Coping with panic attacks, agoraphobia and social phobias - special advice
You will now know, if you have read Part I, that the physiological symptoms of panic can be explained very simply and that it is your interpretation of those symptoms ( ''I'm having a heart attack!" "I can't cope!" ''I'm going to die") that cause them to escalate unbearably. But just knowing that isn't always enough to enable us to get them under control. Fear is an extremely strong emotion and we can easily get locked into it with scary thoughts such as, "I'm sure this is worse than usual! This really is a heart attack!" So we need to know how to switch off a panic attack once we are in full flow.
The sensations associated with a panic attack are the same, whether they are induced by a particular overload of stress, a fear of particular places, a fear of being outside the home (agoraphobia) or of behaving unacceptably in public places or certain settings (social phobias). Therefore, the method below can be applied, whatever the circumstance.
First, you need to stop the excess carbon dioxide loss
If you recall, when you breathe in short breaths or gasps but don't take any physical action, you take in more oxygen than you can use and it gets breathed out again, taking carbon dioxide with it. But oxygen can't be absorbed by body tissues without the help of carbon dioxide, so if too much carbon dioxide is lost in this way, you suffer the terrifying feeling of choking or suffocating, even though you are still taking in air. You can stop excess carbon dioxide loss in one of these ways:
- Hold your breath and count to 10
- Start 7/11 breathing (see: overcoming anxiety). When your out-breath is longer than your in-breath, you are stopping yourself from gasping and are thus delaying the next intake of oxygen that you couldn't use. As soon as you start to breathe in slowly through your nose, you'll find you lose that sensation of suffocation. If you run out of puff before you reach the count of 11, just hold your breath and continue the count, then breathe in again for 7.
- Some health professionals still recommend breathing in and out of a paper bag, held over the nose and mouth. The effect is that this makes you breathe in again the precious excess carbon dioxide you have just breathed out. However the danger is that, if you carry this on for too long, you will get too little oxygen and too much carbon dioxide, leading to carbon dioxide poisoning. (This can lead to dizziness, nausea, headaches, vomiting and rapid breathing. In severe cases this might progress to confusion, convulsions and loss of consciousness.) You might also feel rather a fool breathing in and out of a paper bag in a public place. The 7/11 (or 3/5) breathing is unobtrusive and completely safe. However, if you find it easier to turn off the panic when you have something to concentrate on holding, by all means use the paper bag. But stop as soon as you feel able to switch to 7/11 breathing.
- Do something active If you find calming down difficult in such situations, another option is to take vigorous exercise instead! It may seem a ludicrous idea, if you feel you can't breathe - for how on earth could you take exercise of any kind, let alone the vigorous variety? - but just try it and see how, almost miraculously, the panicky feelings subside. This is because you are using your quick breathing for the purpose it was originally intended - to help you take swift action. So run up and down the stairs a few times, jog on the spot, dance to the radio, run round the block. You'll not only feel better; you'll have proof that you are not having a heart attack!
A psychologist once helped a woman who was terrified that the constricting pain she experienced in her chest when she became anxious was caused by angina. Her mother had suffered from angina and she herself had now reached the age that her mother had been when the angina began. She had been checked out several times by her doctor and at the hospital and was assured there were no signs of angina. But that didn't stop her worrying. Every time she got anxious, she experienced the same pain and was convinced that, this time, the angina was starting. Because she had had her latest check at the doctor's surgery only the day before, the psychologist felt confident enough to induce a panic attack in the woman and then went running with her up the hill near his house. She was both amazed and relieved to find that the pain disappeared instantly and completely.
It is really important when an attack starts to swap negative thoughts for positive ones. Instead of driving up your panic with thoughts of dying, fainting or having an embarrassing accident, try some of the following:
- "I can get through this."
- "I don't like this but I know it is going to pass if I calm down."
- "I know nothing terrible is going to happen really, I've been here before."
- "I can stop this in its tracks."
