During the last few months I am sure everyone one of us at some point has felt stressed, anxious and worried about the impact that the pandemic has had on our lives. Here are some ideas and, I hope, useful information and strategies to help you deal with panic and anxiety. These are based on a cognitive behavioural approach.

 

Panic and Anxiety

STEP 1: Learning about anxiety

This is a very important first step as it helps you to understand what is happening in your body when you are feeling anxious. All the worries and physical feelings you are experiencing have a name: ANXIETY. Learn the facts about anxiety.

FACT 1: Anxiety is normal and adaptive as it helps us prepare for danger. Therefore, the goal is to learn to manage anxiety, not eliminate it.

FACT 2: Anxiety can become a problem when our body tells us that there is danger when there is no real danger.

 

STEP 2: Understanding panic attacks and Panic Disorder

Ensure that you know the facts about panic attacks.

FACT 1: Panic attacks are the body’s “fight-flight-freeze” response kicking in. This response gets our body ready to defend itself (for instance, our heart beats faster to pump blood to our muscles so we have the energy to run away or fight off danger). However, sometimes our body reacts when there is no real danger.

FACT 2: Panic attacks are harmless, although they can feel very uncomfortable or scary. Because panic attacks are the body’s “alarm system,” they are not designed to harm you. You might feel like you are dying or losing control, but you are not. You would have the same feelings in your body if you were facing a real physical threat (for example, if you were in front of a bear).

FACT 3: Panic attacks are brief (typically lasting only 5 to 10 minutes at peak intensity), although they sometimes feel like they go on forever. Because panic attacks take up a lot of energy in the body, they quickly run out of gas. This is why they don’t last very long. In fact, you might find yourself feeling exhausted afterward.

FACT 4: Panic attacks are private experiences. Others (except those very close to you) usually cannot tell that you are having a panic attack.

Panic Disorder results from misinterpreting bodily sensations associated with the “fight-flight-freeze” response as dangerous; for example, believing that an increase in your heart rate means that you are having a heart attack. As a result, you live in fear of additional attacks and you start to avoid things that may trigger panic attacks. You might be going through life on the “lookout”

for the next attack and constantly scanning your body for panic-like sensations. Here’s one way to understand how this apprehension about having more panic attacks keeps people “on guard.”

 

STEP 3: Building your toolbox

The best way to begin managing your panic attacks is to start building a toolbox of strategies that you can use to help manage them. However, it is important to remember that panic attacks are fairly common and that they are not dangerous. Therefore, the goal is not to eliminate panic attacks, but to learn to manage them without fear. For panic disorder, tools in the toolbox include:

TOOL #1: Learning to relax

Two relaxation strategies can be particularly helpful:

1. Calm Breathing: This is a strategy that you can use to help reduce some of the physical symptoms experienced during a panic attack. We tend to breathe faster when we are anxious, which can make us feel dizzy and lightheaded, which in turn can make us even more anxious. Calm breathing involves taking slow, regular breaths through your nose. However, it is important to realize that the goal of calm breathing is not to stop a panic attack because it’s dangerous, but to make it a little easier to “ride out” the feelings.KEY POINT: If you are using relaxation to help you STOP a panic attack, this is NOT helpful. If you are using relaxation to help you turn down the volume on the feelings (but not avoid them) this IS helpful!

2. Muscle Relaxation: Another helpful strategy involves learning to relax your body. This technique involves tensing various muscles and then relaxing them, to help lower overall tension and stress levels, which can contribute to panic attacks.

 

TOOL #2: Realistic thinking

The next tool involves learning to identify scary thoughts that can trigger and fuel physical feelings of panic. First, ask yourself what you are afraid will happen during a panic attack. Examples include: “I will faint,” “It will go on forever,” “I’ll embarrass myself,” “I’ll have a heart attack,” or “I’ll die.” To become more aware of your specific fears, try to identify your thoughts (and write them down) whenever you feel anxious or feel an urge to avoid or escape a situation. Repeat this exercise for a week or so.

Thoughts related to panic attacks can be grouped into two categories:

1. Overestimating: This happens when we believe that something that is highly unlikely is about to happen; for example, when we believe that we will faint or die as a result of a panic

attack. This type of thinking is usually related to physical fears (such as fainting and hurting oneself, having a heart attack, going crazy, or dying)

2. Catastrophizing: This is when we imagine the worst possible thing is about to happen and that we will not be able to cope. For example: “I’ll embarrass myself and everyone will laugh” or “I’ll freak out and no one will help.” This type of thinking is often related to social concerns (such as embarrassing oneself).

