Panic Attacks

What are Panic Attacks?

A panic attack is a short but intense feeling of fear. It can last from a few minutes to several hours (although this may be when a constantly high level of stress is experienced, punctuated by repeated panic attacks). The symptoms can be so severe that you feel as though you are dying, having a heart attack or are out of control.

When the mind is very stressed it is easy for it to be pushed one stage further, being very vulnerable to further stresses. The surge of adrenaline that is produced by the body at such times (a natural part of the body's 'fight or flight' mechanism, designed to protect you in times of great danger) can produce an array of alarming symptoms such as:

  • abdominal pain
  • an urgent need to use the toilet
  • blurred vision
  • chest pain
  • difficulty in swallowing
  • feeling dizzy or faint (and actually fainting)
  • feeling tight across the chest
  • feeling unable to breathe
  • hyperventilation
  • nausea (and vomiting)
  • palpitations
  • rapid heart beats
  • shaking
  • sweating.
    • Although panic attacks are frightening experiences, they are physically harmless. But the experience of having a panic attack can be so disturbing you so fear having another panic attack that your consequently increased levels of anxiety trigger further attacks – each time your fear of having another one becoming stronger. This can lead to avoidance behaviour where you avoid situations that you feel might trigger another panic attack.

      Coping with Anxiety and Panic Attacks
      Coping with anxiety and panic is not an easy task as the key to coping is acceptance and not fighting against your feelings of anxiety. Once you can recognise the first symptoms of anxiety that develop and learn to breathe deeply and slowly, using your diaphragm, you can stop your anxiety escalating. If it does get out of control, let the feelings wash over you and wait for them to pass. This is the quickest way of averting a panic attack or reducing its length and severity.

      Stop yourself from hyperventilating
      You can relieve your anxiety symptoms by dealing with the way you breathe. If you become successful at doing this you may be able to prevent panic attacks. There are five things you can do to stop hyperventilation (that causes many unpleasant symptoms of panic):

      Emergency relief from hyperventilation:
        Breathe deeply into a paper (not plastic) bag, with the opening of the bag covering your nose and mouth. When you do this, you are re-breathing air that you have already exhaled and this brings up the concentration of carbon dioxide in your body, reducing the amount of oxygen. This is a common way to treat hyperventilation.
        Breathe diaphragmatically.
      This can take a while to master. Put one hand on your tummy and another on your chest. When you breathe in (through your nose, not your mouth), use your tummy to push your hand out. Your chest should not move. This ensures that you are breathing deeply and not shallowly. (Try counting to four on the in breath and another four on the out breath to make sure you are breathing regularly and evenly.) This makes you breathe out completely (without forcing the last bit of air out of your lungs) before you breathe in again. Breathing like this stops you hyperventilating. You should practise breathing like this whenever you can – it is the relaxed way to breathe. No one knows when you are practising this form of breathing so you can do it anywhere at any time.
      The more you breathe diaphragmatically, the more you reduce the symptoms of anxiety and panic.
        Count the number of breaths you take per minute. This should be around 12 per minute (one every 5 seconds) when you're at rest. If you are breathing more than this, check that you are breathing diaphragmatically and that your breaths are long and deep taken in through your nose (it takes longer than breathing through your mouth).
        Monitor your breathing and your muscle tension.
      Put a small dab of Tippex on your watch or watchstrap, where you will see it when you check the time. When you see this white dot, focus on your breathing and remind yourself to breathe diaphragmatically. At the same time, mentally scan your muscles (from your scalp to your toes) to see which are tense and consciously relax them. This reduces your underlying tension bringing you to a higher level of relaxation at regular points throughout the day. When you have done this for some weeks, it will become second nature to you to relax and check that you are not becoming tense.

      If there is a situation coming up where you know you will feel tense, try to enjoy it and live through it with floppy muscles and diaphragmatic breathing. This prepares you for dealing with panic-inducing situations, building your confidence to deal with more and more difficult situations.

