Panic Disorder

The goal in therapy is to help you find a way to work with panic attacks so that eventually they: 

1. don't happen as often (frequency)
2. aren't as intense (intensity)
3. don't last as long (duration) 
4. don't significantly interfere with your life goals, life function, life happiness

THE FIRST PANIC ATTACK:

Think back to your first severe panic attack so that you can understand how your thoughts, physical feelings, and need to escape contributed to the spiral that led to a panic attack. Understanding how it may have spiraled the first, scary time, can decrease some of the fear associated with that first panic attack.

The first panic attack is usually an intense, unexpected panic attack accompanied by a catastrophic interpretation (e.g., I’m going to die, I’m going to go crazy, I’m going to lose control, I have a severe illness) that leads to an attempt to escape the situation.

Often the first panic attack seems to happen "out of the blue," but when you step back and look at your life at that time, you may find that you were under a significant amount of stress or change in your life. You may also find that you have a genetic predisposition to anxiety by looking at your sensitivity to anxiety as a child or at your family history of anxiety. You may also find that there were childhood experiences that contributed to your struggle with anxiety or with emotions in general.

During your first panic attack, there may have been many thoughts driving the anxiety spiral. Try to understand the thoughts that may have come up at that time, before you knew anything about panic attacks.

• What were you afraid was going to happen? Then what? Then what?
• What do you think bothered you most?
• What were you afraid this anxiety meant about you or your future?
• What was the worst-case scenario?

Often the first panic attacks are followed by a period of demoralization, depression, or frustration especially when the panic attacks continue despite all your efforts.

You may have also developed a sensitivity to any physical sensation associated with panic attacks and a pattern of avoidance or anxious anticipation of situations that you are afraid will trigger anxiety.

You may have found out later that there’s “nothing wrong,” but there IS something wrong, just not what you think. If you have been medically cleared, then it’s likely that something dangerous is not what is wrong but rather how you have been coping with a sensitive anxiety system is what is contributing to your struggles with anxiety.

FEAR WITH DANGER VS FEAR WITHOUT DANGER (or DISCOMFORT):

Our minds and bodies are meant to experience fear when there is immediate, life-threatening danger. Fear and danger are meant to be intertwined, because it is this experience that propels us to automatically engage in fight or flight, which is then supposed to protect us from danger.

This is Fear with Danger and represents how fear was meant to work as an adaptive, protective mechanism.

When you had your first panic attack and didn’t know what was happening to you, your mind interpreted these symptoms as meaning that that you were in immediate, life-threatening danger, which caused intense fear. Then your body did what it was supposed to do in the face of fear and danger - it set off a fight or flight response that caused even more intense physical symptoms.

With no visible external danger, your mind turned inwards and made an automatic connection between these uncomfortable physical symptoms of anxiety and danger so that afterwards any physical symptoms associated with panic attacks were automatically interpreted as danger leading to more anxiety and to an increase in physical fight or flight symptoms.  

Over time, anxiety becomes a problem when your mind and body experience real fear even though there may not be immediate, life- threatening danger. Essentially, your protective fear system is being triggered in the absence of immediate, life-threatening danger. The discomfort associated with anxiety is being misinterpreted by your mind and body as danger, which then sets off the fight or fight alarm system. It is essentially a false alarm.

Try to think back to your panic attacks. What is the worst thing that has actually happened as a result of a panic attack? You may find that your fears of what might happen are much greater than what has actually happened in the past.

Part of therapy is retraining your mind and body to differentiate between discomfort and danger. Anxiety is discomfort, not danger. Panic attacks are discomfort, not danger. This is not to say that panic attacks are no big deal. They are extremely uncomfortable, they are scary, they are unwanted, and they are frustrating, but they are not necessarily dangerous.

Fear without Danger = Discomfort.

