Prone To Panic?

Panic attacks and anxiety are common conditions that you see often written about. Here’s an article published in Johns Hopkins Magazine from 1999 by a fellow alum, David Levine. He describes in vivid detail his first experiences with panic and anxiety as a college student at age 19. It’s remarkable how these episodes could be attributed instead to new onset apneas.

He quotes, ” The worst attacks struck at the end of dreamless naps. I woke up completely drenched, disoriented, my heart pounding.” His very first episode presented after waking up one morning with an impending sense of doom.

Repeated obstructions to breathing can set off a constant fight-or-flight response, which can carry over into the daytime. Waking up suddenly after suffering from a 20 to 30 second apnea can cause the typical nervous symptom reactions like your heart racking, sweating, and a feeling of doom. Medications like Valium can calm the edginess and anxiety, but never completely “cures” the problem. Eventually these episodes slowly subsided for Mr. Levine after years. Decades later, he’s diagnosed with obstructive sleep apnea (OSA) and is doing well using a mandibular advancement device. 

Of course it’s hard to say if he had sleep apnea at the time of his first panic attack. My guess is no, since a  handful of short obstructions and arousals may not be enough to qualify for a formal diagnosis of OSA.

It’s also no coincidence that most people with anxiety or panic attacks can’t sleep on their backs. Due to crowding of the upper airway from smaller jaws and crowding of the teeth, the tongue and voice box falls back due to gravity. Whenever deeper levels of sleep is reached, the throat muscles relax, and obstruction happens. If it lasts longer than 10 seconds, it’s an apnea. If it’s less than 10 seconds, it’s not counted in the final sleep apnea score. This is one major reason why people may stop breathing 20 to 30 times every hour and have an AHI score of 0. They are usually told they don’t have sleep apnea and that their fatigue and anxiety are due to other potential medical problems. This condition is called upper airway resistance syndrome, which I’ve talked about in detail.

It’s no wonder that patients with depression do better if you address sleep quality. Whether it’s from poor sleep hygiene or OSA, it’s important to address any potential sleep problems before medicating anxiety or panic attacks. 

For those of you who are prone to panic, what’s the quality of your sleep?

 

 

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3 thoughts on “Prone To Panic?

  1. Could your friends “panic attacks” involve hyperventilation?

    In a recent study it was determined that some 36% of those with Obstructive Sleep Apnea (OSA) have high respiratory control loop gain[1]. They tend to overshoot when trying to correct for too little O2 or too much CO2 – or the vice versa of each.

    So the attacks started after some serious time in London did they! At a latitude of 51 degrees with a yearly average of about four hours of sunlight a day and 164 wet days a year I think it is well worth noting that the opportunities to get vitamin D3 from UVB in sunlight in London England are very very limited indeed!

    Dr. Stasha Gominak has noted that many areas of the brain which are involved in the control of breathing are sensitive to D3 levels. She also reports that when D3 levels are raised from low to within 60-80 ng/mL Sleep Apnea sometimes goes away. Those who are working with D3 (e.g. Michael F. Holick, Ph.D., M.D., Vitamin D Council) seem to be finding that the very low side of the “normal” range of 30-100 ng/L produces a range of symptoms including OSA, pain, and infection. All believe that a level lower than 50 ng/mL is not good.

    Since I have been supplementing more vitamin D3 (latitude 47 degrees) I have found that it is much easier to control my breathing, which I have become almost constantly aware of. But that is another story to tell.

    After a severe assault and robbery several years ago, near the time of the robbery each year, I would have several days when my heart would race, I would end up staying up for days, and my breathing would be quite heavy. The doctor said “panic attacks”. During the first two years this resulted in a visit to the emergency room(ER). For the next couple of years I made a strategy of some special medications and activities which at least kept me out of the ER.

    Then, while listening to one of your expert interviews, I realized that my “panic attacks” were times when I was hyperventilating. The interview described a method of eucapnic breathing, actually a beginning exercise designed to help one clear their nose. I was taking notes but just the breathing part of the exercise got the blood back into my feet, a clear nose, a feeling of warmth in general, and my heart slowed down (the presentation of the expert interview occurred near the time of year when the assault and robbery occurred).

