7 |
Panic disorder |
On p. 9 of Part 1 you read a brief description of panic disorder to see whether this might be relevant to you. This chapter will help you work out in more detail whether panic disorder is the best way to describe some or all of your anxiety problems. If panic disorder is a problem for you, this chapter will help you understand it better, why it hasn’t just improved by itself, and how you can take practical steps to stop panic attacks and overcome the fear triggered by particular situations and activities.
The approach in this chapter will help you learn about your panic attacks, work out what keeps your panic disorder going, and how you can make changes. The strategies in this chapter have been shown to be effective in clinical trials and have helped many people worldwide. Notice that overcoming your panic attacks and other anxiety symptoms is not simply a matter of learning to ‘pull yourself together’. If it were that simple you would have recovered long ago. Nobody wants to suffer from panic attacks and worry about them. So overcoming panic and related worry requires an understanding of what happens in panics, plus the application of techniques that will initially help you control your panic attacks when they happen, and later will ideally stop the panics from happening at all.
Most people with panic disorder have at some stage been sceptical that their problem is one of anxiety rather than a physical health problem, such as a heart or breathing problem, fainting problem, or some other physical abnormality. When you had your first attack you almost certainly thought that some terrible physical thing was about to happen or was actually happening. You may have gone to hospital or to your doctor to get help. It may have come as a shock if they suggested that the problem was really one of panic and anxiety. You may still have some doubts about whether your problem is an anxiety, rather than a physical health problem. This is a typical reaction and not surprising. Presumably you’re reading this chapter because you have some belief that your problem may be panic, or others (family, friends, or a therapist) have suggested this to you. As you work through this chapter you will see how panic disorder is both a good explanation for your horrible experiences, and also something that you can overcome.
Note: Occasionally, panic attacks can have a physical cause, for example thyroid problems. Your doctor should check to ensure that your problem is panic disorder. Once your doctor confirms that there is nothing physically wrong with you, then this chapter is for you (even if you still have some doubts at the moment).
People often talk about ‘feeling panicky’ in a variety of situations, such as a job interview, going on a date, and facing things that have scared them in the past, such as spiders perhaps. This is not necessarily the same as a panic attack, which is defined as a sudden rush of physical symptoms that reaches a peak within a few minutes (certainly fewer than ten). The physical symptoms include: breathlessness, palpitations, chest pain, dizziness, trembling, sweating, a feeling of choking, dry mouth, nausea, feeling unreal, numbness or tingling (especially in the lips and fingers), chills or hot flushes, and fears of losing control, dying or going crazy. At least four of these symptoms need to be experienced for an anxiety attack to be diagnosed as a panic attack.
Dan’s account of a panic attack
I suddenly notice my heart racing and my breathing starts to get very shallow. I feel as if I can’t breathe properly. I feel frightened and unreal, and I imagine myself gasping for air. I think I might pass out; I get very dizzy and hot, and I start to sweat and feel shaky. My mind is racing, and my thoughts are confused. I think I am losing my mind, that I might lose control and do crazy things. As I think this I get even more frightened, and the symptoms get even worse. My heart is beating like a drum now, and I have pains in my chest, which make me think that my heart can’t take any more, that I’ll have a heart attack. I think that these feelings will not go away, and that no one will be able to help me. I am frightened that I am going to die. The sensations are so strong and are still getting worse. I want to run somewhere safe, but I don’t know where, and my legs have turned into jelly anyway.
Occasional panic attacks are common in all anxiety disorders. For example, a person with spider phobia might experience a panic attack when confronted with a large spider. A person with obsessive-compulsive disorder might have a panic attack after touching a ‘contaminated’ object. Having occasional panic attacks does not necessarily mean you have panic disorder. This chapter focuses specifically on panic disorder. The main features of this are described below.
The diagnosis of panic disorder is for the people who have repeated panic attacks, some of which come on unexpectedly or out-of-the-blue. The attacks are not always triggered by expecting a particular situation, entering a particular situation, or a sudden increase in the severity of a particular situation (e.g. a spider moving). The main fear in panic disorder is a fear of having a panic attack and/or its consequences, rather than a fear of a specific situation, activity or object (e.g., heights, public speaking, or small animals).
A panic attack is an unpleasant experience. Small wonder that people who have panicked in a particular situation (such as travelling on public transport, being in a crowded shop or a wide open space) often find that they have difficulty going back into those situations. These people develop what we call ‘panic disorder with agoraphobia’. People whose initial attacks were not in a distinctive situation away from home are less likely to develop agoraphobia. However, because they cannot predict when a panic attack occurs, these people often show higher levels of ‘background’ anxiety between attacks.
So who has panic attacks? There are several ways of answering the question. First, it is possible to think in terms of how many people suffer from panic. Research has shown that one in ten of us will have at least one panic attack in a year. Think of the people living near you; on average, one person out of each ten has had a panic in the previous year. Often people think this is impossible, and that they would know if a neighbour had panic attacks. However, think how many people in your street know that you have panic attacks. Does everyone know? Probably not! Think how many people knew about your panics in the first year. Generally, people do not talk much about panic, so you don’t hear about it and will, as a result, underestimate how common it is. Recently several well-known people have spoken out about experiencing panic attacks and panic disorder, including the actress Nicole Kidman, the singer Donny Osmond and the cricketer Marcus Trescothick. Yet it is still massively under-recognized.
So lots of people have panics; but what is it about these people that makes them experience panic? Are they weak or inferior? Are they heading for a nervous breakdown? Are they stupid? Is there something physically wrong with them? The answer to all these questions is NO. Absolutely anyone can have panic attacks, given the right combination of circumstances. Here are some examples of people who have been treated by us for panic attacks.
A sister in charge of a general hospital ward had her first panic at home; and within three months she was panicking at least once a day and could not go into town on her own.
A policeman had his first panic when called to a particularly unpleasant road traffic accident; he was able to continue his work, but frequently found himself panicking when driving on motorways.
A 39-year-old former SAS soldier panicked when in town, and became completely agoraphobic within six months.
We can see then that panic can (and does) happen to people from all walks of life. It is not a sign of deficiency, weakness or of any other problem. As you will see, feelings of panic are based on conclusions that initially seem logical, although when you begin to untangle the thinking you will start to see that the logic is not entirely sound. While panic may be more likely at times of stress, stress is not the main cause of panic. Very shortly we will consider what does cause panic.
Because the approach described here involves your being able to learn more about the problem, each panic attack will not just be a horrid experience, but also an opportunity. At first it will be an opportunity to learn more about your panic. Later it will be a chance to practise the techniques you will have learned to use to overcome your panics. This may seem a strange idea, but think about it for a moment. What is the best way of learning how to deal with difficulties? If we know how, we can learn from mistakes and difficulties. For example, the best way of learning to deal with a skid is to practise on a skidpan – a slippery area where cars skid very easily. The more instruction people have on a skidpan, the better they will drive when it comes to dealing with skidding. Dealing with anxiety is similar. Until now, you have been at the mercy of your anxiety, so have not learned how to overcome the panic. As you go through this chapter, you will learn more and more from each panic attack and will get better at controlling them. Finally, you will see that you don’t even need to try to control these horrible experiences.
