by Jennifer Lee
Nonetheless, the notion that the mind and body are separate things is deeply rooted in our culture (no matter how much contemporary science and philosophy have served to disprove it). We, therefore, tend to assume that our thoughts are purely internal and that nothing we change about our external behavior or surroundings can affect them. For many people with anxiety, panic, depression, and related illnesses, this can lead to a sense of helplessness and hopelessness. One can’t control one’s thoughts, and there they are.
This is part of the reason why, even though cognitive behavioral therapy has the best track record of any method of treatment – and has been recommended by the leading professional associations of mental health practitioners – it is still regarded by many patients with suspicion. People who are suffering anxiety and panic are often in so much emotional distress that they do not have hope that cognitive behavioral methods could be effective.
Instead, many patients, when they first seek out professional help, are hoping they will be prescribed medication. In the throes of panic or anxiety, many people hope there is a simple drug they can take that will “make the fear go away.”
Unfortunately, there is no such miracle pill. The human brain is a very complex thing, and there is no single chemical determining happiness or fear. Rather, as we discussed in Chapter 2, emotional states in the brain are determined through a complicated balance of neurochemicals.
Many medications for psychiatric illnesses – known as Psychotropic Drugs, meaning that they affect one’s mental state, of “psyche” – have been shown to be effective in treating these imbalances. Many people have benefitted from using medications to combat their anxiety and panic disorders. (Moreover, some people report positive results from taking natural supplements to help relieve anxiety, such as St. Johns-wort, valerian, ginseng, etc., though it is also important to do one’s research before purchasing supplements, and not to expect too much from consuming these substances. There is a great deal of false information circulating out there about natural supplements, and this is not a well-regulated area of the health marketplace.)
However, the psychotropic medications used to treat anxiety often have side effects. Some of them can also be habit-forming (another way of saying they can be addictive), and they can lose their effectiveness over time, as a patient’s body builds up tolerance to their effects, just as a person’s energy levels become accustomed to a certain amount of caffeine over time, so that people need to consume more coffee in order to get the same effect. (This happens due to an internal bodily process known as homeostasis, in which the body regulates its own level of various neurochemicals in order to keep them in a state of balance, or equilibrium).
Moreover, these medications often merely affect the symptoms without addressing the underlying thought patterns that fuel anxiety and panic.
Many patients become very excited, for instance, when they first learn about the existence of fast-acting psychotropic medications such as Xanax, which have proven to be effective in halting the immediate symptoms of a panic attack when such an attack is in progress. Xanax is part of a family of medications known as Benzodiazepines, which operate as tranquilizers.
A different but related set of fast-acting medications often prescribed to treat anxiety are those known as Beta Blockers. These drugs operate by blocking the receptor sites for the chemical adrenaline, also known as epinephrine, which we discussed in detail in Chapter 2.
Perhaps you have heard of an “EpiPen,” used to treat asthma and similar conditions? The name comes from epinephrine because EpiPens are used to inject greater degrees of the chemical adrenaline, or epinephrine, which raises a person’s heart rate and causes their throat to expand, reducing the symptoms associated with asthma.
Beta-blockers essentially perform the opposite task. By reducing a person’s response to the chemical adrenaline, they cause the person’s heart rate to slow down – and their respiratory rate as well. This reduces a person’s physical sensations of panic, which diminishes, in turn, one’s internal emotional feeling of anxiety as well. (Here again, we see how “external” physical and somatic, that is, bodily, responses are directly related to “internal” mental and emotional states. Indeed, the great philosopher William James once argued in a famous essay, called “What is an Emotion?” that emotion simply is a bodily response, and that it is impossible to imagine a feeling in the absence of its physical component. The essay makes a profound argument, and helps us to overcome the false distinction between “mind” and “body” that is still so prevalent in our culture.)
For people who have experienced the agony of a panic attack or prolonged anxiety, the idea of Xanax or beta blockers can seem like a dream come true. Many feel that having access to drugs that can immediately “knock out” a panic attack if one starts to form is now a central plank of their sense of personal safety.
While some medications can be helpful in defeating anxiety, therefore, they can also be counterproductive. Carrying around fast-acting medications can lead people to believe that they are not “safe” without these drugs. This can lead to a feeling of powerlessness, helplessness, and dependence on the presence of the drug that can be very disempowering. This feeling, in turn, can prevent people from realizing that they are capable of managing their anxiety and panic, even in the absence of the drug, and that they have the methods to regulate their emotions within themselves and their own bodies.
Medication, therefore, may not always be the best resort in treating anxiety and panic. If you see a mental health professional and they do not recommend medication, this should not necessarily alarm you or cause you to look elsewhere. Indeed, it is often much better to start with cognitive behavioral therapy, which addresses the root causes of anxiety and panic, rather than just the symptoms, by altering the underlying thought patterns that fuel anxiety.
