drops to 7 (normal is around 14). I have had patients with hemoglobin around 7 but their measured oxygenation was in the 90% range and they appeared to have adapted to the anemia. The body will usually compensate if the change in hemoglobin occurs chronically. If you’re concerned, it is now possible to get a pulse oximeter for home use for around $60 at WalMart.

    • cuke says:

      I’ve also seen patients who were having postpartum panic attacks who once the anemia was diagnosed and treated, the panic attacks stopped. Same story with low thyroid (or high thyroid for that matter) — the women I know with pre-existing thyroid problems going into pregnancy, it seems harder to monitor and correct levels towards the end of pregnancy and postpartum/nursing because levels seem to be more fluctuating than before.

      As long as progesterone supplementation is okay for nursing moms, that sure seems like a better thing to try first before putting a nursing mom on an SSRI. Or even if she’s not nursing, since the SSRIs are generally so damn hard to come off of later, while progesterone is not.

      And then a more far-fetched angle for this case: here in New England, Lyme and other tick-borne diseases are increasingly prevalent and doctors are slowly getting better at incorporating screening for these into their standard protocols. Some of the Lyme co-infections, like Babesia (which most doctors don’t even test for), can cause “air hunger” and it’s possible for people who lean toward anxious to turn passing sensations of air hunger into panic.

  14. Civilis says:

    This is immediately relevant, and actually explains a lot.

    A couple of weeks back, I had an incident, for lack of a better word. I was heading back to my car from lunch, and the first sign that something was wrong was it felt like I had pulled a muscle in my left arm. The pain spread quickly to my left shoulder and upper chest. On the drive back to the office, in addition to the pain, I had a few moments where I felt very short of breath to the point of experiencing noticeable tunnel vision. After a few minutes, the pain had lessened and my head had cleared somewhat. Still, chest pain in the left chest, shortness of breath and, I discovered when I calmed down, cold sweats… better be safe than sorry. Urgent care doctor said “you’re not in immediate danger, still, let the emergency room check you out”; emergency room said “No sign of a heart attack, still, we’ll set up an appointment with a cardiologist”; cardiologist said “Heart seems healthy, might have been a panic attack.”

    I’ve got a lingering childhood fear of doctors, and more specifically, of needles. It’s not blood; accidentally cutting myself or the dentist poking away at my gums does nothing. My suspicion is that the initial pain was such that it triggered the “what if this is a heart attack, a major medical incident requiring a lot of scary doctors and needles?” subconscious fear, which triggered the panic reflex, which cascaded until I focused on breathing enough on the drive back that I stopped being afraid.

    I’ve had a couple of incidents in the past which suggest that at some level I’m capable of inducing a panic state. I nearly passed out at my last physical when the doctor was listening to my chest with a stethoscope; she noticed the change in heartbeat enough that she could get me to sit down. I did pass out visiting a relative in the hospital; one moment I’m standing and kind of woozy, next moment I’m on the ground and they’re calling for a nurse.

    I had one incident years back which seems even more interesting given the article, as it involves oxygen supply and not doctors. One morning, after a long hot shower, I made the mistake of taking a very big drink of cold water. End result: had enough time to realize something was very wrong and put down the glass before collapsing face first into the countertop, hard enough to require stitches at the ER. The temperature change plus the momentary deprivation of oxygen because a large amount of water was headed into my stomach was, according to the doctor, enough to trigger the faint reflex.

    Oddly enough, both times I’ve been in the ER as a result of something going badly, my normal fear has been mostly suppressed. In both cases, medical professionals were able to poke me full of needles without the fear reflex kicking in, or at least at nowhere near the same level. I took it as a sign of shock.

    What’s been bothering me since the incident is that I’ve both been hypersensitive to the feeling that something’s wrong and aware that I’m vulnerable to panic attacks, so my body is sending mixed messages.

  15. liz says:

    I have a history of pregnancy, breathing problems, and anxiety attacks! A threefer. 🙂
    I’m also claustrophobic and have social anxiety (of a much milder variety, I’m sure, than most of your patients…as I’ve never gone to specialists for mental health treatment).

    -I’ll start with the (pure, un-anxiety-related) breathing trouble. It actually seems to be pregnancy related in my case. I noticed it with my second pregnancy. I started getting asthmatic symptoms, which did induce a panic attack. My husband was deployed, I was living in a foreign country with a toddler and large pregnant belly (it was a long while ago…I’m guessing I was about six or seven months along if memory serves). I couldn’t get air in, not even enough to call an ambulance and talk on the phone. I was on all fours and by the next morning I was able to talk again, went to the doctor and he gave me an albuterol inhaler. That did the trick. I only had to use it a couple of times. Apparently this is an inherited trait because my sister (four pregnancies) had the same affliction and it got progressively worse with each baby.
    AFTER giving birth I started running pretty much right away…with my inhaler, just in case. I needed it a couple of times but eventually the symptoms passed and after my pregnancies were over I haven’t had the asthma (or asthma-like symptoms again).

    – After a bout with labrynthitis I started having panic attacks. At first they were related to dizziness, but after the dizziness subsided I still had the attacks from time to time. I think those were stress related. A couple of times I hyperventilated to the point I passed out (a poster above recommends walking for distraction, I highly highly advise against this…especially if you have a tile floor).

    – Claustrophobia came first (I’ve always been mildly agoraphobic though). This might be TMI, but…what the heck, when my husband and I had sex I used to like him to push my face into the mattress. But, one time we were on vacation and there was one of those foam mattresses, and I actually couldn’t breath. I got the sensation that I was being suffocated and began flailing, which he didn’t process right away…until I began REALLY flailing. Now, I cannot have him push my head in the mattress anymore, even though I trust him and it’s not foam and whatnot. I start to panic the minute he does. I also have panicked in closed areas since (not an elevator so much…unless it is packed full of people, but the back of a small car would be an example, or a diving mask).

    -Per this bit: “According to Klein, “There is a period of extreme hyperventilation during delivery, which drops the blood carbon dioxide to the minimum recorded under nonpathological conditions”. This explains the extreme protective effect of labor against panic disorder, despite labor’s seeming panic-inducing properties.”

    Hyperventilation occurs in panic attacks too, so I don’t think hyperventilation (even the extreme variety….passing out is pretty extreme, and I’ve done that) is the explanation there. What else happens in labor that might make it an exceptional case? One of the most obvious things is…well, the same thing that would happen if a bear were chasing you (another bad time not to be able to breath and pass out, though you might get a heart attack after). Adrenaline. Adrenaline was so high in my labors I could feel the rush of it leaving my body after. Uncontrollable shaking and feeling of relief, coldness all over. I’m an avid runner and have never experienced anything else like it.
    But an even more likely difference is…oxytocin, which is present in large amounts, and stimulates the labor itself.
    I’m curious if the patient here was breastfeeding, which can stimulate oxytocin. Or perhaps there was something wrong with her let down reflex and the oxytocin wasn’t produced. If she hadn’t slept in three days I highly suspect she wasn’t breastfeeding. When I was, I couldn’t keep my eyes open after a good feeding.

    -Some thoughts on the deep diving and the (possible) relationship to waterboarding someone mentioned above:
    My husband is a spear fisherman and he can hold his breath underwater for almost four minutes. He was trained to do so in a manner similar to how they train Navy Seals. They are able to do relaxation techniques and override their body’s impulse to panic. I’m not sure if everyone can accomplish this or if they are outliers. But one important point that I think fits into the topic here. They have to be wary of something called shallow water blackout. They will hold their breath without the panic response literally until they pass out underwater, and drown (even if they are only sitting on the bottom of a pool with a foot or two of water above them).

