Panic Disorders and Attacks

 INSHAPE NEWS MIND MATTERS

Peter Walker – Clinical Psychologist

Panic attacks are one of the most common symptoms that lead people to seek psychological support. The experience of a panic attack is overwhelming. They usually first occur out-of-the-blue and are characterised by an increased heart and breathing rate, sweating, tingling in the hands and toes, nausea, changes in body temperature (feeling clammy and cold), tightness in the chest and increased urination and defecation.

Panic Disorder Symptoms

Other symptoms that people often find concerning while they are panicking are feelings of dizziness, also known as depersonalisation, and the sense that time slows down or that things aren’t real, also known as derealisation. It is easy to understand how someone might believe that these experiences represent an impending heart attack or a descent into mental illness, especially if they faint and humiliate themselves or have a total loss of control. Others fear that these experiences will be detected by others and represent personal weakness.

Response to a Panic Disorder

In response to panic attacks, a sub-group of people start to avoid situations and experiences that they fear will bring on a panic attack or will put them at risk in the event of an unexpected panic attack. Such feared situations might include being in lifts, sauna’s and busy shopping centres o in planes, trains and tunnels. Sex and other forms of vigorous physical exertion can also cause problems. This avoidance behaviour is called agoraphobia. It is from the Greek meaning “fear of the market-place.” People sometimes confuse this with a general fear of open spaces, but it is technically a fear and avoidance of panic attacks in defined situations. This behaviour, in turn, reinforces them.

Another response factor of panic attacks is the tendency for sufferers to engage in subtle behaviours that they attribute to being “safe”. Examples of “safety behaviours” include  carrying anti-anxiety medication at all times such as benzodiazepines or rescue remedies, carrying a mobile-phone and taking a friend with them wherever they go. One of my client’s would not leave the house without a bag packed with ginger tablets, a fan, bottle of water, ginger tea bags, antacid, rescue remedy, and their mobile phone. Unfortunately, safety behaviours often interfere with the individual’s recovery because they tend to attribute their success to these objects rather than their own courage.

Panic Disorder and Other Conditions

It is important to clarify that panic attacks can be associated with many different psychological conditions, especially other anxiety disorders such as social anxiety and obsessive compulsive disorder. In these situations, treating the problem such as shyness or other behaviours can reduce or even stop the occurrence  of panic attacks.

Simply put, panic disorder is essentially a fear of the physical symptoms associated with physical arousal. When an individual suffers from panic disorder they tend to attribute a fluctuation in heart rate or dizziness to something that is dangerous.

Publicity and Panic Disorders

At times, media and other entertainment can increase problems associated with conditions such as panic attacks. For example, Tony Soprano suffered from panic attacks in the television program ‘The Soprano’s’, this then lead to him fainting behind the wheel of his car when he was driving. At the time this was aired, I noted a spike in client fears associated with the consequences of fainting and their own panic attacks. However, I told them that this was highly unlikely to occur as fainting typically happens when we suffer from a sudden loss of blood pressure. In most cases when people panic they experience a sudden increase in blood pressure. Therefore, it is highly unlikely that Tony Soprano’s panic attacks caused him to faint.

Treatment of Panic Disorders

Encouragingly, there are very effective, quite efficient and inexpensive treatments that can be accessed through mental health practitioners, on-line in treatment programs or through self-help books. The most common treatments available are cognitive and behavioural. These educate the individual about changing their set of behaviours when they feel threatened. This “defensive cascade” occurs automatically and each of the symptoms has a clear survival value such as sustaining a freezing posture, oxygenating the blood for physical exertion or moving blood toward muscles.

The most critical component of treatment is encouraging individuals to gently, but consistently, face their fears in a graded way. This means that we encourage the construction of an exposure hierarchy. Called exposure, this form of treatment starts at the bottom of a person’s fear list and confronts each fear until it is manageable. It can take one of two forms, in-vivo, or fear of actual situations (being in tunnels, lifts) and intero-ceptive, bringing on symptoms that resemble panic for the person (breathing through a straw, spinning in a chair, holding your breath or hyperventilating).

