TREATMENT

OF

PANIC ATTACK
WITH VERGENCE THERAPY
AN UNEXPECTED VISUAL-VAGUS CONNECTION

„ Merrill D. Bowan, O.D. INTRODUCTION Patients who are susceptible to panic dis-
Panic Attack order may have inherited brainstem loci

P
ABSTRACT that are relatively more hyper-excitable
anic attacks are sudden episodes of or anomalous. Stress then appears to have
Panic attacks are a fact of life in today’s
multiple sensations that come upon a an undue effect and excites the brainstem
culture. As much as 10% of the healthy
person who is under stress. The primary loci.3
population can suffer a panic attack with-
cognitive symptom of a panic attack is Parasympathetic innervation of the heart
in a given year. Various methods of treat-
extreme, anticipatory anxiety. The suf- is via the vagus nerve. The vagus has
ment have been described in the literature
ferer can have the perception of a real or also been shown to affect the EEG in a
to counteract these panic attacks. It has
imagined threat to themselves or others, frequency and intensity-dependent fash-
been noted that it is possible to allevi-
fear of dying, “going crazy,” and the most ion when electronic vagal nerve stimula-
ate panic disorder anxiety by performing
frequent worry is the fear of having an- tion is used. The precise mechanism for
convergence therapy. This somatic inter-
other panic attack.1 The emotional stress this effect however, remains uncertain.4,5
vention functions as a vagal maneuver,
causes excessive activation of the auto- The vagus nerve controls a few skeletal
activating the oculocardiac reflex (OCR)
nomic nervous system. This is manifested muscles, as well. This means that the va-
by medial recti traction. It results in bra-
by a parasympathetic overcompensation gus nerve is responsible for such varied
dycardia and other parasympathetic re-
for the strong response of the sympathetic tasks as heart rate, gastrointestinal peri-
sponses. I have found it possible to allevi-
nervous system associated with the stress. stalsis, perspiring, and a fair number of
ate panic attack, non-cardiac chest pain
They generally last no longer than about motor movements in the mouth, including
and other vagally mediated symptoms by
30 minutes and the somatic symptoms can speech, and keeping the larynx open for
using convergence activity with patients
include increased heart rate/palpitation, breathing.6 The vagus nerve also receives
who suffer from panic attacks. I have
non-cardiac chest pain, tremor, breathing some sensation from the outer ear. Physi-
extended this technique to address non-
difficulty, difficulty with or an inability ological responses with vagal stimulation
cardiac chest pain and it may be further
to speak, nausea or stomach irritability, are known to be almost instantaneous,
extended to patients with other anginal-
and severe perspiration.2 The inherent re- and this aspect seems to support, at least
like pains. It may be possible to alleviate
sponse can also lead to temporary loss of in part, the clinical observations being re-
panic attacks, non-cardiac chest pains,
bladder control under moments of extreme ported here.
and other vagally-mediated symptoms
fear. The vagal portion of this reaction can The parasympathetic innervation to the
with this technique. The risk-to-benefit
cause fainting (syncope) because of a sud- heart comes from cardiac branches of the
ratio is nil. Research is needed to further
den drop in blood pressure and heart rate. vagus nerves. Vagal stimulation slows
elaborate the full spectrum of benefits of
Vasovagal syncope affects young children the rhythm of the sinus node of the heart
this novel technique.
and women more frequently than adult while simultaneously decreasing the ex-
males, with the female to male ratio about citability of the internodal pathways.7
Key Words 2:1. Up to 10% of otherwise healthy indi- The net result is a slowing of the heart rate
angina, extraocular muscles, non-cardiac viduals may experience an isolated panic and some decrease in the power of heart
chest pain, oculocardiac reflex, panic at- attack per year. 2 muscle contraction. Very strong stimula-
tack, somatic interventions, visual con-
Mechanism For Panic Attack tion can cause cardiac arrest for ten sec-
vergence therapy, vagus nerve.
