January 30, 2004

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Publication Date: Friday, January 30, 2004

Power over panic

It sneaks up unexpectedly. Suddenly you feel like your stomach was hit by a 2-by-4. Or you feel sharp pains or tightness in your chest. Sweating palms or chills. Breathlessness. Hyperventilating. Intense fear. And an overwhelming desire to escape.

A heart attack? Going crazy? Neither. These intense sensations are the classic signs of a panic attack, also called an anxiety attack. While some may dismiss it as "all in your head," the experience is definitely physical.

Two years ago, Dublin resident Patty Green (not her real name) thought she was having a heart attack because of "horrible chest pains." After a couple of hours of tests in the Kaiser emergency room, Green, 48, was sent home with a clean bill of health. But the pains returned, along with her other symptoms, including dizziness and a surreal feeling, as if she were in another world.

"After this happened four or five times, I wanted to scream, 'What the hell was it?' Because something's going on," she said. "Two of those times I went by ambulance.... Then you feel so stupid after you get there and you find out it's not your heart. And then you start worrying if people think you're crazy or a hypochondriac."

Panic attacks can involve different clusters of symptoms for different people, and vary greatly in severity and frequency. But it's common for people to confuse them with heart attacks. Yet they often leave hospital emergency rooms still clueless about what hit them.

Attacks usually last anywhere from a few minutes to half an hour, but some people, like Green, have had episodes lasting two hours.

Estimates of how many people are affected range from one in every 63 to one in 113. Dr. Will Joel Friedman, a Pleasanton clinical psychologist, said that at least half of his clientele have anxiety issues including panic attacks. It afflicts women twice as often as men and they typically first strike in late adolescence and to a lesser extent in one's mid-30s. If untreated, they tend to be chronic, but waxing and waning, he said.

A clinical diagnosis of panic disorder (Friedman prefers the term "panic challenge") means a person has had repeated attacks for at least a month and presents at least four, and typically more, of 13 possible symptoms. (See box.) Although panic attacks have been "chronicled worldwide for thousands of years," Friedman noted, the diagnosis has only been around for a couple of decades. And before that?

"You're crazy, you're psychotic, you need to be hospitalized," Friedman said. "And the person believed them, of course, because they thought they were going crazy anyways."

With the recent better understanding of the problem has come more helpful treatment, giving millions a chance to get back a normal life. Cognitive-behavioral therapy is usually central to effective treatment, although medication is often used as well. Some people have also found relief using alternative medicine.

Friedman sometimes incorporates hypnosis into his treatment as well as something called "energy psychologies," which takes its inspiration from Chinese medical concepts of energy meridians, or pathways, in the body. According to the medical literature, with appropriate treatment, 70-90 percent of sufferers remain free of panic disorder for many years.

Information about panic attacks is now readily available, but even so it takes most sufferers awhile to realize what they are. That just adds to the fear and anxiety.

"You start catastrophizing and say, 'Oh, I'm having a heart attack,' and then you blow everything out of proportion and your thoughts run wild," explained Green. "Your mind just sort of takes over from there and goes crazy with it."

It may also take a while to accept the diagnosis. In part, that's because of the stigma attached to any mental health condition, and feelings of shame about an apparent weakness, an idea that psychologists emphatically refute. Facing and coping with panic attacks takes a lot of courage, said Friedman.

Moreover, the nature of the symptoms can lead to confusion.

"I had heard of panic attacks," said Green, "but I kind of dismissed it because every time I had it I was having chest pains, so I thought it had to be something more physical."

"It's like your body has turned on you and you don't know what's going on but you're in a war zone now," said Friedman.

He described panic attacks as a misfiring of the flight, fight or freeze reaction that's part of our animal instinctive heritage. "But when that goes haywire we're both flight and fight at the same moment, and freeze, too. And that doesn't work."

Another way to look at it, said Friedman, is that your deep emotional unconscious is fighting your conscious.

"Your unconscious thinks your survival is at stake... (while) your mind cannot accept this and cannot see any obvious danger," he explained.

The intensity of the physical symptoms automatically brings on catastrophic thoughts and a sense of impending doom, which naturally causes fear to spiral.

Simply recognizing the problem opens the door to a critical examination that some describe as "negative self-talk," an internal soundtrack that anticipates doom or dying, and to reframe thoughts into more productive ones.

"A big piece is identifying it before it happens," said Kaiser psychologist Dr. Stuart Proctor. "It's important to understand it's not catastrophic, it feels awful, it's time limited, and it will pass. You can ride it out and you will survive."

Learning coping, relaxation and reframing or mind-taming skills are critical to re-establishing a functioning lifestyle, said Friedman, like a fighter learning how to slide off the punches he can't duck instead of leaning into them. But he also believes panic attacks are a symptom of unresolved trauma, and he therefore encourages his clients to go further.

"My job is to help the client go to the root of what's turning that alarm light on and to turn it off, because that's what continues to trip the person up," he said. "The brain is built to forget ... but we tend to remember things we didn't complete."

Most people with panic disorder also have one or more phobias, especially agoraphobia, driven by the logical fear of having a panic attack in public. About 50 percent suffer from depression.

The causes of panic disorder are not well understood, but heredity appears to play a role. The first attacks are often triggered by a major life stress, physical illness and some medications.

It's possible that all three factors were involved in the onset of panic attacks for Livermore resident E. Lorene Stack. Now 78, Stack experienced her first attacks in the late 1970s.

Stack's husband died in 1972, and soon afterward she re-entered the workforce, both very stressful life events. In addition, she was diagnosed with cancer in 1977 and underwent chemotherapy for an unusually long time.

