You’re sitting in your car trying to will yourself to walk into the grocery store. Anxiety washes over you. You’re cold and hot at the same time with sweat trickling down your back, hair standing on your arms. You finally get out of your car. But as you enter the store, you feel wobbly and like you’re going to pass out. The fluorescent lighting seems especially stifling. The wide aisles, oddly enough, feel claustrophobic. Your breath feels finite, like a balloon floating up to the sky, which you can’t catch. In fact, at times you feel like you’re floating along with the balloon. At times you feel like Edvard Munch’s famous painting “The Scream,” your whole body shrieking.
This happens in other places, too. Sometimes, it happens when you’re at the mall or somewhere new. Sometimes, it happens when you’re enjoying a delicious dinner with friends, watching a movie with your spouse or just driving home. “Suddenly your body surges with adrenaline. You are hit with a feeling of dread and impending doom like you are going to die, go crazy, faint or lose control,” said Tamar Chansky, Ph.D, a clinical psychologist who helps children, teens and adults overcome anxiety.
She defined a panic attack as the brain, suddenly and out of the blue, engaging the emergency response program like it would if you’re in serious danger. “[This] would be great except that it happens in the absence of any actual threat.”
Panic attacks can be terrifying. You might be convinced you’re having a heart attack. You might feel paralyzed. And, of course, you’re experiencing intense fear, which is affecting your entire body.
A panic attack contains four out of 13 physical or cognitive symptoms, said Simon Rego, Psy.D, ABPP, Director of Psychology Training at Montefiore Medical Center/Albert Einstein College of Medicine in New York. They include: “heart racing; dizziness or lightheadedness; shortness of breath; stomach distress; numbness and tingling; chills or hot flashes; feeling like things aren’t real or feeling disconnected from oneself; and thoughts about going crazy or losing control.”
You also start to panic about having panic attacks. For instance, if you’ve had a panic attack while grocery shopping, you start to fear having future panic attacks at supermarkets. This can lead you to avoid them. But avoidance only amplifies and perpetuates anxiety. Over time, you might find yourself saying no to any experience that may trigger discomfort, Chansky said.
Avoidance also “gets patients out of practice when it comes to dealing with challenging emotions, sensations [and] situations. So they typically feel more anxious when they eventually have to enter those situations. [This] ironically makes the situations even more challenging to manage,” Rego said.
There’s a lot of shame associated with having panic attacks. For instance, Chansky finds that her male clients feel very embarrassed. “[T]hey, like anyone, feel out of control. But this feels very high stakes for them [because] of their image of themselves or what they think they are supposed to be.” They think they’re supposed to be invincible or in control, she said.
You, too, might view yourself as weak or a wimp for being afraid. You’re not. You’re also not alone. Panic attacks are quite common, said Rego. About 6 million American adults have panic disorder, a condition marked by recurrent panic attacks, according to the Anxiety and Depression Association of America (ADAA).
According to Chansky, “these symptoms are frightening until you crack the code and know — like the Wizard of Oz — there’s no man behind the curtain. Nothing terrible is going to happen when you have a panic attack. You’ll have uncomfortable feelings, and they will pass if you don’t fan the fires with more fear.”
And that’s the great news. Panic attacks are highly treatable. It doesn’t matter how long you’ve been struggling with panic attacks, there are effective and relatively brief treatments to help you get better, Rego said. Below, you’ll learn more about these treatments along with what you can do on your own.
Treatment of Choice
“Expert consensus guidelines suggest that cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the two ‘first line’ treatments of choice,” Rego said.
CBT is a form of psychotherapy that teaches patients how panic attacks occur and what perpetuates them, he said. Patients learn cognitive skills (such as “decatastrophizing”) to challenge their negative beliefs about panic attacks, he said. “[W]ithout that panic spiral of catastrophizing questions — what’s next, what’s next, what’s next?! — panic attacks really can’t occur anymore,” said Chansky, author of the book Freeing Yourself from Anxiety: 4 Simple Steps to Overcome Worry and Create the Life You Want.
