Arousal is supposed to be regulated automatically, but when this fails, panic is possible.

In humans, arousal is regulated by the autonomic nervous system. The first four letters, A-U-T-O, tell us it is expected to work automatically. This system has two parts: a part that up-regulates us when stress hormones are released, and a part which overrides stress hormones and down-regulates us.

The system that revs us up (the sympathetic nervous system) is mature enough at birth to operate automatically. But the calming system (the parasympathetic nervous system) is immature. It is not ready to operate automatically. For an infant to be calmed, its parasympathetic nervous system must be activated by a caregiver.

How does a caregiver activate the parasympathetic nervous system? A brilliant researcher, Stephen Porges, Ph.D., found that the system is activated by signals from the face, voice, and touch of an attuned person. These signals, he says, are communicated unconsciously. If properly processed, these signals stimulate the vagus nerve, causing it to override stress hormones, slow the heart, and produce general calming.

As a child’s brain develops, he or she becomes able to expect. When hyperaroused, the child expects the caregiver to appear and alleviate its distress. We all know imagination can cause fear. Imagination can also do the opposite. As a crying child anticipates its caregiver’s response, imagination of the caregiver’s face, voice, and touch activates the child’s parasympathetic nervous system.

The next question is reinforcement. When the caregiver reaches the child and finds the child unexpectedly calm, does the caregiver nevertheless follow through and reinforce the child’s expectations? If the child’s expectations—which activated the parasympathetic nervous system—are repeatedly reinforced, a program is “installed” that will independently moderate arousal.

But what if the caregiver walks away, thinking the child does not need any attention? This may seem perfectly logical because, at the moment, the child appears calm. However, the child’s expectations will not be met—and automatic down-regulation will not be established.

The release of stress hormones causes feelings that grab our attention. This is as it should be—if we are deep in concentration when a threat arises, we need alarm to intrude and shift our attention. Once we are aware of possible danger, continued alarm is counterproductive. We need to down-regulate enough for the mind to be clear, and to determine whether the alarm was caused by a real threat or by a false alarm. If our parasympathetic nervous system is well-developed, we are down-regulated enough for executive function to analyze the situation and deal with it effectively.

But if we lack automatic down-regulation, when stress hormones are released, the feeling of alarm persists until the stress hormones simply burn off. For two or three minutes, “fight or flight” dominates our awareness.

Without automatic down-regulation, we are vulnerable to panic. With no down-regulation to override stress hormones, they disable our ability to separate what we imagine from what we perceive. When stressed, imagination takes over. When we imagine a threat, we experience it as real. When we imagine being trapped, we experience being trapped. Panic results.

For example, when stress hormones cause a pounding heart, we may imagine we are having a heart attack. If stress hormones disable our ability to separate what is imagined from what is real, imagination becomes our reality. We become sure we are having a heart attack. Since a threat within the body cannot be escaped by running away, we feel trapped. Panic results.

When treating panic, therapists generally turn to Cognitive Behavioral Therapy. The fact that this therapy is cognitive, however, presents a problem. In a state of panic, we are mentally overwhelmed. Few panic sufferers can rise to the occasion and apply cognitive techniques when overwhelmed. Thus, only 17 percent of the panic sufferers treated by CBT become panic-free.

Fear of flying, for instance, is not always fear of crashing. It is often fear of having a panic attack during a flight, when escape, as a way of gaining relief, is not possible. In the original fear of flying course at Pan Am, we taught clients that breathing exercises and relaxation exercises would control their feelings. Yet on the “graduation flight” at the end of the course, some of our students experienced full-blown panic even as they did their exercises, just as we taught them to.

With breathing and relaxation exercises clearly inadequate, I turned to CBT only to find that, in a state of panic, fearful fliers could not use it. After years of trying to make CBT work, it became clear that if panic was to be controlled, it would have to be controlled automatically. A double-barrel approach was developed:

  1.  inhibit activation of the sympathetic nervous system
  2. cause activation of the parasympathetic nervous system 

To inhibit activation of the sympathetic nervous system, we had clients link challenging aspects of flight to an oxytocin-producing memory. To activate the parasympathetic nervous system, we turned to Stephen Porges’ discovery that signals from another person’s face, voice, and touch can cause down-regulation. Object Relations Theory and Attachment Theory provided a reason to believe that the memory of a person’s face, voice, and touch could calm. After clients linked anxiety-provoking moments of flight to the memory of a calming person, flight events that previously had caused stress—even panic—caused no significant distress. Research at the University of Arizona has shown that when stressed, the thought of a romantic partner lowers blood pressure as effectively as having the romantic partner physically present.

In short, links between a challenging situation and an oxytocin-producing memory inhibit sympathetic nervous system up-regulation. Links between a challenging situation and a memory of a calming person’s face, voice, and touch activate parasympathetic nervous system down-regulation. This double-barrel approach is effective when panic has been triggered by a certain situation.

But panic can also arise “out of the blue.” To answer that problem, we have clients link the onset of panic to a calming person’s face, voice, and touch. Thus, when panic begins to develop, its precursors activate the parasympathetic nervous system which ends the incipient attack. Porges’ discovery—how the parasympathetic nervous system is activated—led to a way to cause the autonomic nervous system to work as it is supposed to: automatically.

Porges’ discovery has made it possible to control panic, not just in the air, but everywhere. My new book, Panic Free: The 10-Day Program to End Panic, Anxiety, and Claustrophobia lays out a plan to control panic automatically when in elevators, crossing bridges, going through tunnels, in MRIs, on high places, etc. This book is informed by his work (and he contributed an afterword for therapists). 

Because his research aids in the control of panic, Porges, in my opinion, has made the most important contribution to psychology in decades. More on his work can be found here.