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The Pediatrician Next Door - Simple Advice on Parenting and Family Health
Ep. 133: Panic Attacks: What Triggers Them and What Helps? - with Natasha Burgert, MD
00:28:20
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- [00:04]
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- [00:32]
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- [01:03]
Dr. Wendy Hunter
Do you know that moment of panic when your child does something and you just don't know what has happened? You can't explain it. Maybe your heart rate goes up. Maybe your child even starts to worry if they're old enough. And you just need an explanation or an answer to what happened. That's what this show is all about. Sometimes I know the answer. I've been seeing patients for 20 years. But when I don't, we go looking together. And today, here's the story we are going to find an answer to. I have seen this same scenario so many times, but here is a specific case I have in mind. A 12 year old girl was sitting on the couch watching TV. She's not worried, she's not upset, at least that's what she says. Then out of nowhere, her chest tightens, her hands tingle, she feels really dizzy and. And she can't catch her breath. She told me she thought she was dying. Her parents panicked. They thought she was having a heart problem, an asthma attack. So they rushed her to the emergency room. And that's where I saw her. I examined her, I asked some questions and then I very confidently, very confidently tell the family, oh, she's just had a panic attack. Nothing to worry about, right? And that's when the parents look at me like I am crazy. How can this be a panic attack? She wasn't even stressed. And am I saying it's just in her head? Because if I am, why did she feel so bad? Why were her hands numb? Okay, well that's what I don't know. Are panic attacks all in your head or is it something happening in the body? Because here's the problem. When parents hear panic attack and when I say it, we feel like we're brushing off their child's suffering. We think we have great news. I do. I think, hey, this is great. Your child isn't actually dying. It's just a panic attack. But that also sounds like. I'm saying it's imaginary or not serious. But if you've ever seen a child clutch their chest, gasp for air, or collapse in fear, you know how terrifying it is. The other problem is that if we don't really understand what's going on, we can't know how to respond. Or worse, we might do things that make the panic even stronger. I don't believe it's as easy as they say. It's all in your head. There is something else going on and I want to figure that out. Because if you know anything about panic attacks, they are terrifying. And even worse, it's terrifying to think it will happen again. So let's find out what's going on and what actually helps with anxiety and panic attacks. If you've ever tried to help someone with one of these, this episode is for you. And if you're new here, make sure to follow the show so you don't miss Future Mysteries. I'm Dr. Wendy Hunter and I'm the pediatrician next door. I'm that doctor friend you call for practical advice about your kid's health. I mix the science of medicine with the reality of parenting. Now, here's why this story story is complicated. This patient had chest pain, shortness of breath and dizziness. Those are serious symptoms. The parents are terrified. And honestly, sometimes we doctors were a little on alert too. We don't want to miss something dangerous, of course, but usually somehow we know when a patient is having a panic attack and not something life threatening. But how do we know? I don't ever want to misdiagnose an event as a panic attack. So I found an expert to help sort this out. Dr. Natasha Burgert is a pediatrician and the author of this incredibly helpful book called Managing Childhood Anxiety for Dummies. This is your go to book if you have a child with anxiety. It's simple and tells you exactly what to try to help your child at any stage. Dr. Burgert is the most practical expert on anxiety I've ever met. I called her into the studio and asked her to describe the typical symptoms of a panic attack. And I asked her how we can tell the difference from a true medical emergency. Here's what she told me.
- [05:13]
Dr. Natasha Burgert
It's hard to discern. We really have to look for patterns. I want families to trust their gut if they think their kid is having A medical emergency, you need to reach out and talk to a doctor, go to the er. That's very common. But most kids are going to have the elephant on their chest. They're going to have their heart racing, they're going to be sweating. Some kids will tell me they feel like they're floating, that their hands and feet are pins and needles. They will say that they don't know where they are, the room is even spinning, or they feel like they're going to pass out. All of these are signs of a hyper alert nervous system and a body system that is trying to protect them. So most of the kids will also tell me it's pretty consistent, the feelings that they get and how their body feels through that panic attack. And the kids don't like it. It makes them feel crummy and they worry that it's gonna happen again. And that's the difference between that panic attack and a true anxiety attack is kids get fearful of having another panic attack. And when that happens, now we are actually talking about panic disorder, which is a subtype of an. And that's different than the anxiety attacks that kids will get. Still very physical, still very emotional, behavioral, but not as severe or as intense as the panic attack. And kids with anxiety attacks don't fear them like kids with panic attacks do.
