How to overcome panic attacks

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What is a panic attack?

Imagine you are walking along the street or you are in the middle of a busy supermarket and you are suddenly overwhelmed by feelings of panic. You begin to perspire, your heart beats loudly, your chest tightens and you struggle to breathe…you are unsteady on your feet, perhaps wanting to run, but feeling unable to do so. Your whole body trembles and you experience dizziness; hands and feet tingle as you gasp for air; you feel a choking or smothering feeling, and with thoughts racing and feeling faint, you worry about losing control, or worst still dying…This is what a typical panic attack might feel like.

Of course, not everyone who experiences a “panic attack” will have all these symptoms, but they can be extremely frightening, and to those who have them regularly, they can be so disabling to the point where sufferers avoid situations and places which they associate with these attacks. Often agoraphobia and panic attacks go hand in hand. For some people, so-called “phobic panic attacks” are associated with a deep rooted fear, such as seeing a spider or being in shops or crowded places where they feel unable to escape. Some people have panic attacks with no obvious external cause and these are known as spontaneous panic attacks. These can be brought about by stressful situations or events; running upstairs or even laughter may trigger attacks in people who are prone to them.

Panic attacks usually start with one or two symptoms, perhaps awareness of heart beating or a hot flush rising to a crescendo, peaking in a few seconds; sometimes they can last for a few minutes but seldom for long.

The actual cause of panic attacks can vary, but in essence it could be described as a surge of intense anxiety. This often leads to the individual taking deep breaths in order to try to overcome anxious thoughts and heightened bodily awareness. Over-breathing in this way leads to an excess of oxygen in the body which gives rise to physical discomfort and causes a vicious circle leading to heightened awareness of symptoms and further panic. Panic. Panic attacks are extremely common with many people experiencing one or more at some stage in their lives.

Recognising panic symptoms

The first step in overcoming panic attacks is recognising the symptoms: 

  • Rapid heartbeat
  • Feeling flushed (or cold)
  • Tightness or pain in chest
  • Lightheaded
  • Feeling dizzy
  • Tingling in hands/arms or numbness
  • Feeling nauseous or sick
  • Sweating
  • Trembling
  • Choking sensations
  • Shortness of breath
  • Worry over loss of control
  • Fear of death
  • Fear of fainting
  • Fear of going crazy
  • Feeling unreal

Panic attacks from a CBT perspective

From a CBT perspective we look at dividing the symptoms into three broad areas:

Physical Symptoms –  As we can see from the list above, physical symptoms are plentiful. Things like rapid heartbeat, shortness of breath and tightness or pain in the chest make this a very real and frightening experience.

Cognitive symptoms – This is to do with our thoughts (cognitive = thoughts). While the physical symptoms are hard to miss, it is the cognitive component that gives rise to anxiety. For example, we experience pain in the chest, shortness of breath with tingling in the hands and arm region. Our thoughts turn to the possibility of us having a “heart attack.” Images of us lying on the floor, clutching chest with a crowd of onlookers and a paramedic in attendance. Our anxiety levels rise and when we focus on our symptoms they seem to magnify. Our sense of panic and fear rises as a vicious cycle is created, In our mind thoughts are racing.

Behavioural symptoms – This is where you quite simply want to ditch the shopping trolley and escape. This is where you worry that you will have a panic attack if you enter certain places (particularly if you experienced a panic attack there before) or where you avoid people or crowded places. (Avoidance can also be cognitive, such as when you use distraction). Likewise, certain behaviours such as drinking water, reaching for the mobile phone, taking rescue remedy or medication are what we call “safety behaviours.”

