by Jennifer Lee
Learning to recognize panic attacks for what they are can, therefore, go a long way toward reducing their effects. You can start to understand that you have not “realized” any scary new truths that you did not know before, you are simply undergoing a common experience of a panic attack.
There is an amusing passage by the British novelist Kingsley Amis on this subject. Amis was writing at the time about his strategies for recovering from a hangover, after a binge of nighttime drinking, but if you replace the word “hangover” in this passage with “panic attack,” it reveals a profound truth that is very helpful to mitigating the effects of panic. Amis advises us to remind ourselves when recovering from a hangover:
“You are not sickening for anything, […] you have not suffered a minor brain lesion, you are not all that bad at your job, your family and friends are not leagued in a conspiracy of barely maintained silence about what a [s***] you are, you have not come at last to see life as it really is[….] What you have is a hangover. [And, h]e who truly believes he has a hangover has no hangover."
By the same token, perhaps after reading this chapter, you will be able to tell yourself, next time you are panicking: I have not come to realize the truth about life, I’m just panicking. And the person who knows they are just panicking will not panic.
Chapter 4: Why Panic Attacks Tend to Become Chronic
The previous chapters have illustrated for us how panic attacks often become self-reinforcing. To go through a panic event is often a frightening enough experience in itself that people begin to organize their “cascading” panic thought processes around the fear of panic itself. As we saw in the examples in the previous chapter, the possibility of experiencing a panic attack can often become the basis for a variety of other fears and avoidant behaviors, such as social phobia, claustrophobia, agoraphobia, etc.
What may be less immediately clear, however, is why people’s efforts to avoid panic attacks or the situations that cause them often leads to more panic attacks in the future.
In order to see how this process works, it may be helpful to look at a hypothetical case history.
Case History: Sarah
Sarah is a young woman in her early twenties. She has just finished college and has decided to drive back home to her parents, who live on the other side of the country. She plans to spend the summer with them and try to decide what she wants to do next with her life.
The drive will take her two days, but she is feeling so anxious to get home and so tired of driving that she contemplates trying to just drive straight through the night without stopping. At 9 PM, therefore, she pulls over into a coffee shop and orders a coffee, to try to keep herself awake on the road over the course of the night.
While driving later that night, she feels a sudden muscular clenching in her chest. It feels like the cliché about a person’s “heart skipping a beat” literally just happened to her. She pulls over to the side of the road to make sure she is okay. She feels her pulse and notes that it appears to be back to normal.
The experience frightens her, however, and as she continues driving, she can’t get it out of her head. She thinks back to something she once overheard a friend’s parent saying – someone who was a doctor. She had said something about feeling like she had an arrhythmia and that she needed to go to the hospital to have it checked out.
The word comes back to Sarah at this moment. Did she just have an arrhythmia? And if so, was it something serious? Should she go to a hospital to have it looked at? Her friend’s mom was a doctor, and she had thought it was serious enough to be considered a medical symptom. Of what though? Of heart disease? Was that possible, at Sarah’s age?
Sarah starts to run through in her head everything she knows about heart attacks from her CPR training in college. How quickly do they happen? What are the signs again that one might be coming on?
She tries to think through what she would do if she suddenly felt the symptoms of a heart attack. She would have to call someone. She glances down at her cell phone and realizes there is not much battery left, and there is no place to plug it in in the car. Would it last long enough? Someone passing in another car would have to help her. But she’s in the middle of nowhere in the middle of the night, on an unfamiliar stretch of highway. Who would stop for her? What perfect stranger would do that?
And if she did have a heart attack while driving, wouldn’t this force her to fly off the road and crash?
As she keeps thinking these thoughts, her heart starts pounding, and her breathing becomes more rapid. She decides that it is imperative that she get off the road and into a hotel right now. Nothing has ever seemed so important. She literally starts to feel as if her life depended upon it because she realizes she can’t think of any way she could keep herself perfectly safe if she had a heart attack while driving the car.
Frantically, she scans each passing sign for an indication of a hotel or motel. Finally, she spots one on a highway exit. She races in and asks if they have any vacancies for the night. She is told they are sold out. She already feels safer, however, just standing in the lobby. If she had a heart attack here, she thinks, at least the hotel clerk will be able to see it and call an ambulance.
How far are they from a hospital out here, though? Would they be able to get here in time? And how will she ever convince herself to get in a car again?
Driving the next day is easier, however. For some reason, with the sun shining, Sarah has a hard time connecting with the intensity of her fears the previous night.
She has never experienced panic or anxiety before, so she has no reason to think that what she went through the previous night had any relation to those disorders. Moreover, all of her fears were “rational.” They were about a real thing – heart disease – and were triggered by a real experience – an arrhythmia – so why would she have any reason to think she was experiencing a mental illness?
