To say that panic attacks feel awful is an understatement. Panic attacks are awful AND confusing. A panic attack is full blown alarm vibrating through every fiber of one’s body that offers no information about the nature of the emergency that it supposedly signals. Worse, it doesn’t come with an off switch. Imagine a usual boring commute on a crowded bus. Frustrating in its dullness. Then, just when you are about to cross the street, you get startled by an unusually fast car and jump to safety. You can feel your heart pound, your breathing is a bit off and you might even feel quite dizzy. That’s a close call, a near miss that you managed to survive.
The alarm system worked as it should, sharpening your senses even if it left you somewhat nauseated in the aftermath. You might emerge a bit shaken but not likely to question the recently experienced physiological reactions. In situations like that, we prioritize getting to safety (i.e., being safe) over attenuating physical sensations (i.e., feeling safe). The whole experience makes sense - it's a normal fear response. It's an equivalent of a smoke detector being activated when something is burning. Our reactions unfold in a sequence from 1 to 7 (triggers, thoughts, physical sensations, emotions, behaviour and outcome followed about an acceptable conclusion about what has happened).
Now, a few days later, you experience a panic attack at the same intersection. You might even feel dread over the idea of crossing a street, any street. This anxiety is annoying, but it is easy to recognize the trigger even if rationally you know that you have crossed streets many times before and everything was fine. Experiencing anxiety in response to identifiable and relatively safe situations is an equivalent of a smoke detector making noise when the battery is about to die. We know that we are safe and we can extinguish the alarm by disabling the device, or, in case of anxiety, by avoiding our triggers. Again, a 1 to 7 sequence that includes a conclusion that feels right. It's understandable anxiety.
Panic is different. It is confusing as it feels that it is impossible to discern its true cause. The more you search for an explanation, the more frightening the story that your mind creates. "What if I will always feel like that?" "What if I am going mad?" The physical symptoms of panic feel awful. "What if there is a serious illness that they just ignored?" "What if I am dying?!" The experience of a seemingly unprovoked panic attack does not follow a 1 to 7 sequence and the conclusion feels unsettled. "This just a panic attack" does not inspire confidence. Not surprisingly, all attention turns to panic symptoms.
The diagram above shows the "confusion of panic". The danger is out there but it is not clear what that danger is. Chronic vigilance (A in our diagram) is the process that transforms an occasional panic attack into a panic disorder. An average panic attack does not last over 30 minutes but many persons with panic disorder report feeling chronically panicked as they have entered into a vicious cycle of panic.
So, you are starting to calm down after a panic attack. You still feel a bit off. The background experience is that of queasiness and exhaustion. The outcome of the experience becomes a new trigger (B in our diagram). If you were to have such background experiences after jumping away from a speeding car, you would not pay much attention. If you were to have such background experiences after an anxiety attack over crossing the street, you would be annoyed but eventually stop paying attention. However, in panic disorder, all of the attention centers on such experiences. There is impatience: "When will it end? Is it over yet?" Worry: "What if it comes back? What if I won't be able to handle it and make a full of myself? What if I die from it?" [1] Misguided diligence: "If I catch it early enough, I can stop it in its tracks". All these efforts just create a sense of urgency and stress. Watched water never boils, monitored panic never ends.
Panic disorder is maintained by a quest to find its cause, urgent need to escape panic sensations, worry about future panic attacks and chronic monitoring that transforms background experiences into triggers.
Treatment for panic disorder is one of those conceptually easy to understand and yet difficult to implement propositions. Our bodies and minds need to be calibrated to respond in a manner that we can make sense of. Panic is an intense false alarm with a broken off switch. Calibration requires that we face what triggers panic attacks and adjusting our responses.
Exposure is the core treatment for panic. Exposure helps us distinguish triggers from dangers and feeling unsafe from being unsafe. It is impossible to visualize or box-breathe your way out of danger. You emerge exhausted but otherwise physically unscathed from a panic attack because you were not in danger to begin with [2].
We deal with danger by recognizing it and taking the necessary course of action (first diagram in this blog). We deal with false alarms/understandable anxiety by recognizing that our emotional response is excessive and do what needs to be done like crossing the street (second diagram in this blog). When panic hits, we might not even understand the reasons for it and see risks of undetermined danger that we cannot escape (third diagram). This confusion, paired with perceived uncontrollability of panic primes us for panic disorder. To overcome panic, we learn to trust to attribute the attacks to the priming process and stop searching for new causes in already familiar patterns. Let's stop the quest for elusive explanations and emotional ointments and instead target the mechanism that, just in case, keeps us unnecessarily and chronically hypervigilant. It might not feel like it, but panic can be treated. Just be gentle with yourself: panic treatment requires that we learn to think of powerful attention grabbing sensations as background experiences.
Fortunately panic comes in patterns. You have survived every single panic attack that fits your panic pattern. That should tell you that although panic is far from enjoyable, it is survivable. So what will happen if you allow panic to run it’s course in the situations that you are the most familiar with? What if you don’t pace, don’t hide in your bed or don’t call for reassurance and take things as they are? You will experience a host of highly unpleasant emotional and physiological reactions that are hard to attribute to anything other than panic disorder itself. You will also feel a strong urge to do something, anything, to make this stop. Eventually this particular panic attack will run its course. There is a very important caveat: patience. If you are impatiently waiting for symptoms to go away, that impatient monitoring will keep the symptoms going. If you understand your panic patterns, you start making more sense of your episodes and build the openness to engage in exposure-based interventions. Then life can happen.
[1]
Panic disorder comes with a host of physical symptoms than can be easily confused for a serious medical condition. Panic disorder is not life threatening. However panic disorder is not a protective factor against other medical conditions so it is always advisable to start with a full medical check-up. If there is an as yet undiagnosed serios medical condition present, effective treatment of panic will clarify the clinical picture. Moreover, treating anxiety in persons with serious medical conditions improves the quality of their lives.
[2]
Box breathing or paced breathing is one of the TIPP skills used in DBT (dialectical behavior therapy). TIPP stands for temperature (use of ice water to slow physiological body responses), intensive exercise, paced breathing and paired muscle relaxation. DBT has been developed to treat borderline personality disorder and TIPP skills have a very important place in prevention of self-harming behaviours. DBT is not an evidence-based treatment for panic disorder. This article focuses on experiences of panic in absence of acting out behaviours.
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