TREATING PANIC DISORDER:
A COUNTER-INTUITIVE APPROACH
Heather Stone, Ph.D.
Clinical Psychologist, PSY 21112
If you suffer from “anxiety sensitivity,” you may be interpreting certain arousal states in your body to be threatening when in fact they are not. This has to do with a common cognitive distortion of giving too much importance and negative value to one’s fleeting or transient internal experiences. I call this “intensified focusing.”
People with anxiety sensitivity sometimes develop Panic Disorder, which may be described as a “fear of fear.” It is the presence of recurrent, unexpected panic attacks followed by at least one month of persistent concern over having another panic attack. A panic attack is a discrete period (20-30 minutes, maximum) in which there is a sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom. During these attacks, the following symptoms may be present: shortness of breath, heart palpitations, chest pain or pressure, choking or smothering sensations, feelings of unreality, or fear of dying, going crazy or losing control. In other words, an alarm is going off but it is really a false alarm, because the body is fine.
Sometimes the brain “misfires” and produces erroneous messages, and sometimes the body does the same kind of thing – it produces symptoms of panic (heightened physiological arousal) out of the blue. How terrible it is for a person who is already so sensitive to have this level of arousal! And it isn’t felt as “good news” to hear that there’s nothing “wrong,” because this level of suffering is really extreme.
As would be expected, people with Panic Disorder eventually tend to regard even “small” internal experiences, including the shifts that occur inside the body, with far too much significance. Feeling light-headed, or having your heart rate speed up, happens to all people pretty regularly, but to a person with anxiety sensitivity, these things are felt to be dangerous. “Intensified focusing” takes place when you feel a shift occurring inside your body and you go, “Oh my God! What was that!!?” That thought creates even more arousal, and it is the thought that triggers the panic. Efforts to control it won’t make it go away, and in fact, becoming “hypervigilant” (scanning your body for danger signs) will probably make you more likely to authenticate those sensations and set off another panic attack. Note: I always encourage people to get a full physical examination if there are any medical questions or concerns. However, once all medical causes of symptoms have been ruled out, it is time to take a different approach.
I recommend doing these two things simultaneously: give yourself a lot of sympathy and compassion for the fact that you are suffering, because your suffering is very real. But at the same time, acknowledge that your interpretations of your suffering may be distorted, and have a healthy skepticism of the catastrophic messages your mind is offering.
“It Feels Real, So it Must be Real.”
Here is a really important question that I want you to consider: Why is it that people who have panic attacks almost always think that they are dying, going crazy, or losing control? The answer is because the mind is set up to seek congruence – in other words, it is not satisfied unless everything feels like it matches up. Unfortunately, however, the explanations that the mind produces are often a) wrong and b) devastating to think about.
Disturbing events beg for credibility, so the mind starts offering assumptions to “help” make sense out ambiguous situations. Because we think that the interpretation should fit the circumstance, and because the circumstance is pretty extreme (e.g., chest pains, racing heart, or sweating), we think we ought to have a really extreme explanation to go along with it. The important message I’m suggesting here is that the mind would actually prefer to give you the really bad news that you are dying rather give you the unclear message: “I haven’t got a clue. It’s just a feeling, nothing more, nothing less. Just move on with no really good explanation, other than something just misfired, or that you’re probably having a panic attack.” And that is precisely what you should be saying, because that is the real explanation. I like this quote from Jeffrey S. Victor:, “A mistaken explanation for emotional pain can be preferable for a confused person to the ambiguity of uncertainty.” This is huge. Please think about this, because it will help you give less credibility to the false messages your mind is offering when you are beginning to panic.
I have often noticed that normal experiences like excitement, or anything that creates an increased state of arousal, can feel threatening to people with anxiety sensitivity. Ask yourself whether you might sometimes be confusing things like anger, anticipation or excitement with anxiety. These heightened emotions can get misinterpreted as anxiety as soon as we put a negative label (judgment) on them, but if you think in terms of “arousal,” you will eventually come to realize that it’s really just neutral (neither good nor bad). I recommend re-labeling many of your heightened internal states as arousal whenever possible, because this interpretation does not carry such an emotional “charge.”
Control is Not the Answer. (Do the Opposite).
Everything about treating anxiety disorders tends to be “counter-intuitive.” It always feels like the opposite of what the person has already tried to do (e.g., avoid, escape, distraction, or control). First and foremost, stop struggling. Probably the best thing for you to do would be to move your body, since it’s already geared up to be in a “fight-or-flight” mode. Go outside and go for a brisk walk. Often people will tell me they tried to deal with a panic by suppressing anxious thoughts, or by lying down. When I ask if that worked, people usually say “no.”
I always know when someone is recovering from Panic Disorder when they say, “I had a panic attack last week, but it wasn’t that bad, it didn’t last that long, and it didn’t really scare me. And then I just went about my day.” Another client really impressed me when I noticed that she stopped insisting that her experiences play out in any particular way. While she used to say, “I can’t do ____________, I might have a panic attack,” she began to say, “I guess I’ll just have to wait and see.” And she actually smiled.
