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Penny’s Story, Part 1

Penny has always been a bit of a worrier, but now she’s started having periods “out of the blue” where she feels suddenly anxious, along with shortness of breath, feeling sweaty. The periods are so severe, that it feels like she’s having a heart attack. Worried that she might be having a heart attack, she goes to the Emergency Department at her local hospital. Good news, she finds out it's not a panic attack. But the bad news is that she keeps on having these attacks, and just doesn’t know what to do. What advice would you give Penny?

What are Panic Attacks?

Panic attacks are periods of intense fear and anxiety, caused by a sudden release of adrenaline in the body causing symptoms such as:

1. Physical symptoms

• Heart symptoms, e.g. heart racing or pounding, chest pain
• Breathing symptoms, e.g. shortness of breath, feeling smothered
• Digestive system symptoms, e.g. nausea, vomiting or stomach pains
• Inner ear (i.e. vestibular) symptoms such as feeling dizzy, lightheaded or faint

2. Emotional symptoms 

• Intense fear, anxiety or dread
• Depersonalization, i.e. feeling that things aren't quite real, or feeling detached from oneself
• Fear of losing control or going crazy, e.g. "I'm worried I'm losing my mind"
• Fear of dying
• The fears in a panic attack can be particularly bad. Until it is diagnosed, people often feel they are having a heart attack, going crazy or feeling like one is going to die.

Although the period of intense panic is relatively brief (lasting only a few minutes up to half an hour), there can be a persisting lower grade anxiety that can continue for hours afterwards.

Why Do People Have Panic Attacks?

It is normal to get anxious from time to time, as this helps protect humans against dangers. Throughout most of human history, the biggest dangers that human beings have faced have been physical dangers. As a result, we developed an alarm system to help us face those physical dangers. When triggered by a potential physical danger (e.g. a sabre tooth tiger attacking us), our alarm system jumps into action, and creates a surge of adrenaline in our brain. The adrenaline surge makes us breathe more quickly (to get more oxygen), and helps us either “fight” the danger, or take “flight” by running away from the danger.

The good news with modern society, most of us no longer worry about physical dangers in our day-to-day lives such as being attacked by sabre tooth tigers.

The bad news however, is that modern society has others stresses and ‘dangers” such as

• Stresses and worries about our work, relationships and finances.

• Physical stresses such as too much caffeine; not getting enough sleep, being sedentary... 

Our primitive hunter gatherer alarm system is not as well suited to modern stresses, and as a result, vulnerable individuals may find that their alarm system becomes trigger to have ‘false alarms’ such as panic attacks.

Terms

Panic attacks are:

• A sudden burst of anxiety with distressing feelings of anxiety and physical symptoms.
• As many as 40% of people have had panic attacks happen out of the blue at some point in their life, but most of them do not go onto develop panic disorder (avoidance of situations) or agoraphobia.

Panic disorder is:

• Repeated panic attacks that leads to avoidance of situations, in an attempt to avoid having another panic attack. .

Agoraphobia is:

• A type of avoidance where individuals avoid public places or open spaces, in an attempt to avoid a panic attack. Individuals can become housebound where they are unable to leave home, out of fear of having an attack in public. The term agoraphobia is from the Greek words “agora-”, the marketplace, and “-phobia”, a fear, meaning  ‘a fear of the marketplace’.

Where to Find Help for Panic and Anxiety

If you are having problems with panic and anxiety, then it might be helpful to:

• See your family doctor, who can 1) make sure that there aren’t any medical problems that are contributing to your anxiety, such as thyroid problems, heart problems, or other conditions and then 2) recommend what types of treatments (such as counselling) and supports may be helpful in your area.

Self-Help for Anxiety and Panic Attacks: Between Attacks

Here are some strategies to try between panic attacks: 

Lifestyle Strategies

• Eat healthy, nutritious meals. Studies show that people have less anxiety (and depression) when they:
  • Eat less animal fat and protein (e.g. less red meat)
  • Replace red meat with fish or chicken
  • Eat more plant protein and plant fats, e.g. avocadoes, olive oil
  • Eat less processed foods
  • Eat less soda drinks
• Spend more time in nature. Nowadays, many us live in cities surrounded by concrete and spending less time than ever in nature. However, during most of our human existence, we lived close with nature and as a result, human beings are wired to require nature in order to feel calm and relaxed (Martyn, 2016).
• Limit recreational screen use, such as video games, social media, etc. Excessive screen time can worsen anxiety as it can be overstimulating for the brain, and because it can contribute to lack of sleep.  
• Limit caffeine. Caffeine is a stimulant, and as a result, it can worsen anxiety.
• Limit alcohol, cigarettes, marijuana and other drugs. Although some people report that activities such as smoking cigarettes helps their anxiety, studies show that although they make you feel better in the short run, in the long run, anxiety is actually worsened.

Dealing with stresses and triggers

• Address the triggers for your panic
  • What are the triggers for your panic?
    • Sensory triggers such as noise?
    • Stress such as tension with other people?
    • Being hungry?
    • Being tired?
    • Any particular situations?
  • If you can figure out the triggers, then try to come up with a plan to address each one of those triggers.

