Managing Panic

• • • Skipping, racing or pounding heart
    • Sweating
    • Trembling or shaking
    • Shortness of breath or difficulty breathing
    • Choking sensations
    • Chest pain, pressure or discomfort
    • Nausea, stomach problems or sudden diarrhea
    • Dizziness, lightheadedness, feeling faint
    • Tingling or numbness in parts of your body
    • Hot flushes or chills
    • Feeling things around you are strange, unreal, detached, unfamiliar, or feeling detached from body
    • Thoughts of losing control or going crazy
    • Fear of dying

As you can see from the list, many of the symptoms are similar to what you might experience if you were in a truly dangerous situation. A panic attack can be very frightening and yo may feel a strong desire to escape the situation. Many of the symptoms may appear to indicate some medical condition and some people seek emergency assistance.

• • • It peaks quickly – between 1 to 10 minutes
    • The apex of the panic attack lasts for approximately 5 to 10 minutes (unless constantly rekindled)
    • The initial attack is usually described as “coming out of the blue” and not consistently associated with a specific situation, although with time panics can become associated with specific situations
    • The attack is not linked to marked physical exertion
    • The attacks are recurrent over time
    • During an attack the person experiences a strong urge to escape to safety.

Many people believe that they may faint whilst having a panic attack. This is highly unlikely because the physiological system producing a panic attack is the opposite of the one that produced fainting.

Sometimes people have panic attacks that occur during the night when they are sleeping. They wake from sleep in a state of panic. These can be very frightening because they occur without an obvious trigger.

Panic attacks in, and of themselves, are not a psychiatric condition. However, panic attacks constitute the key ingredient of Panic Disorder if the person experiences at least 4 symptoms of the list previously described, the attacks peak within about 10 minutes and the person has a persistent fear of having another attack.

When there is real danger, or when we believe there is danger, our bodies go through a series of changes called the fight/flight response. Basically, our bodies are designed to physically respond when we believe a threat exists, in case we need to either run away, or stand and fight. Some of these changes are

• • • An increase in heart rate and strength of heart beat. This enables blood and oxygen to be pumped around the body faster.
    • An increase in the rate and depth of breathing. This allows more oxygen to be taken into the body.
    • An increase in sweating. This causes the body to become more slippery, making it harder for a predator to grab, and also cooling the body.
    • Muscle tension in preparation for fight/flight. This results in subjective feelings of tension, sometimes resulting in aches and pains and trembling and shaking.

When we become anxious and afraid in situations where there is no real danger, our body sets off an automatic biological “alarm”. However, in this case it has set off a “false alarm”, because there is no danger to ‘fight’ or run from.

When we breathe in we take in oxygen that is used by the body, and we breathe out carbon dioxide. In order for the body to run efficiently, there needs to be a balance
between oxygen and carbon dioxide. When we are anxious, this balance is disrupted because we begin to overbreathe. When the body detects that there is an imbalance, it responds with a number of chemical changes. These changes produce symptoms
such as dizziness, light-headedness, confusion, breathlessness, blurred vision, increase in heart rate, numbness and tingling in the extremities, clammy hands
and muscle stiffness. For people with panic, these physiological sensations can be quite distressing, as they may be perceived as being a sign of an oncoming attack,
or something dangerous such as a heart attack. However these are largely related to overbreathing and not to physical problems.

We’ve described the physical symptoms of panic. People who panic are very good at noticing these symptoms. They constantly scan their bodies for these symptoms. This scanning for internal sensations becomes an automatic habit. Once they have noticed the symptoms they are often interpreted as signs of danger. This can result in people thinking that there is something wrong with them, that they must be going crazy or losing control or that they are going to die.
There are a number of types of thinking that often occur during panic, including:

• • • Catastrophic thoughts about normal or anxious physical sensations (eg “My heart skipped a beat – I must be having a heart attack!”)
    • Over-estimating the chance that they will have a panic attack (eg “I’ll definitely have a panic attack if I catch the bus to work”)
    • Over-estimating the cost of having a panic attack: thinking that the consequences of having a panic attack will be very serious or very negative.

