Antidotes to Stress - Your Relaxation Response

The key to successful stress management is to keep a mild, healthy degree of stress in your life, in intermittent amounts. Each person has a unique response to stress, so experiment with techniques that help bring you back into balance, and learn what works best for you.

Stress, You Take My Breath Away — Breath, You Take My Stress Away
Nature has conveniently provided the perfect way to initiate your parasympathetic nervous system, your relaxation response, and it involves the one involuntary bodily function that you can also consciously control — your breathing. Nothing is more convenient than using your breath to bring yourself back into balance. Whether quieting a rapid fearful breath or boosting a shallow anxious one, just a few mindful breaths can shift your experience.

The first step is to simply bring your breathing under control:

• Exhale completely.
• Then slowly take a deep breath in through your nose.
• Expand your diaphragm/belly to bring air into the lower portion of your lungs.
• As you gradually fill your lungs from bottom to top, expand your chest.
• Even lift your shoulders for a last bit of fresh air.
• Briefly pause your breathing and your thoughts.
• Then relax and let the air flow smoothly out of your body.
• Pull in your stomach at the end to expel the last bit of stress.
• Enjoy the emptiness for a few seconds.
• Then begin another breath.

As you do this few times, pay attention to the sound and sensation of your breath. If you get light-headed at first, then breath normally. Your brain is probably not used to all that oxygen.

Rapid Relaxation Breath
New York's Stress Management and Counseling Center recommends a breathing technique for rapid relaxation. According to program director and practicing psychologist Allen Elkin, Ph.D.:

"You take a deep breath, deeper than normal, and hold it in until you notice a little discomfort. At the same time, squeeze your thumb and first finger together (as if you were making the okay sign) for six or seven seconds. Then exhale slowly through your mouth, release the pressure in your fingers, and allow all your tension to drain out. Repeat these deep breaths three times to extend the relaxation. With each breath, allow your shoulders to droop, your jaw to drop and your body to relax."

Control Power
Loss of control is itself a principal cause of stress. For example, when hospital patients are allowed to administer their own painkillers as often as they like, they use less painkillers than patients who have no control over their medication. A study of coronary angioplasty patients found that ones who "perceive control over their futures by having positive expectations . . . seem to be at less risk for a new cardiac event." (Psychosomatic Medicine 1999;61)

By using your breath to take control of the situation, you always have an immediate and natural way to calm down. Then you can proceed with other ways to initiate your relaxation response and get the situation under control.

Derailing Your Train of Thoughts
Concentrating on your breath is just one way to slow and stop the train of normal everyday thoughts that trigger stress — especially the kind of circular thinking that gets you nowhere. Perhaps you have a simple thought or quote, even a word or sound, that you can use to initiate your relaxation response.

"Grant me the serenity to accept things I cannot change, courage to change the things I can, and wisdom to know the difference."

A Sound Way to Counter Stress
Maybe Mozart is the muse whose complex compositions conduct your endocrine ensemble of stress-relieving hormones. Whatever kind of music soothes your savage beast — classical, Celtic, Celine — let it shift your brain into its parasympathetic symphony. Toning, chanting, and other self-generated sounds have transforming effects on the mind end emotions. Augment sounds with mental images of stress being washed or blown away. Let your mind use all its resources to protect itself from stress hormones.

Open Your Mind's Eye —Visualization and Guided Imagery
For a quick shift into a calmer state of mind, simply imagine yourself in a favorite, tranquil place: a serene scene from your past or a hopeful one in your future. Close your eyes, breathe deeply, and try to see and feel your surroundings. The key to successful visualization is first to practice with real objects until you can vividly see them in your mind's eye. Then you will be able to better visualize imaginary ones.

You can start with images from books or listen to audio tapes, but the best images are the ones that your subconscious provides. A skilled guided imagery therapist can facilitate the process of bringing these images into consciousness.

Regular practice of visualization is important. Be sure to take advantage of the transition states between sleeping and waking, when the door to your subconscious mind is open.

Sixty-five patients who listened to guided imagery tapes for three days before and six days after surgery reported less stress and physical pain than a control group. Moreover, they requested only about half as many painkillers as those who had not listened to the tapes. The tapes helped patients imagine themselves in a beautiful and peaceful place along with a person they cared for. They visualized that their upcoming operation caused little pain or stress. (Psychology Today, Mar/Apr 1998)

It's Time We had a Brain-to-Brain Talk
When you're stressed out, first of all, realize what is actually going on inside your body and what the consequences are for your brain cells. Here's a brain transcript from "Attack of the Adrenals!"

"Attention all parasympathetic forces. Urgent. Missile silos mounted atop kidneys have just released chemical weapons of mass destruction. Must mobilize internal defenses. Launch immediate counter-calm before hippocampus hammered by cortisol."

Visualize fire hoses spraying cooling hormones that soak your adrenal glands until they're no longer steaming with cortisol. Then visualize security hormones rounding up the cortisol delinquents still loitering in your hippocampus — and taking them to Kidneyland for a one-way ride on the Bladderhorn.

Guided Metabolism
Create your own metabolic story, one that works vividly for you. Use imagination to reinforce your inner troops as they try to keep you alive and healthy. Have fun with it. Swim with the "endolphins" of your mind. Hey, it's not brain surgery. (And let's keep it that way.) This "guided metabolism" is similar to the way cancer patients use visualization to increase their immune system's T-cell count.

Sleep On It — The Brain Power Nap
Why do cats nap? Because they can. But so can you. Taking a "Brain Power Nap" may be one of the best things you can do to correct poor mental performance, especially after a stressful night of disrupted sleep. It makes sense: naps can help restore what insomnia steals.

It's been found that for every hour of lost sleep you lose an IQ point — reversible with sleep therapy or meditation. One study found that higher cognitive functions in children — verbal creativity and abstract thinking — were impaired after a single night of restricted sleep, even though the children could maintain routine activities. (Sleep 1998;21/8:861-8) A study of Japanese men found that a mid-afternoon nap had positive effects upon the maintenance of their daytime vigilance level. The 20-minute nap improved performance level and their self-confidence. (Clin Neurophysiol 1999;110/2:272-9)

Acute stress is known to modify sleep-wakefulness cycle, which leads to poor mental performance. Reverse the sequence: improve your performance with naps that reduces stress. Learn how easily it is to enjoy a Brain Power Nap, a variation on Tom Edison's famous catnaps. If he found time to take them, so can you.

Meditation — It's Not What You Think
Unlike prayer, where you do the talking, meditation is more akin to listening. And, your breath is the most natural thing to tune in to. Just observe your breathing. Listen to the sounds it makes and feel the sensations it creates. This leads you into a meditative state. If thoughts enter your mind, just let them go. Passively disregard them. Instead, stay with your breath. Let it settle into its own circular rhythm.