The degree of success in treatment you can attain from this method alone may pleasantly surprise you.
How Does it Work?
To have full success with cognitive behavior treatment, many people will need to seek out the help of a professional. Reading a book is not a replacement for working with a trained psychotherapist or licensed clinical social worker (even if it is a quite good book like this one). It is helpful, however, to know a bit about how the cognitive behavioral therapy process works, as you may be able to guide yourself in part through some of these stages.
Cognitive behavior therapy essentially works through three broad stages:
Awareness. In this stage, the treatment focuses simply on helping you to understand the nature of anxiety disorders and how they operate. This helps you to recognize the symptoms when they are occurring so as not to attribute them to other health effects or other things you fear. The therapist will help you understand why panic attacks occur, and the psychological mechanism through which they tend to become chronic, which we have discussed in detail in Chapters 3 and 4 of this book.
Emotional Regulation. In this stage, the therapist helps you learn some of the simple techniques that you can use to manage and reduce your panic or anxiety response in the moment of a panic attack. We will discuss these methods in greater detail later on this chapter and in Chapter 6.
Gradual Exposure. This is the heart of the cognitive behavior technique. When many people hear about it, however, they become alarmed. Exposure to the thing they fear is exactly what they don’t want. That’s why it’s important to emphasize that the exposure methods used in this form of therapy are gradual and consensual. A person who is afraid of snakes is not immediately asked to hold one, for instance.
Many people, when they hear about exposure methods, assume they will be asked to simply “face their fears.” Sometimes, well-intentioned but unhelpful people will give the advice to people struggling with anxiety that they should just “face what their afraid of” and the problem will go away. Most of us with anxiety or panic find this idea so overwhelming that we will never get started, however. If we do get into a situation in wh
ich we need to “face the fear” directly – especially if the experience has been forced on us – we are traumatized by the experience and feel powerless. Cognitive behavioral therapy, by contrast, is not about forcing you to do anything you don’t want to do. It is about guiding you slowly through the process of your own self-discovery, as you realize you are able to do the things you used to fear – indeed, that these things are not actually dangerous and that you are perfectly safe while interacting with them. Far from making you feel powerless, this process actually increases your sense of personal control, independence, and autonomy.
To return to our example of the person who is afraid of snakes, a cognitive behavior therapist will not ask them to hold one, but they might ask if they’d be willing to go see an exhibit about earthworms at the zoo. If the patient finds this a slightly scary or uncomfortable idea, because earthworms are shaped similarly to snakes, but not an “impossible” idea, this means it is in the sweet spot for cognitive behavioral methods. It is a challenge, but not such a hard challenge that it is overwhelming. To borrow terminology from educational theory, this challenge is in the patient’s proximal zone of development, meaning it is difficult and new enough for them that it causes them to learn, but not so difficult that they are forced to give up.
In Chapter 6, I will discuss how the gradual exposure method helped me to overcome a fear of flying. The important thing to note for now is simply that the way to overcome this fear is not just to immediately get on a plane, and cognitive behavior therapists will never ask you to do this. Rather, I worked up through a series of exposures that I found less frightening until I felt naturally ready to fly on a plane. At no point did I have to “force” myself to do anything I did not want to do. Rather, at each stage, I discovered that I was ready and willing to do something now that would have been challenging – even “impossible” – for me in the past.
What Can I Do to Help Myself Without Seeing a Therapist?
If for any reason you do not want to visit a mental health professional, or are worried about the expense of doing so, there are simple self-help practices you can use that have been proven effective for relieving anxiety in many cases. Apart from applying some of the principles of cognitive behavioral therapy (such as the gradual exposure method) through self-coaching, here are some other practices you might like to try:
Meditation. Practiced by religious faiths around the world, meditation can have a spiritual dimension to it for some people. For others, it is a purely secular activity. In any instance, however, meditation is essentially a process of focusing the mind’s attention. Some practitioners refer to this as “emptying” the mind. Others refer to it as simply achieving a state of mental non-intervention, in which one allows thoughts to enter and exit one’s mind without trying to arrest, cling to, or keep out any of the thoughts that come along. Developing these mental habits through meditation can be extremely helpful in managing anxiety and panic symptoms – especially in the moment of a panic attack – as we will see in the following chapter. One simple method that one can use to enter a meditative and focused state in any situation is as follows: simply try to count to ten. Whenever you get to ten, make sure you go no further, and return to one and start counting again. This sounds so simple as to be foolish, but it is actually a good way to keep one’s mind in a state of focused awareness. You’d be surprised how easy it is for one’s mind to just keep on counting to higher and higher numbers if you don’t remember to pull it back down to one again each time.