The vicious panic cycle

Although you might think that panic attacks simply happens, this is not the case. There is a distinct pattern that can be clearly seen when we look closely at the experience. You will see that various things happen in a sequence of events –

  1. The trigger – This might be a sudden thought, perhaps brought on by an image in our mind or perhaps by a bodily sensation. It might be as a result of a frightening experience we are involved in.
  2. Automatic thought – “I’m in danger,” or “Oh no, not a panic attack,” or “What’s happening?”
  3. Emotional response – Usually fear or raised anxiety.
  4. Bodily reaction – A feeling of breathlessness, of chest tightening, light headedness, heart begins to race, feeling increasingly hot and uncomfortable.
  5. Focus on sensation – We zoom in on our bodily reaction, scanning for symptoms.
  6. Sensations increase – With all our attention on focused on our bodily symptoms they magnify as adrenalin and noradrenalin race through our body.  Our brain sends messages to the heart to beat faster in order to send more oxygen rich blood to our  major muscles, our blood pressure rises and our body prepares to fight off the imagined predator about to attack us.
  7. Imagine the worst – “Is it a heart attack, will I faint, am I going to lose control, will I make a fool of myself, will others notice”… The list of possible negative outcomes increases Our natural urge tells us to avoid, escape or engage in some kind of safety behaviour in order to save ourselves.
  8. Panic – The cycle is complete and we in our mind we are back at point 2 and so 2 to 8 are repeated, sometimes several times over and panic escalates.

Your seven step plan to managing panic attacks.

  1. The first thing to remember is that while panic attacks do not feel pleasant they will pass and they are not dangerous. If it will help, write this down on a piece of paper, laminate it and carry it with you to remind yourself.
  2. Stay calm – turn your attention to your breathing. Take slow gentle breaths into your tummy, place your hand above your tummy button and focus on the gentle rise and fall of your diaphragm.
  3. Try to reduce your anxiety by saying to yourself, “everything will be alright” or “calm.” Try to let the fear go moment by moment.
  4. Shift your attention to your muscles, gently stretch and tense them, then relax them and allow tension to slip away.
  5. Accept what is happening, don’t try to fight it. The feelings will pass, be patient, stay with them and watch them as they gradually fade away.
  6. Stay in the situation, no need to escape. Simply focus on relaxed breathing and calming down,
  7. Pa attention to reducing your discomfort by using your breathing as your friend. Stay in the present and rest assured that your panic will pass.

There are a number of very good websites and organisations you can turn to for advice and support. These include:

The voluntary charity – No Panic – www.nopanic.org.uk    

The website – AnxietyBC – www.anxietybc.com                                                                                                                                                                                                    The mental health charity – MIND – www.mind.org.uk 

The information and resource service – Centre for Clinical Interventions – www.cci.health.wa.gov.au

Cognitive Behaviour Therapy (CBT) resources – GET.gg – www.getselfhelp.co.uk 

Remember, panic attacks are very straightforward to treat and a good therapist will be able to help you to overcome them in no time at all. To find a CBT therapist near you look up BABCP – www.babcp.com or contact BPS – www.bps.org.uk to find a psychologist trained in CBT. Alternatively you may contact me at – www.stevecliffordcbt.com

Until next time, Steve Clifford, Cognitive Behavioural Psychotherapist

Please post a comment if you have a good tip to help overcome panic attacks?

www.stevecliffordcbt.com

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How do I stop worrying about sleep?

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Why is it that when I have a busy schedule ahead of me tomorrow that I end up having the worst nights sleep imaginable and yet when it doesn’t matter, I sleep like a baby?

Falling asleep when your worrying about falling asleep, can make it a whole lot harder to fall asleep. You see, the harder you try to sleep the more likely you are to  stimulate the mind and body through frustration and worry, and with sleep being a passive process you simply defeat the object.

A stressful event tomorrow is almost guaranteed to put the kiss of death on a good nights sleep. The secret is to spend the evening before, in exactly the way you would normally, no early night, no putting last minute touches to your presentation, no checking your journey or the itinerary ..this should all have been done at least a day or two ago, with clothes selected, ironed etc. If you experience anxiety the best thing you can do is forget tomorrow and have a normal evening, that means staying up until your normal bedtime, if necessary watch the late film, and if you normally enjoy a beer or a glass of wine do so. When I say “a beer” I do mean “a beer,” or “a glass of wine.” Believe it or not, alcohol actually provokes anxiety. While this is masked initially by its anaesthetic properties, (the chemical name for alcohol is ethyl alcohol and it is related to ether the anaesthetic agent) once this wears off, the body becomes twitchy and aroused, hence problem drinkers often feel irritable, tremulous and anxious and resort to the “hair of the dog.”

