CHAPTER 1
Decoding Panic and Anxiety
Before we begin working on the panic and anxiety program, it is important for you to develop a good working understanding of both concepts. We will begin by defining panic, anxiety, and fear. Next we will go through the difference between panic and anxiety. Finally, we will go over what causes anxiety and panic.
What is a Panic Attack?
"I am running. Breathless, I know there is almost no chance of survival, I know that the tornado is too close to outrun and yet I am compelled to bolt, to run away somewhere and save my life. There is no shelter, just stretches of fields — no hope of escape. The truth is, I have never been in a situation close to a tornado — but that is what my panic attacks feel like, life or death, trying to flee desperately, only to be consumed by a force beyond my control."
"I am locked in a walk-in freezer at work, it feels like the oxygen is running out, I feel I know I am about to pass out. No one else is around — there is no hope. I wake up in a cold sweat — that time it was just a nightmare. I have never worked in food service; I have a desk job, but that is what my panic attacks feel like."
"I have been told that if a lion is going to attack you in the wild, you will not see the lion. You will only see the lion when it will be on top of you, and that is when you know you are in trouble. It is like that with my panic attacks, they just sneak up out of nowhere, and all of a sudden I know there is no escape."
"It is just like that movie where you are alone in the house, and you realize that there is a serial killer in the house with you and you are running around, out of breath, hoping to find a safe nook, and when you finally do — you are face to face! I know that there is no serial killer and that I am not in danger, but my entire body is demanding that I escape!"
Above are some examples of people describing what it feels like to have a panic attack. The danger and the push to escape are so real. Except, it does not make sense. There is no serial killer we are trying to escape. There is no mountain lion attacking us. And yet, we feel the surge of adrenalin that is coursing through our bodies with enough momentum to catapult us into the fastest sprint of our life, should we really need to save ourselves.
Irrational as we may believe it to be, our body tells us, "run for your life!" and we feel the pull, it is hard to dismiss the physical alarms. Even when there is no villain and you know that no one is chasing you. Even when there is no tornado that you are trying to outrun. This book offers you a system to overcome not only panic attacks, but also other anxiety issues, using a simple sixstep process. Before we jump into the process, let's first define panic, anxiety, and fear.
Fear is an internal alarm that tells us that we are in real or perceived danger. Fear is what helps us quickly press on the brake pedal to avoid hitting a child who runs into the street. It is a built-in mechanism that helps keep us safe. Anxiety is a future-oriented response that we experience without the presence of imminent danger or threat. All of us experience some passing feelings of anxiety that are normal. For example, it is normal to feel some anxiety before a job interview or an important exam. When the anxiety becomes chronic or pervasive, or disproportionate to the stressor, it becomes an anxiety disorder. When anxiety peaks quickly and intensely, it is defined as a panic attack. You already read some examples of what it feels like to have a panic attack, below is the clinical definition.
A Panic Attack is defined as:
A discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within ten minutes. (It is entirely possible that the time it takes may feel much longer to you.)
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating, or feeling very hot
3. Trembling or shaking
4. Sensations of shortness of breath or smothering, or difficulty breathing
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Derealization (feelings of unreality), the feeling that you are in a dreamlike state
10. Depersonalization (being detached from oneself), feeling as though you are watching events happening around you from a distance
11. Fear of losing control or going crazy
12. Fear of dying
13. Paresthesias (numbness or tingling sensations) commonly felt in the fingers or toes.
14. Chills or hot flashes
Panic Physiology
The Fight or Flight Response
Our fight or flight response is hard-wired, powerful, and predictable. It is our body's way of safeguarding our survival. It pumps blood to the large muscles in the body, away from the brain, in order to ensure that we can run away from a predator in a life-threatening emergency. Our body temperature goes up, our reaction time quickens, our breathing and heart rate become faster. We are primed to react in a way that protects our survival. The flow of blood to our large muscles can make us feel lightheaded and dizzy, but it is not considered dangerous. What is happening is that you are fully alert and ready for action, should a life-threatening situation arise.
Breathing
Our breathing quickens during a panic attack. We can also feel as though we cannot get enough air or experience a choking sensation. In response, we tend to open our mouths in an effort to take deeper breaths. We may also try to correct our breathing by practicing some kind of relaxation type breathing.