- [06:44]
Dr. Wendy Hunter
Dr. Burger caught my attention with one thing. She said anxiety attacks and panic attacks aren't the same thing. Oh my God. I never knew this. I've been using those terms interchangeably for years. I am super embarrassed, but I probably don't need to be because how many people do know the difference? That's why I'm asking an expert. It seems like the difference matters. A panic attack leaves kids with this lingering fear it's going to happen again, while an anxiety attack doesn't. And I know that will be important because it changes how we approach treatment, which I'll come back to. So I asked Dr. Burgert to break it down for me. What exactly is the difference between an anxiety attack and a panic attack?
- [07:29]
Dr. Natasha Burgert
I try to discern the difference between an anxiety attack and a panic attack, because an anxiety attack, those kids can kind of ramp up a little bit more slowly. They can identify a trigger. They can tell you that they've had a rough day at school or have had a rough time with friends. But. But a true panic attack by definition can happen in the middle of math class without any warning. It can happen when you're just binging Netflix on the couch. It doesn't need to have that trigger. It's simply a stimulus that put that body into fight or flight. The brain has no distinction. Is this something I really need to be fearful of? Is a tiger really chasing me, or am I in math class? The brain has no distinction once that pathway and that cascade of horm starts. So it's not uncommon that we don't find a trigger with a true panic attack, which is partly why they're difficult to treat at times, because we don't have that trigger to kind of lean into to say, okay, I know this is going to happen when I get in this situation.
- [08:38]
Dr. Wendy Hunter
Now that I understand a panic attack, I want to know, why is it so dramatic? The symptoms are very real. Racing heart, shortness of breath, dizziness, tingling. Parents see those things and think, this cannot just be anxiety. And I get that. A person having a panic attack is in a lot of physical distress. It's really scary to watch. I know this much. A panic attack is the body's alarm system getting tricked. The brain signals danger, so it sets off a cascade in the body with adrenaline, which causes the pounding heart, fast breathing. Your body thinks it's running from a lion, even if you're just sitting on the couch. But the part I don't understand and I know makes parents really skeptical to believe that there isn't something really wrong is that apparently panic attacks can happen when there's no real threat at all, Even if you aren't even thinking about something disturbing or stressing. I always ask my patients what they were thinking about or doing when the attack started. I expect they're going to give me a trigger that I can hang my hat on. Like they just read a mean text, their boyfriend broke up with them, or they failed a test. But too often kids tell me they weren't doing or thinking anything when it came on. This I just can't wrap my head around. I asked Dr. Berger to explain what's actually going on in the brain and the body when a panic attack hits.
- [10:02]
Dr. Natasha Burgert
When a kid was having a panic attack, it is just as real as that tiger chasing them. The brain cannot discern in that moment, is this a real threat that I need to be protecting my body from? Or is this. I had an energy drink and now my body has had too much caffeine. Right. It's still going to trigger that same cascade of stress hormones, and the brain can't discern. So that's where maybe we never find a trigger, or it's a mechanical trigger or it's a medication trigger. Like, we have to think of other things too Besides that emotional trigger, because the cascade and those hormones are so.
- [10:39]
Dr. Wendy Hunter
Consistent, that really surprised me. A panic attack doesn't always need an emotional trigger. That's so confusing. It can just as easily be kicked off by something in the body, like caffeine. And then suddenly, the alarm bells are blaring. So if the brain can sound the alarm without a real danger, what is happening under the surface? I wanted Dr. Burgert to walk me through the physiology, step by step. Why kids feel their heart racing, the dizziness, the tingling. And why does it all feel so real?
- [11:11]
Dr. Natasha Burgert
One of the classic symptoms of a panic attack is you start to breathe fast. Your body's preparing to run and hide. And so when you breathe really fast, you hyperventilate, and that increases the amount of carbon dioxide that you have in your blood. And when that happens, it makes your nerves exceptionally sensitive to any sort of sensation. That will also make you feel dizzy, that high carbon dioxide levels. So these feelings are expected. Their body is safe. You can reassure them that their body is safe. But they are uncomfortable, and kids don't like them.
