How to cope with panic attacks

Navit Schechter - PGDip, BABCP (Accred), BSc (Hons)
Photo credit: Richard Phibbs

From Harper's BAZAAR

Anxious, dizzy, short of breath or hyperventilating? You could be having a panic attack. Panic attacks are an exaggerated response to fear, danger, stress or even excitement that, if left undiagnosed, can develop into full-blown panic disorder and start to take over your life.

Qualified CBT therapist Navit Schechter explains why some people suffer from panic disorder, characterised by reoccurring panic attacks, and offers practical tips on learning how to cope:

What is a panic attack?

A panic attack is a brief and intense rush of anxiety that can feel extremely frightening. They usually last between five to 20 minutes and are accompanied by intense and often distressing physical symptoms like an increased heart rate, sweating, tension and dizziness.

A panic attack might occur in response to a dangerous situation although can also be a 'false alarm' happening at times of intense stress or seemingly out of the blue. These panic attacks can be more frightening as it can be harder to understand what is happening.

What is panic disorder?

For some, having a panic attack will be a one off. However for others it can lead to an ongoing fear and worry about having another one. Fears often focus on not being able to cope alone as well as being in places where you think you could have another panic attack or where help might be hard to come by.

If this is accompanied by changes in behaviour such as not venturing far from home, only leaving home with others, avoiding crowded places like supermarkets and public transport or avoiding places where leaving might be hard, then it may be that you have panic disorder.

Some people with panic disorder may have a panic attack once or twice a month, for others this can happen daily. I have worked with clients who were experiencing panic attacks several times a day before starting therapy. Panic disorder can be extremely severe and debilitating, impacting on every area of life including work, social life and relationships. If left untreated, it can lead to other problems such as drug and alcohol misuse, depression and other mental health problems.

Panic disorder signs and symptoms

Cognitive behaviour therapy (CBT) helps us to understand problems by recognising the interconnection between our feelings, physical symptoms, thoughts and behaviours. In therapy, I help clients to understand their symptoms of panic disorder by looking at these four areas.

Physical symptoms of panic disorder can include:

  • Palpitations, a rapid or pounding heartbeat
  • Shortness of breath or finding it hard to breath
  • Feeling like you are choking
  • Feeling hot and sweaty or very cold
  • Feeling dizzy, lightheaded, faint or numb
  • Muscle tension, for example in the jaw or shoulders
  • Shaking or trembling
  • Feeling sick or like you need the toilet
  • Chest pain or discomfort
  • Pins and needles
  • A dry or tingling mouth
  • Feeling weak or like your legs will give way
  • Feelings of restlessness or electric charge in your head
  • A sense of unreality or detachment from your body and surroundings

These are all normal symptoms of anxiety and are completely harmless in themselves. However they are often so intense and uncomfortable that they can feel very frightening and can be misinterpreted as a sign of something catastrophic occurring.

Often people think things like “I'm having a heart attack”, “I'm going to die”, “I'm going crazy” and/or “I'm losing my mind”. This inevitably leads to further anxiety and exacerbates the physical symptoms further creating a vicious cycle of catastrophic thoughts, feelings of anxiety and physical symptoms which eventually reach their peak in a full blown panic attack.

Panic disorder and hyper-vigilance

Panic disorder can be seen as a fear of experiencing the physical symptoms of anxiety or a fear of fear itself. Once someone has developed a fear of panic attacks, it is likely that they will become hyper-vigilant to any signs in their body that could indicate that a panic attack could happen again. Although this is done to try and prevent a panic attack, hyper-vigilance actually makes us more anxious as we pick up on normal body symptoms that would usually go unnoticed but which trigger the vicious cycle of anxiety.

In an attempt to avoid having another panic attack, people will often change their behaviours. Commonly people will avoid situations or places where they think they could have another panic attack, places that would be hard to leave if necessary (such as the middle of the row at the cinema) or situations where help might be hard to come by (like being in a lift).

Panic disorder and safety behaviours

Safety behaviours are another change people can make in their behaviour as a way of managing their feelings of anxiety. These are things that we do to try and prevent our worst feared outcome from happening eg lying or sitting down when we feel anxious as we think it will stop us from fainting.

Although these actions help us to feel less anxious in the short-term, avoidance and safety behaviours maintain anxiety in the long-term as they don't give us the opportunity to see that in reality our worst fears don't actually happen.

Panic disorder diagnosis

According to the DSM-V guidelines which are used to diagnose mental health disorders, panic disorder can be diagnosed when someone has recurring panic attacks which include at least four of the physical symptoms described above. These need to be accompanied by at least one month or more of ongoing worry about having another panic attack and some of the changes in behaviour described above.

If you go out of your way to avoid situations for fear of experiencing symptoms of panic it may be that you also have agoraphobia which can become even more restricting and significantly effect your quality of life.

For a diagnosis of panic disorder, other possible causes must be ruled out such as the direct physiological effects of a substance (e.g. drug use or a medication), another medical condition or another psychological problem such as a specific phobia or post-traumatic stress disorder.

Panic disorder treatment tips

In CBT, I help clients to make changes to patterns of unhelpful thinking and behaviours which in turn reduces uncomfortable physical symptoms and feelings of anxiety, breaking the vicious cycle of panic. To help manage mild feelings of anxiety, you may find the following helpful:

1. Understand what anxiety is and how it affects you

Learning more about anxiety can help you to make sense of the physical symptoms that you are experiencing and in doing so can help to reduce the 'fear of fear'.

