Panic Attacks: They Don't Come Out of the Blue Reason can wrestle and overthrow terror.
--EURIPIDES (484 B.C.-406 B.C.)
"I felt like I was about to die, or go crazy. I felt as if I was losing all control. It was blind panic-sheer terror!"
A shudder of remembered horror passed through the attractive, dark-haired woman seated opposite me. She was in control of herself, but was obviously under some strain. Even to speak of her unpleasant experience seemed like an ordeal. Her face was drawn and pale, her fingers pressed tightly against her purse as she related her experience.
"I was in a rush, and I got stuck in a slow-moving line at the supermarket," she told me, her voice quavering, almost on the verge of tears. "Out of the blue, I was gripped by feelings of terror, and I felt like I was suffocating. I had to get out of there. I left my grocery cart right in the line and ran out of the store.
"What a relief it was to get some air, but at the same time I really felt like an idiot for doing that. I felt ashamed of myself. I just went home, lay on the bed, and cried helplessly."
Kelly, a busy, efficient, 33-year-old executive, was, like millions of others, a sufferer from panic attacks.
What Panic Attacks Feel Like
If you have never experienced a panic attack, then imagine how you might feel if you were trapped in a burning building, or if the plane you were on started diving and spinning out of control, or if you were captured by a maniac who told you he was going to gouge out your eyes. Under these alarming (and very unusual) circumstances, you might expect to feel panic or terror.
What happens in such situations is that your mind concludes that you are probably about to suffer intense physical pain followed by permanent injury or death. Your mind also evaluates this probable outcome as dreadful, terrible, or horrible. This split second mental evaluation causes various bodily events--your heart races, your bowels churn, your blood vessels expand causing an all-over hot sensation, and your mouth becomes dry. These physical symptoms are then labeled by the mind as "terror" or "panic."
The victim of panic attacks experiences these unpleasant sensations in normal, everyday situations without the disastrous or life-threatening provocation. There is no burning building, no out-of-control airplane, and no maniac bent on mutilation. Yet the terror surges up, apparently for no reason at all. With some victims, the terror obviously appears in specific situations; with other sufferers, it seems to come on at any time or place.
The fact that there is no obvious reason for these panic attacks is not usually a consolation to the sufferer. She feels all the more frightened since the panic is inexplicable to her, and therefore strange. Because of the inexplicability, there seems to be no way to predict or control the attacks, so there is usually the added fear that the attacks will get even worse, perhaps becoming "more than she can possibly stand."
Kelly's frightening experience in the supermarket line was the latest in a series of similar episodes. It prompted her to consult a physician.
"He gave me all sorts of tests, but couldn't find a thing wrong with me. He said that physically I was in great shape, and that my trouble was all in my head. That's why he referred me to you. I feel as if I'm going crazy."
I asked Kelly how long she had been afflicted by these panic attacks. She told me they had been going on for two months. The first attack occurred when she was sitting on a bus.
"I was late for an important meeting. The bus was packed and stiflingly hot. All of a sudden, my heart started pounding, and I began feeling weak and light-headed. I started having crazy thoughts like: 'I'm losing my mind,' and 'I just have to get out of here right now or something dreadful will happen.'
"But I knew I dare not get off the bus because I would miss the meeting. After a few minutes of horrible anxiety, these feelings passed, and what a relief that was! But a week later they came back--again while I was on a bus-this time going to work. The anxiety and the crazy thoughts seemed to last twice as long as before. After that, every morning while getting ready for work, I would start worrying that these attacks would hit me again. To avoid them, I started taking a taxi to work, but I really don't want to keep on paying out for taxi fares. Anyway, the attacks have started hitting me in other situations, and they seem to be getting more and more frequent. I'm terrified that I'm going out of my mind."
People in Kelly's position often don't realize how very common such attacks of anxiety are. Millions of human beings suffer episodes of panic or intense anxiety, and millions more have suffered from them at some time in the past. The chances of these people going "out of their minds" (even in the broadest sense) are a lot less than the chances of any one of us being hurt in a serious traffic accident.