We’ve described the physical symptoms of panic. People who panic are very good at noticing these symptoms. They constantly scan their bodies for these symptoms.
This scanning for internal sensations becomes an automatic habit. Once they have noticed the symptoms they are often interpreted as signs of danger. This can result in people thinking that there is something wrong with them, that they must be going crazy or losing control or that they are going to die.

There are a number of types of thinking that often occur during panic, including:

• • • Catastrophic thoughts about normal or anxious physical sensations (eg “My heart skipped a beat – I must be having a heart attack!”)
    • Over-estimating the chance that they will have a panic attack (eg “I’ll definitely have a panic attack if I catch the bus to work”)
    • Over-estimating the cost of having a panic attack: thinking that the consequences of having a panic attack will be very serious or very negative.

If you feel anxious, or anticipate feeling anxious, it makes sense that you will do things to reduce your anxiety. People sometimes try and reduce the anxiety by avoiding the feared situation altogether. This avoidance instantly decreases the anxiety because you have not put yourself in a distressing situation. However, while avoidance makes anxiety better in the short term you have also made the anxiety worse in the long term.

An illustration of this is when you avoid going to a supermarket to do the shopping because that’s where you experience fear. As a result you successfully avoid the distress you associate with supermarkets. In the short term, you do not feel anxious. However in the long term you become even more unwilling to confront anxiety. You continue to believe that emotion is dangerous and should be avoided at all costs. You do not disconfirm your catastrophic predictions about what may happen in the shopping centre. You continue scanning your environment for signals of danger and signals of safety. In this way your anxiety may increase and generalise to other situations.

Vicious cycles play an important role in maintaining anxiety. However, you can turn this cycle around to create a positive cycle that will help you overcome anxiety. One important step in this cycle is gradually confronting feared situations. This will lead to an improved sense of confidence, which will help reduce your anxiety and allow
you to go into situations that are important to you.

Some people might encourage you to tackle your biggest fear first – to “jump in the deep end” and get it over and done with. However, many people prefer to take it “step by-step”. We call this “graded exposure”. You start with situations that are easier for you to handle, then work your way up to more challenging tasks. This allows you to build your confidence slowly, to use other skills you have learned, to get used to the situations, and to challenge your fears about each situational exposure exercise. By doing this in a structured and repeated way, you have a good chance of reducing your anxiety about those situations.

Breathing is an essential part of life, but did you know that breathing plays an essential role in anxiety? This information will briefly discuss the role of breathing in anxiety and guide you through a simple calming technique that uses breathing patterns to help you relax.

Breathing is a powerful determinant of physical state. When our breathing rate becomes elevated, a number of physiological changes begin to occur. Perhaps you’ve noticed this yourself when you‘ve had a fright; you might suddenly gasp, feel a little
breathless and a little light-headed, as well as feeling some tingling sensations around your body. Believe it or not, the way we breathe is a major factor in producing these and other sensations that are noticeable when we are anxious.

You might already know that we breathe in oxygen – which is used by the body – and we breathe out carbon dioxide. In order for the body to run efficiently, there needs to be a balance between oxygen and carbon dioxide, and this balance is maintained through how fast and how deeply we breathe. Of course, the body needs different amounts of oxygen depending on our level of activity. When we exercise, there is an increase in both oxygen and carbon dioxide; in relaxation there is a decrease in both oxygen and carbon dioxide. In both cases the balance is maintained.

When we are anxious though, this balance is disrupted. Essentially, we take in more oxygen than the body needs – in other words we overbreathe, or hyperventilate. When this imbalance is detected, the body responds with a number of chemical changes that produce symptoms such as dizziness, light-headedness, confusion, breathlessness, blurred vision, increase in heart rate to pump more blood around, numbness and tingling in the extremities, cold clammy hands and muscle stiffness.

The normal rate of breathing is 10-12 breaths per minute – what’s your breathing rate?

