[The post that follows was written in 2015. I have added some updates to reflect changes which have occurred since for the purpose of accuracy.]
“Panic” has become one of those words a little like “depression”. We all use it, we all think we know what it means, but when you actually sit down in a clinical psychologist’s room and ask people about their experiences, you get very different and personal answers.
There are of course textbook definitions practitioners like myself use in correspondence with colleagues and for publication (and occasionally in legal settings). We need a shared definition otherwise it would be hard to know which treatments work for whom. Here is one for the diagnosis of Panic Disorder, that is when experiencing panic episodes becomes so debilitating, professional treatment is advised (click to enlarge and make legible):
One of the references cited is authored by Michelle Craske, whom I mention in my section on Claustrophobia here.
So as to be clear, there is a diagnosable condition know as Panic Disorder which is described above. It is eminently treatable without medication, although some prefer the quite quick impact of anxiety-lowering medications such as Xanax.
Panic Disorder consists of experiencing frightening panic attacks. Personally, I find that term tautological, because as I see panic by definition as a surprise attack on one’s equilibrium. So I prefer the terms anxiety attack or panic episode.
Many people, on the hand, use panic in their everyday speech where they don’t refer to unpleasant physical sensations and invasive thinking patterns, and the last thing on their mind is that the experience is abnormal or pathological.
“I got a last minute to call to fill in for our receptionist – I panicked when I couldn’t find a clean uniform.”
“There was a panicked rush for the train when the platform conductor announced it was the last for the evening.”
“I got to the car park and panicked when I couldn’t remember where I’d left the keys.”
“I panicked when I got to the restaurant and remembered I’d left Jane’s birthday present at home.”
Hopefully, you can see how easily we slip the word into everyday conversation and those hearing our plight usually bring some understanding to its use. These aren’t occasions for suggesting our friends seek professional help!
In helping patients define what they’re experiencing as Panic Disorder – and believe it or not, a decade can go by before a patient might receive a formal diagnosis after their first panic episode – I find it helpful to ask patients if they can recall that first experience.
Invariably, that first experience is a standout one. Patients readily recall where they were, who they were with, what they were doing, and what it felt like. And it usually follows they can describe the gap between that first one and the next one, before it blurs into an everyday and often several times a day, experience.
That first one is so memorable because it literally comes out of the blue, unexpected, bewildering, no reason for it (seemingly), and it feels very physical, dangerous and in need of immediate medical assistance. Rarely does the first timer tell themselves they’re having a panic episode, despite all the mentions of the disorder in the popular media. More usually they will tell themselves they are having a heart attack.
My own panic episode
(True story – I’ve had one of each in the course of my lifetime – both saw me take myself to the emergency ward of a major hospital in Melbourne, the panic episode in my very early thirties before I undertook advanced clinical training, and the other a minor episode a few years ago. An EKG stress test in mid-May 2015 showed all clear. I certainly received an insight into the experiences of my patients.)
UPDATE (January 2018): I’ve had several exercise stress EKGs in followup and so far so good. It’s quite an exhausting task and very occasionally someone suffers a major episode doing the test which requires immediate treatment.
This first panic episode is one which can often set the pattern for others. It’s unusual to have one and only one, as it was in my case, above. (I was fortunate enough to be in therapy at the time prior to my clinical training). What makes it interesting compared to phobias, is that for the latter, not all patients can remember the start of their avoidance behaviour, nor describe other than a recent and more debilitating history in much detail. They may be vague about a traumatic experience, or even get it wrong when asked to locate corroborating information from family and friends.
My other criterion for panic is whether the patient fainted, or not. Many will mention they felt nauseous, woozy, and disoriented, but fainting is not one of the things that happens. Other possible diagnoses and causes need to be explored in such cases, starting with one’s primary care physician (GP) or a referral to a specialist such as a neurologist or ENT.
Finding a new narrative about Panic
If patients are going to stop panic being a major element of their fear of flying behaviour (and other anxiety states and behaviours too), they need to come to a different understanding of panic other than something to be scared of, and associated avoidance behaviours.
A way to start this process is to consider panic as an extreme component of the anxiety response, and the anxiety response to be the subjective experience of the fear response. It is by definition unpleasant, and part of an early warning alarm system our bodies (and that of other mammals) have evolved with over tens of thousands of years.
It is part of a biological system of survival which has remained with us because it has survival value. What stresses us in the second decade of the 21st Century may not be the same external triggers as our ancestors faced with their limited and superstitious understanding of how the world worked, but the response is still present.
We know that animals appear to become anxious. A puppy left behind in the house for the first time its owners go out for the evening might be discovered on their return to have chewed through some expensive equipment. My dog Shrek was quite an anxious fellow and when he was not yet 12 months (German Shepherd Dogs tend to be late maturers, with a long adolescence), he chewed through a rather expensive video camera viewfinder, and cable TV wiring.
Even now, aged 11, he is like so many other dogs when it’s a thundery night or when fireworks goes off, the loud bangs and vibrations seeing him moving from room to room, and then trying to hide himself in tiny spaces. Children too go through anxious periods, with fears of the dark, and going to school the first days.
UPDATE January, 2018: We lost Shrek after a bout of cancer in January 2016. Another German Shepherd now graces my practice, and his name is Scout. He’s three and a bit at the time of writing. He greets patients at the door.