Dharma Singh Khalsa, M.D., author of Brain Longevity, found that meditation not only lowers oxygen consumption, heart rate, blood pressure, and blood lactate, it also causes a decline in cortisol production. "Among people who meditate regularly, cortisol levels tend to remain low, day after day. . . . Meditation has been shown to slow the aging process significantly, and to increase not just lifespan but 'health span.'" He also found that meditation promotes theta brain wave activity, which heightens learning ability and creative problem solving.

A daily session of meditation — preferably at the same time every day — will change the way your body responds to stress, because the effects of one session can last throughout the day. There are many nuances to meditation, and a qualified teacher may be advisable.

In a study at the Medical College of Georgia, scientists discovered that the daily practice of transcendental meditation kept blood vessels open, thus significantly lowering the blood pressure of meditators compared to those who just relaxed as completely as possible. (Psychosomatic Medicine, Aug 2, 1999)

Breath is even more than a mind-body interface. It is the gateway to spirit. The ancients knew this, and their language underscores the connection. In Sanskrit, atman means world-soul and atma is breath. In Hebrew, neshuma refers to both spirit and breath. The English word inspiration also hints at the connection. After years of studying meditation, Dr. Khalsa found that "the space between our thoughts — what the Asian healers call 'the sacred space' — is where most spirit-directed healing originates."

Biofeedback and Hypnotherapy
Some people benefit from more modern techniques of initiating the relaxation response. Biofeedback training uses sensitive electronic instruments that enable you to measure and eventually regulate bodily functions such as heart rate and blood pressure. Chronic heart failure patients who used biofeedback in a UCLA study were able to improve their blood flow compared to patients who only rested. In the 20-minute sessions, patients increased their skin temperature by imagining their hands becoming warmer. (Spectrum, Mar/Apr 1998)

A qualified practitioner is essential, as it is with hypnotherapy, which accesses your unconscious mind. From this advanced state of relaxation, a posthypnotic suggestion is given that may help you deal more effectively with stress in your daily life. Patients preparing for coronary bypass surgery who used self-hypnosis relaxation techniques were calmer and required less pain medication after their operations, compared to a control group. (Alternative Therapies, Jan 1998)

LET'S GET PHYSICAL — Flight or Fight (not just Fright)
To avoid stewing in your own juices of adrenaline and cortisol, it can be a good idea to do what nature has best prepared you to do — move it to use it to lose it. Burn up those hormones with physical activity.

• Do exercises that work your leg muscles, as in "Run away!"
• Bounce on a rebounder or jog in place.
• Climb stairs or use a stair-stepper.
• Walk it off or run around the block.
• Use a treadmill. (It works for rats.)

When two groups of rats were given mild shocks, the ones that had an outlet for stress, such as treadmill, had lower levels of cortisol and stress-related illnesses than the group without a way to alleviate their stress.

• Use short bursts of muscular energy, as in "Put 'em up!"
• Kick-box or have a punching bag handy.
• Do push-ups, sit-ups, and other upper body work.

Exercise not only defuses a stressful situation, it better prepares you to cope with future stress and even stimulates your brain to grow.

Progressive Relaxation
Another option — especially if you're stuck in your car or at your desk — is c. Tense, then release different muscles in a set sequence. It's easy to learn, simple to do, and it works. Scientists at Ohio University in Athens found it to be the best therapy for reducing tension headaches. In several studies, chronic headache sufferers experienced a 50 percent reduction in pain and frequency using progressive relaxation. (Prevention, June 1998)

Yoga and Tai Chi
These moving meditations that came to us from Asia are excellent long-term practices that can help you develop a healthy response to stress. A good teacher will get you moving in the right direction.

Special mind-body exercises are the centerpiece of Dr. Khalsa's brain longevity program. These unique combinations of movement, breath, and sound are energizing and regenerating yoga techniques that have helped his patients better cope with stress as well as improve their overall brain health and fitness.

The Medium is the Massage
Because mind and muscle are connected through the peripheral nervous system, massage does more than just relax your muscles. By relieving muscular stress, massage may improve brain function. A study of preschoolers found that those who received a 15-minute massage scored better on tests of cognitive performance than children who just read stories with an adult for the 15 minutes prior to testing. (Touchpoints, Vol. 5 #1)

Massage reduced levels of the stress hormones cortisol and adrenaline in depressed mothers with infants. A study at the Touch Research Institute at the University of Miami Medical School found that massage therapy also improved sleep and reduced the mothers' depression. Massage releases endorphins that calm the peripheral nervous system. It increases circulation and speeds up the removal of toxins from the body. (Alternative & Complementary Therapies, Jan/Feb 1996)

Feet First
Foot reflexology is a form of massage that works with the thousands of nerve endings in the soles of your feet. A session with an experienced reflexologist can be a liberating experience. Simply rolling your foot over a golf ball can be a good way to reduce tension.

In a Chinese study of 86 individuals, blood tests were taken before and after 30- to 45-minute reflexology sessions, ten days in a row. The results showed that levels of free radicals decreased while antioxidant enzymes increased. (China Reflexology China Symposium Report, Oct 1996) In a three-year study, Danish postal workers given access to reflexology therapy missed fewer days of work, saving thousands of dollars per month. (Self Healing, May 1997)

LET'S GET PHILOSOPHICAL — Mind Over What's the Matter

• See problems as opportunities.
• See problems as personal trainers.
• There is no right answer.
• It's not a perfect world.
• Let go, and let God.
• This too shall pass.
• Refute negative thoughts.
• Stop overgeneralizing.
• Control yourself, not others.
• Be you now.
• You are a human being, not a human doing.
• "Don't sweat the small stuff."
• "Work like you will live forever; pray like you may die tomorrow." (Ben Franklin)

Another powerful way to elicit the relaxation response is prayer — your own or the prayer, and care, of another.

News Fast
No, not another media feed. Just the opposite. Stop absorbing all the information — mostly negative — that assaults you throughout the day. Information overload is an insidious form of chronic stress. Turn off your TV. Andrew Weil, M.D., often suggests his patients try a one-week news fast.

Laugh First — Ask Questions Later
Before you react to some stressor, first try becoming an observer whose job it is to find the humor in the situation. Seek belly laughs that release those pain-killing endorphins which make you feel good as well as more stress-proof. The pioneering work of Norman Cousins demonstrated the value of laughter in stress-reduction.

Friends who make you laugh are one of life's greatest blessings. Here's where the right social network pays off. One of the most important anti-stress coping skills is to develop a social support system. For example, in a five-year study of 1350 coronary disease patients, those who had no spouse or intimate friends were three times more likely to die than those who had support. Even pets are effective.

Crying Out Loud
Crying is another one of nature's stress-relieving strategies. A psychiatric chemist named William Frey, Ph.D., showed that not all tears are alike. Emotional tears have a different composition than tears caused by eye irritants, and they are especially abundant in adrenaline and other stress-related chemicals.