In the evening it is good to have a bath as part of your “wind down” procedure. This will also help regulate your body temperature. Avoid showers in the evening as they can stimulate the body. Incorporate a relaxation technique into your evening “wind-down,” the gradual letting go of the stimulation of the day, replacing the high arousal activities with more peaceful one’s. Learn how to do imagery. You can then take yourself to an imaginary place in your mind when you find yourself wrapped up in sleep preventing thoughts. All you have to do is to create a mental picture, perhaps of a holiday or somewhere nice you have been. It may be an imaginary scene, a beach or a meadow in the countryside. See with as much realism as possible, notice the colours, the sounds and the sensations, perhaps of the sand between your toes, the warm breeze or the smell of freshly mown grass. Imagine a calm, tranquil and relaxing scene…and enjoy.

Don’t let the stress of a busy day and demanding schedule get in the way of you and sleep. By all means work hard but stop working late, reduce your hours and reduce your stress. If you are thinking about work into the evening then you’re stressed, whether its eustress (good stress) or distress (bad stress) it’s got to go. Heaven forbid, before you know it you will be thinking about work in bed. For those with sleeping difficulties, work needs to be limited to the working day. That’s the rule, like it or lump it… and by the way, you might wish to find your self a good therapist who can teach you tips to better manage the stress of our busy and demanding lifestyles. A therapist who helps you with sleep could be viewed a “sleep coach”. Small changes in the various different areas of your life are likely to be all that is needed.

If you find yourself busy with children, work, cooking meals whatever, it may be that you don’t have time to think until you get to bed. Then invariably if you are anxious worry may surface, even worry about worrying. The early hours, perhaps when you wake up to go to the toilet can be fatal, worries and concerns can easily magnify and grow out of proportion. I believe it was Napoleon who said, “show me a brave general at three in the morning!” You may find that setting aside some “worry time” helps. Schedule a regular slot each day to review your day, preferably before 7pm. Reflect on events and “put the day to bed.” Consider what needs to be done tomorrow and attend to anything that needs your attention. Write your worries down and then put them away in a drawer and look at them tomorrow. Keep a pad and pen by your bed and write down any worries that won’t go away. Reflect on your worries your prescribed worry period.

Next, take in some exercise, again there is no excuse. Where I go to the local municipal gym it is like a social club. Early in the morning before the school run and daily commute to work, 20 minute working out with the pensioners is great. Some of them put me to shame in terms over overall fitness and the welcoming friendliness makes it a pleasure to attend, plus its nice being the youngest one there! Whether you walk, jog, swim, cycle it doesn’t matter. The important thing to do is to engage in some aerobic activity to burn off the adrenalin. I do it to put me in a good place to start the day, however, if you are looking at using exercise to help with sleep then do it late afternoon or early evening. Leave at least 2 hours before you go to bed or you may likely find your body is not ready to relax.

Try to discipline yourself to say off the computer after a certain time, emails, facebook and ebay can be very engaging. Going on the computer just before bed is definitely not a good idea, for anyone. The problem with computers unlike a good book, is that they are interactive and that is stimulating. While you may think this is not the case, your brain activity will be in a state of latent arousal. Two hours of computer tablet use at maximum brightness level has been found to suppress the normal night-time release of the hormone melatonin. It is this hormone that signals to the body that it is night and makes you sleepy. Postponing this important signal may delay the onset of sleep (Figueiro et al, 2012).

Avoid eating a large meal late in the evening, instead eat early and have a light snack mid evening, something like warm milk or horlicks (milk contains tryptophan which helps sleep) and have a banana or biscuit. Likewise, if you wake in the middle of the night and do not fall back to sleep within twenty minutes, instead of lying in bed worrying, get up and find a comfy place to have a read, with low lights and perhaps a  milky drink in a flask. Then go back to bed only when you are “sleepy tired.”  By this, I mean that your eyes want to close, your yawning and your head nods. Staying up serves to increase your “sleep drive.”

