• Highlights the importance of understanding principles of anxiety treatment so you can troubleshoot the unexpected when using treatment protocols
• Please note that the follow-up response at the end of Padesky’s reply provides critical corrective information

QUESTION: DEAR DR. PADESKY

Hi, could you clarify something please? I’ve been telling clients for years, following your workshops, that they cannot faint in a panic attack, and explaining why. Then the other day I had a client tell me he frequently did faint in a panic attack. I checked with his doctor who said nothing else [medically] was going on and the doctor assured me that hyperventilating in a panic attack can cause fainting – ??? Hope you can help with this.

— Thanks Julia

ANSWER: FROM CHRISTINE A. PADESKY, PhD

Dear Julia,

It was a good idea to consult with your client’s physician first to see if there might be a medical cause of the fainting. Unfortunately, what the physician told you is not consistent with what I’ve been told by physicians over the years. As the Freedom From Fear website (www.FreedomFromFear.org) states:

Panic will not make you faint; While you faint for a variety of reasons that may have nothing to do with panic attacks, (heat, exhaustion, dehydration, poor nutrition, etc.) panic WILL NOT make you faint. When you faint your blood pressure must go down, when you’re having a panic attack your blood pressure is going sagely up, not down. (reference: www.freedomfromfear.org/aanx_factsheet.asp?id=10)

There are several issues raised by your client’s experience:

First, people often say they “fainted” when they felt faint and “needed to sit down.” It is necessary to interview carefully to find out if the person actually lost consciousness as occurs in actual fainting. People do often feel faint when hyperventilating or having a panic attack. While feelings of lightheadedness can be so intense they are labeled “fainting,” the person does not lose consciousness during a panic attack which is part of panic disorder.

Fainting can occur under a variety of situations that can co-occur with panic attacks such as hunger, viral infection, allergy, vertigo from an inner ear disorder, anemia, sinusitis, heat exhaustion, poor eating habits, low blood sugar, salt depletion, standing up quickly, pressure on the vasovagal nerve (e.g., in pregnancy), etc. If fainting is verified, interview to find out if any of these were present when the client fainted. As I may have mentioned in my workshop, one man had been thoroughly tested by a neurologist who ruled out any physical cause for his fainting. Later tests found a small tumor in his brain that was pressing on a nerve and was missed in earlier tests.

As a third point, panic attacks can occur within any anxiety disorder not just panic disorder. It is important to interview and find out what thoughts and images were going through the person’s mind in the middle of the panic attack. With panic disorder you get beliefs such as “I’m having a heart attack.” “If I faint, I will stop breathing and die.” In social anxiety you get thoughts during panic such as “if others see how anxious I am, they will think I am a mental case.” In blood phobia you get thoughts such as “if I see blood I will faint” (which may be true for the reasons in the next paragraph).

If the panic attack is a symptom of severe anxiety when the person has a blood phobia, they would indeed be likely to faint. In blood phobia there is a rapid DROP in blood pressure which leads to fainting. Over time, a person can become so anxious when the anticipate seeing blood or an injury that they become anxious to the point of panic and simultaneously have the drop in blood pressure associated with blood phobia. This would not be diagnosed as panic disorder (and so you would not use hyperventilation as part of treatment) but instead as a blood phobia. Interestingly, the treatment for blood phobia involves teaching the client to raise their blood pressure in the presence of blood or injury through various muscle tightening exercises.

Thus, you need to be a bit of a detective when the client reports fainting during a panic attack. It is important to question with compassionate curiosity (expressing concern for your client) because the client can otherwise think you doubt their veracity.

Please let me know what you learn from your client.

— Christine A. Padesky, PhD

FOLLOW-UP RESPONSE FROM JULIA

Dear Dr Padesky,

Thank you so much for taking the time to answer personally.

I think the client does indeed have blood/injury phobia – which I had never heard of. He does actually faint, and all his triggers are related to blood tests, injuries, hospitals etc. It would also be consistent with a traumatic hospitalization when he was a toddler.

I’m fascinated that the effect of this on blood pressure is the opposite to what happens in panic disorder! I now need to learn more about my interventions.

Thank you for clearing up my mystery and pointing me in the right direction.

— Best Regards, Julia