Allies from Planted Earth
Plants have been at the heart of medicinal systems throughout the history, and today we are verifying that compounds extracted from herbs do indeed have properties that account for the benefits ascribed to the herb. Traditional cultures have always used relaxants such as chamomile, valerian, and kava. A 1998 survey by Consumer Health Sciences showed that 19 percent of individuals with depression used St. John's wort, 18 percent ginseng, and 17 percent ginkgo. The closest pharmaceutical was Prozac (17 percent).

Ginkgo and Depression
A Swiss study found that ginkgo biloba may help improve both sleep and cognitive behavior in depressed patients. "Results from the depressed patients' brain scans provide the first direct evidence that ginkgo biloba may improve their sleep," said Dr. Martin Hatzinger, one of the researchers from Basel Psychiatric University. Ginkgo appeared to significantly reduce the number of awakenings and increase both short wave and slow wave sleep. Both types of sleep returned to original levels however after ginkgo treatment stopped. (American Psychiatric Association's 152nd annual meeting in Washington)

Ginseng and Cortisol Regulation
Ginseng is a traditional herb that has long been valued as an adaptogen that helps the body better handle physical and psychological stressors. Apparently it does this by strengthening of the adrenaline glands, thereby reducing the overproduction of cortisol that is secreted in response to stress.

Ginseng helps to create a calm, focused state of mind, a greater ability to adapt to life's changes so you can bend not break. Numerous studies demonstrate its ability to improve the mental performance of people, especially when they're under stress. Russian telegraph operators who took ginseng for thirty days showed improved concentration and coordination, reflexes and endurance. Another study measured increased blood flow in the main arteries to the brain, while others demonstrated ginseng's positive effects on memory and learning — even for the elderly.

Vitamin C Reduces Stress Hormones
New research shows that high daily doses of vitamin C reduced the levels of stress hormones in rats' blood. P. Samuel Campbell, chairman of the University of Alabama's biological sciences department, reported that megadoses of vitamin C also increased the levels of an immune system antibody in stressed and unstressed rats, as well as reduced other indicators of stress. Rats were given 200 mg of vitamin C daily. The equivalent human dosage would be several grams per day. (Speech to the American Chemical Society, August 23, 1999)

Magnesium helps control the firing rate of neurons, and along with vitamin B1 is an essential nutrient that supports the reparative process that neurons need to offset the stress from the continual firing of the electrical impulse. Low synaptic levels of magnesium can cause hypersensitivity and increase your body's response to stress. Noises will sound too loud and lights will seem too bright. Stress affects your kidneys' ability to recycle magnesium, which in turn increases your sensitivity.

Aromatherapy — Common Scents that Your Brain Knows
The all-encompassing word "chemistry" derives from the Greek khemeia — "the extracting and mixing of medicinal plant juices." The famous 16th century Swiss physician and chemist Paracelsus referred to the oils he distilled from medicinal plants as "quinta essentia," hence our modern term, "essential oil." We obtain these unique compounds from the seeds and flowers, the roots and barks, and the fruits and resins of plants.

Smell was the first sense that animal life developed and is the most nostalgic of all your senses. A certain fragrance can immediately remind you of an experience in your distant past. This is because smell takes a direct route to your limbic brain where emotional memories are processed — and where stress hormones do their worst damage. Perhaps this why the sense of smell if often the first to go in older individuals.

Aromas have an intimate and irresistible effect. Unlike other senses, molecules of the object you are detecting actually come in contact with your brain. Your olfactory receptors are the only part of your brain that is exposed to the outside. Essential oils from plants are very powerful chemicals that influence brain chemistry, hormone production, and stress levels. Obnoxious smells certainly demonstrate this, but positive scents also have a subtle but powerful affect on emotional well being. It's not known for sure how essential oils work on the brain, but it's thought that they interact with certain membrane lipids as well as affect enzymatic processes.

A study of depressed men showed that citrus fragrance in their room reduced their intake of anti-depressants. Lavender has a calming effect on many people. A few drops of lavender oil on a handkerchief can help suppress the distress of frustrating situations, like being stuck in traffic or on the runway. Vaporized lavender oil was used in a British nursing home to help residents relax into sleep. It worked as well as sedative drugs. (Alternative Therapies, May 1997)

Andrew Weil, M.D., mentions research showing that the essential oil of a tropical flower called ylang-ylang causes the pituitary gland to secrete more euphoric endorphins, while oil of grapefruit stimulates the brain to produce natural painkillers called enkephalins. The scent of oil of marjoram boosts production of the calming neurotransmitter serotonin. (Self Healing, Oct 1996)

Essential oils added to bath water or massage oil are good ways to use aromatherapy, because heat helps the oils penetrate into the skin and bloodstream, as well as releases the oil's aromatic molecules for entry through the nose.

Trees are People, Too
Plants have their own stressors and have evolved chemicals to defend themselves. Trees have been shown to react to stress strikingly similar to the way we do. In her excellent book, The Fragrant Mind, Valerie Ann Worwood describes how trees respond to predators. When threatened by deer, a tree produces chemicals called tanins that deter the animals from chewing its leaves. Within 15 minutes, tanin levels in leaves have been observed to increase up to 282 percent, depending on the tree. And, like us, it takes much longer for the tree to return to its normal chemical state — from 24 to 100 hours after the attack.

Quick and Convenient Relaxation Techniques:

• Gain control of your breathing.
• Repeat a helpful quote or word.
• Visualize yourself in a tranquil place.
• Have a brain-to-brain talk.
• Use progressive relaxation.
• Get away from the noise.
• Use good scents.
• Lose the coffee.
• Laugh.

With More Time and on a Regular Basis:

• Exercise.
• Meditate.
• Get a massage.
• Practice yoga or tai chi.
• Take a Brain Power Nap.
• Use guided imagery tapes.
• Take an aromatherapy bath.
• Listen to Mozart or other music.
• Use biofeedback or hypnotherapy.
• Take time-out: a short walk or a long vacation.
• Take a news fast: stop being a receptacle for the world's problems.

"We are disturbed not by things, but by the views we take of things." — Epictetus

"There is nothing either good or bad, but thinking makes it so." — Shakespeare

"I've had many terrible experiences in my life, and some of them actually happened." — anon.

Stress and Your Brain

As we gain greater insight into the effects of stress on the brain, the picture that emerges is not a pretty one. Once thought to be temporary, the stress-response is now proving to have permanent repercussions.

Those irritating things that go wrong in the day and those aggravating things that go bump in the night — disrupting routines and interrupting sleep — all have a cumulative effect on your brain, especially its ability to remember and learn. Why? Because when your brain perceives a threat, it produces a chemical that actually eats away at that part of itself which is largely responsible for memory.

As research reveals the role stress plays in deteriorating mental function, renewed importance is being placed on the many techniques used to activate the relaxation response and counteract the very real consequences of stress.

A Tiger on Your Tail
That "saber-toothed tiger" stalking you today is more likely to be a tailgating SUV or an approaching final exam. No matter. Whether the threat is real, remembered, or imagined, your brain quickly responds with powerful chemicals that initiate dramatic metabolic changes throughout your body.