    -and last thought, there is an author and speaker named Grossman who wrote On Killing. He is your ideological opposite, but he does have some breathing techniques that work really well for countering anxiety and panic attacks (they are also used to combat PTSD).

  16. Murphy says:

    huh. Interesting.

    Any idea if anyone has ever tried treating these sorts of things by pushing people in the opposite direction.

    have people hold their breaths for extended periods, breath into a paper bag or an air supply with slightly lower oxygen etc to attempt to adjust their bodies ideas about what levels of CO2/oxygen are problematic?

    Not during an attack of course.

    perhaps visiting some high-altitude locations with lower pressure/oxygen. You might expect to see a spike in panic events while on the trip but a reduction when they get back….

    Are swimmers and freedivers less inclined to develop panic disorders?

    • greenshackle says:

      Exercise will do it, and it’s known to help with anxiety / panic.

      Anecdotally, my sensitivity to panic is inversely proportional to how regularly I’ve been exercising.

      If I havn’t exercised in several weeks, exercise *induces* panic attacks. It’s a really nasty feedback loop; if I lose the exercise habit it’s *really hard* to get it back, and I get stuck in high-panic mode. At times it’s gotten bad enough that climbing a couple flights of stairs was enough to induce an attack.

      When I’m there the only ways out I’ve found are extraordinary acts of willpower (*exercising through the panic*), ramping up exercise *very gradually*, or exposure therapy, by deliberately inducing panic attacks with drugs in a controlled environment.

      My working hypothesis is that my emotions have a fixed scale, and my brain will adjust whatever stimuli I’ve been getting in the recent past to fit on that scale. If I don’t expose myself to moderate-high intensity stimuli regularly, the entire scale ends up mapping to low intensity stimuli, so that, for instance, a heart rate of 120 becomes enough to induce a state of MAXIMUM VIGILANCE, CHECK FOR MAJOR ORGAN FAILURE, IMMINENT DEATH PROBABLE.

    • cuke says:

      I knew a psychiatrist who used to send his panic attack patients to run up and down the stairs in his building in order to cue the panic attacks so that he could then do cognitive/behavioral interventions with them while they were panicking, but in a safer more controlled environment than if it happened randomly at home. Graded exposure and all that.

      The other common “paradoxical” intervention used with panic is a cognitive strategy that’s really about training people to develop a sort of “bring it on” attitude towards the panic attacks. That cognitive stance helps to interrupt the part of the feedback loop with panic where we learn to fear the panic attacks themselves, and then that produces anticipatory fear that brings on panic attacks with lower and lower thresholds of a stimulus (or entirely uncued as Scott describes when people wake up from sleep having them).

  17. greenshackle says:

    > But exercise doesn’t make people panic.

    Oh you sweet summer child. Try googling ‘exercise induced panic attacks’.

    • sconn says:

      Interesting! I don’t run because I always get wheezy when I’m running and feel like I can’t breathe. Figured it was an out-of-shape thing but since I also have breathing episodes (panic attacks???) when at rest, and DON’T have asthma, maybe I should look into that.

    • mingyuan says:

      Yeah, the worst panic attack I ever had was while exercising. This was when I was on my college’s crew team, and I was pulling a 5k test (basically just DO IT AS FAST AS YOU CAN for like 20 straight minutes). I was in shape but still not used to the intensity of the workouts, so my heart was racing like crazy and my breathing was shallow and labored, and there was tightness in my chest. Combined with the fact that I was quite anxious and moderately depressed at that time in my life, those things triggered a panic attack, and I totally lost focus and ended up injuring myself. I haven’t been able to row seriously since then.

      At the time, I understood this as just my already-anxious brain receiving the same physiological information it did during a panic attack and interpreting it incorrectly. I think this post kind of confirms that assumption, although I’m still not totally clear on the mechanism. Like, I run often and have never had a similar experience, maybe because I’m not pushing myself as hard… I think it’s quite possible that while rowing I was just literally not getting enough oxygen.

      How relevant is the predisposition to panic attacks, do you think? I had had them before but not often enough that I think my body would have updated its priors significantly; but maybe its priors were updated in favor of a panic attack due to my mental state somehow? Is that possible?

  18. J Mann says:

    I have a friend with a similar vicious circle, although suffocation doesn’t play a big part.

    She has a blood pressure issue where her BP can drop suddenly, leading to a fall and in at least one instance a concussion. When she feels it coming on, she sometimes hyperventilates from panic, which leads to muscle cramps to the point where her hands cramp into claws she can’t open. The first couple times that happened, that symptom exacerbated the panic attack, but now she knows that when she feels the cramping, she can resolve it by taking slow breaths.

    Other than the hyperventilation, there’s not a big suffocation component here, but it’s a similar loop.

    • as1018 says:

      Another way to treat sudden low blood pressure is to cross your legs and arms and to talk or shout. All of these increase blood pressure.

    • cuke says:

      Similarly, I know a couple of people who have high blood pressure and any symptoms that they associate with high blood pressure spikes — headache, face flushing, etc, even if they don’t really indicate high blood pressure — can produce panic attacks about the possibility of having a stroke or heart attack. And then once that feedback loop gets going, situational cues can trigger the panic attack separate from the physical symptoms — like being in the same setting as when they previously experienced the headache and face flush (a particular store or doctor’s office, say).

      In this case, treating the borderline hypertension with medication and the patients seeing their blood pressure be reliably controlled (using home BP cuff) led to an end to the panic attacks and all the feedback loops that were contributing, without any need of psychiatric interventions.

    • TheEternallyPerplexed says:

      What can be helpful against dizziness or a syncope:
      1. Activate the “muscle pump”: contracting muscles in the limbs squeeze veins a little => increased venuous flow back to the heart => higher cardiac output because of more incoming volume.
      2. Increase pressure in the thorax to increase reflow from lungs to heart: inhale, close the glottis (as if about to harrumph), and exhale-press for a moment against this block as if about to lift a heavy weight.
      3. Squat or crouch to lower the pressure difference for venuous reflow (get the heart closer to limb level).

      I use 1 and 2 when I get up from lying super-relaxed.

  19. anaisnein says:

    Scott, this is a wonderful piece of writing. A tour de force. Someone let the New Yorker know it’s time to reboot the old Annals of Medicine column; there’s a new Berton Roueche in town.

    I have something along the lines of IBS (the episodes are too rare to meet the criteria but can get quite ugly: I once went to the ER suspecting a bowel obstruction, which is something I’d actually experienced before and it remains my “10” for pain scale calibration) and I’ve definitely found some relief in extremis in going all chin-stroking cerebral observer wrt the physiologic processes underlying the symptoms. At one point I remember the phrase “cholinergic response” became a sort of weird internal mantra. Interesting in this connection because my GI issue seems likely to be linked to my GAD and for all I know it may be my particular system’s choice of alternative to having panic attacks.

  20. Matt M says:

    Perhaps there’s an evolutionary component. I can imagine you being able to condition yourself to exercise because humans have been in exercise-like conditions all the time. The survival of the species has been literally dependent on the brain to be able to accommodate the demands of exercise.

