What is Anxiety and Panic Disorder?
Occasional anxiety is normal, however when it becomes a consistent part of daily life this is known as anxiety, or panic disorder. This is defined as a chronic condition of intense, excessive and persistent sense of apprehension or fear toward everyday situations. This feeling is difficult to control and begins to interfere with a person’s ability to navigate their normal daily activities, such as caring for themselves and their children, or preventing them from going to work. For people suffering from anxiety and panic disorders, their fears are entirely disproportionate to their circumstances.
How Common is Anxiety?
Estimates from the anxiety and depression association of America reveal approximately 40 million individuals over the age of 18 live with anxiety disorders. It is estimated that only 36.9% of those living with anxiety disorder actually pursue and receive treatment. Symptoms may start in childhood or during teenage years, continuing well into adulthood (1).
What Causes Anxiety?
The cause of anxiety and panic disorders is not fully understood and can be triggered by genetic factors, traumatic events, and life experiences (18). For some people, anxiety may be linked to underlying health conditions. Some medical issues associated with anxiety can include heart disease, diabetes, thyroid problems, chronic pain, and possible side effects from medications.
What are the Symptoms of Anxiety?
Physical symptoms can manifest with anxiety and panic disorder, such as sweating, heart palpitations, and feelings of stress. This can sometimes lead to being completely incapacitated and unable to perform typical activities of daily living. These symptoms can grow into what are often referred to as “panic attacks.” Panic attacks can cause a range of symptoms from pounding heart rate and inability to breathe or think, to feelings of numbness or detachment.
These feelings of fear appear at inappropriate times, often with no apparent cause. Although these panic attacks are not life threatening, they are frightening and often impact the quality of life for those experiencing them. Patients with a panic disorder are usually fatigued, feel weak, may experience troubles with concentrating, sleeping, and gastrointestinal function. Naturally, they have the urge to avoid things that trigger their anxiety and often struggle with controlling their worry or fears (1).
There are different types of anxiety or panic disorders. They range from separation anxiety, social anxiety, and specific phobias to generalized anxiety disorder (1).
What are the Consequences of Anxiety?
While it appears that anxiety disorders are associated with a low proportion of healthcare costs on a population level, for the individual experiencing an anxiety disorder, their health care costs are significantly higher compared with people who do not have the condition (2). People with a panic disorder usually develop other mental or physical conditions that contribute to their issues, including (1):
Depression
Substance misuse or abuse
Difficulties sleeping (insomnia)
Digestive or bowel problems
Headaches
Chronic pain
Difficulties maintaining focus and attention on a certain task
Suicidal ideation
Decreased quality of life
What Happens in the Brain with Anxiety?
Key cortical and subcortical brain regions in anxiety are the amygdala, hippocampus, orbitofrontal cortex, anterior cingulate cortex and dorsolateral prefrontal cortex. These brain regions receive neurotransmitters, the chemicals that regulate their rates of activity, from other regions including brainstem structures. These include the locus coeruleus, raphe nucleus, periaqueductal gray matter and the parabrachial nucleus. Key neurotransmitters in anxiety are norepinephrine, dopamine and 5HT.
Anxiety and panic disorders can be broken down into two different types, involving two different circuits in the brain: fear-based anxiety and worry-based anxiety. Fear-based anxiety includes anticipatory anxiety and worry about an impending panic attack. This often leads to unexpected panic attacks and phobic behaviors, such as avoiding situations that may induce a panic attack. This type of anxiety includes a circuit that includes the cortex of the brain, the striatum and the thalamus, also known as cortico-striatal-thalamic-cortical circuit (3).
Worry-based anxiety includes anxious misery, apprehension, negative expectations and obsessions. This type of anxiety has dysfunction that is based more in the amygdala, as it receives too much stimulation from surrounding brain structures (4). The hippocampus is an associated structure that can stimulate the amygdala. It is strongly involved in memory. If there is too much hippocampal stimulation of the amygdala, patients re-experience their trauma, such as with post-traumatic stress disorder (PTSD).
If stimulation of the amygdala produces too much stimulation of the periaqueductal gray, we see motor responses such as physical avoidance of situations, or the typical “fight/flight/freeze” response known to coincide with fear. Increased firing into the parabrachial nucleus in the brainstem results in respiratory difficulties, such as shortness of breath and asthmatic symptoms.