Your heart pounds, chest heaves, muscles tighten. Senses sharpen and time slips into slow motion. You become impervious to pain, and butterflies emerge from their cocoons in your stomach. Under certain conditions, this would be an appropriate healthy reaction, because now you are exquisitely prepared to do battle. The trouble, however, is that you're probably still sitting in your car or at your desk — stewing in your juices.

When the danger finally passes or the perceived threat is over, your brain initiates a reverse course. This releases a different bevy of biochemicals throughout your body to slowly bring you back into balance, as your brain seeks the holy grail of "homeostasis," that elusive state of metabolic equilibrium between the stimulating and the tranquilizing chemical forces in your body.

If one of these forces dominates the other without relief, then you will experience an on-going state of internal imbalance. This condition is known as stress. And it can have serious consequences for your brain cells.

The Internal Tug of War
The term "stress" is short for distress, a word evolved from Latin that means "to draw or pull apart." The Romans even used the term districtia for "a being torn asunder." When stressed-out, most of us can probably relate to this description, but it also suggests the biochemistry of stress.

The primary area of your brain that deals with stress is its limbic system. Because of its enormous influence on emotions and memory, it is often called the emotional brain, or the mammalian brain, because it evolved with our warm-blooded relatives and marked the beginning of social cooperation in the animal kingdom. Whenever you perceive a threat, imminent or imagined, the limbic system immediately responds via your autonomic nervous system — the complex network of endocrine glands that automatically regulates your metabolism. It has two branches, each pulling in opposite directions.

Your sympathetic nervous system (SNS) turns on the "fight or flight" response, while your parasympathetic nervous system (PNS) promotes the "relaxation response." Like two tug of war teams skillfully supporting their rope with a minimum of tension, the SNS and PNS carefully maintain your metabolic equilibrium by making necessary adjustments whenever something disturbs this balance.

The strongmen on these teams are hormones, the chemical messengers produced by your endocrine glands. Named after a Greek word meaning "to set in motion," hormones travel through your bloodstream to accelerate or suppress metabolic functions. The trouble is that certain stress hormones don't know when to quit pulling. They remain active in your brain for too long, injuring and even killing the brain cells you need for memory and learning.

But all is not lost. There are ways that you can learn to overcome evolution and survive this eternal internal tug of war. These techniques are introduced in Brain.com's relaxation section.

Distress Signals from Your Brain
Your sympathetic nervous system does an excellent job of rapidly preparing you to deal with what you perceive as a threat to your safety. Its hormones initiate several metabolic processes that best allow you to cope with sudden danger.

Your adrenal glands release adrenaline (also known as epinephrine) and other hormones that increase breathing, heart rate, and blood pressure. This moves more oxygen-rich blood faster to the brain and to the muscles needed for fighting or fleeing. And you have plenty of energy to do either, because adrenaline causes a rapid release of glucose and fatty acids into your bloodstream. Also, your senses become keener, your memory sharper, and you are less sensitive to pain.

Other hormones shut down functions unnecessary during the emergency. Growth, reproduction, and the immune system all go on hold. Blood flow to the skin is reduced. That's why chronic stress leads to sexual dysfunction, increases your chance of getting sick, and often manifests in skin ailments.

With your body and mind in this temporary state of metabolic overdrive, you are now prepared to respond to a life-threatening situation. After you have done so and the danger has passed, your body then tries to return to normal. But this may not happen so easily and becomes even more difficult as you get older.

Although the hyperactivating sympathetic nervous system jumps into action immediately, it's very slow to turn off and allow the tranquilizing parasympathetic nervous system to take over and calm you down. Once the stress response has been activated, the system wisely keeps you in a state of readiness. (That saber-toothed tiger or SUV might be preparing for another pass at you.) Because of this hierarchical dominance of the SNS over the PNS, it often requires an intentional technique to activate the relaxation response and to reestablish homeostasis.

It's All in Your Head
The irony of the stress response is that it evolved in physical environments very different from the social and psychological ones today. We experience many problems, or stressors, that our brain perceives as life-threatening, although they are not.

The thought of a late menstrual period or mortgage payment does not need an intense physical response, but we get one anyway. A chronic overreaction to stressors overloads us with powerful hormones that were only intended for short-term duty in emergency situations. Their cumulative effect damages and kills brain cells.

For example, too many stress hormones can prevent the brain from laying down a new memory or accessing already existing memories. And, in a nasty irony, stress hormones can damage the very part of the brain that's supposed to signal when to shut-off their production — creating a vicious cycle that degenerates the brain and diminishes the quality of life.

The Cortisol Conspiracy
The renowned brain researcher, Robert M. Sapolsky, has shown that sustained stress can damage the hippocampus, the part of our limbic brain which is central to learning and memory. The culprits are "glucocorticoids," a class of steroid hormones secreted from the adrenal glands during stress. They are more commonly know as corticosteroids or cortisol.

During a perceived threat, your adrenal glands immediately release adrenalin. After a couple of minutes, if the threat is severe or still persists, the adrenals then release cortisol. Once in the brain, cortisol remains much longer than adrenalin and continues to affect brain cells.

Chronic over secretion of cortisol adversely affects brain function, especially memory. Human studies show a correlation between high cortisol levels and decreased memory and cognitive functions like concentration and creativity.

How Cortisol Affects Brain Function
First, because stress hormones divert blood glucose to exercising muscles, the amount of glucose — hence energy — that reaches the hippocampus is diminished. This creates an energy crisis in the hippocampus which makes it unable to create new memories. That's why some people can't remember a very traumatic event, and why short-term memory is usually the first casualty of age-related memory loss resulting from a lifetime of stress.

Cortisol also interferes with the function of neurotransmitters, the chemicals that brain cells use to communicate with each other. This makes it difficult to think or access long-term memories. That's why people get befuddled and confused in a severe crisis. Their mind goes blank because "the lines are down."

Stress Hormones Short-Circuit Memory Retrieval
Thirty minutes after rats were stressed by an electrical shock, they were unable to remember their way around a maze. When the shock was given two minutes or four hours before going through the maze, the rats had no problem. This time-dependent effect on memory performance correlates with the levels of circulating glucocorticoids, which are highest at 30 minutes. The same thing happened when non-stressed rats were injected with glucocorticoids. When glucocorticoid production was chemically suppressed, there were no stress-induced effects on memory retrieval.

According to James McGaugh, director of the Center for the Neurobiology of Learning and Memory at the University of California at Irvine, "This effect only lasts for a couple of hours, so that the impairing effect in this case is a temporary impairment of retrieval. The memory is not lost. It is just inaccessible or less accessible for a period of time." (Nature, Aug 20, 1998)

Degeneration Why
Cortisol also causes excess amounts of calcium to enter brain cells, which eventually leads to the production of free radicals, the reactive molecules that injure and kill cells.