Children, like dogs, find it difficult to articulate their fears, and so wise parents and owners must observe patience while providing a safe base from which the child can esperience their fear and mature out of it. Indeed, many veterinarians will tell anxious owners not to be provide reassurance to their dogs which would reinforce via affection the animal’s fear behaviours. Some suggest, as has the animal behaviour expert, Temple Grandin, to have the animal wear a compression vest to simulate being held and hugged, a primary soothing technique.
In humans, that reassurance is either provided by friends and family (“You’ll be be fine… just sit down and rest”) or if the individual is alone, by escaping the scenario or if that is not possible (when on a plane) offering prayers or admonitions they will be a better person if only this terror would go away. (Many people who have not suffered a panic episode do not realise the level of terror it can produce).
The task of any therapist is to guide their patient to become more self-reliant and resilient in the face of very unpleasant experiences, whether they be actual events which have or are about to occur; or whether they are internal bodily events or sensations. The task is to help the patient construct or reconstruct a reliable appraisal system to know what’s dangerous and not, what they can do about it and when, and when and whom to consult if their current skillset is insufficient.
Above all else, the therapist’s task is to help rekindle the patient’s youthful ability to display curiosity.
It’s curiosity which is the antidote to anxiety, not calmness.
Calmness is a byproduct – an artefact – of curiosity. While anxiety promotes avoidance behaviour, curiosity promotes approach behaviour.
As part of our work together, I see it as my task to help patients recognise their anxiety self-talk and see how it’s possible to change it to curiosity self-talk.
Here’s an example for someone who says they experience the peak of the anxiety during the take-off run, something that lasts between 20 seconds and a minute (the variation depends on the type of aircraft, the temperature, the aircraft’s total weight, the length of the runway, and other lesser factors):
(Engines begin revving, and patient feels the push back in their seat due to G-forces):
“On my God, here we go…!”
This may be what the patient may actually say out aloud to their seat companion. But there is more not said out aloud, for which the spoken words are a shortcut or abbreviation.
Such as: “I can’t stand it… it’ll be like this for hours… this is a terrible experience… my heart is pounding… the forces are unbearable…why is it always like this… why can’t I be normal and enjoy this… this used to be OK, why have I changed… will I survive this flight?”
You may have your own version of such self-talk and the beauty of the Virtual Reality system (you can get some measure of your self talk by watching some of the many takeoffs offered via various YouTube channels) is that we can do multiple takeoffs in a single session and really drill down to the beliefs and ideas about take-off. Are they about what you think will happen? What sensations you are experiencing? What feelings and images are you re-experiencing?
What these thoughts have in common – some describe them as negative or bad thoughts, but I think that’s incorrect – is that they lead to your biological alarm system being triggered into action because they portend danger, catastrophe, chaos, loss of control, self-downing, exaggeration, and fortune-telling, to name a few.
Our danger-threat assessment system consists not just of data detectors observing the world around us outside our bodies (but which could enter or intrude upon us) such as vision and hearing, but also sensors within us often measuring and feeding back data to our brains for assessment and interpretation. That system makes “quick and dirty” decisions and is centred in our Limbic system, an older mid-brain region we have in common with other mammals.
These internal sensors can measure our movement, core temperature, muscle tension, balance, and numerous measures we access when we visit our GPs for a checkup – namely blood tests revealing blood sugar and fats, blood pressure, thyroid activity, heart rhythms and so on. We’re often unaware of these active measures even when they go outside of a healthy range. This is one reason why many in the medical community are excited about new wearable devices like the Applewatch and its ilk which will not only measure then forward vital health measures but can be incorporated into a behavioural health change regime under medical supervision.
Understanding Threat assessment and Appraisal
Because our threat assessment sensors work so rapidly and outside our immediate awareness, they are liable to get it wrong. In Signal Detection Theory, first used by radar operators in World War II to determine incoming rockets and make sure they were not friendly aircraft, getting it wrong can either mean a miss (a missile was not seen when it was present) or a false positive (action was taken to defend when in fact no missile was present, or radar detected a flock of birds or a helium balloon come adrift).
In other words, the electronic radar system can tell the operator something is out there, but it is the trained operator who must make the call, hoping to minimise misses and false positives, and increase his or her rate of hits – an accurate assessment of present danger, and defensive actions being required.
Psychologists like to use this threat assessment metaphor to suggest that anxiety and panic represent too many false alarms. It’s not the case that we need to switch off the alarm system by using drugs or alcohol – the most common way patients do this artificially – but the need to recalibrate it. That is, increase its accuracy, increase the actions that can be taken to minimise harm, and increase the ability of the person to return to a normal state once the danger has been dealt with or it’s been determined that a false alarm occurred and the vigilance system needs to “stand down”, to use a military expression.
Or if you are a movie buff, the scene in Otto Preminger’s Stalag 17 where the mail delivery prisoner tells the assembled soldiers: “At ease!” (see below).
Those who have so far learnt to live with panic and anxiety would do well to learn some new techniques to tell their alarm system to be “at ease”, and to recalibrate their danger detection and reaction systems. These involve physical sensations, emotional states, and thoughts and behaviours.
At ease techniques for fearful flyers (and perhaps others anxiety conditions)
This is such an important part of this website, I am giving it its own separate post soon.