The fight or flight response is the term that is given to the body's normal physical response to danger, it helps us to identify and respond to threats. We experience the fight or flight response as a reaction to real threats as well as imaginary ones such as thinking that we heard footsteps behind us even if there was no-one there. When the brain perceives something as threatening (real or not), adrenaline is released into the bloodstream. This has many temporary effects on the body which are designed to give us the strength to fight our predators or run away as fast as possible.

Examples include signalling to the heart to pump faster to send more blood to the muscles and signalling to the lungs to take in more oxygen. These are incredibly helpful when the dangers we are facing are of a physical nature such as fighting off an attacker or moving out of the way of a speeding vehicle however todays threats are more commonly of a psychological nature.

Despite this, the body responds in exactly the same way and we are left with the physical effects of adrenaline secretion like a rapid heart beat and shortness of breath with no physical outlet for them. This can feel incredibly uncomfortable and confusing and for those with panic disorder rather than seeing these symptoms as harmless and normal symptoms of anxiety they are misinterpreted as a sign of something catastrophic happening eg having a heart attack, dying or going crazy. This leads to intense anxiety and the vicious cycle of panic.

2. Relaxation strategies

Many people experiencing panic disorder will feel heightened levels of anxiety throughout the day. This can be a trigger for further panic attacks due to the misinterpretation of the symptoms of anxiety. Breathing exercises can help to calm the nervous system which in turn reduces feelings and physical symptoms of anxiety.

It is important to note that the goal of these exercises is not to avoid or eliminate anxiety (as this reinforces the idea that anxiety is dangerous and needs to be avoided) but to moderate it and make it easier to deal when it arises.

Try this simple relaxation technique:

  1. Breathe in through the nose for a count of three
  2. Hold for a count of four
  3. Exhale through the mouth for a count of five

Relaxation exercises can be practised at any time and, like with any other skill, the more they are practised the more helpful they can be when you need them. Other relaxation strategies that may help include progressive muscle relaxation (systematically tensing and releasing each set of muscles in the body), practicing yoga or meditation, listening to music, going for a walk in nature or having a bath.

3. Shift your focus of attention

A fear of having another panic attack can lead us to become hyper-vigilant and focus our attention on changes in the body in order to pick up on any signs of 'danger'. When we do this we are more likely to pick up on normal physical sensations and misinterpret them as something dangerous.

When you notice that you are scanning your body for any changes or signs of anxiety you can remind yourself that anxiety, although unpleasant, is not something to fear and you can chose to focus your attention elsewhere.

Try focusing your attention instead on what is happening in front of you such as the people you are with or task you are doing, mind games might suit you better - try counting back from 100 backwards or locating 10 yellow items in your immediate surroundings, or you can try doing something else to distract yourself like taking your phone out and sending a message to a friend.

4. Challenge inaccurate and exaggerated thoughts

If we believe that the physical symptoms of anxiety are a sign that something catastrophic is happening then we will feel anxious. However, just because we think something it doesn't mean it is true and we can determine which of our thoughts are a true and realistic perspective by focusing on the facts of the situation.

Try focusing on the facts and 'evidence' of the situation and asking yourself whether your beliefs are based on 'facts' or 'feelings'. During a panic attack it 'feels' like something catastrophic and completely overwhelming is happening however this is not actually the case. When you notice feelings of anxiety you can tell yourself that you are safe and that these are harmless physical symptoms of anxiety which will soon pass.

5. Face your fears

It is natural to want to avoid the things that we fear. However when we avoid our fears we don't get a chance to see that situations aren't as dangerous as we think and that we can in fact cope with uncomfortable symptoms.

Graded exposure is an exercise that allows us to gradually and repeatedly face feared situations until we feel less anxious in them; starting with situations that cause the least anxiety and working up to more feared scenarios. By testing out your fears in this way, you will see for yourself that, if you allow them, anxiety symptoms will subside by themselves and can't harm you. With practice, your panic attacks will become less frequent and less intense as the vicious cycle of anxiety is broken.

Some of these self-help tips may work better for you than others but to be of benefit they all need to be practiced regularly. However if your anxiety is more moderate or severe, if you have panic disorder or if you are experiencing panic attacks as a result of another problem such as generalised anxiety disorder (GAD) or post-traumatic stress disorder (PTSD) then a short course of CBT therapy may be more suitable in helping you to overcome your symptoms. CBT is recommended by the National Institute for Health and Care Excellence (NICE) as an effective treatment of Panic Disorder.

Additional panic disorder help and support

For additional support with feelings of panic, try one of the following resources:

  • The Samaritans: a charity providing support to anyone in emotional distress
  • Mind: a charity that makes sure no one has to face a mental health problem alone
  • NICE: information and guidelines on treatments for conditions, including anxiety
  • No More Panic: information, support and advice for those with panic disorder
  • No Panic: a helpline, programmes and support for those with anxiety disorders
  • Triumph Over Phobia: self-help therapy groups and support for those with anxiety

Navit Schechter is a qualified CBT Therapist with over 10 years experience working with people with common mental health problems such as anxiety and depression. Navit has a private practice in Cornwall and also offers Skype appointments. For more info visit cbttherapyworks.com.

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