CHAPTER
14

Self-Help for Panic Disorder

In This Chapter

• Learning about emotional hijacking
• Discovering the difference between a panic attack and panic disorder
• Finding out why panic attacks aren’t the real problem
• Developing panic attack coping skills

Drs. Jack Loehr and Jack Groppel, founders of LGE Performance Systems, use this story as part of their corporate training: a group of NFL superstars is given a mission. They must follow a wilderness trail for one mile, touch a white fence, and return to the training center in less than 18 minutes. For such elite runners, this should be easy. However, before the run begins, the runners are warned to look out for water moccasins, alligators, and wild boars in the area. “If you see a wild boar,” says the instructor, “take appropriate action, but complete the mission!”

The run begins. A staff member is planted in the bushes at the half-mile mark; when a runner reaches this point, the hidden instructor makes the sound of a wild boar. Inevitably, in spite of their instructions and with no visible evidence of a wild animal bearing down on them, the runners panic and sprint back to the starting point. The only explanation offered for the failed mission? “I heard something.”

This same “wild boar” exercise, when given to elite law-enforcement or military units, yields dramatically different results. Trained to respond to threats, these individuals stop, turn in the direction of the threat, and assume a crouched position. As a result, they quickly determine that there is no wild boar and are able to complete the mission.

For panic sufferers, this story makes some powerful points. First, fear can overpower anyone’s rational thought. Second, there’s a difference between being “tough” and being prepared; law-enforcement personnel felt the same rush of adrenaline and fear that the other trainees did. Their training didn’t prevent them from feeling fear; it just prevented them from giving in to it.

For the three million Americans who have panic attacks, “wild boars” can show up anywhere at any time—at the grocery store, in the pediatrician’s office, or at work. Suddenly, we experience the terror people feel when faced with life-threatening danger—and the same urge to escape. This chapter is all about training yourself to respond like Green Berets when you face your own “wild boars.”

Emotional Hijacking

Panic disorder sufferers have overwhelming anxiety symptoms spontaneously. The amygdala, the danger-response center in your brain’s limbic system, seems to become activated for no reason. Although the amygdala is a fairly primitive brain structure, it has a very important job: to ensure your survival.

In fact, the amygdala is extremely important. It has the ability to respond directly to input from your senses before your brain’s more rational portion—the neocortex—even begins to register this input. For example, your amygdala can spur you to turn the wheel in response to an oncoming car before you have time to think. The limbic system is one of the oldest parts of your brain evolutionarily; what it lacks in rational thinking it makes up for in speed and action.

MYTH BUSTER

“I’m having a heart attack!” A rapid heartbeat might make you think so, but a healthy heart can beat rapidly for a long time without causing any damage.

Dan Goleman, the author of Emotional Intelligence, used the term emotional hijacking to refer to situations in which your rational mind is taken over by your emotional response. The problem with emotional hijacking is that it doesn’t always result in heroics; emotional hijacking can lead to road rage, domestic violence, and countless other harmful or counterproductive acts. And with panic attacks, the alarm signals go off needlessly; there is no real danger you need to protect yourself from.

Panic Attacks and Panic Disorder

Panic attacks have their origins in your brain, but this doesn’t mean the symptoms aren’t “real.” In fact, many panic symptoms are experienced in your body. Common symptoms include the following:

• Racing or pounding heart
• Dizziness or lightheadedness
• Nausea
• Terror or a sense of impending doom
• A sense of unreality
• Fear of dying, losing control, or doing something embarrassing
• Flushes or chills
• Chest pains
• Tingling or numbness in the hands
• Difficulty breathing

Not everyone experiences all of these symptoms, but all panic attack sufferers experience some of them. Not only are the symptoms themselves terrifying, they’re unpredictable. At first panic attacks often occur “out of the blue,” when you’re doing something ordinary like driving to work, having dinner with friends, sitting on the sofa watching TV, or even sleeping. Because they are so terrifying and mimic primary physical problems, many people drive themselves (or get a ride) to an emergency room after having their first attack.

Not everyone who has a panic attack develops a panic disorder. A fortunate few experience one panic attack and never have another. Others—up to 10 percent of otherwise healthy Americans—have them occasionally but continue to lead unrestricted lives. In fact, it’s not the number of panic attacks that determines whether a person develops panic disorder; it’s the response you have to them.