      Emergency relief from panic
      Perform this breathing cycle taught me by a yoga teacher (you can escape to the toilet or your car or anywhere else where you can be alone):

      • Breathe out.
      • Close your mouth.
      • Pinch your nose with your right hand using your thumb and third finger.
      • Place your second and third fingers together between your eyebrows.
      • Release your thumb and inhale through your right nostril.
      • Close your right nostril and hold your breath for 3 slow counts.
      • Exhale through your left nostril, releasing your third finger.
      • Breathe in through your left nostril and then close it. Hold your breath for 3 slow counts.
      • Exhale through your right nostril, releasing your thumb.
      • Inhale through the same nostril and then close it again. Hold your breath for 3 slow counts.
      • Continue with this cycle until you feel calmer.
      • This exercise takes so much concentration that it can distract your mind, reducing your symptoms of anxiety. Once you have mastered the exercise, increase your level of concentration by counting out slowly to 3 or 4 on your out-breaths, 3 to 4 on your in-breaths and hold to 3 or 4 before you exhale.
        • When you have mastered this, try imagining your breath coming in through your right nostril, past the back of your throat, down the windpipe into your lungs. When you hold your breath imagine the oxygen from the air you just breathed in being exchanged for carbon dioxide from the blood. Then exhale imagining the used air leaving the lungs and travelling up your windpipe, past the back of your throat and out through your left nostril. If you can concentrate on doing all these things, your mind has no room for the thoughts that induced your panic and so your symptoms will gradually recede.

          Distract yourself
          If you can stop your mind concentrating on how bad your body feels, you can get some relief from physical symptoms and have a chance of regaining control, breaking the cycle of increasing fear that leads to a panic attack. Suggestions are:

          Closely examine a pen and note its texture; how it looks – whether shiny or matt, the colour, whether smooth or rough; how the switch works, the size and feel of it; what the nib looks like; how many sections there are to the pen, whether it has any writing on it or a logo and so on.
          Count the number of bricks in the wall opposite you (if it has visible bricks); the number of colours you can see in the room; the number of right angles in the room or visually trace patterns on carpets or wallpaper.

          Use your peripheral vision
          A technique used in Neuro-Linguistic Programming, explained by Andy Smith (NLP trainer based in Manchester) to calm your body is to do the following: 'Find a point on the wall that is straight in front of you and slightly above your eye level and stare at it in soft focus. Let your field of vision gradually broaden out (without moving your eyes) until you are aware of what you can see at the very edge of your vision – both sides at once. At the same time let your jaw muscles relax and breathe easily. Be aware of what is happening behind you too to get 360 degrees' awareness. This activates the parasympathetic nervous system which calms your body down. It also calms your internal dialogue and slows your heartbeat. You may notice your hands gradually become warm. After staying in this relaxed state for a while, gradually come back to normal waking consciousness by narrowing your vision.'

          Learn to relax
          Buy a relaxation tape to help you relax and feel what your body feels like when it is in a deep state of relaxation. You can use it before stressful situations or to help you fall into a relaxed and refreshing sleep. Some people use it two or three times a day when their stress levels are generally too high because they feel they have too much to cope with and feel close to 'cracking up'. (An example is a student taking career-determining exams.)

          A quick way of relaxing is to tense all your muscles, including facial muscles, as tight as you can and hold for three seconds. Then relax them and breathe out imagining hot water trickling down you at the same time or imagining that you are as floppy as a rag doll. Combining this with diaphragmatic breathing (see above) makes this a powerful relief to tension that builds up through the day. Repeat this whenever you are conscious of your tension building up.

          For a longer relaxation session try this:

          • Lie on your bed in a dark and quiet room.
          • Lie on your back with your arms by your sides, your fingers gently curled, and your legs slightly apart.
          • Throughout breathe diaphragmatically (see above) and in turn tense and release different muscle groups. Start by tightly screwing up your face and holding for 3 long counts and then releasing feeling the tension leave your face. Consciously note what it feels like to be relaxed. (Do this after every time you relax a muscle group.)
          • Tense your neck and shoulders, hold and relax.
          • Tense one arm and hand, then the other each time holding and then relaxing.
          • Tense your chest muscles, hold and relax.
          • Tense your abdomen and buttocks, pulling your stomach in and clenching your buttocks. Hold and relax.
          • Tense your right leg and foot (you can hold your leg a few centimetres up from the bed), hold and relax. Then the left.
          • Tense your entire body, concentrating on getting every muscle you can include. Then hold and relax.
          • Concentrate on how your body feels.
          • Keep scanning your body to check that each muscle group is relaxed and, before you leave that group to scan the next, tell yourself how floppy the muscles are and how you feel your face, arm, leg etc. melting into the bed. Let go all your tension. Stay like that for 20 minutes if it is the daytime or until your fall asleep if it's at bedtime.
            • Allow yourself to 'fail'
              Sometimes your personal expectations of yourself are too high and the pressure can be unrelenting. You do not have to be best at everything or succeed in everything you do. People make mistakes. You are a person, so why shouldn't you make mistakes too? Do you think less of people because they haven't always got it right? If you don't, why should you think others would think less of you if you made a mistake?

              None of us can be perfect and trying to be is an impossible task. Go easy on yourself.

              Challenge yourself
              To conquer your fears, you need to challenge yourself. Instead of avoiding every little situation that makes you worry, write a list of things that you find hard (or impossible) to do. Put them in order of difficulty with the easiest first. Then set yourself the task of going through the list, putting yourself in these stressful situations.

              However, don't try to do too much at once. Work with the first item on the list until you feel relatively at ease with it. Then go on to the second and so on. Be prepared for setbacks and allow yourself to drop back – but only temporarily. As soon as you are mentally strong enough, persevere with tackling that list.

              Confide in a friend
              The support of a friend can be invaluable. The relief of not hiding your problems from everyone can be enormous. In confiding you are also giving yourself the right to be you. Try not to hide your weaknesses from everyone – that in itself is a weakness. It is hard to ask for help, but we all need it from time to time.

              Having a friend in the know can also help if you have become too afraid to do certain things because of your anxiety or panic. You may well feel able to perform certain tasks when your friend is with you that were previously beyond you. However, don't become completely dependent on your friend. Once you can do something easily with your friend's company, try to do it without so that you eventually become totally independent and just enjoy your friend's company on the days he can be with you, without it being a disaster if he has to cancel.

              Some men may find it impossible to confide emotional problems to another man because of a fear of losing face or not being macho enough. If this applies to you, make friends with sympathetic women as you may see them as less threatening, and confide in them at levels appropriate to the depth of your friendship to get emotional support (and be prepared to be supportive back). If you have trouble forming relationships read Overcoming Loneliness and Making Friends and, How to be a People Person.

              Deal with underlying stress
              Many people start having panic attacks because their underlying stress is at a constant high. Eventually there comes a point beyond which a panic attack is very likely. Reducing your underlying stress also reduces the likelihood of a repeated panic attack. Examine your life and decide what things are not worth worrying about. Then look at the things that are worth worrying about. Can you improve the situation through your worry? Probably not. Stop letting worrying thoughts overtake your waking (and sleeping) moments. Say, 'STOP' to yourself and put an end to the ceaseless negative chatter that goes on in your head. Give yourself a break.

              If you think that your worries need time spent on them to work out a solution, write down the key words of the problem and then put the paper to one side to deal with at a specific time. Never take your worries to bed with you. Try to keep them completely separate to your night time regime. This will help ensure you have a peaceful sleep and wake up refreshed. Then you will be better able to deal with your problems and you will be coming to them anew.

              If possible, deal with your problems logically. If, for example, you have to make an important decision but cannot decide what is the best course of action, take a sheet of paper and divide it into two columns. One column is for yes, to take action, and the other column is for no, to leave things as they are (or some other choice where appropriate). Then write down reasons for doing the thing and reasons for not doing the thing.

              After you have done this, assign a score of between one and three to each reason. Give it a three if the thing is very important to you, a two if it is fairly important and a one if it is not very important. Then add up the scores for the two columns. If these are very different, it should be clear what you need to do. If they only differ by one or two points, or they are equal, check that you have assigned the right value score and have not forgotten any reasons. If they still remain about equal, perhaps you should do nothing at this time and wait until something happens to tip the balance.