While overbreathing and hyperventilation are not specifically dangerous (it’s even used in medical testing!), continued overbreathing can leave you feeling exhausted or “on edge” so that you’re more likely to respond to stressful situations with intense anxiety and panic.

Gaining control over your breathing involves both slowing your rate of breathing and changing your breathing style. Use the calming technique by following these steps
and you’ll be on your way to developing a better breathing habit.

1.  Ensure that you are sitting on a comfortable chair or laying on a bed
2.  Take a breath in for 4 seconds (through the nose if possible
3.  Hold the breath for 2 seconds
4.  Release the breath taking 6 seconds (through the nose if possible)., then pause slightly before breathing in again.
5.  Practice, practice, practice!

• • • When you first begin changing your breathing, it may be difficult to slow your breathing down to this rate. You may wish to try using a 3-in, 1- hold, 4-out breathing rate to start off with.
    • When you are doing your breathing exercises, make sure that you are using a stomach breathing style rather than a chest breathing style. You can check this by placing one hand on your stomach and one hand on your chest. The hand on your stomach should rise when you breathe in.
    • Try to practice at least once or twice a day at a time when you can relax, relatively free from distraction. This will help to develop a more relaxed breathing habit. The key to progress really is practice, so try to set aside some time each day.

By using the calming technique, you can slow your breathing down and reduce your general level anxiety. With enough practice, it can even help to reduce your anxiety when you are in an anxious situation.

When you are beginning to practice progressive muscle relaxation exercises keep in mind the following points.

• • • Physical injuries. If you have any injuries, or a history of physical problems that may cause muscle pain, always consult your doctor before you start.
    • Select your surroundings. Minimise the distraction to your five senses. Such as turning off the TV and radio, and using soft lighting.
    • Make yourself comfortable. Use a chair that comfortably seats your body, including your head. Wear loose clothing, and take off your shoes.
    • Internal mechanics. Avoid practicing after big, heavy meals, and do not practice after consuming any intoxicants, such as alcohol.

1. Right hand and forearm. Make a fist with your right hand.
2. Right upper arm. Bring your right forearm up to your shoulder to “make a muscle”.
3. Left hand and forearm.
4. Left upper arm.
5. Forehead. Raise your eyebrows as high as they will go, as though you were surprised by something.
6. Eyes and cheeks. Squeeze your eyes tight shut.
7. Mouth and jaw. Open your mouth as wide as you can, as you might when you‘re yawning.
8. Neck. !!! Be careful as you tense these muscles. Face forward and then pull your head back slowly, as though
you are looking up to the ceiling.
9. Shoulders. Tense the muscles in your shoulders as you bring your shoulders up towards your ears.
10. Shoulder blades/Back. Push your shoulder blades back, trying to almost touch them together, so that your chest is pushed forward.
11. Chest and stomach. Breathe in deeply, filling up your lungs and chest with air.
12. Hips and buttocks. Squeeze your buttock muscles
13. Right upper leg. Tighten your right thigh.
14. Right lower leg. !!! Do this slowly and carefully to avoid cramps. Pull your toes towards you to stretch the calf muscle.
15. Right foot. Curl your toes downwards.
16. Left upper leg. Repeat as for right upper leg.
17. Left lower leg. Repeat as for right lower leg.
18. Left foot. Repeat as for right foot.

Practice means progress. Only through practice can you become more aware of your muscles, how they respond with tension, and how you can relax them. Training your body to respond differently to stress is like any training – practising consistently is the key.

1.Be clear about the purpose of the experiment – the point is to test out your negative predictions and help you to develop more realistic and/or balanced predictions.

2. What is the thought or belief that you are trying to test? Rate how strongly you believe this prediction (0-100)
I will have a terrible time at the BBQ. Even if I try to talk to people, no-one will talk to me. (90)

3. What is an alternative prediction or belief? Rate how strongly you believe this alternative (0-100)
I will find at least one person to talk to and will have an ok time. (10)

4. Design the actual experiment – what will you do to test your prediction, when will you do it, how long will it take, and with whom? Try to be as specific as possible. There are no boundaries to how creative you can be, and it is ok to ask for help.