- [11:47]
Dr. Wendy Hunter
This brings me back to the question we started with. Is it all in her head? If panic attacks can strike without warning and set off powerful physical symptoms, we have to wonder, are kids somehow making this happen? Are they creating their own panic? Or is there something happening inside their body that they can't control? That's the heart of this mystery, and it matters because the answer changes how we see these kids and how we help them. So, drumroll. Does my expert, Dr. Natasha Burgert, think panic attacks are all in the head?
- [12:21]
Dr. Natasha Burgert
I think panic attacks are 100% in the body, and they're triggered from the brain. And the brain immediately says, there is something that I need to be very fearful of and I need to fight flight or freeze. It begins a very predictable cascade of neurotransmitters and stress hormones that affect every single organ system that we have in order to defend us. It's a very important thing that we have in our bodies, because we need that when we're being chased by the tiger. But with the panic attack, that same cascade is just happening when we don't have that trigger or that known threat, that known real threat in our midst. And so it's 100% physical. And kids need to be validated for the physical symptoms that they are experiencing, because they're scary and they're severe.
- [13:16]
Dr. Wendy Hunter
Dr. Burger points out that the very first step is simply to validate what a child is going through, because in the moment, it is terrifying. Their chest does hurt. They can't breathe, their body feels out of their control, and whether or not we see a danger, it feels severe and very real to them. And they need us to take it seriously. And that brings us back to the puzzle. If panic attacks aren't all in your head and there's a physiological cascade happening in the body, then why can't kids just snap out of it? Why can't they talk to their brain and stop it? Have you ever been successful at calming a person down during a panic attack by telling them to calm down? I mean, I haven't. After the break, we'll uncover why logic doesn't work when the brain's alarm system takes over, and what actually does help to calm it down.
- [14:17]
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- [14:39]
Dr. Natasha Burgert
There.
- [14:42]
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- [15:12]
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- [15:34]
Dr. Wendy Hunter
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- [15:36]
Dr. Natasha Burgert
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- [15:38]
Dr. Wendy Hunter
Speed slow after 35 gigabytes of networks busy taxes and fees extra. See mintmobile.com have you ever told your child calm down, you're fine only to have that do absolutely nothing. In fact, usually I think it makes things worse. It's like one of our parents superpowers to say the wrong thing. But seriously, when the body is in full fight or flight mode. Why can't kids just will themselves to snap out of it? Why can't they get themselves to calm down? That's definitely what I've seen. They can't do it. The truth is we just have to wait until it subsides. It seems to me that kids can't think their way out of it, no matter how much they want to. And that also explains why panic attacks are so frustrating. We are all doing our best to help our kid, to help ourselves in a way that makes sense, but it doesn't help at all. So I asked Dr. Burgert if she's seen this too. Why can't you tell someone to think their way out of a panic attack?
- [16:38]
Dr. Natasha Burgert
Because it doesn't work the same way that if I said to a drowning person, just swim harder, right? In that moment, they lose capacity to really use their cognitive brains, Their thinking brains and their body and emotional brains have completely taken over. So even though these kids are very smart and in calm moments can tell you all of the grounding exercises they know, and they know all the box breathing and they know how to count backwards from 100 by 6, like they know all of these tricks, in that moment, that thinking brain is completely disengaged. So I have a few kids that if they feel those body symptoms of panic starting, and of course this means that they've had quite a few panic attacks, which is not great. But when they start to kind of notice those symptoms, sometimes my older kids will be able to catch one of those self regulation skills to be able to dampen some of the effect. But for most of the littles, once that cascade starts, really the only thing that the parents can do is start to co regulate and demonstrate one of those skills themselves and really write it down. Because once that cascade starts, you can't stop it. Box breathing is not gonna stop a panic attack. You just have to wait until all those hormones and neurotransmitters just dissipate. And that's gonna take about 30 minutes. And so that's why kids in math class, when they go to the nurses, nurses school nurses are so important in this. If it happens at school, they have to just sit with them and co regulate with them and give them safety to know that their body is safe and calm can continue to repeat that same message. But I'm not gonna encourage a kid in the middle of a panic attack to try to self regulate or do their box breathing or just calm down. That's not gonna work.