The First Panic Attack Doesn't Begin With Panic
There is one important feature of panic attacks like Kelly's which we would do well to notice. The first incident does not begin with panic, intense anxiety, or terror. It usually begins with an unexpected physical discomfort, such as chest pressure or pains, rapid heartbeat, dizziness, weakness, shakiness, a mild case of the jitters, or feeling vaguely unsettled or weird. Frequently the sufferer later forgets or misremembers the first attack, and assumes that all the attacks have come "out of the blue," in the pure form of unalloyed terror. But, when asked to recall step-by-step exactly what happened in the first incident, she usually does remember that it started with physical discomfort or mild uneasiness.
But why do these physical symptoms occur in the first place? Often for no medically detectable reason-but neither are they a creation of deep, dark forces in the unconscious mind. Since we are all human, with imperfectly functioning physiologies, we are commonly vulnerable to such ephemeral physical symptoms. The anxiety-prone person, rather than ignoring these discomforts, dwells on them, thereby magnifying and prolonging them.
So I began by assuring Kelly that hers was a very common problem and one that I had treated frequently with success. I explained that first we would discuss how anxiety and panic work in general, and next we would apply this to her particular situation. I told Kelly that after a little discussion, she would possess the tools to start chipping away at her problem.
Panicky Feelings Come From "Musty" Thoughts
Next, I explained a general psychological principle: "If you're anxious, or I'm anxious, or Sigmund Freud is anxious, it's never the objective situation alone that's making us feel that way, no matter how unpleasant that situation may be. Rather, it's our assessment or evaluation of the situation that's creating the emotion. Its our beliefs, our thinking, that determines our emotional response.
"For instance, suppose I'm about to deliver a speech to a large audience, and a few minutes before I begin I realize there's a possibility I might stutter during the talk. I might start thinking: 'I MUST not stutter. I MUST not stutter. I've GOT to give a good talk. I HAVE to impress these people. I SHOULD be invited back.' It's very likely that thinking this way, putting these demands on myself, I'll make myself anxious and greatly increase the probability that I will stutter.
"But now suppose it's the same situation; I'm going to give the talk to the same audience, and again I think of stuttering. But this time I view it differently. This time I don't think in terms of demands and absolutes. I think in terms of preferences. Then I will say to myself: 'I strongly PREFER not to stutter. I very much DESIRE to give a good talk. I keenly WISH to get invited back. I intensely HOPE to impress this audience.' Viewing it this way, it's probable I would not feel so nervous, and it's quite possible I would actually reduce my chances of stuttering."
Considering this scenario, apparently unrelated to her own problem, Kelly quickly agreed that my argument was quite reasonable.
I emphasized to Kelly that people create problems for themselves by turning their preferences into "musts"; however, the preferences themselves may be perfectly sensible. Preferences exist on a continuum from just barely preferable to very, very highly preferable. You can acknowledge that some outcome is important to you and that you would very much like it to happen, without thereby concluding that it MUST happen. You can also accept that there may be something you would very much like that you are, as a matter of brute fact, unlikely to get.
Wishing For The Moon Is Harmless
Some therapists think that the solution to their clients' problems is for the clients to abandon their "unrealistic" or "inappropriate" desires or wishes. But I believe that this usually doesn't get to the heart of the matter. A person may experience practical difficulties because her view of the world is inaccurate or unrealistic-for instance, if she invests a lot of time and energy in pursuing some goal that is in fact unattainable. I might do that person a favor by questioning the realism of her goal. But no emotional problem is caused by even the most fantastic desire or wish, as long as it is a preference and does not get turned into a "must."
Kelly's "Musts"
Once Kelly had grasped the reasonableness of preferences as contrasted with demands and "musts," we applied this principle to her panic attacks. At first she sincerely denied having any thoughts at all preceding and during her panic attacks. So I recounted the most frequently occurring thoughts reported to me by other panic attack victims over the past twenty years. She immediately recognized some of them as her own.
These thoughts included:
* I MUST know precisely why I'm feeling like this
* I MUST be certain it's not serious
* I MUST never lose control or act crazily
* I MUST not do anything stupid or look foolish
* I MUST have a rock-solid guarantee I'm not about to die or go crazy
* I MUST not make myself anxious
I explained to Kelly that all these notions made perfect sense as preferences:
* I PREFER to know why I'm feeling like this
* I PREFER to be sure it's not serious
* I PREFER to never lose control or act crazily
* I PREFER not to do something stupid or look foolish
* I PREFER to know I'm not going to die or go crazy
* I PREFER not to make myself anxious
But by viewing these as "musts," Kelly increased her level of anxiety and her likelihood of experiencing anxiety and panicky feelings. The solution to the emotional problem consisted of Kelly's eliminating these very destructive demands she now realized that she was continually pounding into her head.