Remember, that a person is only diagnosed with Panic Disorder when they are afraid of having another panic attack. In other words, a person could have one panic attack in their lifetime, and maybe it even happened ten years ago, but if they are living their life in fear of having another one, they qualify for the diagnosis of Panic Disorder. Conversely, when a person has frequent panic attacks but is not afraid of them, they do not have the disorder. With that in mind, recovery is all about the willingness to be uncomfortable. People with anxiety often ask the question, “What is the worst thing that could happen?” But they rarely answer it in this way: “I will be really, really uncomfortable. (But I would be ok).”
One of the things that breaks my heart about people suffering from Panic Disorder is that they are afraid to do the very things that would make them feel better. Since the body has been determined to be their “danger zone,” even getting the person to breathe correctly is an area of resistance. Sadly, the same is true for exercise, which would do wonders for their panic as well as their health, and likewise they might also benefit from taking prescription medication.
Resistance to Medications:
The issue of taking prescription medications comes up often with people suffering from Panic Disorder. Most of these clients tell me that, “I can’t tolerate medication – I’m too sensitive.” Ironically, the same person may feel fine about drinking alcohol to deal with their anxiety, or taking “as needed” anxiolytics that may be actually more “harmful” (e.g., habit-forming). Similarly, many people suffering from panic are much happier taking over-the-counter medications and/or “supplements” that they can “prescribe” for themselves. While there are certainly a few people who generally cannot tolerate certain prescription medications, I have two psychological explanations for this type of treatment-resistance.
One possible explanation for medication refusal is that the psychotropic medications commonly prescribed for Panic Disorder (the “newer” anti-depressants or “SSRI’s”) have the less alluring, unglamorous distinction of having to be taken regularly on a daily basis. And this, believe it or not, is considered by some anxious people to be inherently less attractive. Some anxious people have a tendency to want to control everything about their bodies, including what, where, and when they want to take something. Thus, being medication-compliant, doing something on a regular schedule, and taking “orders” from their doctor – would all be considered completely out of the question!
Another likely reason why people with Panic Disorder often resist taking the appropriate medication has to do with the earlier problem of intensified focusing. While it is often the case that many people who begin taking an SSRI feel some temporary or mild side effect(s) before experiencing any therapeutic benefit, anxious people refuse to experience this possibility. Even though this is usually explained to patients at the time the prescription is given, these patients will say they can’t “tolerate” the side effect – and bail out too soon. I am often disheartened when I see that the person was probably one or two weeks away from feeling better, but they discontinued the medication due to their fear. While another person might regard the side effects as transitory and/or pretty tolerable, the person with anxiety sensitivity will go, “Oh my God! I felt something weird” – and abruptly discontinue their medication.
Another phenomenon that I see happening all too frequently has to do with the person’s insistence that the drug caused them to become “more anxious” and actually increased their symptoms. While I believe this to be probably true, I often attribute this exacerbation of symptoms to the person’s “hypervigilance” after taking the medication. They begin to have anticipatory anxiety about what the drug might do to them, and as explained before, it is their expectation of danger (the thoughts, not the medication) that likely triggered the panic. But don’t forget that often SSRI’s do cause an increase in anxiety early on.
You Can’t “Refuse” to Feel.
My experience of working with clients suffering from anxiety sensitivity is that they pretty much refuse to ever feel uncomfortable, which is really a mistake. Most of us would never go to the doctor and say, “I refuse to have another headache.” We just don’t make those kinds of ultimatums. The doctor might say, “I can give you some medicine so you can get rid of the headaches sooner, and maybe have them less often,” and the patient would be generally satisfied. But as I suggested before, people with anxiety disorders can sometimes be a little controlling. (I say this to you very gently). This controlling approach doesn’t work, because “what we resist persists.” In a way, it is like telling your body what it should be doing, but your body has its own autonomy and the ability to undermine your control. It does not ask your permission in order to function.
Taking a Counter-Intuitive Approach (Willingness).
What is required, then, is to become more flexible. Allow the sensations to just move through you. Be willing to be with whatever is happening. Learn to make friends with your body, and stop bossing it around, because you will lose. If you allow your body to have its fluctuations, it will be nicer to you. Don’t fight it. Acknowledge that your attitude towards your internal responses is extreme, and just try to “float” with the experience. Watch your thoughts and your physical sensations come and go, and stop struggling with your experiences. Learn to say, “It’s just a thought.” Or, “It’s just a feeling.” Practice feeling neutral, and become an observer, not a director, of your own internal states.
You live in a world of mystery and uncertainty, and this includes your body as well. Remember that everything I am suggesting is counter-intuitive.
Learn to control things a little bit less, and you will be more in control.
Allow yourself to have symptoms, and they will be more likely to leave you alone.
Stop clinging to explanations, and things will start to make sense.
Practice detachment, and the world, your body, and your mind will feel more welcoming.
Acknowledge that there is a certain knowledge or truth that exists within uncertainty.
Notice, with compassionate awareness, the lack of fit between your desires and the real experiences you end up with, and you will begin to live more comfortably inside your own skin.
©2012 Heather Stone, Ph.D.