Panic and Pandemic: The 6 Unsuspected Substances you Commonly use that you Need to Avoid to Prevent Suffering from Panic Attacks

As a result of the COVID19 pandemic, in the last 9 months, there has been a massive increase in the number of psychiatric consults for new onset panic attacks or worsening of pre-existing anxiety disorders.

This post will describe the panic attacks, panic disorder, and the chemical factors that promote panic attacks. At the end of the post, I will list the measures that you need to take to prevent panic in these times of COVID-19

What is a Panic Attack

First, I want to start by explaining what a Panic Attack is. And then I will clarify the difference between having sporadic panic attacks in the presence of other anxiety disorders (such as Post Traumatic Stress Disorder, Generalized Anxiety Disorder, or Social Anxiety Disorder), and what is known in Psychiatry as Panic Disorder. I also will define and describe Agoraphobia, which is a typical phobia that develops in those who suffer from Panic Disorder.

So, a Panic Attack is “A severe anxiety attack–or a surge of intense fear or discomfort that reaches a peak within minutes–that occurs suddenly–and that last from a few minutes to a maximum of one hour.”

The typical duration of a Panic Attack is 20 minutes. Because of the presence of multiple physical symptoms–particularly shortness of breath, chest pain or oppression, dizziness and rapid heart beat–most people think they are having a “heart attack” or that they are “going crazy”when they experience a panic episode.

Take notice that one Panic attack does not constitute PANIC DISORDER. You need to have many episodes and over a prolonged period of time to meet criteria for this diagnosis.

The physical symptoms that may accompany a Panic Attack

Below is a list of of more than 15 physical symptoms that can be present during a panic episode besides the feelings of anxiety, dread and fear:

• Palpitations, pounding heart, or a rapid heart beat
• Sweating
• Trembling
• Shortness of breath or smothering feelings
• Feelings of chocking
• Chest pain, discomfort, or heavy oppression on the chest (the “elephant foot” on the chest)
• Nausea or stomach sickness
• Feeling dizzy, unsteady, lightheaded or faint
• Chills or heat sensations (that in women are often confused with menopausal hot flashes)
• Numbness and tingling sensations (“numbness” is the feeling you get in your mouth when you get anesthesia for a dental procedure, and “tingling” is a sensation as if you had crawling ants going up and down your arms and legs or mouth)
• Feelings of estrangements, like you are “not you” (depersonalization) or that your “surroundings are strange and changed” (derealization)
• Fear of having a heart attack or of “going crazy“
• Fear of dying
• There can be many other less frequent symptoms such as headaches, neck pain, uncontrolled screaming or crying, and ringing in the ears, etc.

Agoraphobia and Anticipatory Anxiety

In Panic Disorder, there is at least one episode of panic a month (usually two to three panic attacks a week or more). And the person also suffers from Anticipatory Anxiety (the fear of developing another panic attack). These symptoms are accompanied by extreme avoidance aimed at escaping any situation that can trigger the next panic episode: This is known as Agoraphobia.

Agoraphobia (from Greek, Agora=market; Phobia=severe fear) is the fear of open spaces. It is also the fear of leaving your house or place. Agoraphobics live in a safe zone that they refuse to get out of. For a lot of people with panic, this fear manifests as severe fear of driving. Some sufferers only leave the house or drive if they are accompanied by a significant other. But oftentimes Agoraphobia presents as the fear of being in crowds, freeways, driving, crossing bridges, or finding oneself in a situation in which one feels it may be hard to escape. Claustrophobia (fear of elevators or enclosed spaces is also a possibility).

Examples of agoraphobic situations are:

1-being in a crowded store or a mall

2- being stuck in traffic on the freeway

3-being afraid that you will not get help, you will embarrass yourself in front of others–or that you will not find your way out of a place or circumstance.

To meet full criteria for Panic Disorder, the condition must be spontaneous. The attacks can be triggered (by an anxiogenic situation) or untriggered (without a good reason and out of the blue attack). The latter is more diagnostic of panic disorder.

What your primary doctor must check before calling your condition “Panic Disorder” and send you off to a psychiatrist

The general doctor must exclude physical conditions that may simulate Panic, such as hyperthyroidism (having too much thyroid in your system), heart and lung conditions (including asthma and COPD), or substance abuse.

Panic Disorder runs in families. It is the most genetic of all anxiety disorders. In general, you need to be predisposed to panic to develop this condition. He/she does not develop panic because he/she wants but because he/she is genetically–or chemically–predisposed. It is common to find other members of the family (mother, sister, and others) suffering from it.

What causes Panic Disorder?

