Tuesday, July 8, 2008

Understanding the Vicious Cycle of Panic

The physical symptoms of anxiety lead to increased anxiety which in turn leads to increased physical symptoms, in other words, anxiety feeds off of itself. We would like to take a little time to discuss this "Vicious Cycle of Panic," in more depth because it is a critical concept to understand so that panic attacks can be prevented.

Panic attacks are generally described as being "physically abrupt," or "out of the blue," or occur "without an apparent cause." Indeed, many of my clients will make a comment something like, "One minute I was sitting on my sofa feeling fine, and the next minute I was having a panic attack."

While we agree panic attacks can develop very quickly and abruptly, we strongly believe that they develop from this feedback loop, or "vicious cycle." To explain:

The Vicious Cycle of Panic always starts with stimuli or "triggers", which are either external (outside ourselves) or internal (within ourselves). There are 8 broad categories of triggers, which I will discuss in depth in future SharePosts, but for now, just note that stimuli are wherever we are and cause the experience of a bodily sensation.

For example, where are you right now? Are you sitting on a chair at your computer reading this post? How does the chair feel? Is it soft and comfortable or is it hard and uncomfortable? Maybe it's somewhere in between, not especially soft or hard. Unless your chair is particularly uncomfortable, you probably were not thinking about how it felt until we asked you about it. Also, most likely you do not have strong thoughts or feelings about how your body feels while sitting in your desk chair. If this is true, then at this point you are probably wondering why I'm making such a big deal out of it. The chair is an example of an external stimulus that causes a body sensation when you sit on it.

In order for the Vicious Cycle to start, however, you must first notice the body sensation and have a negative interpretation of it. If you have a neutral or positive interpretation of a body sensation, then you will not head towards a panic attack. Let's look at some examples:

Many people we work with are uncomfortable sitting among large groups of people during an event such as a play, movie, church, or classroom.

Joe* talked to me (Dr. Fee) about sitting in a church service. "I was sitting in the middle of the row and there were people on both sides and our arms were touching. I started to sweat and soon I knew if I didn't get out of there I would panic."

The stimulus for Joe was sitting in close proximity to other people. Their arms touching him is a stimulus. If it is a little warm in the room, that's another stimulus. Sitting in close proximity to other people in a warm room will cause a body sensation that many of us would notice. We might be hot, feel cramped or closed in, or uncomfortable in some other way. However, if we were not scared by this sensation or did not worry about having a panic attack, then nothing would happen, we'd just be hot and uncomfortable.

When I asked Joe what was going through his mind as he sat between the two people he stated, "When I noticed I was sweating I started to think, "Here we go again, I'm going to panic." In other words, he had a negative interpretation of his sweating. Joe is well on his way into the Vicious Cycle of Panic. He had the stimulus (sitting in close proximity to two people in a warm room), the bodily sensation (sweating), and the negative interpretation of the bodily sensation (Here we go again, I'm going to panic).

Negative interpretations often lead into a string of "what if..." thoughts, which for Joe were, "What if I faint?," and "What if I have to get up and leave and everyone stares at me?" What if thoughts tend to turn into catastrophic thoughts, such as, "I will faint in front of everyone." As the intensity of thoughts progress, then the intensity of the physical sensations increases, feeding off of each other which can result in a panic attack.

It is true that this can all happen very, very quickly. However, if you start to become more aware of your reaction to the stimuli around you, you can become more sensitive to your escalating anxiety. As you become more sensitive to when your anxiety is escalating, then you will be more equipped to do something about it before it spirals into a panic attack.

In other words, while panic attacks appear to come out of the blue, once you start to closely examine them, you will often find clues as to what triggered the panic attack. Once you understand triggers, you can learn to prevent panic attacks.

As a first step, start to rate your anxiety on a scale of 0-10. 0 is completely calm and relaxed, and a 10 is a panic attack. Where would you rate yourself right now? Anything from 0-4 is ok, but when you are at a 5-7 it's time to intervene before your anxiety escalates into a panic attack. Start taking your anxiety "temperature" multiple times per day and make a note what you are doing when your anxiety is low, and what you are doing when it is high. For now, look for trends. I'd encourage you to keep a log of your anxiety temperature for a few weeks, and take it into your therapy session if you are in therapy.

In our next few Blogs we'll go into depth about the broad categories of triggers so that you can start to hunt for what your triggers are.

Warm Regards,

Dr. Jennifer Fee & Dr. Diana Walcutt

*Client names and details are always changed to to protect confidentiality

Tuesday, July 1, 2008

Part I: What is Happening to my Body: Knowledge is Power

When you're anxious, or after a panic attack, I'm sure that you can tell me what you are feeling and and perhaps, you can even describe what you were thinking during your anxiety or a panic attack. But there is something else going on, a physical component that can be as much, or even more powerful than what you are feeling or thinking.