Patients gradually and systematically face their feared situations through “graded exposure,” Rego said. This means “facing less anxiety-provoking situations first, and then moving up to more challenging ones.”
Patients also face their feared sensations through “interoceptive exposure,” he said. This means “doing physical exercises to bring on the feared sensations.”
This is important because, as Chansky said, “panic disorder is defined by being afraid of the meaning of uncomfortable physical feelings and thoughts that are actually harmless; they are like a fire drill of the emergency response system in the body.” Bringing on symptoms shows you that they’re truly innocuous, you can survive them and they “don’t have to lead to the spiral of fear.”
For instance, if a patient is afraid of being dizzy, she and Chansky spin around in session to trigger that feeling. They use breathing techniques and relabel what’s happening: “It’s just a feeling, and it’ll pass. You don’t have to be afraid of those symptoms and catastrophize about their meaning.” This is very different from getting dizzy, and saying, “Oh no! I’m dizzy! I’m going to faint. What if I faint here? What if I lose control? What’s going to happen?”
As she noted, these thoughts “would make anyone uncomfortable, but they aren’t necessary or true.”
If a patient is worried about his heart racing, he and Chansky run up and down the stairs over and over. This teaches the patient that the feeling of tightness in the chest and rapid heart rate are normal and nothing to fear.
Rego shared this other example of a typical CBT session: A therapist and patient go into an elevator together. First they go up one floor in a less crowded elevator. Eventually, they go up to the top floor in a crowded elevator. They observe the patient’s symptoms, but they don’t try to fight or eliminate them, he said.
Finding a clinician who specializes in CBT can be hard, because there aren’t enough trained therapists, Rego said. Often this means having to travel for a well-trained clinician. “This is obviously especially challenging for people with panic attacks.”
Many also struggle with agoraphobia: “a fear of going out into places in which help might not be readily available or escape might be difficult in the event of a panic attack.” In order to gain some momentum, it’s OK to have someone go with you, Rego said. However, eventually, it’s important to attend therapy on your own.
Rego suggested checking out these websites for CBT practitioners near you: Association for Behavioral and Cognitive Therapies (ABCT); Anxiety and Depression Association of America (ADAA); and the Academy of Cognitive Therapy (ACT). He also recommended the self-help book Mastery of Your Anxiety and Panic. Alice Boyes, Ph.D, author of The Anxiety Toolkit suggested this free CBT workbook.
“Most people will probably do best with either medication and psychotherapy or psychotherapy alone,” according to William R. Marchand, M.D., a psychiatrist and clinical associate professor of psychiatry at the University of Utah School of Medicine. When medication is prescribed, it’s used to treat panic disorder (not rare panic attacks), he said.
Specifically, antidepressants are the mainstay for treating the condition, he said. These include: SSRIs, such as fluoxetine (Prozac), citalopram (Celexa) and paroxetine (Paxil); and SNRIs, or serotonin-norepinephrine reuptake inhibitors, such as venlafaxine (Effexor) and duloxetine (Cymbalta).
Benzodiazepines are sometimes used to alleviate severe or disruptive symptoms until an antidepressant takes effect, said Marchand, also author of the book Mindfulness for Bipolar Disorder: How Mindfulness and Neuroscience Can Help You Manage Your Bipolar Symptoms. An antidepressant can take several weeks to work, while a benzodiazepine acts immediately.
However, it’s important to be cautious with benzodiazepines because they have the potential for abuse and addiction, he said. For instance, this means not prescribing them to individuals with a current or past substance use disorder, he said. Motor impairment also may be a side effect, which can be problematic for elderly patients because of the increased risk for falls, he said. Cognitive impairment is another potential side effect. So caution also needs to be used with people who have a cognitive disorder or head injury, he said.