More importantly, people are encouraged to face their panic in a new way. When faced with distress we often want to avoid it or push it away. Unfortunately, this approach tends to escalate panic associated feelings making them seem more dangerous. When engaging in exposure or when facing a panic attack that has arisen unexpectedly, panickers are taught to “go with” the feelings, make room for them, to not rush and to not try to distract themselves, but to calmly (this requires practice) remind themselves that this is a normal and healthy physiological response that has many natural causes and will pass. The approach is referred to as ‘panic surfing’. Metaphorically speaking, this is like swimming in a rip, where you feel an urgent need to escape, but as many of us know when caught in a rip you should go with the flow of the water and then swim until you get back in to safety. In this respect it can be said that it is safer to go with the “wave” of panic, using its momentum, this then reduces the impact of the panic attack and its duration. Once mastered, the panic attacks will become less because the fear associated with them is subsiding.    

 Peter Walker has over 12 years experience working as a clinical psychologist. He has worked in both public and private practice, having specialised in complex presentations. He established his private practice, Peter Walker & Associates, clinical psychologists, in 2002 as a service to provide psychological treatments for those experiencing difficulties with anxiety, depression and couples in distress. In addition, the practice was relatively unique in that it offered specialised treatments for those experiencing psychotic disorders and bipolar disorder. At the time Peter Walker & Associates was established the development of psychological treatments for these conditions was in its infancy and Peter was considered an innovator in this field. Peter provides clinical supervision for mental health practitioners, is a sought after presenter and has experience providing expert opinion in the media. In recognition of his experience treating mood disorders he has been asked to take on a role at the Black Dog Institute in 2013.

Jay Spence – Clinical Psychologist and PhD Candidate

If you have ever had a panic attack then you will know how utterly terrifying they can be. It makes sense then that people who experience panic attacks would then try to avoid anything that might cause those feelings to come back. This avoidance is what keeps panic going and can turn a panic attack from a one-off-event into a lifetime trapped by attempts to prevent further panic attacks.

What is a Panic Attack?

A panic attack is different from the gradual build-up of anxiety that often occurs when we are stressed. For instance, it’s possible to feel very anxious and out of control, especially when we have huge pressures on us that we don’t feel we can cope with. In fact, the hallmark of a panic attack is that it often feels like it comes out of the blue. This is also different from panicky feelings that are the result of a specific trigger like seeing blood or feeling like you are about to be attacked. These are very intense fear responses. The difference between panic and these responses is that in panic people catastrophically misinterpret the symptoms of fear.

Catastrophic misinterpretation of fear is like adding fuel to the fire of anxiety so it becomes an inferno. The process goes like this:

1) You experience a symptom or symptoms that you find unusual or uncomfortable. For example: experiencing a pounding heart and dizziness.

2) You worry about what the symptom could mean and quickly jump to a catastrophic conclusion. For example, I must be having a heart attack.

3) This conclusion causes your anxiety levels to go through the roof. This means that you are now experiencing extremely severe levels of symptoms like being unable to breathe, feeling like you are about to pass out, feeling sick or being unable to see properly.

4) You misinterpret these symptoms as confirming your conclusion, that is, “I am having a heart attack and I am about to die!”

Why Does a Panic Disorder Develop?

Panic disorder develops because once people have an experience like this they then spend a lot of time on the lookout for strange and uncomfortable symptoms. They watch their bodies and, of course, because they are fixated on looking for strange and unusual symptoms they tend to notice more and more, as we all would if we checked continually. Constant checking means more noticing, which means more panic and more avoidance of things that cause uncomfortable symptoms. The avoidance can get very severe in panic meaning that people stop going outside, going to work, exercising, and/or seeing people. Once this occurs, the person is likely to feel incompetent and overwhelmed and can become very depressed. It’s a horrible downward spiral.

How is a Panic Disorder Treated?