Tips for supporters
• As you read through the symptoms of panic disorder, encourage the person you are supporting to think about their own symptoms and how they view their own panic disorder.
• If you feel able, share any experiences you may have had about your own experience of panic attacks or anxiety.
As you may have noticed in Dan’s example above, he mentioned some very frightening thoughts. He thought the pounding in his chest in the middle of a panic attack meant he was about to have a heart attack. Extreme thinking of this sort is typical in a panic. People have frightening thoughts about what is happening to them. The thoughts are closely (and logically) linked to the sensations they are experiencing. Examples are shown in Table 7.1. These aren’t the only sensations and thoughts you may have, of course.
Table 7.1 Symptoms of a panic attack and reactions to them
Research shows that these frightening thoughts are the key to panic. This is the cognitive approach to panic. So how does it all work?
Quite small things can trigger panic in the first place. These might be a slight bodily sensation, an upsetting thought, or even going somewhere where a panic attack previously happened. Often it all starts with a mild physical sensation, which can lead to worry if the person believes that the sensation could be the first sign of disaster. For example, someone noticing their heart beating rapidly after drinking strong coffee might (mistakenly) think that this meant there was something wrong with their heart. Not surprisingly, this thought would make them anxious.
Anxiety itself causes the heart to beat more quickly and strongly, as is usual when we are afraid. The anxiety can also make us feel light headed and produce other symptoms as a normal effect of increases in adrenalin. These changes are there to help us to escape real danger (see Part 1, section on fight or flight, pp. 5–6). However, if you are already worried about physical disaster (such as a heart attack), the increase in sensations seems to confirm the first frightening thought; we think that the fast heartbeats and the feeling of lightheadedness mean that we are actually having a heart attack.
These catastrophic thoughts are the key to understanding why you are suffering from panic disorder. As a result of the thoughts, there is a dramatic increase in anxiety, and then there is a big rush of bodily sensations from the extra adrenalin produced as part of the body’s reaction to being in danger. You feel terrified, and your body reacts as it usually does when we are terrified, with more sensations, which seems to provide even more evidence that something is badly wrong. The vicious cycle of panic is complete (see Figure 7.1, p. 138).
A real-life example is given below:
Sundee was in a shopping centre, and had a sudden panic attack which appeared to come on out of the blue. Thinking about it carefully afterwards revealed that the first thing she had noticed was that she was ‘burning up in the face’. This led her to worry that she might be about to have another panic attack. Because she was afraid she felt rather breathless, and began to gasp for breath. This made her feel a bit light headed, which in turn made her think that she might be about to faint, or even collapse and die. Of course, these thoughts made her feel extremely frightened, which gave rise to even more intense sensations in her body.
Sundee could see how the vicious circle was working, but still wondered why her face had got hot in the first place. Thinking carefully helped her to remember that as she entered the precinct she had noticed some boys staring at her. This had made her embarrassed, which caused her to blush. So for Sundee the vicious circle looked like the figure below.
Figure 7.1: The vicious cycle of panic
Panic is driven by the frightening thoughts that people have about the sensations they get when they are afraid. The approach to overcoming panic that we take in this chapter is based on the treatment called cognitive therapy, but this book helps you to help yourself. This approach focuses on the two alternative explanations of what happens in a panic attack. One explanation is that there really is something seriously wrong with you, and the other (which is supported by all the work we have done) is that there is another, far less frightening, explanation for what is happening, and that you are not in fact in any danger.
In this chapter, we will describe special techniques that you can use to help you identify your own upsetting thoughts, and then you (and your supporter, if you have one) will work to find out how realistic they are. The discoveries you make about these thoughts, and about what is really happening in your attacks, will help to put your mind at rest, and will suggest helpful ways of getting rid of your panic attacks completely.
The unique aspect of overcoming panic disorder is the aim to change what you think and feel is happening to your body, or what you fear is about to happen, when you have strong physical sensations. You need to understand what is really happening in your body when the sensations are strong. To fully understand this you will need not only to read the information in this chapter, but also to prove to yourself in practice that nothing dangerous happens in a panic attack. This is difficult and frightening for anyone, so if you are a little hesitant that is entirely natural. We hope that this chapter, your hard work, and any available supporter(s) can help you make the changes you want, in order to be able to live the life you want, without being held back in any way.
First, there are some physical causes of panic attacks and your doctor should check these. Once your doctor and you agree that your problem is anxiety you need to find out more about this problem. In order to find out more about how your panic attacks occur it helps to pay close attention to what happens in each attack. There is a diary on p. 186. Each time you have a panic attack, make notes about it under the various headings. These include what you were doing and where you were when you had the attack, how many symptoms you had, and your thoughts of disaster – thoughts about the worst things you thought could happen during the attack. If you have a supporter, they can encourage you to keep this diary. You will learn more about how to notice these thoughts in the next section. The section will help you think about the sort of thoughts you are looking out for. Using the diary should help you begin to spot what triggers each attack, and will help you to notice the progress you make during the treatment. It is a good idea to photocopy the diary so you can use it over many weeks.
Don’t worry about trying to fill in the alternatives to your thoughts yet. We’re coming on to that and you’ll soon be able to do this.
In this section we will introduce the types of questions that you should ask yourself. Get a pen or pencil and write your answers down. You may want to make rough notes first on a sheet of paper, but when you have worked out what you want to say make sure you write it down here so all your work on your panic disorder is in one place. Don’t be afraid to go back and alter what you have written if you change your mind. Take your time; the idea is to go through the sequence of questions, then to go back to review what you have written to see that it all makes sense. Your supporter can help you by discussing the questions with you.
It is important to write things down and to spend some time thinking about each step. Panics usually happen quickly, so that it can require careful effort to sort out the way in which a single panic develops. The questions below should help you to sort out what might have previously seemed very confusing:
Think back to the last severe panic attack you experienced. Think carefully about it, and have a specific attack in mind. It’s best to choose a fairly typical attack that happened as recently as possible. If you haven’t had an attack for a while then take a little longer to really try to fully remember the last severe attack you did have. Take each step slowly, and make sure that you have a written summary of your answers before you move on to the next step. Some people get a few sensations in their body when they remember back to previous panic attacks. This is normal and not anything to worry about. If you can, try to move through this exercise staying focused on this specific attack.
• When did it happen?
• Where was I just before it began, and when it got going?
• Who was I with?
Try to remember the occasion as fully and clearly as possible.
Now concentrate on the worst part of the attack.
Think about the sensations you had in your body when the attack reached a peak. Write them down.
• What were the most frightening symptoms that I noticed?
• As I noticed these strong sensations what went through my mind?
• What did these symptoms mean to me at that time?
• What seemed to me at that time to be the worst thing that could happen? (These might be thoughts such as ‘I’m going to pass out’, ‘I’m going to have a heart attack’, or ‘I’m going to go mad’.)
• Did I have any images (mental pictures) at that time about what was happening, or might be about to happen? (These might be images of what you most fear, such as seeing yourself lying on the ground unconscious or dead, or even seeing images of what you think is happening inside your body such as seeing your heart beating really fast.)
