Kate was driving when all of a sudden she felt dizzy, had trouble breathing, felt her heart pounding; she thought she might be having a heart attack. Fortunately, she was able to immediately pull off the road and within a few minutes it somehow seemed to pass.
The classic panic attack: Comes out of nowhere, you can’t breathe or feel like you are having a heart attack, you think you’re going to die. Lots of folks wind up in ERs to be told it is “only” a panic attack and are sent home. But now a bigger problem often emerges—a hypervigilance, a heightened state of anxiety based on the understandable fear that if that panic attack came out of nowhere, what’s to stop another from doing the same. Quickly a downward spiral can take hold.
There are several articles on this site and many online that describe the symptoms and some of the common causes and treatment options to manage panic attacks. What’s often not talked about is specific behavioral steps you can take not just to manage them, but to help keep panic attacks at bay over the long-term.
Like other anxiety disorders such as generalized anxiety disorder or obsessive-compulsive disorder, there are, I believe, four key aspects to treatment: first aide, anxiety desensitization, lowering of thresholds, and personality issues. We’ll walk through them one by one.
This is what is most often talked about. Here you’re advised to learn to recognize the signs of possible attack—the heart fluttering, the shortness of breath, the trembling—and the need to take control through deep breathing, including counting to five or seven as you breathe in, hold, breathe out. You also want to deliberately relax your muscles. I suggest to folks to get mindful and focused—this is where Kate begins to read aloud the license plates in front of her when she’s driving and senses symptoms rising.
As with all anxiety disorders, the more first aid tools you have in your toolbox, the more you feel in charge and in control. Rather than feeling always like a potential victim of your anxiety that can spring on you at any moment, by having an array of tools at your fingertips (much in the same way a black belt in karate knows she has the tools to deal with potential muggers) you feel more self-confident, and this in turn reduces the hypervigilance that can feed the panic attack.
This is the key that is often overlooked. After her near-death-feeling panic attack, Kate is worried about another striking. So she is sitting in her car in the parking lot of Walmart and says to herself, “What if I have a panic attack in Walmart? Actually the last time I was there it felt stuffy and crowded and I felt a bit shaky. And look at the parking lot right now—it’s packed. Maybe I should come back tomorrow when it’s less crowded.”
And Kate goes home. Does she now feel better? Absolutely! But therein lies the problem. Again, as what normally happens with other forms of anxiety, every time she listens to what her anxiety is telling her to do (like go home, or wash her hands 10 times to get rid of germs), she is feeding the dragon, making those brain circuits stronger. It won’t take long before she is afraid to leave her house and is agoraphobic. (And this unfortunately in fact is what happens to lots of folks who have continued panic attacks.) If you listen to your anxiety, your world gets smaller and smaller.
The way to avoid going down this road is pushing back, not listening to the anxiety. The goal isn’t to not feel anxious, but to face anxiety and find out that what your anxiety is telling you will happen, doesn’t. You can think of anxiety as hyperactive attack dogs always barking in an effort to be protective; but they are over-reacting. You need to be like the dog owner who tells the yapping dogs to calm down, it’s okay.
What this translates into for Kate is not leaving and going home, but going into Walmart. If that seems too overwhelming, she can go up to the front door and stand there for 10 minutes, but then go back the next day and walk inside and stand by the greeter for 10 minutes. Baby steps but moving forward.
Similarly, if she begins to feel shaky when driving, she should not call her husband to have him help her calm down. Why? Because his calm voice and coaching will work. It may help her get to her destination, but she will only become increasingly dependent on her husband; she is feeding the dragon. Instead, it’s better for her to read the license plates in front of her or do deep breathing, and then check in with him after she’s landed and he can give her the verbal high-five.
The key here is approaching the anxiety, rather than giving into it. The more Kate can do this the more she is increasing her sense of competence and confidence and making herself more panic-attack resistant.
We can think of first-aid techniques and approaching the specific anxiety as action steps towards managing and recovering. Lowering thresholds is anxiety prevention, reducing your overall level of anxiety and tension so that even if anxiety does spike, it does not reach a high, out-of-control level. This is where folks are advised to consider medication—anti-anxiety drugs or more commonly SSRI medications that lower overall anxiety. But there are other behavioral things you can do.
One is check-ins. What I often recommend to clients is that they check-in with themselves every hour and on a scale of 1-10 with one being flat lined, 10 being in panic state, rate where they are at. When they start to get up to a four or five in terms of anxiety or irritability, they need to ask themselves what is going on. Now there is rational and irrational anxiety: Rational anxiety stems from a real problem—you haven’t heard back from your boss about the deadline for the project. If a real problem is nagging at you, take action, do something concrete like send an email following up. Put it to rest, don’t dither.
If irrational—no real problem is identified or your thoughts are just…irrational—that your cough will turn into lung cancer, a meteor will hit your house—that’s about calming yourself down with mindfulness, deep breathing, getting up and taking a brisk walk. Doing the check-ins helps you become more sensitive to your own moods and helps you take action to avoid reaching that tipping point. You can also check out apps like Spire that help monitor your breathing and heart rate and send you a text to take some deep breathes when they begin to go up.
But there are other preventive behaviors you can use—the most well-known being exercise, yoga, and meditation. The key here is finding something that works for you and that you can and are willing to do on a daily basis. By building these into your routines and knowing that you are taking decisive preventative action, you feel more in control and less in that reactive-victim mindset.
While there are genetic components to anxiety, I believe that at some core level, struggling with anxiety is about somehow learning in our early years that the world is unsafe. There are a lot of good reasons to feel this way as a kid—physical or emotional abuse or chaotic home life—that leaves the child feeling always tense, always walking on eggshells, always looking around corners as a way to survive. These little-kid feelings, and brain wiring persist into adulthood.
The longer-term goal is to rewire your brain by changing your coping style. This is a broader and more ongoing project that involves moving away from your little-kid mindset by doing now what you couldn’t do back then. This is about stepping up and being the adult you are in spite of whatever lingering feelings are inside. It’s once again about approaching anxiety.
Here you don’t need to focus on specific situations but instead challenge yourself on a regular basis to step outside of comfort zones so your zones gradually expand in size; speaking up and being assertive when your instincts are to shut up or pull back, in order to find that what you think is going happen (which is based on your childhood fears) doesn’t happen.
If you do this, you discover that in spite of what your guard dogs are yapping about, you don’t get fired or railed at when you ask your boss about changing your schedule; where, when you take the risk of doing what you want rather than going on autopilot and doing what you should, that you actually feel energized and a bit freer by having made such a decision. Just do this 5,000 times and your worldview and your sense of place within it begins to change.
That said, some folks will understandably find this marching ahead more difficult. Here we are talking about those who have post-traumatic stress, whose memories are like landmines that easily set off and trigger fear. This is where therapy (and medication) can help to begin to help them separate past from present and provide support they need to move forward.
There is a clear theme running through each of these four elements—having the tools and taking charge; not allowing yourself to be bullied by your anxiety and panic by behaviorally pushing back against them.
Ready to take them on?