by Jennifer Lee
If you are living in one of these situations and are experiencing panic attacks, the two may be linked, and extricating yourself from the situation in which you feel powerless can help relieve anxiety and your panic symptoms. Seeking outside help can be very useful in reasserting control over your life and thereby reducing your anxiety. Therapists can oftentimes help you navigate, leaving unhealthy or abusive relationships, and friends, family, social workers, and others can be helpful in changing jobs and achieving greater financial independence.
At the physical level, one common cause of panic attacks is hyperventilation. Many people associate this state with overly rapid breathing. People who are hyperventilating feel as if they cannot get enough oxygen, and so they breathe excessively, taking in very rapid and deep breaths.
What is actually happening in your body during hyperventilation is just the opposite of a lack of oxygen. You actually have healthy and normal oxygen levels, but because you are breathing so rapidly, you are expelling carbon dioxide at a rate faster than your body can take it in. This leads to a feeling that you “don’t have enough air,” so people breathe even more rapidly, which exacerbates the problem. These feelings of being “unable to breathe” are closely related to other symptoms of panic, as we saw above.
In Chapter 6, we will discover simple techniques of breath control that can help immediately mitigate hyperventilation when you are experiencing it.
Regardless of the cause of your panic attacks, though, it is important to keep in mind that none of these things is your “fault.” And remember as well that – just as we saw with anxiety above – the specific cause of your panic may turn out to be irrelevant to how you are ultimately able to treat it. No matter the origin or etiology of your panic, many of the same methods and strategies for managing and overcoming it will still apply.
How Can I Tell if I am Having a Panic Attack?
Panic attacks are a vivid experience, and those who suffer from them often come to recognize their symptoms over time. Some of these symptoms are physical. The most recent edition of the DSM, mentioned above, lists some of the bodily feelings or sensations that often accompany a panic attack. Monitoring your own body for these reactions may be one helpful way to tell if you are experiencing panic:
1) Racing or pounding heartbeat (otherwise known as palpitations)
2) Tingling in the arms and legs, hands and feet, etc.
3) Sweating, shaking, trembling
4) Feelings of shortness of breath, choking
5) Fear of losing control or losing one’s sanity
6) Fear of dying
7) Dizziness, nausea, discomfort or pain in the chest
Oftentimes people struggle to identify what they are experiencing as a panic attack, however – especially the first time they go through one – because panic attacks do not just “happen” to you. They do not fall out of the blue. Rather, they are connected to escalating or “cascading” thoughts of fear. Many people who experience panic attacks describe a sensation of the “floor falling out from under them,” metaphorically speaking. As their thoughts seek grounding in a feeling of safety, that is to say, their panic keeps thinking up ways in which that safety is imperfect, and in which they might still be in danger.
To see how this happens, it might be helpful to look at some examples of the kinds of thought patterns that characterize a panic attack episode and to see how panic can originate and escalate from other fears, or other kinds of anxiety disorder. If you have experienced a panic attack yourself, the chances are that one or more of these thought patterns will seem familiar to you.
1.) Fear of Dying.
Most people dislike the thought that they or their loved ones will one day die, and some degree of fear of death is a normal part of life. Indeed, the plot of the classic novel White Noise, by the author of Don DeLillo, deals in depth with the question of whether being afraid of dying is a normal reaction to the fact of mortality, or a sign of mental illness, after a mysterious new drug is placed on the market that promises to be able to “cure the fear of death.”
When we discuss “fear of dying” in the context of panic disorder and panic attacks, however, we do not mean the kind of discomfort with the idea of death than many – if not most – people will experience in the course of their lives. Rather, we mean fear of dying right now, as if one’s body is going to simply up and quit on one as soon as one thinks of the possibility.
A typical panic attack thought pattern for a person experiencing this fear might go like this:
It’s amazing that my heart keeps beating on its own, without my having to do anything to help it along. How would it feel if it just stopped one day? How painful is a heart attack? What would a heart attack feel like? How can people tell if a heart attack is coming or not? How do I know I’m not about to have a heart attack right now? What if it’s just seconds away? I wouldn’t be able to do anything to stop it. How would I get to the hospital if one happened? Is my cellphone on? Is it working? Am I in range of a cell tower? If I really had a heart attack right now, would I be able to dial the phone? Or is it too painful and sudden for me to do anything at all? How quickly do people die after they first start to have a heart attack? Is there anyone else here who would be able to call the hospital for me? Who do I trust to do that?
Before they know it, the person thinking these thoughts is experiencing a pounding heart, sweaty palms, and all the rest of it. They are in the midst of a full-on panic attack.