The good news is that panic disorder is treatable. In fact, panic treatments are among the most effective of many mental health conditions, especially if they are treated early.

Recently, the government created an online clinic (www.mindspot.org.au) where you can get treatment for panic and other anxiety disorders with a psychologist for free. All the treatment is done online and you can do it in your own time. The results from studies of online treatment are very promising with about 6 in 10 people getting better and staying well. Those who don’t improve will probably need face-to-face treatment with a clinician who specialises in the treatment of panic disorder. So, if you have a long-term or very severe condition, make sure you ask for this type of treatment.

Jay Spence is a Clinical Psychologist and PhD candidate who specialises in adult and adolescent mental health. He was joint recipient of the Gold Prize at the Australian and New Zealand Mental Health Service Achievement Awards (2010) and of the St Vincent’s Health Australia National Invention and Innovation Award (2010) and was the recipient of the 2011 New South Wales Institute of Psychiatry Fellowship. He has published numerous papers on the treatment of post-traumatic stress, social phobia, and panic, as well as generalized anxiety and transdiagnostic anxiety processes. He held a conjoint lecturer position at the University of New South Wales from 2009 to 2011, lecturing on the treatment of anxiety and depression. He is currently completing a PhD on internet-based interventions for post-traumatic stress disorder (PTSD). He is developing these treatments as part of the Centre for Emotional Health at Macquarie University because PTSD is the most prevalent anxiety disorder in Australia. However, many people do not have access to effective treatments. He sees patients in private practice in Darlinghurst, Sydney.

Phil Owens – Leading Australian Hypnotherapist and NLP Practitioner

Panic disorders can be seen as extreme forms of anxiety that cause severe psychological and physiological distress. Panic disorders can respond well to specific interventions which can move the client to more appropriate methods of coping.

Anxiety and Panic Disorders

Anxiety is a normal response to situations that are uncertain or contain some ambiguity. Most people manage to feel a measure of anxiety in uncertain situations and still take the appropriate actions to move them forward toward their goals.

People who suffer from more severe and clinical cases of anxiety and panic disorders can be summarised as having a severe intolerance for ambiguity, or suffering from a sense that they are not able to ‘cope’. This, in turn, can give them a negative expectation of what the future may hold.

Often, my clients will say that they are projecting their ‘worst fears’ into the future, in a vain attempt to work out how they would manage. They ask themselves ‘what if’ questions (for example, ‘what if I had an accident’?) and fail to find suitable answers. Their desire to be prepared often leads them to develop the ‘worst’ case scenario which then shapes their view of how their future will play out.

When the feelings of negative expectation and inability to cope become overwhelming, clients can easily shift into ‘panic’ episodes. When this becomes an automatic response to ambiguity in their lives, it then manifests itself as a panic disorder. Often, the sense of anxiety will be overwhelming, such that there is no specific trigger, but rather a ‘generalised’ sense of inability to cope and a constant state of anxiety and ‘panic’.

How to Overcome a Panic Attack

Panic disorders and anxiety respond well to cognitive approaches. In particular, examining the specific cognitive skills that people are applying to uncertain situations can provide a way to begin to unlock panic disorders.

Here are some specific things to work with:

• How is the person with panic disorder considering the situation? Are they thinking about it as a big, ‘global’ experience, or can they learn to break it down into a sequence of specific actions that they can take?

• Is the person seeing a negative future? Helping them see uncertainty as neutral and seeing the future as having ‘possibilities’ – including nice ones – can be important.

• How is the person tolerating the frustration of the ‘feelings’ of anxiety or being overwhelmed and are they still able to take action? Each time the person takes a small action, they have changed their focus, and moved ahead.

• What is their self-talk? Is it appropriate or are they think catastrophically?

• How much of their response is ‘habit’, and how much is relevant to the circumstance?

