Ask the ADAA Experts: Panic Attack or Heart Attack?

I am convinced I am going to die. I have had panic attacks for as long as I can remember, and I am always afraid I am having a heart attack. My chest tightens. My heart beats hard. I am short of breath. I have had all sorts of tests done - EKGs, MRIs, full body scans. I have visited the emergency room and even called paramedics to my home in the middle of the night. I have seen specialists all over town. Each time I learn that I am healthy. I am so embarrassed and scared.

You are not alone. Many people who experience panic attacks believe there is something physically wrong. How can you tell the difference between a panic attack and a heart attack? We asked our experts, ADAA members Peter Roy-Bynre, M.D., and David Carbonell, Ph.D….

Peter Roy-Byrne, M.D., University of Washington School of Medicine:

It can be difficult to tell the difference between a heart attack and a panic attack. This makes it important for anyone experiencing the symptoms of a heart attack to immediately visit the emergency room to rule out any heart or other medical conditions that could be causing these symptoms.

Once a person has a full medical evaluation during an episode and there is no cardiac or other physical problem found, the person should consider seeing a mental health professional to be evaluated for panic disorder. One wants to get panic treated directly after a physical problem has been ruled out, instead of continually seeking new evaluations. Otherwise, this becomes the "what if" problem, i.e. "well, it wasn't cardiac arrest last time, but what if it is this time?" This kind of thinking is the same as the kind that underlies panic, i.e., "well, I didn't die or go crazy this time, but what about next time."

A qualified mental health professional will be able to work with a patient so he or she learns to recognize a panic attack for what it is, and what it isn't. Some patients may find it helpful to have a psychiatrist as part of their mental health team. Their medical background may provide extra reassurance for people who are worried about heart or other medically-related problems.

Peter Roy-Byrne, M.D., is both a researcher and clinician focused on improving the care of people with anxiety disorders. He is Vice Chair of, and Professor in, the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and Chief of Psychiatry at the University's Harborview Medical Center, both in Seattle.

David Carbonell, Ph.D., Anxiety Treatment Center, Ltd.:

It's understandable that a person experiencing chest tightness, heart palpitations or lightheadedness would be concerned that he or she is having a heart attack. But these are also common symptoms of a panic attack. So how can you tell one from the other? People often get tricked into looking for some obvious difference in the physical symptoms. There are good ways you can distinguish the two, and I'll get to those in a moment. But looking for distinctions in the physical symptoms is typically not the way, for two reasons:

One is that panic is the great mimic, imitating not only the physical signs of a heart attack (and other physical ailments), but also filling you with the symptoms of whatever you fear most. If you fear looking nervous, it will make you sweat and flush for everybody to see. If you fear insanity, it will make your thoughts run wild. To a surprising degree, panic produces whatever set of symptoms you most dread.

Second, the physical distinctions between the two are much too subtle to be of help in the midst of a panic attack. Panic attacks and heart attacks can feel frighteningly similar during an episode, but in fact, have little in common. One is frightening but poses no danger. The other is both frightening and dangerous, and requires immediate medical attention. However, it's easy to understand why, while in the throes of a panic attack, it would be difficult for someone to make that distinction. For this reason, it is best following the onset of panic attacks to get a full medical work-up to rule out any underlying medical causes.

But even after receiving reassurance from a physician that there is no underlying medical condition, people often still cannot shake their fear of a heart attack, wondering, What if it's the real thing this time? This is when a person should pay attention to their other (non-physical) symptoms and actions.

A person experiencing their third, fourth or twentieth panic attack will often still feel afraid, as they did during their first attack, but they may also feel embarrassed (as described above), which they likely did not feel the first time. Consider these questions:
If a burglar pointed a gun at you, would you feel embarrassed?
How about if a runaway truck was headed your way - embarrassed?
An accident in which you're losing large quantities of blood - again, embarrassed?

For most people, the answer is no. People generally don't feel embarrassed when their lives are in danger. So in what kind of circumstance might you feel both afraid and embarrassed? One in which you recognize, from your own history, that you're getting fooled by panic. Thus the vicious cycle begins: You can't get the idea of heart attack out of your mind, no matter how hard you try, but you recognize, from your own experience with panic, that you're getting fooled. Again. That's why you feel embarrassed.

This embarrassment will often lead the panic sufferer to try to hide his distress. A person might quietly excuse himself from a meeting or party, and drive himself home so no one finds out about the trouble he's having. He's embarrassed and doesn't want anyone to notice. If it was a heart attack, would he quietly leave the room? Of course not!

So when you notice that you're embarrassed, and want to hide your distress from others, this is a powerful signal that you're experiencing panic rather than a heart attack. In a similar way, people who experience panic attacks often try to distract themselves from the attack. They'll get on their cell phone and chat with friends; they'll hum to themselves; they'll balance their checkbooks. Anything, they hope, that will help get their mind off the panic. If an angry dog charged you on the street, teeth bared and growling, would you balance your checkbook or hum your favorite tune? Of course not. Distraction - unlike fight or flight - is not a human response to danger. People only turn to it when there is no real risk of harm, such as while watching a scary movie. So, if you feel the urge to distract yourself when afraid, that's powerful evidence you weren't in danger to begin with, despite what the phobic part of your mind is telling you.

The questions that have been most useful to my clients, who have had heart and other medical conditions ruled out, in distinguishing a panic attack from a heart attack are: 1) Am I embarrassed? and 2) Am I trying to distract myself? A "yes" answer to either is a good indication that it's panic, not heart attack. Once you get your "yes" answer, put your internal debate aside and move on to some good coping steps for panic attacks.

Dr. David Carbonell is a clinical psychologist who specializes in helping people with fears and phobias. He is the author of Panic Attacks Workbook and the webmaster at the self-help website www.anxietycoach.com.