To help you figure out whether you are overestimating or catastrophizing, ask yourself the following questions:

What would be so bad about that? What would that lead to? What would happen then?

What am I afraid will happen when I have a panic attack? I won’t be able to breathe.

What would happen then? I would die. (Example of OVERESTIMATING)

Example: What am I afraid will happen when I have a panic attack? I’ll get very scared.

What would be so bad about feeling scared? I would get so scared I would pass out.

What would be so bad about that? Other people would notice.

What would happen then? They might laugh or think something is seriously wrong with me. (Example of CATASTROPHIZING).

Challenging overestimating: First, it is important to realize that your thoughts are guesses about what will happen, not actual facts. Next, evaluate the evidence for or against your thoughts. Individuals with panic disorder often confuse a possibility with a probability (for example, just because it can happen, doesn’t mean that it likely will).

Here are some questions to ask yourself:

How many times have I had this thought during a panic attack? How many times has it actually happened? Next time I have this thought, how likely is it that it will really happen?

It is helpful to realize that some of the things you fear are VERY unlikely to occur. Even though you have had this thought many times, it has not come true.

Example:

What am I afraid will happen? When I’m having a panic attack, I am afraid that I won’t be able to breathe or that I’ll die.

How many times have I had this thought when I am having a panic attack? A lot!

How many times has it actually happened? Never. Even when it feels like I am going to die, nothing bad has happened. However, what if THIS is the time it happens?

How many times have I had that thought? Many times.

How many times has it actually happened? Never.

How likely is it that it will really happen? The chances of something bad happen are extremely small. It’s important to remind myself of that when I am having a panic attack!

Challenging catastrophizing: To challenge catastrophic thinking, ask yourself to imagine the worst and then figure out how you would cope. Here are some questions to ask yourself:

What’s the worst that can happen? How bad is it REALLY? Is it a hassle or a horror? Will it make a difference in my life in a week or year from now? What could I do to cope if it did happen? Have I been embarrassed in the past? How did it turn out? Did it make a difference? It is important to understand that some of the things you fear are more of a hassle than a horror, and that there are things you can do to cope with the situation.

Example:

What am I afraid will happen? I will have a panic attack at work.

What would be so bad about that? I might pass out and my co-workers will notice.

What’s the worst that could happen? Everyone will look at me. I would be so embarrassed I would just freeze.

How bad is it really? Well, it would be very embarrassing to “lose it” at work.

Is it a hassle or a horror? It wouldn’t feel very good, but I guess it’s more of a hassle than a major horror.

Will it make a difference in my life in a week or year from now? In a week people may still remember that I had one, but in a year from now it’s unlikely that anyone will remember.

How could I cope if it did happen? I could excuse myself and go to the bathroom.

Have I been embarrassed in the past? Yes, I tripped on the stairs at work.

How has that turned out? Did it make a difference? I felt uncomfortable around my co-workers for a few days. It didn’t really make a difference in my life. I don’t think anyone remembers.

So, how bad is it to embarrass myself? It doesn’t feel good, but it’s not that bad.

You can challenge your worrisome thinking whenever you feel anxious or feel an urge to avoid or escape a situation. Writing it down helps!

GET THE FACTS

Panic attacks will NOT cause you to…

Faint: Fainting is caused by a sudden and significant drop in blood pressure. When you’re anxious, your blood pressure rises. So, it’s extremely unlikely that you will faint when you have a panic attack.

Lose Control: Although it can feel like you are out of control, you are still behaving in ways that show you are in control when you have a panic attack (e.g., pulling the car over on the shoulder of the road or walking to the exit at the grocery store).

Go Crazy: Panic attacks do not cause people to go crazy. No one has ever gone crazy from experiencing a panic attack.

Die: You are not having a heart attack. The chest pain you experience during a panic attack is the result of muscle tension (which is part of the “fight-flightfreeze” response). You are not going to suffocate. The feeling of not getting enough air is due to shallow breathing, but you are still getting enough air to live!

