Stop

Anxiety and Panic Attacks

The Perfect Self-Help Toolkit to Overcome

Anxiety Disorder, end Panic and Find
Relief and Peace for your Mind

Jennifer Lee
Table of Contents
Introduction
Chapter 1: Anxious? You Are Not Alone
The Thing to Fear is Fear Itself
What to keep in mind – a “cheat sheet” for moments of severe anxiety or
panic:
How Can I Escape Fear by Embracing it?
The Author’s Experience: Part 1
The Samuel Butler Principle
Chapter 2: Understanding Anxiety
“What’s wrong with me? I never used to be this way.”
What is anxiety?
What Causes Anxiety?
There are also Physical, Neuro-chemical Causes of Anxiety Disorders.
Chapter 3: What is a Panic Attack?
Why Do I Get Panic Attacks?
How Can I Tell if I am Having a Panic Attack?
Chapter 4: Why Panic Attacks Tend to Become Chronic
Case History: Sarah
Chapter 5: How to Overcome Anxiety and Panic?
How Does it Work?
What Can I Do to Help Myself Without Seeing a Therapist?
Chapter 6: Remedies and Solutions During a Panic Attack Crisis
Steinbeck’s commanding officer
When “Riding the Wave” is not Enough…
 The Author’s Experience, Part II
Conclusion
 Copyright 2019 by Jennifer Lee - All rights reserved.

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Introduction

Congratulations on purchasing your copy of Stop Anxiety and Panic Attacks:
The Perfect Self-Help Toolkit to Overcome Anxiety Disorder, end Panic and
Find Relief and Peace for your Mind. If you have come this far, chances are you
have experienced anxiety, panic disorder, and their related symptoms. Maybe
you find yourself overwhelmed by fears that seem out of control. You may find
that your thoughts “get away from you” and take you to dark places, and you are
trying to figure out how you can get them under your control.

These symptoms are often highly distressing and uncomfortable. Moreover, they
are not helped by the fact that it is often difficult to talk to other people about the
panic symptoms if they have not experienced these symptoms themselves. This
can lead to a feeling of isolation. Many people believe they are alone in their
fears. Some may incorrectly think their condition is unusual, or that there is
something wrong with them if they are experiencing anxiety and panic
symptoms. Others may convince themselves that panic is a chronic state and that
they will suffer from it for the rest of their lives.

This book is designed to counteract these myths. In reality, panic and anxiety
symptoms are extremely common and becoming more so. More importantly,
these conditions are far from incurable. Millions of people – including the author
of this book -- have found ways to treat and to overcome their anxiety and panic
symptoms, often in ways that are surprisingly simple. In many instances,
something as straightforward as a basic change in behavior and thought patterns
could substantially diminish – even eliminate – feelings of anxiety and panic,
freeing you to live your full life. This book is designed to give you the tools and
information you need to begin the journey toward this result.


 Chapter 1: Anxious? You Are Not Alone

The Thing to Fear is Fear Itself

Anxiety and panic attacks are a frightening thing! If you are reading this book,
the chances are that you already know this – probably from direct experience.
You know that the physical symptoms of anxiety are often uncomfortable and
distressing in themselves – shortness of breath, sweaty palms, and a racing heart.

Moreover, in many people’s cases, anxiety and panic symptoms become
associated with specific events or situations that we find frightening in them. For
people suffering from post-traumatic stress disorder, for example – a specific
kind of anxiety-related mental health disorder – anxiety and panic symptoms are
often triggered by reminders of an earlier traumatic event. A traumatic event
might be best defined as one that deprives a person of their sense of agency and
power over their own lives, thereby undermining their sense of self and their
basic feeling of security and stability in the world. No wonder people would
experience panic in situations that reminded them of such a triggering event!

In other cases, panic symptoms can become associated with different, originally
distinct fears and anxiety disorders. For example, people may be afraid of
enclosed spaces (claustrophobia), open or public spaces (agoraphobia), public
speaking, or feelings of public embarrassment or of humiliating oneself in front
of others, which is often referred to as Social Anxiety.

In many cases, however, what people with anxiety or panic disorders come to
fear most is simply the panic attack itself. The reason why is easy to understand,
and we have already noted it above: A panic attack is scary!

For those who have experienced a full-on panic attack, it is something they do
not wish ever to repeat. In many cases, it may seem like the most painful or
frightening moment of their lives. Clichéd phrases like “white-hot terror” often
take on a new and vivid meaning for people who have been through a panic
event.

This is why the specific triggering causes of anxiety or panic episodes tend to
change over time. In many cases, a person may first experience anxiety
symptoms or a panic attack in a situation they associate with a specific fear –
shortly before going on stage to deliver a public speech, for example; shortly
before flying or riding in an elevator; before a party or having to ride a bus with
strangers.

After experiencing the discomfort and distress of a panic event, people will seek
to avoid the situation that first triggered the episode. Again, this is a fully
understandable and rational response. Any of us would wish to avoid having to
even go through such an experience again.

The problem is, however, that as rational as this response may seem, it actually
makes one’s anxiety symptoms even stronger. For reasons, we will discuss more
fully in Chapter 4 of this book, seeking to avoid feelings of anxiety. In fact, it
increases the potency of those anxiety symptoms and the likelihood of future
panic attacks.

By working with a therapist or other helpers – or simply coaching oneself – one
can cut against the grain of one’s fear. By training oneself not to try to resist or
avoid one’s feeling of panic, one can rediscover and reclaim one’s sense of
freedom, agency, and personal control over one’s emotions. Methods by which
to do so will be discussed in depth in Chapters 5 and 6 of this book.

In the meantime, however, living with the fear of panic attacks is no easy task.
No one should ever dismiss or downplay how frightening it can be to experience
anxiety – let alone the acute panic episodes that we describe as “panic attacks.”

To suffer from a “fear of panic” can also be an isolating experience, however, as
mentioned above. The idea that someone might be afraid of having a panic
attack – in other words, that they might be afraid of being afraid – can often
strike those who do not suffer from anxiety or panic disorders as a strange, even
“irrational” idea. This can lead to a feeling in the patient that there must be
something wrong with them.

Indeed, when told that it is unreasonable to be afraid of panic, many people with
anxiety respond that they “know” this to be the case, at an intellectual level, but
that they do not experience a feeling of control over these emotions. This can
lead to a sense that one’s emotions are getting away from one, and maybe even
that one’s life is spinning out of control.

This can lead to a still further related fear. Many people with panic symptoms
are afraid that they may “lose their minds.” This fear that one might “go insane”
can further fuel anxiety, and leads to the sort of avoidant behavioral patterns that
– as we saw above – actually strengthen anxiety symptoms in the very effort to
evade them.

It certainly lends new meaning to the famous words of U.S. President Franklin
D. Roosevelt, who said – in his first inaugural address to the nation in 1933:
“The only thing we have to fear is fear itself.”

What to keep in mind – a “cheat sheet” for moments

of severe anxiety or panic:
When you are feeling overwhelmed by anxiety or panic – or are feeling isolated
and convinced that others do not understand the reality or appreciate the severity
of your symptoms – here are some simple facts to keep in mind:

You are not alone. As we mentioned in the Introduction, anxiety, and
panic disorders are not rare or unusual, even though some of the people
around you may not have heard of them before, or do not understand their
symptoms. In reality, millions of people suffer from anxiety or panic
symptoms around the world. According to most recent data, roughly one
in five adults in the United States – including the author of this book -- has
 experienced an anxiety-related disorder at some point in their lives. Later
on this book, we will see that other surveys have placed the incidence rate
of anxiety disorders even higher. By some estimates, one in three people
in the United States will experience an anxiety disorder in the course of
their lives. Moreover, as we will be discussing in this book, many people
who have lived successful lives and achieved great things have suffered
from anxiety and panic-related disorders. These disorders do not control
your destiny, and they do not last forever.

Anxiety and panic are not dangerous. Panic attacks do not physically
harm your body, even though they can be very distressing and frightening
when they are occurring. As uncomfortable as these experiences may be,
they will not hurt you or cause you to hurt yourself.

Anxiety and panic will not make you do anything you do not want to
do. Because panic is often associated with a sense of “losing control” over
one’s emotions, many people with anxiety fear that they will lose control
as well over their actions and behavior – causing them to hurt themselves,
for instance, or do the very things of which they are most afraid of. People
who are afraid of heights, for example, often report – while being on a
high precipice, for instance – that they are afraid their panic will induce
them to throw themselves off the ledge. Similarly, people who are afraid
of flying often fear that their panic will get so intense that it will force
them to do something that would damage the aircraft, thus bringing on the
very midflight accident they were afraid of in the first place. In reality, as
we will discuss more fully in Chapter 6, even when we are in the midst of
a panic episode, we have more control over our emotions than we may
think. More important to note here, emotions cannot force you to act a
certain way, and fear specifically is especially unlikely to force you to do
the things you are afraid of. While excessive fear is a distressing thing, we
 have fear emotions as a species for a reason. Fear is a valuable emotion,
one that serves an important evolutionary function of alerting us to danger.
Your feelings of fear or panic can never force you to do things you are
afraid of – that is the opposite of the role fear plays in our minds. It will
not lead us into the things we consider dangerous.

Anxiety and panic will never “drive you insane.” There is no causal link
between anxiety and other mental illnesses. Excessive anxiety or panic
will not cause you to start hearing voices, seeing things, or experiencing
other symptoms associated with schizophrenia and similar illnesses. Nor
are anxiety or panic linked to feelings of paranoia or similar mental
disorders that have an element of delusion. Paranoia often involves a false
sense that larger forces, government entities, or a global conspiracy are
engaged in an effort to hunt you down and undermine you personally.
Anxiety and panic, by contrast, are not grounded in delusions. People with
anxiety or panic do not have an inflated sense of their own importance, nor
do they worry that someone is “out to get them.” More often than not, they
are worried about nothing more than the reality of their own symptoms –
the fear of panic and anxiety.

Anxiety and panic can be overcome. Later on in this book, in Chapter 5,
we will discuss some of the treatment options that are available today to
treat anxiety and panic – including fast-acting medication. The important
thing to remember, however, is that there are methods and strategies you
can use in the midst of a panic attack to de-escalate and overcome the
panic episode – including simple somatic, or bodily, exercises that you can
do at the moment – none of which require immediate access to medication.
Many times, people with anxiety or panic come to rely on having ready
access to fast-acting medications, such a Xanax or similar tranquilizers, in
order to feel safe. While medication can be a helpful part of anyone’s
 treatment plan, relying on the idea of having access to medications can
also become one of the avoidant behaviors that strengthen anxiety over
time. This can lead to people experiencing panic attacks, or the fear of
panic attacks (which is often much the same thing) when they are
temporarily deprived of access, for any reason, to their usual medications.
The truth is that you can de-escalate your anxiety even in situations in
which you do not have fast-acting medications in an accessible form. We
will discuss some of the methods for doing so more fully in Chapter 6 of
this book.

How Can I Escape Fear by Embracing it?

Many of the important truths about overcoming anxiety have a ring of paradox
to them, the first time one hears them. Some may find it hard to believe that they
can be true. After all, just as it seems strange to many people that one might be
afraid of a panic attack, it also seems strange to many people with anxiety or
panic disorders that they might be able to overcome their fears not by avoiding
them, but by accepting them. If we have experienced panic episodes, isn’t the
way not to do so again to avoid the situations that bring them on?

Strange as it may sound, the answer is No. Avoiding situations that have been
associated with panic episodes in the past generally increases anxiety symptoms
in the future and increases the likelihood of future panic attacks.

In order to understand why this is so, throughout this book we will not only be
sharing the insights that reflect the consensus view of therapists and mental
health practitioners in this field; we will also be discussing the author’s personal
experiences with suffering from – and eventually overcoming – anxiety and
panic. We will share both the story of the particular way in which the author first
began to develop and experience anxiety symptoms and – in Chapter 6 of this
book – the story of the methods the author used to manage anxiety and panic
attacks.

The Author’s Experience: Part 1
In my case, I have dealt with anxiety and panic for the past four years, and the
nature and targets of that anxiety have changed over time.

The first incident in which I can remember experiencing what I would now
recognize as anxiety came when I was in a theater, watching a musical
performance. I was with my family in the center of a long aisle, and all of the
attendees were seated very closely together.

At some point, during the middle of the performance, I began to feel very thirsty.
It occurred to me that I had not much to drink during the day and that I might be
somewhat dehydrated. This led me to think back to a time when I was a child
and had gotten so dehydrated that I threw up.

This memory, in turn, led me to start wondering what would happen if I threw
up in the middle of the concert. It would be terribly embarrassing, I thought. I
started to look around and to realize that everyone in the theater was packed so
closely together that it would also be very difficult and embarrassing to leave the
aisle if I had to. It would also be time-consuming, and I might not make it to the
bathroom in time before I had to vomit. Oh no, I thought, that means I would
throw up on the lap of some perfect stranger!

The more I thought about this, the more it started to seem essential to me that I
leave the theater as quickly as possible and get myself to a bathroom, just in case
I had to throw up. (Keep in mind that throughout this whole period, I didn’t
actually feel nauseous or close to vomiting at all. This was all just because I
noticed I was thirsty! This shows the power of panic to make apparently
“logical” connections between different fears, even when nothing frightening is
actually happening.)

To my family’s surprise and alarm, therefore, I stood up during the midst of the
concert and made my way across the other people in the aisle. They had to shift
uncomfortably in order to make room for me, and I felt embarrassed. I then got
to the bathroom and drank some water out of the faucet, hoping this would
reduce my feeling of being dehydrated. I then made my way back to my seat to
finish watching the show.

As soon as I was seated, however, the whole thought process started over again.
What if that wasn’t enough water? What if I get sick anyway? Where would I
go? I’d have to climb all over everybody again.

Even from this small example from the author’s personal experience, we can
already see some of the features common to anxiety and panic disorders that we
will be examining throughout this book. We see the ways, for instance, in which
a variety of quite different fears can build on and reinforce each other, through a
seemingly “rational” logical process.

My experience in the theater drew upon a social anxiety (about not wanting to be
on display and to embarrass myself), a fear of enclosed spaces (I was worried
about what my “escape route” would be, if I had to throw up), and fear of losing
control over my physical bodily responses (fear of throwing up) and other
individual fears that we will be examining in detail later on in this book.