Sometimes, particularly if you have had panic attacks for a long time, the first answer that comes to mind may not be about dangerous things happening to you physically, like having a heart attack or stroke. You may have answered, ‘I just thought I might have a panic attack’ or ‘I just wanted to get out of the situation I was in’. If you did not have that type of thought and have already found one or more catastrophic thoughts, go on to the next section. Otherwise a few more questions are needed.
If your thought was ‘I just thought I might have a panic attack’ then you need to ask yourself: ‘At that time what did I think was the worst thing that could happen if I actually did have a panic attack?’
Write down your catastrophic thoughts about what you would have been afraid might happen.
If your thought was ‘I just wanted to get out of the situation I was in’, then you need to ask yourself: ‘Supposing I was not able to escape, what at that time would I have been afraid would be the worst thing that could happen?’
Write your answers to this question here:
We’re looking for the worst catastrophe that you fear could happen as a result of these horrible sensations. You should now be ready to go on to Step Three.
You should now make a short summary of all the sensations that you had in the worst part of the attack and the catastrophic thoughts you had about them. Write the sensations that you had on the left, and the thoughts that you had about them on the right:
We shall come back to this shortly.
Now that you have worked out what was happening at the worst part of the attack, go through the attack slowly and carefully in your mind and answer the questions below to see how the attack built up.
Once again cast your mind back to the situation you were in when the panic started. What was the very first thing that you noticed as the attack started? A range of things can trigger panic. Often the things that trigger panic attacks can be small things, and usually they are not thoughts. Some of the most common triggers are: returning to situations where you have previously had panic attacks, getting worrying sensations in your body, or feeling anxious or upset, either about panic, or about something unrelated.
Write down the first thing that you noticed, i.e. the panic trigger:
This trigger is often followed by a quick thought, such as ‘I’m going to have a panic attack’ or ‘Here it comes again’. Sometimes the panic trigger can be followed by a catastrophic thought straight away (e.g. ‘I’ll collapse, I’m ill, etc.).
Write the sort of quick thoughts that you had at this stage in the space below:
Now look at the diagram on p. 148 (you will need to flick back and forth here a little . . .). You will see that it is a sketch of what happens in a typical panic attack. Fill in what you noticed in the attack you have been thinking about from what you have written above.
• Start by filling in your own panic trigger on the line marked 1) PANIC TRIGGER on the diagram.
• As you began to recall this fear what did you notice happening in your body? Write these sensations on the line next to ‘1st time’ under 5) MILD SENSATIONS.
• Next, write in the thoughts you had as you noticed the trigger, on the line marked 3) QUICK THOUGHTS.
• Next, think about how you felt as these thoughts went through your mind, and write these feelings (e.g. anxious, terrified, worried) on the line under 4) ANXIETY/FEAR, next to ‘1st time’.
• As you noticed these sensations coming on what sort of thoughts went through your mind? Write these thoughts on the line (next to ‘1st time’) under 6) THOUGHTS OF DISASTER.
• As these much more frightening thoughts went through your mind how did you feel? You can write your answer on the second line under 4) ANXIETY/FEAR.
• As your fear began to get much stronger what sensations did you have? Write these next to ‘2nd time’ under 5) SENSATIONS.
You will see that what is happening is that there seems to be a vicious cycle of sensations leading to thoughts of danger, which lead to feelings of fear, which cause an increase in the sensations, and so on.
You can keep filling in the sequence of sensations – fear – thoughts – sensations – fear – thoughts until you come to the peak of the attack when the sensations and thoughts were at their worst (see Step Three). You can look back at the panic cycle on p. 137. Does yours look similar? If not, then perhaps go through these steps again, with a supporter if that is possible.
This vicious cycle is the panic attack. It usually happens very quickly indeed and you may not notice the steps building up in the way we have helped you describe. Don’t worry about that. The crucial point is that it is understandable that you feel so frightened in or before a panic attack if you believe something catastrophic is about to happen to you. We are suggesting here that rather than these attacks actually being dangerous, there is an understandable sequence of events that leads to the rapid build-up of these horrible experiences. Well done on completing this! This is a very important step in starting to overcome your panic disorder.
Tips for supporters
• The person you are helping may become distressed and anxious when going through the steps.
• There is no hurry to do this – sitting together in a quiet place, taking your time and taking breaks when necessary can help the person remain calm and complete the steps.
• Let the person take their own time – don’t try to complete the cycle for them even if you have had panic attacks yourself, as everyone is different.
Figure 7.2: Recognizing that the vicious cycle of panic is the panic attack
As we have seen, the main things driving panic attacks are the frightening thoughts of disaster you have. Actually, in a panic attack you are in no danger and no disaster will happen. These thoughts are ‘misinterpretations’ of the bodily sensations you get in a panic, i.e. you think the sensations mean one thing (‘disaster’), but actually the sensations are your body’s natural anxiety reaction. This means that changing these terrifying thoughts, by weakening your belief that something terrible is about to happen, should break the vicious cycle and put an end to the panic attacks. But if it is as simple as that, why haven’t you been able to do it already? What keeps panic attacks going?
There are several factors that stop the problem going away:
• Evidence: People with panic disorder usually feel that they have good reason to believe that the sensations they have in a panic attack are truly dangerous. They have usually not considered other less frightening explanations for what is happening.
• Attention: As people with panic disorder think the bodily sensations in a panic attack are dangerous, they are alert to what happens in their bodies. This makes them notice sensations that other people wouldn’t notice. Once they notice the sensations, they tend to take them as further evidence for their thoughts of disaster. This process of noticing more sensations is natural and automatic.
• ‘Saving yourself’ and avoidance: People with panic disorder understandably begin to take precautions, which they believe will save them from disaster. For example, if we believe that our racing heart means we are going to have a heart attack, we will do things to reduce our heart rate, such as sit down, and try to relax and take it easy. In addition people usually try to leave or avoid situations where they fear the worst may happen. This means that they never find out whether ‘the worst’ would ever really happen.
• Images: Some people also get brief vivid mental pictures or images of awful things that could happen. These tend to just flash through their minds, but can be accompanied by strong emotions. Often people manage to stop them at their worst point, and push them away, but they can still be left feeling shaken and upset, without really thinking it through.
We are now going to look in detail at which of these factors are keeping your panic attacks going, and what you can do to change them.
One thing you may say is, ‘I’ve heard of (or seen, or read about) other people with symptoms like mine, and those people certainly had something seriously wrong with them.’ Or you may look back to a time when you had what seemed to be similar symptoms, which then appeared to be serious.
Here what you need to do is to consider carefully whether there are any ways in which the situation during your panic attacks is different from the serious situation you have been comparing it to.
In order to get your fears in perspective you may need some information you do not have at the moment to help you tell the difference between what actually is happening, and what you fear is happening.
Jane had once fainted and felt sick at a wedding reception. After this she had often felt very anxious at work, fearing she would faint there too. In fact, during her treatment she worked out that food poisoning had been the cause of her fainting at the wedding reception, and learned that anxiety alone cannot cause fainting (we return to this later).
A little further below is information on a number of topics that people with panic attacks often worry about. Before you look at this, write out your worst fears about what might be about to happen during a panic attack, in the space below. Beside this write a number to indicate how much you believe this right now, on a scale from 0–100%, where 0% means you don’t believe it at all, and 100% means you are convinced this is true. Then write another number from 0–100% to indicate how much you believe this in the middle of a panic attack.