    I can think of few situations where evolution required restrained humans to be able to resist the feeling of being drowned. When people say “it doesn’t simulate drowning, it is drowning” they are speaking in a biological sense, not in a contextual/environmental sense. In the vast majority of “drowning” situations you presumably have some freedom of movement, ability to see your surroundings, knowledge of exactly how terrible and hopeless the situation is. Waterboarding replicates the physical and psychological feeling of drowning, but the context is completely and entirely different. It’s not something that the brain recognizes as necessary, expected, or normal, in any circumstance.

  21. Evan Þ says:

    This is probably part genetic and part learned – I have a panic disorder patient who has a bunch of really bad allergies, whose body would shut down in horrifying ways every time he accidentally ate a crumb of the wrong thing, and this seems to have “sensitized” him into having panic attacks; that is, his body has learned that worrying sensations often foretell a health crisis, and lowered its threshold accordingly to the point where random noise can easily set it off. I’ve done a lot of work with this guy, but none of it has been “just ignore your panic attacks, you’ll be fine”. His body knows what it’s doing, and we’ve got to work from a position of respecting it while also teaching it not to be quite so overzealous.

    Interestingly enough (from a theoretical standpoint), I have a friend who’s trained her body to be in this condition even without any underlying allergy at all. I have no idea what started it, but now she’s fully convinced – despite the results of challenge tests – that she really does have a deathly allergy with a super-low threshold. (Her parents gave her the challenge tests just prior to her eighteenth birthday, so we know they’re genuine. Unfortunately, then she turned eighteen, she wouldn’t listen, and they couldn’t do anything more.)

    I’ve heard some people saying a similar thing’s going on with a lot of peanut allergies. I don’t even know how you could test it, because the body is really reacting to the actual presence of peanut proteins… it just isn’t totally because of the underlying allergy. Any suggestions?

    So anyway, Scott, I hope your panic disorder patient at least recognizes what’s going on? What sort of desensitization therapies are you using?

    • Spookykou says:

      I might not have understood what you described, but couldn’t you test for psychosomatic allergies by surreptitiously exposing a person to their supposed allergen.

      Oh wait, ethics.

      • sconn says:

        But this does get tested all the time – I mean most people having a peanut reaction didn’t eat peanuts on purpose. They ate something they thought was fine, reacted, and later investigated and found the dish had been made with peanut oil or something. That seems an adequate blind test despite occurring in the wild.

  22. shakeddown says:

    There’s a certain thought mode I get, where I’ll become extremist because nothing less can suffice. For example, assume we talk bout gun violence, and I say “Well those pro-gun people love their guns so much they don’t care how many kids die.” And I get a bit angry. And then I’ll think “wait they seriously DON’T CARE KIDS DIE” and get even angrier, until after a few iterations of this self-argument I’ll have convinced myself that pro-gun people are the actual devil. (This is basically “sacred value mode”, I guess).

    If you think of the brain as a Bayesian reasoner, you can think of this as the fallacy of adjusting my prior multiple times over the same observation, without remembering that I accounted for the observation, until I get near 100% certainty over it. I’ve heard an explanation of panic attacks that’s basically this (for example, for people who get panic attacks over airplane phobia). This matches the suffocation description – if the brain is a top-down reasoner, and you throw a cog in the ability to clear away evidence after accounting for it, than a small amount of evidence of suffocation can readjust your priors until they’re super high.

    Alternatively, you can think of this in terms of the Aumann agreement theorem, against an imaginary partner who doesn’t adjust his priors. If your imaginary partner can’t adjust his beliefs (since you’re either too angry or too panicky to simulate him at a sufficiently high theory-of-mind level), AAT implies that you have to keep changing your beliefs until you completely agree with him.

    • carvenvisage says:

      If you think of the brain as a Bayesian reasoner, you can think of this as the fallacy of adjusting my prior multiple times over the same observation, without remembering that I accounted for the observation, until I get near 100% certainty over it.

      But if they really ‘don’t care that kids die’, on the face of it that would be a reason to get enraged. Might the issue just be that you’re not integrating the fact that there’s too many terrible things happening in the world for everyone to care about? Like most anti gun people probably ‘don’t care’ as much as pro gun people that sometimes people have no chance to defend themselves when being armed is illegal, but that’s actually fine because there’s way too much stuff to care about in the world to actually care about most of it.

    • cuke says:

      This strikes me as pretty brilliant how you’ve described this process. And maybe accounts for some of the connection between habits of the mind that fuel anxiety — like black-and-white thinking — and the righteous anger that we experience or witness sometimes in political arguments, online or otherwise. Like one source of fundamentalism (of whatever stripe) is people having sensitive emotional triggers who also have difficulty in clearing away evidence after accounting for it. One of the features of the hypervigilance you see in PTSD is a kind of clinging to all prior (negative) evidence almost like how a hoarder clings to objects.

  23. egoisty says:

    Anecdotal, but I think the Schachter and Singer experiment may explain why I’ve never had a panic attack that was associated with bouts of what felt like restricted breathing. At worst, “Wow, I really feel like I can’t breathe. But I know this is something that happens to people who get panic attacks, so I’m just going to try to ignore it until it goes away (or I pass out in the street).”

  24. martinw says:

    People who are drowning will usually panic eventually, won’t they? The brain doesn’t keep going “hmm, oxygen levels seem to be dropping, but that’s fine, it’s totally normal and expected given that our lungs are filled with water” all the way until you’re actually dead.

    It may be that there are two levels of response: the first is the “bayesian” level as described by Scott, where you get the “drowning alert” signal only if you are getting less oxygen than would be expected given the circumstances. At this level you’re not panicking because it would be counterproductive, you need to be able to focus on finding a way out of your situation.

    The second level is when you have only a few seconds left to live, so your subconscious says “OK conscious mind, whatever you’ve been trying until now clearly isn’t working — let’s try randomly trashing around and see if that does anything”.

    My limited understanding of waterboarding is that it’s a way to artificially trigger that second level of response. Here is an interesting description from someone who tried it on himself (spoiler: it’s not fun). As he describes it, what triggers the instinctive panic response is when water is drawn into the respiratory tract. Because the victim is lying on an inclined plane with the head lower than the chest, water never actually gets into the lungs, but apparently somewhere in the windpipe there is an emergency switch which sets off the “you are drowning RIGHT NOW” reaction.

  25. Squirrel of Doom says:

    So maybe oxygen tanks could be a treatment for postpartum depression?

  26. ScarecrowBoat716 says:

    This is very interesting for me, as a highly introspective panic-disorder sufferer. I have weird problems with water getting into my sinuses. Like as a kid I never understood how people can go underwater without plugging their nose. Doing so to this day gives me a moderate burning sensation in my throat and nose and I come up sputtering and coughing. I have even accidentally waterboarded myself in the shower for a couple seconds while washing my face. Now I have to wait next if this is all related to the same issue.

  27. Elizabeth says:

    In high school, I ended up getting panic attacks whenever I did timed, slow breathing exercises trying to calm myself down. I’d always assumed it was because I was doing the breathing exercises in situations that weren’t in fact super safe (school hallways where I got some amount of hassle) and my brain was resisting the attempt to relax where not adaptive? Anyway, it cleared up after a few years and I can do breathing exercises again.

  28. coreyyanofsky says:

    I have never been more panicked in my whole life. Once your lungs are empty and collapsed and they start to draw fluid it is simply all over. You [b]know[b] you are dead and it’s too late. Involuntary and total panic.

    There is absolutely nothing you can do about it. It would be like telling you not to blink while I stuck a hot needle in your eye.

    At the time my lungs emptied and I began to draw water, I would have sold my children to escape. There was no choice, or chance, and willpower was not involved.