If you find yourself worrying there are several things you could try, the first is to use a relaxation technique such as tensing and relaxing every part of your body in turn, another technique is autogenic relaxation. For this you repeat “my left arm is heavy and warm” eight times, imagining the heaviness and the warmth (both are states of relaxation) and repeat this with each arm, both arms, each leg, both legs and so on through the body. Another technique is known as thought blocking, for this you repeat the word “the,” over and over again. “The” is actually is a meaningless word and therefore useful in this respect. A further technique that I am keen to promote is known as mindfulness and it teaches people to learn to detach from  stress, worry and rumination (see my November 2012 health blog).

Trying to stop anxious thoughts does not work. This is known as “thought suppression” and trying not to think about something actually increases the volume of thoughts. It is because by trying to force out thoughts means you are actually thinking about them  Imagine it is rather like trying to turn down a broken volume knob on a radio. The problem is, the more you turn it down, the louder it goes. Rather like the adverts in between songs on a commercial radio station just let them play and you will begin to not notice them. Try this. Close your eyes and visualise a big fat pink elephant. Now for the next three minutes don’t think about pink elephants…How was that? Did you find that the thought of pink elephants kept popping into your mind?

Worry about not coping during the day because of poor sleep is a very common theme for those with sleep problems. Professor Colin Espie of the University of Glasgow Sleep Centre, tells us that, “although insomnia can be distressing, and can be distressing, people often come to incorrect conclusions about their ability to sleep and the effects that sleeplessness will have.” He tells us that “most people do manage to cope during daytime even after a bad night’s sleep.” With regard to concentration, while ” insomnia can cause problems with concentration, and we can feel tired, edgy and irritable…we must remember to try to keep our thinking about sleep in proportion. After all, good sleepers get bad-tempered too. The less focus your concerns

Sometimes people worry about noises in the night. It may be creaks and banging noises caused by pipes, woodwork expanding and contracting as the temperature changes. Equally it may be noises outside, people in the street, traffic, etc. The problem is that once you focus on these noises, they will seem to magnify and it can be very hard to distract ourselves. Another problem might be your partner snoring or even the sound of their breathing. One simple solution can be the use of earplugs (see ZenPlugs UK).

How do we differentiate between our thoughts and emotions? This is quite difficult because thoughts and emotions often go hand in hand. The way we feel will affect the content of our thoughts, just as our thoughts shape our emotional responses. If you find yourself worrying about work, family, money it can be very hard not to have  waves of powerful emotional reactions at times. You might be thinking about work the next day, rehearsing something in your mind or planning something ahead. Equally you may worry about not performing or making mistakes. All of these can evoke powerful emotions, frustration, anger, guilt, sadness and worry. The problem is, that strong emotions, provoke strong reactions often stimulating and arousing the body. Try keeping a pad and pen by the bed to jot down you brainwave of an idea (preferably with low lights on only). Instead of visualising yourself making mistakes, “flip” your thoughts and visualise yourself calmly doing things well, see yourself smiling, relaxed and positive. This kind of positive visualisation is exactly what athletes and actors do before a performance.

If you are worried that your worry about sleep may be the result of a clinical condition such as depression or generalised anxiety disorder, consult your general practitioner or other health professional. If you would like more information on  sleep clinics look on-line for a  centre near you. If you would like information on “sleep hygiene” with advice on lifestyle, preparation for bed and other changes to improve your sleep pattern, please visit – insomnia-treatment co.uk

Until next time, Steve Clifford, Cognitive Behavioural Psychotherapist.

www.stevecliffordcbt.com

References:

Espie, C. A. (2010) Overcoming insomnia and sleep problems; A self-help guide using Cognitive Behavioural Techniques. Robinson: London.

Figueiro, M., Wood, B., et al. (2012) Light level and duration of exposure determine the impact of self-luminous tablets on melatonin suppression, Lighting Research Center, Rensselaer Polytechnic Institute, USA.

