How To Thwart Panic

Photo: oddsock

I’ve had one panic attack in my life.  It happened when I was a first-year medical student and taking my first biochemistry mid-term exam.  Everyone agreed that all our teacher’s lectures had been virtually incomprehensible.  And unlike most of my classmates, who’d majored in biochemistry or biology in college, I’d majored in English, so the material was almost all entirely new to me.  I remember opening the test, reading the first question, and thinking I had no idea what it was even asking.  So I turned the page to the second question—only to find myself equally at a loss.  I read all seven questions in turn, each time thinking that I’d be able to answer the next one, until I reached the last one and realized I couldn’t answer any of them.

This had never happened to me before.  I realized that, for the first time in my life, I was about to fail an exam.  I broke into a sweat and my heart started pounding.  I looked around the room in a panic, hyperventilating, feeling dizzy.  My best friend, sitting next to me, noticed my distress and whispered with a concerned expression, “What’s wrong?”

“I can’t answer any of the questions,” I whispered back.

“Try,” he said firmly.

I felt as if I was in mortal danger and struggled with an impulse to leap up and run out of the room.

“Calm down,” he told me sharply.

WHAT IS PANIC?

What a full-blown panic attack feels like is difficult to describe to those who’ve never faced one.  Adrenaline surges through your body, readying it for a flight-or-fight response, producing a cascade of physical effects:  sweating, palpitations, dizziness, and tremulousness.  A pervasive sense of doom grips you, making concentration and even rational thought nearly impossible.  Think of the fear you may have experienced prior to delivering a speech and multiply it by a factor of ten.  People who suffer from panic attacks regularly will tell you that being in the middle of one makes them feel like they’re about to die.

WHAT CAUSES PANIC?

Panic is always seeded by a thought.  It may be a thought about a small pain in your chest, or that this plane you’re on isn’t safe, or that you’re going to fail a biochemistry exam.  A thought that leads you to believe you’re trapped in an acutely life-threatening situation (whether physically life-threatening or emotionally life-threatening) from which you have no chance of escape.  It’s the compounding of that last belief with the first belief that often leads to an autonomic response, generating many of the symptoms I mentioned earlier.  These symptoms then lead to a belief that something is wrong with you physically—something that might be serious enough to kill you.  This fear serves only to intensify the physical symptoms, which in turn reinforces and intensifies your fear and conviction that you’re in physical danger—which cycles into full-blown panic.

Or, you don’t find yourself focusing on the physical symptoms but rather on the life consequences that you expect will follow from your inability to extricate yourself from your current predicament.  I wasn’t worried I was in physical danger when I panicked during my exam.  Rather, I experienced the following rapid cascade of thoughts:  if I failed the test, I’d fail the course, and if I failed the course, I’d fail out of medical school, and if I failed out of medical school, I wouldn’t become a doctor, and if I failed to become a doctor—what would I do?  Irrational as it was, that last thought—the abrupt belief that I had no future whatsoever—immediately tethered itself to the likely possibility I was about to fail a test and held me in its grip without mercy.  It engulfed my entire thought process, filled me with dread, and igniting my panic.

WHAT CAN WE DO TO STOP PANIC?

To abort severe, recurrent panic attacks often requires medication.  But short of that, several techniques can be useful:

