In many ways, panic attacks have much in common with a post-traumatic stress reaction. If you have experienced a full-blown panic attack, you might well rate it as the highest level of fear you could ever experience. Indeed, it is utterly terrifying and you will probably have been convinced you were dying.
Because the experience is so catastrophic that it stays vividly in your mind and, when it happens again, and again, it is no surprise if your life starts to fall to pieces, as you do anything to avoid situations where panic might occur, and also are never quite sure that it won't happen in completely new, as yet unsuspected, situations and circumstances.
No doubt, if you suffer from panic attacks, you will have visited your doctor at some point, frightened that you have a heart condition or some other life-threatening illness; or you may have gone straight to the accident and emergency department at your local hospital where you were thoroughly checked out and told you were fine. But that didn't make sense because you know you weren't fine. Something had to be wrong. Or maybe you were told that you had had a panic attack, and that has made you worry that there is something wrong with you mentally. Why else would you go into what seems like a near-death state for no good reason at all?
Well, there is a good reason and when you understand how and why a panic attack takes hold, the fear can be taken out of it almost completely. You will then be able to learn how to prevent these attacks either from happening altogether or from escalating, if they do.
In a small number of cases, panic attacks can be triggered by a physical condition, such as heart and lung irregularities, an undiagnosed thyroid disorder, inner ear disturbance and epilepsy. They can also sometimes be triggered by side effects of prescribed drugs (particularly tranquillisers and anti-depressants), withdrawing from drugs, alcohol or smoking, or even by tight clothing that restricts breathing. It is best to see your doctor if you are concerned about possible causes.
Symptoms of panic explained
Let's look at some common symptoms of a panic attack. All of these symptoms are perfectly normal aspects of the fight-or-flight response that we unconsciously set in motion whenever we feel that we are under threat.
- Palpitations or sensation of a pounding heart: our hearts pumps faster to cope with the increased demand that will be made on it, when we start fighting or running
- Quick, shallow breathing: we need to take in more oxygen quickly to increase our energy, thus fuelling our muscles so they can get moving and shift us out of this emergency quickly
- Copious sweating: our body is expecting to take some serious aerobic exercise (fighting or running for it), and we'll get too hot if we don't sweat
- Sudden feeling 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 get us running faster
- A sense of desperately needing to urinate or defecate: again, this is to enable all available blood to go to the muscles in our legs and arms, the kidneys and intestines and bladder stop working, causing the muscles at the opening of the anus and bladder to relax.
Yet most people experience panic attacks in innocuous situations, like supermarkets or buses or any number of ordinary places that we might find ourselves in on an ordinary day - there is no evident threat and we aren't actually getting ready to run anywhere or fight anyone. And that is what leads to the rest of the frightening symptoms of a panic attack.
- Sensations of shortness of breath, smothering and choking: these horrible sensations are not imaginary! Unfortunately, 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 breathe it out almost straight away and this has a significant effect.
Oxygen is a very sticky molecule and, without the aid of a gas called carbon dioxide, it sticks too closely to the red blood cells that carry it around to the various tissues in our bodies. This means it can't be readily released to be absorbed by the cells that need it. Normally, we breathe in the right amount of oxygen and, with the aid of carbon dioxide, this gets transferred to the body tissues, and then the carbon dioxide is breathed out. But when the oxygen is breathed out almost straight away, as a result of sustained shallow breathing but no action (hyperventilation), it takes precious carbon dioxide with it that hasn't done its job yet, causing the levels of available carbon dioxide in our blood to fall. Without the carbon dioxide to help, the remaining oxygen sticks to the red blood cells and we feel we are oxygen-starved, even though we are actually taking plenty in.
Most people naturally start gasping or panting when this happens, to 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 to get at. However, although the terrifying sensations of smothering or choking are all too real, neither would actually happen. The worst that could ever occur is that you would faint and then your breathing would return to normal - just as normally we breathe correctly automatically, without even thinking about it. It is the panic and the fear of dying that triggers and exacerbates the process that causes the conscious gasping and struggling to breathe.
