LEARNING TO UNDERSTAND PANIC ATTACKS
We are going to try and help you understand panic attacks, we will give information about what happens to your body in a panic and explain why these changes are happening to your body. It will also help with coping strategeries such as a psychological treatment known as Cognitive Behaviour Therapy.
A panic attack has 3 important features:
1. It is accompanied by intense fear and anxiety
2. It usually comes on fairly suddenly
3. The most intense feeling normally last a very brief time (although this may feel like a long time when you are in the middle of an attack, and it may leave you feeling uncomfortable for some time after the panic has passed).
Panic is usually accompanied by a sense that something awful is about to happen. You may feel as if you are going to die, or go mad, or make a complete fool of yourself, or something else. Panic often comes completely unexpected and does not appear to be triggered by anything. Other times, people can recognise particular situations, which are likely to trigger an attack.
Panic attacks are very common and are not a sign of a serious mental illness. Figures show that there are 1 in 10 people who may have a panic attack at sometime in their lives. Some people may only experience panic for a short while then they are others that they may cause problems for a long time. It is also known that some people may not tell anyone for a long time and never seek help at all.
Panic affects your body, your thoughts and your actions. Below is a list of common symptoms.
During an attack people normally have very unpleasant bodily sensations. Some of the common ones are:
- Your heart beating very fast, skipping beats or having palpitations
- Breathing very fast sometimes called hyperventilation
- Feeling short of breath
- Chest pains, headaches or pains in other places
- Tightness in the throat, choking sensations
- Feeling as if you have to go to the toilet
- Feeling faint or dizzy or unsteady on your feet
- Numbness or tingling especially in the toes, fingers or lips
- Trembling or shaking
- Sweating or hot flushes
- Feelings of unreality, as if you are not really there, or as if you are separated from everything around you
These are the commonest sensations, but remember that one of the confusing things about panic is that they do cause a very wide range of sensations.
During a panic attack people tend to think that something dreadful is going to happen. As we have said people may have different fears. Below are some of the most common ones.
- I am going to have a heart attack
- I will collapse or faint
- I will not be able to breathe
- I will lose control of my bowel/bladder
- I will choke
- I will be sick
- I am going crazy
- I am going to make a complete fool of myself in front of everyone
These fears are not going to come true. Many people have panicked and felt awful dozens or even hundreds of times, but they are still alive and well. Nevertheless, at the time that the panic is happening these thoughts may seem very real, and of course very frightening.
When something as frightening as panic happens, you will try to prevent the harm that seems to be threatening you. Listed below are some of the ways people commonly behave when they panic.
- Most people feel that they will be safer if they leave the situation they are in, so they try to escape as soon as possible to what seems a safer place. For many this means going home or finding someone with whom they feel safe.
- You may also try to avoid similar situations in the future
- You may take action to make yourself feel safer e.g. if you fear a heart attack, you may rest. If you feel you may collapse, you may hold onto something. If you fear suffocation, you may open a window to let in more air and so on.
- Sometimes people feel so sure that they are in danger they call an ambulance or go to a doctor.
- Panic is a sudden feeling of intense fear
- It has strong bodily symptoms such as pounding heart, difficulty breathing or sweating
- Panic attacks are associated with thoughts that something terrible is going to happen
People often want to get out of the situation they are in as quickly as possible, or do something else to make themselves safe.
Although the reactions that occur in panic may seem very peculiar, and are certainly uncomfortable, they are actually just an extreme form of normal fear reactions, built into all humans and other animals as an instinct. Why do we feel afraid? What is fear for?
In terms of survival, fear is a very valuable reaction. When you are afraid, your body prepares itself for action with what has been called the fight or flight response. It is this name because it prepares you either to fight against the danger or to flee from it. When the fear response is activated, various changes happen in your body. They happen automatically and very quickly. These changes would help you if you needed to run away or fight, but they can also cause uncomfortable side effects. Some of the common effects of the fight or flight response are:
- You breathe more quickly, so that you can get lots of oxygen to your muscles to help you fight or run. Side effects: rapid breathing may cause feelings such as dizziness, chest pain and breathlessness.
- Your heart beats faster so that the blood is pumped round your body more quickly, again to supply your muscles with what they need. Side effects: You may become uncomfortably aware of your heart pounding, palpitations etc.
