By Daniel Tarade
I am painfully aware of the physical symptoms associated with anxiety. I have suffered from both generalized anxiety disorder and a panic disorder. But in the months before I would receive such a diagnosis, I just assumed that I was physically unwell. I suffered from a perpetual lump-in-throat sensation, which occasionally felt as if my throat was closing. A few months later, heart palpitations would join the list of symptoms. But these were just the chronic symptoms. Occasionally, I would suffer from what I later learned is a panic attack. Each attack was unique. Sometimes it would start with pain or numbness in my left arm. My heart would start racing and I would feel dizzy. During particularly bad attacks, I would feel as if I was on the verge of fainting. I suffered from chills or broke into a hot sweat. Sometimes I would feel nauseous and about to vomit. The attacks continued for up to an hour as waves of faintness ceased to relent. All in all, would not recommend.
My fear was that I was having a heart attack of sorts and would respond to the attack by calling either my girlfriend or family. I just wanted someone to be aware of what was happening in case I lost consciousness. One particularly bad attack prompted me to call my parents and repeatedly give them my address because I was convinced I was going to pass out and that they would need to call me an ambulance. During these attacks, I would often consider calling an ambulance myself. Even after an organic cause for my physical symptoms was eliminated (blood work and an electrocardiogram) and my doctor assuring me that I was in no real danger, I would be tempted by the prospect of seeking urgent medical attention when I had a panic attack. The symptoms were that frightening. My predicament reminded me of Blaise Pascal and his wager that cemented him as the father of modern probability theory.
It goes like this. There are two possibilities; one is that God does exist and the other is that God does not exist. Two other possibilities; one is that you believe in God and the other is that you do not. From this combination of binary possibilities, four outcomes emerge.
One, you do not believe in God and it does not exist = When you die, your soul becomes one with the void
Two, you do believe in God and it does not exist = When you die, your soul becomes one with the void
Three, you do not believe in God and it does not exist = When you die, you go to hell
Four, you do believe in God and it does exist = When you die, you go to heaven
Based on an analysis of these four outcomes, Pascal concluded that belief in God is statistically the best choice, even if you think there is a only a small chance that God actually exists. Ignoring the seemingly petty nature of the Abrahamic God, Pascal puts forward an argument of prudency. Whether or not God exists, you will not suffer for your belief in God whereas the greatest negative outcome can only occur if you lack faith. I would often apply a similar thought process to my panic attacks.
One, you do not call an ambulance and are having a heart attack = you die
Two, you do not call an ambulance and are not having a heart attack = you live
Three, you do call an ambulance and are having a heart attack = you live
Four, you do call an ambulance and are not having a heart attack = you live
A pair of binary possibilities with the worst outcome associated with not going to the hospital. For those who live their lives in an attempt to minimize worse case scenarios, it appears that going to the hospital, even if you think you are having a panic attack (not a heart attack), would be the prudent decision.
However, Pascal’s wager is overly simple. His argument downplays the negative outcome of believing in God. Going to church is inconvenient and annoying. I admit that this argument is subjective and that some people find comfort and routine in church but for the person who is only going to church to avoid hell on the off-chance that God exists, I think it is a fair point. Further, structuring one’s life around a fictional deity conceivably distracts from finding fulfillment in other aspects of your life. If God does not exist, such faith could potentially result in a net negative. Of course, in order to conduct a proper statistical analysis, we would need to predict the relative odds of God existing and ascribe relative values to eternity in heaven or hell as well as to a life where church and prayer is mandatory versus a life where I can sleep in on Sunday. I am not going to debate the actual existence of God, because thankfully the Vienna circle swept that question under the rug years ago. However, with my wager regarding panic disorder and ambulances, numbers are available!
To introduce this next section, I just want to highlight that there are over one million anxiety-related ER visits annually in the United States, representing just over 1% of all ER visits.[i] Researchers have observed that individuals with a panic disorder, like myself, are more likely to access the general health system (i.e. non-psychiatric services, think ER, family doctor, and walk-in clinics) than people suffering from any other psychiatric condition.[ii] The reason for an enrichment of patients suffering from panic disorders in the ER is that the majority think they are “suffering from a serious physical disorder,” most often coronary artery disease (CAD; i.e. the build-up of plaque in a coronary artery, which can lead to a heart attack).[ii] This is further exacerbated by the fact that many of these patients do not get diagnosed with a panic disorder after visiting the ER. In fact, almost zero percent of patients who meet the requirements for a panic disorder, or other psychiatric disorder, are actually diagnosed as such,[iii] even if CAD was eliminated as a possibility.[iv] Of ER patients who have a panic disorder, the majority are not actually suffering from CAD. These patients represent case four (calling an ambulance but not having a heart attack) and are most likely having a severe panic attack. However, although the majority of patients with a panic disorder do not suffer from CAD, the percentage is not 100% - it is only 74%. In fully 26% of cases, a patient co-presented with both a panic disorder and CAD.[iv] These patients are examples of case three (calling an ambulance while suffering acute symptoms of heart disease). Not only that, but people with multiple phobias, a condition often related to panic disorders, were more likely to suffer a lethal CAD event than those without multiple phobias despite a similar incident rate of CAD in general.[v] The theory proposed is that the surge of adrenaline associated with a panic attack damages the heart (specifically the electrical stability of the cardiac muscle), increasing the vulnerability to an arrhythmia. This means that people suffering from panic disorders have further reason for seeking urgent medical attention when suffering from distressing physical symptoms like chest pain because if they are truly having a heart attack, it is more likely to be fatal.
