Friday, May 6, 2011

About Panic Attacks

I recently read Cracked Up To Be, by Courtney Summers. It's a truly fabulous book, an intense psychological portrait of a young woman, Parker, who is dealing with the aftermath of A MAJOR THING that gets revealed as the book progresses. I'm going to devote another post to discussing this book, which was recommended to me by the always-thoughtful aspiring_x, who wrote, "I'd love to know what's going on with Parker." I'll give you my theories and a potential diagnosis (or two) next week.

Today, I'll keep my scope narrow and focus on one thing that Parker has to deal with in the book: panic attacks.

She has several of them, some worse than others. Here's an example of the start of one of them:

I inhale. How can the auditorium be only half full and have all the air gone from it like that? I'm not getting any air. As students continue to mill into the auditorium, it gets smaller and smaller and my heart beats this insane rhythm in my chest. I rub my palms on my skirt. They're sweaty. I really can't breathe. No, I can.

I just think I can't.

Everyone's in. The teachers line up on either side of the walls, ready to shush us should the need arise. The lights overhead dim, but the stage remains bathed in an eerie golden glow. I take a few short breaths in and bring my hand to my chest because I'm afraid my heart is going to pop out of it. The tips of my fingers are tingling.

According to the DSM-IV (the diagnostic manual for psychological disorders) a Panic Attack is a period of intense fear or discomfort, during which at least four of the following symptoms develop abruptly and reach a peak within ten minutes:
  1. accelerated heart rate, pounding heart, or palpitations
  2. sweating
  3. trembling or shaking
  4. sensations of shortness of breath or smothering
  5. feeling of choking
  6. chest pains or discomfort
  7. nausea or abdominal distress
  8. feeling dizzy, unsteady, lightheaded, or faint
  9. feelings of unreality or being detached from oneself
  10. fear of losing control or going crazy
  11. fear of dying
  12. numbness or tingling sensations
  13. chills or hot flushes

As you see in the above passage from Cracked Up To Be, poor Parker experiences symptoms 1, 2, 4, and 12 in just a paragraph or two. After some of her panic attacks, she ends up in the nurse's office.

And during at least two of them ... she faints.

Now here was where I had to take a little pause, and I'll tell you why: people having panic attacks almost never faint*.

Fainting only occurs if there's some underlying medical problem or if something else is wrong. A person having a panic attack might FEEL like she is going to faint. It usually occurs because the person is hyperventilating, which fills the body with too much oxygen and too little carbon dioxide, and that results in a feeling of lightheadedness.

Hyperventilating is part of the body's natural fight-or-flight response, but if you're not doing one of those two things, all that oxygen has nowhere to go. So it builds up in your blood and makes you dizzy. Feeling faint is one of the common symptoms of panic attacks, and fainting is something many people with panic attacks fear (which causes even more anxiety).  But it basically never happens.

Actual fainting occurs with a sudden drop in blood pressure. During a panic attack, a person's blood pressure usually increases a bit. So ... no fainting.

The lifetime prevalence of panic attacks is about 1 in 20. In other words, A LOT of people have them! They're so frightening, and sometimes people are certain they're having a heart attack. People who have this type of episode should, of course, get checked out by a doctor, but the vast, vast majority of panic attacks are NOT medical problems.

And how do you deal with them? Live through them.

There are drugs you can take, and research shows some of them are effective. Research also shows that cognitive-behavioral therapy (CBT) is effective, and that its results are longer-lasting (and without side effects). Part of CBT would be learning to understand exactly what goes on during a panic attack (things like even though it feels like you're going to faint, you WON'T). Another part involves living through the episode without trying to escape the situation. The therapist might even ask you to intentionally cause some of the physical sensations of a panic attack. In fact, I've been in a training on treating panic where I had to hyperventilate, breathe through a tiny coffee straw, shake my head back and forth for a full minute, jog in place, etc. (now imagine a room full of mental health professionals doing it ... I'm surprised something like that hasn't ended up on YouTube). But I digress.

So ... how important is it to you that a novel represents mental health/psychological disorders completely accurately? What if that inaccuracy serves the plot?

*please note I said "almost never", because there are exceptions to every rule, and anyone with panic attacks who faints (or who has chest pain) should be examined by a physician.


  1. If inaccuracies of any sort occur in a book I'm instantly disappointed, no matter whether they serve the plot or not. It indicates that not enough research has been done or at the very least that the research is flawed.
    Of course, if I don't recognise the inaccuracy it doesn't really matter;-)
    Even more, when I am inaccurate, it's excusable . . . LOL!

  2. LOL! I don't know if you're old enough to have experienced the irony, but at least 10 of the above symptoms can also be symptoms of menopause...and boy do I know! One of the things I love about reading (even fiction) is the research the author has done. So yes, I want accuracy.

  3. Hmm, interesting. My wife has suffered from panic attacks. Never very serious, but bad enough that I or one of our friends would need to stay with her and talk her through it as best we can, and they'd leave her rattled for a while afterwards.