- Blood is directed to the muscles in your arms and legs (which would most need it in a fight), and away from less important areas such as skin, fingers and toes. Side effects: this may lead to sensations of numbness and tingling or coldness in the areas where less blood is going
- Your muscles tense up, so that you are ready to leap instantly into action. Side effects: You feel tense, and the increased tension may lead to aches and pains, or trembling.
- You sweat more because fighting or running will generate heat and you need to get rid of that heat. Side effects; you may feel clammy and sweaty
- Digestion and salivation slow down, because they waste energy, which is needed elsewhere.Side effects; you may feel nausea, a dry mouth, or a heavy stomach.
- Your mind becomes focused on looking for possible dangers, so as to be ready to react.Side effect: you feel keyed up and apprehensive and it hard to concentrate.
You can see that all these changes are useful if you are faced with a real, physical threat. They have evolved over millions of years to protect you, and they are very useful at the right time and place. If someone were to attack you, these changes would enable you to react quickly or to run away if you needed to. Your body would have taken the necessary action for your survival.
In other words, the major sensations of panic are not a sign of something going wrong rather, they show that your body is doing the right thing to prepare for the threat, which you have perceived.
Fear reactions also occur in moderation when performance is important. For example, a runner may get a surge of adrenaline, and the same reactions listed above, just before a big race. these feelings may actually help the athlete’s performance. Problems only arise when the fear response is happening at the wrong time or when it persists beyond the point where it is useful. One of the problems with panic and anxiety is that the modern world, the threats we face are not usually physical attacks, but more psychological threats, for example, of looking foolish, or failing in some way, and these reactions may be less useful in such situations or even positively unhelpful. The problem is, your body doesn’t know the difference any threat can lead to switching on the fight or flight response, whether it is actually going to be useful or not.
Although the alarm response may continue for a while, it cannot persist indefinitely. After a while, the body switches of the alarm, and the reactions gradually die away. This switching off is as automatic as the switching on was, although it takes longer. You may continue to feel tense or anxious for sometime afterwards, but the intense fears of a panic attack will not persist—most panic attacks last between a few minutes and an hour or so.
- Fear is a normal automatic reaction, designed to help you survive at all times of real danger
- Fear alerts you to threat and prepares you to take action to cope with it
- When the danger has gone, fear slowly dies down.
There may be many reasons why your panic attacks start below are some examples of the reasons why:
Some people are more concerned about their health and the possibility of things going wrong than most people are. Such concerns may mean that they are more likely to interpret bodily symptoms as a sign of something threatening, and therefore more likely to get into the vicious circles of worrying. For some people, their first panic occurs when they actually do have a mild illness, such as flu or a stomach bug, which then makes them think there is something more seriously wrong.
Periods of stress, caused by work problems, or relationship difficulties, or any other worries, seem to be a factor in causing some people to start to panic. Everybody’s level of anxiety goes up and down from time to time.
Panic may be associated with distress from other difficulties in your life. Such distress can be difficult to deal with. If the distress causes you to bury the feelings or sweep them up under the carpet, they may not just go away. Instead they may result in increased tension and anxiety, which may eventually result in panic. Some panic sufferers find that their panics happen when something else has been bothering them – for instance, an argument with someone important, or other difficulties in relationships.
- Some people may be more vulnerable to panic than average because of concerns about their health and safety
- Panic often begins as a result of stress or other painful feelings
As previously explained panic attacks result from the body’s alarm system being triggered when there is no real danger. This brings us to the crucial role of your thoughts in causing and maintaining panic. The central point of the alarm system doesn’t only go off when there is actual danger it can hang around waiting to check carefully whether the sabre tooth tiger really is going to eat you. The alarm goes off whenever you think there might be danger. The alarm system’s motto is ‘ react first, check it out later’!
Below is an example:
A man is walking home late at night. The street is very quite and dark. He might feel keyed up because it is a bit spooky…..Clang! A noise! His heart is beating, he is scared, and he feels unsteady. He looks around quickly….but it is the cat that has knocked over the bin. Not a dangerous attack after all!
I hope this example shows how thoughts can produce strong feelings even when there is no real danger. The man had an alarm reaction because he thought he was in danger of being attacked. He misinterpreted the noise as indicating an imminent attack, but he started to calm down once he had worked out what was really going on. Once he realised that he was safe, the panic had quickly died away. If he had seen the cat on the bin earlier, he might not have misinterpreted the noise, and it might not have caused him any alarm at all. On the other hand if he had continued to believe that he was about to be attacked, his fear reaction might have blown up into panic. His reaction is all based on what he thinks is going on.