    I was concerned that the actual methods of eucapnic breathing described might be easy to take too far. As I thought about it I decided that the lowest heart rate would likely be the best indicator of the eucapnic state since too much CO2 would open up the circulatory system to flush out the excess while too little CO2 would cause the circulatory system to close off which the heart would work against to try to keep the cells fed. Either way heart rate would go up. Indeed I did feel and perform the best when I did find the lowest heart rates while holding exertion constant controlling breathing.

    I also discovered that my pulse oximeter which I was using to determine the heart rates would read the same SpO2 percentage when the lowest heart rates were reached. At my desk an SpO2 of 96% would be displayed on either of my pulse oximeters when I would find the lowest heart rates at my desk while a reading of 97% would associate with the lowest heart rates while doing moderate exercise on my treadmill. Moving from about 500′ ASL to 2500′ ASL (or perhaps being in much better shape) seems to have moved both readings down a percentage point.

    The pulse oximeter became a good friend and is with me even today (but other physical symptoms now most often guide me). My daytimes became a lot more tolerable. I did sleep every night, however, my nighttimes were often broken up by waking up breathing very heavy, with very dry mouth, and with aerophagia.

    It was nice to have some developed eucapnic breathing skills to bring things rapidly under control during those nasty hyperventilating wake ups!

    Well it did seem that the better circulation fostered by the eucapnic breathing during the daytime made it a lot easier to deal with the stress of the attack in the past. Perhaps, I thought, better circulation at night could help the breathing stability issues. Indeed changing from a beta blocker to an alpha blocker did help. Exercise seems to help as well.

    Looking into what is often referred to in the literature as cpap induced ventilatory instability (complex sleep apnea) and central apnea in general I ran across enhanced expiratory rebreathing space (EERS)[2]. Working under the supervision of my doctor at the time I added a modest amount of EERS to my CPAP vent circuit and was very happy with the result. I use this “as necessary” today. I also ran across Dynamic CO2 therapy[3] and heard a rumor that it was available in the EU.

    I am suspicious that problems with our respiratory control system are the real cause of many so called “panic attacks”. I think that the respiratory control system is greatly affected in our society by low vitamin D3 levels, metabolic health, pollution, and many sources of unmediated stress.

    I do hope we find many better ways to deal with this.

    [1] Danny J. Eckert, David P. White, Amy S. Jordan, Atul Malhotra, and Andrew Wellman “Defining Phenotypic Causes of Obstructive Sleep Apnea. Identification of Novel Therapeutic Targets”, American Journal of Respiratory and Critical Care Medicine, Vol. 188, No. 8 (2013), pp. 996-1004. doi: 10.1164/rccm.201303-0448OC

    [2]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ.
    “Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS)” J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.

    [3]: Yoseph Mebrate, Keith Willson, Charlotte H. Manisty, Resham Baruah, Jamil Mayet, Alun D. Hughes, Kim H. Parker and Darrel P. Francis “Dynamic CO2 therapy in periodic breathing: a modeling study to determine optimal timing and dosage regimes” J Appl Physiol 107:696-706, 2009. First published 23 July 2009; doi: 10.1152/japplphysiol.90308.2008

  2. I have panic attacks and a mix of ocd and a tic disorder. I have tried Paxil, Prozac, Zoloft, Xanax and many natural supplements for this condition. It was unbearable still. But now that I’m treating my narrowed airway and sleep apnea my condition has improved for the first time since I was a kid. I’ve had a lingual frenectomy and am doing myofunctional therapy. I’m right now also using mandibular advancement device with nasal cones. But I do still wake up with nightmares when I roll onto my back. So I’m working on some other things to fix that. But I have no doubt that there is a connection between narrowed airways and panic disorder as well as other anxiety disorders and neurological conditions. Thanks for this article!

  3. I was in London for 9 months when my panic attacks started. I was 20. I had just come back from Italy and Switzerland in the spring so had plenty of exposure to the sun. And who used sunscreen in 1971. So I doubt it was low levels of Vitamin D. But who knows what it was. There is a family history of depression and anxiety. That may have played a role as well.