More importantly, however, my experience can help show us the way in which
panic can start from something extremely small, usually a minor discomfort or
fear (in this case, feeling thirsty), and grow from there. Above all else, the thing
that feeds and reinforces panic is avoidance.

In my case, I thought that by getting up in the theater to get a drink of water, I
could avoid the thing I was afraid of (i.e., throwing up). Instead, this only
reinforced the panic, because my efforts to avoid the fear opened up a new set of
potential fears. Once I had the drink of water, I realized that even drinking water
isn’t a surefire guard against the possibility of throwing up. I still wasn’t entirely
safe from the possibility.

Minor as it may seem, this one experience in the theater led to four years of
struggle with panic and anxiety symptoms. My fear of throwing up in the theater
quickly led me to be afraid of other places in which I would be “trapped” for a
certain period of time in an enclosed space, and therefore would not be able to
get to a bathroom in case I needed to vomit. This led me to begin avoiding
airplanes, subways, and even elevators.

In turn, after I had experienced a number of panic attacks in such places, the fear
of panicking itself began to be reason enough for me to avoid situations that I
associated with my anxiety. Over time, the anxiety began to exert greater and
greater degrees of control over my life, and the range of ordinary activities in
which I felt “safe” in my life felt ever smaller.

Avoidance of panic triggers often leads to this result, because it is not actually
feasible to entirely escape the possibility of panic. The future is always
uncertain, and you cannot screen yourself off entirely from the range of possible
emotions or bodily responses you might undergo. Avoiding various situations
merely serves as a reminder of this frightening truth. As I experienced after my
trip to the bathroom in the theater, I realized I could not entirely forestall the
possibility that what I was afraid of might actually happen.

The important thing to do, therefore, is not to find a way to avoid the possibility
of having a panic attack, because you can’t. The important thing, rather, is to
realize that you do not need to avoid it because panic attacks are not dangerous.
In the concert hall all those years ago, I was confronted by the frightening fact
that I could not foresee all of my future potential bodily responses. None of us
can. We do, however, have the power to keep ourselves anchored in the present
and to realize that we are perfectly safe, even if we start to panic.

The Samuel Butler Principle

Strange as it may seem then, as you come to accept the possibility of panicking,
you will quickly find that a panic event that you fear is far less intense in reality
that you thought it would be in imagining the future. Indeed, you may discover
that the panic attack never comes at all.

Some people who have dealt with panic disorders have even gone as far as to say
that they are not sure they have ever really had a panic attack at all. This is
because so much of the panic attack experience itself is often tied up in an
anticipatory dread of a future panic attack, or the fear that a panic attack will get
worse or go on forever, that telling the difference between a panic attack itself
and the fear of a panic attack is often not easy to do. Indeed, it is possible that
there is no distinction between the two, and the two experiences are one and the
same.

As we will see in the following chapter, anticipating future threats is the essence
of anxiety. As most of us know from our personal experience in other contexts,
however, we are very often more afraid of something before it comes than we
are when we are actually facing it. Think of going on a roller coaster. When do
you experience the most fear and trepidation? During the ride itself? Or during
the long wait, when you are staring up at the towering contraption and its huge
falls? Chances are, it’s the latter.

The same is true with a panic attack: its bark is worse than its bite.

We might call this important insight the “Samuel Butler principle,” after the
famous British author because he once summarized it in a, particularly pithy
way. To paraphrase slightly, he wrote: “Life is so much more often an affair of
being frightened, that it is of being hurt.”

So it is with panic attacks. They are very often frightening. But they do not have
the power to harm.

***

Four years after the incident in that concert hall, I now live my life largely
without anxiety, and without limits, it once imposed on my range of life options.
I travel routinely for work on planes and the subway, I ride elevators, I go to
concerts, and a whole range of other activities that once felt as if they were next
to “impossible” for me. Moreover, I reached this point without the use of
medication. In Chapter 6 of this book, we will discuss some of the simple
methods I used to begin to regulate my panic responses and to reach this result.
 Chapter 2: Understanding Anxiety

Anxiety, by Edvard Munch (1863-1964). Source: Wikimedia Commons. This image is in the public
domain.

“What’s wrong with me? I never used to be this way.”

If you are struggling with anxiety, the chances are that this is a thought that has
occurred to you in the past. Anxiety can strike people at many different stages of
their lives, and some reach their early adulthood, or even later, without noticing
any symptoms of anxiety. When people do first start to experience anxiety, it can
feel as if it “came out of the blue.” Things that used to be extremely easy for
them to become difficult – or even come to seem “impossible.”

People who were immensely sociable in the past, for instance, and had no
trouble going to parties and meeting new people, may suddenly start to
experience forms of social anxiety or phobia that keep them at home. (See
Chapter 3 for a further discussion of social anxiety.) So too, people who have
flown around the world or across the country without any concern throughout
their lives may develop a terror of flying that prevents them from setting foot on
an airplane.

This can lead to a frightening sense that one’s horizons are shrinking, or that one
is losing abilities that one used to have in the past. In the classic novel by Nobel
Prize-winning author V.S. Naipaul, A House for Mr. Biswas, he describes this
feeling in the context of his protagonist’s struggle with symptoms that we would
now recognize as an anxiety disorder. He notes that his protagonist is unable to
imagine how he could have interacted socially with other people in the past
when he now finds it so terrifying. “His whole past became a miracle of calm
and courage," writes Naipaul.

Naipaul knew whereof he spoke. A House for Mr. Biswas – considered by many
to be his masterpiece – is based on his father’s life story. Toward the end of the
novel, Mr. Biswas – the stand-in for Naipaul’s father – realizes that his son is
experiencing the same symptoms of anxiety and depression he once went
through and sends him a book in the mail (perhaps a book much like the one you
now hold in your hands) that will help him manage the symptoms. All of these
events correspond to things that actually happened in Naipaul’s life.

As Naipaul’s example suggests – and as we will see throughout this book –
many famous people who have achieved important things in the world have
grappled with anxiety and its associated disorders. There is nothing “bad” or
strange about you for going through the same, and it is not your fault that you
are experiencing this form of mental illness. You are simply experiencing the
same anxiety symptoms that people have dealt with throughout history.

Moreover, while it can be very disconcerting to find that you feel “incapable” of
doing things that used to come easily to you in your past – because you feel
blocked by your anxiety – you can also use those memories to remind yourself
that it is possible to live without anxiety. You used to do things without being
blocked by anxiety, and you can do so again, you just need a little help.

The first step is simply to reduce the feeling of mystery and stigma around the
disorder itself. Familiarizing yourself with the typical symptoms can help you
recognize and treat your anxiety for what it is.

What is anxiety?
Throughout this book, we will be using the terms “fear” and “anxiety” as
interchangeable, following their everyday uses. Clinicians, however, recognize a
technical distinction between them, pointing out that fear really refers to one’s
reaction at the moment to a perceived threat, whereas “anxiety” has an element
of anticipation to it. We are anxious for the future – for what we think may be
coming up ahead.

It is helpful to consider this distinction because it can enable us to understand the
way anxiety disorders operate. As we will discuss more fully below, anxiety
disorders often function through anticipatory fears that prevent us from putting
ourselves in situations where we feel me may be at risk. Many people who have
overcome anxiety disorders describe a realization after doing so that they often
experience far less fear – maybe even no fear at all – in the moment of facing
what they feared, than they did during the period when they were anticipating,
waiting for, and dreading that fear (see the section on the “Samuel Butler
principle” above).

In the case of people who overcome a fear of flying, for example, many states
that the hardest part of the process was convincing themselves to get on the
plane. Once they were aboard and their seatbelts were fastened, their fear largely
abated.

This can be hard for many people with anxiety to believe until they experience it
directly. The sense of being “past the point of no return” and of having “no way
out,” is often precisely the thing that people with anxiety fear the most. Yet once
the doors of a plane are closed, and there is truly no turning back, people
surprisingly relax.

This is because a great deal of anticipatory anxiety is related to an exhausting
sense of needing to make a decision all the time (a sensation linked to the natural
hormonal “fight or flight response,” discussed below). People with anxiety often
spend enormous mental energy, trying to figure out how to avoid the situations
they fear. Some describe this as a constant sense of trying to figure out their
“escape route.” In situations in which these decisions are out of their hands, and
in which they must simply trust the pilot and crew of the plane they are flying,
many people report feeling a sudden sense of calm. They are able to let go of the
need to make decisions – which is another way of saying, they are able to
abandon the quest for control over a situation. Once they do so, their fight or
flight response diminishes.

In the sense of an anticipatory fear about future threats, anxiety is an entirely
normal part of life. We all experience some amount of anxiety when we are not
fully sure of what the outcome of a situation will be. Likewise, related feelings
of stress are often linked to a sense that events are occurring outside of our
control. While no one likes feeling stress or anxiety, these emotions serve a
healthy evolutionary function in our emotional psychology. They help us foresee
and plan for future threats to our safety so that we can keep ourselves whole and
well.

The important thing, then, is to recognize when a normal amount of anxiety is
starting to tip over into pathological anxiety, meaning anxiety that has become a
form of mental illness, for which you may need to seek professional help.

Some of the signs that your anxiety may be pathological in the form are if your
anxiety is:
preventing you from doing the things you would otherwise like to do with
your life,
preventing you from performing the tasks that others around you are able
to perform in the ordinary course of living, and not as any special feat
(such as traveling, working a regular schedule, sleeping regular hours,
etc.)
becoming something you are afraid of in itself, rather than just a feeling
that accompanies something else that is causing you to fear.

To give an example, if you feel anxiety before giving a presentation at work, that
is a normal and healthy response. However, if your anxiety is so great that you
pretend to be sick in order to avoid the presentation, or if part of the reason you
want to cancel the presentation is precisely because you are afraid it will make
you anxious, or afraid you will panic in the midst of it – and, more importantly,
if these kinds of responses are becoming more and more prevalent in your life,
these might be signs that you are suffering from a pathological form of anxiety.

The physical symptoms of anxiety will be familiar to anyone who has suffered
from various kinds of fear in the past. We will be confronted with a very similar
list in Chapter 3 when we come to consider the symptoms of a panic attack.
These symptoms include:

Heart palpitations, Arrhythmia, Pain in the chest. We will discuss
arrhythmias and anxiety disorders that center around fears of heart trouble
more fully in Chapter 3. The important thing to keep in mind, for now, is
that panic and anxiety may make your heart race or lead to other feelings
of discomfort, but they will not hurt your heart, nor are they linked to
heart disease or any physical heart condition.

Lump in the throat, Shortness of breath, Digestive problems,
Sweating, and other physical symptoms. As with the heart-related effects
in the previous bullet point, it is important to keep in mind that while
these physical symptoms may be uncomfortable, they are not dangerous.
Your body is not capable of “choking” itself, and you will always
continue breathing, even in the midst of a severe panic attack. Many
people with anxiety or panic disorders describe a sensation in which they
feel their throat is constricting, or in which they cannot get enough air to
breathe (this feeling can come from hyperventilation, discussed below).
The famous novelist John Updike reportedly suffered from such a
choking sensation periodically in his young adulthood. The good news is
that this did not prevent him from breathing comfortably until his death at
the ripe age of 76. Your body’s respiratory, or breathing, an involuntary
function, and would continue even if experienced panic, or even if you
passed out. You do not need to worry about maintaining it.

Difficulty sleeping, also known as Insomnia. Some peoples with anxiety
report periodic feelings of being “jolted awake” in the middle of the night.
Many people describe their anxiety thought patterns as most difficult to
escape during the periods when they are trying to get to sleep because
there are fewer external and social stimuli during this time of day to
distract them from these thoughts. We will discuss later in the book some
 of the ways people have found to manage and overcome the sense of
being haunted by recurring thoughts, which can occur in both anxiety
disorders (where they are associated with panic) and depression (where
these recurring thought patterns are known as rumination).

Throughout this book, we will be referring to anxiety loosely as a “disorder,”
and we will at times describe it alongside panic, to which it is closely related.
From a clinical standpoint, however, anxiety is really a larger umbrella category
that includes a number of distinct anxiety-related disorders. Many clinical
references, for example, speak in general of “Anxiety Disorders,” and give
specific examples of the problems that fall within this category.


Such specific anxiety disorders include:
Panic Disorder, often characterized by recurring experiences of high-
intensity feelings of anxiety or panic, known as “panic attacks,” which we
will discuss in detail throughout this book;

Post-Traumatic Stress Disorder (PTSD), which we mentioned above
and which we will discuss again in Chapter 3;

Social Anxiety, Claustrophobia, Agoraphobia, and Separation
Anxiety, all of which we will discuss in detail in Chapter 3

Generalized Anxiety Disorder (GAD), an anxiety condition that often
takes the form of worrying about the implications of normal, everyday
decisions. People with GAD often report feeling plagued by anxious
concerns about their own health, about money or financial troubles, about
their relationships with friends, family members, or significant others, etc.
Many struggles with decisions that are, for other people, simple parts of
 everyday life, such as paying bills on time, making meals, etc.

Obsessive-Compulsive Disorder (OCD), a form of psychological
disturbance in which people feel the need to engage in repetitive tasks and
become excessively focused on minor details. For people with OCD, these
repetitive tasks often become essential to feeling a sense of personal
safety, and they can experience severe anxiety when their ability to
perform these tasks is interrupted. For this reason, OCD is often
considered alongside – or under the heading of – anxiety disorders.

While all of the anxiety-related disorders we have considered above are distinct,
it is important to understand that they have a high degree of co-morbidity. This
means that they often appear alongside one another, in the same person. People
who experience PTSD, for example, or one of the phobias listed above, may also
come to exhibit symptoms of panic disorder, because their phobias may lead to
panic attacks. By the same token, people with panic disorder may come to
exhibit other phobic responses. This happens because their fear of having more
panic attacks leads them to become afraid of being in situations they find
frightening for other reasons, and which they, therefore, begin to fear might
induce a panic response in them.

So too, anxiety disorders often appear alongside with Substance-Abuse
Disorder. This happens both because people may seek to self-medicate with
drugs or alcohol in order to dull their anxiety symptoms, or – in cases where the
line of causality flows in the opposite direction – because consumption of
psychotropic drugs disrupts people’s normal neurochemistry and leads to other
psychological symptoms.