    I think so long as the description of what is happening is kept to a POV that might not be expected to correctly diagnose what's happening to them, I'd usually overlook medical inaccuracies. I don't know enough about medicine myself, and I had no idea that it was impossible to faint from a panic attack.

    That said, I'm a big believer in story and character trumping accuracy. Nothing in fiction is ever fully realistic. It's all varying levels of suspension of disbelief. So if a story's good and I'm enjoying it, I'll forgive a lot of inaccuracies, so long as it's either clearly a conscious decision by the author to overlook the laws of reality (like using a car door as cover in a gunfight in a gritty detective novel) or it doesn't cross the line between focusing on the story and just being lazy with research.

  4. As the wife of someone who suffers from bipolar (and that often includes panic attacks), and the mother of a boy with PDD, I definitely want accuracy. Mental health issues are too often dramatized incorrectly, either in books or film. And you can tell when someone just looked something up on WebMD for their research instead of having/ seeking out first-hand accounts.

    The above description of a panic attack made me pause, too. My husband has had several panic attacks throughout his lifetime and has never once fainted.

    Also, he doesn't have the frame of mind to tell himself something like, "No, I can. I just think I can't," while *experiencing* the panic attack. Afterward, yes, you can make that logical assessment, but not DURING.

    A YA author who has portrayed panic attacks realistically through the viewpoint character's eyes is E. Lockhart in THE BOYFRIEND LIST. I was extremely impressed by how well she portrayed the panic attack as it's happening, and also the character's (and family members) reactions afterward.

    If you haven't read that book yet, I highly recommend it.

  5. I don't care if you're writing fiction, it has to be realistic when you're portraying certain conditions. If you fail to do that, it gives the reader the wrong impression and now in his mind, what he read is true to the condition. Plus, as a writer, you lose credibility with those who know better. Research is a beautiful thing. ;)

  6. I want accuracy. And if inaccuracy serves the plot, I want to hear some explanation as to why this character's presentation is different from normal - something to show me the author did their research! Something as simple as a short scene where the MC's psychologist or doctor or SOMEONE says, "fainting isn't common with panic attacks, let's schedule you for [other test] to see what's going on." It doesn't have to become a major plot point, but it does have to be addressed.

    I'm always disappointed when something isn't accurate, and panic attacks are used so commonly in books, movies, and tv that everyone thinks they know what panic attacks are all about. It's lazy to write about a disorder that you haven't fully researched (and if you HAVE researched it, I want to know that YOU know you're making up symptoms for the purposes of your plot).

  7. This is another fabulous post. I'd like to ask you a question, though, maybe share it with everyone at a later date. What about children? Elementary age or even middle school. What's the difference between a true panic attack and serious anxiety. Children see the world so differently than adults, so sometimes their anxiety seem trivial to us, like over 'not being able to find their toothbrush or homework'. This actually happened with my seven year old this morning and he completely lost it. It was like the world was ending.

    How do you think it would be most affective to handle this issue in a middle grade story?

  8. first off- i LOVED this book, and i'm scared courtney summers is getting a bad rap here!!! eeks!

    secondly- I suffer from panic attacks. i have for years, and they don't always present with the exact same symptoms- and especially between different individual's experiences. when i read her first description of a panic attack, i thought- "YES!!!! That's EACTLY how it feels! finally, someone understands it!" and then after that first panic attack, when she goes to the nurse's office, parker gets chided for worrying the nurse. i can't remember who (i think maybe the principal or counselor) told her something like "no more trips to the nurse's office claiming you can't breathe. what would happen if you actually couldn't breathe and now no one will believe you." because you FEEL like you really can't breathe (or like you're having a heart attack- seriously the symptoms are really similar!) and when you aren't... people say, "Oh. that's JUST a panick attack. No biggie. stop being a baby. just keep going. there's nothing really wrong with you. you're crying wolf." when really that's not what you intend at all!

    also, since i learned it was panic attacks i'm having, i have been able to think my way through them. i don't think i could completely stop one (not yet at least) but i can comfort myself with the knowledge of what is happening with my body, and can make it through some situations i couldn't handle before. also, the intensity of them have lessened, they don't bring me to my knees nearly as often. understanding what is happening to you really does help...

    as far as the fainting thing goes... like i said, i've had panic attacks for years, and i never actually knew i (barring extremely odd circumstances) that i couldn't faint from one... but let call my respiratory therapist husband... ok. yep. he says that you can indeed faint from hyperventilation. because it's not an adequate source for breathing. he says he's seen it happen. he had his information confirmed by our hospital counselor and will ask his coworkers when they come back from the e.r. to make sure. i'll let you know if they disagree.
    i KNOW wiki isn't always accurate, (even though i have full faith that my rt hubby with 10 years experience is) it concurs that fainting is indeed possible with hyperventilation:
    i bet it's very abnormal though...
    i hate to disagree! because i KNOW i don't know much. but i'm betting it isn't out of the realm of possibility- especially for someone who seems to be trying to repress so much of her distress as parker...