Unfortunately, there's a final insult. The hippocampus is extremely sensitive to cortisol. Sapolsky's studies showed that lots of exposure to cortisol or lots of stress itself accelerated the degeneration of the aging hippocampus. And because the hippocampus is part of the feedback mechanism that signals when to stop cortisol production, a damaged hippocampus causes cortisol levels to get out of control — further compromising memory and cognitive function. The cycle of degeneration then continues.

Sleeplessness Kills
Researchers at Harvard Medical School found that cheating on sleep for only a few nights increased brain levels of cortisol. Inadequate sleep also deprived the brain of the time it needs to reestablish its energy. A survey by the National Sleep Foundation revealed that almost two-thirds of Americans fail to get enough sleep. Not only does this lead to impairment and death of hippocampal cells, but also to injury and death from the 100,000 accidents caused by sleepy drivers each year. (Spectrum, Sep/Oct 1998)

Sleep Less in School
A study of 500 children, under five years of age, found that those who slept less than 10 hours a day, including naps, were 25% more likely to misbehave (throw temper tantrums, act aggressively, etc.,) than children who slept 12 or more hours a day. (J Dev and Behavioral Pediatrics 1999;20:28-33)

Depression Shrinks Hippocampus
The size of the hippocampus averaged 14% smaller in a group of septuagenarians who showed high and rising cortisol levels, compared to a group with moderate and decreasing levels. They also did worse at remembering a path through a human maze and pictures they'd seen 24 hours earlier and — two tasks that use the hippocampus. A third of the 60 volunteers, who were between ages 60 and 85, had chronically high cortisol levels, a problem that seems to be fairly common in older people. This study, titled "Cortisol levels during human aging predict hippocampal atrophy and memory deficits," was reported in Nature Neuroscience, May 1998.

Dr. Sapolsky discovered that general SNS arousal is a relative indication of anxiety and vigilance — the individual is trying to deal with the challenge. On the other hand, a heavy secretion of glucocorticoids is more a marker of depression — the individual has given up on trying to cope. This burned-out feeling of depression represents the exhaustion stage of chronic stress, where a person feels worthless and has no energy to do anything about it.

New research suggests that the hippocampus is needed temporarily to bind together the various sites that represent a whole memory — sites that are distributed elsewhere in the brain. (Psychol Rev, July 1999)

Spawn and Die
Salmon amaze us with their spectacular leaps up waterfalls and over dams, in their single-minded quest to return and lay eggs in the freshwater stream of their birth. After that, they die. But why? Dr. Sapolsky explains in his book, Why Zebras Don't Get Ulcers:

"If you catch salmon right after they spawn, just when they are looking a little green abound the gills, you find they have huge adrenal glands, peptic ulcers, and kidney lesions; their immune systems have collapsed, and they are teeming with parasites and infections. . . . Moreover, the salmon have stupendously high glucocorticoid concentrations in their bloodstreams. When salmon spawn, regulation of their glucocorticoid secretion breaks down. Basically, the brain loses its ability to measure accurately the quantities of circulating hormones and keeps sending a signal to the adrenals to secrete more of them. Lots of glucocorticoids can certainly bring about all those diseases with which the salmon are festering. Is this glucocorticoid excess really responsible for their death? Yep. Take a salmon right after spawning, remove its adrenals, and it will live for a year afterward."

The Biochemistry of the Cortisol Feedback Mechanism
In his book, Brain Longevity, Dharma Singh Khalsa, M.D., describes the system:

"Normally, in response to stress, the hypothalamus secretes a substance called 'corticotropin-releasing factor,' which then causes the pituitary gland to secrete a hormone called 'corticotropin' (or ACTH). ACTH then causes the adrenals to secrete cortisol. When levels of cortisol rise to a certain degree — a 'setpoint' — several areas of the brain tell the hypothalamus to turn off the cortisol-producing mechanism. This is the proper 'feedback' response.

"However, one of the areas of the brain that is most responsible for telling the hypothalamus to turn off cortisol production is the hippocampus . . . the area most damaged by cortisol. The hippocampus is often so damaged in older people — who may have lost about 20 to 25 percent of their hippocampus cells — that it is unable to give the proper feedback to the hypothalamus.

"When that happens, the hypothalamus keeps pumping out the chemicals that cause cortisol oversecretion. This, in turn, causes even more to the hippocampus. And this, of course, causes even more cortisol production. Thus, a catch-22, 'degenerative cascade' begins. And this cascade can be very difficult to stop."

What Blood-Brain Barrier?
To protect themselves from chemical and biological weapons during the Gulf War, Israeli soldiers were given a drug called pyridostigmine. Nearly one-quarter of them complained of headaches, nausea, and dizziness — symptoms which occur only if the drug reaches the brain. Pyridostigmine molecules generally can't get into the brain, so why had the side-effects increased during combat?

An Israeli biochemist and physician wondered whether the stress of war might somehow have increased the permeability of the blood-brain barrier. The two researchers took a group of mice and stressed some by dunking them in water. They then injected the rodents with a dye and measured its intensity in the autopsied brains. They found that the dye had passed much more readily into the brains of the stressed animals.

The fact that stress can dramatically increase the ability of chemicals to pass through the blood-brain barrier has enormous implications, since many drugs are developed under the assumption that they will stay in the periphery. (Discover, May 1997)

It's Not All in Your Head
Dr. Sapolsky's research with animals also showed that glucocorticoid excess brings about many problems, including "fatigue, thinning muscles, adult-onset diabetes, hypertension, osteoporosis, reproductive decline, and immune suppression — all conditions more common among the elderly." Dr. Sapolsky concludes that "Aged organisms not only have trouble turning off the stress-response after the end of stress, they also secrete more stress-related hormones even in their normal, nonstressed state. . . . Old individuals of all sorts tend to have the stress-response turned on even when nothing stressful is happening."

Table of Discontents
As youngsters, we were all told to settle down at the dinner table. Fine dining is synonymous with an atmosphere conducive to relaxation. All for good reason. We shouldn't eat while in a state of anxiety. The stress response diverts blood away from the digestive tract, which inhibits the absorption of nutrients from food.

In a study at Temple University in Philadelphia, stress was shown to inhibit the production of alpha-amylase, an enzyme in saliva that digests carbohydrates. Test subjects either meditated or did math problems in their head five minutes before eating cereal. When their alpha-amylase production was measured, those who concentrated on the math had 22% less enzyme than the meditators. (American Health, Dec. 1997)

Ideally, we should be content before as well as after a meal.