Hopefully, this hypothetical example helps us to see why panic attacks can seem to “sneak up” on one. The person thinking these thoughts doesn’t say to themselves, “I’m having a panic attack.” Rather, they are going through an escalating or cascading sequence of anxious cognition – in other words, a thought process – linking together ideas that make them feel increasingly less safe. Before they know it, they are panicking.
This example may also enable us to see why panic tends to become associated with avoidant behaviors. The person who has experienced this frightening sequence of thoughts might start to try to avoid situations in which they fear they would be unable to contact a hospital if they had an unexpected heart attack. They may avoid camping trips with their families because they do not want to be out of range of a cell tower. They may avoid social settings with unfamiliar people because they are afraid that if they were to have a heart attack in front of people that they do not know and trust, no one would come to their aid, no one would call an ambulance, etc.
Pretty soon, that person’s panic attack has limited the range of things they are able to do with their time, and that person is no longer living the full life they would like to live. They are confined to familiar people, familiar settings, cities and urban areas, and a whole range of the human experience and the natural environment has become “off limits” to them. And all because of a panic attack. This is the kind of power that panic disorder can start to exert in one’s life.
Oftentimes, a panic event related to fear of death may be associated with – or triggered by – sensations within their body that people associate with danger. One example would be a heart arrhythmia – or a sudden change in one’s heartbeat or pulse, which people associate with a feeling that one’s heart has “skipped a beat.” While arrhythmias can in some cases be signs of heart disease or other cardiac problems, they are also entirely normal and can be the result of things that are far less frightening and dangerous. For instance, sometimes failing to get enough sleep the night before can lead to an experience of arrhythmia. Drinking a lot of coffee or other caffeinated beverage can lead to it as well. Even eating a lot of potassium has been associated with the arrhythmia sensation.
So, if your heart misses a beat, it does not at all necessarily mean you are in danger. It might just mean that you recently ate a banana!
Nonetheless, for people suffering from panic disorder and panic attacks, this commonplace and perfectly safe phenomenon of a mild arrhythmia can trigger very frightening thoughts of heart fa
ilure, which can lead in turn to another panic attack.
Along similar lines, people with panic disorder may start to fear that their panic itself will lead to a heart attack. In this way, they start to fear that their panic attack will be the cause of their deaths. This causes more avoidant behavior, as people try to minimize the possibility of ever having a panic attack. (We will examine a hypothetical case history involving this fear in Chapter 4). Oftentimes, people start to panic about the possibility of panicking, and so cause the very thing they were afraid of.
The important thing to remember is that, as we said above, panic attacks are not dangerous. While they are distressing and uncomfortable, and often frightening, they will not themselves cause physical harm to your body. Both your heart and your psychological fear response evolved over time to serve the same function: namely, to keep you alive. They will not quit on you, and they will not turn on one another.
Likewise, if you experience an arrhythmia, it can’t be a bad idea to consult a nurse or doctor about it, but you can also remind yourself that arrhythmias are normal and are often related to other physical causes that are not dangerous in themselves.
A famous person who reported that he is often suffering from sensations of arrhythmia throughout his life was the Nobel Prize-winning author Samuel Beckett. And he lived to the ripe old age of 83! So, experiencing an arrhythmia doesn’t necessarily mean you are in poor health or in any danger. And who knows, maybe in Beckett’s case it contributes to the sense of morbid brooding in his works to which the Nobel Committee responded. Not only might the sensation not be bad for you-you might even get a literary prize out of it.
Another important thing to do, in the midst of these fears, is to think back to all the times in your life in which your heart and lungs had gone on keeping you alive when you weren’t even thinking about them. Starting to think about them, or having a panic attack about them, will not lead these organs to stop functioning now.
Even people with chronic panic or other anxiety disorders are not thinking about the possibility of dying all the time. And yet, all the time when they aren’t thinking about it, their organs and bodies go on keeping them alive. Many people with panic disorder describe times of the day when they never think about the possibility of panicking or of dying at all, and in which they feel fine. For many, early mornings are often happier times of day than late at night, when many describe panic symptoms as being at their worst.
This change of the intensity of panic or anxiety symptoms over the course of the day is related to the neurochemical aspects of panic and anxiety disorders, which we discuss elsewhere in this book. Even before the dawn of modern neuroscience, however, it is interesting to note that some writers intuitively grasped the way in which panic disorders function.
The great 19th and early-20th-century writer M.R. James, for instance, writes in one of his stories about a man experiencing something that we would probably now identify as a panic disorder. At night, he tells us, this man often suffers from exactly the “fear of dying” we discussed above. Yet, with the arrival of the dawn, it vanishes. Describing this character lying in bed at night, James writes:
Awake he remained, in any case, long enough to fancy (as I am afraid I often do myself under such conditions) that he was the victim of all manner of fatal disorders: he would lie counting the beats of his heart, convinced that it was going to stop work every moment, and would entertain grave suspicions of his lungs, brain, liver, etc.—suspicions which he was sure would be dispelled by the return of daylight, but which until then refused to be put aside.