    I never felt anything like it, and this was self-inflicted with a watering can, where I was in total control and never in any danger.

  29. snazzybucket says:

    Maybe the way that you can’t waterboard yourself is similar to the way you can’t tickle yourself. Some researchers did a study where they had a button on a machine that when pressed would try tickle you. The body registered that as tickling yourself and so no response. Then they added a delay to the button, and the greater the delay the more ticklish it was. So if there’s a spectrum between holding your breath and drowning, maybe waterboarding is way too close to drowning, so that even like in Hitchen’s case where you know you can stop it, it just doesn’t count as enough of a delay.

    Here’s that study, I got the above from a synopsis and the abstract makes it sounds way more complicated, so maybe I missed some important points.

    http://www.mitpressjournals.org/doi/abs/10.1162/089892999563607#.WOU-_1KB1E5

  30. wintermute92 says:

    So… has anyone tested the panic cures this implies?

    One would be exercise, as a way to rationalize the panic symptoms. I don’t know if people get panic attacks mid-exercise, but even if they do this might help (since it would justify O2 deprivation prior to driving down O2 levels).

    Two is direct O2 supplementation. If progesterone and pregnancy in particular supplement O2, why not just take a few pulls from an inhaler or O2 mask and see if it calms an oversensitive panic sensor?

    (More O2 isn’t a direct cure, as discussed elsewhere. But any low CO2 breathing setup could help, including diver’s trimix systems. Do people get panic attacks while breathing trimix?)

    • greenshackle says:

      Do you mean exercising at onset of panic attack to stop it? Or exercise in general?

      In my experience exercising regularly decreases incidence of panic attacks by a lot, but can cause acute panic attacks mid-exercise.

      • markk116 says:

        I think he might mean exercise to expose the control loop to situations where blood CO2 is high, so it can get “used to it” as it were. I think this comes down to raising your CO2 tolerance.

        • greenshackle says:

          That makes more sense to me, and in my case regular exercise does help reduce the incidence rate of panic attacks, though I don’t know if the mechanism of action is raising CO2 tolerance.

  31. sidereal says:

    I recently lost my job, which made my drinking habit worse, which caused heartburn/reflux, which I interpreted as some sort of heart problem because it was completely novel sensation for me, which caused me to stop drinking immediately out of concern for my health, which caused more uncomfortable symptoms.

    So, for weeks now I have been having health-related panic attacks. I am also hyper-acutely aware of every warning sign in my body. For me the conscious awareness of biofeedback loops makes the problem worse, not better. It’s like some kind of basilisk/intrusive thought demon where I’m afraid of thinking the thought that will make me spiral into death.

    told her if it didn’t go away soon then she might develop panic disorder

    I realize this isn’t the place to ask for medical advice but this post was so apropos of my current situation and this line gave me concern. I have benzos and welbutrin but I haven’t taken them because I don’t like to medicate unnecessarily – I figured I could endure the current panic and normalize eventually. Is that the wrong way of looking at it? Am I conditioning myself in some maladaptive way?

    • J says:

      You’re describing almost exactly what happened to me a few years ago. It was the worst thing I’ve ever gone through. I likewise don’t like to medicate. Short term tactics like mindfulness, pouring water on the wrists, walking, and distraction by having conversations with people were helpful. I carried a backpack with benzos, inositol and food and water; I treated the benzos as my last resort, with the inositol as second to last (it’s super benign and works great at settling my stomach even in fractions of a dose; start at like a quarter of a dose). Knowing I had those layered options was helpful in waiting out spikes. I only used the benzos four times, but carried them religiously for months. I almost used it a fifth time but managed to get into a really interesting technical discussion as I was reaching for the bottle and that got me through.

      Longer term, the name of the game is stretching boundaries. Find things where it’s awesome that your metabolism is running. Rev that engine. Exercise is super good. Eventually I got to the point where I’d be a sort of drill sergeant with myself: oh, you think you’re having a heart attack? I don’t buy it. Better go for a run! Now it’s more of an inner sarcastic voice and rolling off the eyes at the panic thoughts. Also helpful was self reassurance: hey, it’s okay buddy, probably nothing wrong, and even if there was people would do the right thing for you.

      Searching online anxiety forums was super helpful. Tingling feet? Hearing your own heartbeat? Hot flashes? Yep, lots of others have been there.

      Panic is a malfunctioning burglar alarm: the last twenty times it was a false alarm and so you can ignore it this time. Sucks that a real burglar could show up, but it’s not my fault that the alarm broke, and I’m not going to let the false alarms disrupt my life. It’ll heal itself over time.

      For me it got better over a few months. I still dislike the burbling sensations in my thorax that I probably just never noticed before, but I can run two miles and have every indication of being in good health so I don’t worry about it. Sometimes I’ll drink fizzy water so that the burbling is something I put there deliberately. I still notice my heartbeat (especially below my ribs near my stomach; I think the nerves picked up a sympathetic rhythm) when I sleep on my front, but it rarely annoys me.

      Long term good habits include keeping my sleep schedule religiously and trying to use up all my mental and physical energy every day. Excess energy turns to nervousness. I’ll get up and run in the middle of the night if I’m feeling restless. And personally I found a “memento mori” philosophy helpful: someday I’ll die and that’s fine. It might hurt a while, or not. And I’m not going to run to the doctor at every twinge begging for a magic cure. I’m going to enjoy what I’ve got an exit stage right when it’s my time.

      So, it gets better. Have lines of defense, hold out as long as you can before going to the next line. See if you can hold out longer than last time. Use up your energy every day, push your boundaries and congratulate yourself every time for being a badass, be patient with yourself. You’ll look back with pride at how much stronger you’ll be later.

  32. andrewflicker says:

    Another anecdote to support the “two-factor panic” hypothesis: I used to do judo (actually a mixed art, but we mostly focused on judo), and deliberate choking (usually using a part of your opponent’s gi) was a significant part of instruction and actively allowed in sparring.

    More than once, I had to tap out *for* my opponent, because they’d been so conditioned to strangulation that they no longer had a significant panic response when being choked out and thought they could just “keep fighting” when hopelessly locked, and my alternative was to either concede for them or actually knock them out- which carries high risks of stroke, brain damage etc., and should never be encouraged by professional martial arts instruction. Afterwards, they’d realize they should have tapped out and that they had been very oxygen-deprived, but that in the moment they’d felt fine to continue.

  33. Garrett says:

    For agoraphobia, being in places with high ceilings always gave me the sensation that I might fall upward. The same one you get at the top of a high building when looking down (with that vague I-wanna-jump-but-don’t-want-to-die feeling). It’s even more frustrating when you know you don’t have any control because you can’t choose to fall upwards.

  34. Spooky_Rationalist says:

    It can’t be just because of suffocation, maybe that’s one of the potential triggers. Here’s my own case, i started taking adderall/vyvanse from a friend and had a bad experience once where i felt really woozy.

    After I stopped taking them, I kept getting these panic attacks that would be triggered by chest pain. Basically i was interpreting every little pain in the chest as a symptom, and then focusing on it until it hit a high point, then after enough time passed that I realized it wasn’t a heart attack i would eventually calm down. I eventually just trained myself to realize that I wasn’t having a heart attack and the panic attacks went away after a month or so.

    Suffocation is a neat case where there’s some actual specialized mechanism in your body that notifies you, but with chest pain, it seems like a weird problem where general pain detection mixes with the “I’m Having a Heart Attack meme” and forms a similar panic structure.

