Janet Klosko, Ph.D.
Cognitive Therapy Center of Long Island
It is hard to explain to someone who does not have panic attacks what it is like to have one. This is why my patients with panic disorder often feel so alone. It is hard for them to explain to those around them what it feels like to have the attacks -- how frightening they are and how avoiding them at all costs can wreak havoc in their personal and work lives.
This is how one patient named Leonard described a panic attack.
I was driving on the thruway when I drove into a traffic jam. Traffic was down to a crawl. At first there were cars just in front of me, but soon there were cars in back of me too. I felt trapped. I broke into a sweat. I started to panic. My heart started beating a mile a minute.
What if, I started thinking, what if I have a heart attack in this traffic jam, and I can’t get out to get help, and no one can get to me.
My heart hurt and my chest was tight. I couldn’t catch my breath. My arm was numb. I tried to remember the exact symptoms of a heart attack. What if I’m having a heart attack right now, I thought. My heart was pounding so hard it felt like it was going to jump out of my chest. And beating so fast! It couldn’t have been good for my heart to be beating so fast. I had to get out of there but traffic was crawling. Each minute seemed like an eternity. For awhile I thought I was going to die there in that car.
When Leonard has a panic attack he feels like he is dying. He believes he is dying -- he believes he is having a heart attack. Anyone who believes he or she is dying is going to panic. This is one way to describe panic attacks to someone who has never had them. Imagine that suddenly something threatens your life. Your elevator gets stuck and the building is burning, a mugger pulls out a gun, your car swerves out of control. That rush of terror -- that is how it feels to have a panic attack.
Except with a panic attack, you feel this way and you don’t know why. There is no burning building, no mugger with a gun, no car out of control to explain your fear. The symptoms come out of nowhere, out of the blue, apparently for no reason. You’re having dinner in a restaurant, watching a movie, standing in line, driving -- and suddenly the symptoms are there.
A panic attack is a sudden rush of intense fear -- a feeling that something catastrophic is about to happen -- accompanied by at least some of the following symptoms:
Not everyone fears dying during panic attacks as Leonard does. Some people fear going crazy or losing control. They fear that they are having a nervous breakdown, or that they will faint, fall, scream, or throw up. They fear that they will mentally drift into unreality and never return to a normal state again. They fear that they will lose control and jump from a height or swerve into traffic with their car. Or they fear becoming non-functional. In reality, none of these things ever happen.
What you fear during a panic attack depends largely upon which symptoms you feel and focus upon most. Leonard focuses on his heart symptoms and fears he is having a heart attack. Other people focus on the feeling of unreality and fear they are going crazy, or they focus on the dizziness and fear they are passing out, or they focus on the gastrointestinal symptoms and fear they are getting sick, or they focus on the breathing symptoms and fear they are smothering. In reality, none of these things are happening. Panic symptoms are uncomfortable but not dangerous.
If you have panic disorder, you are different than other kinds of phobics. Other phobics fear a specific danger in the world. They fear dogs, cats, spiders, or airplane crashes. They can simply avoid the thing that they fear and feel relatively safe. But the danger you fear comes from within -- from your own body, your own mind -- in the form of these panic symptoms that seem to come out of nowhere and race out of control.
You may avoid going places where you might have a panic attack and be unable to get out or get help. You need to know that you can get out of a place if you want to, and you need to know that you can get help. The places you fear most are those where you are cut off from the exit or cut off from help. Some phobias you have might include being alone, crowds (at theatres, stores, concerts, traffic jams), forms of transportation (buses, trains, planes, cars, elevators, skilifts), tunnels, bridges, heights, restaurants, taking medication, anesthesia, going far from home, going beyond the reach of medical help, certain kinds of physical exertion (exercise, sex, amusement park rides), various foods, and waiting in line.
If you have panic disorder and you have some of these phobias, then we say you are agoraphobic. Other phobics fear things in the world that they believe are dangerous. They fear animals because animals can bite; they fear airplanes because airplanes can crash; they fear germs because germs can cause sickness. However, when agoraphobics to explore what they are afraid of, it is always the panic attack itself.