I am going to go against a lot of experts who recommend different ways and types of breathing. While those techniques can be helpful in reducing your overall anxiety level, they do not help with panic. If you have ever tried to breathe your way through or out of a panic attack, it is likely that it either did nothing or that it actually escalated your panic.
Physiologically, when we think we are practicing corrective breathing, what we are actually doing is trying to take deep breaths. Most of us do this by opening our mouths to try to inhale as much air as possible. This is actually likely to increase your panic symptoms. You will probably begin hyperventilating. The very symptoms that are part of the panic profile, like dizziness, feeling faint, and lightheadedness, are actually brought on by deep, open-mouthed breathing.
Even when we are not taking deep breaths, and we are just practicing well-controlled breathing in an effort to control our panic, we are operating under an illusion. That is, we start believing that we need to take over an automatic function of our body and try to breathe intentionally. So what should you actually do when trying to breathe through a panic attack? The answer is nothing! Just close your mouth and do not interfere with your body – it knows how to breathe! It is best to let your body restore itself. If you are a fan of breathing techniques and have found them helpful, it is absolutely fine to use them, just don't use them during a panic attack. In my experience, breathing techniques can be a great way to reduce overall stress, and they serve that purpose best when practiced regularly. I will speak to that more later on in the book.
Here's a quick tip to stop hyperventilating: The most important thing to do to stop hyperventilating during a panic attack is to close your mouth so that you do not breathe through it. Open-mouthed breathing does the opposite of what we want it to do – it will make your panic attack worse, not better.
CHAPTER 2
The Difference Between Panic and Anxiety
"True happiness is ... to enjoy the present without anxious dependence on the future." — Seneca
This is one of the most common questions I am asked in my practice: how do I know if I am having panic attacks or just anxiety attacks? A panic attack feels scary, frightening, and like you are about to lose control. It usually peaks quickly and often comes out of the blue with strong physical symptoms that typically affect breathing rate and produce a faster heartbeat.
Anxiety, by contrast, is usually a subjective feeling that may build over days or weeks, or come and go without ever turning into a panic attack, or it may come and go between panic attacks. Anxiety refers to fear in the absence of danger, and involves a future-oriented scenario. You may feel that something may go wrong: a sense of worry, dread, or a feeling of paralysis brought on by a strong sense that something (not otherwise dangerous) should be avoided. You may also experience feeling restless, keyed-up or on edge, being easily fatigued, more distractible, or have difficulty concentrating, irritability, muscle tension, gastrointestinal upset, and disruptions to your sleep. Below are two examples of what anxiety and panic feel like.
Jack came in for treatment after having several panic attacks that came on suddenly. During the panic attack, he described experiencing his heart beating very fast, feeling like he could not get enough air, and starting to feel very faint. He was also afraid that he would do something out of control, although he had not previously had any instance to suggest he actually would. All he wanted to do was to get out of the situation and to be somewhere comfortable where he could get to safety. Jack was engaged to be married to a woman he loved deeply and with whom he was excited to start a family in the near future. His current fear was that he was going to pass out during the wedding ceremony, which was going to be in a Catholic church and last over an hour. Since he would be the focus of everyone's attention, he was very worried about having a panic attack and not being able to just "slip out unnoticed."
Karen came in for a consultation due to severe anxiety she was experiencing at work. She had recently been promoted and now needed to give presentations to her department during large company meetings. Karen was terrified of public speaking. She was worried that she would do or say something that would embarrass her or cause others to think that she was not a competent professional. The night before a presentation, she could not get any sleep and noticed that she became very short with her husband and friends. Karen knew that these presentations were key to being successful in her new role, and so she endured them with great distress. Although she did not experience panic attacks, she would get sweaty palms and her voice would get shaky when she presented. This only made her more self- conscious, and she found herself over-preparing and dreading these presentations.
Both Jack and Karen (not their real names) were in quite a bit of distress when they started treatment. Jack had Panic Disorder and Karen had Social Anxiety. While only a mental health professional can provide a diagnosis, these vignettes can provide some clues into the types of symptoms you may be experiencing.
What Causes Anxiety?
We have some good ideas about what causes anxiety, and I will now share what the scientific community believes on this topic. The primary components of what contributes to the development of an anxiety disorder or panic disorder are: biology, learning, and stressors such as traumatic events.