This solution involved two steps:
STEP ONE
The first step consisted of recognizing that the "musts"-but not the preferences-are entirely false and unfounded; that although it would be highly preferable to avoid great discomfort, it's never a "must"; that she doesn't always "have to" feel entirely comfortable, and she often won't; that although it might be wonderful for Kelly never to upset herself, she assuredly will do so occasionally, since she is an imperfect human being like the rest of us.
In the worst-case scenario, Kelly might "lose control," go crazy, or even die. Similarly, she might be struck by lightning. This is unlikely, but if it does happen, it is very unfortunate and very sad. Although the worst-case scenario is highly improbable, it's unreasonable and unrealistic for Kelly to demand a cast-iron guarantee that it will not happen. No such guarantee is available to any human being.
STEP TWO
The second step consisted of Kelly thoroughly convincing herself of the truth of these insights. This would involve more than just nodding in agreement. It would mean confronting and disputing her "musts"-meaningfully, persistently, and vigorously-until she gave them up.
Kelly was following my explanation intently because she began to see some hope for overcoming those dreaded feelings that had so frighteningly enveloped her for two long months. But she was a bit skeptical that the cure could be so simple.
"Just repeat to myself 'I PREFER' instead of 'I MUST' and I won't get so upset?" she asked dubiously.
"That's partly right. But if you really think it through rather than just mouthing the words, you'll get more mileage out of the process," I assured her. "Don't merely parrot these phrases, but go over them carefully many times until you really begin to believe and feel that they are true."
Practice Makes Progress
Like many clients, Kelly had the idea in the back of her head that something could happen in therapy that would cause all her troubles to vanish, with very little effort on her part. I explained to Kelly that learning to think more rationally was a skill that required practice and sustained attention, just like learning any other skill.
Suppose that you want to play the piano but don't even know where middle C is. You listen to a few lectures about the piano or read a short book on the subject. You then practice for a couple of hours-and stop. It would be silly to expect to be able to play the piano. Everyone knows that it takes practice, practice, practice, every day for several years, to be able to reach a level of modest competence at playing the piano.
Changing your habitual thinking patterns isn't quite so difficult. You don't have to practice several hours a day for years on end. But at least a few minutes a day for a few months will probably be necessary. After all, you have spent most of your life so far inadvertently "practicing" thinking in terms of "musts." You won't change this overnight, just as you won't play a simple piece by Mozart after one week at the piano. But you will observe some small signs of progress almost immediately, and these will grow if you keep at it.
Kelly's Three Minute Exercise
I explained to Kelly the Three Minute Exercises-simple-looking drills somewhat like the five-finger exercises, scales, and arpeggios employed by pianists. Since she seemed to agree with my arguments, or was at least convinced enough to give the method a try, we wrote out a Three Minute Exercise for her to review every day in order to change her thinking:
1. (Activating event): I'm sitting on the bus and for no apparent reason my heart starts racing, my legs get wobbly, and I feel light-headed.
2. (irrational Belief): I MUST not feel this way.
3. (emotional Consequences): Anxiety, dread, panic.
4. (Disputing): Why MUST I not feel this way?
5. (Effective new thinking): No eleventh commandment states that I MUST not feel this way. I strongly prefer not to feel so uncomfortable but discomfort won't kill me. I've survived it before and will survive it again. Although I distinctly do not like these symptoms, I can bear what I don't like. Humans commonly experience physical pain. I can accept that rather than eat myself up inside about it. This is a chance for me to face discomfort, not magnify it, and go on with my life. The more I am determined to confront it, rather than escape from it, the better off I'll be in the long run."
6. (new Feeling): Concern rather than panic.
Within a few weeks, Kelly had greatly reduced her fear of panic attacks, and the attacks, when they came, passed quickly. Feeling now that she was able to make progress, she even began to look forward to the onset of symptoms as a golden opportunity to practice the technique, knowing that she could cope with the attack.
Within a couple more months, Kelly's ordeal was largely over. But that doesn't mean that she will never again suffer anxiety, or that she can now be guaranteed against ever having a panic attack.