Now write some notes in the space below about the evidence you have that this could happen. This might include things you have heard about, or read about, or an illness you suffered from in the past, or that someone you know suffered from, and so on. Write anything that makes you worry that the worst could happen.
Do you have any doubts about this evidence? What would your supporters say?
Is there any evidence that your worst fears won’t come true, and that this is best seen as an anxiety problem rather than a physical problem?
Tip for supporters
Look carefully at the evidence that the worst fears might come true. Does it seem convincing? Are there any doubts you have that you can share? Why won’t the worst fears happen?
Listed here are some common questions that people with panic disorder ask. Quick answers are provided here. Some further information and ideas to test this out are at the end of this chapter. This will help you assess the evidence for your worst fears.
Remember, there are more detailed explanations of these common experiences on pp. 189–96.
Now you have read some information about your worst fears, and learned more about them, please re-rate them below:
If this helped you, that’s good. However, if you still have major doubts, don’t worry. Most people need to go over things in a number of different ways before they are convinced. The remaining sections of this chapter will take you through some more ways of working on thoughts of disaster.
Tips for supporters
• The goal of this part of overcoming panic is to help the person with panic disorder distinguish between what they fear is happening and what is actually happening.
• To do this, you will need to help them identify what they fear is happening (e.g. the person is having a heart attack) and what is actually happening (e.g. the person is afraid they are having a heart attack so is very anxious and experiencing a lot of sensations of anxiety).
The thing people with panic attacks often feel is evidence that something must be seriously wrong since the symptoms seem so intense. If you sometimes feel this, read through this section. Otherwise move on to the next section which looks at the importance of considering other explanations for your symptoms.
So is it always true that feeling strong symptoms means there is something seriously wrong with you? Go over in your mind other times when you might have had the same symptoms but not felt frightened. This may not seem very likely at first, but just try to remember the last time you were really excited. Perhaps you were watching an exciting football match, or a thrilling film on a huge cinema screen, or perhaps you discovered that you had won the lottery, or went out with your present partner for the first time after you had fallen in love. Write down what the occasion was, and the main physical symptoms you noticed at that time. If you can’t remember a time when you felt excited, you can think about a time when you had other strong feelings like being angry, or a time when you had lots of sensations in your body, like when doing exercise.
The last occasion on which I felt excited was (e.g. was angry or doing exercise):
The physical sensations I noticed at that time were:
How similar are these symptoms to the ones I get during panic attacks?
What are the differences?
Usually the symptoms are quite similar, and certainly they are also intense, but the thoughts that go with them make them seem different. So why should the symptoms be similar? Read the next section to find out.
When you get excited or frightened your body starts to get ready to take action. It does this by making your muscles tense up, your heart pound, and so on; this is just what you need if you might have to do something energetic, but it feels strange if you are just sitting still or walking about. This reaction was useful for our primitive ancestors, because it would make them better at fighting or running away (this fight-or-flight response is also talked about in Chapter 1, pp. 5–6). Athletes and football players need to be ready for action: it usually improves their game. However, if you get a burst of this reaction when you are walking about your house or in the supermarket, it feels very odd.
The body’s reactions during an anxiety attack are all appropriate ways of dealing with a real danger. The release of adrenalin and redistribution of blood flow to the muscles are excellent ways of getting one ready to fight or flee. These sensations are not dangerous. Indeed, they are a sign that the body’s anxiety alarm system is working as it was intended. The only problem is that the system is being triggered by an imagined danger, rather than a real danger.
So why do you get a feeling of being ready for action when you panic? It’s back to those thoughts again. If you have a thought about something terrible being about to happen, your body sets off its alarm reaction, and gets you ready for action. The trouble is, there is no action to be carried out! Your heart pounds, you feel dizzy and you are so tense that the muscles in your chest and neck start to hurt, and you feel wobbly. It makes you feel you want to run away – but there is nowhere to run to.
However, this reaction cannot hurt you. In fact, a burst of it can be good for you – it is a bit like starting the car up in the drive and revving it up for a few minutes to get the oil circulating and all the parts in working order. After all, people with exciting jobs, like pilots, racing drivers and stunt artists, don’t worry that excitement will damage their health.
The amount that your heart speeds up during a panic attack is almost always less than that caused by running upstairs. In addition we are all encouraged to take exercise that increases our heart rate because it strengthens our bodies.
Another thing that happens to people when they are anxious is that they tend to focus on frightening, dangerous possibilities, and ignore the fact that there may be much less alarming explanations for what is happening. Let’s take the example of someone who is afraid they may have heart disease. Every time they notice their heart racing they think there must be something seriously wrong with it. However, this ignores the fact that there are many, many reasons why the heart races, and almost all of them are not serious.
In the list below you will see a few causes of a racing heart:
• Anxiety
• Taking exercise
• Smoking cigarettes
• Drinking coffee
• Looking forward to something exciting
• Feeling embarrassed
• Having a temperature (e.g. if you have the flu)
• Feeling afraid of something
• Being very busy and ‘wound up’
• Lifting heavy things
• Worrying about something
• Hurrying
• Falling in love
By now, you will realize that in only a very few cases is a racing heart a sign that something is wrong with the heart. Yet often people with panic attacks only consider the very worst explanation if they notice a racing heart.
If there is a symptom that often makes you think of your worst fears it would be worth taking some time to try this exercise for yourself.
Worksheet 7.1: Identifying what makes you anxious
Make a list of all the possible causes of this symptom. Put the worst explanation last on your list. It would also be worth asking your supporter and other people what explanations might occur to them if they had this symptom, and adding them to your list.
The symptom you worry about most:
The possible cause you fear the most:
Various possible causes of this symptom
1.
2.
3.
4.
5.
6.
7.
8.
9.
The cause I fear the most:
You will probably realize that this symptom has many possible causes, only some of which are frightening. It is also important to remember that sometimes we have symptoms and cannot find an explanation for them; this doesn’t mean that they must then be serious.
Tip for supporters
Encourage the person you are supporting to have an open mind and consider the possibility that there is an alternative explanation for their panic attacks other than that their bodily sensations are signalling impending disaster, or that having a panic attack is dangerous.
A lot of people with panic attacks say, ‘I get lots of symptoms during the day, not just when I panic; I never used to get so many symptoms before I had panic attacks, so there must be something seriously wrong with me.’
Sometimes it comes as a surprise to discover how much you can be affected by the way you focus your attention. If you have a car, remember what happened just after you bought it. Suddenly it seemed as if there were lots of cars of the same colour and type on the road, many more than before you got yours. Of course, what was happening was that this type of car meant something different and was more important to you, so you noticed it much more.
The same thing goes for symptoms. If you are worried about getting a cold or flu, you may notice that your throat is a little sore, or you have a slight sniffle, although you don’t actually get a cold. So if you think you have a serious illness (like a heart condition) think how sensitive that would make you to noticing changes in the way your heart works. Or, if you think you might be going to lose control over your behaviour and go crazy, you might notice changes in the way you think, or a slight trembling in your hands.