Why Stress Slows Healing
The wound healing process depends on the activity of two key healing compounds, but stress from emotional upset appears to reduce their activity. Interleukin-1 and interleukin-8 help protect against infection and prepare injured tissue for repair. In a study of women who were healing from blisters, researchers at Ohio State University found interleukin compounds at significantly lower levels in the women with the highest levels of cortisol. As stress and cortisol levels rise, interleukin levels fall — triggering a slowdown in the healing process. (Archives of General Psychiatry 1999;56:450-456)

Stress Adds Injury to Insult
Athletes are two to five times more likely to get injured if they're experiencing recent life stress, compared to less stressed counterparts — according to at least 18 different studies. (Spectrum, Sep/Oct 1997)

A Prescription for Dementia?
At Neuroscience 2000, a worldwide gathering of neurologists sponsored by the Society for Neuroscience, Robert Sapolsky of Stanford University expressed concern about the use of certain steroid hormones to treat arthritis. He noted that hydrocortisone may damage the hippocampus and has been linked to cases of "steroid dementia."

Stress is Not All Bad
Bear in mind that an appropriate stress response is a healthy and necessary part of life. One of the things it does is to release norepinephrine, one of the principal excitatory neurotransmitters. Norepinephrine is needed to create new memories. It improves mood. Problems feel more like challenges, which encourages creative thinking that stimulates your brain to grow new connections within itself.

The challenge in this day and age is to not let your sympathetic nervous system stay chronically aroused, but this takes a conscious effort and requires knowledge of techniques that work to activate your relaxation response.

Obsessive-Compulsive Disorder (OCD): Facts And Myths

The Facts

1. YOU ARE NOT MAD

Obsessive-compulsive disorder is a psychological condition, characterized by high anxiety. Symptoms can include washing, checking, 'ruminating', ordering, hoarding, fears of harm and 'body dysmorphic disorder'. These can consume a lot of time. They can also affect family relationships, work and social life.

While the cause of obsessive-compulsive disorder has not been scientifically established yet, it is probably a chemical imbalance in the brain. The symptoms are nothing to do with the individual's basic personality, and it does not seem likely that they are caused by childhood experience.

People with OCD are usually aware that their compulsions and obsessions are irrational. They simply cannot find a way of stopping without help. Perceptions of reality are usually not distorted in other ways.


2. YOU ARE NOT ALONE

Many people have symptoms of OCD. It possibly affects as many as one in thirty of the adult population. People who suffer from OCD are often very surprised to learn that there are other people who do exactly the same things.


3. YOU CAN GET SUPPORT

OCD has been recognised for many years. During that time, a number of effective responses have been identified. These include:

Medication - particularly the Prozac family (SSRIs) and an older anti-depressant called Clomipramine

Cognitive-behavioural therapy - usually done with a psychologist, this involves the individual learning strategies for mastering their symptoms

Social support - one good way of finding this is to join a self-help group

Information - there are many useful books and leaflets available

Self-help - for some people, particularly those whose symptoms are quite mild, this can be effective


4. YOU CAN GET BETTER

In most cases, cognitive-behavioural therapy is the best treatment. Medication is also effective for many people. It can reduce symptoms by thirty to sixty per cent. A combination of medication and behavioural therapy is often recommended. The majority of people with OCD can master their symptoms with appropriate support and live a normal life.


The Myths


1. I CAN'T TELL ANYONE

Many people recognise that their obsessional thoughts and compulsive behaviours are odd, and feel so embarrassed about their symptoms that they keep them to themselves. If they don't talk to anyone, they can never get support.
It is often helpful to realise that this sort of embarrassment is very common with OCD. Sometimes it is easier to talk to a close friend or family member, or to talk in confidence to an adviser on the telephone before talking to a doctor.


2. I CAN'T TELL THE DOCTOR

People with OCD are often nervous about describing their symptoms to a doctor. They think that they will be wasting the doctor's time, or that the doctor will think they are mad.

In the last few years, doctors have become much more aware of OCD. GPs are much better at recognising the symptoms, and can often treat mild cases of OCD themselves.
GPs are also the first point of contact if you want to see a psychiatrist or a psychologist on the National Health.

If you are nervous about talking to a doctor, speaking to fellow-sufferers in support groups or to a confidential adviser on the telephone first is often helpful.


3. I DON'T NEED HELP

People with OCD sometimes imagine that there is something wrong with them if they can't master their symptoms on their own. This isn't true. Almost everybody with OCD copes better if they can get support at the right time.


4. I CAN'T GET HELP

OCD is a recognised condition, and the effective forms of treatment are well known. While there may be waiting lists, everybody who needs treatment should be able to get it on the NHS.

If you have a problem finding support in your area, it may be worth telephoning a group like Obsessive Action to discuss the problem.


5. I WILL NEVER GET BETTER

People with OCD quite often get depressed, and become pessimistic about their chances of recovery. It is important to remember that people who get the right kind of support usually make significant improvements. Individuals with OCD can have normal, satisfying lives.

Black or White, All or Nothing

One of the great downfalls of anxious people is their tendency to think in "all or nothing" terms. This is the essence of the pessimistic mindset.

The pessimist has a marked inability (through accumulated habits of thought) to see things as they are: a mixture of good and bad, simple and difficult, positive and negative. To such people, an endeavor with a downside is not worth undertaking. A relationship with a flaw it rotten through and through. A misbehaving child or a trying spouse is all bad, all the time. Such a perspective overwhelms and creates a sense of hopelessness. Hopelessness begets anxiety and depression.

Such pessimism is not realism. Far from it. It is skewed, unwarranted thinking. Pessimists, for example, talk about how "my whole day is ruined" because of one negative event. But if forced to sit down with paper and pen, such complainers could find plenty of good - in fact, probably much more good than bad.

The most devastating aspect of "all or nothing" pessimism relates to events that may or may not occur in the future. "If that were to happen," the inner voice says, "it would be terrible. I couldn't stand it." Of course, that's not true. You could stand it. You might be miserable for a time or face a daunting challenge, but that's not the same thing as being unable to face it. But we convince ourselves and become fretful.

We're not forever stuck in our mindset. Thankfully, optimism is a learned discipline. What we must do is gain a more realistic vantage point, to cease our steady focus on what's wrong. We remind ourselves again and again that things are usually not as bad as they seem. That few things we encounter are unmitigated evils. That we really have more inner strength - even more life options - than we normally acknowledge.

When a pessimistic thought arises, challenge it. Ask yourself if it is truly rational. Would a disinterested bystander conclude the same thing? In other words, make the pessimistic thought prove itself - don't just swallow it as dogma. Make the thought answer logical objections that someone might bring against it, just as in a court of law. "All or nothing" thinking withers up under such scrutiny, because it's based on faulty reasoning.

Through repetition, we form our habits. The ice skater falls repeatedly until learning to glide over the ice. So it is with habits of thought. Cultivate the tendency to reject "all or nothing" and you'll become more optimistic, better able to face what life dishes out.

This is not a pie-in-the-sky philosophy that everything will turn out OK no matter what. That is naïve and presumptuous. True optimism - an attitude shorn of "black or white" assessments - helps us live well and find greater happiness.

It puts a lens over anxious eyes that they may no longer see such a distorted world.

A Roadblock to Recovery

"What am I doing in Dallas?" I asked myself the question almost daily for the duration of my stay there. Not that there was anything wrong with Dallas. There’s plenty right with it. It’s just that I was homesick for the Michigan – for family and friends, for familiar sights. After only a couple of months in Texas, I was ready to go home.