To help your mind and body relearn how to respond to anxiety as discomfort, not danger, you can:

1. Learn about anxiety and panic, in general and regarding your specific situation, to reduce the fear that comes along with the unknown or misunderstood. See Understanding Anxiety for a thorough explanation of the symptoms of anxiety.
2. Use self-monitoring to break anxiety down into thoughts, physical feelings, intensity, and behavioral responses which can help take the fear and mystery out of anxiety. You will feel less confused and overwhelmed and you will be better prepared to respond to the different parts of anxiety in a way that doesn’t make them worse.
3. Learn how to recognize the thoughts that increase fear and then learn to defuse them or talk through them. Being aware of your anxious thoughts can help you step outside your anxiety and become an observer (rather than a victim) so that you are less likely to be swept away by thoughts that fuel anxiety. Ultimately, you are trying to shift your perspective or your attitude about anxiety. That is the key to change.
4. Gradually reenter situations that trigger anxiety so that your mind and body can recalibrate and relearn the difference between discomfort and danger. There is only so much reading, talking, and thinking you can do to change the automatic anxiety response. Actual experience is necessary for your brain and body to learn a new response.

It is essential that you experience some discomfort, some arousal, some anxiety, as you need to “fire to rewire,” meaning that the amygdala (the mind) and your nervous system (the body) need to be activated for learning to occur.

It is through experience that you develop the skills necessary to cope with future anxiety. It is through experience that you gain the confidence in your ability to be safe and cope with anxiety in the future.

All of these things take practice, practice, practice and repetition, repetition, repetition for your mind and body to learn a new way of responding.

FEAR W/ DANGER = FIGHT, FLIGHT, OR FREEZE vs FEAR W/O DANGER = FLOAT:

When we are faced with fear w/ danger we need to fight, flight, or freeze to stay alive. Fight, flight, and freeze are adaptive responses to immediate, life-threatening dangers, but when there is no external danger, we end up just standing or sitting there leading to a build up of this intense energy meant to protect our lives.

On the other hand, when we are faced with fear w/o danger (or discomfort), we need to float because when we try to resist the surge of energy, the anxiety gets worse. It is important to recognize anxiety as thoughts, physical feelings, and behaviors that are signs that you are nervous, scared, anxious. Take them as signs of nervousness rather than warnings of danger.

The rule in the real world is, “The harder I try and the more I struggle against something, the more likely I am to get what I want. If I set my sight on a goal and persevere, I will probably get it, so long as I keep working on it.” This is why so many people try to resist against the fight or flight response, or they might try to make it go away by ignoring it.

The problem is that the rule for anxiety is, “The harder I try and the more I struggle against something and the more I ignore it, the more likely I am to get what I DON’T want. The more I struggle against my fear, the more afraid I become.”

What you resist, persists.

ESCAPE AND AVOIDANCE

Escape and avoidance are understandable reactions to anxiety…if you are in immediate, life-threatening danger. The problem is that in your current situation, these reactions that are meant to keep you safe are actually maintaining and strengthening the anxiety and interfering with your ability to live a full and meaningful life.

Types of escape and avoidance can also include rules/rituals, superstitions, support people/objects, distractions, fighting the fear. It might also include things that seem helpful at first like telling yourself, “Don’t think about it. Focus on your breathing, not your anxiety. Just get through this.”

Safety behaviors can be used temporarily to help you get started (like crutches), then discarded. Try not to rely on them for too long.

Escape and avoidance behaviors may have been effective in the beginning in relieving you of anxiety or discomfort, but in the long run, they end up becoming causing more problems because they:

1. Do not directly address the source of the problem
2. Cause MORE anxiety and other problems in the long-run
3. No longer work as well in relieving distress for any significant amount of time
4. Do not allow baseline levels of anxiety to return to original levels 
5. Do not allow you to learn that you are able to handle a situation, that you can be okay

The goal is to ultimately choose long-term freedom over immediate comfort. Choosing immediate comfort often leads to becoming more sensitive to the fear and creating greater problem in the long run whereas choosing long-term freedom often means advancing your recovery and taking a step in the right direction (but temporarily feeling worse).

DISTRACTION:

Distraction is a form of escape/avoidance. It is a way to try to mentally escape the anxiety. The problem with distraction is similar to the problems listed above with other types of escape/avoidance. Distraction is also ineffective because the more you try to NOT think of something, the more you will think of it.

The other problem with distraction is that you are basically telling yourself, “I can’t think about panic because if I do, I’m going to panic and that’s bad because I can’t cope,” which is increasing your anxiety about anxiety. It is making anxiety and panic into a big, horrible monster in your mind that needs to be avoided at all costs. This perspective contributes to the maintenance of anxiety.