The origin of Panic Disorder is not known. But, current theories point to a hypersensitivity of the breathing centers in the brain stem to the suffocation response. These centers are seen in the image below.

Side view of the brain and enlargement of the Brain Stem and Breathing centers

The Amygdala is the Alarm center of your brain

From the brain stem, the sudden stimulation radiates to the rest of the brain, stimulating and activating the amygdala (the alarm center of the brain). This, in turn, hyper-activates the internal brain (the emotional limbic system) that surrounds it. From there, through a phenomenon called “kindling” (setting neurons “on fire”) the attack extends to the rest of your brain (as an epileptic seizure). Eventually it reaches your cortex where you exist as a thinking being, scaring the hell out of you. The brain and body responds as if you were suddenly suffocating (asphyxiating for lack of Oxygen).

In reality, not only you are not asphyxiating but you are actually BREATHING TOO MUCH AND TOO OFTEN during an anxiety attackt.

As a result of this fact, any substance that stimulates the breathing centers of the brain has the potential to trigger panic attacks. Most of these “substances” are no perceived by the public as “drugs;” and, therefore they are not associated by them as ‘triggers” of panic, but they ARE.

Keep in mind that the three most commonly used drugs in our culture are, in this order: 1- Caffeine; 2-Alcohol; 3-Nicotine.

Commonly Used Substances that Increase Anxiety and Panic Attacks

Here is the list of substances that will make you much more prone to having a panic attack if you are predisposed.

You should AVOID these substances if you want to be panic free, in general, and in times of COVID-19 even more so:

• CAFFEINE
• ASPARTAME (this is the most widely used sweetener in pop Sodas nowadays and other many diet products).
• NICOTINE (in all its forms), whether you smoke cigarettes, vape, chew, or use nicotine gum.
• DECONGESTANTS ( such as over-the-counter “SUDAFED” and any of the ones that have Pseudo-ephedrine as a component), NASAL SPRAYS DECONGESTANTS, AND ANTI-ASTHMA INHALERS.
• ALCOHOL (because of the rebound effect when you are coming down from its sedating effects).
• MARIJUANA (after using it for a while)
• ASPIRIN

I will briefly address each of these commonly used substances in this post (all of them are drugs but people do not regard them as such).

Caffeine, is a strong stimulant of the breathing center. It inhibits the production of one of the most important tranquilizing molecules in our brains called Adenosine. Caffeine is the most widely used and abused drug in the US and in most of the world. In the US, coffee and caffeine products in general are used in excess as a stimulant to keep going, remain alert, and to remain be productive beyond our physical and mental capacities.

Aspartame, is a sweetener that has been around for almost 40 years now. For this reason, it is the most commonly used sweetener in the US market at present. Aspartame is made from two Amino-acids (Aspartic Acid) and Phenylalanine (this latter one is the building block and precursor of the two most stimulant transmitting neurotransmitters in our brains: DOPAMINE, NOR-EPINEPHRINE, and EPINEPHRINE (ADRENALINE).

Needless to say, that the more stimulating substances present in your brain and brain-stem, the more anxiety and panic you will have. And, as you probably know, most people who drink coffee, sodas, E-drinks also smoke and drink alcoholic beverages.

Nicotine is a strong stimulant of DOPAMINE and NOREPINEPHRINE both in your brain and elsewhere in your body. It has particularly noticeable effects on your heart rate and functionality and on your vascular system (increasing your blood pressure by causing vasoconstriction on your arterioles in your entire body).

Nicotine does this by increasing the SYMPATHETIC NERVOUS SYSTEM ACTIVITY (the Fight-or-Flight response in our bodies); and locally, by stimulating the muscles of your arterioles (little arteries) through increasing NOR-EPINEPHRINE activity.

Besides, when people smoke, they also inhale smoke. This cigarette smoke contains Carbodioxide and Carbomonoxide (the gas that kills you if you forget to turn off your stove or furnace at night an you run out of Oxygen).

Carbodioxide is the gas responsible for increasing global warming. The more of it in our atmosphere, the more warming. These two gases are powerful stimulants of your breathing center, as when you smoke your brain stem thinks you are “suffocating” and throws a panic attack to offset this suffocation.

Asthma medications–but particularly most of the inhalers–are Norephinephrine stimulants. They all stimulate the breathing center. They all make you breath more, and much more frequently.

Note for Asthmatics

If you suffer from Asthma and Panic Disorder, it can be a very difficult situation to deal with. You may think you are “not breathing enough” due to your Asthma (and you keep on pumping yourself up with your inhalers), when you are actually experiencing the increasing sensation of shortness of breath (SOB) due to an excess stimulation of the breathing center. This situation may eventually lead you into full blown panic attacks that will only worsen with your increased use of your inhalers.

