“Basically, attempts to resist these feelings teach your brain that experiencing anxiety and panic is a threat and you are unsafe.”
Part one of this blog series examined the symptoms of panic, the difference between Panic Disorder and panic attacks that occur as part of another mental disorder, and how avoidance behaviors meant to reduce discomfort can actually perpetuate panic symptoms. This continuation of the series will address the most effective, evidence-based treatment approaches for panic.
Panic attacks are treatable!
How do I fight it? How do I get rid of it? How can I shake this feeling? It can feel as if fighting against anxiety and panic is the right thing to do, but fighting panic symptoms only makes things harder in the long term. Calling for help/ambulance, escaping your current environment, or avoiding potentially triggering people/places/events may bring you momentary relief, but when you try to forcibly stop the panic experience, it actually prolongs it. Basically, attempts to resist these feelings teach your brain that experiencing anxiety and panic is a threat and you are unsafe. Some sufferers have reported that the energy they use trying to hide the fact that they are having a panic attack can make the panic symptoms seem even more intense. Of course, there may be situations where it feels too vulnerable to openly panic in front of others, and escaping or hiding your symptoms may be the better choice for you in that moment. However, always attempting to control or hide your symptoms will keep you stuck. Like a bully chasing you on the playground, if you run, the bully will just keep chasing. However, if you stand your ground, the bully will eventually back off. The keys to standing your ground are:
- Acknowledge that you are feeling uncomfortable, scared, worried, etc.
- Accept that those feelings are present in the body and a part of your experience.
- Allow those feelings to be there until they subside naturally without fighting for control.
“I acknowledge that I am feeling very uncomfortable, scary sensations in my body, and I am worried I might panic; but, I am willing to accept these feelings because I am not in any danger, so I don’t have to try to avoid this experience.”
Cognitive Behavior Therapy for Panic Attack
Research is well established that cognitive behavior therapy (CBT) is the most effective treatment for panic. Part of CBT is cognitive therapy, which involves modifying the way you think about an experience. Here are some common thoughts that come up for people who experience panic attacks:
- I can’t do this.
- I feel like I’m dying!
- I’m unreliable.
- I don’t want to feel this way. I just want this feeling to go away.
- I think I’m going crazy!
- What if I never get better and I feel this way forever?
- I think I’m having a heart attack!
Recognizing when it’s unhelpful to buy in to certain thoughts is the first step in being able to reframe your thinking into more honest, useful language. In treatment, you may discover you hold on to some unhelpful core beliefs, which can be identified and changed. Challenging this negatively-biased thinking teaches the brain to back off from promoting the types of thoughts that keep you stuck. For example, “I can’t do this!” may be more accurately presented as, “This feels really hard and I don’t know for sure how things will go, but I have always gotten through the panic.”
Exposure with Response Prevention (ERP) for Panic
In addition to challenging unhelpful beliefs, treatment should also include exposure with response prevention (ERP) around people/places/situations that are associated with or may trigger panic symptoms. For example, if you have been avoiding driving out of fear of having a panic attack, you will need to start driving again. It’s normal to assume you’ll start again after it doesn’t feel so scary, but it’s actually the behavior change that brings about the feelings change. You can start with small steps, such as just sitting in your car and pulling in and out of your parking spot, then build up to taking very short drives around the block a couple times a day. If doing this alone feels too hard, you may start with having a coach or safety person with you in the car. Gradually, you will give yourself permission to make longer drives with the coach or start doing the shorter drives without the coach. You can’t talk yourself into feeling better about driving or wait around until your feelings decide to change on their own — you have to actually change the behavior that gives the feelings their power. In fact, the longer you avoid driving, the stronger the narrative grows that driving causes panic attacks and must be too risky for someone like you.
You may also engage in something called interoceptive exposures, which are exposures to the physical symptoms associated with your panic attacks to help practice coping with them effectively. As discussed in part one of this series, panic attacks are typically triggered by feelings of dread around uncomfortable physical sensations or by the situations in which you experience those sensations. Additionally, you may have a belief that these physical sensations will cause you physical or mental harm. By generating the feared sensations on purpose and tolerating them, interoceptive exposures address both the erroneous belief about the physical symptoms (that they will harm you) and the distorted beliefs about the conditions where these symptoms may arise (that they are inherently dangerous). For example, increased heart rate, sweating, and shaking may be accepted, even welcomed, following a great workout or when you feel excited in anticipation of some desired event. However, you may view those same physical sensations as dangerous when feeling anxious. In treatment, a therapist may invite you to engage in an activity to intentionally raise your heart rate, have you cover yourself with a blanket to make you feel too warm, or have you breathe through a straw to stimulate feeling lightheaded or shaky. When experienced outside the context of anxiety, these symptoms gradually begin to lose their catastrophic meaning.
Mindfulness for Panic
In addition to challenging distorted beliefs and engaging in exposures to feared conditions, engaging in mindfulness skills training is very effective at improving one’s ability to recognize resistance to panic and, ultimately, to let go of that resistance. Mindfulness is the skill of observing your experience (internal and external) exactly the way it is in the present moment. By doing this you can recognize when your attention is stuck on fear and panic and, instead of trying to push that away, you can open up your attention to something else in the present moment. In other words, you can notice panic symptoms and choose to do valued things, rather than get consumed by the story of panic in your head.
What About the Breathing?
Breathing is a good thing, and I highly recommend you continue to do it for as long as possible! When it comes to engaging breathing modification during panic attacks, different experts have different approaches. Some believe that controlling breathing during a panic attack helps one take in enough air, with the right ratio of oxygen to carbon dioxide to slow down the panic cycle. Some experts believe it’s more helpful to simply sit with the anxiety without engaging in any behaviors aimed at reducing it on your own – because you aren’t in danger. Studies are not conclusive that breathing training increases the effectiveness of CBT. What studies do show is that successful treatment doesn’t involve treating the overwhelming sensations themselves, but is all about effectively reframing flawed, catastrophic beliefs about those sensations, (i.e., feeling queasy or short of breath does not automatically mean fainting and vomiting), (Meuret, Wolitzky-Taylor, Twohig, & Craske, 2012). What some of my clients have found helpful is engaging in deep diaphragmatic breathing during a panic attack because it helps them to think a little more clearly and remind themselves that, while very uncomfortable, they are in no danger of dying or going crazy. Focusing on controlled breathing also gives them something to anchor their attention on (mindfulness) instead of remaining stuck in the mental story of fear and panic.
Panic attacks are scary, unwanted, and sometimes truly life disrupting, but you are not a lost cause. Panic is treatable and you are more resilient than you think!
Meuret, A.E., Wolitzky-Taylor, K.B., Twohig, M.P., & Craske, M.G. (2012). Coping Skills and Exposure Therapy in Panic Disorder and Agoraphobia: Latest Advances and Future Directions. Behavior Therapy, 43(2), 271–284.