For 1 in 75 U.S. citizens, though, the first panic attack sets in motion a vicious cycle. The fear of another panic attack—of having to go through those distressing symptoms again—causes the panic attack sufferer to worry about having another one. You may avoid situations in which you have experienced panic attacks in the past. As a result, even when you are not in the grip of an attack, you’re consumed with the desire to avoid one.

MYTH BUSTER

“I’m going to lose my mind!” It is extremely uncomfortable to have a spontaneous panic attack, and panic sufferers rightly note that their emotions are out of control during attacks. But panic sufferers are aware of how irrational the symptoms are; they haven’t lost touch with reality.

Others May Not “Get It”

Unfortunately, the people you rely on to help or support you can unintentionally make things worse. Physicians, for example, sometimes do not recognize panic disorder. Many panic attack sufferers see as many as 10 doctors before meeting one who makes the right diagnosis. In the meantime, they’ve undergone all sorts of unnecessary, expensive, and anxiety-provoking tests!

Then when they finally meet a medical professional who identifies panic disorder, the explanation often sounds as if there is nothing really wrong. “There’s nothing to worry about; you’re just having a panic attack” or “It’s just nerves.” Although meant to be reassuring, such words can be dispiriting to the frantic person whose terrifying symptoms keep recurring.

The same can be true of well-meaning friends and family members. People who’ve never had a panic attack sometimes assume that it’s just a matter of feeling nervous or anxious—the sort of feelings that everyone is familiar with. I was so nervous about that test I almost had a panic attack! I just panicked at the thought of my boss realizing I hadn’t quite finished that project.

A friend and fellow panic attack sufferer once told Joni that, during the worst period of her life, she had disclosed her experience of panic attacks to a work colleague, who responded with something like, “You know, I get pretty uptight about things sometimes. I wonder if I have panic attacks.” Joni’s friend comically asked her co-worker if she knew of any new mothers who wondered whether or not they had experienced labor pains. If you’ve had them, you know it. If you haven’t, there’s no way anyone can adequately describe them to you.

Panic, Phobias, and Other Problems

We’ve already outlined the vicious cycle characteristic of panic disorder: panic attacks trigger intense fears of having others and a strong motivation to avoid panic-associated situations and sensations. If you have a panic attack while in a crowded store, you may avoid the store when it’s crowded. If you have two or three panic attacks in stores, you may avoid stores altogether. If your panic attacks begin with palpitations and shortness of breath, you may avoid exercise. Even if you know logically that the situation or sensation did not cause the panic attack, the fact that the two are associated can make you fearful that revisiting the same situation or sensation will bring on another attack. If your fear leads to avoidance of a situation or sensation, you could have a panic-induced phobia.

Of course, people who suffer from phobias can have intense anxiety or even panic attacks in the presence of the feared object or situation. Social anxiety sufferers, for example, might have panic attacks only in distressing social situations. A person who has a spider phobia may be so afraid of them that just seeing a tarantula on TV triggers a panic attack. In these cases, the panic attack did not “cause” the phobia; rather, the irrational fear of the object or situation caused the panic attack. We discuss self-help strategies for phobias in Chapters 15 and 16.

ANXIETY ATTACK

Like many other anxiety disorders, panic disorder seems to be due to a combination of biological vulnerability and life experiences. Panic attacks often start during a stressful period in a person’s life.

When panic attacks occur randomly and frequently, you can come to fear any situation in which you can’t easily escape. This is called agoraphobia, and it affects about one third of people with panic disorder. Other mental and physical conditions that can coexist with panic disorder include the following:

• Depression. Affects about half of all panic disorder sufferers.
• Alcohol and drug abuse. About 30 percent of patients with panic disorder misuse alcohol; 17 percent misuse other substances.
• Irritable bowel syndrome. When someone has IBS, panic disorder may be overlooked as a contributing cause of the symptoms.
• Mitral valve prolapse. This is a generally benign heart condition that can lead to chest pain, rapid heartbeat, breathing difficulties, and headache. Some experts think that people with this defect are more likely to develop panic disorder.

Because spontaneous panic attacks are so disturbing, they can quickly take over your life. Not only can they impact day-to-day activities, your attempts to avoid them can create additional problems. The good news is that you can learn to cope with panic attacks. They don’t have to lead to panic disorder, depression, or social isolation.