Finally, anxiety disorders have features in common with depression, bipolar
disorder, and related psychological problems. Some of these similarities will be
discussed in more detail in Chapter 3.

Good to Know: How Common is Anxiety, Really?

To remind yourself that you are by no means alone in suffering from an anxiety-
related disorder, it might be helpful to look at some recent public health surveys
of the incidence of various mental disorders. One such recent study shows the
relative incidence rates of different forms of anxiety. This survey shows that the
most common form of anxiety is a specific phobia (including claustrophobia)
and that nearly 14% of people suffer from this condition in the course of a
lifetime. The next most common form is social anxiety, which 13% of people
reportedly experience in the course of a lifetime.

Overall, nearly 34% of people will experience some form of anxiety disorder in
the course of their life, or about one out of every three people. Here is a chart
showing the relative prevalence of various kinds of anxiety disorder in the
general population:


Source: Data on relative incidence rates taken from the National Comorbidity Survey-Replication, as
reported in Bandelow, Borwin & Michaelis, Sophie. (2015). Epidemiology of anxiety disorders in the 21st
century. Dialogues in Clinical Neuroscience. 17. 327-335. Chart created for this book.

What Causes Anxiety?

The first and most important thing to know in looking for the causes of your
anxiety is that it is not the “fault” of any particular person. You are not to blame
for your anxiety, nor is any other person or event necessarily responsible. While
some forms of anxiety disorder – such as post-traumatic stress disorder – are
often linked to particular triggering events from a person’s past, many other
forms of anxiety have no relation to anything that a person experienced before.

Bearing this in mind, there are some habits that seem to be linked to anxiety
disorders – at least in some cases. Having frantic, fast-paced work habits, for
example, which interfere with a person’s ability to maintain a regular sleep
schedule or enjoy sufficient leisure time and quality time with the significant
people in their lives, can trigger or exacerbate the symptoms of an anxiety
disorder.

So too, prolonged abuse of psychotropic substances (which can include both
illegal narcotics and controlled prescription drugs, when these are used
excessively and without medical oversight) can also affect a person’s brain
chemistry in unanticipated ways.

Just as often, if not more so, however, anxiety is not linked to any particular
behavior, habit, or lifestyle. Anxiety symptoms often first begin to manifest
during a person’s early adulthood – a time when the brain is still undergoing
major biochemical changes, as the pre-frontal cortex finishes developing and a
person’s neural system is transitioning from its adolescent to adult form.

Oftentimes, therefore, anxiety symptoms may simply be related to difficulties
regulating one’s emotions and making the adjustments to the natural processes
happening in one’s brain, and to the lifestyle changes involved in early
adulthood.

Genetic factors – that is, traits inherited from the genes of one’s biological
parents – may also play a factor in predisposing people to anxiety or related
disorders. On the other hand, it is important to remember that even people with a
genetic predisposition to anxiety-related conditions are capable of successfully
treating and managing anxiety. With anxiety and panic, as in other parts of life,
genes are not destiny.

There are also Physical, Neuro-chemical Causes of

Anxiety Disorders.
Ultimately, the things that happen inside the human brain are still somewhat
mysterious to us. While enormous progress has been made in neurochemistry in
recent years, the precise way in which the chemicals inside the human brain
influence our emotions and behavior is still a subject for further investigation
and research. We know, however, that imbalances of certain important
chemicals in the brain, such as noradrenaline and serotonin, are directly related
to anxiety disorders.

Good to Know: The Chemical Side of Anxiety

Noradrenaline chemical structure. Source: Wikimedia Commons. This image is in the public domain.

Noradrenaline, also known as norepinephrine, is – as the name implies –
closely related to the chemical adrenaline (which is also referred to as
epinephrine). You may have heard of adrenaline since it has entered our
everyday language through phrases such as having “a rush of adrenaline.”

Basically, both adrenaline and noradrenaline are chemicals that operate as
neurotransmitters in the body. Neurotransmitters are key to performing all
muscular and bodily tasks because they are the chemicals that carry messages
from the brain to other parts of the body in order to trigger them to engage in
certain actions.

The body produces both adrenaline and noradrenaline, specifically when it is
engaged in what’s known as the “fight or flight response.” This response
evolved in humans, as in other animals, in order to help us respond to imminent
danger. It leads to a racing heart rate, hyper-focused awareness, rapid breathing,
and other physical indicators that we associate with the emotions of fear,
tension, and the need to make rapid, instantaneous decisions concerning our
safety (such as whether to fight or to flee).

During a state of anxiety or a panic attack, the body is essentially kicking the
“fight or flight response” into overdrive, even though there is no actual threat,
and you are not in any danger. This response causes the body to produce
noradrenaline, which transmits only to “alpha” receptors, which are located in
the arteries, and adrenaline, with transmits to “beta” receptors in the heart,
lungs, and elsewhere in the skeletal and muscular structure.

This is why fast-acting medications that halt the immediate effects of panic
attacks are called beta blockers. These medications interfere with the effects of
adrenaline on beta receptors – in order words, blocking the chemical from
having its full impact on the heart and lungs, and thereby decreasing one’s heart
rate and rate of breathing. We will discuss these in greater detail in Chapter 5.

The effects of adrenaline/epinephrine are therefore somewhat more extensive
than those of noradrenalin/epinephrine because they affect more parts of the
body. By affecting alpha receptors, noradrenaline can cause blood vessels to
constrict (which make it a useful chemical for treating low blood pressure, but a
potentially harmful one for people experiencing high blood pressure).
Adrenaline, meanwhile, can lead to heightened heart rate, rapid breathing, and
the other physical indicators we discussed above, which are associated with the
“fight or flight response” and which show up during panic attacks.

While the body is often producing too much adrenaline and noradrenaline
during a panic attack, however, it is important to understand that these are not
“bad” chemicals, and treating your anxiety through medication that “blocks” the
effects of adrenaline is only a short-term way to mitigate a panic attack, not a
long-term method of treating the causes of anxiety.

Adrenaline and noradrenaline are essential and useful chemicals in the way the
body regulates its emotional and physical responses, and it is an imbalance of
these chemicals that leads to mental disturbance, not their mere presence.
Indeed, low levels of noradrenaline have also been linked to anxiety and
depression, even though the body is often flooding you with noradrenaline in
the moment of a panic attack.

Serotonin chemical structure. Source: Wikimedia Commons. This image is in the public domain.

Much the same applies to serotonin, which is a chemical often implicated in
cases of anxiety and depression. Like noradrenaline and adrenaline, serotonin is
a neurotransmitter. This means it carries messages from the brain that help
instruct other parts of the body to carry out specific functions. While much
about the action of serotonin remains mysterious and a subject of controversy, it
is generally understood that the functions serotonin triggers in the body are
those related to happiness and well-being, such as social responses, positive
feelings, natural sleep patterns, and sexual responses.

Low levels of serotonin, therefore, have been linked to mental disorders
associated with feelings of depression and anxiety. Having too little serotonin is
also believed to be linked to migraine headaches, as the great author Joan
Didion describes in one of her essays, “In bed,” published in her collection The
White Album. (This essay is definitely recommended reading for anyone
suffering from anxiety and panic attacks, as the symptoms are very similar to
the experience Didion describes when treating of her own lifelong struggle with
recurring migraine headaches.)

Again, it is important to understand that serotonin is not simply a “happiness”
chemical. While low levels of it are linked to anxiety and depression, these
conditions cannot be simply treated by infusing large amounts of serotonin into
the body, and antidepressant medications operate in far more complex ways
than that. As we saw above, the important thing in neurochemistry is
maintaining a balance between the various chemicals our brains need to
function. Too much or too little of any can cause serious mental disturbances.
As the great American author Jack London once wrote, in words that still ring
true a century later, speaking of the “laws of organic chemistry” in the body:
“One pays according to an iron schedule—for every strength the balanced
weakness; for every high a corresponding low.”

***

Understanding these and other potential causes of anxiety can be helpful in
deepening your awareness of what is happening inside your mind. At the end of
the day, however, the causes of anxiety are a lot less important than what we can
do about it in the future. Always remember: regardless of where a particular
person’s anxiety came from, or how it started, many of the same methods for
treating and managing anxiety will still apply.

In the earlier days of the practice of clinical psychology, psychotherapists often
devoted much more attention to discovering where particular mental
disturbances came from, and how they originated in a given person’s case (in
medical terms, this is known as the etiology of an illness). Influenced by
Freudian psychoanalysis, many earlier practitioners of psychotherapy believed
that it was important to isolate particular triggering events or symbols in a
person’s past that first induced them to develop a mental disorder (or neurosis, in
Freudian terms).

Over time, however, these methods bore little fruit. Modern clinical experience
has shown that tracing mental illnesses back to earlier events in a person’s
biography often has little impact on their ability to recover from them in the
present. Human memory, moreover, is extremely malleable, meaning it is
subject to change, and the events of one’s past do not determine one’s present
and future.

Finally, dwelling on earlier occurrences can even be counter-productive; as it
can lead to people feeling trapped by the past and can reinforce the memory of
traumatic events.

Meanwhile, modern clinical practice has often shown that enormous progress
can be made even when a patient has no knowledge of any earlier event that
could have led to symptoms of anxiety, panic, or related phenomena.

Contemporary psychotherapists are therefore a lot less concerned with a person’s
past than they are with the future. Modern-day professionals do not go looking
for “recovered memories” through hypnosis; nor do they interpret dreams or
sexual symbols from a person’s childhood, or look for “archetypes” in a
supposed “collective unconscious.” Indeed, many clinical psychologists today
would consider those practices to be forms of pseudoscience.

Many of the clichés associated with mental health professionals in our popular
culture, in other words, are badly out of date.

Contemporary clinical psychology focuses on how people can get well in the
here and now. In particular, it is interested in how people can alter their thought
processes and behavioral patterns in ways that help them achieve greater
happiness, freedom, and autonomy in their daily lives. Many of the methods
used most often by psychotherapists today fall under the heading of cognitive
behavioral therapy, which we will discuss more fully in subsequent chapters.
 Chapter 3: What is a Panic Attack?

In technical term used by most mental health practitioners – and found in such
important reference works as the Diagnostic and Statistical Manual of Mental
Disorders, or DSM – anxiety, and panic disorder are distinct. Specifically, panic
disorder is one particular form of a variety of conditions that fall under the
heading of anxiety disorders.

As we saw above, however, the various forms of anxiety disorder often overlap
and can bleed into one another. A person may experience a specific phobia or
fear – such as a fear of dying, social phobia (a fear of being on display, of
making a fool of oneself, etc.), fear of losing control of their actions, etc. –
which causes them to experience a panic attack in a particular situation. They
then become afraid of having another panic attack, and so they start to engage in
avoidant behaviors so as to escape the kinds of situations that originally
provoked the attack.

Having an occasional panic attack in the course of your life is not necessarily a
sign of a disorder or a larger problem. Moreover, it is completely normal to
experience times of fear, anxiety about the future, and stress in the ordinary
course of living. If panic attacks are becoming a recurrent feature of your life,
however, and if you are engaging in behaviors to avoid them that are preventing
you from living your life fully or are blocking you from the things you would
like to do, then it might be time to seek help from a therapist or other mental
health professional.

Why Do I Get Panic Attacks?

In the case of anxiety disorders in general, the reasons why some people and not
others develop panic disorders are not easy to pin down. Your panic attacks may
be related to other anxiety or depression-related disorders; if you suffer from
PTSD, these attacks may have been triggered by a past traumatic event; they
may be the result of genetic factors or elements of your current lifestyle; they
may be due to nothing more than your individual personality traits.

Prolonged stress of any kind has been linked to panic disorder, and it is
important to understand what I mean by “stress” in a therapeutic context. Many
of us refer to being “stressed out” loosely in contexts where we are working hard
and feel very busy.

What stress really is, however, is not just a sense of putting in a lot of effort at
something, but the sense that something in our lives is beyond our control. When
people spend large parts of their lives without a sense of basic control over what
is happening to them, this can lead to what physicians call toxic stress. This can
be very bad for your overall mental wellbeing because it holds the brain in a
state of constant “fight or flight” response and prevents you from performing the
other cognitive tasks that are essential to higher functioning and human
happiness. (For this reason, children who experience poverty, hunger, abuse, or
other forms of deprivation often have a harder time concentrating at school than
their peers, and may fall behind their classmates, compounding the other
difficulties they face.)

Prolonged or toxic levels of stress may be caused by poverty or financial
difficulties, conflict or instability in core interpersonal relationships, abusive or
controlling partners or ex-partners, unhealthy and exploitative work
environments, and similar situations in which we feel we are losing control of
our lives.

If you are living in one of these situations and are experiencing panic attacks, the
two may be linked, and extricating yourself from the situation in which you feel
powerless can help relieve anxiety and your panic symptoms. Seeking outside
help can be very useful in reasserting control over your life and thereby reducing
your anxiety. Therapists can oftentimes help you navigate, leaving unhealthy or
abusive relationships, and friends, family, social workers, and others can be
helpful in changing jobs and achieving greater financial independence.

At the physical level, one common cause of panic attacks is hyperventilation.
Many people associate this state with overly rapid breathing. People who are
hyperventilating feel as if they cannot get enough oxygen, and so they breathe
excessively, taking in very rapid and deep breaths.

What is actually happening in your body during hyperventilation is just the
opposite of a lack of oxygen. You actually have healthy and normal oxygen
levels, but because you are breathing so rapidly, you are expelling carbon
dioxide at a rate faster than your body can take it in. This leads to a feeling that
you “don’t have enough air,” so people breathe even more rapidly, which
exacerbates the problem. These feelings of being “unable to breathe” are closely
related to other symptoms of panic, as we saw above.

In Chapter 6, we will discover simple techniques of breath control that can help
immediately mitigate hyperventilation when you are experiencing it.

Regardless of the cause of your panic attacks, though, it is important to keep in
mind that none of these things is your “fault.” And remember as well that – just
as we saw with anxiety above – the specific cause of your panic may turn out to
be irrelevant to how you are ultimately able to treat it. No matter the origin or
etiology of your panic, many of the same methods and strategies for managing
and overcoming it will still apply.

How Can I Tell if I am Having a Panic Attack?