The vagus nerve is the major source of onds or more.
parasympathetic stimulation to the vis- Treatment For Panic Attack
cera. It supplies sensory parasympathetic Somatic interventions have long been
fibers to all the organs, except the supra- used to control the body’s responses to
renal glands, from the neck down to the stress.6 They are often, but not always,
second segment of the transverse colon.
Journal of Behavioral Optometry Volume 19/2008/Number 6/Page 155
non-invasive strategies for altering physi- therapy might specifically decrease a sen- ing after enucleation.7, 16 This is believed
ological and psychological processes by sation of panic. There must be plausible to be mediated by the trigeminocardiac
working directly with tissue systems. reasoning for why the observations might reflex.18
Mild degrees of intermittent vagal nerve be associated, a rationale to support the OCULOCARDIAC
stimulation by daily performance of cer- responses. It is my belief that the most CONVERGENCE TECHNIQUE
tain breathing exercises, over a period of reasonable explanation is the oculocardi-
several weeks, has been known to lower ac reflex (OCR). OCR stimulation of the Mechanism
blood pressure and heart rate in persons vagus nerve through convergence therapy Via the relationships described above, Oc-
with elevated blood pressure or heart rate. offers another, perhaps more practical, ulocardiac Convergence Therapy (OCT), as
The same breathing technique may also type of somatic intervention. a somatic intervention, appears to result in
stabilize mood and affect. Another effec- the stimulation of the primary parasympa-
Oculocardiac Reflex thetic vagus nerve, resulting in bradycar-
tive method used is to take a deep breath, To understand the probable mechanism of
and forcefully blow out through a small dia (Table 1). The somatic interaction of
the OCR, we should consider the neurol- the OCR offers a credible mechanism for
hole in your mouth, puffing one’s cheeks.6 ogy of the eye. The ophthalmic division
The Valsalva maneuver (attempt to exhale the reduction of stress with its associated
of the trigeminal nerve is the afferent limb panic symptoms, including non-cardiac
against a closed glottis, or to bear down of the OCR. The major pathway mediat-
as if having a bowel movement) also acti- chest pain. The palliation may also em-
ing the OCR6 consists of an afferent link brace the diverse symptoms of pulmonary
vates the vagus nerve.8 These techniques through the ophthalmic portion of the tri-
stimulate the vagus nerve, telling it to and gastric distress that can accompany
geminal nerve to the vagus nuclei and an congestive heart failure patients. Vol-
reset. Other examples of somatic inter- efferent link through the vagus nerve to
ventions are: electroconvulsive therapy, untary convergence stimulates the EOM
the heart. Impulses pass through the re- insertions, especially those of the medial
transcranial electrical stimulation, tran- ticular formation to the vagus nerve’s vis-
scranial magnetic stimulation, deep brain recti, plausibly resulting in vago-depres-
ceral motor nuclei. The efferent limb mes- sive responses. The site of origin for this
stimulation, and electronic vagal nerve sage is then carried by the vagus nerve
stimulation.9 phenomenon, most likely, is the muscle
to the heart and stomach.16 The OCR is insertion into the globe, since topical an-
Optometric Therapy Effects On usually understood to refer to a decrease esthesia will greatly reduce the OCR.25
The Central Nervous System in pulse rate (bradycardia) upon ocular OCT as reported here has been seen clini-
Central nervous system effects of vision stimulation—even to the point of actu- cally to result in amelioration of non-car-
therapy (VT) have been reported for about ally stopping the heart (asystole). This diac chest pain and also the symptoms
three decades.10 In the family of binocu- phenomenon is associated with traction of panic attacks and anxiety disorder in
lar dysfunctions, both vergence and ac- applied to extraocular muscles (EOMs) humans. The strategy is employed for a
commodative problems can be treated by and/or compression of the eyeball. This minute or less when any distress is sensed
VT.11,12 Recently, a study of convergence reflex is especially sensitive in newborn in either its prodromal stages or during an
insufficiency (CI) has reported that vari- and children and cardiac arrest may result active attack. It does not replace medi-