Preparing for a Panic Attack

Whether or not you get professional help, you can do a lot to overcome your panic attacks. It might be hard to imagine right now, but you can prepare for panic ahead of time, building up your coping skills so that you are able to cope with your symptoms and, over time, reduce the number or severity of attacks you have. Think of it as panic attack training camp, equivalent to the elite military training that enabled the soldiers and law-enforcement professionals to succeed in the story at the beginning of this chapter.

You will also be in charge of how hard you work and how quickly you progress. Before we get to specifics, though, make sure you have the right attitude.

ANXIETY ATTACK

To jump-start your self-help program, visit panic-attacks.co.uk for a free online course.

Evaluate your progress in terms of what you do, not how you feel. The more you are able to remain in an uncomfortable situation despite anxiety or panic, the more progress you will make in taking away the grip your distress currently holds on you.

Expect the beginning to be the hardest. Why is it that the first 10 minutes of an exercise routine are the hardest? It’s true for new exercisers as well as seasoned athletes. The difference between those who stick with it and those who don’t is commitment coupled with frequent self-reminders that the initial discomfort will pass, and the end result will be worth it.

Make deals with yourself. It takes a leap of faith to stop running from panic attacks and turn around to face them. You may find a part of yourself “shouting” to get out of there, while another part is struggling to stay put; when this happens, strike a bargain. If your anxiety is a “9/10,” try to stay in the situation until it subsides to a “5/10.” If you have to leave, go back in when the panic subsides. Feel good about each step forward, no matter how small.

In addition to these empowering attitudes, examine your beliefs about asking for help. You may hide your panic symptoms from friends and family or feel tremendous guilt because your panic attacks are disrupting your home life. As a result, many of us don’t get social support that can help us get through the stress and help us stretch ourselves. While you’re helping yourself, why not let your family help? They can be valuable cheerleaders, especially when they see you trying hard to overcome obstacles.

Therapists, support group members, and online communities can also be resources, including in the middle of a panic attack. Some panic sufferers carry a list of phone numbers they can call day or night—though they might never have used it. Having outside resources can help you feel stronger; in fact, just knowing you have the option of calling someone at the peak of your anxiety can give you the courage to stay in a frightening situation until the symptoms resolve.

ANXIETY ATTACK

An additional resource for panic attack sufferers is the National Institute of Mental Health’s Hotline: 888-826-9438.

Relaxation

Since panic attacks make you feel so mentally and physically out of control, skills that help you relax are useful. For instance, the hyperventilation that often accompanies a panic attack can be countered—or prevented—by diaphragmatic breathing.

The middle of a panic attack is no time to learn new breathing techniques; but if you practice breathing techniques for five minutes twice a day for a few weeks, you can perform them more easily when you feel the onset of panic symptoms. The kind of steady, consistent breathing practice outlined here will get your body in the habit of always breathing deeply and slowly. This will decrease and may eliminate panic attacks while at the same time reducing your anxiety.

1. Begin by lying flat on your back or standing up straight. You may also sit up straight in a chair, if that is more comfortable.
2. Place your hand on your stomach area.
3. Breathe as you normally would and notice whether your hand rises or your chest rises. To breathe properly, your stomach area must rise as your diaphragm expands.
4. Begin by slowly breathing in through your nose to the count of five while gently pushing your hand up with your stomach.
5. Hold the breath for a count of five.
6. Slowly exhale through your mouth for a count of five while gently pushing down on your stomach.
7. Repeat this process for five minutes.

Any activity (biofeedback, progressive muscle relaxation, meditation) that helps you become familiar with how your body feels when you are under stress can help you consciously relax. Numerous meditation and relaxation exercises are available on CD or video.

Don’t get frustrated or impatient with yourself and give up if you cannot do these exercises correctly right away—or if you feel yourself panicking when you try them. They take practice. In the beginning, do them only as long as you are able. Remember that you can stop at any time. Take it slowly if necessary.

If you continue to practice your breathing techniques or other relaxation exercises, you will soon be more naturally relaxed throughout the day. As you gain more awareness and control over your body, you will be able to tolerate daily hassles and minor stressors with a greater sense of calm and peace.

ANXIETY ATTACK

Because the physical sensations (rapid heartbeat and breathing) during aerobic exercise can closely match those of panic attacks, some panic suffers have trouble with aerobic exercise. Even if intense aerobic exercise seems overwhelming, you can engage in other health-boosting activities, such as leisurely walking or swimming.