- [18:28]
Dr. Wendy Hunter
Of course, kids can't pull themselves out of a panic attack on their own, their brain is in full alarm mode. The only thing that works in that moment, apparently, is CO regulation. And I realized I've been doing this with my patients and even with my own kids, but I've never had a name for it. I didn't actually know what co regulation meant, So I asked Dr. Bergert to explain it and to give an example of what it looks like for parents when they're in the middle of dealing with a panic attack.
- [18:55]
Dr. Natasha Burgert
My best example of co regulating, and I'm sure that you've seen it a million times in your office, Dr. Hunter, is that when I go up to a 8 or 9 year old who is a new patient of mine, and I approach them with that stethoscope, those kids immediately look to their mom and dad. They wanna look to their mom and dad because they wanna know, is this person safe? Is this okay, this is new. I'm uncomfortable, but what do you think? So co regulation is that it's being that calm person to say, yes, that person's safe. We're gonna do a checkup now. If you're uncomfortable, if this is making you nervous, I'm gonna start. I've felt that before. When I feel nervous, I start to do some deep breathing. I'm gonna start to do some deep breathing. You join me. When co regulation is articulating that you are doing something to calm your body and having your kid join in, you are becoming their external source of explanation of their environment, of calmness, of helping them breathe and learn those skills that help them hopefully self regulate as they get older. So co regulation is kind of the precursor to self regulation. But it's going to take a million little moments of CO regulation before we can expect kids to be able to do that on their own.
- [20:12]
Dr. Wendy Hunter
Hearing this makes so much sense. We can't expect kids to control something they can't. So instead we give them an anchor. We have to be calm for them. That's co regulation. But what does this actually look like in the middle of a panic attack? I mean, what exactly should parents do in that scary moment? I asked Dr. Berger to walk me through her recommendations for literally, really, truly exactly what to do when a child is having a panic attack. Because I don't know what to do with the theoretical. So just tell me what to say and where to sit and you know, whether to give them candy or not. Is that helpful?
- [20:48]
Dr. Natasha Burgert
I like calm presence, physical touch, usually very. Just firm, consistent touch. And co regulation demonstrate where you want them to go. Cause even kids in the middle of a panic attack, it's very difficult to e even ask them questions. My daughter had a few panic attacks and it was like she was a different person. So it's having that physical contact, firm, consistent pressure, often on the kiddos to let them try to ground with you, start to do that co regulation that, you know, they may be able to join in and join what you are doing. And that's how I would encourage a family member to kind of support them through it. Which is very different than how you would help a kid with an anxiety attack, meaning asking them questions and engaging their cognition and trying to get them to problem solve and pushing them through that feeling of discomfort, knowing that their body is safe. They have a cognitive ability to do that. With a kid with panic, you're present and you're co regulating.
- [21:51]
Dr. Wendy Hunter
Now it makes sense to me why a child can't just think their way out of a panic attack. Why it doesn't work when we tell them why. Calm down, you're fine. The amygdala, that's the brain's alarm center, has taken over. Logic gets drowned out, and kids can't access the part of their brain that helps them to reason or problem solve. This was a really important shift for me. It's not that kids are ignoring us or refusing to listen. Their brain literally can't respond to logic in the moment. So if they can't think their way out, the question becomes, what will work? Even distraction, which seems to work really well with anxiety attacks, doesn't work with panic attacks. In my experience, there have to be other things that can help. If I have a patient dealing with panic attacks or who has had one and is afraid of having another one, what do I tell them to try next time? Here's Dr. Burgert's strategy.