Once Sarah gets home, she decides to visit a doctor. Not to talk about anything related to anxiety, however, but just to talk about her arrhythmia. The doctor runs an EKG on her chest and says that there is no sign of any heart trouble and that she is perfectly healthy. The doctor says that many people experience arrhythmias without these being connected to other illnesses.
Sarah is comforted by this. However, she still can’t shake those disturbing thoughts she had on the road. It seems to her to be inescapably true that if she had a heart attack or other health episode in the middle of the highway during the night, there would be nothing she could do about it – she would be trapped, and no one would be able to help her.
Isn’t the safe, logical thing to do, therefore, to simply stop driving alone? Why would anyone drive alone for long distances? Isn't Sarah the rational one, rather than everyone else?
Sarah decides to give up driving, much to her family’s alarm. Everywhere else she goes her mind starts performing some quick maneuvers to try to imagine what she would do if she had a heart attack in that setting. When she and her parents go out to a restaurant, she keeps trying to imagine to herself who she would call if this happened.
The most frightening situations for Sarah become those in which she would have to be out of cell phone range for long periods. She decides she can’t fly anymore, because if she had a heart attack in mid-air, it would take too long to land the plane and get her to a hospital. She is aware that they have defibrillator machines onboard aircraft and that flight attendant is trained to provide medical first-aid and CPR. But why take the risk?
The next year, Sarah turns down an exciting job that would require her to travel to places in other parts of the world, because she decides she doesn’t trust other countries’ health care systems. She recognizes this is probably an unfair attitude. She is a smart and well-read person and not generally judgmental about other places and cultures. Again, however, she thinks to herself: Why even take the risk? Isn’t the most important thing to stay safe? What could be more important than keeping herself alive?
For Thanksgivi
ng that same year, Sarah’s parents decide to visit her brother, who lives on the other side of the state. They know that their daughter doesn’t like to drive, so they plan to drive the van instead, and Sarah sits in the back seat.
As they are going, Sarah keeps plotting out to herself what she would do at each stage of the trip if she had a heart attack. Here she would call 9-1-1. Here they could pull over at that exit, where it looks like there’s a clinic or an urgent care center.
As they get further and further away from home, however, Sarah’s anxiety becomes more acute. Eventually, they reach a stretch of highway out in a rural part of the state. Sarah looks down at her phone, and she realizes there is no cell service out here. She starts to panic. Her heart is racing, and her arms and legs are tingling. “I’m trapped,” she thinks. “If it happens right here, there will be nothing I can do about it. I’ll be dead, and that’s that.”
At some previous point in her life, Sarah has heard the term “panic attack.” She had never connected it to her own experiences before. But now she starts to wonder if that is what is happening to her. If so, a “panic attack” is way worse than she ever imagined it could be, she thinks. More than that – she starts to worry – what if having a panic attack can bring on a heart attack? What if I’m about to cause the very thing I’m most afraid of?
Soon, Sarah can’t imagine why she could ever have been such a “fool” not to have thought of these possible dangers. She is astonished that her parents are able to drive long distances in unfamiliar places without panicking. Don’t they realize that if something happened, they’d be at the mercy of fate? There’d be nothing they could do about it?
Sarah can’t imagine doing the things that other people seem to do without effort or trepidation. She can’t imagine taking planes, flying to other countries, going on long road trips, or taking jobs that might require any of these things. The places that feel safe to her are her own room at home and pretty much nowhere else.
***
We can see from Sarah’s story many of the traits that are common to other forms of panic disorder. Sarah first begins to experience anxiety in a time of her life – early adulthood – when the brain is still developing and taking its final shape, and when a person’s lifestyle is in turmoil. Sarah’s anxiety and panic disorder are therefore, a new experience for her, which she does not immediately know how to recognize.
Because driving a car was where her attack first occurred, she comes to associate panic with this location, and she starts to avoid situations that might force her to drive. (The same applies to all other situations. A person who first experienced a panic attack in a supermarket will start to associate buying groceries with danger, and so forth. Over time, she changes the whole structure of her life to accommodate this new fear. The panic starts to dictate what kinds of professional opportunities she can pursue, where she can live, etc.
In short, Sarah has entered a cycle of avoidance that perpetuates and exacerbates (meaning worsens) the symptoms of panic and anxiety over time. At each stage of this cycle, she tried to avoid the possibility of ever being in a place where she is not within reach of a cellphone. Yet she continually realizes, however, that no matter how “safe” she makes herself, she cannot entirely prevent the possibility that something bad will happen to her, because she cannot see or control the future. This, therefore, makes an even wider range of activities seem scary to her, and the cycle goes on.