This process of noticing things more because they have become important to you works particularly strongly when you have nothing to distract you. This is why people often tend to notice worrying symptoms when they sit down to relax in the evenings. The sensations they notice are probably ones that were around before, but to which they paid no attention because they didn’t seem important.
Thinking about it now, do you think any of your symptoms associated with your worst fears tend to be more noticeable at the moment because they are so worrying and important to you?
Now try a small experiment. Think about all the sensations you have in your feet as they press against the floor inside your shoes. Do this for a couple of minutes, really focusing. Do you notice how your feet feel? Were these feelings noticeable to you before you began to think about your feet? Another example would be to focus on the sensations you have on the top of your head. How does it feel now you are focusing on it? Are you noticing it getting a bit itchy? Make some notes about this here.
Now that you have done quite a bit of work on weighing up the evidence for your thoughts and considering alternative, less frightening explanations, fill in the last column in the panic diary each time you have an attack. This is headed ‘Answers to your thoughts of disaster’, and it is a space for you to try challenging your frightening thoughts and arguing against them. An example is given below:
June was seeing a therapist for help with her panic disorder. Throughout therapy, she wrongly believed she was suffering from heart disease. Negative medical tests and reassurance from her doctor failed to change this belief. When asked what evidence she had for the idea that she had heart disease, she said that she noticed her heart more frequently than did her husband or colleagues at work and she thought this must indicate that there was something seriously wrong with it. The therapist suggested the alternative interpretation that the problem was her belief that there was something wrong with her heart. This belief might lead her to selectively focus on her body, which in turn would increase her awareness of her heart.
When asked what she thought of this alternative, she replied, ‘You psychologists are very good at thinking of clever explanations and this would, no doubt, apply to some people but I don’t think that the effects of attention could be strong enough to account for my sensations.’ Rather than argue with this assertion, the therapist said, ‘You may be right. Perhaps to get more information it would be good if we did an experiment to see how strong the effects of attention are for you?’
The patient was asked to close her eyes and concentrate on her heart for five minutes. To her great surprise, she found that simply focusing on her heart enabled her to detect the pulse in her forehead, neck, arms, chest and legs, without touching those parts of the body. Furthermore, when she was subsequently asked to describe out loud the contents of the room for five minutes, she ceased to be aware of her heart. This demonstration reduced her belief that she had heart disease. It also increased her belief in the alternative explanation, that it was her belief that there is something wrong with her heart that was increasing her awareness of it.
Don’t worry at this stage if you cannot yet fill in a completely convincing answer in the ‘answers’ column. In the next section we move on to other ways of answering your thoughts.
Now re-rate how much you believe that your worst fears could come true. Remember 0% means that you would not believe them at all, and 100% means you would be totally convinced the worst could happen.
It’s fine to still have doubts. You can work on them in the final section of this chapter.
As you continue to fill in the panic diary you can use the things you have learned in this section to help you fill in the ‘answers to your thoughts of disaster’ columns.
Earlier in this chapter we mentioned that lots of different things can trigger panic attacks. The two main categories are sensations in your body, and going into a situation where you fear you may have a panic attack.
It is probably clear to you that going back to a place where you have panicked before can make you feel anxious. The anxiety causes various sensations in your body, which you can then misinterpret, which can then spiral into a panic attack.
It is probably also clear that physical symptoms like rapid heart beats (from too much coffee, or from exercise) or dizziness (if you stand up too suddenly, or after a hot bath) can also trigger panic.
It is sometimes harder to see that other emotional events can also trigger panic. This happens especially in situations that are stressful, but in which it is not clear what you can do about the situation, or in which it does not seem safe to look at or express your feelings. Here are a couple of examples:
Kwazi worked in a restaurant with his fiancée, and they both lived in accommodation provided by their boss. The boss exploited them, making them work overtime, never paying their wages on time, and not letting them take holidays at the same time. Kwazi was worried about the possibility of finding another job and alternative accommodation, and did not dare to stand up to the boss. The unexpressed anger would sometimes make him hot, dizzy and shaky. He misinterpreted these sensations as meaning he was ill, or about to pass out or even die. In therapy, Kwazi learned to spot what was triggering the sensations and to challenge the thoughts of illness, passing out or dying. He also began to stand up to his boss, and to explore other possible ways of finding accommodation or employment.
Susie was worried because most of her panic attacks seemed to come on ‘out of the blue’. However, when she and her therapist went over some of these attacks very slowly and carefully they noticed that often an emotional event had triggered them off. For example, on one occasion, Susie felt worried and sad when her mother-in-law criticised her for not being able to go into the centre of town, and on another occasion she felt angry when her husband asked her late at night to type a few urgent letters for him. Each of these situations gave her various physical sensations in her body, and she had then focused on them rather than thinking about what had upset her in the first place. Once she realised what was happening she was able to respond that these were normal emotional reactions, to which she had become over sensitive. Realising this was helpful in preventing her reactions from spiralling up into panic attacks
In these two cases the vicious cycle was working like this:
Do you think that some of your panic attacks may be triggered by emotional reactions to ordinary things? If so, make some notes below about recent examples:
Often people with panic attacks feel as if the worst could happen – but that so far they have been lucky and got away with it. You may say, ‘I’ve had lots of attacks when I have been very close to disaster and just managed to escape it each time.’
Understandably, if you are pretty well convinced that something disastrous will happen to you during a panic attack you will begin to do all you can to prevent the worst from happening. Typical examples of things people fear, and the precautions they take, are given in Table 7.1 (p. 135). These precautions are technically called ‘safety-seeking behaviours’ (see Table 1.3, p. 11).
Table 7.2 Safety-seeking behaviours
In addition to these precautions that you may take linked to these specific fears, there is also a common further precaution, which is to leave the situation. You are likely to do this no matter what your specific fears are.
First of all, put a tick beside your worst fears if they are listed above. Are these the things you do when you are afraid the worst will happen? Or are there other things you do to ‘save yourself’ as well as (or instead of) the things listed above? On page 188 and in the appendices there is a brief questionnaire, the Safety Seeking Behaviour Questionnaire. This lists other precautions you might take in order to save yourself. You can use this to monitor how much you are using these precautions.
Write down below all the things you do to ‘save yourself’ when you are afraid that the worst is about to happen. Remember only to write about your worst fears at this stage.
Thinking about it now, do you think that any of the precautions you take have the effect of making you feel worse?
If the answer is ‘yes’ how would that work?
In fact, taking precautions keeps the fear going in several ways.
One is that it tends to focus your attention on the part of your body that you are worried about, and so make you notice even more worrying sensations. The second is that if you deliberately try to control your reactions, a lot of the things you do make the sensations worse. Here are some examples:
In the example from earlier, Sundee was in a shopping centre when she had a sudden panic attack. As she started to notice feeling breathless she believed that she would stop breathing. As well as making her feel anxious she tried to ‘save herself’ by breathing deeply to make sure she ‘got enough air in’. This breathing made her feel more light headed. Sundee then thought that she might be about to faint, or even collapse and die. Of course, these thoughts made her feel extremely frightened, which gave rise to even more intense sensations in her body.
Here, the way Sundee was breathing in order to save herself from stopping breathing was actually making the situation worse and led to a full panic attack.
