Mental Health

What to do when you feel a panic attack coming

There are basically two options for what to do when you feel a panic attack coming on. The first is to use a coping technique. The second is to do an exposure. And yes, I will explain what coping techniques and exposures are! But first, let’s start off with my favourite analogy: Notice: The following is presented for informational purposes only. Assessment and treatment should always be directed through one-on-one consultation with a trained professional.

This is one of my favourite questions and obviously one of the most important ones for people who are trying to gain mastery over panic.

There are basically two options for what to do when you feel a panic attack coming on. The first is to use a coping technique. The second is to do an exposure. And yes, I will explain what coping techniques and exposures are! But first, let’s start off with my favourite analogy:

The Demon Analogy

Panic disorder can be thought of as a demon. There are two ways to fight this particular demon. The first way is to use your shield — Using your shield means using medications (such as Xanax), leaving the situation for a while to calm down, using relaxation techniques, and/or talking back to your anxious thoughts to quiet them down. Below I will describe these coping techniques in detail including their pros and cons. But apart from your shield, there is also a second way to fight this particular demon – it turns out that every time you face the demon head on, he gets weaker. Each time you challenge him, he gets smaller. That is where exposures come in to play. Exposures involve turning the tables on the demon by jumping him, challenging him, and saying “Bring it on. Is that all you’ve got?”

Initially, most coping techniques alone are actually not strong enough to stop a panic attack . For example, you may try relaxation to stop a panic attack but it’s just not working. The demon is so large, that he just swipes your “shield” aside. However, usually after one to two months of starting to face the demon (i.e. doing exposures), the demon become so small that the shield techniques finally start working! And after several months of exposures, the demon typically becomes so tiny that he stops coming around at all and eventually dies.

These combined tactics of using your shield and periodically facing the demon head on will help you gain mastery over panic once and for all. If you learn these techniques (in a type of therapy known as Cognitive Behavioral Therapy) it is very likely that you can eventually enjoy going out with your friends, driving your car, flying overseas, and enjoying a sunny day at the beach without having to worry about panic any more.

The Shield (i.e. Coping Techiqnues):

Benzodiazepines (ie Xanax, Ativan, Klonopin, Valium): These are usually the most immediately powerful of all of the coping techniques. It usually takes about 20 minutes for benzodiazepines to kick in, and they strong enough to stop and even full blown panic attack. The main drawbacks of these medications are that if you take too much, they can make you tired, and if you take them everyday, you might get used to them after 1-3 months (i.e. they might stop working). In addition, people with a history of addiction problems can get addicted to these medications (although in general, they produce a pretty weak high, so it’s exceedingly rare for a non-addict to become addicted to these drugs). I prescribe benzodiazepines to my patients while they are learning the other coping techniques and starting the exposures. I typically recommend using benzodiazepines on an emergency basis to stop panic attacks, and occasionally I even recommend using benzodiazepines on a regular daily basis for people who are in a chronic state of panic / high anxiety. Although benzodiazepines will not cure panic disorder, they can provide relief while you are engaged in a more definitive treatment (such as Cognitive Behavioral Therapy).

Leaving the Situation: This is one of the strongest coping techniques, but also can eventually lead to problems. Leaving a crowd, pulling over on the side of the road while driving, or avoiding vigorous exercise are examples of leaving the situation. These are effective coping techniques because they can frequently avert a panic attack. However, these techniques have the obvious drawback of encouraging agoraphobia (i.e. the avoidance of activities because of a fear of panic). I would say that leaving a situation is useful, but only if you are also engaging in a definitive treatment to help you complete control over panic disorder.

Relaxation Techniques: It’s hard to stop thinking about something “cold turkey.” It’s easier to stop thinking about something if you replace your thoughts with something else. Relaxation and meditation techniques aim at getting you to stop thinking by giving you an effective distraction to replace your thoughts with. For example, many Buddhist forms of meditation replace your thoughts with a focus on repeated sounds and/or breathing. In addition, various visualization exercises replace your thoughts with vivid imagery. The relaxation techniques I have found to be most effective for panic attacks are 11-muscle relaxation with Abdominal Breathing, Sensation Focusing, and Permission Breath Counting. These are all cognitive-behavioral techniques and they can be found at Panic Mastery. I never teach patients just one coping technique because different techniques seem to work for different people. Relaxation techniques initially may not be strong enough to stop a panic attack, but they become much more effective once you have started doing exposures.

Thought Restructuring: This coping technique teaches you ways to stop your anxiety by talking back to it. Thought restructuring is a type of journaling done on paper for 10 minutes a day for 1-2 weeks. After 1-2 weeks, I usually encourage my patients to stop talking back to their thoughts on paper and start doing it in their heads. Much like relaxation techniques, this is a cognitive behavioral therapy technique, it gets better with practice, and it becomes much more effective once you have started exposures.

Thoughts restructuring along with Relaxation Techniques eventually form the two most healthy and permanent parts of your “shield” because they can be used extensively without having the drawbacks of avoiding situations or relying on medications. However, these “shield” techniques are usually not strong enough alone to completely cure panic disorder, most patient need to do exposures.

Facing the demon (i.e. Exposures)

Exposures involve voluntarily bringing on a mild to moderate level of anxiety In other words, exposures show you ways to face the demon, challenge him head on, and kill him once and for all. There are two keys to exposures: 1. They have to be voluntary (which means that you can’t do them all the time, because you won’t always be in the mood) and 2. If you imagine your anxiety from a 0-8 (with 0 being calm and 8 being a panic attack), you want to hit a 4 during any given exposure (because if you go above a 4, the anxiety might get ahead of you and no longer be voluntary and under your control). Exposures are used to gain mastery over any phobia. They work for panic disorder because the core of panic disorder is usually phobia as well: A phobia to certain physical sensations. Whether it’s a racing heart, dizziness, nausea, a choking sensation, or a certain pain, every panic disorder patient has at least one or two physical symptoms that trigger their panic cycle. Exposures show you how to experience these sensations in such a way that you finally stop being triggered by them. After 1-2 months of exposures, most patients find that coping techniques begin to be effective (i.e. the shield actually starts working). Once patient are good at exposures, they can often use them to actually stop a panic attack that is coming on. In other words, once the demon appears, they can turn the tables on the demon, challenge it, and get it to run scared with it’s tale between it’s legs. After several months of exposures, most of my patients become completely panic free (and can usually be taken off on any panic-related medications they have started). Exposures are at the heart of Cognitive Behavioral Therapy, and they are by far the most useful techniques for killing the Demon and gaining mastery over panic once and for all.

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