Panic Attacks

In many ways panic attacks have a lot in common with a post traumatic stress reaction. A full blown panic attack can be totally terrifying and people report that they were convinced they were going to die. Because the experience is so catastrophic it can stay vividly in your mind.

SYMPTOMS OF PANIC EXPLAINED You may be surprised to learn that panic is an entirely natural bodily reaction that simply occurs out of context. All symptoms are perfectly ‘normal’ aspects of the fight or flight response that are unconsciously set in motion whenever we feel that we are under threat: - Palpitations – our hearts pump faster to cope with the increased demand made on it when we start to run or fight. - Shallow, quick breathing – we need to take in more oxygen quickly to increase our energy. - feelings of nausea and dry mouth – this is because digestion stops when we are in an emergency situation so that more blood can be diverted to the muscles in our arms and legs to enable us to run faster. - A sense of desperately needing to urinate or defecate – again to enable all available blood to go to the muscles in our legs and arms the kidneys, intestines and bladder stop working, causing the muscles at the bladder and opening of the anus to relax. - Most people experience panic attacks in ‘safe’ situations e.g. in a supermarket or on a bus or in places where there is no evident threat and we aren’t actually getting ready to run anywhere or fight anyone – that is what leads to the rest of the frightening symptoms of a panic attack – shortness of breath, choking – these frightening sensations are not imaginary. Because we aren’t usually running anywhere or fighting we can’t use the extra oxygen we have just breathed in in our short, shallow breaths, so we immediately breathe it out and this has a significant effect. Normally we breathe in the right amount of oxygen and with the aid of carbon dioxide this gets transported to our body tissues and then the carbon dioxide is breathed out. But when the oxygen is breathed out immediately because of sustained shallow breathing it takes with it our much needed carbon dioxide that hasn’t yet done its job, causing our levels of carbon dioxide in our blood to fall. Without the carbon dioxide to help, the remaining oxygen sticks to our red blood cells causing us to feel oxygen starved (even though we are actually taking plenty in). This leads to gasping or panting to try and take in more air to breathe, but unfortunately this has the opposite effect because then even more carbon dioxide gets breathed out and even less oxygen is available for the body cells. It is the panic and fear of dying that triggers and exacerbates the process that causes the gasping and struggling to breathe. However this is not dangerous: - A panic attack cannot cause heart failure or Cardiac arrest. - A panic attack will not cause you to stop breathing or to suffocate. - You won’t fall over or cease to walk when you feel ‘weak in the knees’ - You can’t ‘go crazy’ during a panic attack. In therapy, breaking the connection between bodily symptoms and catastrophic thoughts can greatly help the process of no longer experiencing panic attacks.

APPLYING A LITTLE THEORY It is typical during panic for the hippocampus in the brain to become overwhelmed by stress hormones. It is then unable to give the memory related to the panic the accurate time context that helps it to get properly logged into our past. Without this function of the hippocampus, the mind and body continue to respond to an event has caused panic as though it persists or recurs on a regular basis. So without the hippocampus doing its job properly in remembering facts, the amygdala (the brains emotional response system) takes over in activating emotional responses and activates the fight/flight response and all the bodily reactions associated with it.

INTERNAL AND EXTERNAL REALITY Another tool for handling panic is based in gaining an understanding of the body’s sensory system. Panic can disrupt the natural regulation of our sensory perception, fooling us that there is danger when there is not and vice versa. We have two sensory systems – one of them connects us to internal reality (the inside of our bodies) and gives us the ability to feel what is happening e.g. butterflies in the stomach, heart racing, breathing, tremors, muscle aches. The other sensory system connects us to our external reality – the world around us – our five senses: hearing, sight, taste, touch and smell. These senses gather information from the environment that is external to our bodies (e.g. what you see and hear) and evaluates whether a place/situation is safe. Our internal senses evaluate what is happening inside ( Am I hungry, thirsty, sad/happy etc). Unfortunately during a panic attack something very different can happen. People evaluate their external reality based on what they feel inside, which is backward and hazardous. When someone is overwhelmed by panic they are consciously or unconsciously ignoring their actual environment. Evaluating external reality by inner sensations is how a panic attack can take hold. All of the frightening sensory stimuli are generated on the inside of the body from the memory of past trauma and panic. Something in the environment can trigger the panic but triggers are often benign, such as a colour or sound. We may be in the safest place eve r but unable to recognise it because of paying more attention to what is going on inside that outside. Equally, an actual danger may not be noticed because the focus in inward rather than outward. DON’T FIGHT PANIC - face the symptoms – don’t run from them. Attempting to suppress or run away from the early symptoms of panic is a way of telling yourself that you can’t handle a particular situation. This will often create more panic. A more constructive attitude to cultivate is one that says ‘ O.k, here it is again, I can allow my body to go through it’s reactions and handle this. I’ve done it before’. - Accept what your body is doing – don’t fight against it. Observe what your body is doing ( however unusual or uncomfortable without reacting to it with further fear or anxiety). - The human brain is a pattern matching organism. It is matching patterns millions of times per day. Problems can arise when something in the here and now is pattern matched to something which has caused us problems from the past. This is often the root of panic attacks - a first attack may have occurred somewhere where there were rows of seats for example and then later, rows of seats in for example, a theatre, cinema or on a bus may produce anxiety symptoms. If you find yourself overreacting in the here and now to an incident of person, think what the current situation reminds you of from the past then try and consciously separate the two events and breathe away any anxiety using the parasympathetic breathing technique ( See Abdominal breathing). Stay in the situation until the anxiety settles. You are now establishing a new response and interrupting the previous pattern match.