Exposure strategies

• Avoid the avoidance. Start to face your fears step-by-step. When people have  panic disorder, they may start avoiding places where they fear there may be a panic attack. This makes sense if these places are truly dangerous, but in panic disorder, such avoidance is not helpful.
  
  Strategies for avoidance 

• Make a list of all the places where you have troubles going out of fear of having a panic attack.
• Order these from the least stressful, to the most stressful. 
• Gradually expose yourself to the least stressful situations.
• For example, if you avoid busy grocery stores, then try to come up  with less stressful situations, and start with a less stressful situation, such as:
  • Grocery store on a quiet Sun morning at 8 AM, going with my friend 4/10 stress
  • Grocery store on a quiet weeknight at 7 PM, going with my friend 6/10 stress
  • Grocery store on a quiet weeknight at 7 PM - 8/10 stress
  • Grocery store at on a busy Saturday afternoon - 10/10 stress. 
• For example, if you are afraid of dogs, then an example of a step-by-step hierarchy would be:
  • Look at drawings of dogs
  • Look at pictures of dogs 
  • Look at dogs at a pet store; 
  • Ask a friend/neighbour to visit their dog and simply look at their dog
  • Ask a friend/neighbour to visit their dog and pet their dog, etc. 
  • And seeing that it won’t harm you…

People strategies

• Connect with people in your support network.  Human beings are social creatures. We feel safer when we feel emotionally, or physically connected to other people.
  • Who are the people that you trust the most? (e.g. friends, family)
  • What can they do to help you with your anxiety? (e.g. spend time with me; listen to how I feel; distract me, etc.) 
  • What are the things that they do that aren’t so helpful? (e.g. giving unwanted advice)
  • What would you rather they do differently?  (e.g. just listen and agree with how I’m feeling)
     
• Support others in your network. Call up a family member or friend. Listen to how they feel and validate how they feel. Don’t jump in with advice or telling them what to do. Ask them how you can be helpful.

Write down your plan 

• When you are in a calm space, write down your plan on how you will deal with anxiety, also known as a coping plan. For examples of coping plans, read more here...

Self-Help for Anxiety and Panic Attacks: During an Anxiety / Panic Attack 

These strategies may be helpful when you feel anxiety coming on. It is best of course, to practice these ahead of time so that you will be prepared in case of an anxiety attack. 

1. Learn deep breathing. When anxious, people tend to breathe more quickly which can worsen anxiety, as well as lead to feeling tingling or numbness. On the other hand, breathing deeply and slowly through the nostrils is soothing and calming for our body.

Ways to help encourage slow, deep breathing include:

• Breath counting: Slow down your breathing by counting up to 6 as you breathe all the way in, and then count to 10 as you breathe all the way out.
• Relaxation and deep breathing apps. There are all sorts of relaxation and deep breathing apps that you can download onto your smartphone, or videos that you can watch on Youtube.
  
• Combat breathing. Does the idea of relaxation seem silly to you? Well, it turns out even soldiers find that relaxation and deep breathing strategies can be helpful.  There are many examples of Youtube videos, and apps, such as “Tactical Breather” to help teach this.
  
• There’s an App for that. Try one of the many Apps and other online tools for breathing and meditation such as Headspace, Breathing Zone, and Calm.
• Not breathing into a paper bag. Breathing into paper bags is no longer recommended. One study showed it is no more effective than breathing into an open tube. And for people with conditions such as asthma, breathing into a paper bag can be harmful because it reduces the amount of oxygen they are getting.

2. Coping thoughts. When you start to feel anxious, come up with some thoughts that help you cope such as:

• “I’m starting to feel the anxiety.”
• “This feels horrible, but I know this is just a false alarm going off in my brain; its not dangerous or life threatening.”“I’ve survived attacks before, and I will survive this one.”

3. Visualization: Imagining a calming soothing place in order to calm yourself down such as being on a beach; sitting at a park on a sunny day; etc. 
 

4. Grounding strategies. These strategies directing your brain’s attention away from the anxiety, and to compelling sensory input.  

• Name 5 things that you can see
• Name 4 things that you can touch
• Name 3 things that you can hear
• Name 2 things that you can smell
• Name 1 things that you are grateful for.

How to Support Someone with Panic Attacks

Between Panic Attacks 

• Spend quality time with them.
  
• Ask if they might be interested in doing healthy activities with you such as:
  • Going for a walk in nature; 
  • Going out for a herbal tea (as it is best to avoid anything with alcohol or caffeine).
  • Doing any of their day-to-day chores with you, e.g. groceries, laundry, etc.
• Provide emotional support, i.e. listen, empathize and validate any stresses they may be having. 
  
• Let them know that you care about them, and ask how you can support them with their anxiety or panic.
  • Specifically, you might ask them, "If you are ever having a panic attack, how can I best support you?" 

During a Panic Attack

• Support them with the strategies that you talked with them ahead of time outside of a panic attack, for example, it might be
  • Just being with them and making sure they are safe.
  • Asking them if they want to do deep breathing with you, OR it might also be NOT ASKING them to do deep breathing -- it all depends on the person.
  • Grounding them by holding their hand, etc. 
  • Being with them until the panic passes. 