Panic attacks are a vivid experience, and those who suffer from them often come
to recognize their symptoms over time. Some of these symptoms are physical.
The most recent edition of the DSM, mentioned above, lists some of the bodily
feelings or sensations that often accompany a panic attack. Monitoring your own
body for these reactions may be one helpful way to tell if you are experiencing
panic:

1) Racing or pounding heartbeat (otherwise known as palpitations)
2) Tingling in the arms and legs, hands and feet, etc.
3) Sweating, shaking, trembling
4) Feelings of shortness of breath, choking
5) Fear of losing control or losing one’s sanity
 6) Fear of dying
7) Dizziness, nausea, discomfort or pain in the chest

Oftentimes people struggle to identify what they are experiencing as a panic
attack, however – especially the first time they go through one – because panic
attacks do not just “happen” to you. They do not fall out of the blue. Rather, they
are connected to escalating or “cascading” thoughts of fear. Many people who
experience panic attacks describe a sensation of the “floor falling out from under
them,” metaphorically speaking. As their thoughts seek grounding in a feeling of
safety, that is to say, their panic keeps thinking up ways in which that safety is
imperfect, and in which they might still be in danger.

To see how this happens, it might be helpful to look at some examples of the
kinds of thought patterns that characterize a panic attack episode and to see how
panic can originate and escalate from other fears, or other kinds of anxiety
disorder. If you have experienced a panic attack yourself, the chances are that
one or more of these thought patterns will seem familiar to you.

1.) Fear of Dying.

Most people dislike the thought that they or their loved ones will one day die,
and some degree of fear of death is a normal part of life. Indeed, the plot of the
classic novel White Noise, by the author of Don DeLillo, deals in depth with the
question of whether being afraid of dying is a normal reaction to the fact of
mortality, or a sign of mental illness, after a mysterious new drug is placed on
the market that promises to be able to “cure the fear of death.”

When we discuss “fear of dying” in the context of panic disorder and panic
attacks, however, we do not mean the kind of discomfort with the idea of death
than many – if not most – people will experience in the course of their lives.
Rather, we mean fear of dying right now, as if one’s body is going to simply up
and quit on one as soon as one thinks of the possibility.

A typical panic attack thought pattern for a person experiencing this fear might
go like this:

It’s amazing that my heart keeps beating on its own, without my having to do
anything to help it along. How would it feel if it just stopped one day? How
painful is a heart attack? What would a heart attack feel like? How can people
tell if a heart attack is coming or not? How do I know I’m not about to have a
heart attack right now? What if it’s just seconds away? I wouldn’t be able to do
anything to stop it. How would I get to the hospital if one happened? Is my
cellphone on? Is it working? Am I in range of a cell tower? If I really had a
heart attack right now, would I be able to dial the phone? Or is it too painful
and sudden for me to do anything at all? How quickly do people die after they
first start to have a heart attack? Is there anyone else here who would be able to
call the hospital for me? Who do I trust to do that?

Before they know it, the person thinking these thoughts is experiencing a
pounding heart, sweaty palms, and all the rest of it. They are in the midst of a
full-on panic attack.

Hopefully, this hypothetical example helps us to see why panic attacks can seem
to “sneak up” on one. The person thinking these thoughts doesn’t say to
themselves, “I’m having a panic attack.” Rather, they are going through an
escalating or cascading sequence of anxious cognition – in other words, a
thought process – linking together ideas that make them feel increasingly less
safe. Before they know it, they are panicking.

This example may also enable us to see why panic tends to become associated
with avoidant behaviors. The person who has experienced this frightening
sequence of thoughts might start to try to avoid situations in which they fear they
would be unable to contact a hospital if they had an unexpected heart attack.
They may avoid camping trips with their families because they do not want to be
out of range of a cell tower. They may avoid social settings with unfamiliar
people because they are afraid that if they were to have a heart attack in front of
people that they do not know and trust, no one would come to their aid, no one
would call an ambulance, etc.

Pretty soon, that person’s panic attack has limited the range of things they are
able to do with their time, and that person is no longer living the full life they
would like to live. They are confined to familiar people, familiar settings, cities
and urban areas, and a whole range of the human experience and the natural
environment has become “off limits” to them. And all because of a panic attack.
This is the kind of power that panic disorder can start to exert in one’s life.

Oftentimes, a panic event related to fear of death may be associated with – or
triggered by – sensations within their body that people associate with danger.
One example would be a heart arrhythmia – or a sudden change in one’s
heartbeat or pulse, which people associate with a feeling that one’s heart has
“skipped a beat.” While arrhythmias can in some cases be signs of heart disease
or other cardiac problems, they are also entirely normal and can be the result of
things that are far less frightening and dangerous. For instance, sometimes
failing to get enough sleep the night before can lead to an experience of
arrhythmia. Drinking a lot of coffee or other caffeinated beverage can lead to it
as well. Even eating a lot of potassium has been associated with the arrhythmia
sensation.

So, if your heart misses a beat, it does not at all necessarily mean you are in
danger. It might just mean that you recently ate a banana!

Nonetheless, for people suffering from panic disorder and panic attacks, this
commonplace and perfectly safe phenomenon of a mild arrhythmia can trigger
very frightening thoughts of heart failure, which can lead in turn to another panic
attack.

Along similar lines, people with panic disorder may start to fear that their panic
itself will lead to a heart attack. In this way, they start to fear that their panic
attack will be the cause of their deaths. This causes more avoidant behavior, as
people try to minimize the possibility of ever having a panic attack. (We will
examine a hypothetical case history involving this fear in Chapter 4).
Oftentimes, people start to panic about the possibility of panicking, and so cause
the very thing they were afraid of.

The important thing to remember is that, as we said above, panic attacks are not
dangerous. While they are distressing and uncomfortable, and often frightening,
they will not themselves cause physical harm to your body. Both your heart and
your psychological fear response evolved over time to serve the same function:
namely, to keep you alive. They will not quit on you, and they will not turn on
one another.

Likewise, if you experience an arrhythmia, it can’t be a bad idea to consult a
nurse or doctor about it, but you can also remind yourself that arrhythmias are
normal and are often related to other physical causes that are not dangerous in
themselves.

A famous person who reported that he is often suffering from sensations of
arrhythmia throughout his life was the Nobel Prize-winning author Samuel
Beckett. And he lived to the ripe old age of 83! So, experiencing an arrhythmia
doesn’t necessarily mean you are in poor health or in any danger. And who
knows, maybe in Beckett’s case it contributes to the sense of morbid brooding in
his works to which the Nobel Committee responded. Not only might the
sensation not be bad for you-you might even get a literary prize out of it.

Another important thing to do, in the midst of these fears, is to think back to all
the times in your life in which your heart and lungs had gone on keeping you
alive when you weren’t even thinking about them. Starting to think about them,
or having a panic attack about them, will not lead these organs to stop
functioning now.

Even people with chronic panic or other anxiety disorders are not thinking about
the possibility of dying all the time. And yet, all the time when they aren’t
thinking about it, their organs and bodies go on keeping them alive. Many
people with panic disorder describe times of the day when they never think
about the possibility of panicking or of dying at all, and in which they feel fine.
For many, early mornings are often happier times of day than late at night, when
many describe panic symptoms as being at their worst.

This change of the intensity of panic or anxiety symptoms over the course of the
day is related to the neurochemical aspects of panic and anxiety disorders, which
we discuss elsewhere in this book. Even before the dawn of modern
neuroscience, however, it is interesting to note that some writers intuitively
grasped the way in which panic disorders function.

The great 19th and early-20th-century writer M.R. James, for instance, writes in
one of his stories about a man experiencing something that we would probably
now identify as a panic disorder. At night, he tells us, this man often suffers from
exactly the “fear of dying” we discussed above. Yet, with the arrival of the
dawn, it vanishes. Describing this character lying in bed at night, James writes:

Awake he remained, in any case, long enough to fancy (as I am afraid I often do
myself under such conditions) that he was the victim of all manner of fatal
disorders: he would lie counting the beats of his heart, convinced that it was
going to stop work every moment, and would entertain grave suspicions of his
lungs, brain, liver, etc.—suspicions which he was sure would be dispelled by the
return of daylight, but which until then refused to be put aside.

Perhaps many of us can relate to James’ character. After all, as we have seen
above, anxiety is not an unusual condition. Also, it is not a modern one. People
from as far back as James’ day experienced similar symptoms, even if they did
not have the same vocabulary to describe them.

Before turning to other matters, however, let us see a few more examples of the
typical thought patterns associated with panic attacks connected to other fears.

2.) Fear of Going Insane.

The great British poet of World War I, Siegfried Sassoon, once wrote a poem
about his wartime experience that described symptoms we would now recognize
as a form of anxiety or panic disorder.

Indeed, when soldiers returned from fighting in the trenches in World War I,
many reported a common psychological experience of having intense fear
reactions to visual and auditory stimuli that reminded them of their experiences
in the war. This reaction came to be known as “shell shock.” It was the first
publicly-recognized and acknowledged the form of what we would now call
post-traumatic stress disorder – a form of psychological disturbance (as we saw
above) linked to a traumatic personal experience, and which is ignited by certain
triggers that put one in mind of the original traumatic event.

Sassoon’s poem – called “Repression of War Experience” -- uses the first-person
narration to vividly describe the experience of “shell shock.” Writes Sassoon:

No, no, not that, it's bad to think of war,
When thoughts you've gagged all day come back to scare you;
And it's been proved that soldiers don't go mad
Unless they lose control of ugly thoughts
That drives them out to jabber among the trees.

Sassoon offers here an excellent example of the way in which the fear of “going
crazy” can be linked to a panic attack. A person suffering from this thought
pattern thinks to themselves that they can prevent themselves from panicking so
long as they avoid certain thoughts. But then, as they think about trying to avoid
these thoughts, this brings these thoughts back to the forefront of their minds.
They then panic, because they feel they are losing control of their ability to
prevent themselves from thinking about these things. These fuels fear that they
are losing control over their minds entirely – in other words, that they are going
insane.

This example also helpfully illustrates why avoidant responses to panic attacks
are often counter-productive. As anyone who has ever played the game “Don’t
think of an elephant” can tell you, reminding oneself not to think of a specific
thing will only succeed in bringing that thing to mind. If you say to someone
“don’t think of an elephant,” the very first thing they picture will, of course, be
an elephant.

This is why we – and the poet – both know that the soldier is going about things
the wrong way. By trying to force himself not to think about the war, he will
only think about it more, fueling his sense that he is – as he puts it “los[ing]
control of ugly thoughts.” In other words, he is going crazy.

As we will be discussing in more detail later on in this book, the more effective
way for the soldier to combat his panic – and the thought processes associated
with it -- would simply be to allow it to happen. In this sense, the type of thought
pattern associated with a panic attack is very similar in nature to what is known
as rumination, and which tends to be associated with depression.


Good to Know: Similarities and Difference between Depression and
Anxiety

Depression and anxiety are not the same things. Indeed, they can often seem
like polar opposites. Anxiety and panic are associated with rapid breathing,
sweaty palms, and feelings of being tense and on-edge. Depression, by contrast,
often leaves people feeling listless, fatigued, and bored. In its extreme forms,
depression can even make people catatonic, meaning they are virtually unable
to move.

At the neurochemical level, however, depression and anxiety are closely related,
and many people who experience anxiety and panic also report going through
periods of depression. In clinical parlance, this is referred to as comorbidity,
which means that one of these disorders is often present alongside the other. In
this sense, anxiety and depression can often seem less like opposites than like
two sides of the same coin.

Another important similarity between the two conditions – anxiety and
depression – relates to the thought processes that tend to be associated with
them. As we have seen, anxiety tends to produce feelings of escalating panic.
People feel as if they are “realizing” they are in danger and are able to
continually come up with new reasons why they are unsafe. These new thoughts
about ways in which they might be in danger are unwelcome. People with these
thoughts would go away, but the more they think about trying to get rid of them,
the more prevalent and inescapable these thoughts seem to become.

People with depression often experience something similar. In their case, their
depression is often fueled by repetitive, unwelcome thought patterns. People
with depression describe feeling as if they were “stuck in a loop,” or as if their
thoughts cannot get out of a single “rut.” As with the examples of panic
thoughts we have seen above, depressive thoughts often seem to escalate and to
build on one another, as if they followed logically from one another and each
one reinforced the other.

This process is known as rumination, which comes from a Latin root word
which literally meant to “chew” (this is why large mammals that primarily get
their nutrients through grazing are technically referred to as “ruminants”). For
people with depression, the idea that rumination comes from the word “to
chew” makes a lot of sense. People who ruminate often feel as if they are forced
to “chew over” the same mealy thoughts time and again, never making any
progress with them.

An example of a rumination thought process might go like this:

I’m so tired; I don’t want to get out of bed. Why am I always so tired? No one
else seems to have this problem. It’s my depression again. It must be back. It
seems to be getting worse. Why am I like this? I must have been born this way.
No one else I know has this problem. And it never seems to get better. I’m
going to have this depression until the day I die. All I can do is lie here and
hope it goes away. Which it never will.

And so forth. We can see from this example the way in which depressive
thoughts often trap people into experiencing the very thing they are afraid will
happen. What begins in this example as a very normal experience that nearly
everyone in the world goes through sometimes – the experience of being tired in
the morning and not wanting to get out of bed – is used to fuel a downward
spiral of depressive thoughts.

Panic attacks, as we have seen, operate in much the same way (except, if
depressive rumination spirals down, metaphorically speaking, panic thoughts
seem to spiral up – into greater and greater intensities). Oftentimes, panic
attacks begin from mild feelings of anxiety that are a normal part of life. Many
people feel discomfort before public speaking or going to a party with strangers,
for example. To feel anxious about these things is normal and not a sign of any
mental disturbance. Panic attacks build on these ordinary feelings to trigger a
fear of panic. The sense that one might have a panic attack – and that one is
prone to panic attacks – often turn this very fear into a reality.

Let us examine a few other examples of hypothetical panic thought processes to
see how this is so.

3.) Social anxiety – or Social Phobia

As mentioned above, some degree of anxiety or trepidation about meeting new
people, speaking in front of others, etc. is a normal part of life. Indeed, social
anxiety may be becoming more prevalent in our society, due to the rise of social
media and the fact that most people maintain multiple public personas or public
“selves.” If social anxiety stems from a fear of being “on display,” or a sense
that one might be judged, ridiculed, humiliated, or shamed in front of others,
then it is no small wonder that the feeling may be increasing in a society in
which so many of us are literally “on [computer] displays” all the time.