As we will return to time and again in this book, the key to breaking this cycle is to remind ourselves that the future is unknowable. No matter how much we try to change our lives in order to ward off the possibility of ever putting ourselves in danger, it remains true that some element of chance and risk is a part of any human life. The key, therefore, is not to control the future, but to remind ourselves to stay rooted in the present.
In Sarah’s case, after all, she kept worrying about the possibility that she might have a heart attack. You could almost forget that during all of this time, she never had a heart attack or even heart illness. Indeed, her own doctor had examined her and reassured her that she was perfectly healthy! If she had stayed rooted in this knowledge, that in the here and now there is nothing wrong with her body, and she is not having a heart attack and has no reason to think that she is remotely likely to have a heart attack, then she would be able to ride with her parents in the car with ease.
***
There is one interesting thing to note in Sarah’s case, that is a recurring theme in anxiety and panic disorders. Namely, we can see once again that anxiety and panic often begin from very small causes – minor episodes of discomfort and unease. In Sarah’s case, her first panic attack is brought on by an arrhythmia, which as we have seen, are often not dangerous in themselves. So too, panic attacks can be initiated by minor feelings of light-headedness (leading to the fear of passing out), nausea (leading to the fear of vomiting) and other feelings of discomfort that occur in the ordinary course of life, and which are often no signs of any greater problem.
Because they come to associate their panic with these everyday occurrences, however, people with anxiety or panic disorders often start to fear that the slightest physical discomfort is a sign of an approaching panic attack.
It is important to remember, therefore, that discomfort – while it is no one’s favorite thing – is a perfectly normal part of life. You can expect to feel a certain amount of anxiety, stress, physical tension, etc. in the course of your life, and it does not mean you are about to panic or do anything against your will. (Most people dislike long plane trips and long car rides, for example. If you feel a certain amount of trepidation before going on one, this does not mean it is a “sign” that you are about to have a panic attack or an anxiety episode).
In her memoir, Wishful Drinking, the great actress and writer Carrie Fisher – best known for playing Princess Leia in the Star Wars movies, and for her novel-cum-screenplay Postcards from the Edge – tells an amusing story about how coming to this realization helped her overcome her struggles with alcoholism and drug addiction. The insights she learned here apply just as well to people working to manage and overcome their anxiety.
In detailing her efforts to join Alcoholics Anonymous (AA), Fisher notes that at first the hardest part for her was simply getting herself to AA meetings because she did not like going to them. Eventually, however, her sponsor in the program told her something important. He told her that she “didn’t have to like going to [the AA meetings], [she] just had to go to them,” in Fisher’s words. “Well this was a revelation to me,” she then proceeds to tell us. “I thought I had to like everything I did. […] But if what this person told me were true, then I didn’t have to actually be comfortable all the time. If I could, in fact, learn to experience a quota of discomfort, it would be awesome news.”
“Learning to experience a quota of discomfort” is key to overcoming anxiety and panic as well. If you experience fear, anxiety, or similar emotions, it does not mean these emotions are bound to escalate in an uncontrollable way. Discomfort is a part of life. The important thing is to continually draw yourself back to the things that give you joy, even in the midst of the inevitable discomforts.
Chapter 5: How to Overcome Anxiety and Panic?
The most effective method of treating anxiety disorders is known as cognitive behavioral therapy. This is the method recommended by the American Psychiatric Association, and of all the tactics people have tried over the years to combat anxiety, this is the one with the longest proven track record of success.
As the name implies, cognitive behavioral therapy is a method of treatment that focuses on the way in which thought processes (i.e., cognition) and patterns of behavior influence one another. As we have seen above, people who suffer from anxiety and panic often exaggerate the power of their thoughts to influence their behavior. We have seen that people with panic often experience a fear that the severity of their panic feelings will “force” them to do something against their will –
such as harming themselves. In reality, emotions do not have this kind of power to control our behavior, and the emotion of fear, in particular, will not force a person to do the thing they are afraid of.
On the reverse side, people with anxiety and panic disorder often tend to downplay the power that behavior has to influence our patterns of thinking. After all, the things that happen inside our heads feel like they are “purely mental.” We don’t intuitively sense that they are connected to the physical world or to our own actions and behavior, and therefore, we can’t imagine how changing our behavior could affect our thoughts.
This is a silly notion when one thinks about it. In the ordinary course of living, we see every day how physical changes to our bodies and surroundings also impact the way we think. If we drink a cup of coffee, for example, the caffeine we have just consumed affects our body by raising our heart rate. This effect isn’t just physical, it also impacts our cognition. We feel more awake. We think more quickly. So too, we often think more slowly just after we have eaten a heavy meal. We have a harder time being creative in the late afternoon than we do in the early morning. And so on.