  1. Carry anti-anxiety medication with you.  Patients often report that simply having an anti-anxiety medication on their person often itself obviates their need to take it when they encounter situations that typically cause them to panic.  One explanation for this is that the cause of panic isn’t merely facing a potentially life-threatening obstacle but feeling as if you have no solution to resolve it.  That you have no way out.  Though a pill won’t remove you from the situation that threatens to induce panic (e.g., being in an airplane or being unable to answer a single question on a biochemistry exam), it will relieve the awful feelings that such circumstances stir up—and knowing you have a way at least to control those feelings often becomes the solution itself that controls those feelings.
  2. Don’t fight panic—accept it.  If I tell you now not to think of an elephant, what happens?  You think of an elephant.  And often the more you try not to think of an elephant, the more you do.  In the same way, by making the suppression of panic your goal, you end up focusing on it more and paradoxically making it worse.  A far better technique is to try to distract yourself from your panic.  A good first step toward this aim would be to separate yourself from your panic.  Think of your feeling of panic like a hunger pang that you acknowledge but simply choose to ignore.  You might dialogue with yourself this way:  “Boy, am I ever panicked right now.  I can feel it moving through me very strongly.”  “Moving through me” are the operative words.  Imagine your panic as a wind blowing over you.  All you need to do is wait for it to stop.
  3. Rate the severity of your panic moment by moment.  Nothing bounces you out of an experience more quickly than being forced to rate its intensity on a scale of one to ten.  Think of how you’d feel if, in the middle of making love, your partner stopped you and asked, “So, on a scale of one to ten, how’s this going for you?”
  4. Look for mistakes in the thought process that led you to panic.  Assumptions underlie the beliefs that lead to panic (e.g., the plane you’re on has a high likelihood of crashing).  Engage the rational part of your mind to stir up counterbalancing beliefs to fight your irrational ones (e.g., it’s well known that flying is far safer than driving, statistically).
  5. Desensitize yourself to situations that induce panic.  For patients who panic in specific situations (e.g., riding in elevators), therapists often employ the technique of habituation.  It’s like getting allergy shots.  By increasing the “dose” or intensity of the panic-inducing stimulus gradually, people tend to become habituated to them and therefore less likely to panic.  You might begin, for example, by looking at pictures of an elevator until doing so ceases to induce panic.  Then you might stand several feet away from a closed elevator.  Then you might stand directly in front of one.  Then you might stand directly in front of one with the doors open.  Then you might stand inside one with the doors open with a companion.  Then you might take a short ride in one with a companion.  Then a longer ride.  Then a ride alone.  If you experience this kind of panic, it’s probably best to work at overcoming it with a trained psychologist.

In the end, I did fail my biochemistry test.  But I didn’t flunk out of medical school.  I applied myself, retook the test, and scored well, ultimately passing the class by a comfortable margin.  The experience taught me several valuable lessons, the most important one being this:  our minds cannot be trusted.  Often they can’t help but leap forward to the worst possible outcome when we’re confronted with even mildly threatening situations.  For this reason, we must remain on guard against our own negative impulses constantly, seeking always to become the master of our minds rather than allowing our minds to master us.

Next weekHow Touching Saves Lives

20 comments to How To Thwart Panic

  • Amy

    Alex…it is so true that just having an anti-anxiety medication with you at all times seems to quell the anxiety itself whether it be a panic attack or generalized anxiety feelings. It took me two years to figure out that my excessive anxiety was being caused by focal atrial tachycardia (agh, who would think a heart problem would cause massive anxiety?)…and…another year to get the right beta-blocker dosage. I’m good now, but still carry an anti-anxiety medication with me so I know that if the feelings of excess adrenaline come back I’ll have a fall back. My primary care doctor was reluctant to prescribe the anti-anxiety medication because I think he thought I’d abuse it and need more and more. I haven’t really needed it, but knowing that I can take it makes daily life pretty much normal again. Thanks for acknowledging the fact that having the option of taking an anti-anxiety medication can make all the difference between being paralyzed or living a normal life, whether you take it or not.

  • louise

    Alex,
    In Feb 2006, I began to experience anal bleeding with my morning bowel movement (thought it was hemorrhoids) and my first ever panic attacks. The attacks were incapacitating and very frightening. My family doctor prescribed anti-anxiety medication without asking me if there were other changes going on in my life and/or in my body. The medication (Xanax) was excellent at stemming the attacks but…in June 2006, when I got around to a rectal exam, etc., I was diagnosed with Stage 2 anal cancer. I blieve that my panic attacks were indeed warning me that there was something life threatening happening in my body. P.S. I survived the chemotherapy, stopped smoking, social drinking, took up yoga/mediation, continued to work out and try to practice tenets of Buddhism. I remain cancer free. My point is that, sometimes, panic attacks ARE the body’s way of frantically trying to get our attention. We (and our doctors) can get so caught up in getting away from/preventing more panic attacks, that we can forget to address possible underlying medical conditions.

  • JLRivers

    I wonder how you did on the test…

    Back in 2007 when I was applying to graduate schools in New York, I almost had a panic attack, which was induced by the unrelenting thought that I would not do well on the GMAT.

    Had I come across a post like this back then, I would have known how to deal better with the situation.

    I ended up doing well on the test because I over-prepared for it and was accepted at one of the best schools in the country.

  • Biochem—you, too? How ironic! Like you, my background was English, and I was a stranger in a strange land. I was saved by the student in front of me who passed my 2nd failed test back. He was a cutie, and he asked mock-seriously, “Can’t you do better than that?” At that point, I had given up, but he offered to tutor me—for the price of a six-pack.

