Get a grip on Panic Attacks

Jeff was sure he was having a heart attack. His heart was pounding faster than it ever had before. His chest ached and the pain radiated toward his left arm. He felt shaky. As he tried to focus on what was happening to him, the world grew distant and unreal. Anxiety welled up. Jeff managed to call his physician, who arranged for quick transport to the emergency room. There, however, a battery of tests failed to reveal the cause of his symptoms. A second attack occurred a few days later, and still no physiological cause could be found. Before long, panic attacks had become part of Jeff’s life.

Recognizing Panic Disorder
Everyone sometimes feels anxious for no identifiable reason. At these times we think, “Something is happening—I must stay alert.” Panic victims share these feelings, but for them the stakes are higher. Their distress is so overwhelming that the fearful possibilities take on mammoth proportions. “I’m having a heart attack,” they think, or “I’m losing my mind.” We all experience periods of vague anxiety, which often pass without our ever discovering or having to acknowledge the causes. Panic anxiety, however, is the cue for a determined (and often desperate) search for a source.

Panic attacks are characterized by rapidly escalating and overwhelming anxiety. In the beginning, panickers are rarely able to identify what has made them anxious, describing the episodes as occurring “out of the blue.” The attacks are triggered by frightening physical sensations that occur suddenly, much like an unconscious reflex. Among the most common are shortness of breath, a rapid heart rate, heart palpitations, sweating, trembling, a feeling of choking, chest pain, nausea, and dizziness. Frightened sufferers develop painfully sharp sensitivity to these sensations, often making several trips to the emergency room before they finally realize that their symptoms are panic-related.

Physical sensations alone are not the core of the illness. Fearful thoughts, unpleasant emotions, avoidant behaviors, disturbing sensations, and deteriorating relationships all collude with one another to maintain panic. Thoughts such as the fear of dying or of having a mental breakdown are common. Even mild anxiety can trigger an attack, and any disturbing emotion can be interpreted as a precursor to full-fledged panic.

Gradually, the fear of having an attack in public leads the panicker to avoid those places—a disorder known as agoraphobia. Problems in relationships, which may have been the original source of anxiety, become worse as panic episodes develop. Difficulty with self-assertiveness and with the resolution of conflicts increases. Friends and partners are often frustrated because they cannot understand what is happening.

The Road to Recovery
Fortunately, panic disorder can be treated successfully, frequently with a combination of psychotherapy and medication. Panic sufferers are now turning to yoga for help as well, for yoga offers a wide range of stress-reducing tools. An ancient model of recovery can be found in the Yoga Sutra of Patanjali, one which is also embodied in the Four Noble Truths of the Buddha. In its briefest form, this model is an outline of the stages in the healing process, presented here as four questions:

1. What is the nature of the pain that all humans experience?
2. What is the cause of that pain?
3. What will be experienced when the pain is removed?
4. How can the pain be removed?

Yoga tells us that before searching for a cure it is important to look deeply into the nature and causes of illness. It is also important to get an idea of how things will be when symptoms have been removed, because otherwise we may have illusions about what recovery will be like. For example, eliminating anxiety is not the outcome of treatment for panic—the outcome is the ability to manage anxious feelings.
If we rewrite the four questions of the ancient model, focusing on panic attacks, they might read:

1. What is panic disorder?
2. What causes it?
3. What will life be like for the person who has overcome panic attacks?
4. How is recovery accomplished?

Looking for a Cause
Biologically oriented physicians have tended to attribute panic symptoms to problems of the nervous system. Jacob DaCosta, a Civil War physician, set the tone when he wrote, “It seems to me most likely that the heart has become irritable from its overreaction and frequent excitement, and that disordered innervation keeps it so.” This focus on biochemistry and physiology led to the development of tranquilizers.

Not long afterwards, Freud identified a form of anxiety that appeared in discrete, time-limited episodes. “An anxiety attack of this sort,” he wrote, “may have linked to it a disturbance of one or more of the bodily functions—such as respiration, heart action, vasomotor innervation, or glandular activity.” Nearly one hundred years later, this focus on the emotional component of panic has resulted in the psychiatric diagnosis called Panic Disorder.

