It’s a beautiful winter’s day in suburban Ontario and you’re shoveling snow. It’s the first snowfall of the year so you don’t absolutely hate the task at hand. Yet. You stop to breath in the beauti—-

BLAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR.

The snow plow is on you in seconds and quickly packs your hard-shoveled driveway back in. As you swear to yourself, you continue to shovel.

Suddenly, there’s chest pain. Your vision goes black in the corners and you grab for something. You stabilize yourself on the side of your home and take deep, laboured breaths. You manage to pull your cell phone from your pocket, and dial 911.

“Hello you’ve reached 911 what’s your emergency?”

“I think I’m having a heart attack.”

***

“I don’t get what you’re saying.”

“Let me start from the beginning. Everything checked out fine with your heart. Your rhythm is normal and there are no signs of a heart attack. I think the most likely explanation is a panic attack.”

“So you’re saying it’s in my head? That’s ridiculous. How could you possibly know it’s not a heart attack?”

“Besides the fact that your blood tests and EKG were normal, sir, you are 28. You have no previous cardiac history, you don’t smoke, and your family history is insignificant. Taking all of this together, there is no likelihood that this is a heart attack.”

“So I’m going crazy?”

“I didn’t say that…”

Panic attacks are real, intense manifestations of anxiety. Features of panic attacks include chest pain, shortness of breath, tunnel vision, dizziness, sweating, anxiety, and a fear you are dying, just to name a few. Best of all, panic attacks can have a clear trigger (snakes, for example!), or culminate out of apparent nothingness. Panic attacks can be unpredictable and debilitating, and are definitely uncomfortable. To put the icing on the cake, panic attacks can often present like a heart attack. Your fear of dying just got a lot better, didn’t it?

One of the most common consultations I have seen in my office are individuals who have presented to hospital numerous times with non-cardiac chest pain. The consulting physicians are usually suspicious of panic attacks. These consultations often unfold in a similar fashion – the discussion around the patients understanding of what’s going on, a discussion of their mental health and personal lives, and inevitably, feedback.

To all of my doctor friends out there in the internet, here’s what not to say when you suspect someone is experiencing panic attacks:

“It’s all in your head.”

Medicine and psychiatry are a lot of things, the least of which is not, being a source of reassurance. By dismissing an individual’s symptoms as “in their head,” you have immediately invalidated that person and there’s little chance they will listen to anything else you have to say.

But panic attacks are in your head, and so is the chest pain. But this is also the case with true cardiac chest pain. What am I saying? Everything, including true heart attacks, are to some extent, in your head!

What the hell am I talking about?

In your body, there are a specialized type of nerve cell called neurons. Neurons are like wires that connect different parts of the body and allow parts of the body to communicate with each other. There are neurons that go from your brain to your muscles, for example, which send messages on how to move. There are neurons that go from our skin to out brain which tell our brain what we are feeling.

This is equally true in heart attacks.

When you are having a heart attack, blood is suddenly cut off from a part of the heart and damages the heart muscle. This causes chest pain. The neuron that goes from your heart to your brain sends a message to your brain that you are having chest pain. This is how you become aware of it. As is appropriate when you’re having a heart attack and experiencing chest pain, you then begin to feel anxious. This anxiety protects us and drives us to call an ambulance and seek help.

So what’s going on in a panic attack?

If you recall, neurons are like wires. Like wires, messages can pass down nerve bundles in both directions. Messages can be sent from the heart to the brain (as in a heart attack), or from the brain to the heart. In panic attacks, our brain “hijacks” our natural nerve circuitry and sends the message in the opposite direction (brain to heart). This causes the cycle (chest pain -> brain aware -> anxiety) to reverse (anxiety -> brain aware -> chest pain)!

The take home message? The chest pain in panic attacks is as real as the chest pain in a heart attack. The difference is that the pain in each scenario is driven by a different cause (heart damage vs anxiety).

Why do I find this is important to understand? In my experience, when people seek help for panic attacks, often times a patient and physician can get too caught up on whether the chest pain is “really” happening. It definitely is. But to understand and accept that your chest pain is real and is highly unlikely to be caused by heart damage, for all of the reasons listed in the opening dialogue of this post, is empowering and indespensible.

Editor’s note: This article is not a substitute for medical consultation! If you think you are having a heart attack, particularly if you carry risks factors, you should seek medical attention.

Dr. Travis Barron is a resident physician in Toronto, Canada.