Coping with panic attacks
I’ve always been a fairly anxious person, but I didn’t experience my first panic attack until I was 20 years old. I had a summer job working as a hostess at a busy restaurant in downtown Toronto, and was mid-shift, when I started to feel dizzy. I couldn’t catch my breath. I began to shake. It felt like someone was squeezing my ribcage in a vice grip. My hands and feet started to tingle. The harder I fought to breathe, the more impossible it became until I was hyperventilating. My heart was racing. My field of vision started to fill with spots. I thought I was having a heart attack, certain I was dying.
Luckily, another staff member recognized the symptoms for what they were and found me a quiet seat behind the restaurant where I could focus on catching my breath between terrified tears. My boyfriend at the time rollerbladed across the city to calm me down and take me home. The following week, I had another panic attack. And so began my nearly decade-long quest for relief from these unexpected episodes.
The DSM-5 defines a panic attack as:
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of the following symptoms occur: palpitations, pounding heart, or accelerated heart rate; sweating; trembling or shaking; a sensation of being short of breath or being smothered; choking; chest pain or discomfort; feeling dizzy, lightheaded or faint; feelings of depersonalization or derealization; fear of dying; fear of losing control; paresthesias (tingling or numbing sensations); and chills or heat sensations.
Panic attacks are thought to be rooted in the body’s flight or fight response. In a dangerous situation, when this response is triggered, the nervous system comes to life sending adrenaline shooting through the body. The heart rate increases as more blood is circulated to the muscles, and breathing becomes fast and shallow to allow more oxygen to enter the body. Panic attacks happen when your body goes on alert for no reason.
Scientists and doctors still aren’t exactly sure about what triggers panic attacks, but they’re more likely to be experienced by people who have a family history of panic attacks or panic disorder (persistent, recurring panic attacks), those who have just experienced a major life stress (for example, the death of a loved one), people who have been exposed to traumatic events, those who are experiencing major life changes (for example, a divorce or a new baby); or people with a history of childhood physical or sexual abuse. Caffeine use is also thought to be a risk factor.
Whatever the cause, there are a number of treatments shown to be effective in managing panic attacks. Therapeutically, cognitive behavioural therapy (CBT) continues to show success in treating panic attacks. Personally, I saw very little improvement in my panic attacks when I was being treated with CBT alone. Instead, I found dialectical behavioural therapy, or DBT, to be far more effective (possibly because of my specific mental illnesses) in minimizing my symptoms and heading off full-blown attacks.
DBT was created by Marsha M. Linehan in the 1980s to treat borderline personality disorder (BPD). Based in CBT, the theory behind this approach is that some people’s arousal levels increase more quickly than others, they feel their feelings more deeply, and take longer to return to baseline arousal. The primary difference between CBT and DBT is that CBT focuses on learning ways to change unhelpful thoughts and behaviours, whereas DBT focuses on accepting unhelpful thoughts and feelings and the techniques to change them, with an emphasis on interpersonal skills.
Over a year ago, I was lucky enough to gain entry to the Centre for Addiction and Mental Health’s (CAMH) DBT skills training group, following a trip to the hospital’s ER. During the group therapy sessions, which took place over three months, we identified skills to use in all sorts of emotional crises, including panic attacks. The DBT skill I found most effective for treating panic attacks is the TIPP skill.
TIPP (also represented as TIP) stands for Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation. It’s meant to reduce extreme “emotion mind” (a state where our emotions our likely to inform our reactions), but I’ve found it can also head off panic attacks. The skill breaks down as follows:
Temperature: Remember when you were a kid and you were upset, and your parent told you to splash some cold water on your face to calm down? It turns out there’s actually some science to that advice. By submerging your face in a bowl full of cold water for 30 seconds at a time, you can actually decrease your heart rate and help get your breathing under control. If that’s a little too scary, you can also try holding an ice pack over your eyes and cheeks, which works just as well. I’ve used the “T” part of the TIPP skill countless times when I’ve been hyperventilating to slow my breathing, still my shakiness, and return to my physical body, which can stop a panic attack that’s underway. This skill is also very good for calming down fast in any emotional state.
Intense exercise: Admittedly, intense exercise is not a TIPP skill I use. But, the logic tracks. If you can engage in intense exercise during the onset of a panic attack, you can steady uneven breath patterns and reengage with your body. You might recognize this skill if you ever watched early seasons of Orange is the New Black. When one of the imprisoned characters, Daya, starts having a panic attack, a correctional officer tells her to get on her feet and do jumping jacks. Her breathing slows. This is also a good skill to use when you find your body “revved up” by emotion.
Paced breathing: If you practice yoga, you’ll be familiar with the concept of paced breathing and its benefits. Paced breathing can do a lot to reduce panic and help return your body to a normal state during an attack. The aim is to breathe deeply into your belly, and slow the pace of your inhales and exhales way down. You can achieve this by counting the pace of your breath, and focusing on breathing out more slowly than you breathe in (for example, you can take a five-second inhale, followed by seven-second exhale). This can be a tough skill to practice when you’re in the throes of panic, so I find it helpful to have others (whether it’s my partner, an EMT, or a guided YouTube video) prompt me to do paced breathing when I’m having a panic attack. This is another skill that reduces the duration of attacks.