More recently, clinicians have been exploring the role of disturbed breathing in panic attacks. As early as 1950, the physician R. L. Rice maintained that anxiety attacks were often the result, not the cause, of disturbed breathing; now psychotherapies for panic that include breath training are state-of-the-art. (Even so, very little training in this area is available to clinicians.)

Those who are familiar with yoga will recognize the classic body-breath-mind triad in these three points of view. But if a single cause for panic disorder exists, it has yet to be discovered. Instead, these three areas seem to interact with one another, forming feedback loops that grow larger if not addressed in some way.

For example, if someone is afraid of going to public places, then self-esteem plummets, fears increase, opportunities for relationships are limited, and panic-prone factors such as the fear of being labeled “incompetent” grow. Conversely, if the fear has been overcome, then self-esteem improves, fearful thinking is reduced, opportunities for relationships expand, and panic-prone factors are undermined.

The First Steps to Recovery
We have already seen what panic disorder is and we have a general idea of what causes it. Our next step is to discover how yoga, coupled with clinical experience, can help panickers take the steps necessary to recover. The first priority is to manage the frightening physical sensations accompanying panic attacks, because they will make any other work impossible. Panickers walk on pins and needles attempting to avoid the sudden, uncontrollable symptoms of their disorder, and because these involve rapid arousal of the nervous system, it is imperative to find ways to strengthen the nerves and calm anxiety.

Arousal is subtle and is triggered in a number of ways, but the key to calming it is to learn how to “talk” to the nerves, how to communicate across the great divide between voluntary and involuntary functioning. Once the panicker has learned to manage involuntary reactions, the sense of being out of control is enormously reduced.

Yoga training can be particularly useful here, for yoga teaches us how to interact with the nervous system. If we want to soothe and strengthen it, we need to learn deep, relaxed yogic breathing. Regardless of the pathways of arousal, breathing is the language of nervous system balance and control.

To illustrate this relationship, imagine how you would react if you were walking along a dark street, and a pointed object were thrust suddenly into your back. You might gasp, then tense your whole body. Gasping is the natural reaction to sudden fear. If you discovered that the attacker was only a friend playing a joke, you might sigh with relief. Then your breath might become agitated as your fear turned to irritation. The way you breathe reflects how you feel.

This relationship between breath and nerves is a two-way street. Just as emotions create changes in breathing, so changing our style of breathing can alter the way we feel. Breathing is the only involuntary function that can be easily and voluntarily controlled. During times of panic, relaxed, controlled breathing will give us immediate access to the nervous system. This means that by changing our breathing, we can change the condition of our nerves when tension disturbs and frightens us. Then, when breathing is relaxed and the panic response has been calmed, the underlying anxiety can be gradually brought to conscious awareness for processing.

Learning Relaxed Breathing
Practicing yoga is a good way to learn breathing skills, for it is a gradual process, often needing considerable support over a period of time. Yoga teachers quickly recognize when a student is having trouble (as is often the case with panickers), and they know a wide variety of alternate practices that will help the student master breathing skills.

The ultimate goal of breath training is to make smooth, diaphragmatic breathing a twenty-four hour habit. The corpse pose (lying on the back) and the crocodile pose (lying on the stomach with arms folded under the forehead) are both helpful training postures. Breathing with a ten-pound sandbag on the upper abdomen while lying in the corpse pose will help to strengthen the diaphragm and serve as a reminder to focus on the abdomen as well. In addition, it is helpful if the panicker learns to pay attention to breathing as often as possible during the day. Notice when the breath stops, notice when it jerks, for once an irregularity is obvious, it can be corrected. This practice not only fosters awareness, it makes the relationship between stress and breathing abundantly clear.

