Responding to comment

Hi again.  I have received some great comments on here and I just wanted to take the time to respond to this latest one publicly so everyone can learn from it:

Hi Panic Remission,
I am panic attack patient like you and I have several phobias which make my life terrible.
I am also writing a blog in Turkey regarding panic attack and phobias.
Just keep sharing , I think we may be of help to other people.
May I learn whether you have any of the following health problems as well :
Autoimmune Disorder
Allergies
Diabet
Heart Rythm problems
Vitamin D deficiency.

I have been suffering frm Panic Attack since 2007 , and I am both on medication and therapy.

I have Hashimoto thyroiditis, had Heart Rhythm problems which was fixed via EPS Ablation.
I dont know whether I have allergies and Vitamin D deficiency.I will search for it .
I just wanted to eliminate all physical problems that may cause panic attack:(
But I recommend you, if you have not visited yet , visit an Endocrinology doctor for hormonal controls and please share whether you have any of these problems Thanks a lot
And wish you best ! 


Thanks for your comment!!  I am sorry that you are struggling with panic attacks and phobias and think that your life is terrible =(  Just keep working on it and think positive - things will get better, I promise!  I am not personally diagnosed with any of the health problems that you list above - but certainly it is possible that I have one or more of those, as I have not seen specialists that would be able to make the diagnoses.  But it is interesting that you bring this up.

There are a lot of medical problems (physical) that can mimic or cause panic attacks.  Certain cardiac issues for sure, thyroid problems as you mention, autoimmune diseases such as celiac disease (where you have to go on a gluten-free diet because your immune system is attacking the wheat that you eat and it damages your intestines).  This is definitely all true and that is why in my first post about what to do when you are starting your panic disorder treatment, I recommend getting a full evaluation from a doctor to make sure that everything checks out.  And I am specifically talking about just a regular primary care doctor here.  I'll explain why.

Many of us with this disorder have related problems with hypochondria.  A panic attack is associated with intense fear - specifically fear that something may be wrong with our bodies.  So we may constantly go to the ER with the fear that we are dying or having a heart attack.  Or constantly visit the doctor, desperately trying to find a physical explanation for what is causing all of this.

But you know what?  I don't want to live my life like that.  I don't want to go to the ER all the time, or go see a million specialists all of the time and get put on a ton of medication.

I am actively choosing to believe that my panic attacks are caused by anxiety, not by a physical disease.  And by making this choice, I acknowledge the fact that I may be wrong.  Maybe I do have a heart problem or thyroid problem that leads to my panic attacks.  Maybe I will have a heart attack and die tomorrow.  But to overcome this disorder, I need to, and I do, 100% believe that my panic attack is just a panic attack.  And I want to emphasize again that it took me a very long time to be able to have this mindset.  But it is very powerful if you manage to get there.

And so far, it is working for me.  The brain is a very powerful organ and so even if I had an actual physical disease, it wouldn't surprise me that this type of thinking would still lessen or prevent panic attacks from happening. 

And now, just because in my "real" life I have a lot of experience with endocrinology (not as a patient, in fact I have never seen an endocrinologist as a patient), I'm going to turn on the science a little bit and explain why it is unusual - but not impossible - for panic attacks to be associated with Hashimoto's, which typically causes hypothyroidism.  Feel free to ignore this paragraph if you want =)