Decongestants that contain Pseudo-ephedrine are strong stimulants of the nervous system and they increase Nor-epinephrine in your system triggering anxiety, high blood pressure, and panic.

The fickle tranquilizers: Alcohol and Marijuana

Alcohol is initially a SEDATIVE. For this reason, it is used by many as their “anxiolytic of choice” (the preferred method to self-treating anxiety and bring down tension).

However, the problem is that, whenever you use a SEDATIVE (another word for Anxiolytic), there is always the opposite effect a few hours later called a REBOUND. So, when you come down from your alcohol binge you enter an overstimulated state with an EXCESS OF SYMPATHETIC ACTIVITY IN YOUR NERVOUS SYSTEM. This is accompanied by a storm of ADRENALINE in your system caused by a marked increase in Adrenaline and Norepinephrine activity. This sympathetic rebound triggers PANIC ATTACKS.

Marijuana deserves special mention. As of lately, Marijuana and its products have become a particularly common offender when it comes to the new onset of panic in people that used to be panic-free. This is the reason why we have now an epidemics of new onset panic disorder in young and middle age people.

Panic Disorder is two to three times more common in women than in men for poorly understood genetic reasons. However, in my office, now I see droves of young men with new onset panic disorder caused by long-term use of CANNABIS PRODUCTS. This is very important important source of new onset panic to KEEP IN MIND.

Cannabis use which has markedly increased–and has been legalized in many states in the US in the last decade–has become widespread. Cannabis “positive effects” have been touted as the cure-all for many conditions for which there is no clear scientific evidence.

Remember that Cannabis in the US today is supported by a billion dollar industry promoting its consumption. The current situation with Cannabis is not very different than what happened with the Tobacco industry back in the fifties and sixties.

As a result of these decades long propaganda campaigns, most people have come to regard Marijuana as “a natural herb” and not a as a potentially dangerous drug. And most people that use Marijuana and Cannabis products today do it to relax and feel less anxious or less angry. But the irony is that Marijuana sensitizes receptors in the brain and brain stem that make you much more likely to experience a panic attack.

Finally, Aspirin, (Acetyl Salicylic Acid) is a stimulant of the breathing center and therefore has the potential ability to make you more prone to experiencing panic attacks.

What should you avoid to prevent panic attacks

In summary:

To avoid or decrease the chances of having panic attacks you should:

1-Discontinue caffeine use. (If you have been drinking a large amount of coffee, sodas or Energy drinks for a long time, you should do it very gradually to avoid headaches and withdrawals)

2-Quit using any diet products that contain Aspartame. (Check out diet sodas that use Splenda as sweetener instead, or save money and better drink plain water). Read labels of any “light”, low fat or “Diet” products and do not use them if you read “contains Aspartame” in them.

3-Quit smoking, vaping, chewing or using nicotine products of any kind. If you smoke less than half a pack a day, set a quitting date and quit cold turkey. If you cannot do it alone, discuss with your doctor using Bupropion SR (Wellbutrin) as a cigarette quitting aid medication. If you smoke a pack or more, go down by one cigarette every three days, and when you get down to 7 set the quitting date and quit cold turkey.

4-Stay away from oral decongestants that contain Pseudo-ephedrine. (Do not take decongestants as pills over the counter and watch out for the ones that read on their labels “DAYTIME” because those are more likely to contain stimulants in them).

5-Avoid overusing your inhalers and asthma medications. A way of differentiating an asthma attack from a panic attack is that in an Asthma episode you have problems exhaling air. In this situation, you hear a wheezing when you breathe (a characteristic high pitch sound). While in panic, the sensation is of breathing too fast and of not being able to get enough air into your lungs. No sounds are present in panic attacks or anxiety.

6-Quit drinking. If you drink regularly and significantly (more than 2 light alcoholic drinks a day or binge on weekends), you have to do it gradually and under medical supervision. Attend AA meetings of go to Alcohol rehabilitation. See a psychiatrist to get help with medications that will help you maintain your sobriety. Get supportive psychotherapy as needed to address your underlying emotional problems that lead you to drink in excess.

Avoid taking Aspirin if you suffer from panic disorder or from Asthma attacks for the above mentioned reasons. Use Tylenol instead.

In following articles I will go deeper into the problem of panic disorder, what it is, and how to treat it with medications and psychotherapy.

Make a decision to lead a substance and panic-free life NOW.

Remember the “YOLO” philosophy:

YOU ONLY LIVE ONCE: THEREFORE, TAKE THE BEST CARE POSSIBLE OF YOUR LIFE

Dr T