Panic Attacks

Panic attacks can happen at stressful moments. They occur suddenly, peak in the first 10 minutes, and are usually gone in 30 minutes.

Ten years ago, Becky and I were taking off in a jet from LAX to fly to Santa Fe. The young flight attendant had teased me earlier about one of my bags and was sitting in the front of the cabin as the plane took off and began rapidly ascending.

Suddenly, about five rows ahead, a middle-aged woman started having a panic attack. I could see the flight attendant becoming alarmed, since the plane would have to land if the attack kept worsening. I said something I never thought I’d hear myself say, since it was the punchline of so many jokes over the years, “I’m a psychologist, let me help.”

The flight attendant nodded vigorously. I unbuckled my seat belt as we kept ascending and sat next to the woman, relaxing and looking into her eyes. I gently put my left arm around her shoulders and told her, “You’re having a panic attack. Let me help.” As I continued to connect and talk softly, encouraging her to keep looking into my eyes, she calmed down and we finished our flight without incident. It was a sweet moment. Everyone was grateful we didn’t have turn around and land at LAX.

I know panic attacks inside and out. I had my first panic attack at 17 and it freaked me out. It was like I was helplessly adrift, alone in infinite despairing blackness. The next night I had another one and called my therapist to ask for help. He was reassuring and supportive and I stopped having panic attacks for many years after. Panic attacks are like that—sometimes one intervention changes something and they stop, and sometimes they figure into long term work and deep transformation.

With my panic attacks, I have learned to quickly regulate them when one shows up. Through fifty years of being a psychotherapist, I’ve helped countless people suffering from panic attacks. Everyone who decided to receive caring influence resolved and grew.

Panic attacks are common.

Panic attacks can accompany any anxiety disorder like OCD, PTSD, social phobia, generalized anxiety, etc, and personality disorders like borderline personality disorder, dependent personality disorder, obsessive compulsive personality disorder, and paranoid personality disorder. They can also occur randomly with people who have no particular psychological problem, usually in response to elevated stress levels.

Panic attacks are a human capacity linked to our defensive instincts. The rush of fear generally immobilizes us and drives us towards the freeze part of flight/fight/freeze. Even if someone is around, we feel cut off, not connected, and isolated during the attack. Panic attacks seem to be associated with the separation distress attachment system, mediated by the hypothalamus. The woman on the plane initially couldn’t look me in the eyes, since the horror of the experience is so isolating. I gently insisted because I knew her mirror neuron system would be activated by eye contact and would resonate with my calm.

People in the grip of panic attacks often feel they are dying, choking, having a heart attack, going crazy, or about to black out. Their pulse pounds, their hands sweat, their bodies feel captured and out of control. Their unconscious desperately creates meanings (like “I’m dying!” “I’m having a heart attack!” or “I’m going to pass out!”) to explain the experience.

The sequence in the body is:

• Stress leads to sympathetic nervous system arousal and exaggerated alarm.
• After a trigger that creates a bloom of alarm, the parasympathetic nervous system can’t effectively self-soothe, opening up the possibility of an escalating out-of-control catastrophe.
• In a desperate attempt at defense, the unconscious paralyzes us into urgent terror—panic attack.

The parasympathetic part of the autonomic nervous system is the rest and digest, relax and mellow system. We lose it in panic attacks.

The brain areas that are especially hyperactivated during panic are the amygdala (probably more the right amygdala) associated with emotional arousal, and the periaqueductal gray region in the midbrain associated with defensive responses such as running or freezing.

I suspect similar brain areas are activated during night terrors and sometimes nightmares but haven’t seen data one way or the other.

What to do?

If you do start having panic attacks, don’t panic! They are a human defensive capacity that we can integrate into our larger selves so that they hardly ever occur, and we are not burdened by them if they do. There are two major components of dealing with panic attacks:

#1: Reduce subjective stress.

This means learning how to soothe yourself in stressful situations using breath, body, thought, human contact, and various parasympathetic-friendly activities. In non-stressful situations, regular healthy practices that generate pleasure, calm, and social connection help reduce our general stress levels. Some examples are:

• Good sleep hygiene.
• Healthy diet.
• Psychotherapy that involves self-soothing skills and learning how to deconstruct the hostile, frightened, or defensive stories that accompany panic.
• Good social connections and ease at asking for and receiving help and contact when you need it.
• Learning how to self-observe, accept, and soothe all emotional states and especially painful ones like fear, anger, shame, guilt, and anxiety. The best self-observer is your Wise Self. Be Wise Self witnessing panic with compassion and interest.
• Engaging in meditation, yoga, and other self-soothing activities that increase HRV (heart rate variability), body awareness, and compassionate self-observation.
• Accepting the reality of the attack and using a panic attack as a cue to grow in a particular stressful area, often with the help of a therapist.
• Identifying and treating trauma, ideally accessing all four stages of trauma treatment as described in my book, Trauma into Transcendence (available for free on drkeithwitt.com).

#2: Develop strategies to deal with panic as it arises.

There are countless practices that help when a panic attack strikes. A few of my favorites are:

• Deep inhale, slow exhale while relaxing your body, focusing on what is your purpose in the present moment.
• Nature mysticism—feel unity with a leaf, a tree, a bird, or all of nature.
• Relax, get comfortable, connect with caring person if possible, and know that there is an arc in panic attacks where your distress will rapidly diminish over the next five to thirty minutes.
• Seek intimate physical contact and loving eye contact with a caring person. Hugs are good.
• If you can, go outside and engage in physical activities like walking, running, dancing, etc. (this definitely was not available in our Santa Fe jet!).

Medications

Psychologists are not medical doctors and can’t give medical advice, but of course we have personal opinions. I’m not a fan of the SSRI medications like Prozac and Zoloft—they often have severe side effects, are only marginally effective for depression, and have painful discontinuation effects—but sometimes they help limit or prevent panic attacks if you take them regularly. A good symptomatic medication for panic (if you are not prone to drug addiction—some are and some aren’t) is one of the benzodiazepines like Xanax or Ativan. These often provide relief within a few minutes. This can be quite useful since just having an effective medication handy is often calming enough that the attack doesn’t occur during an anxious moment. All psychiatrists and most general practitioners—almost certainly including your primary care doctor—have training and experience with these drugs.

The Bottom Line

The most important principle for dealing with panic attacks is to accept that they are occurring and to ask for and receive help in addressing what might be generating them. Like many of life’s problems, facing the symptom and growing with the help of caring others doesn’t just solve the problem, it makes us wiser and stronger.