For example, you don’t fear airplanes because they can crash; you fear them because you might have a panic attack in the plane and be trapped there. It is the panic symptoms, not crashing, that you fear. You believe that the symptoms are dangerous. It is the symptoms that convince you that you are about to die, go crazy, or lose control. Ultimately what you fear is the panic itself. You fear the fear.
When you have to go somewhere you become anxious. You may worry for days or even weeks. You think: “What if I have a panic attack there? Will I be trapped? How embarrassing will it be for me to leave? Will I be able to get help? Will I be able to get home? Will I be alone?” This anticipatory anxiety is a feature of panic disorder, and it can be excruciating. Between attacks you live in dread of the next one; and, although you can guess, you can never be sure where or when the next one is going to strike. You might have “safe people” or “safe places” that make you feel better, but you cannot reach a feeling of total safety.
I always tell my panic disorder patients that it is not the panic we are going to treat, but rather their reaction to the panic. They are going to learn to master the panic. The key to mastering panic attacks is to stop running away from them and start facing them and learning to control them. That this can be done I have witnessed hundreds of time. We will now discuss how you can learn to master your panic attacks.
Learning to Master Panic Attacks
An effective panic treatment should include the following:
1. Education about panic.
2. Learning skills to control panic symptoms in your body.
3. Learning skills to control panic symptoms in your mind.
4. Gradual exposure to the symptoms and situations that you fear.
5. Consideration of the stressors in your life.
1. Education about panic.
Suppose you go to the bank and as you open the door you see a man point a gun at the teller’s head. In the split second it takes you to understand what is happening your body begins to react. Nature has prepared your body to react to such emergencies in some very helpful ways.
You get a rush of adrenaline, which energizes you. Your senses all become more acute. You start hyperventilating -- your body takes in more oxygen, making more available for organs and muscles. Your heart pumps harder and faster, carrying the oxygen throughout your body. Unnecessary systems such as digestion shut down, preserving all your energy for the emergency at hand.
This “fight or flight” response could save your life in this situation. If you were to run, you could run faster than normal. If you were to fight, you would be stronger and fight better than usual. Your body would perform at its peak.
Let us suppose that you decide to run. As you turn you see another robber behind you, looking right at you, holding a gun. You are trapped.
Nature has prepared you for this situation, too, with another response -- the “freeze” response. It is the opposite of fight-or-flight. Everything in your body slows down. You stop moving (probably a good idea when someone is pointing a gun), and may even feel “frozen.” Things seem unreal, (which is a blessing because it keeps you calm). Your blood pressure drops (which makes you somewhat dizzy, but this helps because if you were to be shot you would bleed less).
If you have panic disorder, the “fight-or-flight” or “freeze” responses are what are happening to your body when you have a panic attack.
There are two things you should know. First, the “fight-or-flight” and “freeze” responses are not dangerous in any way. A panic attack does not harm you. In all the vast literature on panic, there is not a single reported case of someone dying, going crazy, or losing control during an attack. Afterwards perhaps you are tired, but you have not been harmed.
Second, the attack always passes. Time alone ends a panic attack. The panic always comes to an end, and you always return to your normal state.
In fact, panic attacks are by their nature very quick. On their own they end in minutes. If they last longer you are doing something to maintain them. What you are doing to maintain them has to do with the way you are thinking about the attacks -- you are interpreting them as far more dangerous than they really are.
2. Learn skills to control panic symptoms in your body.
Here is a simple relaxation technique. It has two parts: a breathing part and a meditation part.
Breathe slowly and deeply. That is, take no more than eight breaths a minute, and when you breathe, move only your diaphragm. Your chest should be totally still. Breathing this way will prevent you from hyperventilating, the major cause of most panic symptoms.
The meditation part follows the rhythm of your breathing. Focus your attention on your breath. Notice the cool air as you breathe in, and the warm, most air as you breathe out. If your attention wanders, do not get frustrated. Just gently bring your attention back to your breathing. Meditating can help center your body and your mind.
