Panic and Panic Disorder

What is the difference between a panic attack and panic disorder? Many of us have had an isolated panic attack, without it developing into something more, and mostly it doesn't. What is the difference between high anxiety and panic? It's not always clear, but often there is a strong sense of losing control, a sense of being totally overwhelmed by the intensity of the fear, which is not characteristic of everyday anxiety, at least not as much. For some of us, the fear of having another panic attack can come to dominate our everyday experience to the extent that we spend our days increasingly vigilant for signs of a possible panic attack, and this is known as anticipatory anxiety. If this routine becomes established, we are talking of panic disorder. A full blown panic attack is one of the most unpleasant experiences a human can have, but the good news is that it is highly treatable, both with and without meditation, though here we will focus on the psycho-therapeutic aspect.

What is a panic attack?

Broadly speaking, a panic attack is a misfiring of the body's "flight or flight" response. This is the body's survival impulse, so, to say that it is strong is an understatement. Imagine that you are one of our ancestors on the plains of Eastern Africa, and you are suddenly faced with a predator, a lion perhaps. There is no time to think, only to fight, or run away, if you can. The conscious reflecting on what to do is too slow in this situation, so the brain bypasses this function entirely as your body instantly mobilizes, filling with adrenaline and cortisol. The blood flow shifts to the torso and away from the extremities, hands and feet, to protect your vital organs. This results in cold, clammy hands and feet, an increased heartbeat, and our muscles experience an energy surge as we are immediately faced with the very real choice to flee or brace ourselves to fight.

This is all well and good if there is indeed a lion in front of us, but panic attacks for us can appear out of the blue, for no apparent reason, which is part of what makes them terrifying. Our minds struggle to understand what is going on and we wonder, or come to believe, that we are having a heart attack, losing control, going crazy, and so on, none of which actually happens, but if our mind thinks it knows what is going on, then perhaps we can do something about it. Panic attacks themselves peak after about 10 minutes or so, though we can keep the process going for longer, by becoming over-vigilant about every shift in our inner experiences.

Misinterpretation of bodily sensations

Once we have had a panic attack, or several, we become increasingly sensitized to the bodily sensations associated with it, which are basically physiological symptoms of fight of flight:  sweating, trembling, dizziness, dry mouth, and muscles tensing in expectation of a threat, all of which are typically accompanied by a deep sense of dread. And in those of us with a history of some panic, we notice the smallest change in our bodies, something we may have overlooked in the past, and which may be completely normal in the circumstances. So a slight queasiness in the stomach, a sense of feeling weird, an increase in our heart rate, may all contribute to the fear that "Oh no, its happening again", a thought which we will fasten onto if it seems true, which will itself make us considerably more anxious, which in turn seems like evidence that the dreaded thing is indeed overwhelming us again. Usually we don't realize it is rising anxiety only, and not a heart attack or whatever. In this way, we contribute substantially to the anxiety through misinterpreting these bodily signs, and this can in many cases lead to exactly what we're trying so desperately to avoid, a panic attack.

By misinterpretation of bodily sensations, I mean the early signs of anxiety that we associate with a possible panic attack, which I have found in my practice are quite specific to our own history. If a panic attack was in the past preceded by a certain lightheadedness or sweaty palms, for example, then when this occurs now, we will immediately be on the alert, though the particular symptom or cluster of symptoms that sets us off will vary for each individual. Becoming familiar with our own triggers in this respect, is a key part to intervening early in the process before we are automatically "off to the races" and pulled into our own style of the panic cycle - early mindfulness is thus the central skill we need to develop to address this issue, something we many be studiously avoiding in the hope that it will go away on its own.

The problem is that lightheadedness or queasiness or sweaty palms don't in general mean anything except what is being presented, they are not dangerous in themselves. True, I may be worrying about the next business meeting, but that is different from interpreting this as something more, based on associations with past panic episodes. If we interpret them this way, as dangerous, then the self-fulfilling cycle can begin to take over, as we resist and try to avoid that we think is happening, i.e. that we are losing control and that thought itself perpetrates more anxiety, which becomes "evidence" that control is indeed being lost. In fact, the attempt to control these feelings is precisely what keeps us locked in this cycle.