From now on, it is important to work on reducing your belief in your frightening thoughts still further, by giving up the precautions you have been taking, so that you can find out what really happens. This can be scary. It is important to remember all of the information and evidence, and things you have learned so far in this chapter. As we have said in other parts of this chapter, a panic attack can’t cause you to pass out, go mad, have a heart attack, etc. You will of course feel anxious, but the more often you try to stop using your precautions the less anxious you will feel as your body learns through experience that it is in fact safe.
To fully prove to yourself that the sensations in a panic attack are not in fact dangerous you will need to experience that even when the sensations are very strong and your worst fears are activated, the disaster doesn’t occur. You also need to discover that you don’t need to save yourself. When you really understand and believe this then the cycle that currently keeps the panic going will be broken. The problem will be beaten.
This will, of course, feel horrible, but it is not dangerous. If you have a supporter it would probably be helpful to try not using your precautions (‘save yourself’) with him or her first so they can give encouragement and support.
A note on ‘controlled breathing’ or ‘breathing retraining’
You may have read or been told that learning to control your breathing is an important way to overcome panic attacks and panic disorder. This is a common part of some treatments for panic disorder. Although smooth, shallow breathing is sometimes given as a way to control breathing, we have found that this may become a precaution (a safety-seeking behaviour) in itself. You may still fear panic attacks and worry what would happen if you didn’t do your controlled breathing early enough or well enough. You need to learn that your sensations are harmless even if you don’t control your breathing in any way.
Of course, when under stress, such as before a job interview, breathing slowly and smoothly can help you feel calmer. But in those situations, it is not being used as a precaution to save yourself like in panic disorder.
However, in this approach, to fully overcome panic disorder, there is no need to learn how to control your breathing, and no need to try to do so when you have a panic attack. Even without controlling your breathing nothing bad will happen.
Tip for supporters
Try controlling your own reactions, too, and discuss with the person you are supporting what it felt like for you.
Many people who have panic attacks start to change their lifestyle in order to avoid the unpleasant sensations that they fear will lead to a panic attack. Typical changes that are driven by this fear of further attacks include reducing or stopping exercise, stopping drinking coffee and/ or alcohol, and stopping having sex. Even if you don’t stop doing these things you may find that you will only do them once you have checked how you are feeling, and judge that you are feeling well enough.
We have found that a good place to start overcoming avoidance is to try to get back to doing the things you used to do in your life but have given up because of the fear of having a panic attack. All of these are activities you may have avoided as they can cause changes in your body, which you may then fear will develop into a panic attack that leads to physical disaster. To take this further you can try to do these activities on days when you aren’t feeling so well, too, just to show yourself that it is still safe to do so. In time you will learn that you don’t need to check how you are feeling, but can simply do what you want when you want to.
You may also have tried to keep a firm lid on your emotions to prevent the normal physical sensations that come with strong emotions. This is the time now to allow yourself to become excited about things (or angry, or any other emotion you have been trying not to feel), so you can learn there is no physical danger from such feelings.
In addition, people with panic disorder avoid places where they fear they may panic. In this way what we call ‘agoraphobia’ starts to develop. Once you have understood what is happening in panic attacks you are in a good position to tackle any situation you have been avoiding. You may have already started to do this.
You will probably have read or heard that the best way to overcome agoraphobia is to repeatedly go into the situations you fear, until you no longer feel afraid of them, starting with the least frightening.
We now know that there is a better way to work on overcoming agoraphobia. When you put yourself into frightening situations what you need to do before you are in the actual situation is:
1. Notice what frightening thoughts are going through your mind.
2. Do your best to reason with yourself and answer these fears. You may find it helps to write brief answers to your thoughts on cards (or similar, like having a note on your phone), which you can read through just before entering a feared situation.
3. Notice whether you are making predictions about what will happen (e.g. I’ll fall down if I let go, I’ll faint if I stay here, etc.).
4. Then try to test the predictions by deliberately not taking precautions, and even by testing things further, by doing things like swaying around or standing on one leg (to be certain that you will not fall) or running up and down the stairs if your heart is racing (to be certain you will not have a heart attack). The more daring you can be, the quicker you will feel confident again.
It is usual to go into situations that are only slightly frightening first, before going into more scary ones. However, we would encourage you to go into the most difficult situations that you are willing to try out, rather than building up too slowly or gradually. The aim of this approach isn’t to learn that you can gradually get used to situations. Rather the aim is to learn that the worst fears you have about your physical sensations will not occur at all. The best way to find this out is to make sure that you go into situations in which these fears are properly activated, to not use precautions, and to discover that nothing catastrophic happens.
When overcoming avoidance and not ‘saving yourself’ you will learn the most, and make the quickest progress, if you record what you do. We have found that this is best done in a structured way. In the following pages there is a worksheet for recording the times you test out your thoughts of disaster. There is also an example of an experiment that Sundee did to test out her fears of fainting and dying (below).
As you can see from Sundee’s worksheet she found that she did not faint when she went to the shopping centre but that she still had some remaining doubts.
There are a number of questions you need to ask yourself. You should then fill these in on the sheet on p. 177.
• What are your worst fears of disaster?
• How will you test these?
• What precautions do you usually use? You’ll need to not do these to fully test your fears.
After you have put your worst fears to the test you can complete the final two columns of the sheet.
• What actually happened?
• What you have learned?
• Any ‘yes, but’s? What could you do to really convince yourself that your worst fears won’t happen?
These can be called ‘behavioural experiments’. This form of behavioural experiment is one in which you test out your predictions. These are used in treating all anxiety disorders (see pp. 62–4 in Chapter 1). An alternative behavioural experiment worksheet is provided on p. 65 in Chapter 1. These worksheets are different ways of recording the same information. You can use whichever form you prefer.
If you follow the above guidelines you will find that the process of making your reactions to perceived threats more manageable will go more quickly and easily for you. Good luck!
We wouldn’t expect that doing a single experiment will suddenly convince you that your worst fears won’t happen – and hence break the panic cycle and make the panic attacks stop. This didn’t happen for Sundee in the example on p. 176. We expect that you can put things to the test in more and more situations and reflect on what you learn. From this you can learn through experience (‘in your heart and body’) what we hope you already know logically (‘in your head’) – that panic attacks are horrible but not dangerous, and your worst fears won’t come true. Each time you think ‘yes, but’ this is a chance to try to do another test in a new situation.
Ultimately the very best test of this is to have a panic attack without using any of your precautions and finding that your worst fears don’t occur – or even try to make the worst fears happen and find that you can’t! We know this can be hard to do. It will help to remind yourself of the other information you have learned from this chapter and from your supporter(s). It can help to have this information written down for yourself (like you have been doing on the panic diary) and to keep it with you as a reminder when you put your worst fears to the test.
• This is usually the hardest part of overcoming panic and people need lots of support and encouragement. You will also need to remind the person with panic disorder that panic attacks are not dangerous (although they are horrible), testing the worst fears out is not in fact risky, and that this is the key to fully beating panic disorder.
• It’s also possible that you may become a precaution yourself and that the person you are supporting won’t go into certain situations without you – that you are the way the person ‘saves themselves’. This is normal and understandable, and this is where you need to encourage the person to test out strategies alone.
