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.

Handling a fear of passing out

Okay so just a quick side note for anyone that is worried about riding out a panic attack with a fear of passing out / fainting / becoming unconscious.  First of all, it is extremely extremely unlikely that someone would lose consciousness during a panic attack.  Why?  As you are now aware, a panic attack is your body going into fight-or-flight mode and this involves, among everything else that is explained below, an increase in your blood pressure to deliver oxygen to your muscles so you are ready to fight or run.  Fainting, or passing out, involves low blood pressure - your brain doesn't have enough oxygen and since it is all the way up there at the top of your head, the easiest thing for it to do is cause you to lose consciousness, thus ending up on the ground where your blood doesn't have to fight against all of that gravity to deliver oxygen to your brain (again, a defense mechanism, this isn't going to harm your body at all).  So anyway with your high blood pressure during the attack it is HIGHLY unlikely that you will ever pass out.  I know it feels like you might, trust me!!!  But it just won't happen.  You might feel lightheaded, yes, and that is probably due to you hyperventilating without realizing it which is why the breathing exercises are so important.  And you don't have to breathe in super super deep - just a natural, slow pace like in....1....2....3....out...1...2...3.  Focus on filling your lungs with oxygen and then emptying them completely.  It is also easier while sitting or lying down because that way you will breathe with your diaphragm (lower chest) instead of your upper chest, which helps even more.  

The one thing I have noticed with my panic attacks is that since you feel like you aren't getting enough air (sometimes called "air hunger"), you tend to do a lot of inhaling but then sort of forget about the exhaling, or don't exhale completely.  The exhale is really important and I can get into all of the details about blood oxygenation levels if necessary but just trust me that you want to inhale completely and also exhale completely - focus on your exhale during the attack if you realize that it is a problem for you as well.  You don't want to be taking huge breathes and then not exhaling because this might lead you to feel more lightheaded or dizzy (which isn't dangerous so don't worry but it is just unnecessarily uncomfortable).  Okay good luck!!!!  Email me if you need help or advice!

First Step to Remission

Okay so the first thing you need to do, although I'm sure most of you have already, is go to the doctor and just make sure that everything checks out.  Let the doctor listen to your heart and lungs and really listen to them when they tell you that everything sounds good.  And I think it is really important to find a doctor who understands your condition and doesn't make you feel bad, or disregard what you are saying.  You will need to be honest with them and tell him that you have been struggling with anxiety.  Depending on how the doctor reacts, you should be able to tell if you have found the right person for you or not.  It needs to be someone that feels comforting.  Someone who understands what panic attacks actually are and does not blame you for your condition.  So let this person give you a full physical and try as hard as you can to believe them when they tell you that you are okay. 

Now you need to do something that will probably seem really scary.  But hopefully from what you have read in my previous posts and from what you hear from your doctor, there is absolutely no risk to doing this.  You need to ride out the panic attack.  You need to let the adrenaline wash over you and teach your amygdala that the fight-or-flight response is not dangerous.  Up until this point, your brain thinks that panic attack is a dangerous and potentially deadly experience.  In reality, it is not.  But you will need to teach your amygdala that.  In order to prepare for this you need to practice a few techniques.  One of these is the ability to separate yourself from your thoughts (it sounds really weird, okay, but just trust me on this one).  So just take 10 minutes per day and sit down in a quiet area and just notice what you are thinking.  Without any judgement about the thought.  Just be aware of what you are thinking.  So just say to yourself: "Okay I am now having the thought that I should be doing dishes.  Now I am having the thought that this is really boring.  Now I am having the thought that this exercise is incredibly stupid....etc" (and yes, until I realized the power of this exercise, a lot of my thoughts tended to be about how I thought this whole listening-to-your-thoughts thing was stupid - and that is perfectly fine but remember there is no judgement.  Just notice the thought, period).  One of the other benefits of this exercise is that, at least for me, I ended up feeling noticeably calmer after this 10 minute break.  Just sit or lie down, set a timer and close your eyes...  

Anyway this ability to separate yourself from your thoughts is really important because during a panic attack your mind will be flooded with thoughts of "I'm going to die" "I'm having a heart attack" "I can't breathe" "I hate this" "I need to go to the ER" etc etc.  and you need to be able to recognize that these thoughts are actually symptoms of the panic attack just like heart palpitations and dizziness are symptoms.  These thoughts are linked to your fight-or-flight response and will keep coming up with each panic attack but that doesn't mean they are correct and that you need to listen to them or believe them.  So if you can separate yourself from these thoughts, and just notice "okay, I'm having the thought that I can't breathe" it is actually super powerful.  Instead of thinking "I can't breathe!!!!!!!!" it is "I am having the thought that I can't breathe".  This reminds you that you are only having a thought that you can't breathe, not that you actually can't breathe.  And this shift in thinking is really critical for you to retrain your amygdala.