For this reason, many contemporary psychologists believe that excessive worry
about and overthinking of social interactions is one of the key drivers of
psychological distress in the modern era.

That said, social anxiety comes in degrees, and when it is blocking you from
engaging in social interactions in which you would otherwise like to participate,
that is a good sign your anxiety may have crossed the line into becoming an
outright psychological disorder.

A panic attack thought process linked to social anxiety might take a form like
this:

I don’t want to go to this party. If I do, I might have a panic attack. It would be
so embarrassing. Everyone would think I was a freak. I’d have to explain. I
might panic so bad during the attack that I throw up in front of everyone. That
would be so humiliating. I have to bring along my Xanax. But how will I be able
to take it in time, if I start panicking? How do I know it will act fast enough to
stop the panic attack? What if I take it and it makes me sick? Then I’d throw up
in front of everybody! What if I throw it up before it has a chance to start
working? Then I’d have to deal with the embarrassment of throwing up at a
party, and I would still be panicking, and the Xanax wouldn’t work. I might be
panicking forever. Who’s to say I would ever stop? Why should I?

As we saw in the author’s own experience, described in Chapter 1, fear of losing
control over one’s bodily responses is often associated with social anxiety. One
may be afraid that one will be unable to prevent oneself from throwing up or that
one will lose control of one’s bowels or other digestive functions in front of
others. Finally, fear of fainting, of passing out, or of going unconscious is
another manifestation of the fear of losing control of one’s body and thereby
“embarrassing” oneself in front of others.

If one starts to associate this danger with panicking specifically – that is to say, if
one starts to be afraid of panic itself because it might lead one to lose control of
one’s bodily responses, then the fear of panic can often bring on panic itself.

Some important things to remember when one is experiencing social anxiety of
this sort include:
Your panic is not visible to others. While it is happening inside you, a
panic attack often feels like it is the most important thing in the world.
That does not mean, however, that anyone else can see it. Just remember
that panic does not have the power to change your behavior or make you
do things you don’t want to do. Many people who experience panic attacks
report that no one ever notices that it is happening to them.
Panic is not associated with loss of bodily control. Panic will not force
you to lose muscle control of your bowels, force you to pass gas in
inappropriate situations, force you to vomit, etc. It is true that when and
where we vomit is often not really in our control, which is why it can be a
frightening thing for people with panic disorder and social anxiety. In
technical terms, vomiting is part of the autonomic nervous system, which
means the part of our bodily responses that operate as reflexes, without
conscious thought. (Other bodily responses that are part of the autonomic
system include breathing, the heart-beat, sneezing, the gag reflex, passing
out, etc.) For this very reason, however, vomiting essentially “just
happens.” While it may be slightly socially embarrassing, it is not
preceded by a long build-up of anxiety in which one worries about the
possibility that one might throw up. If you struggle with a fear of
vomiting, just think back to the last time you actually did vomit, and ask
yourself: did it happen at a time when you were particularly afraid you
might vomit or did it happen when you were hardly thinking about the
possibility? Chances are it was the latter.
Remember that other people are not as focused on you as you are on
yourself. People with social anxiety are hyper-attuned to their own
behavior and responses. Just remember that no one else is paying that kind
of close attention and scrutiny to you. One exercise that people have found
helpful in dealing with social anxiety is to attempt to focus one’s attention
on the other people in the room. Scrutinize the minute details of their
appearance and behavior. Once you are thinking about them, you will stop
thinking so much about your own role in the situation.
If you did throw up or pass out in front of other people, it might not
be as scary as you imagined it would be. With a great many of the fears
that people endure, it is often the case that anticipatory anxiety is far worse
than the fear they experience at the moment (this is the “Samuel Butler
principle” again). Many people who suffer from extreme fears of the
possibility of vomiting often describe having almost no fear reaction at all
on the rare occasions when they do actually throw up (because of course
they don’t – they are too busy throwing up!). So too, if people really faint
or pass out, this will be a process beyond their control, and they will not be
conscious of any discomfort or embarrassment while it is happening.
Finally, most people in social situations don’t actually respond in the ways
we fear they will, even if we do have a bodily response we can’t control.
When someone throws up or passes out around us, most of us respond
with sympathy, trying to help the person who is sick and contacting health
professionals to make sure they get the help they need. We do not stand
 around passing judgment.

4.) Claustrophobia – or Fear of Enclosed Spaces

Sometimes claustrophobia may be associated with a specific kind of enclosed
space – such as an airplane, a subway car, or an elevator. In other instances, a
person may be afraid of finding themselves in any of these places or other,
similarly enclosed spaces.

From the outside, such fears can often appear to people as “irrational.” Those
who do not experience anxiety disorders themselves will often try to “talk people
out of it.” They may remind the person with anxiety that flying is actually the
safest way to travel; that the accident rate on elevators is extremely low and that
modern elevators have fail-safe mechanisms build into them which would
prevent the elevator car from ever falling or losing control for long distances.
They may ask: when was the last time you ever heard of someone being hurt on
the subway? They may remind people of all the millions of people who
commute to work every single day and back on the subway and who are never
harmed.

All of these things are true. What the person making these arguments needs to
understand, however, is that panic attacks do not follow an “irrational” structure.
They often follow a logical structure, in which each fear follows directly from
the one that preceded it. Moreover, people with anxiety are often not afraid only
that they will be harmed directly by entering one of the enclosed spaces they
fear. They are also afraid of what their own emotional reaction may be once they
are in that enclosed space, and of what it may cause them to do.

Someone who is afraid of subway cars, for example, may understand at an
intellectual level that other people ride subway cars every day without being
harmed and that the chances of being hurt on the subway are very low. They
may be afraid, though, that once they are on the subway, they will panic and lose
control of their emotions, and that this may lead them to jump out of the subway
at the wrong time, fail to notice an oncoming train, etc.

Understanding these thought processes can help us respond with greater empathy
when we encounter someone struggling with feelings of claustrophobia.

5.) Agoraphobia – or Fear of Open, Public Spaces

As the opposite of claustrophobia, agoraphobia is the fear of open, public spaces
(the word comes from the Greek term agora, referring to the area at the center of
the ancient Greek polis, or city-state, in which assemblies and other public
business were conducted). Paradoxically, however, many people who suffer
from claustrophobia may also experience agoraphobia in certain circumstances.

As with claustrophobia above, many people who do not suffer from this fear
may find it hard to relate to or empathize with. Why would open spaces be
scary? And how could someone who dislikes closed spaces be no less afraid of
open, public ones?

Once again, however, it is important to understand that a person experiencing an
agoraphobic panic response is often motivated by a thought process that presents
itself to them as fully rational and logical. People are often not afraid of the open
space itself, but of what they fear may happen to them within it.

Here is an example of an agoraphobic thought process that might underlie a
panic attack in a public area or an open space – perhaps while a person is
walking someplace outdoors:

I’m fairly far from home out here. If I had a panic attack out here, it would be a
really long time before I could get home. If the panic attack was really bad, I’m
not sure how I’d get myself home at all. I’m not sure I could walk that far. How
long would I be stuck out here? Would anyone find me? I have to make sure I
brought my Xanax with me. Yes, I did, good. What if it doesn’t work this time…
And so on.
6.) Separation anxiety

This is one form of anxiety disorder that is most prevalent among children and is
associated with a particular stage of developmental psychology. As most experts
in child psychology have long recognized, children go through a crucial stage of
bonding with adult caregivers in their lives, which has been described as the
attachment phase. As early developmental psychologist Erik Erikson put it, this
is the stage of a child’s life in which they need to develop a sense of “basic
trust.” Having this sense of basic trust is crucial to all later stages of
development that children – and adults – undergo.

Separation anxiety reflects an excessive fear of the loss of attachment that
reflects the instability of the “basic trust” that children are ideally in the process
of developing. Oftentimes, a child will experience an intense fear of even short
periods of separation from their adult caregivers. As with all anxiety disorders,
this excessive fear is not necessarily related to any external event. Some anxiety
is simply caused by specific personality traits or chemical imbalances that are
unique to each person, and which cannot be “blamed” on any outside action or
occurrence.

In other cases, however, separation anxiety has been found to be triggered by
actual events that interrupt the development of a child’s healthy sense of “basic
trust.” Sometimes, these events involve actual periods of involuntary separation
from a child’s adult caregivers, which breaks the bonds of attachment that a
child is forming at the very developmental stage at which these bonds are most
vulnerable and most essential to the child’s healthy psychological growth.

For this reason, many childcare experts regard public policies that result in the
separation of children from their adult caregivers as particularly heinous abuses
of human rights. Such policies include the practice of separating immigrant
children from their parents that occurred at the U.S.-Mexico border during the
spring and summer of 2018, as well as practices in many immigration detentions
and prison facilities in the United States that result in the temporary removal of
newborn children from their mothers while their mothers are in confinement.

Good to know: The “Logic” of Panic and Anxiety

Children and adults respond very differently to anxiety, and as a result,
recognizing the symptoms of anxiety or panic disorder in each age group will
require looking for different things. Children often respond to separation anxiety
and similar disorders through abrupt behavior changes or outbursts that are not
consciously examined.

Adults, by contrast, often report just the opposite. For adults, as we have seen,
anxiety and panic take the form of highly “logical” thought processes that
unfold in a graded series of stages. These stages escalate or “cascade” into
increasingly frightening thoughts – often very rapidly. Many people with
anxiety, depression, or kindred syndromes report feeling as if they were
“thinking too much,” and over-thinking their lives. As we saw in the case of
Sassoon’s soldier, it was “ugly thoughts” that he believed were the source of his
doom.

An older term for this kind of thought process is ratiocination. In medieval and
early modern literature, writers tended to associate anxiety and depression with
one another, placing both under the heading of the generalized disorder
melancholy. Moreover, writers from these earlier periods also associated
melancholy with ratiocination, meaning orderly and logical processes of
thought. What is strange about this is that anxiety and depression are also a form
of mental illness, and therefore tend to be seen as quintessentially irrational and
illogical.

The 19th Scottish poet James Thomson – the author of one of the most profound
works of literature ever penned on the topic of depression and anxiety, called
“The City of Dreadful Night” – captures the paradox of this situation perfectly:

They are the most rational and yet insane: ⁠
And outward madness not to be controlled;
A perfect reason in the central brain,
Which has no power, but sitteth wan and cold,
And sees the madness, and foresees as plainly
The ruin in its path, and trieth vainly ⁠
To cheat itself, refusing to behold.

Expressing a similar thought, the great poet Sor Juana Inés de la Cruz – a
cloistered nun who lived and wrote in Mexico during the 1600s – once
addressed a poem to “Melancholy Thought.” In the poem, she argues with her
own melancholy, expressing the wish that she could stop overthinking her
problems. To use our contemporary language, Sor Juana is expressing the hope
that she might be able to stop ruminating. She writes:

"Let my understanding at times/allow me rest a while,/ and let my wits not
always be/ opposed to my own advantage/ [...] Oh, if there were only a
school/or seminary where they taught/ classes in how not to know/ as they teach
classes in knowing." (Translation by Edith Grossman).

Toward the end of Thomson’s poem, likewise, he refers to a classic sketch by
the German Renaissance artist and printmaker Albrecht Dürer, which depicts a
seated figure who represents Melancholy embodied. Thomson notes that the
character in Dürer’s painting is surrounded by compasses and other instruments
of “logical” deductive thought – otherwise known as ratiocination.

This shows once again that, as “irrational” as panic and anxiety may seem to
people who have not suffered from these conditions, they have been linked
throughout history – by those who have experienced them – to processes of
logical thought.


Melancholia I by Albrecht Dürer. Source: Wikimedia Commons. This image is in the public domain.

***
We have seen throughout this chapter, that some of the ways in which a simple
thought process can often provoke and undergird a full-scale panic attack. In
Chapter 6 of this book, we will discuss some methods you can use to manage
and overcome these panic attacks – and their associated thought processes –
even in the moment when they are happening.

An important first step before applying these methods, however, is simply to
learn how to recognize a panic attack for what it is. This can go a long way in
itself toward helping you to calm down and manage your panic response.

After all, we’ve seen throughout the examples in this chapter that panic often
doesn’t present itself to our minds as what it is. It disguises itself. It appears first
to us as simply a “logical” consequence of another fear. Therefore, the first few
times we panic, we do not think we are experiencing a new physical reaction we
have never undergone before, we simply think that we have “realized”
something frightening about the world or about our own lack of safety within it
that we never noticed before.

Learning to recognize panic attacks for what they are can, therefore, go a long
way toward reducing their effects. You can start to understand that you have not
“realized” any scary new truths that you did not know before, you are simply
undergoing a common experience of a panic attack.
There is an amusing passage by the British novelist Kingsley Amis on this
subject. Amis was writing at the time about his strategies for recovering from a
hangover, after a binge of nighttime drinking, but if you replace the word
“hangover” in this passage with “panic attack,” it reveals a profound truth that is
very helpful to mitigating the effects of panic. Amis advises us to remind
ourselves when recovering from a hangover:

“You are not sickening for anything, […] you have not suffered a minor brain
lesion, you are not all that bad at your job, your family and friends are not
leagued in a conspiracy of barely maintained silence about what a [s***] you
are, you have not come at last to see life as it really is[….] What you have is a
hangover. [And, h]e who truly believes he has a hangover has no hangover."

By the same token, perhaps after reading this chapter, you will be able to tell
yourself, next time you are panicking: I have not come to realize the truth about
life, I’m just panicking. And the person who knows they are just panicking will
not panic.




 Chapter 4: Why Panic Attacks Tend to Become
Chronic

The previous chapters have illustrated for us how panic attacks often become
self-reinforcing. To go through a panic event is often a frightening enough
experience in itself that people begin to organize their “cascading” panic thought
processes around the fear of panic itself. As we saw in the examples in the
previous chapter, the possibility of experiencing a panic attack can often become
the basis for a variety of other fears and avoidant behaviors, such as social
phobia, claustrophobia, agoraphobia, etc.

What may be less immediately clear, however, is why people’s efforts to avoid
panic attacks or the situations that cause them often leads to more panic attacks
in the future.