Similarly, panic attacks occur when someone thinks that something awful is happening. In the same way as the man above, people misinterpreted an ordinary event as indicating an imminent catastrophe some kind. However in panic, these misinterpretations are not usually about being attacked in the street, instead they most commonly involve people noticing some of the ordinary sensations caused by anxiety, and then thinking that these sensations mean that something dreadful is happening. Below are listed some of possible interpretations:
ANXIETY SYMPTOM MISINTERPRETATION
Heart pounding, palpitations “I’m having a heart attack?”
Shortness of breath “I will suffocate”
Dizziness, unsteadiness “I will collapse, or faint”
Feeling of unreality, lack of “I am going mad”
The problem with this kind of misinterpretation is that it leads into a vicious circle. If you take the original anxiety symptoms as meaning something catastrophic like a heart attack, then this increases the anxiety after all who wouldn’t be frightened if they thought they were about to die or go mad. The increased anxiety then causes more symptoms, which seem to confirm your fear. “It’s getting worse, there really must be something wrong”. This causes yet more fear “It’s getting worse, there really must be something wrong”. This causes yet more fear, which causes more symptoms and so it goes on, round and round in a vicious circle, which may spiral up into a full-blown panic attack.
This is known as a misinterpretation, which is crucial in driving this cycle. If you see the original symptoms as just indicating anxiety and nothing more, then you still may feel anxious and that will be uncomfortable but you won’t get into a panic, because there is nothing to escalate the whole process.
Sometimes when you get anxious your breathing can escalate into what is known as ‘hyperventilation’. This just means you are breathing faster than your body actually needs at that time. Although this is not dangerous in any way it can lead to even more bodily sensations such as feeling dizzy or chest pains and thus speed up the vicious circle.
What triggers a panic attack in the first place? Sometimes there is no trigger, the panic comes ‘out of the blue’, and this may make people even more sure that there must be something badly wrong. The central feature of the panic cycle is misinterpretation of normal sensations, particularly those caused by anxiety or tension. It follows from this that panic can be triggered by anything, which causes a change in bodily sensations, so that even a small change can trigger of an attack. Even an upsetting thought or image may be enough to do this, and sometimes this can happen so quickly that you do not even realise it has happened. As this small increase in tension might not be consciously noticed, the attack seems to ‘come out of the blue’. These are some of the factors, which may be involved in triggering a panic attack.
- Even slight increases in anxiety or tension, for whatever reason may come from persistent worrying about the possibility of having a panic attack
- Other emotional states, such as worry or anger may cause bodily reactions
- Physical exertion, which causes changes in your heart rate or breathing
- Other changes in your physical state, caused for example by pre menstrual tension, illness, hunger or tiredness.
- The effects of drugs, including caffeine and alcohol
- Being alone and unoccupied, and thus having more time to focus attention on your body
It is important to remember that these factors may contribute to a panic starting, but they are not actually dangerous and should not be avoided. Avoidance of triggers is not generally a good way of tackling the problem.
Although it can be helpful to try to find out what is triggering your panic, don’t get too preoccupied with it, and don’t worry if sometimes you can’t find a clear trigger. It may be more helpful to focus your efforts on learning how to cope with them and remembering that panic attacks are not dangerous, even if you don’t know what triggered them.
We have seen how panic attacks affect your body’s responses, the types of thoughts you have and the way you behave. Some of these thoughts and actions, whilst very understandable actually seem to work against you. They keep you having panics. They do this because they act in various ways to keep you believing there is a real danger, and therefore they maintain your fear. Listed are some thoughts and actions and how they work and keep panic going.
Another problem that often develops in people who have panic attacks is called ‘anticipatory anxiety’. This means that you will start to dread being in situations where an attack previously happened, because you are afraid of another panic attack occurring. This dread can be so strong that it can trigger an attack when you are next in that situation.
This is a vicious circle, previous panic attacks lead to negative thoughts about going back to the situation, “what if I have another panic attack? That would be terrible, I couldn’t cope…….” This leads to anticipatory anxiety, which will make you more sensitive. This in turn increases the likelihood of having an attack.