Distraction

In addition to bodily discomfort, panic attacks can set off a spiral of fear. Your thoughts begin to race, filling you with dire predictions that you are going to pass out, die, make a fool of yourself, or lose control. The sooner you can interrupt this spiral, the more you can allow your uncomfortable anxiety symptoms to pass through you without overwhelming you.

The best way to control catastrophic thoughts is to focus your attention on something else, something simple enough that you can do it while you’re very anxious. This is not the time, for example, to try to rationally combat irrational thoughts. On the other hand, your mental exercise must be complex enough that it requires some effort. Turning your breathing exercise into a mental activity is one idea; you might count each inhale and each exhale. You could perform simple arithmetic (counting backward or reciting the multiplication tables), repeat the words to a favorite song or poem, focus on memorizing the details of your environment, or play simple word games. It doesn’t matter what it is as long as it keeps you from “what ifs” and grounds you in the present.

One potentially useful distraction is to repeatedly recite a list of rational reassurances that you have memorized or written down. These symptoms are unpleasant but they’re not dangerous. This is just my alarm system going off. These feelings have passed before and they’ll pass again. What doesn’t kill me makes me stronger.

You’ll probably find clues to the most effective reassurances by examining the self-talk that typically surfaces during a panic attack. Think back to the automatic thoughts you had during your last panic attack and write out a rational reassurance in response. For example, if one of your thoughts was “I can’t stand this!” consider something like “I’ve been through this before. It’s not fun, but I can stand it.”

What personal items tend to calm you? A journal? An MP3 player with a favorite playlist? A rosary? A cell phone? Anything you can carry with you that will help you feel more secure can be helpful. Some people keep an antianxiety medication with them even if they don’t really need it. Knowing they could take a pill can give extra courage and confidence to keep moving forward.

MYTH BUSTER

“I’m going to pass out!” A sudden drop in blood pressure is what causes fainting. However, heart rate and blood pressure typically rise during a panic attack, so you are probably not going to faint.

Approach Panic Differently

When Joni was at the mercy of her panic symptoms, she felt like a slave. Her panic attacks would come out of nowhere and “hijack” her feelings and thoughts. All she could do was react; all she could focus on was survival.

However, as she learned ways to prepare for panic, this began to change. Instead of feeling powerless, she began to feel an increasing sense of mastery about what she could do when panic occurred. She and many other panic sufferers have discovered a paradox: the less she feared panic attacks, the less frequent and less intense they were. When she tried to avoid them, they hung on tighter; when she quit fighting, they loosened their grip.

Just knowing this, however, doesn’t make it easy. To handle panic in this way is to go against your basic instincts. Logic tells you that, in a situation that feels threatening, you should turn on your emergency responses, tense your body, and get ready to fight or run before you get hurt. What you need to do, though, is turn on your controlled breathing, relax your muscles, not fight your physical sensations, and stay in the situation. Martial artists know these tricks well. Someone who doesn’t know how to fight will let his or her anger take over, will wildly attack someone, and will likely end up getting hurt. A trained martial arts expert will stay calm, controlled, and focused—and will be much more likely to win a fight.

Refusing to Give In

With anxiety, the very act of choosing to relax in response to panic helps the neocortex (the rational portion of your brain) to tamp down the alarm from the amygdala.

Refusing to give in to your panic symptoms allows you to think about them differently. Instead of doing all you can to avoid those feelings, you can take an interest in them, even get scientific about them. For example, you can create a worksheet like the following to track your systems. Use a simple symptom severity scale—1 signals complete relaxation, and 10 indicates outright panic. Practice doing this when you have symptoms and when you don’t. Notice which thoughts and actions raise or lower the rating. Notice that, even at their worst, panic symptoms actually have a very short life. They can’t stay at a very high intensity for more than a few seconds.

Investigating your symptoms gives your thinking a focus, making it less susceptible to emotional hijacking. If you’re busy observing your symptoms, you’re not as caught up fighting or escaping from them. In fact, when you learn to observe your panic symptoms without resisting them, you may consider purposefully increasing them.

Advanced Training

When you’re having trouble tolerating your panic symptoms, it can seem impossible to consider inviting them. Yet, when you consider how much the unpredictability of panic attacks contributes to the damage they cause, you can see how empowering it would be to consciously seek them out.