USE COPING POSITIVE STATEMENTS ( Repeat however many you like, or choose just one as a mantra. You may also want to do abdominal breathing). - This feeling isn’t comfortable or pleasant but I can accept it. - I can be anxious and still deal with this situation - I can handle these symptoms or sensations - This isn’t an emergency – it’s o.k. to think slowly about what I need to do. - I’m going to go with this and wait for my anxiety to decrease - This will pass – I’ll just let my body do it’s thing - I can take all the time I need in order to let go and relax - I’ve survived this before and I’ll survive this time too - I can do my coping strategies ( next page) and allow this to pass - The anxiety won’t hurt me, even if it doesn’t feel good. - Nothing serious is going to happen to me - Fighting and resisting this isn’t going to help so I’ll just let it pass - These are just thoughts, not truths, facts or reality - I don’t need those thoughts – I can choose to think differently - This isn’t dangerous If you have frequent panic attacks you may wish to write your own favourite coping statements on a card of your phone and read it when you feel panic symptoms coming on.

COPING STRATEGIES TO COUNTERACT PANIC AT AN EARLY STAGE Once you have identified your preliminary warning signs of a potential panic attack there are some helpful tools you can engage to cope and to stop the panic attack becoming full blown and getting out of control.

Here are a few effective methods to induce calm and relaxation:

PRACTICE ABDOMINAL BREATHING - breathing slowly from the abdomen ( as opposed to shallow, quick breaths from the chest) can reverse two of the reactions associated with the fight or flight response – increased respiratory rate and increased constriction of your chest wall muscles. After 3 or 4 minutes of slow, regular, abdominal breathing you are likely to feel that you have slowed down a ‘runaway reaction’ that was threatening to get out of control. - can reduce symptoms of hyperventilation that may cause or aggravate a panic attack. The dizziness, disorientation and tingly sensations associated with hyperventilation are produced by rapid, shallow, chest – level breathing. - When you breathe focus on the palms of your hands to avoid getting distracted. Focus on your breath and begin to notice what count is right for you – whether breathing in slowly to a count of 7 and out for 11 or 3/6 or 5/9. The important factor is that the outbreath is longer – this stimulates the parasympathetic nervous system and engages the body’s natural relaxation response. Concentrate mindfully on the counting to help your mind to stay focused. - You can choose one or more of your ‘positive coping statements’ whilst breathing or you can breathe in positive feelings e.g. calm, love, hope, balance, gratitude, acceptance and breathe out your fear, anxiety, panic, worry etc.,

STAY IN THE PRESENT - focus on concrete objects around you in your immediate environment - staying in the present and focusing on external objects will help minimize the attention you give to trouble some physical symptoms or catastrophic what if’ thoughts. - Try finding and focusing on 5 things you can see (if you can’t find 5, imagine them), 4 things you can hear (or imagine them), 3 things you can touch, 2 things you can smell and 1 thing you can taste. Mindfully focusing on these distraction techniques can greatly help with coping with anxiety and panic by interrupting the chain of events that takes place. - Other techniques include: counting backwards slowly in three’s – 100, 97, 94 and so on. - Counting the number of people in front of you in a queue. - snap a rubber band on your wrist to snap your mind away from anxious thoughts.

RELAX THE WHOLE BODY - work gradually through the main muscles of your body tensing each for a count of 10 and then relaxing them. - try starting with your feet, move up to your calf muscles, then knees, thighs, tummy muscles and so on. Remember to let the relaxing sensation spread all through your body – relax your shoulders, throat, jaw, teeth not clenched), cheek muscles, brow and so on.

OTHER STRATEGIES - talk to a supportive person nearby or on the phone. Talking to someone can help get your mind away from your anxious bodily symptoms and thoughts. In a public speaking situation, confiding in your audience and owning your feelings can often help to dispel initial anxiety. - Move around or engage in some physical activity – moving and doing something physical lets you dissipate the extra energy or adrenaline created by the fight or flight reaction – you move with the physiological arousal e.g. even if at work, get up and walk to the toilet and do some slow, mindful, abdominal breathing, say positive statements, do a quick relaxing body scan and stay in the present...