TOOL #3: Making coping cards

It can be tough to remember how to challenge scary thoughts when we are anxious. It can help to make up a “coping card” that includes realistic thoughts about panic attacks (e.g., “It’s a hassle, not a horror,” “It won’t last for forever”) that you can carry with you during the day to help manage anxiety. To make a “coping card,” use an index card or a piece of paper, write down your realistic thoughts, and keep it with you (i.e., in your purse, wallet, or pocket). It can be helpful to read this card daily, just as a reminder!

TOOL #4: Facing fears

The most important step in managing anxiety and panic is to face what you fear, which includes:

1. Unpleasant body sensations associated with panic attacks
2. Avoided situations, places, or activities

Facing feared body sensations: Individuals with panic disorder are typically sensitive to physical sensations (for example, increased heart rate, dizziness, blurred vision, chest pain). In order to overcome panic, you need to repeatedly bring on the sensations you fear so that over time those sensations no longer make you anxious. This also gives you a chance to see that your fears do not come true (for example, you don’t pass out or die).

Try each one and rate your anxiety level from 0 (no fear/anxiety at all) to 10 (very severe fear/anxiety) while doing the exercises. Identify the exercises that cause anxiety and bring on sensations that feel very similar to what you experience during a panic attack.

How to do exposure to feared sensations. Start with the exercise that is the least scary and build up to the scariest. Exercises can be broken up into smaller steps if necessary (e.g., start with running on the spot for 30 seconds, then 45 seconds and finally 1 minute). Continue the exercise until you start to experience the feared sensations. Rate your anxiety level from 0 (no fear/anxiety at all) to 10 (very severe fear/anxiety) while doing the exercises. Repeat the

exercise until your anxiety drops by about half (for example, if your initial rating is a 6, repeat the exercise until you experience a 3). Focus on one exercise at a time. Once you experience very little anxiety when completing that exercise (on several different occasions), move onto the next one.

Remember: The goal is to let yourself feel the feelings - Don’t fight them! These sensations are NOT dangerous. In fact, before you started having panic attacks, you may have even sought out activities that produced these sensations. For example, going jogging and having your heart rate and breathing increase; riding a roller coaster and feeling dizzy or nauseated; or sitting in a sauna and feeling warm and sweaty.

TIP: Practices should be planned in advance and you should aim to have at least one practice session a day. Make sure to set aside a chunk of time to practice, as it can take several repetitions of the exercise to experience a decrease in anxiety. The more you practise the faster your fear will decrease. It can also be helpful to try this with a friend or family member who is doing the exercise at the same time

3. Facing feared places or situations: It will be important for you to start entering situations that you have been avoiding due to fears of having panic attacks. First, identify feared situations or places (e.g., going places alone, entering crowded stores, riding the bus). Then, arrange the list from the least scary to the most scary. Starting with the situation that causes the least anxiety, repeatedly enter the situation and remain there until your anxiety decreases. Once you can enter that situation without experiencing much anxiety (on numerous occasions), move on to the next thing on the list. Remember, you will experience anxiety when facing fears - this is normal.

 

It will also be important to start eliminating various “safety behaviours” and subtle ways you avoid. These behaviours include carrying safety objects (e.g., medication, water, cell phone), sitting near exits, using distraction (as a means to avoid feeling anxious), avoiding certain foods (spicy dishes) or beverages (caffeine or alcohol), constantly seeking reassurance from others, or being accompanied by a trusted companion. First, make a list of your safety behaviours. Second, try to gradually reduce these behaviours, starting with the ones that are easiest to drop.

Step 4: Building on bravery

Learning to manage anxiety takes a lot of hard work. If you are noticing improvements, take some time to give yourself some credit: reward yourself! For example, purchase a special gift for yourself (DVD, CD, book, treat) or engage in a fun activity (rent a movie, go to the movies, go out for lunch or dinner, plan a relaxing evening, watch your favorite television program). Don’t forget the power of positive self-talk (e.g., “I did it!”)

How do you maintain all the progress you’ve made?

Practice! Practice! Practice!

In a way, learning to manage anxiety is a lot like exercise – you need to "keep in shape" and practise your skills regularly. Make them a habit! This is necessary even after you are feeling better and have reached your goals.

Don't be discouraged if you start using old behaviours. This can happen during stressful times or during transitions (for example, starting a new job or moving). This is normal. It just means that you need to start practising using the tools. Remember, coping with anxiety is a lifelong process.

(Thanks to Gerry Cunningham)