  35. rahien.din says:

    Waterboarding’s whole deal is artificially inducing the feeling of suffocation

    Competing hypothesis : liquid entering the sinuses engages a different neurologic system than high blood CO2 levels.

  36. Fluffy Buffalo says:

    Interesting. My immediate question was, so, is this the reason why every meditation technique I’ve ever heard of somehow has conscious breathing as one of its core ingredients? If the oxygen/ CO2 control circuits and the circuits that control panic vs. calmness are strongly connected, that would make sense. I’ve told my son about a hundred times, “okay, take a deep breath” when he’s agitated, but I really didn’t know why that works.
    The next question is, as other commenters have stated, how can we use that knownledge? Meditation? Diving or Brazilian Jiu-Jitsu as confrontation therapy to get used to situations with limited oxygen?

    • anthropicprincipal says:

      I do Brazilian jiu jitsu. One of the things new people have to learn is to suppress their panic reflex when someone is sitting on their lungs or strangling them. I wonder how well that skill transfers.

  37. Pete Michaud says:

    Given what you wrote about the probable mechanisms at work, it seems like a pretty cheap experiment to recommend that if she notices the attack starting, she should exercise to get her heart rate up. Eg. she notices the signs, and immediately jumps on her elliptical or does 100 jumping jacks. That might just work?

  38. whynotqat says:

    Unrelated question: why does this patient need an SSRI? Are they effective for panic attacks in the near term?

    • markk116 says:

      This article on WebMD says it’s effective against panic disorders:
      http://www.webmd.com/anxiety-panic/selective-serotonin-reuptake-inhibitors-for-panic-disorder

      Although I don’t know how reliable WebMD is, this would explain why SSRI is prescribed.

    • John Schilling says:

      SSRIs, as I understand it, aren’t effective against anything in the near term. But they are also pretty harmless, and broadly effective in the long term. If you’ve got a drug that might help in a month and you’re not sure you’ll be able to solve the problem on a day, why not get the clock running on that month?

      And they’re probably a better placebo than a sugar pill, but it would presumably be unethical to officially use them that way.

      • cuke says:

        While prescribing placebos isn’t ethical, some doctors do something close to that by prescribing supplements for which there is some reported track record of helping for anxiety and then telling a good story about how quickly the patient might be expected to notice a difference and what they might notice.

        I have seen doctors recommend particular formulations of magnesium, sublingual B-12, and L-theanine for anxiety, insomnia, and panic. Often it’s good enough for a patient to know they have something at hand that is likely to help their anxiety and that is enough to prevent the anxiety from escalating to panic.

        After all, all the cognitive and behavioral strategies are essentially using placebo effect (in the form of the mind using itself) to short-circuit the escalation into panic. And long-term, having those tools on board is more helpful than just taking SSRIs, and certainly more helpful than benzos. Pot can be helpful too for some folks obviously — one hit gets into the bloodstream really fast. But anything you have to inhale or swallow seems less helpful long-term than learning a different way to relate to your mind, which we carry with us everywhere.

        • sconn says:

          I had a friend who dealt with her anxiety by getting a prescription for meds and keeping it in her purse. That way it was always in her mind that she was dealing with her anxiety exactly as long as she wanted to, and that if it ever got bad, she could go ahead and take the meds. That was enough to make her feel in control of her anxiety instead spiraling into “oh no, this will get worse and there will be nothing I can do!”

  39. TheRadicalModerate says:

    It seems like there ought to be a way to train some of these autonomic set-points to move a bit in one direction or another. And now for my anecdote:

    I swim a lot. More accurately, I tread water a lot. One of my favorite things to do is swim a couple of hundred yards offshore in a lake and then just float around for a while (15 mins – 1 hr). I do this a lot in the summer (when I have access to a lake).

    Also during the summer, I develop something a bit like central apnea. (I also have obstructive sleep apnea, so that’s a confounding detail.) My wife and I will be reading in bed during the summer and she’ll occasionally whack me just to make sure I’m alive. I’m wide awake, perfectly comfortable, don’t notice any changes in airway muscle tone; I just… don’t feel the need to breathe very often.

    As any serious floater will tell you (so many jokes are possible…), the key to a nice, relaxing float is keeping your lungs inflated most of the time. If you’re swimming, forward momentum generates enough lift to let you breathe fairly regularly, but floating requires buoyancy, and buoyancy requires more low-density volume. So, instead of breathing in, out, in, out, you wind up breathing in… out-in… out-in… And instead of breathing 12-18 resps per minute, you’re maybe down to 6 or so.

    In the winter, I don’t float, and my wakeful breathing is perfectly normal. But even after a couple of weeks in the summer, I’m back to freaking my wife out.

    I take this as evidence that the (or at least my) suffocation set-point is pretty plastic. I wonder what a training regime would look like to de-sensitize the suffocation reflex in people suffering from panic attacks.

    • carvenvisage says:

      I just… don’t feel the need to breathe very often.

      Is that bad? I do this too and always thought it was a good exercise so I wonder if it might just be something you happen to do while hapening to seperately have sleep apnea.

      • TheRadicalModerate says:

        My understanding is that apnea comes in two basic flavors:

        1) Obstructive apnea, where for whatever reason your airway doesn’t have the muscle tone to stay open when it’s relaxed, and you don’t inhale until you startle a little from too much CO2, which clears the airway. (This is by far the most common form sleep apnea, and the little startle pretty much brings you out of anything resembling deep or REM sleep, so you can’t figure out why you’re wandering around like a zombie.)

        2) Central apnea, where the “too much CO2” signal is treated kinda casually, or not at all. This is considerably rarer, and in its clinical forms is usually some kind of neurological oddity.

        It’s entirely possible that what I really have is just obstructive apnea when I’m awake–that’s a thing. But the correlation with an activity where I wind up partially holding my breath a lot makes me curious about how much the alarm can be conditioned.

        As a general rule, low O2 saturation and excess CO2 aren’t exactly good for you. It’s usually not a big deal, but it can aggravate some underlying conditions. Given the choice between being fully oxygenated and not, I’d choose the former.

  40. AnonYEmous says:

    For example, this theory would seem to predict that waterboarding shouldn’t work. After all, its whole deal is artificially inducing the feeling of suffocation in a situation where the victim presumably knows that the interrogators aren’t going to let him suffocate. You would think that eventually the alarm realizes that “is being waterboarded” is a confounder to control for, but this doesn’t seem to be true.

    Maybe this is because of the severity of the stimuli, though? Like, humans can’t refuse to breathe and die that way; you can hold your breath and tell your brain that there is a confounder, but past a certain point your brain just stops caring and you WILL breathe. Waterboarding seems designed to take you to that edge or close to it. I’d also imagine that you can get better at being waterboarded, but only to a point – eventually your brain reaches the upper limit.

  41. romeostevens says:

    This really makes me wonder if an explanatory factor in psychiatric effectiveness is the psychiatrist being able to notice when the patient’s mental model of how the psychiatrist’s explanation should map to predictions about their experience is wrong and then nudge the explanation until the patient’s model is correct.

  42. Bellefry says:

    Without knowing anything about Hitchens’ experiment, I did something similar but much more low-budget on basically the same principle: if people were arguing about whether it was ‘really’ torture, that was basically an empirical question I could test, right?

    I used a T-shirt for the filter and my dorm’s shower. Literally no one was there to hold me down or force me to go through with it, nobody I had to trust to let me up if I did an emergency signal. Just me and a shower I’d used a hundred times before.