Hashimoto's thyroiditis is an autoimmune disease where your immune system accidentally thinks your thyroid is a foreign pathogen (like a virus or bacteria) and thinks that it needs to destroy it.  The thyroid is a very important gland in the body as it regulates everything from your metabolism to growth to organ function (liver, heart, etc).  Very important.  It does this by secreting two hormones: T3 and T4 - these then go around to the rest of the body and help regulate everything.  But how does the thyroid know how much T3 and T4 to make and how much?  It gets a signal from the brain in the form of a hormone called TSH (thyroid stimulating hormone).  So the brain releases TSH, this goes to the thyroid and tells the thyroid to make T3 and T4.  If the thyroid successfully makes T3 and T4, these can go up to the brain and tell it "Yep, here we are, you can turn off the TSH now".  This is called a feedback loop: TSH tells the thyroid to make T3/T4, then once enough is made, the T3/T4 tell the brain to stop making the TSH.  Okay back to hashimoto's.  So your immune system starts attacking your thyroid.  And so your thyroid starts getting pretty bad at making T3 and T4.  And because you don't have enough T3/T4, you get symptoms like: decreased heart rate, tiredness, weight gain, muscle weakness, hair loss, etc.  This is called hypothyroidism because your thyroid is underproducing T3/T4.  The opposite of this is hyperthyroidism where your thyroid produces too much T3/T4.  The symptoms of hyperthyroidism are: fast heart rate, anxiety, weight loss, sweating.  Hyperthyroidism is the endocrine disorder that typically leads to panic symptoms.  Now how can hashimoto's cause this too?  As the thyroid is being destroyed by your immune system, the parts that are still working start to work EXTRA hard to make up for the parts that are damaged.  So sometimes you can get extra T3/T4 in the body and cause the symptoms of hyperthyroidism, including panic attacks.  Depending on how much damage is done, a person actually cycle between hyper- and hypo- thyroidism, until finally the whole thyroid is damaged and it just can't make T3 and T4 anymore and you would have permanent hypothyroidism.  Luckily both of these conditions are treated with excellent drugs so there is nothing to really worry about with these disorders!

But anyway back to my reasons why you need to visit your primary care doctor: if you go to the doctor and describe your symptoms of anxiety, they will most likely order a bunch of blood tests to rule out many of the physical diseases associated with panic attacks.  And I am fairly confident that they will order a test to measure your TSH or T3/T4 because hyperthyroidism is one of the most common physical reasons for panic attacks.  And they will listen to your heart.  And they will check all of the other good stuff.  Now, if they tell you that you are okay, please listen to them.  If you go to a cardiologist, they might find some tiny heart murmur or if you go to an endocrinologist they might find a small nodule (non-cancerous lump) in your thyroid.  These things are most likely not causing your panic attacks but will require you to go to a billion doctors all of the time and I think it just lowers the quality of life and causes a lot of unnecessary worrying.  Especially for those of us who have panic disorder and are hypochondriacs. 

One more medically related note: I will look in the literature but I currently do not know of any published, peer-reviewed studies linking allergies, diabetes or vitamin D deficiency with panic attacks. 

Oh wow sorry this is so long.  I will leave you with this piece of advice that I have been following after learning the cognitive behavioral therapy (with the note that I am currently not diagnosed with any physical diseases so I don't have to see any specialists):

I go to the doctor for my regular physical (no more than once per year, I usually do every other year)

Other than that, I will only go to the doctor if someone else tells me that I should go to the doctor.  (i.e. I am so sick that my mom or friend or whoever says "dude you should really go to the doctor")

Thanks again for reading.  Please write a comment or email me with any questions you may have.  I am here to help!

The importance of taking things slow

I have written down a lot about riding out panic attacks, talking to your amygdala and staying put during attacks.  The one thing I need to bring it is the importance of doing it all correctly.  If you have been avoiding movie theaters for the past 10 years you might think that it is a good idea to jump right in.  And maybe with other aspects of life, this is a useful tactic.  But when you are retraining your amygdala, it is very important to go slowly.  If you do not think that you will be able to appropriately use the "skills" that I have laid out here, it actually might be better to tackle whatever you are facing at a later time.

Here is an example.

I was in the middle of my CBT treatment for panic disorder.  I was 4 months in and it was around the holidays so we were taking some time off.  And I was going through a stage where I could constantly feel my heart beating at all times.  And it would trigger a panic attack whenever it got pretty high, which of course would make it even higher and it would spiral out of control.  Well I was walking up the stairs in my house one day and I felt a pop in my chest and suddenly my heart rate was insanely high.  Like I couldn't even count the beats, it just felt like it was fluttering around.  And I freaked out and got my boyfriend to drive me to urgent care.  By the time we got there, I had actually calmed down a bit and my heart rate slowed to 120-130 or so but as a precaution they forced me to go to the ER where I got to spend my entire Saturday.