              Approaching decision making in this way can be reassuring because you have the evidence before you that you have made your choice with valid reasons.

              Cope with insomnia
              Insomnia often accompanies underlying stress. (Transient insomnia lasts two to three days. Short-term insomnia lasts up to three weeks. Chronic insomnia is when you've had trouble sleeping for three weeks or more.) Adults commonly need seven to eight hours sleep a night although some people manage on far less. You tend to need less sleep as you get older.

              It is a good idea to reduce your general anxiety during the day using methods described in Learn to relax, above. This will help when you follow a relaxation programme at bedtime, as your anxiety levels will already be grounded to a lower level.

              The following also help:

              • Exercise for 20 to 30 minutes three times a week: it helps your body to relax and reduces overall stress counteracting the effects of hyperventilation and helps you to sleep.
              • Don't be tempted to nap in the daytime to make up lost sleep.
              • Keep to a routine at bedtime.
              • Go to bed and get up at the same time every day, even on the weekends.
              • Only use your bed for sleeping (and sex) and do not allow yourself to ponder over decisions and stressful things: they can be done when you are up. This helps you train your body to expect to go to sleep in the bed and little else. (You can write everything down that you need to spend time thinking about before you go to bed: it'll be there for you in the morning so you don't need to worry about forgetting it.)
              • Avoid stimulants: caffeine, nicotine, watching television and reading an exciting book before bed: allow yourself to wind down.
              • Avoid alcohol: although it helps you to sleep, it's not a natural sleep.
              • Don't have too much to drink in the evening (or you'll have to keep getting out of bed to go to the toilet).
              • Make sure you have enough to eat so that you aren't hungry: but don't eat too much as that can make you feel uncomfortable, making it hard to sleep.
              • Have a warm bath in a darkened room, or by candlelight. The warm water will relax you (and lower your blood pressure ready for sleep) and the dark will help the conscious part of your brain shut down.
              • Make sure that you are not too hot or too cold and that your bed is comfortable. If noise is a problem you could try wearing earplugs. If light disturbs you, you could try wearing an eye mask.
              • If you can't sleep, try not to panic. As long as you lie in bed in a relaxed state (keep checking your muscles are relaxed and that you're breathing diaphragmatically) you won't feel hugely bad when it's time for you to get up. You will have had a good measure of rest (don't be tempted to sleep in to catch up). It is possible to have a full day after little or no sleep: this is not the same as when you are up half the night partying – then you get very little rest and will feel bad. Lack of sleep when you're relaxed and resting is not a catastrophe.
                • Chasing sleep never works. You have to let it come to you. Help it by:

                  Staying relaxed (after you've relaxed with your relaxation recording).
                  Distracting your mind from stimulating thoughts by, for example, listening to a talk radio station that broadcasts at night such as the BBC World Service (at times when no plays or music are broadcast). Repeated world news and world affairs programmes can occupy your mind so that it switches off from everyday worries without stimulating you. You keep hearing the same things again and again and the style of the broadcast is that of a soothing one rather than 'wake up it's morning and let's get the world going'. (Phone in radio shows are too stimulating.)
                  Boring your over-active mind by going over what you did that day in reverse order. (This is unexciting as you've already done it.) However, this does not include going over conversations you've had with people as that can be too stimulating. You could also mentally walk a route remembering every detail of it; or count back from 100 in threes, each count being related to one diaphragmatic breath.
                  You could try over-the-counter herbal remedies to help you sleep: ask your pharmacist for suggestions.
                  If none of these suggestions help, you should see your doctor.

                  Eat a balanced diet
                  Eating a healthy balanced diet can make you feel more alive and energetic than one full of sugar, salt, fat and artificial additives. It is also better for your body as it is more likely to supply all the nutrients your body needs to stay healthy.

                  If you are prone to anxiety and/or have problems getting to sleep, try to cut out caffeine that is found in coffee, tea, and some fizzy drinks such as cola. Caffeine increases the effect of adrenaline in your body so makes your symptoms worse.