I had finished one semester of grad school in nearby Denton when I decided to quit and enter the job market. My wife was working inhuman hours at the hospital to get me through school and support our three kids. Enough was enough. I was going to give her a break.

Trouble was, I bristled at the idea of staying in Dallas. In the back of my mind, I think I really hoped no one would hire me. A job means roots, and I didn’t want to plant roots there.

There were some symbolic attempts to find work -- a phone call here and there, an occasional interview. But soon I was spending consecutive days doing light chores at home rather than job-hunting. And I was getting depressed, because I knew I was shirking responsibility.

It was only a couple of weeks later when a jolting panic attack turned my life inside out. I was stunned. For days, I woke up every morning terrified at the prospect of another day. Those days became weeks. Then a month passed without any improvement in my wretched condition. "How long is this going to last?" I wondered. "How long CAN it last before I lose all of my marbles?"

Of course, looking for a job was a low priority at that point. I was in serious trouble. My life was ebbing away as I watched in bewilderment. My wife was scared. She agreed to pack up and move back to our home town – my safe haven.

Why am I relating all of this? To make a point. Many people with anxiety problems have a vested interest in staying anxious. They have a disincentive to get better. Their anxiety is an unhealthy investment that pays dividends in one form or another. For me, it was a ticket back home. It precluded my getting a job and staying in a town that I didn’t want to settle in.

Was I consciously staying anxious so I could gain these things? No. But the joyous prospect of moving back home proved a hindrance to my recovery from this episode. What I really needed was to get a job, not pack up my family and move across the country again. Had I entered the workplace, I believe I would have felt better before long. It’s possible I would even have adopted Dallas as my new hometown, and done so gladly. Instead, I retreated to the Michigan, whipped, defeated – and still anxious.

Other sufferers, I’m convinced, have their own disincentives to recovery. Maybe their anxiety furnishes an excuse to avoid doing something unpleasant. It routes them away from a challenge they’d rather not face. And so they slacken a little. They don’t do everything they can to get over their problem. They’re not entirely in earnest about moving forward and getting through it.

Are you one of those people? Are you holding back in your recovery efforts because you see anxiety as the lesser of two evils? If so, it is time to face that thing you would rather not face, whatever it is.

Be assured that any gains you or I derive from anxiety will all prove losses in the end.

The Conflict Within

Many anxiety sufferers, especially those with persistent worries and obsessions, fight constant inner battles. Those conflicts are usually between the emotions and the intellect. The content of the mental struggle may vary, but the pattern is the same: A troublesome thought arises and the emotions are galvanized into a fight-or-flight mode. The intellect, however, tries to shut the emotions down, recognizing the worry as baseless. But the emotions do not give up so easily. They fight on. The agitated feelings oppose the intellect’s assertions and keep the sufferer in a state of alarm.

The longer and more furiously this goes on, the more the intellect is worn down and gradually succumbs to these fears. While it was once offering such reassurances as, "This is silly, there’s nothing to worry about," it now says things like, "Well, I don’t know, maybe there is something to worry about here." The paradox is that the more the intellect openly engages the emotions, the stronger they become. The stronger they become, the fainter the intellect’s reassurances become – the fearful feelings effectively drown out the voice of reason.

Clearly, the intellect must win if we are going to be emotionally healthy people. The intellect is the arbiter of what is right and wrong, reasonable and unreasonable. While the feelings enrich our lives and make us more authentically human, they easily lead us down the wrong path. We can multiply examples of this unhappy fact. There’s the woman whose feelings of neediness push her back into a physically abusive relationship. Or the teen who adopts reckless behavior to win the approval of his peers. Everywhere we see examples of havoc that results when feelings drive a person’s life.

The bottom line is this: We cannot live well unless the intellect – the rational faculty each of us possesses -- rules. This is doubly true of anxiety sufferers. The feelings of dread and panic cannot be permitted to carry the day. We know better than to heed irrational worries, but we do so because they become so emotion-charged, so arresting. So what do we do?

The secret is to allow these feelings to burn themselves out. The intellect must stop engaging the fearful impulses in open conflict. They must be allowed to simply spend themselves and dissipate over time.

Let’s say an obsessive worry arises. The emotions begin to flare. Instead of engaging them in open conflict, try sorting out in your mind what your feelings are telling you and what your intellect is telling you. Remind yourself that your intellect is less likely to mislead you than your emotions. Make a decision – a firm act of the will – to follow your intellect, no matter how intense your feelings are. This will take some self-discipline, but you must do it.

It may be helpful to ask yourself what belief your feelings are trying to impose upon you. At the bottom of every worry is a belief, such as "I am in terrible danger" or "I am on the verge of insanity." The intellect may reject it, but the feelings behave as if you really do believe it in your inmost being.

Having determined the belief that is being presented to you by your worries, take a short reality check. Ask yourself these questions about the belief that your emotions are presenting to you:

• Dispassionately considered, is this a rational, sensible belief?
  
  
• Does it look foolish written down on paper?
  
  
• Would I recommend such a belief to another person?
  
  
• Would an emotionally healthy person entertain such a belief?
  
  
• In my stronger, more clear-headed moments, would I think it worthy of belief?
  

After this brief inventory, end the inner struggle right then and there and go about your business. Don’t spend any more time thinking the matter over. You will feel a prod to analyze and dissect the worry further, but you must refuse to do this -- uncomforatable as this may be. The feelings, of course, will rage on. Let them. Don’t fight them anymore. Don’t analyze them. Just keep doing whatever you were doing before the anxiety started. Or find something else to do.

As this drama is playing itself out, it’s important to tell yourself that it’s OK to feel anxious for a while. Your feelings will fire off all their artillery until they are exhausted. In time, the worries will fade. That’s the good news. Anxiety that is not fought against tends to drop off – cancelled due to lack of interest.

This is not easy to do, of course. You may have to remind yourself to hang in there, using statements like:

• "I’m not going to let my feelings do my thinking for me."
  
  
• "This is an irrational worry, and I don’t argue against irrational worries. They don’t deserve my attention."
  
  
• "I’ll just feel some discomfort for a time, but then it will subside. It’s OK."
  
  
• "I know I don’t really believe what my feelings are telling me is true, so I’m going to act like I don’t – no matter how I feel."
  
  
• "Regardless of what my emotions are telling me, this is really no big deal. It’s only anxiety."
  

So don’t let your intellect and emotions battle any more. You’ll be the loser if you do. Instead, let your feelings punch themselves out. It’s the only way to win the anxiety war.

Healing Panic: Chapter Four: Beginning Your Eight Week Recovery Program

Fou are ready to begin practice breathing in such a way that you will no longer be subject to panic attacks. These same exercises will help you control your tendency to hyperventilate in trigger situations, such as driving, that have brought on panic
attacks before.