Now in the moment of a panic attack this takes a LOT of practice.  The fight-or-flight response is such a powerful response that it is very difficult to do the above exercise in the heat of the moment (especially if you are not at home) but if you keep practicing it becomes so natural that you can do this shift in thinking in any context.  But since it is so difficult, I want you to just have one goal in mind for the first few panic attacks that you ride out: just breathe.  Sit down and just focus on breathing in and out very slowly.  If you can start to recognize your thoughts as thoughts, that is awesome.  If not, just breathe.  Breathe and know that it will be over in about 10 minutes (and if you really are just breathing through it, it will be much shorter).  And importantly, NEVER feel bad about yourself if you fail, if you forget everything you are supposed to practice in the heat of the moment.  This stuff is SO HARD.  Even just to sit still is so difficult, I know it is.  You might be panicking for 20 minutes before you remember to focus on your breathing.  That is fine.  Do not get mad at yourself, do not judge yourself.  Recognize how hard it is to do this and celebrate every single baby step you make during this process.  I cannot emphasize this enough.  If you are constantly berating yourself every time you forget these exercises during a panic attack it will slow your progress.  Celebrate any possible positive change from the last time you had an attack.  And also recognize that there are good and bad days.  This is completely normal, and in no way does this mean that you are taking steps backwards (even though it might feel like it, try to be positive!!). The process of retraining your amygdala does not happen overnight.  It is a tough road but one that is so well worth it.  I know that you can do it.  Just start simple: Breathe.

 So the first steps towards getting over your panic attacks are the following:

1) Get checked out by a doctor and try as hard as you can to believe them when they tell you that you are fine.

2) Try to sit in a quiet place for 10 minutes per day and notice what you are thinking without judging your thoughts

3) Sit through a panic attack (don't run away, don't pace, just sit) and focus on breathing in and out.  Let the adrenaline surge through your body and just breathe.  The panic attack won't hurt you at all.  It SUCKS but it won't hurt you. 

4) Try to notice your thoughts during the panic attack, and recognize that they are symptoms of the panic attack itself.  They are only thoughts, they are probably not true.

Good luck.  I am proud of you for taking this step forward.  I know how hard it is.  If you have questions or need help or support do not hesitate to contact me: panicremission@gmail.com

Fight or Flight response explained II

So you can probably start to see the difficulty with the situation that you are now faced with.  Every time your heart rate increases, or you feel a little lightheaded, your amygdala wakes up and senses "danger" and does the only thing it knows how to do to protect you: initiate the fight-or-flight response.  Giving you the exact same feelings that you have come to dread and hate.  And not only that, every time you are in that same restaurant, maybe at around the same time or with the same people -  if your amygdala decides that this situation seems an awful lot like that one other time where there was danger, it will press the ON button and initiate the fight-or-flight response.  You will probably leave the restaurant (after all, your mind is telling you to run away) and eventually the response will go away.  Then your amygdala will think, okay good I survived that dangerous situation.  And then it will catalog all of the new information about that experience.  What you were wearing, what you were thinking, what you ordered.

You know how it seems like you have panic attacks completely out of the blue?  I tend to think that that isn't exactly true.  Example: maybe you have a panic attack while you are at home eating some cheerios wearing a red shirt and thinking about the ninja turtles.  Cheerios, red shirt and ninja turtles are now cataloged as "dangerous".  So now lets say you are at a grocery store and you happen to be wearing that same shirt.  And then you walk past the cheerios in aisle 5 and the box is advertising a free ninja turtle action figure with every purchase.  Your amygdala recognizes cheerios + red shirt + ninja turtles = danger and presses the ON button.  To you, it feels like you are having a panic attack for no reason at a grocery store.  But actually it is your amygdala working incredibly hard to protect you from what it believes to be dangerous. 

So the amygdala starts to gather this enormous amount of material that it thinks is dangerous.  I mean seriously it is probably an unbelievable amount of material, especially if you have had panic attacks for a while now.  To the point where yes, the attacks do seem unpredictable because you can't possibly remember every detail about every situation in which you had a panic attack.

But armed with all of this knowledge, this understanding of what is actually going on - you can start to do something about it.