Each client is different. I find hypnosis with cognitive behavioural therapy (CBT) incredibly effective in helping client’s re-examine their experience and learn cognitive skills that can help them to make a big difference in their lives. Utilising their unique circumstances and looking at their ‘response’ pattern, makes it far easier to move on from anxiety and panic than most people suffering from the disorder can often believe.

Philip Owens is owner and director of Reflective Resolutions and is a leading Australian hypnotherapist and NLP practitioner based in Melbourne, Australia. Using scientifically validated and pragmatic approaches, Philip is a passionate about creating lasting change in and for his clients.

Working in his clinic with individuals and also with corporate clients, Philip’s international experience, state of the art training and processes have led to successful and happy clients all over the world.  Focusing on the issues of modern life, Philip routinely works with clients presenting with anxiety, fears and phobias, addictions, traumas, weight loss, insomnia and smoking cessation’.

Dr Joann Lukin – Sport and Performance Psychologist

Apprehension, fear and anxiety can be highly distressing emotional experiences. When such emotions are experienced on a more regular basis they can be considered as part of anxiety disorders or panic experiences.

What is a Panic Disorder?

A panic disorder is a condition where people experience a sudden and repeated attack of fear that can last for several minutes, sometimes longer. These attacks are referred to as panic attacks. Other symptoms may include feeling choked, nausea, hot flushes or chills, and increased heart rate. One of the challenges with a panic attack is that it can feel so overwhelmingly physically, but its origins are psychological in nature. It is not uncommon for someone to feel like they are having a heart attack when they are actually suffering from a panic attack.

Panic disorders include a worrying about subsequent panic attacks, and changing behaviours due to the worry about attacks. The ongoing and unexpected timing of these attacks can leave people feeling fearful of going out in public and may also impact upon work.

Panic Disorders are experienced by approximately 5 percent of the population at some stage in their life. However, it is important to note that the experience of a one-off panic attack, which is common, does not constitute a panic disorder.

There is a need for us to have a better understanding of the causes of panic disorders. For some people there is a tendency for panic disorders to run in families. It is the case for many people who stress and environmental factors also play a role in the condition. Some medical conditions, such as asthma and pulmonary diseases, are also associated with panic disorders.

Treatment of a Panic Disorder

Panic disorders are treated through a variety of means. The starting point, if you think you have experienced a panic attack, is to discuss it with your doctor. It is crucial that other physical conditions that may be causing the symptoms are ruled out first.

Panic disorders are often treated through a mix of medication, psychotherapy or both. Medication options most commonly used are anti-anxiety and antidepressant medications. Your doctor will discuss potential side effects of the medication and any risks for your medical history.

There are a number of psychotherapies that can be used to treat panic disorders. One with a strong evidence base for treatment is cognitive behaviour therapy (CBT). CBT addresses thinking and behaving reactions to situations. Clients are taught to challenge their previous patterns and find alternative, more helpful ways to react and think to manage their anxiety.

If you find yourself in the midst of a possible panic attack, the following pointers may help:

• Take several slow breaths (breath in for 3 seconds and out for 3 seconds).
• Stretch your body.
• Focus on an external object, such as a chair and sit down if you can.
• Know that a panic attack will end – it will always pass.
• If there is a possibility that it is a physical condition you are experiencing, seek immediate medical help.

Dr Lukins is a psychologist who has specialised in sport and performance psychology for over 20 years. During that time, Dr Lukins has consulted individuals, teams, coaches, and organisations across the country.  She is committed to the field of positive psychology — a scientific framework that studies human potential and happiness. The primary focus of her work is to assist clients to find strategies to achieve their goals and reach their potential. Joann’s work helps clients to understand what makes them be healthy, fulfilled and focussed on their personal well-being.

Disclaimer: The information published in this column is based on each of the author’s own professional and personal knowledge and opinion. This information and opinion are not intended to be a substitute for professional medical advice, diagnosis or treatment of any manner. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding any medical condition and consult a qualified medical professional before beginning any nutritional or exercise program. Never disregard professional medical advice or delay in seeking it because of something you have read on InShape News.

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