Anyway after that incident I was basically terrified of stairs.  Yes, stairs.  I know how ridiculous it sounds.  And I have to walk up a few flights of stairs to go to work every day.  Being determined to fight my panic disorder, I forced myself up the stairs every day only to have really severe panic attacks to the point where I had to get to work 20 minutes early just so I could go through all of that and calm down before I actually had to start working.

It turns out that this was the wrong approach.  By going up the stairs and having panic attacks, I was confirming to my amygdala that what I was doing was scary and dangerous.  What I learned is that I should only go up the stairs if I was truly mentally prepared to face a panic attack - let the adrenaline wash over me, talk to my amygdala, and throw myself into the CBT.  If I was rushed that day or just didn't feel like I would be able to use the skills appropriately, it was better to take the elevator.  And by doing this, it made my recovery SO much faster!

So the lesson here is that if you are just having a bad day or are exhausted or think you will get overwhelmed with triggering a panic attack - don't do it.  And I'm talking about situational panic attacks here, like where you know that if you go into that movie theater or you go into that store you WILL have an attack.  If you are not in the right mental state, do it when you are ready.  When you are determined and think to yourself - I want to get over this.  Let's f*%ing doing this.  THAT'S when you go for it.

Medication Revisited

I have written about my views on medication in the past but I felt like I should revisit it. 

Browsing through panic disorder message boards on the web, it has surprised me how many people are taking multiple medications in order to escape from their panic disorder.  I completely understand the thought behind this: They say that a panic attack can be the most frightening experience of a person's entire life.  And I can say that it is for mine so far.  Even Vietnam war veterans have said they would rather go back to that experience than go through another panic attack.  Why would you not want to take a pill and make it all go away?  I get that.

One major problem I have is the notion that taking a benzo or SSRI is treating a person's panic disorder.  This is wrong.  That is like saying that giving pain killers to a person that broke their leg is treating the broken limb.  It is not.  Yes it alleviates the symptoms, but take away the medication and you are back at square one.  The only way to treat panic disorder is to understand the biology behind it and use CBT to retrain your brain to respond differently to your thoughts.  I hope that by reading through the rest of this blog you can start to understand why this is the case. 

Medication to panic disorder is just a security blanket: Imagine you are on a crowded bus and start to feel panicked so you reach into your purse to grab a pill.  But you can't find any.  What do you think this will do to your anxiety level?  To the severity of your panic attack?  Yes, it will be WORSE.  Remember, with this disorder you need to show your amygdala that a panic attack is not scary or dangerous.  By taking a pill, you are telling it that yes the experience was scary or dangerous so you took a pill to make all of those feelings go away.  You are only going to make it harder for yourself when you decide to treat your panic attacks for good.

What bothers me is how many people try the CBT thing and decide "It doesn't work for me".  In my opinion, these people were not trained to properly use these techniques, or else they have not spent enough time working hard to learn the techniques.  For the first 4 months of my therapy, I thought I was trying, and I thought I was doing everything right.  But you know what?  Each panic attack scared the hell of out me and I wasn't able to use the skills properly.  It takes a LONG TIME to be able to do this.  It takes a lot of practice and a lot of patience.  But if you tell me that it "doesn't work for you"....I will just have trouble believing that.  If you work hard and honestly give 100% of yourself, it will work.  Trust me.  Please put down your medication and start actually treating your anxiety disorder!!

Uh oh...new sensation

Sorry for the long delay in posts.  I felt like I was writing to myself and no one was finding the site.  If you are reading this and have any questions or comments please please do not hesitate to contact me (panicremission@gmail.com).  I understand if you want to remain anonymous so just leave a comment on the site or create a random email address.  This disorder can be debilitating if not managed properly and I want to help in anyway I can.  Thanks guys.

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Okay so by now you hopefully have a pretty good handle on riding out a panic attack.  It sort of runs through the same motions each time and you just breathe through it and continue what you were doing.  No big deal.  But sometimes there is a new sensation that can throw you off - maybe your panic attacks are largely focused on chest pain and chest tightness but then one time you feel like your throat was closing up.  And you haven't experienced that before.  You get scared and suddenly you are back to fearing the panic attack, or at least fearing this new sensation to the point that it leads to a panic attack.  I like to do two things in this situation.