PANIC CYCLE

Part of managing anxiety is understanding your panic cycle - how it is triggered, how it builds, and which parts are out of your conscious control versus those you may be able to have some effect on.

Situations: In what situations are panic attacks more likely to occur?

1. Situations that remind you of your first panic attack
2. Situations that make you feel “trapped”
3. During leisure time activities and situations
4. When there is no emergency (of after an emergency ends)

Initial Event: In a panic cycle (or spiral) there is usually a cue that triggers an initial event. The initial reaction is automatic and is usually the first panic symptom that you notice. It can be a physical symptom, scary thought, emotion, or behavior. Usually your first panic symptoms. 

Reflex Fear: Initial panic symptoms leads to an automatic, conditioned reflex reaction (anxiety reflex) that you have little conscious control over. This is the initial whoosh of anxiety, the initial adrenaline rush. This reflex reaction includes additional symptoms of anxiety that may be caused when the fight/flight response is triggered or when you react by doing things like holding your breath or tightening your muscles. You have limited control over this initial reflex fear.

You may have an intense reflex fear reaction for several reasons: After several rounds through the panic cycle, your sensitivity to any physical symptoms associated with anxiety likely has increased. You may have been born with a sensitive anxiety system that responds strongly to any hint of danger. You may be under a lot of stress, even the stress associated with panic attacks, which has left you with a sensitized anxiety response system. Your breathing may have shifted to anxious breathing, which leaves you vulnerable to symptoms associated with anxiety. See Anxiety and the Breath.

Interpretation: The way in which you interpret the initial whoosh of anxiety, the initial reflex fear, can have a significant impact on whether you continue to feel anxiety symptoms, worsening the panic cycle. If you interpret the initial reflex fear with thoughts such as “This is dangerous. This is bad. This is urgent. I can’t cope,” then a second wave of more intense anxiety can be triggered.

Response Fear: The second wave of more intense anxiety is the interpretive fear, or the response fear, and usually feels much worse than the initial reflex fear. This is what people call, “the fear of fear.”

This second wave of fear can lead to even more catastrophic interpretations (“Oh no it’s happening. It’s going to be bad. I feel more symptoms. I have to make this stop. What if this never ends?”) which further escalate the symptoms of anxiety, creating more fear, and more catastrophic interpretations, thoughts and symptoms escalating until eventually a panic attack occurs.

ESCAPE/RELIEF:

A normal, adaptive, understandable response to scary thoughts and scary sensations is escape (or avoidance, distraction, etc.) By leaving the situation, the anxiety is avoided, the cycle is stopped. There is relief. Because it works (initially) It becomes a go-to response for future anxiety episodes. The problem is:

1. You do not directly address the source of the problem
2. Escape causes MORE anxiety and other problems in the long-run
3. Escape stops working in relieving distress for any significant amount of time
4. Escape does not allow baseline levels of anxiety to return to original levels 
5. Escape does not allow you to learn that you are able to handle a situation or that you can be okay

Every time you avoid a situation where the amygdala could be activated (anxiety response), you may be missing a chance to teach the amygdala, to change its connections, to create a learning experience, to have a new experience. Remember, you need to “fire to rewire.”

ANXIOUS ANTICIPATION:

After a couple of rounds through the panic cycle, it is normal for you to develop anxious anticipation of future anxiety attacks. These are easy to identify because they start with, “What if…..” What if I have a panic attack? What if I pass out? What if I lose control? What if others see me? What if there is something seriously wrong with me? What if this never goes away?

BREAKING THE PANIC CYCLE

LEARNING TO FLOAT WITH THE INITIAL REFLEX FEAR:

There is little you can do to make the initial reflex fear go away. Over time, the initial reflex fear will decrease in intensity, frequency, and duration (how intense it is, how often it happens, how long it lasts), but initially, the strategy is accepting the anxiety as it is in the meantime and learning to float with the initial surge of anxiety.