ous symptoms associated with CI were as a major consequence. The mechanism cations, but can be employed in conjunc-
resolved with VT and statistically demon- may come from stimulation of the nerve tion with or, if it is possible to intervene,
strated the superiority of in-office VT to endings of the EOMs.17 There are many prior to, the use of pharmacologicals. It
other forms of treatment.13 nerve endings in the EOM insertions in- is strictly an intervention technique to
Ludlam used convergence therapy to re- cluding Golgi tendon organs, palisade be used spontaneously, at any needful
store proper alpha blocking in several pa- endings, stretch receptors, muscle spin- moment. To this point, there have been
tients indicating a reduction in stress and dles, trigeminal nerve terminals and other no reports of adverse reactions while us-
an increase in attention.10 He empirically afferents.18 These sensors are thought to ing this technique, though it theoretically
introduced convergence techniques to as offer positional information to the EOM might be possible to create transient asys-
many patients as possible. He used con- nerve nuclei and to higher processes. 18, 19 tole if performed too vigorously, or for a
vergence techniques with those patients Veterinarians have used the OCR for some prolonged period of time. This potential
who showed attention deficit disorder or time, compressing the globes of the eye as transient asystole has not been reported,
attention deficit hyperactivity disorder a vagal maneuver to reduce tachycardia however.
(ADD/ADHD) and where normal patterns in their patients.20 Strabismus surgeons
of electroencephalogram (EEG) rhythms and anesthesiologists are quite aware of CASE STUDY
are often disrupted.14,15 the risks of OCR stimulation. Medicine A 62-year-old white female, with a history
Based on the experiences with the patient has devised tests to predict which patients of panic attacks over a period of over six
in this report, I have since found that con- are particularly sensitive to the OCR.21, 22 years or more has remained essentially
vergence techniques are particularly useful Anesthesia is then adjusted based upon panic attack-free after about half a dozen
with individuals who have anxiety, panic the test results to reduce the possibility of episodes and OCT interventions over a
attacks or panic symptoms. Convergence an untoward event.23, 24 Other areas of the year’s time. The activity was performed
innervation has consistently shown good head and face can result in vagal changes: strictly as necessary when the symptoms
results with these patients. These clinical pressing on the mandible, maxilla, eye lid were experienced. The patient later began
experiences might seem spurious without or other facial bony structures can produce to suffer classic effects of what were then
describing a unifying neuro-physiological bradycardia. One may demonstrate OCR thought to be congestive heart failure, in-
mechanism to explain how convergence by pressing on the muscle mass remain- cluding what were initially thought to be
angina attacks. The attacks were not clas-
Volume 19/2008/Number 6/Page 156 Journal of Behavioral Optometry
 ple procedure has the potential to reduce
Table 1. the distress from both physical and emo-
tional factors. It has the potential to reduce
OCULOCARDIAC CONVERGENCE THERAPY
not only tachycardia, but also non-cardiac
METHOD: This technique may be done in any posture but is probably best per- chest pain and similar cardiac responses
formed while seated. Any target, a finger, a pen, or a printed card of any sort, is in perhaps a majority of sufferers.
centered before the face at a distance of about four to six inches. A downward Many of the medications used in ame-
gaze position is not a preferred posture, since that angle reduces the role of the liorating the conditions mentioned above
medial recti in convergence and they are the muscles that are most stimulatory to have varying side effects. An effective so-
the OCR. matic intervention like the one described
The patient is to converge to the near-point target and hold the fixation for about here should be welcome to those who ex-
two seconds, then look to a distant target ten or more feet away, for about two perience side effects while taking those
seconds. This is one cycle. (A “tromboning” movement will not be as effective, medications. The risk to benefit ratio of
because of the reduced intensity level.) this technique is virtually not a factor.