We are all fallible human beings. We are all imperfect. None of us will ever achieve perfect rationality. In all probability, Kelly will occasionally experience episodes of anxiety at various times.
But having gone through two months of therapy and practiced her Three Minute Exercises consistently, Kelly was now far better equipped to nip anxiety in the bud. When anxiety appeared, she was able to invest three minutes to dispute her "musts" in writing. In this way, she successfully avoided the escalation of anxiety into panic attacks.
Ashamed Of Being Afraid
Panic attacks may occur at only one period in a person's life, or they may recur several times at intervals, or they may plague a person over a long period. These attacks are usually associated with fears of physical symptoms, fears of "losing control," fears of "going crazy," or of being trapped, being alone, or dying.
Another common theme is the dread of panicking which is felt to be a sign of personal weakness or inadequacy. The case of William, a 58-year-old high school principal, married with two grown children, is a good example.
William appeared hale and hearty, tall, handsome, and somewhat portly. He had an intense manner and seemed to take himself rather seriously. In explaining why he had come to see me, he related the following grim experience:
"Just about a month ago, on a hot summer day, I was in the County Office Building on an elevator that suddenly got stuck between floors. Since I have a history of atrial fibrillation, I got really scared about having a heart attack. Immediately, I felt my heart pounding uncontrollably.
"I panicked. I yelled 'Help! Get me out of here!' and banged on the elevator walls. After about thirty minutes, which seemed like a lifetime, an elevator repairman came and got me out through a trapdoor in the ceiling. I was drenched in my own sweat, and I felt like a fool.
"Now I panic just at the thought of taking an elevator. Living and working in a small town, I've found it fairly easy to avoid the few buildings with elevators. I can't use the stairs either, because I have chronically ailing knees, turning even a few flights of stairs into an ordeal.
"Six months ago my wife booked the two of us on a Caribbean cruise for our first real vacation in I don't know how many years. But last week she discovered that the liner has three levels and an elevator.
"Now I shudder at the thought of that elevator. I was looking forward to a wonderful vacation, but now it's a nightmare."
With some difficulty, William admitted to me that he was very ashamed of his fears. He was "petrified," he said, that his own fears would ruin the vacation, and he was already feeling ashamed that this might happen.
Fear Is Nothing To Be Afraid Of
"A grown man behaving like a baby! I feel so humiliated. A mature person would just have waited quietly for the repairman. Now, I know that it's extremely unlikely that I'll ever again be stuck in an elevator. And even if I do get stuck, sooner or later someone would come and get me out, like last time. I know that the chances of my dying of a heart attack in a stuck elevator because medical aid can't reach me are about the same as being hit on the head by a meteorite.
"You don't need to tell me it's irrational. I tell myself that over and over again. I tell myself I'm being stupid and ridiculous, but this doesn't help. I'm still petrified at the mere thought.
"I have to do something about this. My wife insisted that I consult you. I doubt that you can do anything-it's just a last resort. I know I'm the only one who can help me, and I'm utterly defeated."
"You're not defeated at all," I said optimistically. "But you do have two very different emotional problems. First, you're making yourself panicky about getting trapped in the elevator and having a heart attack."
"You got that right," William affirmed sullenly. The tone of his voice said: "Tell me something I don't know."
"Second, you're making yourself ashamed about the prospect of getting a panic attack in the elevator."
"I'm making myself ashamed?"
"Correct. And what does making yourself ashamed accomplish?"
"I guess, just one more problem." William admitted reluctantly.
"Exactly right. Shame, further worry, and the greater likelihood that you'll make yourself panic in an elevator. You're mentally rehearsing for this great event. You're working yourself up to it."
"I know, I know. I tell myself it's ridiculous, but that doesn't help. In fact, the more I keep telling myself that the whole thing's plain silly, and I shouldn't get upset, the worse things seem to get."
"That's right," I told him. "Saying 'I SHOULD not panic' will make it worse. Since you haven't had any previous training in Three Minute Therapy, it's not really surprising that when you desperately try to help yourself you're likely to fail. Unfortunately, the public schools never taught you a few basic principles for maintaining your sanity. It's a rather simple message, and one that could help you immensely for the rest of your life."
William was now eager to hear that simple message. "Could I learn that now?" he asked.