Adrenaline has already been released into your system, so it is about allowing it to dissipate without dumping more adrenaline into the system. Know that it will come to an end, regardless of what you do. Your job is to make yourself as comfortable as possible while waiting for the anxiety symptoms to run their course.

Imagine it as a wave of anxiety that you learn to ride over, and the more you fight it, the more you will be get tossed around. Float. Breathe. Let it pass without adding fuel to the fire.

CHANGING THE INTERPRETATION:

How you respond to the reflex fear can alter the course of the panic cycle. Instead of seeing the initial reflex fear as a danger that needs to be avoided, you may be able to learn how to interpret it as discomfort, not danger.

You could practice responding to the initial reflex fear with thoughts such as, “This is anxiety…it feels like danger but this is discomfort, not danger. My brain is used to interpreting this as danger but I am learning to see it from a different perspective. It feels urgent but this is not urgent. I am learning to sit with this discomfort because I need to fire to rewire. This is a learning opportunity. I can cope. I am learning to cope. Each anxiety episode is an opportunity for me to grow, to become more flexible, to learn a wider range of coping skills. If I panic, I’ll just have to deal with it.”

To help take some of the fear out of the physical symptoms, it is important to understand the explanations for those symptoms. They are described in much detail in Understanding Anxiety.

CHANGING YOUR PERSPECTIVE:

Your perspective of anxiety needs to shift for there to be a significant shift in the anxiety experience (See Attitudes of Anxiety). It is not about being calm in the face of danger, it is about being able to tolerate the discomfort of anxiety, sitting with anxiety without making it worse, and using it as an opportunity.

Using breathing to calm down or acceptance to make anxiety go away will not be as helpful as using breathing to help you through the anxiety or using acceptance to help the anxiety flow through you.

ELIMINATE ESCAPE/AVOIDANCE:

Another important way to break the cycle of panic is by eliminating escape and avoidance behaviors. By sitting with the anxiety:

• You’ll learn that the anxiety will go away eventually on its own
• You’ll develop resilience to the anxiety
• You’ll feel more confident in your ability to cope
• You’ll be able to practice new coping skills
• You’ll be able to engage in activities that provide you with meaning and happiness
• You’re working towards long term freedom

ADDRESSING ANXIOUS ANTICIPATION:

When your mind is full of “what if” scenarios, it can be hard to let go of control and float with anxiety. It can help to sit down with each of your “what if” fears and see them through. “What if it did happen? What would that look like? How likely is it? If it did happen, how would I cope?” Instead of focusing on future unknown possibilities, perhaps you can learn to shift your focus on the present moment – “how am I feeling now, and how shall I respond?”

MINDFULNESS:

Mindfulness is the practice of observing your wandering mind and bringing it back to a place of focus. By practicing brief mindfulness meditations when you’re not anxious, you’re strengthening your ability to catch your thoughts and shift your focus. When you feel your anxious mind starting to go off the rails, you’ll notice it quicker each time and will be able to refocus your attention on your breath, on your thoughts, on your activity. See section on Mindfulness.

BELLY BREATHING:

Some people use breathing exercises to try to make their anxiety go away but find that it is not very effective. Breathing exercises can be used to calm your overall day-to-day physiological arousal or to train your brain for mindfulness meditation but once your initial reflex fear is triggered no amount of breathing will make it disappear completely. Breathing can be used more to help you sit with the anxiety as you wait for it to go away on its own and can be a way from preventing yourself from adding fuel to the fire with more anxious thoughts and behaviors. See explanation on Breathing.

References: 

• Panic Attacks Workbook: A Guided Program for Beating the Panic Trick by David Carbonell.

• The Anxiety and Phobia Workbook (6th Edition) by Edmund Bourne

• Dare: The New Way to End Anxiety and Stop Panic Attacks by Barry McDonaghMastery of Your Anxiety and Panic by David

• Barlow and Michelle Craske

• Face Your Fears: A Proven Plan to Beat Anxiety, Panic, Phobias, & Obsessions by David Tolin

• The Relaxation and Stress Reduction Workbook (7th Edition) by Martha Davis, Elizabeth Eshelman, and Matthew McKay

• Anxiety and Avoidance by Michael Tompkins

• The Anxiety and Worry Workbook by David Clark and Aaron Beck