                  Slow down
                  It is also important for you not to try to fit too much into each day and not to spend your day rushing around which will make you tense and hyperventilate. You should timetable yourself some time to be alone and to do nothing stimulating. Your mind needs to learn to slow-down and switch off sometimes instead of working at full speed. This will also help you fall asleep at night and make it less likely that you wake early in the morning, unable to get back to sleep. An over-active mind can keep you awake no matter how tired you are.

                  As well as trying to slow your body down, try to slow all your thoughts down. Deliberately think about everything you do so that you concentrate on the task in hand, not letting your mind race ahead, pressurising you or thinking unhelpful thoughts. Take it slowly and steadily.

                  Take exercise
                  Regular gentle exercise (20 to 30 minutes, 3 times a week) can reduce stress and make you feel more relaxed. It also helps you to sleep, relaxing your muscles. Having excess energy at night can make you feel restless.

                  However, this does not mean that it is good for you to suddenly start vigorous exercise, particularly if you are unused to it. You need to build up gradually. If you are unsure, check with your doctor first. One of the best forms of exercise is swimming because it involves many muscle groups but is also gentle. There are no sudden jerks where you have to hit a squash ball as hard as you can and then do nothing for a few seconds. Swimming is a smooth and continuous way to exercise that is safe for most people. Brisk walking is also good.

                  Using positive thoughts to reassure yourself and deal with your panic
                  When you feel panicky, your thoughts are often negative, telling you that you can't cope and that you're going to embarrass yourself, making the situation worse. Try to reassure yourself using positive self-talk:

                  • 'I have coped before and can again.'
                  • 'It's only anxiety that makes me feel like this. I'm not ill and the feelings will go away as soon as I stop worrying.'
                  • 'If I try to ignore what is happening to me the feelings will eventually go away.'
                  • 'I must distract myself and wait for the feelings to pass.'
                  • 'Although I feel horrible now, I know these feelings won't harm me.' Your symptoms may not go straight away but they are likely to be less intense and last less time if you just accept them and let them run their course.
                    • Write down all the negative thoughts you have when you are anxious or having a panic attack. Leave space beside these sentences to add other sentences that are positive. Use these positive sentences to give yourself alternative thoughts. This helps to break the vicious circle of spiralling negative thoughts adding to your anxiety. For example, if you think, 'Everyone will see that I'm anxious', try replacing the thought with, 'If I concentrate on other people instead of myself I won't have the time to worry about what other people think of me'.

                      Other negative thoughts with alternative positive thoughts are:
                      Negative thought:   Positive thought:
                      'I don't want to go.' 'If I never go anywhere, my life won't change.'
                      'People with think I'm stupid.' 'People won't have a chance to think I'm stupid if I show I am interested in their lives and take the trouble to listen.'
                      'No one likes me.' 'I need to let people get closer to me so that they get the chance to know me better.'
                      'I'm boring.' 'The most boring people are those that talk about themselves all the time. If I don't do that, I'm OK.'
                      'I have to hide my weaknesses or I'll be laughed at.' 'I don't have to hide them from everyone. If I tell someone supportive I'll feel relief and there'll be less pressure on me. Others are not perfect either. I do not have to feel ashamed. These things can happen to anyone.'

                      Understand that panic and anxiety are difficult things to beat. It will take time. But with perseverance and repeated effort you will get there. Don't give up.

                      When to seek professional help
                      If you have tried all the above but you find that they have not helped or have not helped enough, ask your doctor to refer you to a professional. Your life is worth fighting over. If the quality of your life is poor due to anxiety, you owe it to yourself to break the mould.

                      Sometimes professionals might suggest a course of medication to help relieve your symptoms. If you think this will help, or it is your last resort, give it a try. With medication you may be able to continue with life as you did before anxiety took over. Once you have built up your confidence by putting yourself in stressful situations and showing yourself you can cope with them, you can consider reducing the dosage under medical supervision.

                      The above information has been extracted from Take Charge of Your Future Banish Your Past (Right Way Books, Constable & Robinson).