Now rate your worst fears again:
We don’t expect that these beliefs will change easily. The next section on images may provide extra help. The best way to further change these beliefs is to continue to test them in the ways described above.
Many people have images that pop into their mind in the middle of a panic attack. These images usually involve seeing in their mind what they most fear will happen. For example, people afraid of passing out may have an image of themselves lying unconscious on the floor; or someone afraid of dying of a heart attack may see a picture of their heart exploding or their body lying in a coffin. Research shows that images are more frightening than words. So, seeing a picture of yourself collapsing can be even more scary than just thinking it.
Steve was a 26-year-old working in a call centre. In his panic attacks the strongest physical sensations were chest pain, racing heart and dizziness. At these times he also had a picture come into his mind of a large clot of blood circulating in his body. It was so real he described he could feel it. As the attack got to the worst point he saw this clot moving towards his heart or his head. This made him strongly believe that he was going to have a heart attack or a stroke, caused by the clot. Even though he knew in reality that he was experiencing a panic attack and that he was perfectly safe, this image was very powerful. In order to fully overcome his panic disorder he needed to change his image to better fit with what he knew – that there was no danger from a blood clot in his body. He did this by imagining the clot harmlessly dissolving and in fact coming out of his body. By practising changing the image in his mind when he was not in panic-attack mode, he was then able to change it when it occurred in the midst of a panic.
In order to deal with your images and the fear that comes with them, there are a few steps you need to follow:
1. Identify the image or images you have in the middle of a panic.
2. Work out what this image means – what you think is the worst that is going to happen. Often this is what is happening in the image itself, such as collapsing. This is almost certainly one of the worst fears you have already worked on.
3. Remember that this is just an unrealistic image and nothing dangerous can actually happen. Remind yourself of all the work you have already done on this worst fear.
4. Think about how you might change the image in your mind so that it better fits with reality – i.e. showing that your worst fear won’t happen. Remember, they are only images, not reality, and you can change them however you like. This could be you jumping up from the floor or out of the coffin!
5. Practise changing this image first when you are not feeling very anxious. Bring the frightening image to mind. When it is at the worst point (and your anxiety might be raising now . . .) change the image in your mind to show that your worst fear doesn’t happen.
6. When you get this image during a panic attack, try changing it in the way you have already practised.
Sometimes this seems a little strange – to play around with changing the picture in your head. But this is something that professional sportsmen and women practise repeatedly before their race, football match, etc. It helps change how they feel, and improve how they actually play or perform. Just give it a try and if changing the image in one way doesn’t seem to work then simply try changing it another way. This is something you have to experience rather than read about.
Preventing relapse is important for all anxiety problems and you can read more about this in Chapter 14 in Part 3. As you regain your confidence in overcoming your panic disorder it is a good idea to look into the future and think about situations that might stir the problem up again. Then try to think through what you could do to prevent yourself from developing panic attacks and starting to avoid things.
Write a list below of any problems you anticipate in the future, and any ideas you have about how you could avoid developing panic attacks:
At this stage it is often useful to make a list of all the things you have learned so far about your panic attacks, what has kept them going, and how to overcome them. You can use the space below to write short notes about the different things you have learned.
Below you will see someone else’s notes on what they learned about panic. The notes need only be brief, like those in the example.
You cannot faint when your pulse is racing.
Panic attacks can happen to anyone.
One in ten people suffers one attack each year.
They are caused by fear of something and are kept going by adrenalin being released into the bloodstream causing a high pulse, sweating, and breathing harder due to extra work by the heart affected by this hormone.
Light headedness is caused through more blood going to the muscles for either fight or flight to happen.
Focusing your attention on your symptoms makes them worse, causing a belief that there is something seriously wrong. The more you worry, the more symptoms you notice. Positive thinking and knowledge of panic attacks can bring them to an end when you acknowledge them as sensations caused by the mind.
During an attack, it is best not to ‘save yourself’. Instead, press on and try not to focus your attention on the attack.
We hope you have found this account of the nature of panic and what you can do about it helpful. It is not a magic wand and it requires lots of hard work from you, and often those supporting you. Once you fully believe (in your heart and body as well as your head) that panic attacks are only horrible rather than dangerous then there will be no need to fear them. Then they will stop, not come back, and allow you to live your life as you want.
Table 7.3: Safety-seeking behaviour questionnaire
When you are at your most anxious or panicky, how often do you do the following things?
Reproduced with permission from Panic Disorder Therapist Manual for IAPT High Intensity Therapists, Clark and Salkovskis, 2009.
People feel unsteady when they are anxious, because they breathe rapidly and this can make them feel wobbly and shaky. However, it can’t lead to falling over; it is just a feeling.
When we are having a panic attack the symptoms come on very quickly at first, and we become afraid that they will carry on increasing quickly until something awful happens, e.g. collapsing or falling over.
But many of the symptoms can be caused by the way we breathe in a panic attack to try to keep the problem under control. For a few minutes breathe in the same way that you do in a panic attack. Remember to do it the same way you actually do in a panic attack, rather than how you would like to do it. What do you notice?
Many people notice the symptoms of a panic attack starting to build up. If you then start to feel wobbly and believe you will fall over it is common to try to sit down or keep still. But you’ll never find out what would happen if you carried on – would you really fall over or is it just a horrible feeling? It’s also common to walk differently if you start to feel wobbly. Many people walk with their legs slightly wider apart as they think this will stop them falling over. But if you try this now you will find that this can actually make you feel more wobbly. Once again the things you do (understandably) to save yourself can be making the symptoms and the panic worse.
You may feel wobbly when you are anxious, but this will not lead to your falling over.
People who panic often fear that they may be about to faint. In movies, people are often shown fainting away if they receive a bad shock. In fact panic itself cannot lead to fainting.
Why is this? In order to faint you need to have a drop in blood pressure. When you are anxious, what happens to your blood pressure? It temporarily goes up and your heart beats faster, as part of your body’s ‘alarm reaction’ to danger. This actually has the effect of protecting you from fainting.
You can check whether this is true for you. Next time you have a panic attack and fear you may faint, take your pulse. Count the number of times your heart beats in one minute. (If you don’t know how to take your pulse ask someone to show you how.)
You cannot faint unless your pulse falls to below 40 beats per minute.
If you take your pulse a few times when you are anxious or panicky, and a few more times when you feel fine, you will probably find that your pulse will be a little higher when you feel nervous. It will never drop as low as 40 beats per minute, unless something else is going on (see below):
• Being physically ill (e.g. having flu)
• During hormonal changes (e.g. a period, pregnancy, menopause, puberty)
• Having sunstroke (not just being hot). It is the light that gives you sunstroke.
• Seeing a lot of blood, or other injury to the body.
This last reason affects about 10 per cent of people, who experience a blood pressure drop in this situation. If you are one of these people, and it is a problem to you, there is a simple technique to increase your blood pressure and put your heart rate up to normal. This is called applied tension (see p. 111–13). Essentially you tense your muscles, such as in your fists, arms and legs, when you see blood or an injury, or when you expect it.
So why do people sometimes feel faint when they are anxious? This is because when you fear you are in danger, blood surges to your muscles to get you ready to run away, or to fight. This means a little less blood goes to your head. However, as your overall blood pressure doesn’t drop there is no danger of you fainting.
