Dr. Katherine Shear is the Marion E. Kenworthy Professor of Psychiatry in Social Work at Columbia University. A graduate of the University of Chicago and Tufts University Medical School, her primary areas of investigation include anxiety disorders, depression, and (most recently) bereavement and grief. Her research has produced a number of widely used clinical assessment tools, including the Panic Disorder Severity Scale and the Generalized Anxiety Disorder Severity Scale. Dr. Shear's groundbreaking grief research was recently featured in the New York Times.
Question: What triggers a panic attack?
Dr. Katherine Shear: So what triggers a panic attack is – I'm hesitating because there's sort of two main models of this. I mean, one is that – I guess both of them center on the idea that everyone, you know, is capable of having a panic attack. If a tiger suddenly ran into the room, you would probably have a panic attack. And so that means that we have the brain circuitry to have a panic attack. And the idea is that the circuitry is meant to be triggered by actual immediate danger. And people who have clinical panic attacks have those attacks when there is no real danger. And so what we think is the trigger is more easily set off, so to speak.
Now, what sets it off? It can almost be like a loose wire. You can think of it as a loose wire in your fire alarm system or something. So sometimes it can just set off. But a lot of times, there's a lot of evidence that what triggers a panic attack is an actual bodily sensation of the sort that you have when you have anxiety. So if you think about adrenalin rush, you have heart palpitations; you get a little short of breath, you feel a little shaky, sweaty. Any of those kinds of feelings can trigger kind of what we call catastrophic misinterpretations on the part of the person who's prone to having panic attacks so that they're – what we know about such people is that they're more sensitive than the rest of us to the bodily sensations to start with.
So if you had, for example, panic attacks, you would be better able to tell me right now what your heart rate is, then I would be able to tell you. And so there's that sensitivity to start with and then something starts your heart racing. And that could be running up a flight of stairs. It could be drinking a cup of coffee. It could be getting mad at someone, you know, any of those kinds of things. Your heart starts to race and all the sudden, you sense that pretty early on when it starts to beat faster. And all the sudden, you are feeling – and your mind automatically thinks something terrible is happening – something very dangerous is happening within your body. You might think you're having a heart attack or a stroke or some such thing. And so that is frightening in itself, right? So then that triggers more fear, more bodily sensations in your continuing in that.
Question: How can you bring a panic attack under control?
Dr. Katherine Shear: Sure. I mean, I think that the treatments that we do that have been proven to be helpful for people center on kind of – it's almost like you have a phobia of your own bodily sensations. So you know how we work with phobias. If you were afraid of cats, someone who's afraid of cats, we'd put them in front of cats, right, so that they essentially learn that cats really aren’t that dangerous. And so we follow that same principal with panic attacks and we evoke bodily sensations. So we might have someone run in place in the office and their heart starts to race and they see that that's a normal reaction to running in place. And we're sort of there with them and helping them with that. And we basically desensitize them and teach them also what is behind a panic attack.
Question: Where does normal anxiety end and clinical anxiety begin?
Dr. Katherine Shear: Well, you know, that's a very good question because that's what we're grappling with right this minute in the new diagnostic system that's being – you know, every so often we rewrite the psychiatric diagnostic system. And so one of the big questions is should we be looking at anxiety and mood and other kinds of psychological problems on a dimensional scale like that. And if so, where's the cutoff? And so it's probably not just in one place. Now the scales that I've developed are ones that are focused very much so on diagnoses that we already make. And so there, the cutoff is basically determined by when we can diagnose panic disorder, for example. The Panic Disorder Severity Scale, we can say that – I can tell you a number. But, you know, there's a number that corresponds to the best kind of indicator that someone will have a diagnosis of panic disorders. So that's how we do that.
But it's absolutely true that there's a dimension – that these symptoms occur in a dimensional way such that certainly there's normal anxiety and there's normal panic, even. So panic's different from anxiety because panic is an immediate fear reaction, right? Whereas anxiety is more something we think is going to happen in the future. So panic occurs when you think, like I said before, if there's a tiger in the room or someone's pointing a gun at you. It's the future, but it's the immediate future, as opposed to I'm anxious about a test I'm going to have to take next week or something.
Recorded on November 3, 2009
Interviewed by Austin Allen