    Little did I know he was a nascent alcoholic, and I ended up exceeding him, with a “B.” All it took was the concern of one other person to cause me to live up to my potential. (I am a terrible creature of habit, unless challenged.)

    I have also suffered panic attacks during school years, and they stemmed from fear of a particular uncontrollable situation. However, a nurse at the student health center recognized my hyperventllation for what it was, and taught me how to control my breathing. So introducing that aspect of control seems essential to curbing the response.

  • Maria

    I once saw a teacher stop a developing panic attack on someone by telling the person not to worry, that no one in the class had ever seen a panic attack and we would like to know how it looked like, so to go on and have one. The person never managed to get the panic attack. This leads me to think that part of the anguish of a panic attack may come from knowing you will be vulnerable during the attack (since you can’t control yourself) and the pressure of what others will think.

  • Camilo

    I have suffered from panic attacks and anxiety for the last five years. My first panic attack came one time as a graduate student when I was in a hotel room preparing to give a talk that morning. After that, panic invaded my life and to this day I still get anxious (though much less) when I have to travel by myself for job-related trips. After trying CBT-based therapies and some medication for a while, I’ve found that what has worked best for me is following a novel therapy called ACT (Acceptance and Commitment Therapy):

    http://en.wikipedia.org/wiki/Acceptance_and_commitment_therapy

    Its bases are mindfulness acceptance of the anxiety as something normal in our lives. Very similar to what Alex described above about not confronting and engaging panic.

  • ChronicKneePain

    Wow—thanks for publishing this cheat-sheet about panic. I’m lucky that my physical therapist for knee pain intuitively led me through the same steps to quell my anxiety&panic. Excellent summary!

  • Paddy

    This is a great article! I have just started an intense post-graduate course in teaching, and I have a feeling that this will be of great assistance throughout the year…

    Thanks

    Paddy: Glad you found it helpful.

    Alex

  • Good post. I had some panic attacks when I was younger. The one book that helped me the most was Hope and Help for your Nerves by Claire Weekes. It remains, in my opinion, the best book for help with debilitating anxiety attacks.

    That and Xanax. Deep breathing helps, too.

  • Kassie

    Hi, Alex! This is my first time posting, but I felt compelled to do so because the scenario you’ve describe is also similar to my current situation. I have a degree in Business, but I am now enrolled in an accelerated Nursing program. Everybody in this program has graduated from life sciences or has even gotten a master’s degree in the sciences. I have no background knowledge in sciences and I am constantly feeling anxious by the idea of taking my first exam. So I find this post to have had perfect timing and incredibly helpful. Thank you!

    Kassie: Glad to hear from you and glad you found the post helpful.

    Alex

  • Colette Gurin

    Dr. L:

    This was great. I used to have severe panic attacks. Before I knew what they were I just knew I was having a heart attack and dying. They were terrible. Numerous trips to the E.R. where I was diagnosed with everything from a pulmonary embolism to mitral valve prolapse. They are horrifying. Went through this for years and years until I found a wise doctor who told me what these were and that I was not dying. Ever since then I am able to talk myself out of them or, as you mentioned, distract myself. I also carry an epipen with me just in case of a bee sting. Never have been stung but am terrified. Your advice is right on. I thought I was going crazy—now I really know with your story I am not and was not. Thank you so much for all your knowledge that you are sharing. You can’t imagine how it helps. Colette

    Colette: So good to hear from you. Glad you found the post helpful.

    Alex

  • campykid

    A former PCP attributed my numerous episodes of palpitations, high heart rate, spiking BP, and years-long struggle with insomnia to panic attacks/generalized anxiety disorder. Further, she accused me of “magical thinking” when I questioned her. Finally, after 10 years of progressively worsening symptoms and the results of a Holter monitor the cause was found to be atrial fibrillation. Since then, I have been told by several electrophysiologists that PCPs are notoriously inept at making a proper diagnosis for atrial fibrillation and that women are commonly and erroneously told their a-fib symptoms are due to panic attacks. I felt a bit better when a man I met at a party told me he’d gone through the same challenges…and he’s a physician!

    My advice: if the “attacks” go on for days for no discernible reason, see a cardiologist (and not a dismissive one, either).

    campykid: Thank you for making this excellent point. Diagnosing panic attacks can actually be a tricky business. There are always other things in the differential diagnosis that must be considered, especially arrhythmias like a-fib.