Understanding and Acceptance

To unwind what is essentially a learned behavior and address this cycle, we can understand that as awful as a panic attack feels, it is not harmful. Our bodies are designed to respond in this way, and left to itself, the anxiety will rise and fall on its own, and what we fear the most will not (and cannot) happen. If you are familiar with this process, you will know that no matter how many panic attacks you have had, you have survived, you have not lost your mind, or whatever, though it can certainly feel like it for a while! I have had clients who have been to several emergency room visits for possible heart attacks before they realize it is actually a panic attack. If you are worried you are having an actual heart attack, or other physical heath issue, by all means talk to a Doctor, but if the news is good, i.e, that you are not sick or unwell, I encourage you to believe them, and consider the possibility of it being panic.

Once we understand that anxiety is just anxiety, and panic just panic, as dramatic as they are, and that these feelings will come and go, then we can practice acceptance. When we notice a concerning bodily sensation, whether its dizziness, or clammy hands, or butterflies in the stomach, then we can reassure ourselves that it is just this, and nothing more. Even with strong anxiety, we can tell ourselves that this is just anxiety, as overwhelming as it may appear, which is nothing more than unpleasant bodily energy that comes and goes, and nothing more need be read into this. In fact, one of the principle therapies for panic is to induce a panic attack in a session with a therapist, so that we can see for ourselves that it is a collection of physical sensations that we can cope with, and most certainly survive, thus taking some of the sting out of our catastrophic interpretations of these feelings.

Accepting - not resisting or trying to avoid - these uncomfortable thoughts and feelings as early as possible in the process can help us head off the cycle before it can develop into something more. If a feeling of anxiety of queasiness or muscle tension in the body is nothing more than that, the panic cycle is stopped in its tracks, as it were, with nothing to feed on. Which is how most of us go about our days anyway, experiencing various stresses and strains, which while sometimes uncomfortable in some way, come and go in their own time and don't develop into something more if we don't object to them and try to control them. Remember, that acceptance of feelings is not approval.

It may take a little while for the truth of this to sink in, though. In time we will see that this is likely the case; after all, we've survived these before, nothing awful that we imagined might happen has happened. Still, it usually takes a little while, because these feelings can be so overwhelming, and our minds tend to make the worst of it, to protect ourselves, just in case. We may need to go back to the emergency room or escape from this or that social situation one more time, in case this really is a heart attack or I finally do something incredibility embarrassing like running screaming from the room.

Once we start taking this view of things, however, we can more deeply trust that while these fight or flight sensations are meant to get our attention and are thus not easily dismissed - it seems sometimes as if we will even die on the spot - when in fact this is not the case, and acceptance helps give us the trust to allow things to unfold, as we naturally become less frightened of ourselves.

Once this occurs, we can truly see that we need not worry and obsess about the smallest (or largest) change in the state of our physiology, indeed that this ongoing internal scanning of the body has become the problem itself, and that we need not continue it.

Stress Reduction

So why might we liable to panic attacks in the first place? We have been discussing the acute aspects of panic, how to deal with anxiety escalating in the moment. There is also what we could call the chronic aspect, which is more about managing stress. The more frazzled we are over a period time, the more susceptible we might be to a panic attack; it is not at all inevitable, but managing stress can also assist with keeping the incidence of panic attacks down. As always, exercise and meditation are practices that lead to a natural reduction in overall stress over time.

And lastly, it is also useful to note that panic may be a sign that something is askew in our lives more generally, whether it be stress or something more specific that we are not attending to, and panic will most certainly get our attention in this regard. Getting to the bottom of what else might be bothering us may not immediately solve the problem, but as part of our working through our panic, and anxiety generally, we might well get to other aspects of our lives that need attention and work, and sometimes some kindness and compassion, especially if we've been assiduously avoiding it. A common underlying cause of panic I have found, is unacknowledged anger, anger we feel we're not entitled to, perhaps anger at someone whose love and approval we might fear losing if we express our anger and become confrontational, which can feel very disturbing to those of us who have been socialized to avoid this at all costs.

Further reading: Mindfulness and Acceptance for anxiety