  9. Hi Everyone--first, I'd like to say again that, overall, I really loved Cracked Up To Be and would highly recommend it. It's complex and very, very well-done, which is why I think it's worth another post to talk about Parker's overall presentation. In addition, it's an amazing book to study if you want to try to figure out how to make a seemingly unsympathetic character completely sympathetic.

    aspiring_x: Although it's possible to faint with hyperventilation, this really never happens during a panic attack, and that's well-known in the clinical community (but NOT in the general public). Panic disorder/attacks are really well-studied, too, because they're so common, so if people fainted, we'd know. HOWEVER, people who have panic attacks actually have to be taught that, 1) because it's not well-known, and 2) because it TOTALLY feels like they're going to faint, with lightheadedness and everything. And you are absolutely right-- panic attacks should NOT be dismissed, because they cause incredible suffering and lead to avoidance of things that shouldn't be avoided.

  10. I think that if we're writing contemporary, realistic fiction, we need to be authentic as possible. However, I'd read the whole phone book if Courtney Summers wrote it--I think she's amazing. :)

  11. Well, if you hadn't pointed it out, I'd have been fine with Parker fainting. Ignorance is bliss and all that.

    If obtuseness were in the DSM-IV, I'd have a clinical presentation of it. You basically have to beat me about the head with an inaccuracy for me to pop out of the fictive dream. (I.e. if Parker had levitated, it might have given me pause.)

  12. I've suffered from a LOT of panic attacks over the years. Sometimes they were caused by my arachnophobia, and other times they were caused by something I don't really want to get into. But I HAVE fainted from at least one or two before. I don't really know how or why (I'm not a professional, obviously), but it has happened.

  13. It is VERY important to me!! In fact I am using a fairly serious mental disorder in my current WIP. I've even toyed with emailing you, but I'm not sure I want to share. :D I'm terrible that way. BUT I have been consulting with some friends of mine who are child and adolescent psychologists. Oh and BTW, I HAVE HAD panic attacks. Not my proudest admission, but yep. It's pretty much like that (the DSM description or most of them for me). And nope. I never fainted.

  14. I'd pay to see that YouTube video, Sarah. Hahaha! But of course panic attacks are no laughing matter. I think it's really important to be accurate in writing about diagnosable conditions. Not only to provide correct information to the general public, but especially to those readers who also suffer from the condition. Misinformation can be harmful in all sorts of ways.

  15. Excellent post! I have an anxiety disorder and have panic attacks often :( And I must admit just reading about them in this post made my palms sweat.

    I did lose consciousness once during a panic attack - not sure why if that isn't something that usually happens - and it has only happened that once. Although I was pregnant at the time, which might have had something to do with it?

    Luckily, I was at the hospital when it happened, so they gave me oxygen and my baby was fine in the end - though when I fainted they were about to do an emergency c-section! Which probably would have given me another panic attack! :P

  16. Very interesting post! I think accuracy is important when I'm reading, but I understand if some slip up occurs (like the fainting in Cracked Up To Be.) It wouldn't ruin the book for me, unless it was ALL inaccurate and I knew it was. Then it'd probably really annoy me.

  17. I like accuracy in my fiction. If I have to do research to write what I want to write, I want others to do it as well. If you are going to change something, then it should be noted in an author notes section at the back of the book.

    As for panic attacks, I have had two or three, but I knew what they were and got myself through them. I knew I wasn't having a heart attack. And Em is right, there are several symtoms attributed to menopause up there.

  18. I'm of two minds on this. (How appropriate!) I think since this book you're describing highlights a lot of psychology, it should be as accurate as humanly possible. I appreciate accuracy. On the other hand, I wouldn't have known if you didn't tell me.

  19. Thanks for the insight, Sarah. It sounds like another intersting book. I really enjoyed Dirty Little Secret. It was an amazing look into the life of a hoarding family and the stress it causes the non-hoarding members of the family. And Wow, what a surprise at the end!

    I actually had a panic attack when we were leaving the Dominican Republic. As I was going through security to leave the country I lost my Green Card. Almost no one spoke English...a TSA official found it and gave it to me, but by then I was a mess. It took me a long time to regain my composure. I've been carrying a green card since 1974 and never lost it. Just thinking about it is stressful. I thought my heart was going to explode.

  20. loved that book and I used to have panic/anxiety attacks. It was awful except I could pretty much time them - 10 minutes from start to finish. Sooo glad I don't have them anymore.

  21. Thanks for sharing this! My protagonist in my WIP has a panic attack and I want to portray it realistically. I think it's important!

  22. accuracy is important. The moment a novel includes something inaccurate, the author looses credibilty and the reader is jolted out of the story.

  23. the MC in my MS going out has a panic attack after revisiting the scene of a near-fatal accident involving her. It's pretty cool b/c I have her NOT faint. Of course, I've had panic attacks before, so I knew what I was talking about. But I did WONDER if fainting was ever the ultimate result... Thanks, guh~ :D <3