If you’ve ever had a panic attack, you’ve been told you won’t die from it, but it sure feels like it. You have frightening body sensations. You feel you’re completely out of control and that you or everything around you is so different it seems unreal. I’m having a heart attack, you think to yourself. Or I’m going crazy. These are the two most common interpretations of what you’re experiencing. Once you’ve had a panic attack, the fear and anxiety of having another one is almost as bad as having one.

If this describes you or someone you know, I want you to know that you are not alone and that this is a treatable condition. In this article, I’ll tell you about panic attacks and panic disorder and how they are being treated today. New approaches to treatment provide complete or significant relief to most people. But first, make sure you see a health care professional to rule out possible medical conditions or contributors to your symptoms.

panic attack is an episode of intense fear and discomfort that begins abruptly and often out of the blue, with no identifiable trigger. It typically peaks in about ten minutes and fades away over minutes or hours; in rare cases, days. It includes a number of the symptoms listed below. A panic disorder is diagnosed after at least two unexpected attacks and a period of growing concern over having another attack. The anticipatory fear of another attack and the behaviors and feelings that follow from that are what make it a “panic disorder”, not just the attacks themselves.

Different people experience attacks somewhat differently, but everyone has some of the following:

Physical Symptoms. What many people fear most are the physical sensations they are having, such as:
hyperventilation; difficulty breathing
rapid heart beat
trembling or weakness
numbness or tingling in arms or legs
muscle tension
feeling cold or hot and sweaty
dizziness and nausea
abdominal pains or other G.I. symptoms
feeling light-headed
vision changes
chest pains

These sensations are what many people fear most and why they may be convinced they are having a heart attack. You first want to be checked by a doctor to rule out heart problems or other medical conditions. Then, a therapist who specializes in anxiety disorders can help you understand these symptoms and why they happen, and help you eliminate or greatly reduce them. I’ll talk more about this in the section on treatment.

Mental symptoms. Mental symptoms include:
Feeling you are going out of control or going crazy
Experiencing yourself as unreal
Experiencing your surroundings as unreal
Perceptual distortions
Feeling detached from yourself, or “not myself”

It is these symptoms that make some people fear they are going crazy. They may be afraid to tell other people about their experience for fear others will think they’re crazy. But these symptoms stem from a combination of hyperventilation, which causes a deficiency of oxygen to the brain, and the thoughts you have about your symptoms. As I’ll discuss below, therapy will help you learn protective breathing and how to work with your thoughts.

Negative Cognitions. This is what goes on inside your mind:

Negative thoughts, interpretations, self talk
Frightening images

These cognitions fuel the fear and increase the intensity of the other symptoms.

Feelings and emotions. These include:

A sense of doom

Behavioral symptoms. These include:

Avoidance behavior
Escape behavior

After one or more panic attacks, people usually start to avoid any situation they feel might trigger an attack. You may avoid situations where you might be alone and without help if you do have an attack. If avoidance is impossible, you want to escape the triggering situation you’re in. If you possibly can, you flee. If you can’t flee, you withdraw to whatever extent you can. After a while, some people don’t even want to leave home for fear of having attack away from a safe place. Then, panic has become agoraphobia, the fear of being away from home.

The specifics of my treatment are tailored to the individual person, but usually include the following components. Together, this is a version of cognitive-behavioral therapy, or CBT, designed especially for anxiety disorders.

Education Component. Because there is a lot of misunderstanding about panic attacks, panic disorder, and their symptoms, getting your questions and concerns answered is very important. This alone goes a long way toward reducing the fear that is so much a part of panic.

Altering Mental Symptoms. Many of the mental symptoms mentioned above (feelings of going out of control, feeling unreal, etc.) stem from a combination of hyperventilation (over-breathing), which causes a deficiency of oxygen to the brain, and the thoughts you have about your symptoms. Retraining your breathing and your thoughts will help change these symptoms.

Biofeedback. The physical sensations of a panic attack are signs that the nervous system is in over-drive, or hyper-aroused. You are experiencing extreme stress, the “fight-or-flight response”. But since there is nothing to fight or to flee from, this arousal can’t be discharged and instead is experienced as extreme anxiety. Biofeedback monitors various bodily processes such as breathing, muscle tension, blood flow and heart rate. With feedback on a computer screen, you can learn to calm your nervous system and tame these out-of-control responses. Breathing retraining is especially important because over-breathing, or hyperventilation, is a central feature of panic and accounts for many of its most frightening symptoms. Hyperventilation decreases oxygen flow to the brain and causes a sense of unreality and dissociation from yourself and your surroundings. It also helps to increase the arousal level of the nervous system and contributes to the physical sensations of an attack.

Cognitive Retraining. When your cognitions — your thoughts, self-talk, interpretations and images — are negative and catastrophic, they make your situation worse because they increase anticipatory fear and anxiety. They escalate physical symptoms. This in turn usually makes the cognitions worse. A vicious, escalating cycle is created. The cognitions also contribute to depression about your condition. You must alter these self-defeating cognitions by cognitions that are more realistic. Instead of I’m going to die, a more realistic thought is “This feels bad, but it is not going to kill me. I just have to ride it through”. Instead of “I can’t do anything. I’m a loser”, it is more helpful and more truthful to understand that this is a thought that doesn’t capture the whole of you and your abilities. Your therapist will explain that these are “all-or-nothing”, over-generalized”, “negative filtering”, types of thoughts and will help you learn to identify and replace them.

Life Style Changes. For some people, stress-producing activities or relationships, diet, alcohol consumption, drug use, exercise, sleep habits, etc., contribute to their attacks. These life style contributors must be faced and altered to get full control over recurrence of attacks.

Medication. For some people, medication to help reduce the symptoms and the likelihood of an attack may be suggested. It is not necessary for everyone and should never be taken with the expectation that this is all that’s needed. It is our opinion that medication should only be used on a temporary basis to create a calmer, less agitated foundation on which to do all the other work outlined above. Dysfunctional habits in the body and mind have been created and it is important to replace these with new habits and skills. These new habits and skills, created by you, serve to make you less vulnerable to future panic attacks, more confident in your ability to control your own thoughts and feelings, and will help you in all other aspects of your life, as well. If you and your therapist decide to include medication, you will be referred to a psychiatrist who will determine which one is right for you.

Is this approach right for everyone who experiences panic attacks? If your extreme anxiety is part of another disorder, medical or psychiatric, this approach may not be appropriate for you. The other disorder must be treated. After that treatment, or along with it, some of these approaches may be helpful. Depression often accompanies anxiety and panic and definitely does not rule out this form of treatment. In fact, cognitive-behavioral therapy is highly recommended for depression. If you use alcohol excessively or recreational drugs and are unwilling to give them up, this treatment will be unsuccessful. You must also be willing to take an active part in changing your life and your habits.

I hope this helps you understand what panic attacks and panic disorder are and how they are treated. It is important for you to know that they are highly treatable and you don’t have to live with this condition. It is also important to be aware that the treatment for panic is not a passive treatment. You do not simply come into the office and talk about your problems and stop there. It is a highly active treatment on your part and the part of the therapist. It involves dedicated work between your sessions to alter the habits of mind and body that sustain the disorder. It is well worth the effort, not only for eliminating panic but for creating a stronger internal foundation and set of skills for the rest of your life. YOU can be in control! I find great satisfaction in helping people to do this.