We all know someone who has experienced a panic attack, or worse, we have experienced one ourselves! A panic attack is a discrete period of intense fear or discomfort that develops quickly, often out of the blue and peaks within 10 minutes. A person in the throes of a panic attack may experience any of the following symptoms: pounding and accelerated heart rate, sweating, trembling, shaking, shortness of breath, choking, chest pains, nausea, dizziness, numbness, chills, hot flashes, fear of losing control and fear of dying. Sounds like a lot of fun!

Panic attacks do not themselves constitute a diagnosis, but are a feature in a number of anxiety disorders.

If the panic attacks are un-cued (not in response to an obvious stressor) and happen recurrently, the person may have Panic Disorder. Further, sometimes people with recurring panic attacks start to avoid going places where there are other people, and eventually even going out of the house at all for fear of losing control in public. If the avoidance is extreme and significantly interferes with their lives, they may be diagnosed with a condition called Agoraphobia (from the Greek “phobia” - fear of- and “agora” - open spaces). Sometimes the panic attack may be attached to social situations (Social Phobia) or a particular situation (Specific Phobia). A common specific phobia on the North Shore is fear of the Lion's Gate Bridge. A person with panic may be afraid they are going to "lose it" while on the bridge and not be able to get off. The high level of traffic and closed in feel of the bridge make it a particularly potent trigger for a panic-driven phobia. I have seen clients who haven't driven over the Lion's Gate Bridge in 20 years and live on the North Shore!

Fortunately, panic attacks are completely treatable. I highly recommend a book by psychologist Reid Wilson, called Don’t Panic. Dr. Wilson does a great job of explaining the dynamics of panic and a targeted cognitive behavioural treatment program. According to Dr. Wilson, panic often develops in a person when they notice a troubling physical sensation such as their heart skipping a beat, shortness of breath or a tingling sensation. In most cases, these physical sensations are actually harmless, but the person begins to believe that they are having a heart attack or are in some other physical peril. The body's emergency response system then kicks in and an adrenalin reaction occurs. This accounts for a lot of the symptoms of panic as the heart rate goes up, muscles tighten and breathing becomes shallow and more rapid. Increase serum oxygen level from rapid breathing causes lightheadedness and a feeling they are going to faint.

All the while the person is carrying on a conversation in their head which is negative and frightening. "There is something wrong with me", "I can't handle this", "I'll never be able to handle this", "I'm going to die", "I'll be humiliated in front of all these people", "I'm going nuts". This self-talk is worried, critical and hopeless – overall quite negative and unsupportive. It contributes to a feeling of being without options and hence fuels the panic. Dr. Wilson calls self- talk the "Mind's Observer". In this case, the observer is helping to generate the problem. Part of the solution is to develop a new more supportive "Independent Observer", one that focuses on positive options, "what CAN I do here?"

Treatment first involves educating oneself about one's body. For example, unless a person has had a history of heart disease, the heart is a muscle and can handle rapid beating. Many panic-prone people have a harmless condition called mitral valve prolapse in which a flap gets temporarily stuck and it feels like missing a beat. In terms of lightheadedness, it is pretty much impossible to faint is you are sitting down. Slow natural breaths can restore the oxygen-CO2 balance in the blood and eliminate this symptom. Having information like that illustrated in these examples can short circuit some of the irrational physical fears that fuel panic.

The second step is to develop some skills in calming the body's physical response through techniques like muscle relaxation, natural abdominal breathing and visualization. These techniques take practice, but some can be helpful immediately. For example, "breathing and counting", taking ten natural breaths and counting at the end of each exhale can both restore oxygen levels and distract from negative thinking.

The third step is to develop the new supportive Independent Observer – that is to change your self-talk. This new observer provides a sense of choice, a sense of safety, a sense of support, and a sense of confidence. Its central self-statements are "I can ..." And "it's OK ...". The supportive independent observer reminds you of your freedoms and choices, supports all your efforts, invites trust and confidence, expects a positive future, points out successes, looks around for support and knows that there is always more than one option and focuses on solutions.

The fourth step is to set up behavioural challenges that can build confidence. If you are afraid of going out, set small goals and systematically practice going out. If it is the bridge, then work up to the most difficult conditions (rush hour when the Canucks are playing) by going at quieter times.

Though this program can be done using this book, a trained therapist may help a client with the nuances of implementing this steps of this program and can provide emotional support and accountability.

Do medications have a role in treating panic? The answer is that there are a variety of medications available that can reduce panic reactions. Anti-anxiety agents like Ativan can provide immediate relief, but aren't meant for long term use. However, I have worked with clients that carry a tranquilizer around in their pocket, but never use it. Just knowing that it is there improves their confidence! Some of the SSRI medications are effective in treating anxiety and panic, but need to be taken for long periods of time. Once the medication is stopped, there is a possibility of relapse, if the requisite skills have not been learned. Medication can be an important part of a person’s treatment program when combined with therapy. In some cases, a person may be so anxious that they cannot get to square one with therapy. Ultimately, long range success depends on the person's confidence level in dealing with anxiety.

Dr. Jim Browning