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Living with the death of a loved one

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The death of a loved one is probably one of the most distressing events we ever have to experience. For anyone who has suffered loss, whether recent or past, the pain can seem unbearable. A great big empty space, a chasm so deep that it seems never ending.

If you have lost someone you love, a parent, partner, lover, a pet or a dear friend, or if you have been forced to re-evaluate your life with the loss of a job, illness or divorce, the feelings you experience will be those of grief.

It is a shame that even those close to us do not always know what to say. Sometimes it can feel as if people are avoiding us. The problem is that people find it very difficult to know just what to say to someone who has experienced a deep personal loss. It’s not that they don’t care, but it’s because they feel uncomfortable and think it’s easier to say nothing. Sadly, in doing so, this deprives the person who is grieving of human contact which could actually serve to make their lives less painful.

Here in the western world we are not very good at grief. Organisations will generally grant a day off when somebody dies and another day for the funeral. Compassionate leave is generally unpaid and at the discretion of the employer, particularly with small or medium sized companies in these difficult financial times. After as little as a couple of months people are expected to have “moved on.” Often the ink is yet dry on probate or whatever. But that’s it, that’s your lot mate, time to move on! We are simply not a nation of mourners, unless you count public grief for members of Royalty such as princess Diana. Today, cremations are little more than sanitised affairs, 20 minutes then the curtain comes round and it’s a walk in the garden of remembrance, with a cursory look at the flowers. In countries like Italy, Spain or Greece they have a different take on death. Womenfolk wear black, maybe for twenty years  or more, so that people will know that even in their everyday lives and occupation they are still grieving.

If we are locked in grief, unable to overcome our pain, we are destined to a life of inner sadness. Avoiding all reminders and memories simply serves to fuel a deep sense of sadness and pain. The legacy of our sadness may be passed on and our families may suffer in a myriad of ways. We may indeed hurt those we love as we struggle to rise above the painful memories by avoiding. It need not be like this… grief is both normal and healthy. Often working through the stages of grief can take a long time. In my opinion, we need to come through every anniversary and only then can we begin to let go.

The first stage of grief is often denial; the bereaved person will often go through a very painful time of searching. Next there may be anger, sadness and fear; often guilt may surface and “if only” questions arise. Finally, with time and support we begin to reconcile ourselves to the loss, and begin to come to terms and accept it. This may still be a dark, grey and oppressive time but occasional flashes of good humour and well-being will begin to emerge. There may be guilt at first at experiencing happiness again, but with brief windows of light, life may slowly begin again.

Whether seemingly simple and uncomplicated loss, or more complex grief, sometimes people struggle to move forward. Friends, families and local groups such as Cruse are invaluable in helping people through this difficult time. Counselling and psychotherapy can play an important role in helping the grieving person to come to terms with their loss. Feeling depressed, unhappy and even hopeless after a personal loss is usually a transient phenomenon. Sometimes, particularly in the case of traumatic grief, feelings of hopelessness may be engulfed in despair. This is often a sign of unresolved grief and professional help should be sought. (See earlier post – Coping with trauma).

The following signs may indicate that further assistance may be needed:

  • Relatively minor events serve to trigger an intense emotional grief.
  • Just talking about the loss can provoke feelings of anguish and intense pain.
  • Themes of loss appear everywhere and in everyday conversation.
  • Nothing is allowed to be changed and the environment has to remain lust as it was when the loss occurred
  • The bereaved person experiences physical symptoms similar to those the deceased person experienced.
  • The bereaved person undertakes radical lifestyle changes from which friends and family are excluded.
  • Whether consciously or unconsciously the bereaved person imitates the dead person.
  • Complete lack of emotional responses to grief, as if nothing happened.
  • Rapid changes of mood, with euphoria replacing sadness and low mood.

From a psychotherapeutic perspective Grief has a quality of healing in it that is very deep because we are forced to a depth of emotion that is usually below the threshold of our awareness. (Stephen Levine).

Do you agree with the statement made by Stephen Levine above?

Until next time, Steve Clifford. Cognitive Behavioural Psychotherapist.

www.stevecliffordcbt.com

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