"Certainly. Here's lesson one. Look for your 'must.' You have a 'must' such as 'I MUST not panic,' 'I MUST not act weakly,' 'I MUST not behave foolishly.' "
"That's right. That's what I keep telling myself. 'I MUST not panic.' "
"But that 'must' is responsible for your secondary problem. That 'must' generates shame, anxiety, and panic and accounts for what blocks you from facing the elevators. But there's no evidence for the 'must,' is there?"
"I don't understand. You mean I should panic? I should make a fool of myself? But I don't want to panic."
"I agree. It's highly desirable not to panic or act foolishly. And we could list many good reasons why that's so. But listen more carefully to exactly what I'm saying. I'm not asking you, 'Why is it preferable not to panic or act weakly?' We agree it's not preferable. What I am asking is: 'Why MUST you not do what it's preferable not to do? You're an imperfect, fallible human being, like all human beings. Why aren't you allowed to make mistakes and act foolishly? What good reason could you possibly have for the unconditional demand that you never make mistakes or act foolishly? Isn't this about as reasonable as saying 'I MUST never catch a cold'?"
"Well," William said thoughtfully, "I don't know. Putting it that way, I guess I am allowed to make mistakes. I guess I am allowed to panic and act foolishly."
"Right. You're allowed to make mistakes. You're allowed to panic. You're allowed to function weakly. But what happens when you keep repeating to yourself: 'I MUST act my age. I SHOULD not panic or act foolishly. I MUST not be ridiculous or look ridiculous'? You're not allowing yourself to be imperfect. And that kind of thinking will almost always lead to shame, anxiety, panic-the exact opposite of what you would really like."
"I think I see what you mean."
William had reached the stage where he had some glimmering of the crucial insight that his preferences made sense, but as demands they were entirely unreasonable Once you have come this far, your task is to convince yourself of this truth, thoroughly and in detail. Although it may seem paradoxical, when you accept yourself-really accept yourself-as an imperfect individual subject to panic and other human failings, your feelings of anxiety are likely to diminish.
Rather than fearing fear, as FDR recommended, we can view the onset of fear as a golden opportunity to practice viewing fear rationally: as an extremely uncomfortable emotion rather than something horrible, awful, or terrible.
William wasn't immediately convinced. It took another session of discussion before he would accept that his 'musts' might lie at the root of his problem, and that a likely solution to his problem would be to work hard at combatting these 'musts.' He could do this by disputing them ad nauseum and by deliberately creating and seizing opportunities to take elevators.
William's Three Minute Exercise
William was eventually persuaded to do the Three Minute Exercises on a regular basis. Here is an early example:
1. (Activating event): Suppose I get into an elevator, it gets stuck between floors, and I panic and act foolishly.
2. (irrational Belief): I MUST not panic or act foolishly.
3. (emotional Consequences): Shame, anxiety, worse panic.
4. (Disputing): Why MUST I not panic or act foolishly?
5. (Effective new thinking): Since I find panicking and acting foolishly extraordinarily unpleasant, I keenly prefer not to panic. But no good reason exists why I MUST never panic. After all, anxiety is part of the human condition. Being imperfect, I will act foolishly at times, but that merely demonstrates that I'm a fallible human like billions of other fallible humans-not a totally weak person. And given my vulnerable heart condition, it's understandable that I might get panicky, though I don't HAVE to. Facing the prospect of a panic attack is a definite disadvantage of going on the cruise, but in order to get the pleasures of the cruise, it's unavoidable to bear the displeasures associated with it. The more I face panic attacks and practice thinking rationally about them, the less I'll tend to upset myself in the long run, and that will minimize further attacks. The upcoming cruise is a fine opportunity to practice accepting panic and accepting my weaknesses, instead of magnifying them and running away from them.
6. (new Feeling): Great concern rather than shame about panic.
Bon Voyage!
William practiced writing out his Three Minute Exercises at least once a day, causing this new way of thinking to become second nature to him. Then he was better able to tackle his initial fear of elevators. He accomplished this again using Three Minute Exercises, which he applied conscientiously.
On the morning of his embarkation for the cruise, he experienced only slight trepidation. On his return, William reported to me that he had taken the elevator a few times each day, at first with difficulty but then with only slight anxiety, and had thoroughly enjoyed the cruise. And he also assured me that whenever the thought of panicking crossed his mind he said to himself forcefully: "If I panic, I panic. Tough luck. I'll survive!"
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