These near-to-far cycles are repeated for 20 to 60 seconds. If there has been no re-
lief of the panic attack or chest pain in a minute or less, then the usual medications
CONCLUSIONS
This new and novel method of employ-
should be taken. The procedure may be repeated as necessary. The response appears
ing convergence therapy in panic disor-
to be further enhanced by having the patient attempting to visualize, be mentally
der attacks may be extended to non-car-
aware of, the distance between the near and distance targets (stereoscopic depth
diac chest pain sufferers. It may also be
becomes involved).
of merit to make an attempt to apply the
sic angina, in part because the pains did patterns using heart rhythm biofeedback technique as a palliative to those who
not come on with or after exertion, nor did equipment (HeartMath FreezeFramer® suffer gastric disturbances, situational
resting relieve them substantially. Nitro- 2.0).28 This is especially true when the breathing distress, and perhaps even with
glycerine sublingual tablets were moder- medial recti are engaged by appropriate the prodromal stages of migraine. The re-
ately effective in relieving the pains. head posture (thus isolating their action sponse in panic disorder and non-cardiac
A Cardiolite Stress test and, subsequently, field) while the heart rate is being moni- chest pain has been seen to be swift and
a heart catheterization revealed a healthy tored. Regulation of heart rate variability effective. Panic attacks and pain began to
heart with minimal to no obstructive dis- has been called cardiac coherence training subside within 20 to 60 seconds. The re-
ease, so she continued to do OCT with the and is seen when the intervals between sults lasted from hours to days and upon
onset of any angina-like pain or even the beats become more consistently regular continued practice, weeks and months.
prodromal signs of pressure or tingling, as through entrainment exercises (activities Alterations in vagal tone have been pro-
she described it. The results were gratify- that can influence neural frequencies to posed as a factor in the origin of panic
ing in that within four to six cycles, the adjust themselves to other functional fre- attacks.30 This technique for stimulation
somatic awareness dissipated. This tech- quencies, such as respiration).28 of the vagus, and its tentative hypothesis,
nique rarely, if ever, failed to work for her The use of oculocardiac convergence ther- is based upon an initial set of observations
and continues to do so for the rare occa- apy may be used as a possible treatment, a and empirical clinical applications in a
sions that require intervention. She no somatic intervention, in the event of non- limited population. One case is reported
longer needs nitroglycerine tablets. The cardiac chest pain, panic disorders and above. Any stronger assertion will neces-
patient has even begun to use this so- vagally-mediated stomach and breathing sitate rigorous trials. Research in the form
matic intervention with mild respiratory problems. And, because of the efferent fi- of controlled or cohort studies and/or ad-
and gastric distresses that she more rarely bers to the striated muscle of the pharynx ditional case studies can be designed to
experiences, with comparable results. Re- and larynx, OCT may even treat globus explore and verify the precise mechanism
lief is experienced within a few cycles hystericus, a lump-in-the-throat sensation of this intervention technique and the de-
of OCT. This would be consistent with that causes difficulty in swallowing in the gree of amelioration that occurs. In doing
a generalized vagal response, in all likeli- absence of a physical cause. This maneu- so, it is difficult to conceive of how a true
hood. This has been clinically replicated ver is an interesting and novel use of OCR placebo control group might be designed.
in our office with a number of similar suf- activation, because it appears to manage The patient is always aware that the treat-
ferers. symptoms of autonomic hyperactivity. ment and traction upon all of the EOMs
OCT appears capable of providing a quick can stimulate the OCR, though to lesser
DISCUSSION degrees than the medial recti.19 It would
“Noncardiac” chest pain is present in palliation to these distressing symptoms in
many situations. It is quite likely that there also be of great interest to verify if there
about 20-30% of patients complaining of is—indeed—an accumulative result.
chest pain but who have no or insignifi- may be a conditioning—an accumulative
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