A patient walked into my office last week describing panic attacks that felt like "heart attacks"—chest pain, racing heart, shortness of breath, and overwhelming fear. She'd been to the emergency room three times in two months, each time told her heart was fine. What she experienced wasn't cardiac pathology; it was sympathetic nervous system activation so intense that it mimicked cardiovascular crisis. This is panic disorder, but it's also something more fundamental: a dysregulated fear response where the amygdala hijacks the prefrontal cortex.
Anxiety disorders aren't just "feeling worried." They're dysregulation of the threat detection system—specifically, the HPA axis (hypothalamic-pituitary-adrenal) and the autonomic nervous system. When I assess anxiety, I'm evaluating how the brain detects threat, processes fear, and regulates the stress response. Chronic anxiety isn't just psychological—it's physiological. Sustained cortisol elevation, autonomic dysregulation, and inflammatory activation create a cascade that makes the brain more reactive to perceived threats.
What makes integrative psychiatry essential for anxiety is recognizing that anxiety has multiple drivers. A patient might have classic panic disorder with hyperactive amygdala responses, but also chronic inflammation from stress, sleep disruption that prevents proper cortisol reset, and sometimes nutritional factors affecting GABA synthesis. I've seen patients whose panic attacks resolved completely when we addressed their sleep architecture and optimized their magnesium and B-vitamin levels—not because panic is "nutritional," but because nutritional deficiencies can destabilize the nervous system that panic depends on. Learn more about integrative psychiatry from a medical perspective.
Patients don't need to understand the neurobiology of the locus coeruleus and norepinephrine release to benefit from treatment. But they do need to understand that what they're experiencing isn't just "in their head"—it's a dysregulated nervous system response. The distinction matters because it changes how we approach treatment. If anxiety is purely cognitive, you'd use cognitive interventions. But when it's neurobiological, you need interventions that target the underlying systems: medications that stabilize the fear response, lifestyle modifications that reduce autonomic reactivity, and sometimes interventions that address the inflammation and sleep disruption that maintain anxiety.
Here's what I've learned treating hundreds of patients with anxiety: panic attacks aren't uniform. Some patients have pure panic disorder with sudden, unexpected attacks. Others have panic secondary to social anxiety, where panic emerges in specific situations. Some have panic triggered by physical sensations—cardiac awareness, shortness of breath, or dizziness—where panic and physical symptoms create a feedback loop. Each requires different approaches. Panic triggered by physical sensations needs interoceptive exposure. Panic triggered by situations needs situational exposure. Panic triggered by chronic stress needs stress reduction and autonomic regulation.
There's a common misconception that treating anxiety is just about finding the right medication or learning coping skills. That's part of it, but not all of it. Chronic anxiety requires more than neurotransmitter balance—it requires circadian rhythm stability for proper cortisol reset, reduced inflammatory burden that can sensitize the fear response, and often, addressing underlying trauma or attachment patterns that can keep the threat detection system hypervigilant. This is why I assess sleep patterns, cortisol rhythms, inflammatory markers, and autonomic function alongside traditional psychiatric evaluation.
What I tell patients experiencing panic: understanding the mechanism matters. Panic attacks involve sudden activation of the sympathetic nervous system—the fight-or-flight response triggered inappropriately. This isn't "just anxiety"—it's a physiological cascade: amygdala activation triggers locus coeruleus norepinephrine release, which activates the sympathetic nervous system, causing rapid heart rate, hyperventilation, and the cascade of physical symptoms that make panic feel like dying. Understanding this helps patients recognize that panic is intense but not dangerous—the body is responding as if there's a threat, but there isn't one.
But here's what most articles don't tell you: panic can also be a downstream effect of other conditions. Sleep disorders can trigger panic attacks. Dysautonomia can cause panic-like symptoms. Thyroid dysfunction can cause anxiety. I've diagnosed patients who thought they had panic disorder but actually had POTS (postural orthostatic tachycardia syndrome) or hyperthyroidism causing their symptoms. Proper psychiatric assessment requires ruling out these possibilities—not just assuming it's anxiety.
What I've learned after years of integrating multiple approaches is that anxiety treatment requires precision. SSRIs and SNRIs are effective for many patients, but they work best when combined with interventions that address the systems maintaining anxiety: sleep optimization, stress reduction, inflammation reduction, and sometimes nutritional support. I've seen patients who didn't respond to medication alone but saw dramatic improvement when we combined medication with lifestyle modifications that reduced their baseline autonomic reactivity.
If you're experiencing anxiety, panic, or chronic stress, here's my practical guidance: get proper assessment—not just for anxiety, but for sleep disorders, autonomic dysfunction, inflammatory markers, and other medical conditions that can cause or maintain anxiety. Treatment might involve medication, but it should also involve lifestyle modifications: optimizing sleep for proper cortisol reset, reducing inflammation through diet and stress management, practicing techniques that increase parasympathetic tone (like breathing exercises and meditation), and addressing any underlying trauma. The goal isn't just to reduce anxiety—it's to restore the nervous system's capacity to distinguish real threats from perceived ones.