What is a panic attack? In the midst of one it can feel like you're having a heart attack; you can faint, vomit, hyperventilate, or feel like you're dying. This feeling can last anywhere from 5 - 30 minutes. What makes them so scary is that they are unprovoked and unpredictable (unlike an anxiety attack), and are not caused by any external or internal stressor. Sounds horrible, right? Some people suffer panic attacks several times a day and these can be absolutely debilitating.
The DSM defines a panic attack as "an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of the following symptoms occur. The abrupt surge can occur from a calm state or an anxious state". An individual must have at least 4 of these symptoms for the episode to be qualified as a panic attack:
1. Palpitations, pounding heart, or accelerated heart rate
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. Fear of losing control or going crazy
13. Fear of dying
If you've ever had a panic attack, you know that the fear of one coming on is just as uncomfortable as the attack itself, and can even cause one to happen. No one can stop a panic attack in the middle of it, unfortunately, so you must ride it out until it ends. But there are actions you can take to make it more bearable. So what can you do to calm yourself when you feel one coming on?
- An important part of struggling with panic attacks is to accept that this is a problem you have. Denying or ignoring this fact will only make your panic attacks worse and more frequent. Although it may sound like it, acceptance is not the same thing as liking your attacks or giving up working on your mental health issues. Acceptance means that you let go of wishing you didn't have this problem and acknowledging your present reality. This will eventually lead to overcoming your attacks. When you start to feel you are panicking, tell yourself that it is OK that you will be in the midst of a full-fledged panic attack in a few minutes. They are not dangerous and cannot harm you even though it may feel that way during them. However, you should also know the warning signs of a heart attack or stroke and not to pass these symptoms off as a panic attack when inappropriate. If you are unsure, call 911 or go to your nearest emergency room!
- Take yourself out of your current situation and go to a quiet, uncrowded place where you will be able to calm yourself down. If you have a friend that you trust who is with you, ask him or her to come with you and help you through your panic attack. However, if you would rather be alone or you feel your friend would not be helpful, skip this step. If you have a piece of paper and a pen with you, begin writing down how you feel. Your mental health provider can give you a panic diary worksheet if you ask them, which will help to identify your feelings, bodily sensations, and thoughts. Things to ask yourself may include, "What sensations am I feeling in my body right now?" or "What are the thoughts I am having about my panic attack?" This exercise allows you to think about your symptoms in an objective way and puts a little bit of space in between you and your panic attack.
- Belly breathing! Breathing properly is a very important part of relaxation in general, and can be extremely beneficial in the midst of a panic attack. Most of us breathe with our chests when really we should be breathing from our diaphragm (a muscle below our lungs that extends across the body and is crucial in the respiratory process). To make sure you are belly breathing, you can place your hand on your belly and watch as it rises and falls while you inhale through your nose and exhale out your mouth. Try inhaling for a count of 4 seconds, hold for 4 seconds, exhale for 4 seconds, and hold for 4 seconds. This is called square breathing (because of the 4x4 seconds and because you can also visualize outlining the lines of a square as you breathe). While you are belly breathing, try to keep your body and muscles relaxed, and pay attention to your bodily sensations. Be sure to practice this type of breathing during a calm state, so that you know how to do it properly to calm yourself down during a panic attack.
- Another distraction technique you can try is engaging with your surroundings. Staying in the present moment is an important part of making it through a panic attack, as thinking about the past or future may have been what sparked your panic attack in the first place. Obviously if your situation is in fact dangerous, if you are being robbed for example, your body is responding appropriately to a threat. But if you are actually safe, naming and describing objects in your view can be helpful to keep your mind in the present. For example, if you see a tree in your surroundings, you can think in your head, "Tree. Green. Brown. Leaves. Bark. Birds' nest. Smooth. Rough". Or you can also keep something textured interestingly with you at all times, like a smooth rock or a stress ball, and play with it mindfully to keep yourself focused.
- In addition to practicing relaxation and grounding techniques in the midst of a panic attack, there are some preventative measures you can take to reduce the frequency of your attacks. Avoidance or minimization of stimulants is very helpful. Avoid caffeine and minimize the use of asthma medications if possible (bronchodilators, theophylline). Some cold and cough medications like nasal decongestants as well as diet pills can increase anxiety, so try to stay away from these. Good sleep habits are also crucial in decreasing panic attacks. Getting adequate, restful sleep improves response to interventions to treat anxiety disorders. Furthermore, identifying and removing or reducing stressful tasks or situations at home, school and work can help to minimize anxiety.
- If these behavioral techniques aren't effective enough, pharmacological treatment is a very successful intervention. Always remember to take all medications as prescribed by your provider.
Benzodiazepines: Long-acting ones are best (Klonopin, Ativan, Valium, Librium, Serax) to quickly (almost immediately) reduce the symptoms of a panic attack.
SSRIs: Work to balance serotonin in the brain. Serotonin is a neurotransmitter responsible for regulating many bodily functions. Effective SSRIs for anxiety include Luvox, Prozac, Zoloft, Paxil. These are daily medications that can take up to 4-6 weeks to work fully.
Tricyclic Antidepressants (TCAs): Older antidepressants with more side effects typically than the serotonergic agents, but are also effective. Takes 4 to 6 weeks for full response (Tofranil, Elavil, Pamelor, Sinequan)
Antihistamines: Older medications have been used for mild to moderate anxiety for many years. These, like the benzodiazepines, work fairly quickly (Atarax, Vistaril).
Buspirone (BuSpar): a serotonergic combination agonist/antagonist. Is nonaddicting, but may take 2 to 4 weeks for full effect.
Major Tranquilizers: Have been used in situations where anxiety is severe enough to cause disorganization of thoughts and abnormal physical and mental sensations, such as the sense that things around you aren't real (derealization) or that you are disconnected with your body (derealization). Commonly used neuroleptics: Zyprexa, Risperdal, Seroquel.
- Most importantly, remember that panic attacks END and that they are not harmful to you. You can and WILL get through them, and if you practice your techniques, you can eventually overcome them.