A three-time cancer survivor (breast, lung and uterine), Stack is grateful for the treatments that probably saved her life against long odds. But she wonders whether the strong drugs also helped trigger her panic disorder.

A friendly, outgoing and active individual, Stack found the panic attacks devastating. And while today she has effective strategies to cope with them, she remains susceptible to the occasional attack.

"Unless you've had an anxiety attack, you tend to think a person can just get over it," she commented. "I think you have to be really strong to live through panic attacks. To go through your day never knowing when it will come over you, you need to have a strength almost like superwoman."

Panic attacks can be strongly associated with specific phobias, brought on by triggers like bridges, freeways, crowded stores or high places. For some, however, the panic reactions to such triggers are delayed. For still others, the attacks seem to have no triggers, striking out of the blue, and therefore all the more disturbing.

Stack recalls a number of severe panic attacks when she was relaxed and enjoying outings with close friends, yet she has never had one during an emergency. And she frequently has had them at bedtime, a time of apparent relaxation.

Sometimes called "night terrors" such attacks are perplexing to many who experience them. Stack employs various distraction techniques to calm them when needed - relaxation tapes, music CDs, reading or watching TV.

Along with the panic disorder, Stack has several phobias, including a fear of flying. She finds this puzzling, since she used to be very comfortable in airplanes.

"When I was little, I had a friend whose father was a pilot with an airplane held together with bailing wire and chewing gum," she recalled. "I flew all around in that thing."

During her worst period, attacks came almost daily and eventually forced Stack to quit her job. For a time, she also was quite fearful of driving so that a weekly drive to a psychologist in Pleasanton became a major challenge. A sympathetic chiropractor, who Stack described as a bit of a natural psychologist, once mentally walked her step by step through the drive, pointing out that when she was halfway there, she had made it because if she turned around she had just as far to drive.

Mental tricks like these are part of a gamut of strategies that Stack has adopted over the years. Instead of staying away from public places, Stack has an escape plan in case an attack occurs. For example, in theaters or her church, she will sit in an aisle seat in the last row, close to the exit.

Another helpful approach is to desensitize yourself by gradually and repeatedly exposing yourself to potential triggers. A man Stack knew told her how he practiced driving through the Caldecott Tunnel 20-30 times before making the trip to a job interview.

Strategies like these are often incorporated into cognitive behavioral therapy for panic disorder, whether in one-on-one counseling or in group therapy classes.

Green now attends such a class at Kaiser in Pleasanton. Led by Dr. Stephen Gross, these eight-week sessions teach the skills to control panic from three different angles.

"The first is breathing; the second, our thoughts or cognition; and the third is the uncomfortable physical sensations and becoming less fearful of them," Gross explained.

He teaches diaphragm (deep) breathing as opposed to hyperventilation breathing, he said. Just knowing how to breathe is not enough, however.

"It's important to have practiced the breathing over some period, say a week or so," he explained. "Then when in a panic, it sort of kicks in automatically. (Otherwise) it's pretty hard if not impossible to remember what to do." Even a couple of minutes a few times a day will do the trick, he said.

Secondly, he focuses on those upsetting automatic thoughts that always accompany an attack.

"We have to slow those thoughts down and take a look at them and take some of the emotional power out of them," he said. "The homework is to keep track of your thoughts during a panic attack. It sounds pretty basic and simple but you've got to do it."

To address those uncomfortable physical sensations, he has the group do exercises that bring on in "an extremely small way" one of those sensations, allowing them to get more comfortable with it.

Green said that even just the first three sessions she has attended so far have helped a lot, particularly the breathing techniques. Jane Howard (not her real name) also finds breathing exercises the most useful strategy to control attacks. Howard, 35, began having them when she was 19 and is taking the class as a "refresher."

"I see what I've stopped doing and just have to relearn it," she explained. Howard's attacks are episodic, absent for long periods before they return. For her, major life stresses are a key factor.

Looking back, she connects her first attacks with the release from prison of a man who molested her when she was 5. At the same time she was involved in a bad relationship and working a demanding job. Later a "really nasty divorce" triggered a new round of panic attacks.

Howard, who also suffers from depression, has been on medication for the last nine years. Currently she takes a combination of two antidepressants and a mild tranquilizer as needed.

Individuals vary, but frequently medication is needed only short term to give people a chance to develop better strategies to control their attacks, said Friedman.

Stack finds medication helpful in low doses, using it only when she feels an attack coming on to limit its severity. Fortunately, her attacks have become far fewer in recent years.

She believes this is largely due to acupuncture and "jin shin jyutsu" treatments, a type of acupressure, she started three years ago for her neuropathy in her hands and feet.

"The very first time I was treated I had the sensation of a waterfall of all the anxiety flowing out of my abdomen," she recalled. "I generally have a feeling of calm when I leave there."

Her acupuncturist, Aurora Matthias, who practices in Pleasanton, said that she has successfully treated three or four patients with panic attacks. Treatments will vary from one individual to another, but the underlying principle is to correct imbalances in the energy or "chi" pathways in the body.

"By bringing the body into balance it helps to bring the mind or emotions into balance and allows people to deal with the day-to-day issues of life," she explained.

In Howard's case, she expects she will need to take medication for the rest of her life. But she doesn't use them as a substitute for the hard work of confronting her fears.

She has learned that after an attack it's important to return to the place where it happened, like getting back on the horse after a fall. After a recent attack at Costco, her doctor advised her to go back and buy something she really wanted.

"I'm a big reader so I picked out five books," she said. "It was great advice - to buy something that I didn't want to put back."

"Costco's lines are 30 minutes long," she continued. "When I got there my knees shook and I felt lightheaded." But she stuck it out.

"Afterward you think, 'God, that was horrible, but I survived.'"

What is a panic attack?

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