Remember what you have already learned about fainting. In order to faint you need to have a drop in blood pressure. If you are anxious in a situation you will feel hotter, but this is because your blood pressure increases slightly for a while, so you will not faint. To test out whether feeling hot can make you faint you could try the following little experiments:
a) Try to make yourself very hot at home, where you can test out what happens in privacy. Put on a lot of clothes, including a scarf or a heavy coat, turn up the heating, drink a hot drink, turn on an extra fan heater or hair dryer, and keep the windows and doors closed. Stand up to see what happens. Make some notes below on what happened:
b) Next time you go somewhere hot (e.g. a big department store) wear some extra clothes. Once again to test that being hot (and anxious) can’t make you faint, although you may feel uncomfortable. What happened when you tried to do this?
Now you will realize that heat alone cannot make you faint. Firemen face intense heat, and can still do their jobs. The same is true of people who work near furnaces making metal or glass objects and people who live in hot countries.
You may notice sensations more than you used to because you think they are a sign that something bad will happen, and you want to avoid that happening. Sensations are more noticeable when you pay attention to them. So that when you are not thinking about other things you will become more aware of them. The following exercise demonstrates the effects of attention on how noticeable sensations are:
a) Sit quietly and focus on your body. Make a note of the sensations in your legs, arms, shoulders and body. Were you aware of all of these sensations before doing this?
b) Now look around the room, and describe one of the objects in it out loud. How many sensations were you aware of when you were paying attention to something else?
Some people with chest pain have heart disease. However, we are assuming that if you are reading this you have been checked out by your doctor who has confirmed that you do not and that your problem is anxiety.
When you have been tense for a while do you ever notice pain or discomfort in your chest? This may make you worry that there is something wrong with your heart. But this type of pain is due to harmless muscle spasm. There are lots of muscles in your chest, between each pair of ribs. These muscles can start to ache if you breathe in a tense way.
To see if this is true for you, try this small test:
Take a deep breath, and do not let it out again. While holding this air in your lungs take short breaths in and out for two minutes, if you can manage it.
What do you notice happening?
Most people get uncomfortable sensations in the chest when they are anxious because they breathe in a tense way. This tends to persist for a while even when they relax. This is something like a cramp in the muscles between the ribs. Any muscle held tensely for any length of time tends to ache. If we sit in a chair with one leg stuck out in front of us it would start to feel uncomfortable quite quickly. We also get aches and pains when we exercise muscles we haven’t used for a long time (e.g. if we carry a heavy suitcase).
This sort of pain does not mean there is something wrong with our heart. When we are anxious we probably do not relax our chest between breaths, but breathe in and out in a tense way.
Try to notice how you are breathing next time you feel a pain in your chest when you are feeling tense. Then try letting your breath out fully as you breathe out, and wait a moment for the next breath to come in. This gives the muscles a chance to relax, and will probably feel more comfortable. Remember, even if you don’t try to breathe differently nothing bad will happen to your heart or anything else.
Many people who have panic attacks doubt that strong sensations can be caused by anxiety. If you share this view you could try the following brief experiment:
Sit in a place where you won’t be disturbed and remember a recent severe panic attack. Close your eyes and picture where you were, what was around you, and how you were feeling in your body. Try to recall all the sights, sounds and smells as if it were actually happening again now.
Make some notes about what you noticed below:
Most people who have panic attacks worry about the sensations they get, and whether they may mean that they are ill in some way. Remembering past attacks is often enough to bring on worrying thoughts, and the anxiety generated can sometimes bring on strong sensations in the body.
If this happened to you, doesn’t this suggest that strong sensations really can be caused by anxiety?
It if didn’t happen, read on.
You have probably had other experiences which demonstrate the connection between feeling anxious and getting strong sensations in your body.
Think of a time when you knew you would have to do something that frightened you, like giving a talk or going on an aeroplane. Or think of a time recently when you woke up in the middle of a nightmare.
• What was the situation?
• How did you feel? (e.g. anxious, nervous, terrified, embarrassed)
• What kind of strong sensations did you notice in your body? (e.g. heart racing, sweaty, upset stomach, feeling sick or shaky)
• To what extent were they similar to the sensations you get when you have a panic attack?
Really strong sensations can be caused by anxiety, and are not dangerous.
Muscle tension in the arms and hands can exaggerate the normal, usually unnoticed, hand tremor that everyone has. If you are trying to control shaking by tensing your muscles you are probably making it worse. In order to prove to yourself that other people have hand tremors you can do the following test: ask your supporter to stretch out one arm, and then place a sheet of paper on the palm of their hand. Can you see the paper quivering?
Now try the following experiments to see whether tensing your muscles is making the shaking worse:
1. Place a sheet of paper on your own hand with your arm outstretched. Notice how the paper moves. Now tense the muscles in your arm and hand to try to stop it moving. What do you notice?
2. When you are next in a situation where you notice yourself shaking do not try to control it. Just let it happen. Did this make the shaking better or worse?
If tensing your muscles is making the shaking worse the answer is to relax, not to try to control the shaking.
When a room is stuffy it is not because there isn’t enough air (or oxygen) in the room. Rooms feel stuffy when the air is warm, and contains quite a bit of water vapour (i.e. it is humid). Stale odours can also hang around and make a room feel stuffy. None of this means that there isn’t enough oxygen around. Even if a small room were completely sealed the air in it would last for a few days before you would pass out.
Actually rooms are never totally sealed. Tiny draughts of air pass through cracks and gaps around doors and windows, so it would never be possible to run out of air in an ordinary room, even if the doors and windows were closed.
You can prove this to yourself with a small experiment:
Get an aerosol of scented air freshener. Get a friend to squirt it into the air a few times on one side of a closed door while you stand on the other side of a door. How long is it before you can smell the air freshener?
This experiment shows how quickly air spreads from room to room, bringing with it fresh oxygen for you to breathe. You can also notice that if you are cooking something smelly, like fish or cabbage, people are able to smell it in the next room, even if you have the door closed.
Something appearing to move or shimmer in front of a person’s eyes is a common experience. Ask someone you know if it ever happens to them. It is caused by a number of things. Firstly, it often occurs if people stare at objects (which anxious people sometimes do if they believe this will help them to stay in control, or keep their balance). Secondly, shimmering movements can be produced as a sort of optical illusion by certain patterns. Striped patterns of lines close together, which are sometimes found on floors or ceilings in shops, can produce this effect. Strong fluorescent light can also make things look unreal and unsteady.
The following experiments show these effects:
1. To show how staring can produce visual disturbances, try the following: fix your gaze on a specific spot in front of you on the wall. Stare at the spot. What happens to your vision?
2. To show how some patterns can produce unpleasant visual effects, try gazing at the illusions at this website: www.psy.ritsumei.ac.jp/akitaoka. What happened?
Some people are particularly sensitive to visual effects caused by certain patterns, and others feel unsteady in certain types of fluorescent light. However, although this feels strange, it is not harmful. You will not lose your balance and it doesn’t mean there is something wrong with your eyes or brain.
1 As with all the other chapters in Part 2, this chapter is intended as a self-help guide for individuals with panic disorder and their supporters. It is NOT a therapist manual
