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What's happening? Am I dying?

Panic attacks are becoming more common. A panic attack can be terrifying, an event in which you think you are about to die. Aine Tubridy explains what's going on, and what to do about it


Picture this fictional scenario. Your home has been broken into, and the intruder has assaulted you dozens of times over the last month, leaving you battered, bruised, and exhausted. None of your familiar surroundings appear the same any more, the rooms you used to so enjoy are ruined. In spite of all your efforts, there seems nothing you can do to either predict or prevent the attacks. You think of nothing else now, vigilant all the time, waiting, expecting the worst. Sometimes the attack is during the night, taking you off guard, when you're at your most alone. Of those you seek help from, some question whether you're not imagining it, since the intruder is never caught, and suggest that your distress is an over-reaction, tell you to ‘pull yourself together', and then leave you to handle him on your own.

If this were really happening to you, do you suppose you might feel your zest for life ebbing away, since it would now all be sapped by having to be constantly watchful for the next onslaught, or recovering from the last one? Each morning on waking, might you not be likely to begin thinking ‘oh God, another day, maybe I'll just stay in here under the covers'? It's hard to believe you wouldn't begin to lose faith in yourself, becoming ruthlessly self-critical over your inability to get your life back on track.

Would you still be as keen to socialise, when that would mean hearing about the trouble-free lives others were living, when all that was on your mind was your hopeless situation? Might you lose interest in sex, in keeping the garden, in reading, while it seemed more urgent to keep checking the windows and doors, a permanent ear out for any sign of impending danger? Surely the future would begin to look bleak if all it held was more terror? Would anaesthesia, in the form of a couple of glasses of wine, even during the day, look like a reasonable solution to blot out the constant paranoia in your head?

And if your doctor offered you a pill as the solution to your distress, would you not be unbelievably relieved that it could be sorted so easily, even though deep down you would wonder how that could make the continual assaults cease? And if the side effects of that medication involved gaining weight, becoming impotent, or nausea, might you not think it was a reasonable trade-off?

The experience of panic attacks has some parallels with this scenario, but in many ways is so much worse because your assailant is inside your own body, and when the assault happens, there is literally nowhere to hide, and often no-one to turn to. There are few experiences so terrifying, and the fact that there's no rational explanation of why it's happening causes most to fear the worst - that it's life-threatening, that it'll cause a heart attack or stroke, that it's the first signs of a terrible psychiatric illness. Instinctively you want to hide it from others, lest you be labelled mad, stupid or weak. The isolation is profound.

Panic attacks are extremely common and becoming ever more so, given the increasing stresses modern living brings. They are caused by a sudden surge of the hormone adrenaline in the bloodstream, so you can be feeling perfectly normal one moment, doing some routine activity, and the next begin to experience a cascade of symptoms which you never had before and which most people find terribly alarming and highly unpleasant.


The main symptoms are

  • Difficulty breathing

  • Fast, forceful heartbeat

  • Dizziness, unsteadiness or feeling faint

  • Excessive sweating

  • Lump in the throat, difficulty swallowing

  • Trembling or shaking

  • Nausea, churning stomach or urge to use the toilet

  • Perceptual changes, feelings of unreality

  • Numbness or tingling in the face, hands or feet

  • Intense fears - of dying, losing control, going mad

  • Urgency to get to safety, to have someone near, to leave

 

The attack feels like a wave passing over you, coming out of nowhere, rising to a crescendo and lasting for a varied amount of time, averaging from less than a minute to an hour. But many ‘hover' all day on the verge of having one, in a state of heightened anxiety. When it's over you feel exhausted and drained. One patient of mine aptly described it as a negative orgasm, only in the case of panic it's a positive thing to know you won't have another one for a while.

In the wake of your first few attacks, you're overwhelmed with questions, absolutely convinced that something has to be seriously wrong. Visits to the doctor or hospital may follow, but invariably nothing is found to explain it, and many become increasingly anxious if more attacks follow and no cause is found. At this point medication is usually tried, generally something like Xanax for anxiety, but most people find that it has a hit-and-miss result and don't feel comfortable becoming reliant on it.

As the attacks continue, occurring often in more and more different situations, apprehension and vigilance sets in, and a permanent state of watchfulness becomes the norm. When is the next one going to happen? This begins to dictate where you can go and what you can and can't do, because your over-riding goal now is to avoid triggering another attack. Ordinary everyday activities can become excessively challenging, such as supermarket shopping, using public transport, attending meetings, going to the cinema, even driving the car, your sense of safety always measured by the distance to the nearest exit.

A policy of avoiding the terrifying sensations at all costs can lead on to phobias of anywhere it is difficult to escape from, such as planes, lifts, trains. Or anything which brings on intense fear, which for you could be dogs, birds, or spiders.

Life begins to shrink, and you can find it a strain working at hiding your anxiety from others, fearing their judgment. Indeed, you yourself are disgusted at your inability to control things, feeling constantly fed up at letting yourself down. Although you might only get one attack a week or a month, you're living with a consistently high level of anxiety, thinking of little else.