Treatment of Panic Attacks and Panic Disorder: Psychotherapy

Have you tried various strategies on your own, but the anxiety and panic is not getting better? 

• Consider seeing a mental health professional (e.g. social worker, psychologist, psychiatrist) for talk therapies.

Cognitive-behavioral therapy (CBT) is a common type used for anxiety, and a  typical course of CBT is usually 1-hr/week for 5-10 sessions.

When people with panic attacks are triggered by a situation or event, they tend to get worry thoughts (“I’m going to die!”) which then worsen the feelings of anxiety, which then cause negative behaviours (e.g. avoiding situations) which then becomes a vicious cycle.

In CBT, people learn more helpful coping thoughts and coping strategies, in order to counter the anxiety.

Typical thoughts/feelings/behaviours seen in Panic Disorder before doing CBT: 

Example of  helpful thoughts/feelings/behaviours that might be practiced with CBT:

One particular powerful technique therapists may use are: 

• Exposure to the feelings of panic. When people have had a panic attack, they tend to become hypersensitive to even the littlest sensations in their body, which leads to worry thoughts and worsened anxiety. By exposing yourself to those same physical feelings that you have in a panic attack and seeing that these feelings are not dangerous, it will help make these feelings less frightening in the future, if you have another panic attack (Lee et al., 2006).  Studies have shown that this type of exposure (interoceptive exposure) on its own can reduce feelings of panic (without needing other strategies such as cognitive restructuring), and it was even more effective than deep breathing (Craske, 1997).
  
  Typical exercises to cause similar feelings as seen with panic attacks include (Anthony, 2006).

  • Hyperventilation,

  • Breathe as deeply and as quickly as you can for one minute.

  • Shaking your head

  • Shake your head from side to side for 30 seconds.

  • Step-ups

  • Run up and down on the spot as fast as you can for one minute.

  • Putting your head between the legs

  • Holding your breath

  • Hold your breath for 30 seconds.

  • Body tension,

  • Spinning,

  • Stand up and turn around in circles as quickly as you can for 30 seconds to make yourself dizzy.

  • Breathing through a straw

  • Breathe through a thin straw for one minute while holding your nose.

  • Chest breathing

These exercises are not fun. They are best done with the assistance of a trained CBT therapist, and are not meant to be used alone. 

Treatment of Panic Attacks and Panic Disorder: Medications

Medications may be helpful when talking therapies such as CBT haven’t worked, or when the anxiety is so severe that it is not possible for one to participate in talking therapy.

Medications include:

• Serotonin reuptake inhibitors (SSRIs), which work by increasing the function of the brain chemical serotonin.

Advantages of medication are that they can be helpful for severe anxiety, especially if the severe anxiety has prevented one from being able to do psychotherapy.

Disadvantages of medication are that they may cause side effects.

Interested in medication treatment?

• See your family physician, psychiatrist or nurse practitioner (NP).

Penny’s Story, Part 2

Penny has been having problems with panic attacks. She has always been somewhat shy, and recent stresses include her parents’ health and disagreements with her partner.

She sees her family physician, who helps recommend a nearby mental health agency where she is able to a counselor. Her action plan includes the following:

• An app to help with relaxation breathing
• She switches from coffee to decaffeinated herbal tea
• She gets more sleep
• She sees a counselor, who helps supports her with the various stresses in her life

Over time, things get gradually back to normal for Penny. And now with the new strategies that she has learned about being more assertive, and realizing what is truly important in her life, she is feeling better than ever.

Canadian Resources for Anxiety

Anxiety Disorders Association of Canada

http://www.anxietycanada.ca

Lifeline Anxiety Disorder Newsletter

http://www.designandcopy.ca/lifeline

Operational Injury Stress Support Group, for members of the armed forces and their families who are coping with operational stress and trauma.
http://www.osiss.ca

Provincial

Anxiety Disorders Association of Ontario, (613) 729-6761, 797 Somerset W, Suite 14, Ottawa, Ontario. Programs include educational workshops on coping with anxiety and mood problems; volunteer companion program; youth education programs in schools.

http://www.anxietyontario.com

Association des Troubles Anxieux du Quebec.

http://www.ataq.org

Readings

Don’t Panic, Reid Wilson, 1996

Anxiety and Phobia Workbook, Edmund Bourne, June 2005

References

Martyn P, Brymer E. The relationship between nature relatedness and anxiety. Journal of Health Psychology. July 2016, 21(7): 1436-1445.

Li P, Stamatakis J: What happens in the brain when we experience panic attacks, Scientific American MIND, July 1, 2011. Retrieved Dec 24, 2018 from

https://www.scientificamerican.com/article/what-happens-in-the-brain-when-we-experience/

About this Document

Written by members of the Mental Health Information Team at the Children’s Hospital of Eastern Ontario (CHEO), a multidisciplinary team which includes representatives from psychiatry, psychology, child/youth care, social work, nursing, and occupational therapy, as well as input from parent and youth stakeholders.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

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