Practice this technique often. As you go about your day, notice your breathing. If you are breathing incorrectly (breathing too fast, breathing from your chest), correct your breathing. Be mindful of your breathing. Research shows that many panickers chronically breathe incorrectly, even when they are not anxious. In fact, this habit of breathing incorrectly is probably the major reason you have the attacks in the first place. It sets the physical vulnerability which stress attacks.
Another technique to control panic symptoms is mindfulness. Bring your attention outward, into the present moment, using all of your senses. What do you see, hear, smell, taste, and feel?
Use these techniques whenever you feel anxious or have an attack. If you practice the techniques and become good at them, they can help immeasurably.
3. Learn skills to control panic symptoms in your mind.
Catastrophic thinking drives your panic attacks. “Catastrophizing” is jumping to the worst possible conclusion -- without the evidence to warrant such a jump. The nickname for catastrophizing is “what if-ing”: “What if I am having a heart attack,” “What if the panic never ends,” “What if I am having a nervous breakdown,” “What if I lose control and jump,” “What if I smother to death,” “What if I fall and embarrass myself?”
As long as you continue to think catastrophically you pour fuel on the fire of your panic attacks. Your catastrophic thoughts increase your physical symptoms, which in turn increase your catastrophic thoughts, in a vicious circle that can keep panic going for hours.
Instead, think more realistically. This flashcard can be your guide. Carry it with you and read it whenever you have a panic attack.
Right now I am having a panic attack. I am afraid that I am going to die, go crazy, or lose control.
However, I am catastrophizing. In reality no one has ever died, gone crazy, or lost control during a panic attack. In fact, I am experiencing the “fight-or-flight” or “freeze” response that is common to all living creatures who feel threatened. If I relax and correct my breathing, the symptoms will pass, and I will be my normal self again. Panic is uncomfortable, but it is not dangerous. I just have to stay in the situation until the anxiety comes down, and next time I come here I won’t feel as anxious. I can and will stay in the situation until the anxiety comes down.
Stop thinking you are that one special person who will really die, go crazy, or lose control during a panic. Every panicker feels this way. Instead of telling yourself lies that scare you, tell yourself the truth.
4. Gradual exposure to the symptoms and situations that you fear.
This, ultimately, is the most important part of the treatment. You have to gradually start entering the situations that you fear and staying until your anxiety comes down.
Make a list of the situations that you are avoiding, ranging from situations that make you only mildly anxious all the way up to the situations that you fear most. Remember Leonard, the patient whose traffic jam panic attack I described in the first part of this article? Here is his list: Getting stuck in traffic, riding the elevator, taking a nap and waking up in the middle of the day, riding a boat, riding a train, riding an airplane, swimming underwater, taking medication, drinking alcohol, having to get general anesthesia for surgery, being alone in the house at night, empty time, and camping.”
Pick the easiest item and start with that. Enter the situation. Now here is the important part: stay in the situation until your anxiety comes down to at least mild. If you flee from the situation when your panic is high, the exposure will not help you.
For example, for his first item Leonard picked, “riding the elevator.” He got into an elevator, and his anxiety rose to a mild level. He began practicing his breathing exercise and correcting his thinking. Leonard rode the elevator up and down until his anxiety went away. Leonard practiced riding elevators until the situation did not produce any anxiety anymore. He thus mastered the situation, and did not fear it any more. He then moved up to a more difficult item.
Make sure you choose items that are easy enough. Ideally, by the time you get to an item, the anxiety it produces should be no more than mild. Work your way up the list slowly. You should be totally confident that you can succeed in staying until your anxiety comes down. It is better to choose an item that is too easy than an item that is too hard.
Each time you complete an exposure, take a moment to acknowledge yourself. Do not devalue what you have just done. Each completed exposure is a step towards mastering your panic disorder.
5. Consideration of the stressors in your life.
Panic disorder is a stress disorder. The symptoms flare up in times of stress, and abate in times of calm. Like other stress disorders -- migraine headaches, insomnia, irritable bowel, skin rashes, etc. -- your panic attacks are telling you something about your life. Listen to what they are saying. What are the stressors in your life, and how can you manage them better? How can you add activities that are more deeply fulfilling?
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