I will go to the BBQ at 8pm, alone, and will stay for at least one hour. I will try to make conversation with at least three people, one that I did not know already. I will only drink one glass of wine.

5.Make sure you set your experiment at an appropriate level. It is best to start simply and
increase the challenge step-by-step. Identify likely problems and how to deal with them.

There might not be anyone I know at the BBQ. But I will at least know the host and I can ask to be introduced to some other people.

1. Carry out the experiment as planned. Remember to take notice of your thoughts, feelings, and behaviours.

2. Write down what happened, what did you observe? Consider the evidence for and against your original prediction. What did this say about your negative prediction

I felt quite nervous at first and wanted to leave. I used
breathing to calm myself. The host was friendly and seemed
happy to talk to me, and I also spoke to Kelly, who I hadn’t
seen in some time. Kelly introduced me to her partner Jim
and we had a good chat about travel. At one point I worried
I had said something stupid, but Jim didn’t seem to notice so
my worry passed.

3. What have you learned?

I am capable of making conversation and enjoying myself in a casual social situation.

4. Rate how strongly you now believe in your original prediction and the alternative (0-100)
I will have a terrible time at the BBQ. Even if I try to talk to
people, no-one will talk to me. (10)
I will find at least one person to talk to and will have an ok
time. (80)

One of the ways that people avoid feeling anxiety in certain situations is to avoid those situations
wherever possible. However, by not exposing yourself to those situations you don’t get the chance to
disconfirm your fears, which in turn can make those fears even stronger. If being in those situations is important to you, you will need to face your fears in a real situation and begin to turn social activity into a positive experience. This information sheet is designed to show you how you can begin to do that.

Some people might encourage you to tackle your biggest fear first – to “jump in the deep end” and get it over and done with. However, many people prefer to take it “step by- step”, what some people call “graded exposure”. By using graded exposure you start with situations that are easier for you to handle, then work your way up to more challenging tasks. This allows you to build your confidence slowly, to use other skills you have learned, to get used to the situations, and to challenge your fears about each situational exposure exercise. By doing this in a structured and repeated way, you have a good chance of reducing your anxiety about those situations.

The first thing to do is to think about the situations that you fear and try to avoid. For example, some people might fear and avoid going to social places, or being assertive with others. Make a list of these situations.

Once you have made the list, indicate how much distress you feel in those situations by giving them each a rating on a scale of 0 to 100.

0 – You are perfectly relaxed
25-49 – Mild: You can still cope with the situation
50-64 – Moderate: You are distracted by the anxiety, but are still aware of what’s happening
65-84 – High: Difficult to concentrate, thinking about how to escape
85-100 – Extreme: The anxiety is overwhelming and you just want to escape from the situation

Now you can start to turn the situations you avoid into goals that you’d like to achieve. For example, a situation that you avoid might be “Going to pubs“, which has a distress rating of 75. A goal for this might be “To go out to a pub on a weekend night with friends and stay there for at least 2 hours”.
When you are developing a goal, it helps to make them
SMART:

Specific: It needs to be as clear (eg compare “To eat in public”
with “To eat lunch in a local restaurant on my own.”
Measurable: It needs to be easily assessed (eg compare
“Being friendly” with “Staying for 2 hrs” – what does
‘friendly’ mean?)
Achievable: It needs to be possible and probable to achieve
Relevant: It needs to be important to you
Timebound: It needs to have an end date for completion

Now that you have a personal, realistic, achievable, measurable, and specific goal that you’d like to achieve, you can plan your “graded exposure” program. This involves breaking the goal down so that
you can work step-by-step towards your major goal. Of course, goals with high distress (eg a rating of 80+) will need more steps than a medium distress goal (eg a rating of 40+). You can break your
goal into smaller steps by changing WHO is there, WHAT you do, WHEN you do it, WHERE you do it, and HOW long you do it for. Follow the SMART criteria for developing each step. Here’s an example.