April 17, 1998

Searching for the link between panic and asthma

Six years ago, Alanna thought she was having just another asthma attack. It was a particularly stressful time in her life, and her asthma was "out of control." So when her heart started racing, her palms started sweating, and she was struck with intense fear one day at school, she naturally assumed her lungs must be seizing up as well.

When she was taken to the school nurse's office, however, something didn't fit the picture. Strangely, her lungs were absolutely clear. "With an asthma attack there would be the wheezing, the coughing, but that was missing," says Alanna (who asked not to be identified by her last name).

"My heart was racing, I had trouble breathing, I was feeling frightened, and I was really warm, except when I did take a breath the air went in. With asthma the air won't go in."

As it turned out, what Alanna was experiencing was not asthma at all. It was her first panic attack, a terrifying symptom of what is now classified as panic disorder.

The combination of asthma and panic disorder is more than anybody needs, but it's not as rare as it might seem, or until recently, many in the medical community were willing to admit. New research shows that 10 per cent of those with asthma suffer from panic disorder, and as many as 38 per cent suffer from some form of anxiety disorder, says Dr. Terry Davis in the Faculty of Nursing. That's compared to one per cent and about six per cent respectively in the general population.

According to Davis and her colleague, Dr. Carolyn Ross, these high numbers mean everyone with asthma should be screened for symptoms of anxiety, and certainly for panic disorder. If left untreated, says Davis, panic disorder on its own can -- in between 40 to 60 per cent of cases -- produce secondary depression and agoraphobia.

Davis and Ross say they aren't sure why those who suffer from asthma appear to have a predisposition to anxiety disorder. It may be natural for anyone to become anxious during the onset of an asthma attack, says Davis, but anxiety disorder is "qualitatively different," so when coupled with severe asthma, the consequences can be life threatening.

"It's well recognized that anxiety can exacerbate ... the bronchial constriction that occurs with asthma," says Ross. "We're hoping that by treating panic we can reduce the number of emergency visits."

Davis and Ross have just received a $100,000 Medical Heritage Foundation grant to come up with strategies for treating panic and asthma together. Strategies already exist to control either condition separately, but since the two often strike at once, and since it's difficult to know precisely where one ends and the other begins, the conjunction of the two needs to be treated with a fresh clinical perspective, says Davis.

Panic disorder, for example, is typically accompanied by irrational fears that one will completely lose control, go crazy, have a heart attack, or even die, which stimulate physiological responses such as shortness of breath, heart palpitations, sweating and trembling. These symptoms in turn arouse more fear, and the sufferer is soon swirling in a vicious circle of terror.

With asthma, however, panic is accompanied by the very real fear that the anxiety will exacerbate the asthma. If your throat is closing up while your heart is pounding, conquering the fear of fear itself may not be terribly effective, says Davis.

"What they fear is reality based. With panic disorder I can say there's no possibility of you going crazy, but in this instance it's different. How we're going to modify the cognitive behavioral treatment is going to be a real challenge for us."

Davis and Ross will work with 60 women who have panic disorder and asthma (women with the condition outnumber men by roughly two to one) to help them develop a descriptive vocabulary for their attacks, the first step towards gaining control.

The two professors are acutely aware they are charting new territory, and are hesitant to draw any kind of causal relationship between the two conditions. Sometimes the asthma will be the trigger, sometimes the panic, and Davis says it can go either way in the same person.

Better education and awareness, however, are crucial to successful treatment, since much of it consists of self-monitoring. When patients understand what's happening to them, says Davis, they are better able to disarm the panic.

"Often what happens in a panic is a person experiences a physical sensation, for example shortness of breath or a racing heart, and there is an interpretation of that symptom. Panic comes on really suddenly, really intense within ten minutes, so it's understandable that the person catastrophizes it ... It's a question of helping the person recognize the symptom and understand the disorder ... to affect a break between the physical sensation and the catastrophizing."

"You may not be able to do anything direct and immediate for the asthma, but there is something you can do for the panic."

Until recently, it was difficult for even doctors to diagnose anxiety disorder since it was only added to the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association in 1980. Before that, panic and anxiety were considered symptoms of neurosis or psychosis.

Ross says it can still be an uphill battle getting doctors to see anxiety for what it is, especially when connected with asthma. "When we go and talk about our project and speak about getting access to patients, there is resistance to, in any way, our implying to patients or to physicians that it is a psychological disorder rather than a physiological one."

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