    I lasted about fifteen, maybe twenty seconds. I distinctly remember it being way less time than I could hold my breath. (I grew up in Texas and I’ve been swimming since I was a toddler, so holding my breath for full immersion was a basic happy childhood activity). But the spray+trying to breathe in spite of it+not getting quite enough air was terrifying. I really did get a pure animal kind of fear of dying. It’s maybe worth noting that I do have mild anxiety, but it’s usually social, and have only had straight up panic attacks a few times. I didn’t get a full blow panic attack when I tried to waterboard myself either, but only because I failed to make myself stay under the water long enough for the panic to go from ‘oh shit you’re dying ABORT ABORT’ to ‘YOU’RE DEFINITELY STILL DYING FOR THE NEXT SEVERAL MINUTES.’ So my brain was able to account for the fact that I HAD stopped, but not for the fact that I COULD stop. Given that I’m the kind of person to waterboard myself for an experiment, possibly my brain is correct not to trust me with these kinds of decisions.

  43. spencer says:

    I find that pointing out the physiological factors leading to a particular state is very helpful even for mundane things. For instance, realizing that I haven’t eaten in a while typically reduces my grumpiness quite a lot (although perhaps not as much as eating some sugar). It also seems to help my wife’s PMS moodiness, although I’ve learned the hard way that pointing this out makes me sound like a chauvinistic jerk and tends to have the opposite effect.

  44. amphibious says:

    I wonder if anyone has ever tried letting someone waterboard themselves and giving them the on-off switch for the waterboarding device.

    I did try to waterboard myself at some point, basically wringing out a wet washcloth over my face when I was lying down with my head tilted back. Since there was far less water, I wasn’t tied up, and I didn’t have some cloth covering my face, it should have been far less bad than actual waterboarding in every respect. And it still caused an extremely unpleasant moment of panic and a very elevated heart rate.

    Take this anecdote for the non-data it is 😉

  45. egoburnswell says:

    since she didn’t know I used Google I probably looked very smart

    This is probably the way to go. The smarter you look to her the more she will be convinced of the explanation you give. And this might perhaps, in some small way, filter into her “I’m suffocating alarm” more strongly, thus providing more benefit.

  46. Thegnskald says:

    So childhood asthma should be predictive of adult panic attacks, if I understand correctly?

  47. linzarella says:

    This reminds me of a really strange experience I had as a teen. When I was 16, I started feeling depressed. I went from being an engaged, happy teen to wondering why I had never noticed how bleak and pointless everything was. I had never felt that way before. It lasted for a month or so, until I randomly happened on an article that mentioned that depression was an occasional side effect of starting birth control pills. I had just started them a couple months earlier. As soon as I read that, the depression started to subside, and now, 15 years later, I’ve never felt it again in my life.

  48. 27chaos says:

    It’s implicit in a lot of what you write here, but an explicit reference to prospect theory might benefit this article.

  49. carvenvisage says:

    Would it be good to have a seperate area for purely ‘fisking’ comments? A lot of the time I feel I have nothing to add, except some minor criticisms, but posting them straight feels bare and negative, and I don’t always have the energy/social skill to introduce and phrase them in a gracious manner.

    _

    >waterboarding

    I second, fifth, or hundredth that most people’s mental state in that situation won’t (remotely) resemble “knowing” that you’re not going to drown.

    _

    …is the equivalent of telling them “You’re not really angry, your agitation comes from us giving you a drug that’s known to produce agitation

    ‘Actual anger’ is what their ‘appropriate level of anger’ heuristic actually outputs, not what it should output.

    Compare: “you’re not really paranoid, because we really were out to get you”

    • Schibes says:

      Would it be good to have a seperate area for purely ‘fisking’ comments?

      I like seeing the irrelevant stuff mixed in with the substantive stuff, if you make a little ghetto for the irrelevant nitpicky stuff no one will ever go there except maybe Scott when he is REALLY bored which, given the content of this site, is probably only once a month or so. So yeah, separate area = no one goes there, ever, IMO.

      As for the main topic, panic attacks: I suffered panic attacks around 3 or 4 times a year from 2011 to 2015. They were caused by three physiological issues and one psychological issue:

      Phy. 1) Hiatal hernia/acid reflux
      Phy. 2) Strong side effects (irregular heartbeat) from the medicine used to treat the above
      Phy. 3) Moderate to severe alcoholism
      Psy. 1) My coworker in the cubicle immediately adjacent to mine, who I respected professionally and greatly enjoyed working with, dropping dead of a heart attack at age 47 (I was 35 at the time)

      Everything sort of went into a feedback loop for a few years where the combination of certain things (eat too much, got too drunk, spent too much time thinking about my coworker) would send my heart racing madly above 150 beats per minute, I would start sweating and feeling dizzy, and I would feel severe pain in my chest. It was bad enough that I checked myself into a hospital for a couple days in 2012 and had numerous tests done and the doctors all said my heart was in great shape. They suggested I drink less alcohol and think about my dead coworker less often.

      I gradually cut back on alcohol (LONG story and kind of worthy of its own post some other day) until by fall 2015 I was practically a teetotaller. This reduced the panic attacks’ severity, and yet I still would have one once every few months where I could feel my heart try to beat its way out of my chest for no reason whatsoever while I was sitting completely still. It was like pushing the accelerator pedal of a car down to the floor with the transmission in neutral.

      What finally made my panic attacks go away (for the last two years at least, who knows if they’ll return some day) was switch my medication used to treat my gastric issues, to one that did not have cardiac side effects. I forget who it was (it wasn’t my GP) who suggested I switch in 2015 but that was what did it. I don’t claim to have the answer for all panic attacks. I only offer my story as another data point supporting a “panic attacks can come from almost anywhere” thesis.

  50. aciddc says:

    That makes a ton of sense to me. I had a panic attack a while ago, which seemed like it was triggered in part by my having a hard time taking a deep enough breath to get a burp out. In my attempt to control myself I discovered to my surprise that when I controlled my breathing I actually felt pretty okay and wasn’t too distressed by the other stuff I was worrying about, but then when I started trying to take that deep breath and burp again I went back into panic attack mode. I didn’t really have a good explanation for it at the time beyond that steady breathing is calming, which didn’t really seem adequate to explain the rapid shifts in mental state depending on how I was breathing at a given moment.

  51. Peter Gerdes says:

    The feeling that one is suffocating is a real downer (and I think differs from simply generalized panic attacks at least those my family members have) but in my experience can certainly be the result of changes that reduce your oxygen intake.

    For instance, I’ve been on adderall for a very long time but when something goes wrong (you have no idea how difficult pharmacies can be about filling scripts for these kind of drugs in ways that are simply judgemental and have nothing to do with stopping fraud) and I’ve had to go off it I also frequently feel like I’m suffocating. I presume that, like the woman, stopping taking a compound that increased my blood oxygenation (and limited mucos production) is causing my body to fear it is suffocating.

  52. ChuckleberryFinn says:

    This post is really compelling. Maybe asthma is a contributing cause in anxiety? I’m not at all familiar with the literature but here’s the first paper that comes up on pubmed when I searched “asthma cause anxiety”: https://www.ncbi.nlm.nih.gov/pubmed/28284954.

  53. moridinamael says:

    Chronic migraine also exhibits what looks to me like a similar failure mode of interacting oversensitized feedback loops. Migraines can classically be “triggered” by practically any strong stimulus, especially if the migraineur is sensitized or compromised in some other way – sleep deprived, dehydrated, stressed.