In order to see how this process works, it may be helpful to look at a
hypothetical case history.

Case History: Sarah

Sarah is a young woman in her early twenties. She has just finished college and
has decided to drive back home to her parents, who live on the other side of the
country. She plans to spend the summer with them and try to decide what she
wants to do next with her life.

The drive will take her two days, but she is feeling so anxious to get home and
so tired of driving that she contemplates trying to just drive straight through the
night without stopping. At 9 PM, therefore, she pulls over into a coffee shop and
orders a coffee, to try to keep herself awake on the road over the course of the
night.

While driving later that night, she feels a sudden muscular clenching in her
chest. It feels like the cliché about a person’s “heart skipping a beat” literally just
happened to her. She pulls over to the side of the road to make sure she is okay.
She feels her pulse and notes that it appears to be back to normal.

The experience frightens her, however, and as she continues driving, she can’t
get it out of her head. She thinks back to something she once overheard a
friend’s parent saying – someone who was a doctor. She had said something
about feeling like she had an arrhythmia and that she needed to go to the hospital
to have it checked out.

The word comes back to Sarah at this moment. Did she just have an arrhythmia?
And if so, was it something serious? Should she go to a hospital to have it
looked at? Her friend’s mom was a doctor, and she had thought it was serious
enough to be considered a medical symptom. Of what though? Of heart disease?
Was that possible, at Sarah’s age?

Sarah starts to run through in her head everything she knows about heart attacks
from her CPR training in college. How quickly do they happen? What are the
signs again that one might be coming on?

She tries to think through what she would do if she suddenly felt the symptoms
of a heart attack. She would have to call someone. She glances down at her cell
phone and realizes there is not much battery left, and there is no place to plug it
in in the car. Would it last long enough? Someone passing in another car would
have to help her. But she’s in the middle of nowhere in the middle of the night,
on an unfamiliar stretch of highway. Who would stop for her? What perfect
stranger would do that?

And if she did have a heart attack while driving, wouldn’t this force her to fly off
the road and crash?

As she keeps thinking these thoughts, her heart starts pounding, and her
breathing becomes more rapid. She decides that it is imperative that she get off
the road and into a hotel right now. Nothing has ever seemed so important. She
literally starts to feel as if her life depended upon it because she realizes she
can’t think of any way she could keep herself perfectly safe if she had a heart
attack while driving the car.

Frantically, she scans each passing sign for an indication of a hotel or motel.
Finally, she spots one on a highway exit. She races in and asks if they have any
vacancies for the night. She is told they are sold out. She already feels safer,
however, just standing in the lobby. If she had a heart attack here, she thinks, at
least the hotel clerk will be able to see it and call an ambulance.

How far are they from a hospital out here, though? Would they be able to get
here in time? And how will she ever convince herself to get in a car again?

Driving the next day is easier, however. For some reason, with the sun shining,
Sarah has a hard time connecting with the intensity of her fears the previous
night.

She has never experienced panic or anxiety before, so she has no reason to think
that what she went through the previous night had any relation to those
disorders. Moreover, all of her fears were “rational.” They were about a real
thing – heart disease – and were triggered by a real experience – an arrhythmia –
so why would she have any reason to think she was experiencing a mental
illness?

Once Sarah gets home, she decides to visit a doctor. Not to talk about anything
related to anxiety, however, but just to talk about her arrhythmia. The doctor
runs an EKG on her chest and says that there is no sign of any heart trouble and
that she is perfectly healthy. The doctor says that many people experience
arrhythmias without these being connected to other illnesses.

Sarah is comforted by this. However, she still can’t shake those disturbing
thoughts she had on the road. It seems to her to be inescapably true that if she
had a heart attack or other health episode in the middle of the highway during
the night, there would be nothing she could do about it – she would be trapped,
and no one would be able to help her.

Isn’t the safe, logical thing to do, therefore, to simply stop driving alone? Why
would anyone drive alone for long distances? Isn't Sarah the rational one, rather
than everyone else?

Sarah decides to give up driving, much to her family’s alarm. Everywhere else
she goes her mind starts performing some quick maneuvers to try to imagine
what she would do if she had a heart attack in that setting. When she and her
parents go out to a restaurant, she keeps trying to imagine to herself who she
would call if this happened.

The most frightening situations for Sarah become those in which she would have
to be out of cell phone range for long periods. She decides she can’t fly
anymore, because if she had a heart attack in mid-air, it would take too long to
land the plane and get her to a hospital. She is aware that they have defibrillator
machines onboard aircraft and that flight attendant is trained to provide medical
first-aid and CPR. But why take the risk?

The next year, Sarah turns down an exciting job that would require her to travel
to places in other parts of the world, because she decides she doesn’t trust other
countries’ health care systems. She recognizes this is probably an unfair attitude.
She is a smart and well-read person and not generally judgmental about other
places and cultures. Again, however, she thinks to herself: Why even take the
risk? Isn’t the most important thing to stay safe? What could be more important
than keeping herself alive?

For Thanksgiving that same year, Sarah’s parents decide to visit her brother,
who lives on the other side of the state. They know that their daughter doesn’t
like to drive, so they plan to drive the van instead, and Sarah sits in the back seat.

As they are going, Sarah keeps plotting out to herself what she would do at each
stage of the trip if she had a heart attack. Here she would call 9-1-1. Here they
could pull over at that exit, where it looks like there’s a clinic or an urgent care
center.

As they get further and further away from home, however, Sarah’s anxiety
becomes more acute. Eventually, they reach a stretch of highway out in a rural
part of the state. Sarah looks down at her phone, and she realizes there is no cell
service out here. She starts to panic. Her heart is racing, and her arms and legs
are tingling. “I’m trapped,” she thinks. “If it happens right here, there will be
nothing I can do about it. I’ll be dead, and that’s that.”

At some previous point in her life, Sarah has heard the term “panic attack.” She
had never connected it to her own experiences before. But now she starts to
wonder if that is what is happening to her. If so, a “panic attack” is way worse
than she ever imagined it could be, she thinks. More than that – she starts to
worry – what if having a panic attack can bring on a heart attack? What if I’m
about to cause the very thing I’m most afraid of?

Soon, Sarah can’t imagine why she could ever have been such a “fool” not to
have thought of these possible dangers. She is astonished that her parents are
able to drive long distances in unfamiliar places without panicking. Don’t they
realize that if something happened, they’d be at the mercy of fate? There’d be
nothing they could do about it?

Sarah can’t imagine doing the things that other people seem to do without effort
or trepidation. She can’t imagine taking planes, flying to other countries, going
on long road trips, or taking jobs that might require any of these things. The
places that feel safe to her are her own room at home and pretty much nowhere
else.


***

We can see from Sarah’s story many of the traits that are common to other forms
of panic disorder. Sarah first begins to experience anxiety in a time of her life –
early adulthood – when the brain is still developing and taking its final shape,
and when a person’s lifestyle is in turmoil. Sarah’s anxiety and panic disorder
are therefore, a new experience for her, which she does not immediately know
how to recognize.

Because driving a car was where her attack first occurred, she comes to associate
panic with this location, and she starts to avoid situations that might force her to
drive. (The same applies to all other situations. A person who first experienced a
panic attack in a supermarket will start to associate buying groceries with
danger, and so forth. Over time, she changes the whole structure of her life to
accommodate this new fear. The panic starts to dictate what kinds of
professional opportunities she can pursue, where she can live, etc.

In short, Sarah has entered a cycle of avoidance that perpetuates and exacerbates
(meaning worsens) the symptoms of panic and anxiety over time. At each stage
of this cycle, she tried to avoid the possibility of ever being in a place where she
is not within reach of a cellphone. Yet she continually realizes, however, that no
matter how “safe” she makes herself, she cannot entirely prevent the possibility
that something bad will happen to her, because she cannot see or control the
future. This, therefore, makes an even wider range of activities seem scary to
her, and the cycle goes on.

As we will return to time and again in this book, the key to breaking this cycle is
to remind ourselves that the future is unknowable. No matter how much we try
to change our lives in order to ward off the possibility of ever putting ourselves
in danger, it remains true that some element of chance and risk is a part of any
human life. The key, therefore, is not to control the future, but to remind
ourselves to stay rooted in the present.

In Sarah’s case, after all, she kept worrying about the possibility that she might
have a heart attack. You could almost forget that during all of this time, she
never had a heart attack or even heart illness. Indeed, her own doctor had
examined her and reassured her that she was perfectly healthy! If she had stayed
rooted in this knowledge, that in the here and now there is nothing wrong with
her body, and she is not having a heart attack and has no reason to think that she
is remotely likely to have a heart attack, then she would be able to ride with her
parents in the car with ease.

***
There is one interesting thing to note in Sarah’s case, that is a recurring theme in
anxiety and panic disorders. Namely, we can see once again that anxiety and
panic often begin from very small causes – minor episodes of discomfort and
unease. In Sarah’s case, her first panic attack is brought on by an arrhythmia,
which as we have seen, are often not dangerous in themselves. So too, panic
attacks can be initiated by minor feelings of light-headedness (leading to the fear
of passing out), nausea (leading to the fear of vomiting) and other feelings of
discomfort that occur in the ordinary course of life, and which are often no signs
of any greater problem.

Because they come to associate their panic with these everyday occurrences,
however, people with anxiety or panic disorders often start to fear that the
slightest physical discomfort is a sign of an approaching panic attack.

It is important to remember, therefore, that discomfort – while it is no one’s
favorite thing – is a perfectly normal part of life. You can expect to feel a certain
amount of anxiety, stress, physical tension, etc. in the course of your life, and it
does not mean you are about to panic or do anything against your will. (Most
people dislike long plane trips and long car rides, for example. If you feel a
certain amount of trepidation before going on one, this does not mean it is a
“sign” that you are about to have a panic attack or an anxiety episode).

In her memoir, Wishful Drinking, the great actress and writer Carrie Fisher –
best known for playing Princess Leia in the Star Wars movies, and for her novel-
cum-screenplay Postcards from the Edge – tells an amusing story about how
coming to this realization helped her overcome her struggles with alcoholism
and drug addiction. The insights she learned here apply just as well to people
working to manage and overcome their anxiety.

In detailing her efforts to join Alcoholics Anonymous (AA), Fisher notes that at
first the hardest part for her was simply getting herself to AA meetings because
she did not like going to them. Eventually, however, her sponsor in the program
told her something important. He told her that she “didn’t have to like going to
[the AA meetings], [she] just had to go to them,” in Fisher’s words. “Well this
was a revelation to me,” she then proceeds to tell us. “I thought I had to like
everything I did. […] But if what this person told me were true, then I didn’t
have to actually be comfortable all the time. If I could, in fact, learn to
experience a quota of discomfort, it would be awesome news.”

“Learning to experience a quota of discomfort” is key to overcoming anxiety and
panic as well. If you experience fear, anxiety, or similar emotions, it does not
mean these emotions are bound to escalate in an uncontrollable way. Discomfort
is a part of life. The important thing is to continually draw yourself back to the
things that give you joy, even in the midst of the inevitable discomforts.

 Chapter 5: How to Overcome Anxiety and Panic?

The most effective method of treating anxiety disorders is known as cognitive
behavioral therapy. This is the method recommended by the American
Psychiatric Association, and of all the tactics people have tried over the years to
combat anxiety, this is the one with the longest proven track record of success.

As the name implies, cognitive behavioral therapy is a method of treatment that
focuses on the way in which thought processes (i.e., cognition) and patterns of
behavior influence one another. As we have seen above, people who suffer from
anxiety and panic often exaggerate the power of their thoughts to influence their
behavior. We have seen that people with panic often experience a fear that the
severity of their panic feelings will “force” them to do something against their
will – such as harming themselves. In reality, emotions do not have this kind of
power to control our behavior, and the emotion of fear, in particular, will not
force a person to do the thing they are afraid of.

On the reverse side, people with anxiety and panic disorder often tend to
downplay the power that behavior has to influence our patterns of thinking.
After all, the things that happen inside our heads feel like they are “purely
mental.” We don’t intuitively sense that they are connected to the physical world
or to our own actions and behavior, and therefore, we can’t imagine how
changing our behavior could affect our thoughts.

This is a silly notion when one thinks about it. In the ordinary course of living,
we see every day how physical changes to our bodies and surroundings also
impact the way we think. If we drink a cup of coffee, for example, the caffeine
we have just consumed affects our body by raising our heart rate. This effect
isn’t just physical, it also impacts our cognition. We feel more awake. We think
more quickly. So too, we often think more slowly just after we have eaten a
heavy meal. We have a harder time being creative in the late afternoon than we
do in the early morning. And so on.

Nonetheless, the notion that the mind and body are separate things is deeply
rooted in our culture (no matter how much contemporary science and philosophy
have served to disprove it). We, therefore, tend to assume that our thoughts are
purely internal and that nothing we change about our external behavior or
surroundings can affect them. For many people with anxiety, panic, depression,
and related illnesses, this can lead to a sense of helplessness and hopelessness.
One can’t control one’s thoughts, and there they are.

This is part of the reason why, even though cognitive behavioral therapy has the
best track record of any method of treatment – and has been recommended by
the leading professional associations of mental health practitioners – it is still
regarded by many patients with suspicion. People who are suffering anxiety and
panic are often in so much emotional distress that they do not have hope that
cognitive behavioral methods could be effective.

Instead, many patients, when they first seek out professional help, are hoping
they will be prescribed medication. In the throes of panic or anxiety, many
people hope there is a simple drug they can take that will “make the fear go
away.”

Unfortunately, there is no such miracle pill. The human brain is a very complex
thing, and there is no single chemical determining happiness or fear. Rather, as
we discussed in Chapter 2, emotional states in the brain are determined through a
complicated balance of neurochemicals.

Many medications for psychiatric illnesses – known as Psychotropic Drugs,
meaning that they affect one’s mental state, of “psyche” – have been shown to
be effective in treating these imbalances. Many people have benefitted from
using medications to combat their anxiety and panic disorders. (Moreover, some
people report positive results from taking natural supplements to help relieve
anxiety, such as St. Johns-wort, valerian, ginseng, etc., though it is also
important to do one’s research before purchasing supplements, and not to expect
too much from consuming these substances. There is a great deal of false
information circulating out there about natural supplements, and this is not a
well-regulated area of the health marketplace.)