    Alex

  • Editormum

    Dr. L: I’d never had a panic attack in my life until after I was rear-ended at high speed in 2005. I was 36. About three months after the attack, I went to a conference and…well, I can’t really describe what happened, but I ended up spending much of the weekend in my room, focusing on breathing slowly and deeply. When I described the incident to him, my doctor told me that I’d had a panic attack. I have gone on to have panic attacks in church, at parties, at company functions, while shopping…anywhere there’s a large crowd and noisy or chaotic behavior. It seems to be a question of severe sensory overload. My doctor is helping me learn to prevent and deal with these attacks, as it seems they are likely to be permanent. Thank you for the insight into coping strategies—I found your thoughts encouraging and helpful.

  • I agree, the first thing to do is to rule out several common medical problems. Hyperthyroidism is not uncommon and it does occur in men. Another etiology is the sudden cessation or decrease in dosage of SSRIs. Other medications can cause panic disorder, or the sudden release of adrenal hormones.

  • Colette Gurin

    Hi again,
    I did not realize that hyperthyroidism could cause panic attacks. What about hypothyroidism? And by the way, Dr. L., I love the photo of “The Scream”—very appropriate and one of my favorite pieces of art. I have it hanging in my home, thanks to my sister, Maryann.
    Colette

    Colette: No, hypothyroidism doesn’t cause panic attacks.

    Alex

  • Diana

    I really benefited from this post. I don’t suffer panic attacks, but do have constant anxiety. What also impressed me was Camilo’s response, mentioning ACT (Acceptance and Commitment Therapy). I pulled out my workbook on CBT and ACT to review it. Some similar therapies, Dialectical Behavior Therapy, are based on Buddhist ideas.

  • hidflect

    Dread is the only emotion I think is useless. It’s an aberrant or delusional state. The tips you give to combat this are genuinely helpful. They might all be generally corralled under the idea of “externalization.” It’s a good technique for everything stressful. It forces one into the objective state from where a sense of proportion can re-establish itself. I fancy that most anti-anxiety medicines achieve the same effect, only chemically, creating a sense of dis-embodiment. I think mastering the trick mentally is the healthier way to go for sure.

  • Andrea

    Alex,
    Very interesting info. I never had a panic attack myself, but I think I’ve seen somebody I know having one, and I couldn’t help because I wasn’t sure what was going on and what I was supposed to do. How can we recognize panic attacks in other people, and what can we do, if anything, to help them?

    Thank you

    Andrea: It can actually be quite difficult to diagnose a panic attack for the first time, even for medical professionals. In a young woman, for example, who starts hyperventilating and saying she “feels like she’s dying” because of some readily identifiable stress or anxiety trigger, panic is probably the right diagnosis. But in a fifty-five-year-old man who smokes and has hypertension, the same symptoms may be a heart attack. If, on the other hand, someone already carries a diagnosis of panic (meaning other alternatives have been ruled out) and they can tell you they’re having a panic attack, the goal would be to try to identify the source of their panic and make them in some way feel safe from it—not easily done even for mental health professionals. Reassurance that they’re not actually dying or in danger is probably best. But if you have any doubt whatsoever that what you’re witnessing is a panic attack, call 9-1-1.

    Alex

  • Robyn

    I have emailed you before but this is one of my most disturbing problems. I wake up every morning with a horrible sense of panic and fear—is it from a dream? Where it comes from I don’t know (years ago I did a course in dream therapy and now dream vividly, much to my chagrin) but I have tried relaxation and breathing techniques before I get up and also tried getting up and into the shower quickly and other things, but the sense of fear stays with me. Now I dread it.

  • Looking back on my life, I have always struggled with anxiety. I think it is my pursuit of perfectionism. My first panic attack happened while deciding how to end a terrible marriage and keep everyone happy. I felt the dizziness, the numbness in my arms and face, and then my airway seemed to close. That is when the panic set in. I trembled uncontrollably and thought I was losing control of my body. It literally felt like I was dying. The urgent care doctor was perplexed, told me I was healthy and to see my regular doctor. Immediately, my family physician knew based on the symptoms I described that it was a panic attack. He told me that I needed to see a therapist and figure out what was causing my anxiety and prescribed me Xanax (which is very helpful). I did eventually divorce however; I continued to have the panic attacks. That is until I read the book mentioned in a previous post, Hope and Help for your Nerves by Claire Weekes. She gives the same advice as this posting. Basically, let it happen: encourage the panic attack, do not fight it. Three years after I read the book, I no longer have panic attacks. I still feel the anxiety but I now know how to not control it. I also carry Xanax with me at all times. It is a great security blanket.

Leave a Reply

You can use these HTML tags

<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>

  

  

  

*