Relaxation. Relaxation, you say? If only! For many people with anxiety and panic, relaxing is the one thing they’d love to do more than anything, and the one thing they can’t seem to do. How can anyone recommend it to them? The answer is, once again, that relaxation has both an internal emotional component and an external somatic, bodily component. And by influencing one’s somatic response, one can alter one’s internal emotional response as well. For instance, by consciously willing oneself to release the grip of each muscle, one can reduce one’s feeling of anxious tension. We will be discussing other ways to counter anxious feelings through simple somatic exercises in the following chapter.
Diaphragmatic Breathing. Many times, when people are in the midst of an anxiety or panic episode, well-intentioned people around them will advise them to “breathe deeply.” Unfortunately, this advice is often not helpful, because many of us when we take a deep breath tend to fill our chests and suck in our bellies, with is a kind of breathing associated with anxiety, and which does not prevent hyperventilating. What people should really be advising is to practice diaphragmatic breathing, in which one fills and extends one’s whole diaphragm – the large muscle that surrounds and controls the lungs. This is the sort of breathing in which one can feel one’s belly extending. This is a sort of breathing that is practiced most often in childhood. Even though it is available to us at any moment as a method of respiration, many of us forget about it as adults, unless we consciously remind ourselves to practice it in a moment of tension. This method of deep breathing “with one’s belly” is associated with immediate feelings of relief and the relaxation of tension. This breathing method is therefore extremely helpful in regulating one’s feelings while struggling with anxiety, and even in the midst of a full-on panic attack. Many people may find this hard to believe. How could something as frightening and seemingly uncontrollable as anxiety or a panic attack be affected by something as simple and familiar as breathing while extending one’s belly? Try it though, and see if you do not notice that you very quickly begin to feel much calmer. The next time you are in a situation in which you are beginning to feel a panic attack coming on, therefore, instead of looking for an “escape route,” or asking yourself if you remembered to pack your Xanax, try reminding yourself that at any moment, you have access to the ability to calm yourself through your own body, through the simple act of deep, diaphragmatic breathing.
Sleeping Well. For anything in the world of human health, this is always a good idea! Healthy, natural sleep is essential for both physical and mental wellness. Yet people with chronic anxiety may take a look at this and think: easier said than done! Do not despair, however. If you are having trouble sleeping due to your anxiety, here are some simple methods you can apply. First of all, do not lie in bed trying to force yourself to sleep, if you are not managing to drift off. Lying in bed trying to sleep at night is often the time of day that people report having the most trouble with rumination and repetitive anxious thoughts. It is much better to distract oneself with a different activity until you feel genuinely tired and ready for bed. Do not distract yourself with a screen, however, as the light used in electronic screens is built to remind our brains of daylight, thus confusing our body’s sense of its natural sleep pattern – also known as our circadian rhythm – which is timed to correspond to the presence of daylight. This is what often leads to the feeling when we are looking at screens that we are wide awake – even “wired.” Reading a book (but one printed on paper or on a reader with a dim screen, not on a computer or TV screen) or doing a simple repetitive chore can often generate the sort of natural fatigue that leads to healthy sleep. Moreover, avoid drinking or eating anything that has caffeine in it late in the day. This may seem obvious, but many people forget to put it into practice, and the chemical effects of caffeine often last far longer than people expect it to.
Yoga and Other forms of physical activity. Yoga, sports, running, and other kinds of physical activities have been proven to be remarkably effective in reducing symptoms of anxiety and relieving all kinds of stress. Partly this is because these activities naturally trigger the release of the chemicals associated with anxiety and panic responses, channeling them in healthy ways, and leading to natural feelings of physical tiredness that lead to healthy sleep at night. Competitive sports, for instance, can induce a “fight or flight” response that helps the body to regulate the production of the chemicals involved in this response and channel their use in a naturally-occurring way. E
ven beyond other forms of physical exercise, however, yoga has been found to be particularly helpful, as it includes elements of mental concentration and focuses similar to the effects of meditation described above.
Chapter 6: Remedies and Solutions During a Panic Attack Crisis
Steinbeck’s commanding officer
We saw in Chapter 3 that depression and anxiety are often very similar to one another because both often take the form of repetitive thought patterns that seem as if they were “out of control.” In anxiety, these escalating fear thoughts lead to a panic attack. In depression, these repetitive unwelcome thoughts are known as rumination.
We also saw in Chapter 3 that efforts to avoid these repetitive thoughts by suppressing them do not work – indeed, it often makes them worse. The effort to force oneself to stop ruminating or to stop panicking often leads to a frantic effort to look for “escape routes,” only to realize that there is no absolute way to prevent oneself from panicking or ruminating, which only increases one’s sense of feeling trapped and at the mercy of forces beyond one’s control.
This is why, when we looked at the poem about Siegfried Sassoon’s soldier above, we saw that his effort to force himself not to think “ugly thoughts” was ineffective. The more he tried to avoid them, the more this effort brought them even more into the center of his focus.