Perhaps many of us can relate to James’ character. After all, as we have seen above, anxiety is not an unusual condition. Also, it is not a modern one. People from as far back as James’ day experienced similar symptoms, even if they did not have the same vocabulary to describe them.
Before turning to other matters, however, let us see a few more examples of the typical thought patterns associated with panic attacks connected to other fears.
2.) Fear of Going Insane.
The great British poet of World War I, Siegfried Sassoon, once wrote a poem about his wartime experience that described symptoms we would now recognize as a form of anxiety or panic disorder.
Indeed, when soldiers returned from fighting in the trenches in World War I, many reported a common psychological experience of having intense fear reactions to visual and auditory stimuli that reminded them of their experiences in the war. This reaction came to be known as “shell shock.” It was the first publicly-recognized and acknowledged the form of what we would now call post-traumatic stress disorder – a form of psychological disturbance (as we saw above) linked to a traumatic personal experience, and which is ignited by certain triggers that put one in mind of the original traumatic event.
Sassoon’s poem – called “Repression of War Experience” -- uses the first-person narration to vividly describe the experience of “shell shock.” Writes Sassoon:
No, no, not that, it's bad to think of war,
When thoughts you've gagged all day come back to scare you;
And it's been proved that soldiers don't go mad
Unless they lose control of ugly thoughts
That drives them out to jabber among the trees.
Sassoon offers here an excellent example of the way in which the fear of “going crazy” can be linked to a panic attack. A person suffering from this thought pattern thinks to themselves that they can prevent themselves from panicking so long as they avoid certain thoughts. But then, as they think about trying to avoid these thoughts, this brings these thoughts back to the forefront of their minds. They then panic, because they feel they are losing control of their ability to prevent themselves from thinking about these things. These fuels fear that they are losing control over their minds entirely – in other words, that they are going insane.
This example also helpfully illustrates why avoidant responses to panic attacks are often counter-productive. As anyone who has ever played the game “Don’t think of an elephant” can tell you, reminding oneself not to think of a specific thing will only succeed in bringing that thing to mind. If you say to someone “don’t think of an elephant,” the very first thing they picture will, of course, be an elephant.
This is why we – and the poet – both know that the soldier is going about things the wrong way. By trying to force himself not to think about the war, he will only think about it more, fueling his sense that he is – as he puts it “los[ing] control of ugly thoughts.” In other words, he is going crazy.
As we will be discussing in more detail later on in this book, the more effective way for the soldier to combat his panic – and the thought processes associated with it -- would simply be to allow it to happen. In this sense, the type of thought pattern associated with a panic attack is very similar in nature to what is known as rumination, and which tends to be associated with depression.
Good to Know: Similarities and Difference between Depression and Anxiety
Depression and anxiety are not the same things. Indeed, they can often seem like polar opposites. Anxiety and panic are associated with rapid breathing, sweaty palms, and feelings of being tense and on-edge. Depression, by contrast, often leaves people feeling listless, fatigued, and bored. In its extreme forms, depression can even make people catatonic, meaning they are virtually unable to move.
At the neurochemical level, however, depression and anxiety are closely related, and many people who experience anxiety and panic also report going through periods of depression. In clinical parlance, this is referred to as comorbidity, which means that one of these disorders is often present alongside the other. In this sense, anxiety and depression can often seem less like opposites than like two sides of the same coin.
Another important similarity between the two conditions – anxiety and depression – relates to the thought processes that tend to be associated with them. As we have seen, anxiety tends to produce feelings of escalating panic. Peopl
e feel as if they are “realizing” they are in danger and are able to continually come up with new reasons why they are unsafe. These new thoughts about ways in which they might be in danger are unwelcome. People with these thoughts would go away, but the more they think about trying to get rid of them, the more prevalent and inescapable these thoughts seem to become.
People with depression often experience something similar. In their case, their depression is often fueled by repetitive, unwelcome thought patterns. People with depression describe feeling as if they were “stuck in a loop,” or as if their thoughts cannot get out of a single “rut.” As with the examples of panic thoughts we have seen above, depressive thoughts often seem to escalate and to build on one another, as if they followed logically from one another and each one reinforced the other.
This process is known as rumination, which comes from a Latin root word which literally meant to “chew” (this is why large mammals that primarily get their nutrients through grazing are technically referred to as “ruminants”). For people with depression, the idea that rumination comes from the word “to chew” makes a lot of sense. People who ruminate often feel as if they are forced to “chew over” the same mealy thoughts time and again, never making any progress with them.