However, the psychotropic medications used to treat anxiety often have side
effects. Some of them can also be habit-forming (another way of saying they can
be addictive), and they can lose their effectiveness over time, as a patient’s body
builds up tolerance to their effects, just as a person’s energy levels become
accustomed to a certain amount of caffeine over time, so that people need to
consume more coffee in order to get the same effect. (This happens due to an
internal bodily process known as homeostasis, in which the body regulates its
own level of various neurochemicals in order to keep them in a state of balance,
or equilibrium).

Moreover, these medications often merely affect the symptoms without
addressing the underlying thought patterns that fuel anxiety and panic.

Many patients become very excited, for instance, when they first learn about the
existence of fast-acting psychotropic medications such as Xanax, which have
proven to be effective in halting the immediate symptoms of a panic attack when
such an attack is in progress. Xanax is part of a family of medications known as
Benzodiazepines, which operate as tranquilizers.

A different but related set of fast-acting medications often prescribed to treat
anxiety are those known as Beta Blockers. These drugs operate by blocking the
receptor sites for the chemical adrenaline, also known as epinephrine, which we
discussed in detail in Chapter 2.

Perhaps you have heard of an “EpiPen,” used to treat asthma and similar
conditions? The name comes from epinephrine because EpiPens are used to
inject greater degrees of the chemical adrenaline, or epinephrine, which raises a
person’s heart rate and causes their throat to expand, reducing the symptoms
associated with asthma.

Beta-blockers essentially perform the opposite task. By reducing a person’s
response to the chemical adrenaline, they cause the person’s heart rate to slow
down – and their respiratory rate as well. This reduces a person’s physical
sensations of panic, which diminishes, in turn, one’s internal emotional feeling
of anxiety as well. (Here again, we see how “external” physical and somatic, that
is, bodily, responses are directly related to “internal” mental and emotional
states. Indeed, the great philosopher William James once argued in a famous
essay, called “What is an Emotion?” that emotion simply is a bodily response,
and that it is impossible to imagine a feeling in the absence of its physical
component. The essay makes a profound argument, and helps us to overcome the
false distinction between “mind” and “body” that is still so prevalent in our
culture.)

For people who have experienced the agony of a panic attack or prolonged
anxiety, the idea of Xanax or beta blockers can seem like a dream come true.
Many feel that having access to drugs that can immediately “knock out” a panic
attack if one starts to form is now a central plank of their sense of personal
safety.

While some medications can be helpful in defeating anxiety, therefore, they can
also be counterproductive. Carrying around fast-acting medications can lead
people to believe that they are not “safe” without these drugs. This can lead to a
feeling of powerlessness, helplessness, and dependence on the presence of the
drug that can be very disempowering. This feeling, in turn, can prevent people
from realizing that they are capable of managing their anxiety and panic, even in
the absence of the drug, and that they have the methods to regulate their
emotions within themselves and their own bodies.

Medication, therefore, may not always be the best resort in treating anxiety and
panic. If you see a mental health professional and they do not recommend
medication, this should not necessarily alarm you or cause you to look
elsewhere. Indeed, it is often much better to start with cognitive behavioral
therapy, which addresses the root causes of anxiety and panic, rather than just
the symptoms, by altering the underlying thought patterns that fuel anxiety.

The degree of success in treatment you can attain from this method alone may
pleasantly surprise you.

How Does it Work?

To have full success with cognitive behavior treatment, many people will need
to seek out the help of a professional. Reading a book is not a replacement for
working with a trained psychotherapist or licensed clinical social worker (even if
it is a quite good book like this one). It is helpful, however, to know a bit about
how the cognitive behavioral therapy process works, as you may be able to guide
yourself in part through some of these stages.

Cognitive behavior therapy essentially works through three broad stages:

Awareness. In this stage, the treatment focuses simply on helping you to
understand the nature of anxiety disorders and how they operate. This
helps you to recognize the symptoms when they are occurring so as not to
attribute them to other health effects or other things you fear. The therapist
will help you understand why panic attacks occur, and the psychological
mechanism through which they tend to become chronic, which we have
discussed in detail in Chapters 3 and 4 of this book.
Emotional Regulation. In this stage, the therapist helps you learn some of
the simple techniques that you can use to manage and reduce your panic or
anxiety response in the moment of a panic attack. We will discuss these
methods in greater detail later on this chapter and in Chapter 6.
Gradual Exposure. This is the heart of the cognitive behavior technique.
When many people hear about it, however, they become alarmed.
Exposure to the thing they fear is exactly what they don’t want. That’s
why it’s important to emphasize that the exposure methods used in this
form of therapy are gradual and consensual. A person who is afraid of
snakes is not immediately asked to hold one, for instance.
Many people, when they hear about exposure methods, assume they will
be asked to simply “face their fears.” Sometimes, well-intentioned but
unhelpful people will give the advice to people struggling with anxiety
that they should just “face what their afraid of” and the problem will go
away. Most of us with anxiety or panic find this idea so overwhelming that
we will never get started, however. If we do get into a situation in which
we need to “face the fear” directly – especially if the experience has been
forced on us – we are traumatized by the experience and feel powerless.
Cognitive behavioral therapy, by contrast, is not about forcing you to do
anything you don’t want to do. It is about guiding you slowly through the
process of your own self-discovery, as you realize you are able to do the
things you used to fear – indeed, that these things are not actually
dangerous and that you are perfectly safe while interacting with them. Far
from making you feel powerless, this process actually increases your sense
of personal control, independence, and autonomy.
To return to our example of the person who is afraid of snakes, a cognitive
behavior therapist will not ask them to hold one, but they might ask if
they’d be willing to go see an exhibit about earthworms at the zoo. If the
patient finds this a slightly scary or uncomfortable idea, because
earthworms are shaped similarly to snakes, but not an “impossible” idea,
this means it is in the sweet spot for cognitive behavioral methods. It is a
challenge, but not such a hard challenge that it is overwhelming. To
borrow terminology from educational theory, this challenge is in the
 patient’s proximal zone of development, meaning it is difficult and new
enough for them that it causes them to learn, but not so difficult that they
are forced to give up.
In Chapter 6, I will discuss how the gradual exposure method helped me to
overcome a fear of flying. The important thing to note for now is simply
that the way to overcome this fear is not just to immediately get on a
plane, and cognitive behavior therapists will never ask you to do this.
Rather, I worked up through a series of exposures that I found less
frightening until I felt naturally ready to fly on a plane. At no point did I
have to “force” myself to do anything I did not want to do. Rather, at each
stage, I discovered that I was ready and willing to do something now that
would have been challenging – even “impossible” – for me in the past.

What Can I Do to Help Myself Without Seeing a

Therapist?
If for any reason you do not want to visit a mental health professional, or are
worried about the expense of doing so, there are simple self-help practices you
can use that have been proven effective for relieving anxiety in many cases.
Apart from applying some of the principles of cognitive behavioral therapy
(such as the gradual exposure method) through self-coaching, here are some
other practices you might like to try:

Meditation. Practiced by religious faiths around the world, meditation can
have a spiritual dimension to it for some people. For others, it is a purely
secular activity. In any instance, however, meditation is essentially a
process of focusing the mind’s attention. Some practitioners refer to this as
“emptying” the mind. Others refer to it as simply achieving a state of
mental non-intervention, in which one allows thoughts to enter and exit
one’s mind without trying to arrest, cling to, or keep out any of the
thoughts that come along. Developing these mental habits through
meditation can be extremely helpful in managing anxiety and panic
symptoms – especially in the moment of a panic attack – as we will see in
the following chapter. One simple method that one can use to enter a
meditative and focused state in any situation is as follows: simply try to
count to ten. Whenever you get to ten, make sure you go no further, and
return to one and start counting again. This sounds so simple as to be
foolish, but it is actually a good way to keep one’s mind in a state of
focused awareness. You’d be surprised how easy it is for one’s mind to
just keep on counting to higher and higher numbers if you don’t remember
to pull it back down to one again each time.

Relaxation. Relaxation, you say? If only! For many people with anxiety
and panic, relaxing is the one thing they’d love to do more than anything,
and the one thing they can’t seem to do. How can anyone recommend it to
them? The answer is, once again, that relaxation has both an internal
emotional component and an external somatic, bodily component. And by
influencing one’s somatic response, one can alter one’s internal emotional
response as well. For instance, by consciously willing oneself to release
the grip of each muscle, one can reduce one’s feeling of anxious tension.
We will be discussing other ways to counter anxious feelings through
simple somatic exercises in the following chapter.

Diaphragmatic Breathing. Many times, when people are in the midst of
an anxiety or panic episode, well-intentioned people around them will
advise them to “breathe deeply.” Unfortunately, this advice is often not
helpful, because many of us when we take a deep breath tend to fill our
chests and suck in our bellies, with is a kind of breathing associated with
anxiety, and which does not prevent hyperventilating. What people should
really be advising is to practice diaphragmatic breathing, in which one
fills and extends one’s whole diaphragm – the large muscle that surrounds
and controls the lungs. This is the sort of breathing in which one can feel
one’s belly extending. This is a sort of breathing that is practiced most
often in childhood. Even though it is available to us at any moment as a
method of respiration, many of us forget about it as adults, unless we
consciously remind ourselves to practice it in a moment of tension. This
method of deep breathing “with one’s belly” is associated with immediate
feelings of relief and the relaxation of tension. This breathing method is
therefore extremely helpful in regulating one’s feelings while struggling
with anxiety, and even in the midst of a full-on panic attack. Many people
may find this hard to believe. How could something as frightening and
seemingly uncontrollable as anxiety or a panic attack be affected by
something as simple and familiar as breathing while extending one’s
belly? Try it though, and see if you do not notice that you very quickly
begin to feel much calmer. The next time you are in a situation in which
you are beginning to feel a panic attack coming on, therefore, instead of
looking for an “escape route,” or asking yourself if you remembered to
pack your Xanax, try reminding yourself that at any moment, you have
access to the ability to calm yourself through your own body, through the
simple act of deep, diaphragmatic breathing.

Sleeping Well. For anything in the world of human health, this is always a
good idea! Healthy, natural sleep is essential for both physical and mental
wellness. Yet people with chronic anxiety may take a look at this and
think: easier said than done! Do not despair, however. If you are having
trouble sleeping due to your anxiety, here are some simple methods you
can apply. First of all, do not lie in bed trying to force yourself to sleep, if
you are not managing to drift off. Lying in bed trying to sleep at night is
often the time of day that people report having the most trouble with
 rumination and repetitive anxious thoughts. It is much better to distract
oneself with a different activity until you feel genuinely tired and ready for
bed. Do not distract yourself with a screen, however, as the light used in
electronic screens is built to remind our brains of daylight, thus confusing
our body’s sense of its natural sleep pattern – also known as our circadian
rhythm – which is timed to correspond to the presence of daylight. This is
what often leads to the feeling when we are looking at screens that we are
wide awake – even “wired.” Reading a book (but one printed on paper or
on a reader with a dim screen, not on a computer or TV screen) or doing a
simple repetitive chore can often generate the sort of natural fatigue that
leads to healthy sleep. Moreover, avoid drinking or eating anything that
has caffeine in it late in the day. This may seem obvious, but many people
forget to put it into practice, and the chemical effects of caffeine often last
far longer than people expect it to.

Yoga and Other forms of physical activity. Yoga, sports, running, and
other kinds of physical activities have been proven to be remarkably
effective in reducing symptoms of anxiety and relieving all kinds of stress.
Partly this is because these activities naturally trigger the release of the
chemicals associated with anxiety and panic responses, channeling them in
healthy ways, and leading to natural feelings of physical tiredness that lead
to healthy sleep at night. Competitive sports, for instance, can induce a
“fight or flight” response that helps the body to regulate the production of
the chemicals involved in this response and channel their use in a
naturally-occurring way. Even beyond other forms of physical exercise,
however, yoga has been found to be particularly helpful, as it includes
elements of mental concentration and focuses similar to the effects of
meditation described above.







 Chapter 6: Remedies and Solutions During a Panic
Attack Crisis

Steinbeck’s commanding officer

We saw in Chapter 3 that depression and anxiety are often very similar to one
another because both often take the form of repetitive thought patterns that seem
as if they were “out of control.” In anxiety, these escalating fear thoughts lead to
a panic attack. In depression, these repetitive unwelcome thoughts are known as
rumination.

We also saw in Chapter 3 that efforts to avoid these repetitive thoughts by
suppressing them do not work – indeed, it often makes them worse. The effort to
force oneself to stop ruminating or to stop panicking often leads to a frantic
effort to look for “escape routes,” only to realize that there is no absolute way to
prevent oneself from panicking or ruminating, which only increases one’s sense
of feeling trapped and at the mercy of forces beyond one’s control.

This is why, when we looked at the poem about Siegfried Sassoon’s soldier
above, we saw that his effort to force himself not to think “ugly thoughts” was
ineffective. The more he tried to avoid them, the more this effort brought them
even more into the center of his focus.

In one of his late novels, The Winter of Our Discontent, the Nobel Prize-winning
author John Steinbeck offers a very different approach to managing panic and
rumination. Like the soldier in Sassoon’s poem, the speaker here is someone
who is struggling with feelings of “shell shock” – a psychological reaction to
war that we would now consider to be a form of post-traumatic stress disorder.
The speaker is a former commanding officer of the narrator of the novel, back
when he was in the army, and he offers interesting words of advice about how to
prevent oneself from being overwhelmed by “ugly thoughts” of wartime
experience:

Trouble is, he says, a guy tries to shove it out of his head. That don’t work. What
you got to do is kind of welcome it. […] Take it’s something kind of long – you
start at the beginning and remember everything you can, right to the end. Every
time it comes back, you do that, from the first right through to the finish. Pretty
soon it’ll get tired and pieces of it will go, and before long the whole thing will
go.

Even though he was writing in the early 1960s, long before modern clinical
therapeutic practice, Steinbeck had stumbled by intuition onto one of the most
important insights of modern psychotherapy. Paradoxical as it may seem, the
best way to halt rumination or panic is to “welcome” both mental states, just as
the character quoted above advises us. Allow them both to happen, remember
that they are not actually dangerous, and see what happens.