- [22:44]
Dr. Natasha Burgert
I always tell my patients, if you can control your breathing, you can control your brain. And the reason that you can do that is because deep breathing, especially exhalation, a nice calm breath out, is gonna stimulate your parasympathetic nervous system. Your parasympathetic nervous system is your body's brake pedal. It's going to be the one that's going to put the brakes on any sort of physical symptoms or often emotional or behavioral symptoms that you might be experiencing when your body's starting to get anxious or starting to feel fearful. And so by engaging that breath, you are physically engaging a part of the nervous system that's important for your entire body system to calm down, which is such a cool Thing. And I think that a lot of families know, like, yeah, we should help our kids breathe when they're starting to get anxious, or I've heard the Calm app or whatever tells us to stop and breathe. But understanding that there's a physiological reason why it's important to be able to learn how to do this, I think is really important because it motivates kids to learn how to control their body, and it motivates parents to do it a million little times, because it takes a million little times to be able to learn how to do that on your own.
- [23:56]
Dr. Wendy Hunter
I love that these strategies are simple and something we can practice with kids ahead of time. They may not prevent every panic attack, but at least they give us something to try so kids know how to bring the body back into control. Maybe. Another tip that Dr. Burgit includes in her book is called grounding. Grounding is really just a way to pull the brain into the present moment. So instead of getting lost in racing thoughts, you help your kid use their senses, what they can see, hear, touch, smell, or taste, to remind the body that it's safe.
- [24:28]
Dr. Natasha Burgert
Grounding activities are anything really to make them aware of their environment or aware of their physical self in space. So I give kids calm strips when they're in my office. So those little spiky little calm strips they can put on their computers at school. If they're starting to feel uncomfortable, you can press on them, and it kind of hurts your thumbs almost. It's like a. A sticky velcro tab almost where you can kind of feel that pressure and it reminds you where you are. Sensory rings are great hedgehog bracelets. That's all that physicality that they can wear, and it's very subtle. They can do that at school, and nobody's really going to know that they're using that as a grounding technique. Other grounding techniques that I like are. I think of movement as a grounding technique at times. Do I need to take a walk? Do I need to do jumping jacks? Especially for littler kids that it's hard for them to sit and calm their bodies. You can also ground by doing jumping jacks or touching your toes or playing I Spy or counting to fives. Like, all of these things are going to be engaging with our environment. A lot of times people will talk about 5, 4, 3, 2, 1, where five things that you can see or four things you can smell or whatever order that you want to do them in. I find that difficult to do with kids when they're starting to feel anxious because I practice all of these when kids are starting to get shots. It's a great time to practice if they're nervous about shots, these different techniques. So in the office, specifically, I'll say I have a sticker that I have on one of my boxes over my shoulder in the office. And so when I'm looking at them, I'll be like, look over my shoulder. What color is that sticker? Now find three other things in the room that that's that same color. So I have kind of setups to be able to show them and the parents, oh, this is what we can do when, when kids are feeling anxious. We could do something like this when we're at church or at school or at the park. Same concepts in different places.
- [26:17]
Dr. Wendy Hunter
Grounding isn't complicated. And I'll put links in the show notes to the items that she mentioned, like calm strips, sensory rings, and hedgehog bracelets. If there's one thing I want you to take away, it's this. Panic attacks are real, they're scary, and they aren't in your head. They are physiologic and we can't control when they happen, but they're also treatable. Dr. Burgert has a ton more information to help you in her book. I want to give a big thank you to my guest, Dr. Natasha Burgert, for sharing her wisdom. Her new book, Managing Childhood Anxiety for Dummies, is packed with practical strategies like the ones we talked about today. I highly recommend you check it out, especially if you're a dummy like me. And if you found this episode helpful, please follow the show so you don't miss the next mystery we solve. Share it with a friend who might be struggling with the same questions, and if you have a moment, please leave a review on Apple Podcasts. It helps more parents find the support they need. Thanks for listening and I'll see you next time for more from the pediatrician next door. Or find me on the web@ pediatriciannextdoorpodcast.com if you've got a question about the weird things kids do, send an email to helloediatriciannextdoorpodcast.com for a chance to hear your voice on the show. I'm Dr. Wendy Hunter and I'm the pediatrician nextdoor. This show is produced by Red Rock Music. Make sure to subscribe and leave a review wherever it is you're listening. I'll be back next time with more.
- [28:03]
Dr. Natasha Burgert
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- [28:04]
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- [28:23]
Dr. Wendy Hunter
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Dr. Wendy Hunter
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