Cognitive behavioral therapists often encourage patients to invite anxiety symptoms in the controlled environment of therapy sessions, so the patients can have the experience that these harmless (but seemingly life-threatening) symptoms don’t have to be so frightening. For example, a patient who hyperventilates during a panic attack might be instructed to breathe rapidly; a patient who gets dizzy might be encouraged to spin around and around. A patient may be asked to respond to mild symptoms by consciously attempting to make them worse—letting their anxiety be present until it decreases on its own. All of these exercises allow the panic attack sufferer to start to experience symptoms as they are (harmless), not what they seem to be (dangerous).

Panic disorder develops when you repeatedly try to control or avoid your anxiety—and fail. By embracing your anxiety, you don’t set yourself up for failure. As you get better at tolerating your symptoms, you can stay put long enough to calm a bit so your mind can register that there’s no real danger in the situation.

Think about any new activity you felt nervous about. Maybe you sang in church or gave a school presentation. Maybe it was asking your girlfriend out on a date or going on your first job interview. It was nerve-wracking at first, but you became more comfortable as you got used to it; your brain recognized you weren’t in danger and called off the “red alert.” As a result, your butterflies subsided and your heart quit beating so fast.

MYTH BUSTER

“I might lose control during a panic attack.” Some people with panic disorder are afraid they’ll either become totally paralyzed or run around wildly, yelling obscenities and hurting other people. But these are cognitive distortions due to intense anxiety symptoms.

Here’s another analogy. Imagine a new security system installed in your house has a bug in it. As a result, it occasionally triggers a false alarm. Imagine the police showed up in response—and you tried to keep them out of the house, shouting, “There’s no danger!” through the door. Without question, they would insist on coming in to make sure you’re safe. The tighter you held the door shut, the more insistent they’d become. On the other hand, if you sheepishly invited them in and assured them you had no emergency, they’d look around the house and leave. If this happened often enough, they might just call to ensure it’s a false alarm.

Practice

Initially, as you learn to stay put in panic situations, the goal is to keep your discomfort zone from spreading. Make a pact with yourself that you will not leave a situation until your anxiety subsides. If the anxiety is intense, give yourself a small but manageable goal: “I will leave in 20 seconds” or “I will go down one more aisle and then leave.” The idea is to delay your exit long enough for the panic to subside—and it will subside; the most frightening part of a panic attack rarely lasts longer than 10 to 20 seconds.

When your goal is met, leave if you have to. But go back to the situation as soon as possible. The longer you delay returning, the harder it will be. Spend as much time as possible in the anxiety-producing situation; the more time you spend, the easier it will become. Be prepared to backslide occasionally; don’t beat yourself up if you give in once in a while.

But what if you’ve developed panic-induced phobias? It is very common to develop strong mental links between your panic attacks and certain situations. A couple of panic attacks on the road can trigger a driving phobia, or a panic attack at the mall can lead to a fear of crowded places in general. In Chapters 15 and 16, we examine self-help strategies for phobias—panic induced or not.

For now, focus on setting up small goals that force you to stay in situations. Every time you attempt to master your response to panic symptoms is a step in the right direction. Hold yourself accountable, but don’t judge yourself too harshly. Replace any harsh self-talk or discouragement with this truth: “I am working to rewire a complex system. I don’t have to do it perfectly. As long as I keep practicing, I’m going to get where I want to go.” And give yourself permission to bring in professional help if the going gets too hard.

In this chapter, we’ve explored panic disorder. We’ve seen how your brain’s misfiring results in a terrifying cascade of symptoms that traps you in an endless cycle of anxiety and avoidance. We’ve also seen how the best way to deal with them is exactly the opposite of what every fiber of your being tells you to do. By accepting (rather than fighting) your symptoms and staying in (rather than fleeing) the situation, you ultimately regain your sense of mastery and power.

The Least You Need to Know

• Panic disorder starts in the brain, but the symptoms are very real—caused by the misfiring of your brain’s alarm center, the amygdala.
• Left untreated, panic disorder can become complicated by phobias, depression, and other disabling conditions.
• The fears that are typical during panic attacks, such as fears of dying or losing control, are cognitive distortions in the context of intense anxiety.
• Panic disorder can be successfully treated with cognitive-behavioral therapy, medication, or an intensive self-help program. Most often, it is through a combination of some or all of these.
• Tried-and-true self-strategies center on breathing/relaxation techniques, distraction strategies to stop fearful thoughts, and practice sessions that require staying in an anxious situation until the symptoms subside.