Overactivation from the amygdala to the hypothalamus increases our stress response, releasing cortisol and putting us in a state of “chronic stress.” Over time, this can lead to coronary artery disease, type 2 diabetes and stroke. When the DLPFC is overactivated, this leads to worry and perseveration, or persistent repetition of a thought, words or phrases. When it is not activated enough, the amygdala’s ability to perceive a legitimate threat becomes compromised and they become hypervigilant (7).
A normal stress response exists in a circuit between the hypothalamus and pituitary gland in the brain and the adrenal glands in the kidneys, also called the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is also responsible for maintaining a normal sleep-wake cycle, or circadian rhythm, which is why sleep disturbances are common in disrupted HPA axis function (10). These structures signal to each other using chemical signals called hormones.
Normally, stress causes the hypothalamus to release corticotropin-releasing hormone (CRH), which travels to the pituitary gland and causes it to release adrenocorticotropic hormone (ACTH). From there, this hormone travels to the kidneys where it stimulates the release of glucocorticoids. Glucocorticoids then leave to act on several target tissues, including the heart, fat, muscle and blood vessels (8). Glucocorticoids also eventually end up back at the hypothalamus and tell it to stop releasing CRH. This is a negative feedback loop, as the hypothalamus is told to inhibit itself once it has done its job sufficiently. The hippocampus, another subcortical brain structure, is also responsible for helping turn off this loop.
The stress response described above evolved to help our ancestors in extremely stressful situations, such as running away from a bear. Stress that we experience today on a daily basis is usually not this drastic, but our daily stressors still evoke the same physiological response.
What does this mean? It means that this loop is stimulated way more frequently than it should be, and over time, the hypothalamus starts to ignore cortisol’s instructions to stop producing CRH and the hippocampus cannot do its job to regulate the loop, either. We then get stuck in a state of chronic stress and the hippocampus begins to degenerate over time, which also leads to symptoms such as memory problems.
Remember how glucocorticoids act on muscle tissue? They tell muscle to release stored glucose (as blood sugar) so that there is plenty in our blood stream in case we need the extra energy to run from the bear. But when we have elevated blood sugar over a prolonged period of time, we can start to see other health conditions emerge, such as reduced insulin sensitivity and eventual type 2 diabetes (9). We also see cardiovascular (8) and respiratory issues emerge, along with sleep disturbance from being in a state of chronic stress. Anxiety disorders also produce this stress response and can lead to other chronic health diseases over time, so it is important to manage anxiety disorders appropriately and remove the body and brain from a state of chronic stress (6).
How is Anxiety Usually Treated?
Anxiety disorders are most often treated through the use of psychotherapy and/or the utilization of medications prescribed by a psychiatric provider, usually in a combination of the two. Cognitive behavioral therapy (CBT) is the most effective form of physiological counseling, as it focuses on improving your symptoms and gradually helps you return to the activities you have avoided. Medications can be helpful at times however they do not directly address the root cause of the dysfunction, that being problems with specific pathways. Rather, medications affect global neurotransmitter function, not just that within the neurological pathway creating the problem. This inevitably leads to side effects that can be in many cases extremely problematic.
CBT helps anxiety and panic sufferers learn new cognitive strategies to redirect their thoughts away from the catastrophic self-talk that occurs during anxiety and panic. CBT does not directly affect the pathways creating the problem, only the cognitive strategies one may employ to deal with the problem. We feel that CBT is necessary for anyone suffering from a significant anxiety or panic disorder, however many of our patients come to us after already completing a CBT program and still have symptoms. We find that CBT is more effective when performed after the problematic pathways have been rehabilitated.
How is the NeuroRescue Program Different?
One of the main things your brain does, and maybe even the primary thing, is help you determine where you are in the world. Your brain uses inputs from your inner ear to figure out where your head is in relation to gravity and how it is moving. It uses inputs from your muscles and joints to figure out where your body is in relation to your head and what your body is doing. It uses inputs from your eyes to figure out where your body is in relation to the visual environment.