1) I don't normally advocate looking up sensations online.  I am a hypochondriac, as I am sure a lot of people with panic disorder are.  Looking up medical stuff online is just a bad idea, it will make you feel worse, not better.  The ONLY time I think it is okay to look up a sensation is to confirm that it is due to anxiety (and you probably should just take your own word for it, and not even look online).  If you are EVER going to look something up online, type the following into google "[your sensation here], anxiety".  There is also this website that lists anxiety symptoms: http://www.anxietycentre.com/anxiety-symptoms.shtml  I sometimes find it helpful to review the list, and just remember how many crazy sensations you can feel as a result of anxiety.

2) Put some humor into it.  You have trained yourself to be okay with a physical sensation.  Be okay with having a headache, being dizzy or having chest pain.  And now suddenly you have this sensation that your throat is tightening up and you can't breathe.  Its almost like your body is *searching* for a sensation that will get your attention (at least sometimes it feels like that!).  When this happens I try to have the attitude like "Well I see you've found something new to try, amygdala...you're going to try to get me to believe that I can't breathe huh?  Well you are doing a pretty decent job, I mean my throat feels pretty tight.  Unfortunately, I can still breathe.  See?  I'm breathing in....and now I'm breathing out.  Good try though."  Sometimes I will be working or doing something and feel a sensation and I will even smile a little and be like "oh amygdala, what are you up to now you troublemaker?"

You just have to do whatever it takes to get away from *fearing* the sensation.  I know it is hard, but fear is what fuels panic so you never want to give it that fuel.

Remission and Relapse

Okay so with all of your hard work and talking to your amygdala and riding out a panic attack, the panic will definitely lessen but I am hesitant to say that it will go away completely (but for some people it might!).  For the rest of you, it definitely won't bother you as much, and you will be able to continue to live a normal life but it would be a lie to say that you will never have another panic attack in your lifetime.  So I consider this to be a "remission".  In medicine, remission means that you have a chronic illness but that you are not experiencing symptoms at the present time.

Unfortunately, bad stuff can happen - maybe you lose your job or a parent is sick and you start to feel a lot of stress.  The symptoms may slowly start to creep back up to you.  You have to try and recognize that you are feeling this way because you are stressed out.  Not because you have a life-threatening illness.  With this new stress, it is possible that you will relapse a little bit into your old state.  Try to use this knowledge to your advantage and practice the skills that you have learned.  What has happened to me in the past is that I will be stressed out about work or relationships or what have you and have a couple of days where I am experiencing a few panic attacks per day (which I ride out fine).  But when your body goes through a bunch of attacks like that it can start to take a physical toll.  Suddenly you are hyper-aware of every little sensation in your body and your muscles are probably really tight and sore - this can create anxiety.  Recognize this series of events so you do not think something is wrong with you.  Yes, you might feel out of sorts for a few days after the fact.  Don't let this turn into a cycle of thinking something is wrong, having a panic attack and then feeling worse and then worrying and then having another attack etc etc.  Remember that during a stressful time, a relapse may occur.  That is okay.  Deal with it the best that you can.  Remember that your body might not be quite right for a little while after that but that is normal and nothing is wrong with you.  You are not spiraling out of control, you are not going back to the beginning.  You might have a few "off" days, but everyone does right?  With our disorder you have to make sure to recognize that this is normal, it is part of being a human being and you will feel better shortly.  Keep a positive attitude about your condition.  Attitude is everything with panic disorder.

A word about medication...

Okay so I thought I would say a few words about medications for panic disorder.  The typical medication prescribed for panic disorder are benzodiazepines (xanax, klonopin, etc) and SSRI/SNRIs (prozac, zoloft, etc).  Benzos act on your brain and basically calm down your brain if it is overexcited and your neurons are firing way too much.  They act pretty quickly, within minutes, and so people like to take these when they feel a panic attack coming on because it will lessen or stop the attack.  When I have taken these in the past I could almost feel them slowing my brain down.  SSRIs are pretty complicated so I won't get into the mechanism of action but these are antidepressants and keep you in a "happier" basal state, I guess, so that you aren't as prone to feeling anxiety on a daily basis.  You take them regularly every day.  SSRIs would be considered more of a long term, in-the-background sort of thing whereas a benzo is short-acting and would be taken at the onset of a panic attack to achieve instant results. 

