TREATING PANIC DISORDER
A COUNTER-INTUITIVE APPROACH
by
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 “hyper-vigilant” (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.
© 2010 Heather Stone, Ph.D.