Also, according to Rego, there’s some evidence that suggests benzodiazepines “are unhelpful in the long term and may even have a negative impact on cognitive behavioral therapy (CBT) — unless the patient works with his or her psychiatrist to taper off of them during CBT.”
Be honest with your therapist.
Often people will avoid treatment or self-help materials because they fear that talking or reading about anxiety will trigger a panic attack, Boyes said. (“Writing about panic attacks sometimes triggers panicky feelings for me.”) But even though this is anxiety-provoking, these actions (not avoidance) will help you get better. Boyes suggested being open with your therapist about your fears about treatment. “Working through them is part of the treatment process.”
This means engaging in healthy habits and minimizing your stress. “Yes, panic can happen out of the blue. But if you are overtired, not eating right or overly stressed at work, you will start your day with a high baseline of anxiety. And there will be little buffer between you and panic,” Chansky said. Having a low baseline of stress gives you the opportunity to more accurately interpret “the false alarm of panic rather than getting roped in.”
Learn about the physiological reasons for your symptoms.
According to Boyes, “When you understand that all the physical symptoms have an adaptive purpose, you understand that fear is your body working as it should and that it knows what to do; it’s just being a little overactive (OK, a lot overactive).” One of her favorites is the theory behind goose bumps: They cause our hair to stand on end. If we still had long hair, we’d look bigger and scarier this way — just like cats.
(Learn more in module 1, on pages 3 and 4 in the “physiology” section.)
Challenge the thoughts and predictions related to panic attacks.
According to Rego, there are two primary ways to challenge your thoughts and predictions about panic attacks. One strategy is to question the probability that a physical consequence will actually occur. You might ask yourself: How many times have I feared that X will happen during an attack? How many times did X actually happen?
The second strategy is to question the severity of any social consequences you fear of having a panic attack in public, Rego said. Ask yourself: How embarrassed would I feel? Have I even felt embarrassed before? How did I cope? How bad does it feel now?
Work on eliminating “safety behaviors.”
“Safety behaviors are all the little things patients do that they believe will keep them ‘safe’ in the event of a panic attack,” Rego said. He shared these examples: carrying a bottle of water; sitting near exits; carrying old (and typically empty) bottles of medication; standing up slowly to prevent lightheadedness; walking slowly to prevent your heart from racing; and distracting yourself.
Some research, Rego said, even suggests that tips such as taking deep breaths and practicing muscle relaxation may be problematic. “Some researchers have proposed that these skills serve only as a temporary aid (distraction). And if the patient believes that these types of coping skills prevent some catastrophic event from occurring, the fear will live on until tested.”
The research is mixed, and other experts believe that teaching the above skills helps patients face their fears faster. Eventually, it’s helpful for patients to stop using such skills, so they can learn their panic attacks are not dangerous. “If not, the fear of future panic attacks seems to live on despite the patient having learned these skills.”
Remember false messages are the real issue.
Chansky encouraged readers to remind yourself that the problem isn’t the party, supermarket or your car. The problem lies in the “false messages [your] over protective brain is sending out about those situations.”
So when you start receiving those messages, instead of assuming your thoughts are correct, you can notice and analyze them, she said. Pretend you’re a reporter: “My mind is telling me that this isn’t safe. That’s not true; this is fine. Nothing has changed in this moment. Everything is the same. These feelings will pass. They are temporary and harmless. I am fine. What’s happening isn’t a sign of something being wrong; it’s just the alarm system in my body went off at the wrong time.”
Panic attacks are horrible, Boyes said. “But what’s worse is constant fear of panic attacks.” What’s worst is structuring your life to avoid panic and discomfort, because all this does is narrow your world and amplify your anxiety. As Boyes added, “you can’t organize your life to avoid anxiety or anxiety will eat you alive. Part of the process of healing is being willing to do things that trigger anxiety for you, and learning how to cope when that happens.” Because you can cope. Check out the above websites and books. And seek professional help. Remember that you are not alone. And you can get better.
Panic attack photo available from Shutterstock