Panic Attacks and Sleep

Patients with histories of panic attacks or chronic tension often appear hyperarousable in sleep

  • In our experience, many of these individuals experience repeated partial arousals from non-REM sleep–with up to several arousals per minute, and often with abrupt increases in pulse, flushing of the face and clenching of the teeth.
  • These arousals, too brief for the person to recall, can result in light, fragmented sleep, daytime sleepiness or both.
  • Some patients even experience attacks of full-blown panic from sleep: with screaming, frantic behaviors and running with serious risk of self-injury, should the individual fail to awaken during the attack. Sleep-related panic attacks can even mimic REM sleep behavior disorder, but the attacks occur from non-REM sleep.

Individuals who experience the above often seem to be extremely conscientious–perfectionists in an imperfect world.

They typically appear to be striving to complete impossible work loads, after which they sleep much as if they had “dragged a load of adrenaline to bed with them”.

We also have noted that many seem to have “two basic speed: off and way too fast”–a number of them swing between extremes of intense work at high speed, followed by exhaustion and fatigue.

What Causes This Problem?

Understanding the problem can help patients manage it!

It is our feeling, based upon research by a cardiologist that we then confirmed, that many–if not most–patients with sleep-related panic attacks have beta-adrenergic hyperresponsiveness.

  • These individuals have normal levels of epinephrine (“adrenalin”) in their blood but they appear excessively sensitive to normal amounts of epinephrine .
  • The symptoms of an “adrenalin rush” are well-known: shakiness, sweatiness, intense nervousness, and flushing of the face.
  • If patients with sleep-related panic attacks are given a drug that resembles their own epinephrine by vein, in a small dosage that would barely be noticed by normal individuals, they typically have an exaggerated response with intense anxiety, an abnormally rapid pulse and a flushed face.
  • Hence, anything that will cause a person to release more epinephrine may trigger panic attack symptoms in patients with beta-adrenergic hyperresponsiveness.

Examples of “triggers” to avoid and/or manage panic attacks from sleep

  • Caffeine
  • Sweets: because after they are ingested, they cause an increase in blood sugar levels, followed by a drop. When blood sugar levels are falling, the body reacts by releasing epinephrine to stabilize the blood sugar level. In fact, many patients with beta-adrenergic hyperresponsiveness suspect that they have reactive hypoglycemia and if they undergo a glucose tolerance test, they may have a typical attack but without abnormally low blood sugar levels, which can result in the patient being told that their problem is “all in their head”.
  • Stress and anxiety. In fact, it was noted years ago that after their first panic attack, many patients would then experience more in rapid succession, which makes sense since worrying about experiencing another attack logically could help precipitate recurrences. Good relaxation training can be very useful since people can learn to voluntarily reduce their own epinephrine release (for example, with techniques such as yoga and biofeedback).

Obstructive sleep apnea and upper airway resistance syndrome can trigger panic attacks from sleep by virtue of increased release of epinephrine during repeated struggling to overcome upper airway collapse.

How Can The Problem Be Treated?

Our approach at the Regional Neurology and Sleep Medicine Institute is as follows:

  • First, we ensure that the symptoms or attacks being experienced are truly related to typical beta-adrenergic hyperresponsiveness: rather than being due to other problems that can present in a similar manner (such as REM Sleep Behavior Disorder, sleep terrors, and seizures).
  • Next, we concentrate on identifying and addressing aggravating factors which otherwise could render medications less effective or create a need for higher dosages, with an increased chance of side effects.
  • We recommend avoidance of caffeine and sweets.
  • We encourage formal relaxation training if stress and anxiety are factors.
  • Obstructive sleep apnea and upper airway resistance syndrome (UARS) should be identified and treated if present. Note that because UARS is easily missed by conventional sleep center monitoring techniques and it should be looked for very carefully since it often escapes detection.
  • In some cases, medications are needed. For example, some antidepressants that can decrease the sensitivity of brain beta-adrenergic receptors can be useful. However, many patients with sleep-related panic attacks seem to be very sensitive to medications, and we find it best to identify and correct aggravating factors first so patients will respond well to the lowest possible medication doses.
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