Some people like the thrill of excitement, or the "adrenaline rush" as we call it. Another term for this is the "Flight or Fight Response, or Syndrome". You've probably heard these terms, and I will discuss what is going on physically, so you can identify those physical signs and triggers. Have you ever wondered why you feel anxious and others feel really great when confronted by similar challenges? How is it that some people who enjoy the adrenaline rush may actually be physically different from those who suffer from panic attacks? Part of the difference is your perception of what is actually happening, and who is in control of the situation. We can go into that further in another blog. Right now, we're going to stick to the physical part.

The Flight or Fight Syndrome is given to us by Nature to deal with emergencies. Beginning with the creation of mankind, this physical response to a perceived threat is rapid, effective, and complete, at the first sign of danger.

The first thing that must happen, is that your brain is alerted to some kind of danger. The danger may be real or something perceived as dangerous. Think about your brain as a three pound computer, sitting in it's case on top of your neck. While it's pretty sophisticated, it has two jobs and two jobs only; to drive your mind and your body. How does it do this? Though feedback from internal and external sources. That is, it takes information put in by your five senses; hearing, smell, eyesight, touch, taste, or by signals sent from within the body via chemicals, neurotransmitters, hormones, electricity, allowing it to respond. While this is a really elegant piece of equipment that you are responsible for, it doesn't always function perfectly. That does not mean, however, that we shouldn't help it out in anyway that we can.

So let's just track an external source of anxiety, ok? Let's just say you hear a loud crash in the other room. You're startled, right? Then what happens? Well, there are a lot of theories, and I will explain one of them to you.

OK, since we're tracking this startle response, the sound causes the Amygdala to register fear in the form of the startle response. The amygdala is a little almond-shaped structure in the brain that processes emotions. This is the control center for the identification of danger and is fundamental for self preservation.

The Amygdala is a component of the Limbic System, the part of the brain deep inside that manages more of the primitive parts of your functioning. This is the part that has a lot to do with your survival; that is, your hunger, sex drive, and emotions. Among other structures, the amygdala is connected to the hippocampus.

This structure, shaped somewhat like a sea horse, which is what hippocampus means, is in charge of memories. The left and right hippocampi are involved in long-term memory storage. When these are damaged, you cannot store new memories.

The hippocampus allows you to compare the conditions of a present threat with similar past experiences and enables you to choose the best option to guarantee your survival. This structure then sends signals to the cortex, or the outer layer of your brain where you can think about what is happening and make your choices.

The cortex is responsible for the more sophisticated functioning in the brain, such as talking and thinking, as well as movement and sensory control. So it controls the fact that you heard the crash, the fact that you jumped when you heard it, and the fact that your first words, or sounds such as a scream, were uttered about the crash.

So, those are some of the structures that respond to the sound of the crash. What else happens?
Everything speeds up inside you, including the brain, the heart, your breathing, your muscles tense up, your blood vessels contract in our arms and legs, and you become very fast. This is part of your automatic response mechanism or Autonomic Nervous System (ANS), designed to keep you alive. What a terrific gift, right?

The Autonomic Nervous system is divided into two parts, the sympathetic and parasympathetic nervous systems (SNS and PNS). Part of the sympathetic nervous system's job is to help you stay awake, respond to stress and react to emergencies. Adrenaline is produced on the sympathetic nervous system's side of your body.

Part of the parasympathetic nervous system's job is to facilitate relaxation and help you go to sleep. When the parasympathetic system is activated, the bowel and other non-muscle organs receive good blood flow, the pupils of your eyes constrict and your glands function well and secrete their various compounds. Absence of parasympathetic activity leads to poor digestion, poor healing and poor organ function.

If we don't find time to care for our bodies, over time they will break down. It's not like we can go to a body mechanic to fix it, either. Once organs are destroyed by stress, we can't just get new ones. Part of the reason you are listening to these tracks it to help your body restore some of the functioning of your weary cells and organs. It is very important to take time out from your life to allow for rest and proper parasympathetic action in our bodies. Proper sleep, nutrition and balance in your life will help you feel better. You can purchase CD's from our website; http://www.thestressmasters.com/ that will teach you breathing exercises and offer relaxation tracks that will help you achieve this.

Have you ever experienced a wave of relief when something that has frightened you has passed? Have you laughed yourself silly when people have jumped out and startled you at a surprise birthday party? Hate it, don't you? Some of us do, others revel in it. Part of that response is caused by a substance named adrenaline. Adrenaline is a chemical that is produced in your body by the little Adrenal Glands that sit on top of each kidney. Adrenaline actually kicks the body into overdrive when it's needed. When it's in the brain, adrenaline is called norepinephrine. There are also medications that focus on managing norepinephrine levels in your brain.

This is the end of Part One, "The Stress Masters: What's happening to my body? Knowledge is power." I will write Part Two in a few days.

Dr. Diana L. Walcutt