I think both of these medications are great, and they have their purposes with other medical problems.  But not ours.  Our problem is essentially a fear of the fear response.  To get over this you need to prove to your brain that this fight-or-flight response is NOT something to be scared of.  But if you are someone that pops a xanax every time you have an attack you are telling your brain "Yes, amygdala, this is a VERY scary and dangerous situation, so I am going to take this pill and make it go away".  You are confirming to your amygdala that there was in fact a dangerous or scary event going on.  This is the opposite of what you want to do.    

Think about it: what is so scary about a panic attack?  It is the fear of death, of going crazy, of having something terribly wrong with you, of passing out.  If you are having an attack and you take a xanax and then your attack goes away....guess what - you just confirmed that you were having a panic attack and it is not some life threatening illness.  It means that you are not going to die, you are not going crazy, you do not have anything terribly wrong with you and you are not going to pass out.  This, if anything, should give you all of the confidence in the world to go out there and power through a panic attack and start to retrain your amygdala.

If you have been on medication for a while I know it will be very scary to get off of it.  But if you want to get rid of this disorder for good, you have to show your amygdala that a panic attack is nothing to be afraid of.  And unfortunately you can't do that with medication as a security blanket.   

Don't Leave

Okay so I think the single most difficult thing for me during my panic disorder treatment was staying put during an attack.  Your mind is telling you to leave whatever situation you are in - to run away, to go home.  And it is extremely hard not to listen to it.  You just feel this intense need to escape.  This is all part of the fight-or-flight response: your body is responding as if you were faced with a bear.  Of course it is going to tell you to run away!!  But to overcome panic disorder you need to show your amygdala that there is actually no real danger.  You are not faced with a bear and your life is not threatened in any way.  In order for your amygdala to understand this, you can't give into this need to escape.  If you have an attack at your desk at work and then you go into the bathroom to calm down, you are indirectly telling your amygdala that yes, there was danger at your desk, it was very scary so you "escaped" from your desk.  Your amygdala will then recognize your desk as dangerous and you will continue to have anxiety and/or panic associated with being at your desk at work.  

To break this cycle, it is absolutely imperative not to give into the need to flee the situation.  You just have to sit there and breathe through the attack.  It actually helps to talk yourself (or as I prefer, your amygdala) through the situation.  If you are having a panic attack at your desk at work, you can say something like "Oh so I see that my fight-or-flight response must have gotten triggered by some set of cue at my desk.  Interesting.  Well I am just going to sit here and continue to work on this document.  There is nothing dangerous about the situation I am in so there is no reason for me to get up and leave."  The trick here is that you cannot be angry with yourself because anger actually comes from a very similar emotional place as fear so you don't want this to trigger further attacks.  You just have to be matter-of-factly with it.  Just observe your emotional and physical response with curiosity.  And don't get up.  I know how hard it is to stay put with all of the adrenaline coursing through you - you might squirm a little and that is okay.  But try really hard not to get up and leave. 

Another mistake that I have made in the past is to try to figure out what the cues were that triggered the attack.  I became almost obsessed with figuring it out.  The problem is that when I didn't find a "satisfying" answer I had a lot more trouble coming out of my anxious state.  The best thing to do is try not to overanalyze the situation.  Just say "Yep, something here must have triggered my panic attack.  Okay.  Well that's fine.  Doesn't matter what it was.  I'm just going to continue what I was doing".  (this is very hard, just to warn you!!).  The good news is that if you can manage to do all of this, to stay put and talk to yourself without anger and to not overanalyze what trigger may have caused your panic, your attack will probably last about 90 seconds (this is how long it takes your body to break down the adrenaline that has been released).  

I don't know about you, but I can handle 90 seconds of discomfort every once in a while.