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The Four Causes of Panic Disorder

by Dr. Blumberg on December 26, 2010


The first Attack “Out of the Blue”

The Primary Trigger (1): The Core Emotional Source of Panic Attacks

*Mary, a 32 year old married school teacher, had just lost her father to a sudden heart attack five months ago.  The holidays were quickly approaching and, as usual, Mary had overextended herself to family and friends.  On a Monday morning during the holiday school break, Mary was driving on the highway to a scheduled dentist appointment for her two children.   A song was playing on the radio that reminded her of the wonderful holidays she had spent with her father. All of a sudden “Out of the Blue”, Mary was hit with heat waves, heart thumping, and dizziness.  Then her legs turned to jelly.  She thought this is it, “I will collapse at the wheel, lose control of the car, I will never see my children again!

The core trigger strikes, “Out of the Blue,” for no apparent reason.  But, there is a reason.  The pre panic emotional management system minimizes the build-up of holiday stressors. The first attack seems to strike “Out of the Blue.”

Secondary Trigger (2): Anticipatory Anxiety-The Fear of Future Attack

That first panic attack was so intense and terrifying that Mary lived in dread of another attack. This thought “what if it happens again when I am out, far from safety?” becomes a secondary trigger for future attacks.  Now, Mary worries herself into panic attacks on the highway, in restaurants, in the waiting room of her doctor’s office.  Just the thought of going out far away from home can trigger panic attack symptoms, even before Mary leaves her house in the morning.

Tertiary Trigger (3): Trapped Situations

Now, Mary starts to avoid and escape from trapped situations where she fears she might be unable to get help quickly, in the event of a panic attack strike.  Mary begins to avoid any situation where she had experienced a panic attack.  Mary relies on avoidance of triggering situations as her method of panic relief.  She avoids crowded lines in the market. She avoids traveling on the highway. Her world shrinks.  Her safety zone is limited to short distances from her home. Any situation, where she cannot exit quickly becomes a potential trigger for panic attacks.

Quaternary Trigger (4): The Panic Imitator-The Fear of Normal Bodily Sensations

Now Mary is limiting her travel and building her life more around the safety of her own home. Rather than traveling to a nearby gym for exercise, she buys a treadmill so she can exercise at home. While walking vigorously on the treadmill, Mary notices an unusually strong heart pounding.  She immediately alarms herself, thinking, “Oh no, something is wrong with my heart!”  She, then, feels her heart accelerating and jumps off the treadmill to avoid “damage to my heart.” Mary starts to avoid strenuous exertion, and fears getting emotionally upset.  “What if I trigger heart pounding and cause damage to my heart?”  Mary begins to avoid any situation that she believes could produce an increase in her heart pounding.

Beyond CBT

Scientifically grounded Cognitive Behavioral Treatment (CBT) Programs for Panic Disorder and Agoraphobia provide very effective methods to take control of Triggers (1), (2) and (3). Discovery and mastery of your Core Primary Trigger (1) The Emotional Source of Panic Disorder, is the key to prevention of recurring panic attacks and achieving lasting panic relief.

Preview the panicLINK Program at for a sample of a comprehensive program for panic disorder that can guide you to living panic-free.

*References to real persons, places and events are made in a fictional context, and are not intended in any way to be libelous, defamatory or in any way factual. This educational information should always be used in consultation with your doctor to confirm a diagnosis and review available treatments for panic disorder.

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