Your brain needs to put all of that together to make sense of where the world is, and where you are in relation to the world. It needs to be able to localize you effectively in the environment, in order for you to be able to respond to the environment properly.
When your brain is affected by anxiety, we regularly see degeneration or dysfunction in pathways that involve the eyes, the inner ear, muscles and joints, among many others. This is because these areas utilize the same regions of your brain and brainstem that are affected by anxiety.
It is important to understand that anxiety is rarely only about too much of one neurotransmitter or not enough of another. Perhaps the primary problem in anxiety is the failure of appropriate communication of neurological mechanisms that allow all of these systems to work together. In most cases of anxiety and panic disorders, at a foundational level a failure of regulatory systems has occurred, allowing for other circuits to get out of control. Anxiety and panic cannot be reduced to neurochemical problems, or issues with cognitive strategies. They must be viewed in terms of the totality of their neurochemical, psychological, and neurological pathway function, and how all of these systems intersect and integrate.
This is why many patients fail to fully resolve their anxiety with medication, psychotherapy or alternative therapies, even if all of their therapies are performed at the same time. While all of these therapies can help with problems in the individual systems, none of them take the comprehensive NeuroRescue Program approach to address all of the systems involved in anxiety disorders and their ability to work together in harmony.
How Does the NeuroRescue Program Work?
We design your unique NeuroRescue Program to be among the most comprehensive diagnostic and therapeutic protocols available today. We create individual NeuroRescue Programs based on a comprehensive analysis of every relevant neurological system and pathway, using gold-standard, cutting edge neurodiagnostic technologies and examination procedures and state-of-the-art therapies.
We begin with your Discovery Day, wherein we perform a comprehensive history of not only your condition, but your life on a timeline. This allows us to dive deeply into your case and see all of the factors that led to where you are now. It helps us uncover hidden problems and associated conditions that may be making it difficult for you to move your recovery forward.
Our examination allows us to identify the areas and pathways of your brain that have been impacted by your anxiety. We begin by precisely quantifying the function of your visual, vestibular, and proprioceptive systems through computerized analysis of your eye movements, your inner ear reflexes, and your balance in a host of different sensory conditions.
We employ technologies including Videooculography and Saccadometry to measure several classes of eye movements. We use Video Head Impulse Testing to measure the function of your inner ear, and Computerized Dynamic Posturography to assess your balance under varying circumstances.
We use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and perception of vertical in a virtual reality environment.
We combine all of this with a comprehensive physical and neurological examination of your sensory, motor, autonomic, and cognitive systems. We review any relevant laboratory testing, radiological imaging, and prior neurodiagnostic testing, and integrate that information with our findings.
We use this information to identify which parts of your brain are working properly, which systems are struggling, and the precise point at which your systems fatigue.
We can then design a NeuroRescue Program that is unique and specific to your brain, and yours alone. Your NeuroRescue Program works to rejuvenate and reintegrate the damaged neurons and pathways in your brain. It works to improve energy, endurance, and functional capacity within your fragile systems.
Our therapies may involve everything from specific eye exercises (11), to exercises that integrate your eyes with your inner ear (12), to therapies that directly address the inner ear contributions to anxiety (13). We may include specific types of electrical stimulation (14), or transcranial magnetic stimulation (15). We may include laser and LED photobiomodulation (16), or even engage in exercises in a virtual reality environment (17). All of our therapies have been shown to be effective in current neuroscience literature. The therapies that are right for you will be determined by your unique diagnostic findings.
We use our technologies and procedures to not only see what we need to address, but also when it is time to stop and let you rest. We address your impaired neurological function from multiple angles of therapy, and provide metabolic support to improve neurological recovery.
While we cannot bring back neurons that have been lost, your NeuroRescue Program allows us to take the pathways that remain and maximize their efficiency and endurance. And by focusing on the integration of systems, we can do more than just get pathways working better, we can get them working together again. This gives us our best opportunity to get your anxiety under control, to reduce the frequency and severity of your panic attacks, and ultimately to return you to living a healthy, vibrant, and fulfilling life.
Your Next Best Step:
Living with anxiety and panic disorder can be extremely challenging, but there is hope for recovery and remission. To see if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.
And remember, it’s never too late to start getting better.