For psychotherapists working with depression, this method has come to be
known as acceptance therapy. In essence, it simply means that when one notices
that one is ruminating, one should not try to stop ruminating. Instead, simply
notice that one is ruminating and tell oneself that it is okay. Tell oneself that
rumination does not have the power to harm you and that you will, therefore,
simply let yourself ruminate for as long as it takes. In other words, accept the
rumination.

Applying the method of Steinbeck’s commanding officer is an interesting way to
reach this state of acceptance. Rather than trying to prevent oneself from
ruminating on a frightening or upsetting topic that is trying to force itself onto
one’s awareness, actively try to think the whole topic out from start to finish.

While everyone’s experience is different, chances are you will find that your
rumination has nothing to proceed on, as soon as you are no longer blocking it,
but actually encouraging it. It is as if rumination feeds on resistance, and as soon
as you relax and welcome it, it disappears.

A very similar method has been shown to be remarkably effective in managing
panic attacks – including in the author’s own personal experience.

Very often, feelings of panic are associated with a frantic effort to escape, as we
have seen. One feels that one must make an instantaneous decision in order to
protect oneself. This is the essence of the basic “fight or flight response” that all
animals enter when they are in a position of perceived threat or danger.

Just remind yourself once again that panic attacks are not actually dangerous,
and that it is safe to allow the panic attack to take place. Remember as well that
panic attacks are nearly always quite short. A panic attack does not exceed ten to
fifteen minutes in duration, and they are nearly always shorter events than that.
Even if the panic attack is an unpleasant and uncomfortable experience, you are
not putting yourself in any danger by simply allowing the attack to unfold.

You will eventually find that the panic will subside, and you are still perfectly
safe and sound. Moreover, you may even find that the panic never comes. You
may discover that the tense process of trying to avoid the panic attack, in reality,
was the panic attack, and by opening oneself to the possibility of panic, one has
actually robbed it of its power.

In psychotherapy circles, this approach is known as “riding the wave.” It is
essentially exactly what it sounds like. Instead of trying to swim against the
current by halting one’s anxiety, you can simply ride it where it takes you. It will
not ever take you to a dangerous place.
In short, 1) try to accept and not oppose the panic attack; 2) remember that you
will not die from a panic attack; and 3) remind yourself that it will all be over
soon – at most in ten minutes from now, but probably sooner.

When “Riding the Wave” is not Enough…

Simply “riding the wave” of a panic attack can sound like a tall order. For most
of us, it feels like an unnatural response to simply sit and allow something scary
to happen inside us. Indeed, trying to tell oneself to accept and not oppose a
panic attack can itself become another form of trying to “control” one’s
emotions, instead of welcoming them.

This can lead back to the same kinds of anxious thought patterns we have been
discussing throughout this book: Why can’t I accept this panic attack? Why is
this panic attack still happening even though I tried to accept it? The usual
methods must not work on me. I’m not like other people. I’m doomed to suffer
from this problem forever.

Here, the insights of people who practice meditation, as mentioned in the
previous chapter, can be very helpful. Many meditation guides – including those
associated with the Buddhist religion – encourage the person meditating to
assume a non-interventionist posture to their own thoughts. This means that
instead of trying to empty their minds by brute force – which is what some
people assume meditation must involve – the person meditating should simply
allow thoughts to enter their minds and notice them without trying to change
them.

People who are new to meditation, however, often misapply this advice. They
may find themselves thinking things like “I wish I wasn’t thinking about that.”
They then realize this thought violates the instructions, and they start to reproach
themselves for not being perfectly open to new thoughts. What they forget is that
the thought “I wish I wasn’t thinking about that,” is also just a thought. If they
follow the instructions, they will remember to welcome this thought along with
the others, instead of trying to fight it.

Something similar applies to people experiencing panic. We have seen that
trying to “control” your emotions often backfire. You cannot simply “force
yourself” to calm down in the hopes that the panic attack will “disappear.” Most
of us know this from our personal experience. If you have ever been angry, you
know that it does no good for someone to tell you to “just calm down.”

Nevertheless, because people often struggle to understand or empathize with
anxiety if they have not experienced it themselves, you may have often received
unhelpful advice of this sort from people around you when you are in the midst
of a panic attack. How many times, while panicking (or ruminating, if you
struggle with depression), have you been told to “just let it go” or to “think about
something else”? People with anxiety know that this is easier said than done.

All of that is true; however, it is also true that there are simple methods you can
apply in the moment of a panic attack that will help mitigate and manage the
intense emotions you are feeling. Again, it is important to note that these are not
devices to “control” your emotions or to “force” yourself to stop panicking, but
quite the opposite – they are ways to help you retain an open and accepting
attitude toward yourself and what you are feeling.

So, while you are reminding yourself that it is okay to “ride the wave,” and that
you are not in any danger no matter what happens with your emotions, you can
also apply the following remedies and solutions during a panic attack:

Engage in simple behaviors or actions that are countervailing to your
anxiety and that “cut against the grain” of your panic. Remember
above, when we discussed the essay by William James called “What is an
Emotion?” James, a famous American philosopher who is best known for
helping to invent the philosophy of pragmatism, argued in this short essay
that an emotion is really a physical response, rather than a purely mental
“internal” state. Applying this insight, we can see that by altering our
physical responses, we can also change what we “feel” is happening to us
emotionally. In the case of a panic or anxiety response, this means
deliberately doing the opposite with your body of what your panic is
telling you to do. Perhaps you are thinking anxious thoughts, and you
notice that you have tensed your muscles, balled up your firsts, and
squared your shoulders. Try simply letting your hand fall open and resting
it palm up on your lap instead. Perhaps you notice that you are chewing
your fingernails or running your hands through your hair. Try just leaning
back in your seat, leaving your hands open on your legs, and staring out a
window. You will be surprised by how much calmer you feel within
minutes – or even moments – of doing something with your body that is
different from what your anxiety normally dictates. You may not be able
to “control” your emotions internally, but you can control your outward
bodily actions in response to your emotions, and these actions, in turn,
influence what you are feeling. This is one of the core insights of cognitive
behavioral therapy. At the moment – and almost immediately – you can
change your emotional response by changing what you are doing with
your body.

Monitor and alter your breathing. As we saw above, hyperventilation is
a major physical cause of panic attacks. Because they are breathing so
quickly, people who are hyperventilating are expelling carbon dioxide
through respiration faster than they can replenish it. This, in turn, causes
them to feel as if they can’t get enough air, which causes them to breathe
even faster, making the problem worse. The good news is that by simple
practices of breath control, you can quickly lower your anxiety levels,
bring down your panic, and eliminate hyperventilation. Remind yourself to
simply try breathing slowly and deeply (not through shallow chest breaths,
however, but through deep, belly breaths – discussed above – known as
diaphragmatic breathing). Ideally, you should aim for about six breathing
cycles a minute. If you have reached this rate of slow breathing, your
panic and anxiety levels have probably also been significantly lowered as
well. You can try taking out a stopwatch (either a physical one or one on
your smartphone) and counting the number of times you breathe each
minute until you get down to only six respiratory cycles (inhale and
exhale) per minute.

Distract yourself, talk to someone near you, call someone on the
phone, play a game, or something else to take your mind off the
attack. You may be thinking in response to this – “how could I possibly
talk to anyone else or do anything else? – I’m panicking!” Just remember
though what we said above. Your panic is not visible to others, even
though inside you, it may be the most important thing that’s happening.
Moreover, you are more in control of your behavior than you think you
are. Even in the midst of a panic attack, you are actually still consciously
controlling your external actions. Therefore, try a few simple activities to
distract yourself from your feelings of panic. The purpose of doing so, it is
important to note, is not to “shut down” your anxiety. As we have seen
time and again, forcing yourself not to panic goes nowhere. The purpose,
rather, is to find a way to stay grounded in the present. Panic preys on the
inescapable truth that the future is unknowable. While we can predict
certain things fairly well, there is always an element of chance in human
life, and we cannot know everything that is going to happen to us in
advance. This is why the future can be scary. The way to halt or mitigate a
panic attack, therefore, is to return one’s focus to the present and to realize
that nothing scary or dangerous is actually happening in the here and now.

Other specific ways to stay focused on the present. Let me offer an
example that I use to help manage my fear of airborne turbulence during a
bumpy plane ride. It used to be the case that I felt very helpless and
frightened when a plane entered a patch of turbulence. Each time the plane
would go over a bump, my thoughts kept leaping toward the unknowable
future. “What if the next bump is even bigger?” I would think. “What if
they just keep getting bigger and bigger and never stop? What if it’s just
like this for the whole rest of the flight?” A helpful technique I learned
through cognitive behavior methods is to focus on each bump as it
happens, not on hypothetical future bumps. When a bump goes by, try to
rate it on a scale of 1 to 10, with 1 being a minor bump, and 10 being the
most frightening bump you can imagine. You will quickly see that the
worst bumps you imagine never come, and a surprising number of the
bumps you used to find so scary in the past are actually now in the 1 to 2
range. I have been playing this game for years now, and have flown all
over the world on numerous plane rides, and I don’t think I’ve ever ranked
 a bump higher than 4.

A very similar method applies to manage all forms of panic. Instead of
focusing on anxious thoughts of “how bad might my panic attack get in
the future” – which you can’t know because this question has no knowable
answer – focus instead of ranking the level of fear you are actually feeling
in the present. You might even try the 1 to 10 “scoring” game, trying to
rank each wave of panic as it comes to see how bad it actually is. Chances
are, you will find that you never rate anything very highly, because you
have already trained yourself not to focus on the key driver of panic – the
unknowable future – but to stay with the present, where you realize you
are in fact perfectly safe. This 1 to 10 “scoring” technique was invented by
Dr. Martin Seif – a psychotherapist who specializes in treating fear of
flying through cognitive behavioral methods – and he recommends it as a
simple way to stay anchored in the present.

The Author’s Experience, Part II
If you are struggling with panic and anxiety, it may be difficult to believe that
the path to ridding oneself of these conditions can really be as simple as some of
the methods described in this book. Given how much pain and discomfort these
conditions cause, is the path to freedom really that easy and direct?

Every individual’s experience is different, of course, but it might be helpful at
this stage to return to the author’s experience. In the first chapter, I explained
how, over a period of several years, I gradually came to feel more and more
hemmed in by my feelings of anxiety. At the age of twenty-five, I found it
“impossible” to set foot on an airplane, and the prospect of even taking a subway
filled me with a certain degree of dread.

At around this time, however, two things happened that made me want to change
this situation. A job opportunity opened up that I was very excited about, but I
knew that taking it would eventually require me to travel by plane. Secondly, my
family wanted to take a trip together to Iceland, and I did not want to be left out.

I suddenly became very tired of being limited by my anxiety. I wanted to do the
kinds of things I had done in the past without a second thought – things like
traveling and taking up exciting offers. I wanted to do things that other people
found it easy to do. In short, I wanted my life back. I wanted to lead my full life
again.

I started researching online about methods people had found to overcome
anxiety, and I discovered the writings of Dr. Martin Seif, mentioned above. His
work introduced me to the basic concepts of cognitive behavioral therapy, and
the methods he prescribes worked wonders in enabling me to gradually regain
my ability to travel and see the world.

The first important insight I gleaned was one we have already discussed above,
in treating the methods of cognitive behavioral therapy. I realized, in short, that I
did not have to start by tackling the one thing I dreaded most. I didn’t have to
just “suck it up” and get on board an airplane. Instead, in the months leading up
to the Iceland trip, I could work my way up to this challenge through stages I
found less intimidating.

I was mildly uncomfortable with taking the train on my own, for instance, but I
did not find this “impossible,” so I experimented for a few days with simply
taking the subway long distances. I visited the art museum. I went to the tallest
building in the city and rode on an elevator to the highest floor.

I realized as I did so, that I actually felt empowered by allowing myself to do
something I had been afraid of before. This was surprising to me because all that
time, I had been afraid of losing power, afraid of losing control. I was worried
that if I put myself in a situation, I found “scary,” then I would panic and lose
control of my emotions.

What I found instead, however, was that as soon as I started putting myself into
situations that I found mildly scary, I felt more empowered, and more in control,
than I had in years. I had proved to myself that I could still choose to do things,
even though I found them frightening. My panic was not in control of my actions
and my life. I was in control.

Pretty soon, I started to look forward to these moments when I was placing
myself in a situation that I had previously associated with panic. They became
opportunities to prove myself and reclaim power over my life.

My next step was to sign up for a helicopter ride. My sister kindly agreed to go
with me. We lifted off and were airborne for only a few minutes. While I had
been very afraid just before the trip, however, I realized as soon as we were aloft
that I felt great. I had done the one thing I feared the most – I was in the air.

After that, it was a simple step to taking the plane ride to Iceland. And more
importantly, once I had realized that I could fly on airplanes and nothing bad
would happen and that I would not panic while doing so, I realized that I was
capable of surviving a panic attack anywhere. If it did not trouble me in the one
place, I was most afraid of. I could handle it anywhere else as well.

Before I knew it, panic and anxiety were simply no longer a major part of my
life. I took the job offer, and still work for the same company today. Since that
time, I have flown around the country and around the world on innumerable
flights.

The same can be true for you.
















Conclusion

Simple as they may seem, all the remedies described in this book are useful for
fighting anxiety and panic attacks. During my own more than four years of
coping with anxiety and panic, I have repeatedly found them to be of immense
benefit. You too have the power to reclaim your full life.

The first step is there waiting to be taken. Keep in mind the Samuel Butler
principle, and remember that panic attacks may scare you, but they can never
hurt you. Panic does not have the power to change reality. Your emotions will
not bring on the terrible things that you fear, and simply worrying about
something does not make it so. Having frightening ideas in your mind is a
terrifying thing at times, but they are still only that – they are pictures in your
head, not real things in the world with the power to harm you.

The road ahead will not always be easy, but it will get better from here. If you
can internalize the lessons of this book, you will find that the panic and anxiety
you currently live with can be gradually managed and overcome. Some may
even find that they need to look no further. Many people with anxiety disorders
are effectively cured simply by learning to recognize their anxiety for what it is.
For others, it may require a longer journey and more professional help. In every
case, however, progress is possible and is out there ready to be made.

The world is an open place. There is no way of knowing the future fully, and
while we have seen that this can be a source of anxiety, it can also be a source of
hope. You are not doomed to your anxiety, and you are not condemned by the
past. You can have your full life back. It is out there waiting for you.