Panickers will find that diaphragmatic breathing not only calms the effect of arousal at the time of panic, it also provides an alternative focus for attention, allowing them to focus on their breathing instead of on the panic symptoms. As diaphragmatic breathing becomes a habit, the nervous system is less susceptible to panic in the first place. It usually takes about two weeks to become accustomed to the feeling of diaphragmatic breathing, and about six months of regular practice to make it a habit.


Special Problems in Breath Training
There are a few potential problems that panickers may experience during breath training, and it is well for both student and teacher to understand them at the outset. The most common is that panickers have often developed a highly self-vigilant style that can lead to performance anxiety. (“Is it supposed to feel this way?”) Micro-managing has become a way of life to panickers. The teacher needs to be warm—reassuring but firm, letting the practice do the teaching, without becoming over-analytical. Breathing does not need to be perfect to be good enough.

Sometimes panickers carry a great deal of physical tension in their bodies, and in these cases the natural unblocking effect of yoga stretches and postures can be helpful. Releasing abdominal tension while resting between postures promotes deep breathing. Covering the body with a blanket during relaxation and breath training can ease the feeling of being exposed or vulnerable.

A knot may sometimes form in the abdomen during panic attacks, making breathing difficult. As the attack continues hunger for air increases, but despite the need for air the panicker may feel that holding the breath is the way to “catch” it. Relaxed, continuous breathing, on the other hand, releases the unconscious tension created by holding the breath, and with practice it is possible to actually breathe through the knot that forms in the stomach during periods of anxiety. As increased awareness makes it possible to recognize tension early, it becomes easier to remain relaxed. To establish a smooth, unbroken flow of breath, the teacher might say, “When you come to the end of the inhalation and your abdomen has fully expanded, simply relax and let the exhalation begin. When you come to the end of the exhalation and your abdomen has contracted, simply relax and let the inhalation begin. Let each breath flow into the next breath by relaxing.”

Beyond Diaphragmatic Breathing
Many therapists have begun to use breath training in their work with clients, but few have been trained to teach more than the basics of diaphragmatic breathing. Yoga, on the other hand, offers many additional breathing and relaxation skills that can help recovering panickers. Perhaps the most effective of these is nadi shodhanam (channel purification). As its name suggests, nadi shodhanam works to unblock tensions and resistance in the energy-conveying channels of the physical and subtle bodies, thus calming and strengthening sensitive nerves.

Normal breathing carries away wastes and brings in fresh energy with each breath. As energy is brought in, it must be assimilated and distributed efficiently in order to fulfill the purpose of breathing. That’s where nadi shodhanam comes in. The process of channel purification slows breathing down and focuses our attention on its flow. At the same time, according to yoga masters, this practice cleanses the subtle vessels through which physical and mental energy is passing. As these vessels become cleaner, energy moves with less effort, and its distribution and assimilation within the mind and body are improved. The result is reduced tension in the nervous system as well as a calmer mind.

Nadi shodhanam is not the only yoga tool for deepening relaxation. Techniques combining postures, breathing, and systematic relaxation kindle a sense of confidence in us no matter how much daily life seems to bend us out of shape. Exercises that relax both muscles and joints, as well as the 61-points relaxation exercise, lead further toward relaxed self-awareness. These techniques can be taught once students are familiar with the beginning practices. (For a detailed description of nadi shodhanam, see the Yoga International reprint “Balancing Active and Receptive Energies: The Practice of Nadi Shodhanam.”

Expanding the Recovery Process
Along with breath training, panickers need to begin the process of resolving their fears. Sometimes they do this work on their own or with the help of friends and family members. Often, however, a period of psychotherapy is needed because the worries and stresses that initially contributed to the onset of panic require objective attention. Before treatment these factors are outside of the panicker’s awareness for some reason. As recovery continues, however, they become the proverbial elephant in the living room—there is no way to avoid noticing and dealing with them.

Often the stresses that are most difficult to recognize have to do with significant relationships. A question that can elicit awareness is, “Am I avoiding conflicts within myself?” As one panicker continued in recovery, for example, he was able to explain that his younger brother, who was in line to become a co-partner in the family business, was performing very poorly. Despite many signs to the contrary, the younger brother continued to imagine that he was doing well at his work. Addressing this problem raised many fears, for it would affect a complex web of family relationships. As a result, the older brother resisted speaking up and began having panic attacks instead.