    Treatments like biofeedback and botox injections help with chronic migraine because (in my assessment, by introspection) they interrupt the feedback loops. Botox completely prevents the targeted muscles from spasming the way they are prone to. Biofeedback makes you habitually aware of your breathing, your muscle tension, your hydration, your blood sugar, so that you can proactively prevent any of these things from going into the red, inciting the other systems to mutually freak out, and precipitating the neurovascular shitstorm of a migraine.

  54. Katja Grace says:

    Thank you, this is pretty interesting.

    The thing where hyperventilation seems to often cause panic attacks is pretty confusing though (like, isn’t it used to reliably induce panic attacks for exposure therapy? And I’ve never heard it recommended as help). Also relatedly, why do people always tell you to breathe slowly to relax? e.g. as part of treatment for panic disorder.

    I could sort of imagine both of these things just being misunderstandings about the direction of causality on the part of observers—people who are not panicking are usually breathing more slowly than people who are, because the breathing fast is intended to help. (I could especially imagine this because neither works when I do them intentionally). I could also imagine they are both just complicated because they are in feedback loops. But these both seem like a stretch. Observations being exactly the reverse of what you expect still seems more evidence for something like this being right than observations just being randomly unrelated.

    Is there some reason on this theory that hypermobility disorder should be so associated with panic attacks? (Wikipedia used to say people with benign hypermobility disorder were way more likely to have panic disorder than the normal population, but maybe that whole page has disappeared. This article says ‘the most significant and important association between joint hypermobility syndrome (JHS) and any other disorder from a clinical point of view is with panic disorder.’)

    Re agoraphobia, I thought the word ‘agoraphobia’ had two uses, and that the one people mostly experience is not a fear of open places, but just of all kinds of places other than one’s own room, say. This kind seems to make sense on this theory, as just a sensitisation thing—like, if several other times I did anything at all I nearly suffocated, then staying exactly where I am seems like a great option. My own experience with panic attacks and ‘agoraphobia’ fits this—after a bad panic attack I sometimes feel like my brain has deeply associated miscellaneous things with doom, even if I consciously know this is ridiculous—e.g. putting on pants feels viscerally scary, because last time I put on pants, look what happened three hours later. So I think e.g. hiding in your house is partly just a result of a large fraction of actions feeling risky, and staying still requiring the fewest actions. If the risk were of suffocation in particular, that would make as much sense as anything else.

    My speculative-mostly-based-on-introspection guess is that there is also some reverse-causality confusion going on, where panic attacks in public are more humiliating, and the extra badness of that gets interpreted as extra doominess, and therefore more chance of suffocating/whatever if you come to be in public, even though you know consciously that the humiliation doesn’t feed back into the impending doom.

  55. hollyluja says:

    I read up on panic attacks and something like 96% of COPD patients have a panic disorder. That seems to support Klein’s theory.

  56. foggen says:

    This reminds me of two phenomena.
    1. Combat-induced PTSD. I’m neither an expert nor a sufferer, but it seems like the experience maps pretty well onto the lowered-threshold model, where a soldier who has been subject to prolonged periods of sudden mortal threat will, as a matter of survival, develop an extreme sensitivity to danger and conflict, with an enhanced aggression response.

    2. The relationship between personal control and comfort. This has to do with a series of observations of my own experiences. Basically, it seems that negative responses to virtually any stressful stimulus seem to be reduced if I myself am in control of the event. For example, if I go to give blood there are two moments where I get stuck with a needle. First is a tiny prick on the finger for a hemoglobin test, and second is THE IV line for the actual donation. In both of these cases, including the hemoglobin one which is quick and objectively superficial, I have to fight down tension, panic, and a flinch response. However if I do something like put an accidental inch-long cut on my finger (leading to stitches) or deliberately cut the skin on my toe to resolve an ingrown toenail, I can experience the pain with detachment. Similarly, after years of almost always being the one to drive in any friend group, I find that others’ driving patterns are almost uniformly more alarming than my own (despite being objectively similar or safer) and that I’m several times more likely to get motion-sick when not in control of the vehicle.

  57. Tomas says:

    At the risk of saying something many people here know already – there have been a lot of articles recently on chronic pain. The story usually goes like – pain is basically an opinion of your brain what’s going on. That being said, chronic pain typically happens when there’s nothing wrong with the tissue itself, but the brain’s protective mechanisms are still on, trying to disuade you from doing something it thinks is dangerous.
    And typicall chronic pain sufferers worry there’s something wrong with them, at the structural level. They fear they’re going to fall apart, some are even suicidal. See e.g this video: https://www.youtube.com/watch?v=dlSQLUE4brQ

    One comment regarding carbon dioxide – I think in hyperventillation its levels fall in everyone, not only during the delivery. (At least that’s what I believe you’re saying). I was under the impression that low co2 is not ok and that it can actully cause insufficient oxygenation (can’t remember the name of that effect)

  58. Eli says:

    The embodied mind is indeed one of those ideas where I find it hard to understand how I ever lived without it.

  59. karinhenriettapz says:

    I used to suffer from panic disorders and had a particularly difficult attack when I was in Mozambique.

    We (me, my husband and his family) were driving from Maputo to a remote resort located five – six hours from Maputo.
    The further we got from Maputo (i.e civilisation) , the more i felt I was actually suffocating, and in the end I wasn’t even able to speak – gasping for breath, cold sweating and with a racing heart .

    We figured I might had an allergic reaction to the malaria prophylaxis and drove quickly to a small foreign aid sponsored hospital in the middle of nowhere (I remember my husband actually googled how fast we would be able to get a helicopter from South Africa…).

    When I finally met the doctor (at a hospital full of people being treated for AIDS etc) the feeling gradually disappeared, and I was able to speak and breath fairly normal again. Of course, the doctor couldn’t find anything but they recommended me to stop using the prohylaxis and prescribed antibiotics.

    The panic attacks returned continuously during the trip and back home in Sweden, if not as severely as the first major attack. Other returning symptoms were numbness, swollen hands and fingers, chest pains and chills – resulting in more appointments with doctors and nurses in Sweden. As soon as they heard I’ve been in Africa they prescribed more antibiotics. Even if they couldn’t find anything and in lack of a clear diagnosis. In the end I had been eating antibiotics for 2 months when I finally, after weeks of googling, realized that my condition had to be psychosomatic / panic disorder. The attacks disappeared after i started to exercise mindfulness and different breathing techniques.

    Today, when I think about it, I’m surprised how not only my body, but even the society – such as family and doctors – managed to trick me into believing I was suffocating / ill.

    Also, did my body/mind react as it did outside Maputo because when monitoring itself, it takes in account things like access to help or that certain symtoms should be taken more serious when you are in a “risk area”? I finds this very interesting.

  60. BrandonReinhart says:

    My wife suffered from postpartum cardiomyopathy. During pregnancy she gained a bunch of weight from excess fluid retention. She’s a very slight and skinny woman, but became pretty large by month nine. Two days after birth her heart failed. Her blood pressure had spiked causing a back flow that filled her lungs with fluid.

    The exact cause of PPCM is unknown, but there are a host of theories. Some are alloimmunological (involving the body attacking the child’s cells in the mother’s heart), some are autoimmunological, and others are abstract conditional chains like “maybe there’s a virus that we haven’t detected yet that some people have causes this rare condition in some of the people with the virus.” It’s rare. Only something like 3 cases in Seattle the year my son was born. The amount of literature on the condition is thin, because of it’s rarity.