Anticipatory anxiety means that you are too scared to see what would happen if you went into a panic-inducing situation and stayed there.
Another way that panic attacks may be kept going is through scanning (sometimes called ‘hypervigelence’. This means that you become over sensitive to picking up possible threats, and particularly to normal bodily signals. All of us have bodily sensations from time to time e.g. missing a heartbeat, getting a pain somewhere, or feeling short of breath. All our bodily systems vary from hour to hour, so these sensations are common and do not necessary mean anything at all.
But if you have become concerned about these things, you may be subconsciously looking out for them, or scanning them.
We tend to notice more easily things, which are important to us, for whatever reason. For example, you may have had the experience of thinking about buying a particular model of car. Suddenly, the roads may seem to be full of that make of car, everywhere you go you see them. How likely is it that those people with those cars have suddenly decided to follow you around? Those cars were always there, but because they were of no importance to you before, you didn’t seem to consciously notice them. Now that they have become important you start to notice them and they are “everywhere!”
This is the same as bodily sensations. They are always there, but ordinarily we do not notice them. Because they are so common, if you start to look for them, even unconsciously, you will probably find something. The frightening thoughts then turn up “what does this mean am I having a heart attack? And the spiral into panic may begin.
- Every time you run away from a panic attack you are actually making life harder for yourself in the long run.
- By running away during a panic attack, or taking precaution to avoid a disaster, you
– Never give yourself the chance to see that nothing terrible will happen
– May dread being in that situation again because you fear having another attack
– May become so unconfident of your ability to cope, that you dare not go back to that situation
– Anticipatory anxiety, and ‘scanning’ for bodily changes, also keeps panic going.
There are techniques, which may help you prevent or alleviate panic attacks before they get out of control.
- Slow breathing
- Do not avoid, focus on the situation then challenge them
- Dealing with worries instead of ignoring them
Remind yourself that nothing disastrous is going to happen. The panic feels awful, but nothing worse than that is going to happen. You have survived panic before, and you will survive it this time as well.
As you have seen, worrying thoughts about what might happen to you are a central problem in panic. Distraction or other approaches often work well as a temporary way of coping with an anxious situation, but what is really necessary is to change those worrying thoughts. This is called ‘thought challenging’
1. Work out what your thoughts are. What is it that you fear happening?
2. Work out whether these thoughts are realistic or whether in fact be unnecessary frightening. If they are exaggerated then you need to look for more realistic thoughts.
- Identifying and challenging your catastrophic thoughts is the best way to deal with panic attacks in the long run.
Try not to avoid anxious situations, but test out what really happens through behavioural experiments.
Perhaps the main message is “don’t despair!” Lots of people suffer from panic but lots of people also learn to cope with it. Panic does not have to rule your life, it is a bully and the only way to stop the bullying is to fight back, to get out there and challenge your negative thinking.
People do faint sometimes, but what causes this to happen? People faint when their blood pressure drops enough to begin to reduce the blood supply to the brain. Now think what happens in a panic attack. When we are fearful our hearts pump faster and harder than usual. As a result, when you panic the blood pressure rises – exactly opposite to a faint. Therefore, it is impossible to faint when having a panic attack, because your panicking makes your blood pressure high not low.
CHALLENGING YOUR THOUGHTS THROUGH ACTION
Changing how you behave will help you overcome panic. As described previously avoidance and other safety behaviours may keep your panic going. Often the most powerful way of fighting back and testing out your thoughts is through action. Test out the situation, which frightens you, you can prove to yourself what really is going on. This kind of test is sometimes called a behavioural experiment because you set up an experiment to find out what really happens when you change your behaviour.
Think about what you need to test out, for example you may fear going in a supermarket alone because you will faint or collapse unless you hold onto a trolley. On the other hand, our ‘anxiety’ theory would predict that you would feel anxious, but that you will not faint. Now it is to see if this is true.
- You need to go into the supermarket alone, without holding your trolley no matter how uncomfortable you feel and see what really happens.
- Then evaluate your results. Did you collapse? You will almost certainly have felt anxious or maybe even panic, but did you actually faint or collapse? If you did not what does that suggest about the fearful thoughts?
You have learnt to be anxious in these situations, and that will not go away all at once. But anxiety is NOT dangerous. The point is does your fear actually happen? Do you die, or collapse or lose control? By testing out your fears, you can gradually begin to build up your confidence.
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