- "I am going to concentrate on counting my in-breath and out-breath."
- "I can tum this off like a tap."
Better still, come up with some good ones of your own.
Distance yourself from the panic
Try to become aware, as an observer, of what is going on in your body and then name it:"I am panicking". This can be an extremely powerful means of getting the sensations under control. Late one night, as a result of an undiagnosed illness, the husband of one of a psychologist started coughing up blood through his mouth and nose (the latter itself a result of panic, although they didn't realise it at the tirne). It was, understandably, an extremely frightening experience for them both. She called an ambulance and tried to calm her husband, then found herself shaking and struggling to breathe. She remembers saying to herself, "I'm panicking. This isn't going to help me help Tom." Observing herself in that way was sufficient to enable her to re-focus on reassuring her husband till the ambulance arrived to take him to safe recovery in hospital.
Another helpful way to distance yourself is to put the situation into context. When a psychologist was a young man, he once started to have a panic attack on an underground train in London. He was taking his university finals at the time and was on his way to sit what he feared might be an especially difficult paper. He was also under stress because the rent on his digs had just gone up and a family member was unwell. As he sat on the train with panic rising, he decided to imagine extra terrestrial life looking down on earth from the Milky Way. England would be a tiny blob, London a minute speck - and his exam room completely undetectable. Thinking this way made him laugh and put his situation into perspective.
In emergencies a tendency to put distance between oneself and the moment often arises quite naturally. Being 'in shock' is not necessarily a terrible thing. Indeed, it can be quite protective and better than getting hysterical. At the age of 15, for example, a man called Ivan attempted to vault a horse in the gym at his school. It was high and he caught his foot on it as he went over and fell, badly breaking his left arm. Although in shock he felt calm and detached. With his left arm now stuck out at an unnatural angle and bone poking through the skin, he raised his right arm and said calmly, "Please sir! I've broken my arm." As he was led out of the hall by the grim-faced gym teacher, he still felt strangely calm and had the dreamlike experience of being amused at seeing the faces of his classmates turning white and a couple of them even fainting at the unexpected sight.
Some people find it easier to concentrate hard on something such as counting leaves or bricks or paving stones (if walking in the street), or tins or cereal boxes (if in a supermarket), or reciting a favourite poem or recalling any kind of familiar list. Ideal, of course, is to get moving. If in a supermarket, you could start walking briskly up and down the aisles as if you are searching for something you have forgotten. In the street, you could just start walking fast, glancing at your watch now and then, as if in a hurry. If you are at a party, you could offer to get someone another drink or go to get one for yourself (preferably not alcohol, or not too much) or help with clearing plates and glasses for a while.
Stay in the situation
This will provide you with the best possible evidence that the circumstance you are in is not actually life-threatening at all. If you run, you are confirming for the amygdala that there was danger to flee from, and that, in such circumstances or similar ones, you had better run for it again. Whereas, if you stay and calm down, you start breaking the pattern match for next time, and you gain access to the rational part of your brain. Then you can go on to:
Consider what caused you to panic
You might want to do this straight away or later. Are you under a mounting level of stress? Did something just happen that acted as 'the last straw'? Have you had a panic attack in this place before and you've pattern matched to the previous event? Did you unwittingly induce a panic attack by thinking, "I wonder if I'm going to have a panic attack here" "It would be terrible if I were to have a panic attack here?" When we have an explanation, the event becomes less overwhelming and frightening.
Escape if you absolutely have to
If you just cannot get a grip on controlling your panic on a particular occasion, time take out. Leave the shop. Step out of the party or the pub. Get out of the lift. Pull over in the car. But then work hard to calm yourself and, once you have thought about what might have induced the panic, go back, in your calm state, and try to carry on with what you were doing before. You will be lessening the association with danger, if you are successful this second time round. But if you just cannot carry on, don't beat yourself up with guilt about it. Treat this as a reminder to practise your self-calming techniques more.