To be honest, when I began researching this topic, I did not expect such a high percentage of actual CAD. However, the above referenced study is biased towards patients with CAD because the total cohort discussed are ER patients, not individuals suffering from the physical symptom of chest pain, chest tightness, elevated heart rate, heart palpitations, etc. The people who go to the ER are those who are truly suffering from very frightening symptoms that are reminiscent of a heart attack. Despite having many horrible experiences with my panic disorder, I was fortunate in not experiencing much chest pain. Of course, a study that analyzes all instances of person suffering from heart palpitations, chest pain, etc rather than ER visits is necessary to discern how often these symptoms are associated with CAD or are instead related to a panic disorder. However, this type of study would only shed light on global percentages. If you are unsure of whether you are having a panic attack or a heart attack, it would be important to consider your own health background. Are you at risk of heart disease? In my case, I am a young individual of normal weight, decent fitness, who has never smoked, and maintains a healthy diet. Consideration of these factors helped me avoid ever visiting the ER during a panic attack. Another consideration that helped was the fact that I had experienced similar symptoms in the past and never has it been a heart attack. With more experience and a proper diagnosis of a panic disorder I gained confidence in the fact that I was not at risk of dying whenever I experienced heart palpitations or a numb left arm. This approach to dealing with panic disorder is employed during cognitive behaviour therapy, which was of immense benefit to me. Cognitive behaviour therapy also outlined one benefit associated with not going to the ER when having a panic attack; it breaks the cycle of safety behaviour. I mentioned earlier that I would call my parents when having a panic attack. That act was my version of visiting the ER. I would look for reassurance and ensure that assistance would be prompt if I did suffer a heart attack. However, the act of calling home became a safety behaviour, a crutch such that if my parents were not available, I would feel even more panicky, unsure of how to navigate. Just like Pascal’s wager glosses over potential negatives associated with believing in God, my earlier description of the four outcomes associated with ambiguous physical symptoms ignores the negatives of calling an ambulance; namely, calling an ambulance reinforces the notion that what you are experiencing is a life-threatening event and perpetuates panic, both in an acute and chronic sense. However, as discussed earlier, there is a non-zero percent chance that what you are experiencing is actually coronary artery disease. In roughly a quarter of all cases, an ER visit by a person with a panic disorder results in the diagnosis of CAD. Although this number is not reflective of all instances of panic attacks, it does highlight that any of the symptoms that I’ve described (faintness, dizziness, heart palpitations, chest pain, chest tightness, elevated heart rate) warrants proper medical attention. However, if CAD and other organic causes are eliminated via medical investigation, then a panic disorder is a likely culprit. In such an instance, it may still be tempting to call an ambulance when having a panic attack but it may do more harm than good.
Postscript on the Math of Pascals' Wager
Pascal's wager itself sidestepped any maths by appealing to the infinite nature of heaven and hell, which by definition outweigh any negative or positives incurred during a finite life. Even if a secular life is associated with more pleasure than a life lived in accordance with religious doctrine, the infinite pain associated with hell, however unlikely in nature, is not worth the risk. After all, infinity multiplied by a positive number, no matter how small, is still infinity. By ignoring our mortal lives in deference to the concept of an afterlife, Pascal's wager is escapist in nature. However, my use of a similar framework to discuss panic disorder is meant to subvert escapism. I am not willing to ascribe infinite negative value to death, which would again completely eliminate the need for discussion about the negative impact of continually visiting the ER for every instance of chest pain. Once obvious physical health concerns are eliminated as a possibility, a person with panic disorder has much to gain by overcoming the fear intimately entangled with physical symptoms like heart palpitations, dizziness, chest pain, etc. I contend that a triumph over one's own mental health issues is worth something even in the face of death.
[i] Dark et al. (2016). Epidemiology of Emergency Department Visits for Anxiety in the United States: 2009–2011. Psychiatric Services, 68(3), 238-244.
[ii] Lynch & Galbraith. (2003). Panic in the Emergency Room. The Canadian Journal of Psychiatry, 48, 361-366.
[iii] Wulsin et al. (1989). Screening Emergency Room Patients with Atypical Chest Pain for Depression and Panic Disorder. The International Journal of Psychiatry in Medicine, 18(4), 315-323.
[iv] Fleet et al. (1996). Panic disorder in emergency department chest pain patients: Prevalence, comorbidity, suicidal ideation, and physician recognition. The American Journal of Medicine, 101(4), 371-380.
[v] Haines et al. (1987). Phobic anxiety and ischemic heart disease. British Medical Journal, 295, 297-299.