There are many possible causes of panic attacks—stressful relationships, past traumas, fear of separation from loved ones are among the most common. One panicker’s attacks began when her husband’s promotion resulted in his being away from her and their infant twins at night. Pleased about the promotion, the husband had not been willing to see the effect it was having on his family, and the wife had not been able to express her fears directly. In the course of psychotherapy, this woman learned that finding practical ways to expand the scope of awareness and implement stress-reducing changes (ask for them, create them, or compromise for them in some way), although difficult, was the most satisfying process in the entire recovery.

There will inevitably be leaps forward as well as setbacks while recovery continues. This is natural, for the recovering panicker is learning to work with him- or herself in an entirely new way. Whether or not the panicker is undergoing psychotherapy, the psychological insights acquired through yoga can make a profound contribution to this process. A young student once remarked, “Yoga stands for You Oughta Get Aware,” because it provides such a wide range of tools to help everyone, including recovering panickers, do just that.

The Role of Meditation
In addition to the body and breath, yoga works with emotions, mental images, thoughts, and relationships, seeing them all as part of an integrated whole. During meditation, for example, a normally disturbing image arising in the mind is greeted by a very different reaction than might otherwise be the case. Now the body remains rested and still; the breath sends messages of steadiness and balance to the emotions and nervous system. Though the image might seem upsetting at another time, now the meditator can witness it with equanimity. This neutral reaction allows time and space for the image either to be processed or to pass through the mind without disturbance.

What is more, meditation seems to pace itself; it allows the mind to gradually gather strength before bringing up the images that might prove most frightening or challenging. Trivia can be dismissed, but the thoughts and images that persist are the ones that have important consequences to us. For instance, suppose I begin to recognize a deep-seated unhappiness with my work, but at the same time I see no other way to support my family. This conflict haunts me, affecting my work and frustrating my family relationships. Panickers may force themselves to push such conflicts out of awareness because they cause a discord that seems unresolvable. Meditation will allow them to recognize it with less fear so that they can see their way through the problem.

Conflict Resolution
Yoga psychology also suggests many techniques for resolving conflicts, including acknowledging and accepting the conflict in all its depth; recognizing the need for some kind of change; resisting the inclination to act out feelings or to do nothing; exploring alternatives; communicating with others without blaming them; accepting feedback from others; using discrimination in accepting or rejecting alternatives; surrendering to necessary losses; acting with determination; accepting outcomes with equanimity; working calmly on a problem even if a negative outcome, or no outcome, seems inevitable; and letting intuition suggest new possibilities. These strategies are derived from what in yoga are called the yamas and niyamas—the attitudes toward life that are the basis of all yoga practices.


Finding Refuge in Our True Nature
Ultimately, yoga provides a philosophy that places the relationships between body, mind, and spirit in a new perspective. The Bhagavad Gita, a classic yoga text, tells us that “No one has the power to bring to destruction this unalterable entity [our true inner self]. . . . The body-bearer in everyone’s body is eternally undestroyable.” Anxiety arises from attachment to passing and impermanent things, but the more we are aware of our own true nature, the less anxious we become.

Yoga gives us a practical tool for working at this level of awareness—the mantra. This is a word or phrase that can guide and protect us. It serves as a focus of attention in times of panic, and it is a resting place for awareness leading to our true nature. Through its connection to the deep spiritual resources that lie within us, the mantra pacifies fear and encourages us to persist in the face of disturbing thoughts and upsetting emotions.

We cannot prevent life from changing. Life is inherently unstable. But during periods of change we can have the courage to identify and express our needs. We can look for ways to surrender gracefully to the inevitable. We can trust, through our experience of yoga, that the essential Self within us will guide us through the emotions of change successfully.

Dr. Rolf Sovik is a licensed clinical psychologist in private practice in Buffalo, NewYork. He has been practicing and teaching yoga for more than twenty year