You begin to be drained and defeated by the whole thing, just wanting your old life back, and unsure how to plan your future any more, with your new travelling companion now having to be factored in. How can you accept a promotion if it's going to involve giving presentations to clients and there's a danger you might have an attack in front of them? How can you go abroad if you might get one far away from home, or if the flight was a couple of hours long? How could you go ahead with a pregnancy before the panic had ceased?

This is the breeding ground for depression. Whenever you feel you have little power to change a situation, when nothing you do seems to be making any difference, when there appears to be no hope of things improving, when the future just looks like containing more of the same frustrations and obstacles as today, your emotional response as a normal human being is depression. In terms of chemistry, while anger is fuelled by a predominance of the ‘fight' hormones, testosterone and adrenaline, as we struggle to protect something of value to us, and while fear is a predominance of adrenaline, as we face the uncertainty of whether that is possible to do, the emotional state of depression shows a different profile. Our system is flooded by cortisol, the ‘giving up' hormone, always in evidence whenever we perceive ourselves to be powerless in a situation, when there is no hope of protecting that which is of value to us (our life as we knew it) any longer.

The collateral damage at this point can be profound. Sufferers begin to withdraw, feeling overwhelmed by the daily onslaught of fear. Many will cut out socialising, since hot pubs and crowded restaurants can trigger attacks, and they feel more vulnerable to having attacks the day after a night out. Leisure pursuits can become a thing of the past, since exercise can bring on attacks for some. Relationships go downhill as too many restrictions now have to be placed on a couple's activities, and you may even avoid sex as it can act as a trigger. Work standards may deteriorate, as your concentration wanes, and sick days become more frequent, causing many to worry for the future. Substance misuse is common, which brings its own set of problems. You're living life with the flag only at half-mast.

This is the point where you may seek help from your doctor. Anti-depressants are often prescribed as you're being asked to adjust to this new idea of yourself, that of a person with an illness about which you know very little — nor your doctor either. If you experience a ‘lift', it is from the mood-altering aspect and the energising effect of these ‘uppers'. A sense of having some control may return, but only as long as the medication is continued, its discontinuance becoming a hurdle to be tackled in the future, since you know nothing has been permanently ‘cured', only anaesthetised.

For many, however, no such relief occurs, and for others the panic attacks may even worsen, due to the extra ‘buzz' being introduced into a system which is already over-excitable. Now a sufferer may feel they have reached the end of the road, when even the medicine, their last hope, hasn't worked. Suicide becomes an option entertained more and more, as their thoughts drift towards the possibility of permanent oblivion. When the quality of daily life has deteriorated so radically, many figure ‘what's there to lose?'.

Imagine how different this entire story would be if things went differently from the beginning, from right after your first attack. If you were told early on what these attacks were and what had initiated them. If you were reassured that you were definitely not showing the first signs of a psychiatric illness, that the attacks do not lead to a heart attack or a brain haemorrhage, that you could never stop breathing, or that they would not cause you to collapse or lose control - how much less afraid of them might you have been?

Wouldn't it help to be told why they had happened in the first place, that they usually first occur in a context of extra challenge or stress, or some imminent change in a person's identity with which they feel ill-equipped to cope? How different if your initial attacks had been explained to you in this manner, as a state which would pass as soon as the issues going on for you were settled and life became less turbulent. And how much more empowered you might have felt if you had been referred to a therapist who could help you learn the skills to reduce the excitability in your system, techniques to help you lessen the severity of the awful symptoms. Chances are you would not have become depressed at all if the ingredients which foster such a state of powerlessness had been eliminated from the beginning. Chances are you might not have needed to start medication, or needed the anaesthesia of alcohol. Chances are some might have been saved from reaching the end-of-the-road state of suicide.

Panic attacks are treatable. Many find immense benefit from the help of a psychotherapist trained in this area. It can provide a supportive atmosphere in which to work on those issues which created the turbulence within you in the first place, which can be current or a carry-over from times past.

The right therapist can teach you the appropriate skills to control attacks while you look at the reasons behind the attacks, and your mind's reaction to them such as:

  • Physical threats such as accidents, assaults, operations, out-of-body experiences, burn-out.

  • Emotional threats such as bereavement, betrayal, bullying, rejection, a broken heart.

  • Mental threats such as drug-induced changes in perception, or the terrifying experience of the flashbacks, memory lapses, and hallucinations which can accompany post-traumatic stress syndrome.

  • Social changes of status, such as those following unemployment, redundancy, financial ruin, divorce, or public humiliation.

  • Spiritual and afterlife dilemmas following bereavement or Kundalini experiences.

 

Dr Áine Tubridy wrote the best-selling book When Panic Attacks. As a psychotherapist, she practiced at the Institute of Psychosocial Medicine in Dun Laoghaire.

Áine passed away on 5 April 2011.



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