Sharp chest pain: again, this is real, not imaginary. But it is the result of strain on the chest muscles caused when you hyperventilate.
Trembling and shaking: A little of this is the normal accompaniment of shallow breathing. But the more you hyperventilate, the stronger and more uncontrollable the trembling and shaking will be.
Dizziness or faintness: the hyperventilating is to blame.
Numbness: the hyperventilating is to blame.
Weakness: again, the hyperventilating is to blame. The body is getting exhausted.
Difficulty speaking: yet another result of hyperventilating.
Fear of losing control: this is a realistic reaction. You have, unwittingly, turned on the fight-or-flight response to escape from danger and yet you are not escaping from danger. Every cell in your body is screaming for you to run or fight and you are staying put, so of course it feels as if you are losing control. But it is a feeling, not a reality. People have said to us, "But I did lose control. I was in the supermarket and I just put down my basket and fled." Our response is usually, "Did you leave by the door or the window? If you left by the door, you didn't lose control. You simply did the only thing you knew how to do that might possibly lower your panic."
A sense of being unreal: people often find themselves thinking, "This can't be real. It's like a dream." They feel detached, as if they are looking at themselves going through this dreadful experience, and because of this they may jump to the conclusion that they are going insane. But this sense of dissociation is again just a natural defence mechanism in the circumstances, an attempt to lower the soaring arousal and calm yourself down. (We make positive use of this natural mechanism for the same purpose, in treatment.)
You think you are dying: with all the alarming, escalating physical symptoms that you are experiencing, it is no wonder that you fear you are dying, if you don't understand what, physically, is going on!
So, amazingly, all this results from hyperventilating. If you were to breathe noisily through your open mouth now for two minutes, you would get these very same symptoms. (There is more carbon dioxide loss through an open mouth than through the narrower outlet of the nostrils.) We don't suggest you do this but we do sometimes suggest it to our patients - as we are there to calm them down again - so that they can see for themselves.
It would all be over in moments if ...
A panic attack, then, is just nature's normal response to the perception of a strong physical or emotional threat and it would burn itself out within probably two or three minutes, if left to follow its natural course. Fight or flight symptoms will always naturally peak within 10 minutes at most. (If symptoms last for hours, you are not having a panic attack.) The only reason symptoms don't peak quickly when we are having a panic attack is because our terrified thoughts and dire imaginings lead us to hyperventilate and thus increase and perpetuate the symptoms. In effect, we are frightening ourselves half to death! Our bodies aren't doing it. It is fuelled by our imagination and such thoughts as:
"My chest! I'm having a heart attack!"
"It has never been this bad before. 1 know it was only a panic attack last time but this time it has really got to be a heart attack!"
"1 can't move my tongue. I'm having a stroke!"
"Why am 1 sweating like this? 1 must be seriously ill."
"1 can't breathe!" "What am 1 doing here? 1 don't remember getting here."
''I'm going to be sick! I'm going to disgrace myself! Oh, 1 couldn't stand the embarrassment!"
The symptoms of a panic attack are understandably frightening if you don't know what's causing them, whereas understanding can make all the difference. Some people find that the explanatory information we have provided here is all they need to enable them to gain control over such unhelpful thoughts. When they know that their bodies are, in fact, reacting in a natural way to some highly stressful situation, and that they aren't going to die, they can stop churning up the action with panicky thoughts.
But what's so threatening about a supermarket?
Imagine this scenario:
Jenny is a single mother of a three-year-old and a baby girl. Today, as usual, she has dropped off Alex, her three-year-old, for his morning session at nursery school and then she has raced into town to try to get her errands done before she needs to return to pick him up. She goes to the post office and the shoe repair shop. She doesn't dare go into the bank - she is overdrawn and really worried about how she is going to handle her financial prob-lems. She is just about to set off back to the nursery when she remembers that she is out of ketchup. If Alex doesn't have ketchup-and it has to be a particular brand of ketchup - with his lunch, he will have one of his monster tantrums, and Jenny just can't cope. She is already chronically sleep-deprived as it is, what with the baby waking up several times in the night and Alex coming in to her early in the morning. Will she have time to dart into the super-market, pick up a bottle of ketchup and get out quickly in the hand basket queue? She decides to risk it, as the tantrum alternative is so unthinkable today.