    This article made me think that the behavior you describe sounds loosely familiar to the development arc of PPCM. It gives me a few new keywords to search on to see if anyone has drawn any connections here. The progesterone crash after birth and it’s connection to respiration sound like they could be related to PPCM. PPCM moms usually have their heart failure after birth as their hormonal levels crash back toward the non-gestational equilibrium. Makes me wonder things like “what about giving supplemental progesterone to PPCM mothers after birth to slow their hormonal fall-off.” Right now they give you beta blockers to bolster the heart and aggressive diuretics to pull all the water weight off as fast as possible, but this only works in mothers that have the PPCM diagnosed correctly. It’s often incorrectly diagnosed as pre-eclampsia and only corrected after full on heart failure hits.

    Anyway, thanks for the detailed and interesting analysis. Gives us more stuff to research.

    If you’re curious, my wife was lucky and her heart function has recovered to a very high EF and no visible lasting heart damage. She still spends time helping inform other mothers of the risks and studying the disorder in case we are able to have a second child (relapse is common, but manageable).

  61. Kittyno says:

    Scott, your suffocating woman scenario happened to me.

    Postpartum, I developed panic disorder, the year following it lead to daily headaches (sometimes migraines), bouts of dizziness, then chronic pain/fibromyalgia. This progression happened gradually over the course of three years. None of it had a clear emotional origin or obvious stressor. I come from a family of migraineurs and am one myself. I think conditions started with my first child, but ramped up after the birth of my second child. SSRIs were not effective for me.

    It took a long time to get a diagnosis and med that worked. My neurologist finally diagnosed me with acephalgic migraines and chronic pain (I’m not sure if he’s categorized this as fibromyalgia or neuropathy).

    Acephalgic migraines can develop postpartum in migraineurs that have auras. (Which is what I am.) Once my period was regular–a good two to three years following birth–I was able to see that the bouts of dizziness and serious memory issues were much worse during menses and ovulation.

    What interests me about your article, is that in terms of chronic pain, in my case, I felt like there was connection between the progression of my panic disorder to pain disorder.

    “Suffocation alarm” involves protein ASC1A acting as CO2 sensor in amygdala. Coincidentally, it also inhibits neuromuscular transmission and may explain why people exhibiting high expression or activation of ASC1A channels experience muscle fatigue–fibro and chronic fatigue patients. Chronic fatigue patients also exhibit a high expression of ASC13 receptors. (I’m having issues with your WP link tool, so I’m just cutting and pasting the research links that sugges this.):
    https://www.elsevier.com/about/press-releases/research-and-journals/understanding-the-brains-suffocation-alarm
    http://ajpcell.physiology.org/content/306/4/C396
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3391217/
    https://www.ncbi.nlm.nih.gov/pubmed/26035524

    I am currently on gabapentin, which prevents/disrupts synaptogenesis and helps with sleep. I no longer get daily headaches and panic. I can think more clearly now. Overall, life is much better. I still deal with some chronic pain. And I have issues with memory–both chronic pain and the gabapentin are problematic in this area. In all honesty, codeine was the most effective drug in terms of improving my pain, panic, and memory. But, good luck trying to tell a doctor that an opioid has been effective and that you have no issues with addiction. So, gabapentin it is, and compared to the myriad of other drug families I’ve tried, it’s pretty effective.

    You can read about how gabapentin disrupts synaptogenesis involving these ion channels–Ben Barres’ team at Stanford med:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791798/

    I’m not a med student (I spent time in genomics research). But, to the somewhat uneducated eye, it seems like there is potential for connection between states of panic disorder and pain disorder (chronic, fibro, and c. fatigue) and possible the progression of one to the other.

    As someone who has been through the wringer with regards to doctor biases regarding women–especially older mothers–I’d love to see exploration of that potential connection. I’m tired (literally) of having doctors insinuate that what I’m experiencing might be derived from sexual abuse (I have no history of this), lack of exercise (I exercise regularly and am constantly picking up and carrying my 35 lb block of a toddler), and/or female hysteria. Good times.

    With regards to my pre-medicated state:
    Before postpartum changes I was mentally sharp and physically active. Afterwards, my behavior became strange, and I could recognize that, understand it, and yet not alter it in a daily sense.

    Some of the changes were pretty random. Yawning in the first five minutes of exercising. Which, reading the papers, makes sense to me… (I’m pretty sure the doctors thought I was off my rocker for mentioning this, but the yawning was really odd–especially for someone who has been athletic all her life.) Really weird muscle fatigue. I could not remember things–names, common words, daily schedules. Which became progressively worse.

    If the changes were solely due to lack of sleep because of a new infant (as was suggested several times), you would expect the issues to get better as the infant’s sleep lengthened and the mother’s sleep lengthened. That didn’t happen in my case. Things became worse, not better.

    In addition to SSRIs that didn’t work, I tried shit-tons of CBT. Three years of it. (Because, who knows, maybe it was all hysteria?) It was pleasant, because I liked the therapists, but ineffective. Physical therapy, which was pleasant, but mostly ineffective. I had MRIs done on my spine and brain. Tests for lupus, Lymes, etc. The full work-up. As aforesaid, it was suggested to me many times that my problems were emotional in origin–being a mother, female hysteria, hypochondriasis, and the product of sexual abuse. I had some asshat neuro-opthamologist suggest that people like me needed a lot of compassion (this was after he inquired as to whether or not I’d been sexually abused). I have no doubt that emotional response exacerbates the problem, but none of these fit my experience. Chronic lack of sleep, shitty feedback loops, and silent migraines had and have more demonstrable weight as an explanation.

  62. markfoote says:

    I thought I would kick in my experience with topical progesterone. Yup, it’s available over the counter at Whole Foods and other health food outlets, I’m currently using “Transitions for Health” Emerita progest cream. It’s 450mg per ounce, you wipe it on an different area of skin with good circulation every day, and take a break once a month for a week. For women, and especially menstruating women, it’s twice a day and a two week break.

    I started using it after hearing Dr. John Lee speak about treating his osteoporosis patients who were at risk for ovarian or mammarian cancer with topical progesterone. In 1995, he was touring the country speaking to groups of women (“I will educate the women, they will educate their doctors”). Seems due to malpractice being defined as not doing what other doctors are doing, generally, and the treatment of choice being estrogen replacement therapy at the time, the doctors didn’t want to hear what John Lee had to say.

    I’ve been using it since 1995. Dr. Lee has a small pamphlet about “Hormone Balance for Men”, but I started using it for joint stiffness here on the damp Mendocino coast of Northern California. Works a little for that, gives me a little energy I think. He spoke about the benefits his arthritis patients experienced, he had just read that the schwann cells utilize lots of progesterone in sheathing nerves.

    So this affects the level of CO2 in my blood, interesting. I also sit the lotus in the mornings, usually 40 minutes, and I love to dance. Both in sitting and in dancing, I’m looking for the ability to breathe spontaneously in the midst of everything. It’s a peculiar ability, and I’m thinking it must be a lot like the inhibition of panic that was described for divers who hold their breath. In my case I am utilizing a coordination of the vestibular and proprioceptive senses, along with my sense of gravity and my vision, to be able to experience the nature of the breath in relationship to my sense of self-location (which moves).

    Too bad there’s never been a national test of the synthesized progesterone that is molecularly identical to human progesterone, in doses resembling the amounts naturally present in the body. Guess that would be because there’s money to be made when the structure of the drug is one or two molecules different from the human version, so that the drug can be patented, even if the progestins (as the changed versions are called) have pages of side effects in the physician’s desk reference and the “natural” version has none.

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