There is a biological component to anxiety, and we know that some people are born with a more anxious temperament. This means that some people are more prone or sensitive to experiencing anxiety or responding with anxiety to a stressful situation or life event.
We also know that anxiety has a learned component. Learning theory suggests that anxiety can be acquired through learning and making associations between certain non-dangerous situations and anxious responses. This means that if we witness another person's anxious response, we may learn that that response is necessary. Children, in particular, learn about danger and safety from their surroundings. What this means is that if you had an anxious parent or caregiver, you may have inherited the predisposition to be anxious, and you may have also learned some responses that triggered anxiety in the absence of danger.
This may include behavioral and cognitive learning. Behavioral learning is learning about how to act in a certain situation. It may include learning to avoid situations that are anxiety-provoking. Cognitive learning is about how we think and assess a situation. It may include labeling certain situations as "dangerous" instead of "anxietyprovoking" or "uncomfortable." It also can prime our development of beliefs that not only is our world dangerous, but that our capacity to respond to that danger is inadequate or insufficient.
Trauma is also linked to developing anxiety. In particular, surviving or witnessing a traumatic event in childhood has been linked to changes in the brain and the likelihood of developing an anxiety disorder later in life. What we define as trauma varies, and can range from being bitten by a puppy to surviving a war. We also know that these events do not automatically result in anxiety disorders and are not destiny; they just increase the probability of a person developing an anxiety disorder.
In my clinical practice, the biggest unspoken question that I encounter is, "What did I do to get anxiety or panic?" It may not sound logical, and it is not. However, I find it is universally useful to dispel the myth that you did something to "catch" or "deserve" having panic or anxiety. To be perfectly clear, there is nothing that you did, and you are not to blame for experiencing panic or strong anxiety, PERIOD. You are only responsible for how you choose to respond to it today. As the great George Bernard Shaw said, "We are made wise not by the recollection of our past, but by the responsibility for our future."
CHAPTER 3
The U.N.L.O.C.K. System
In Part One of this book we went over the basics of panic and anxiety. Now that you are familiar with both, we will go through the thinking processes involved, including panic and anxiety beliefs and the way they influence your thinking. We will also be introduced to the steps you will need to take in order to manage panic and social anxiety.
Sitting on the couch in my office, Jane looked forlorn. The anxiety she was describing seemed overwhelming to her, and she felt paralyzed to do anything about it. Her life had become a series of safe routines designed to avoid anxiety. She had changed jobs so that she could be closer to home. She barely left the house, other than to go to work or run an occasional errand. Worst of all, she felt like she was perpetually in a state of dread, waiting for another anxiety attack. She looked frightened, and felt that anxiety had chained her to a life she did not want.
What Jane wanted was the key to getting better. What she needed was to unlock her power so that she could live her life, decide her direction, and exercise her freedom.
The U.N.L.O.C.K. System does just that. Through a series of exercises, I propose a framework to free yourself from the shackles of panic and anxiety and to unlock your life, your potential, and your emotional freedom. Now that you have a good understanding of both panic and anxiety, let's go over the U.N.L.O.C.K. system to begin your journey to overcoming panic and anxiety.
Step 1. Understand
The first step involves understanding anxiety and panic symptoms and their cycle. Next, we dismantle myths about panic and anxiety. Finally, we look at how we unintentionally increase our anxiety through our various attempts to control it. Understanding anxiety allows you to approach your treatment from a place of knowledge rather than fear. It includes building awareness about your symptoms and how to address them. Armed with this knowledge, you will be better able to gauge which attempts at anxiety reduction work and which make it worse. In my consultation room, often the first time that I see relief on a client's face is when they come to understand their symptoms.
I will always remember my session with Joe; he was visibly nervous after having been referred to a therapist following two visits to the emergency room. Both visits were prompted by a feeling that he was about to have a heart attack – but after thorough physical examinations, each lasting several hours, he was medically cleared and told he was having panic attacks. Let me be clear, that is all Joe was told. He was then referred to a therapist and that is how he found himself sitting in front of me, not really sure what a panic attack was. I would love to say that Joe's story is an exception – it is not. Emergency rooms are busy places, and many people leave with no information about what their symptoms mean. As soon as I took some time to explain to Joe exactly what was happening to his body when he was having a panic attack, he became visibly relaxed. This understanding alone led him to feel much better about his situation and reduced his stress level immensely.