She grabs the bottle and makes straight for the quick checkout. There are two people ahead of her, but they don't have much in their baskets. But there does seem to be a problem at the front of the queue. A customer is arguing with the cashier about something or other. Jenny starts to get anxious about the time. If she is late and Alex is the last child left, that will bring on another tantrum and she will virtually have to drag him down the road, with everyone looking at her, thinking her a terrible mother. The customer is still arguing. The cashier is just shrugging her shoulders. Jenny can feel herself getting tense. Then the cashier puts on her light, to signal for a supervisor. Jenny looks around. There is no supervisor in sight. Her anxiety is soaring. And then she remembers that Alex's teacher has already told her off several times for being late and had said that, if it happened again, she might have to call social services, because she couldn't be expected to give up her short lunch hour to look after other people's children ... !
Suddenly, Jenny feels a stabbing pain. She can't catch her breath. She can't breathe ... !
And no doubt you can picture the rest of the story.
There is, of course, nothing inherently threatening about supermarkets or any other innocent places in which panic attacks occur. They just happen to be the places you are in when an intolerable load of stresses, put together, suddenly rise above the level that you can cope with. For Jenny, this was a combination of coping alone with a very young family, being sleep-deprived, having financial worries and fearing the consequences of being late to pick up her child. She was only conscious of the last concern at the time. But our friend the amygdala had other ideas. It sensed the emotional temperature rocketing, diagnosed highly probable danger, set the fight-or-flight response in motion - and the result is a panic attack.
But that, alas, is not the end of it. As a panic attack is such a terrifying experience, the amygdala will definitely file away the information for future pattern-matching purposes. As it works with sensory knowledge, it won't be interested in all of the circumstances that led to Jenny's collapse. It will only register the fact that she was in a bright, busy place, where people were queueing. And so, on another occasion, even though Alex and the baby are with their grandmother and an unexpected windfall has sorted her finances out, Jenny has another panic attack while standing in a post office queue.
Even when someone knows there was a clear cause for their first panic attack - for instance, they felt sick whilst taking an exam and hadn't dared to ask to rush out to the toilet - that doesn't stop it from happening again, if the original predicament produced enough panic. The amygdala has noted the occasion - being shut in a room where people are working silently - and the next panic attack occurs in the local library. And so it goes on, with new features of each situation noted by the amygdala, to serve as further triggers for raising the alarm the next time. (We will consider the full consequences of this shortly, when we look at agoraphobia.)
Smoke alarms and washing machines
When people don't understand what a panic attack is and why it is happening to them, they often think they are having 'a nervous breakdown'. But nerves don't break down. That idea comes from a quaint metaphor coined around the time that telephones were invented. After all, nerves could be considered to be a bit like telephone cables and cables break down. But there the similarity ends.
However, a good metaphor does provide a helpful way of getting a handle on complex events. And we think that there are much better metaphors for understanding panic attacks. For instance, a panic attack that occurs when there is no actual emergency is a rather like a smoke alarm that is so sensitive that it sometimes goes off even when there isn't a fire. Everyone wonders what is happening for a moment or two but then they realise they can just safely tum it off. Nothing dire happens as a result.
Or maybe a panic attack is like the fast spin in a washing machine. Just as your washing machine is designed to spin and vibrate and withstand all that sudden activity at certain times in the washing cycle, so your heart and your body are designed to thump and shake when you get highly aroused. Normally you would run like the clappers as a result but, if there is nothing to run from and if you don't keep repeatedly pressing the 'spin' button (i.e. think frightening thoughts), your arousal will settle down again quickly of its own accord.
Easier said than done, of course, but in Part 2 we will show you how. The rewind technique, which is so successful in resolving symptoms of post-traumatic stress, is also highly effective in bringing down the emotional arousal associated with past panic attacks (see Part 3).
Continued in this article: Agoraphobia