Paired muscle relaxation: I find depersonalization and derealization to be some of the toughest panic symptoms to contend with because they disconnect you from your body and your environment, which makes practicing the TIPP skill a lot harder. Paired muscle relaxation helps bring me back into my body during a panic attack, and alleviates symptoms of smothering or suffocating. While breathing in deeply, tense as many body muscles as you can (without causing pain or cramping). Notice the tension. While breathing out, visualize or say the word “relax,” and let go of the tension. Notice the difference in your body. The skill is beautifully paired with paced breathing, though I do find it can take a few rounds before I really start to regain my physicality.
While the TIPP skill has really helped improve my panic attacks, it’s not the only treatment contributing to my reduced panic levels. For a year, I regularly practiced kundalini yoga geared toward trauma survivors, which focused on getting comfortable with a lot of breath work similar to breathing patterns you might encounter during a panic attack. In addition to DBT skill building and yoga, I see a weekly therapist at CAMH who helps me overcome some of the root causes of my panic using Somatic Experiencing and Internal Family Systems (IFS) therapy, which I’ll have to break down in a future edition of the newsletter.
And, of course, as is the case with most mental health symptoms, there are a wide variety of pharmacological options that have proven to be helpful in treating panic attacks. These tend to fall under the categories of selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), or benzodiazepines. I’ll speak to my experience with specific SSRIs and benzos, though please keep in mind each person’s body chemistry is different, so my reaction to these drugs may be very different from someone else’s.
When I experienced my first panic attack, I was already taking citalopram, so this SSRI definitely didn’t help reduce or improve symptoms. These days, I’m taking escitalopram, citalopram’s successor, and while I do find it helps put a cap on the range of emotions I’m capable of experiencing, I don’t feel it does much to minimize my anxiety or panic attacks. Which brings me to the benzos: these highly-addictive fucking delicious class of drugs can, in my experience, do wonders to reduce panic attacks and anxiety; however, and I can’t stress this enough, THEY ARE ONLY APPROVED FOR SHORT-TERM USE. I’ve had doctors encourage me to pop lorazepam (also known by its brand name, Ativan) daily, which I did, only to find myself dependent and experiencing withdrawal when I tried to stop. I still have a prescription for lorazepam, but, these days, I only use it during a panic attack, when I’m unable to practice therapeutic techniques. I’ve had a very positive, medically-supervised, experience with clonazepam (also known by its brand name, Klonopin), which I took when I was experiencing daily panic attacks, for a few weeks, until they subsided.
I wish I could say this blend of therapeutic and pharmacological treatments has completely eradicated my panic attacks, but I do still suffer from the occasional overwhelming bout of anxiety. These days, instead of experiencing a full-blown panic attacks, I have “limited symptom” attacks, or panic attacks that are less comprehensive and feature fewer than four bodily symptoms. It’s also become much easier for me to reduce the duration and strength of my panic attacks.
Mad History
This issue: Malcolm H. Lader and a very brief history of benzo use and abuse
In the 1960s, a new drug was being developed that, within a decade, would become one of the most commonly-prescribed drugs in the world: benzodiazepines. Designed to replace barbiturates, which had high rates of dependence and severe withdrawal symptoms, benzos were marketed as completely safe to take and without side effects.
“It is more difficult to withdraw people from benzodiazepines than it is from heroin.” This is an observation made by Malcolm H. Lader, a British psychopharmacologist, in 1994. He had been concerned about the pharmacology of addictions since the late 1960s, despite prevailing wisdom at the time. In the early 1980s, Ladner chaired two meetings of top British medical professionals, the Medical Research Council (MRC), which were called due to concerns about the dependent nature of benzos. Despite presenting evidence of this, and the damage benzo addiction can cause to the brain, the MRC declined to support Lader’s request for further research or a special safety committee to look into his concerns. Though Lader continued to contribute to the understanding of benzo addiction throughout his career, these particular findings were swept under the rug for nearly 30 years, until The Independent uncovered the unsealed documents.
When asked about the MRC meeting in 2010, Lader expressed regret: “I should have been more proactive... I assumed the prescribing would peter out, but GPs are still swinging them around like Smarties.”
Recommended Reading
The Mindful Way Through Anxiety: Break Free From Chronic Worry and Reclaim Your Life
By: Susan M. Orsillo and Lizabeth Roemer
It took me years to read this book, mostly because I was told to purchase it by a therapist I did not care for, but when I finally got over my negative association, I found it had quite a bit to offer. The Mindful Way Through Anxiety is a great introduction to the concept of mindfulness and how it can be applied to ease anxiety. Ultimately, this book aims to change the reader’s relationship with their anxiety, through practical step-by-step mindfulness exercises, accessible concrete examples, and personal reflection. It’s an excellent resource for anyone who’s grappling with anxiety, and one I certainly wish I had picked up sooner.
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