This series of exercises is designed to help you quickly gain control of panic symptoms and attacks; to remain in control; and if needed, to help you overcome the residual fears some people have after they gain control of their hyperventilation and panic.

Phase One: GAINING CONTROL

GOAL: Learning deep, relaxed diaphragmatic breathing.

You do this by:

• Learning to switch from upper-chest to diaphragmatic breathing
  
  
• Practice slower, deeper breathing.
  
  
• Increasing your breath volume by practicing with a volumetric exerciser.
  
  
• Cut back on tranquilizing medications as soon as you see progress.
  
  
• Practice neutralizing anxiety-producing thoughts.
  

Once you have gained control, staying in control becomes the focus. This takes some further awareness and practice.

Phase Two: STAYING IN CONTROL

GOAL: Make relaxed, diaphragmatic breathing a part of everyday life.

You do this by:

• Using Reminders during the day to breathe using the diaphragm.
  
  
• Continuing diaphragmatic breathing under stress conditions.
  
  
• Reconnecting breathing with talking and moving.
  
  
• Learning to relax using diaphragmatic breathing, relaxation tape and hand warming.
  
  
• Learning to detect early warning signs
  

As you go through the exercises you will note that there is an overlap between Phase One and Phase Two exercises. Many Phase One exercises are used for the entire eight weeks of practice. Using the volumetric exerciser for more than six weeks, for instance, helps you achieve complete recovery from panic attacks.

Using the Daily Logsheets

As you get into the training you will see that more than one thing is being taught and learned at one time. The logsheets help you keep doing one exercise long enough, drop those exercises that have accomplished their purpose, and start a new phase. By keeping a written record, you can go back through the daily logsheets and see your progress. This is self-validating and provides you with an added measure of confidence.

You will notice that when something is added to the exercises, a + symbol is used to call your attention to the new material.

You have been given daily logsheets for eight Weeks and instructions of how to proceed from the Ninth Week onward. Each Week begins with goals and special instructions for that Week. Many weekly sections are preceded by additional information about the exercises you will be doing that Week. The reading and exercises appear in the order you will be using them. If you want to clarify something, you can go back and reread the information.

You may find that the pace of treatment is too fast. There is no harm, and definite
benefits, in repeating one or more of the Days or Weeks as you go along. How long you continue practicing the various exercises is up to you, but keep in mind that you don't have to achieve perfect mastery before moving on. Some of the exercises may not seem necessary to you. Try them first, then decide whether or not to continue using them. Don't give up if they are too hard; persistence pays off. Only stop if the exercises become too easy!

If you suffer from Panic Disorder without Agoraphobia, you may need only eight to ten
weeks of practice. Some people respond very quickly to this treatment. For people who have suffered for many years and have, through necessity, developed many compensatory strategies to try and avoid panic attacks, eight to ten weeks is a minimum course for learning skills. These skills will provide a good start on the road of recovery.

USING THE GRAPHS IN THE DAILY LOGSHEETS

The graph at the top of each logsheet is where you record the intensity of your symptoms, and this is where you can go back to see your progress. It is important that you fill in the graph at least once a day, as this helps you identify when your symptoms are most intense and any suspected causes of your symptoms. The grids for your charting are labeled by time of day (X axis) and severity of symptoms (Y axis). The severity scale is None (no symptoms), Mild, Moderate, Severe, and Panic Fear. Record the intensity of any type of panic or hyperventilation symptom as Mild, Moderate, or Severe. Symptoms can include trembling, dizziness, chest pains, or abdominal upset. Use "Panic Fear" when you experienced an attack during which you felt like you were being suffocated and could not breathe for a period of time.

This is an idea of how the graph might look after you have marked it to record your
symptoms.

Record the Intensity of Your Symptoms Each Day

SYMPTOMS	4am	6am	8am	10a	12N	2pm	4pm	6pm	8pm	10p	12M	2am
PanicFear
Severe								X
Moderate					X				X
Mild			X	X		X	X			X	X
None	X	X										X

By marking X's in the squares, you can keep a day-to-day record of your improvement.
Also, if the graphs indicate that your symptoms are habitually more severe at certain
times of the day, these are the times to watch your breathing, reduce stress, or make sure your blood sugar doesn't get too low. You may also want to consider changing the time you take a medication.

RECORD ANXIETY MEDICATIONS

The record of medications is another way you can see progress. As your symptoms are
alleviated you will feel less need for medication, take it less often, and probably stop it altogether.

If you are taking one of the benzodiazepine medications (Xanax, Valium, Atavan, and
Klonopin are the most commonly used) or buspirone (BuSpar), it is important that you
get your doctor's help in tapering off and withdrawing as soon as you are able. Starting to cut back during the first week of breathing practice is not too soon, but you may have to take more time to develop confidence in your ability to control the attacks by yourself. Do not stop taking these medications abruptly, as this can lead to extreme anxiety and provoke intense panic attacks or seizures. These medications get in the way of learning and remembering, to a much greater degree than is generally appreciated. Treatment failure for panic disorder is associated with continued use of these types of drugs. This is true even if you are taking benzodiazepine medications on only an "as needed" basis.

Choose whether you want to record each time you take a medication or simply record
your daily intake. In the case of benzodiazepine medications, it is not recommended that you space out your medications, as your body has grown accustomed to having the drug at certain times. Rather, you should taper off by cutting back on the amount you take each time (generally three or four times per day).

The following table shows an example of how you might want to take as long as 8 weeks
to taper off of alprazolam (Xanax) as you do the exercises. This helps prevent rebound anxiety and withdrawal symptoms. Tell your doctor that this is how you want to go about it.

Example of Gradual Reduction of Alprazolam (Xanax) and Other Benzodiazepines

	First Dose (AM)	Second Dose (AM)	Third Dose (PM)	Fourth Dose (Bedtime)
1st Week	Usual dose	1/2 usual dose	Usual dose	Usual dose
2nd Week	Usual dose	1/2 usual dose	Usual dose	1/2 usual dose
3rd Week	Usual dose	1/2 usual dose	1/2 usual dose	1/2 usual dose
4th Week	1/2 usual dose	1/2 usual dose	1/2 usual dose	1/2 usual dose
5th Week	1/2 usual dose	1/4 usual dose	1/2 usual dose	1/4 usual dose
6th Week	1/4 usual dose	1/4 usual dose	1/4 usual dose	1/4 usual dose
7th Week	1/4 usual dose	None	1/4 usual dose	None
From now on	None	None	None	None

Following the Exercise Directions

The program includes three types of exercises. First, there are those that you will do every Day throughout the 8-week training period. Next, there are "fall back" exercises that you will use if you experience symptoms of hyperventilation. Finally, there are those that you will do while you are in a particular phase of your training. The training logsheets are designed to remind you of all three types of exercises.

Meanwhile, you need to be aware of some general directions before you actually begin.

Practice when you are feeling at your best.

Especially in the beginning, your best may not be very good, but that's O.K. The point is that in the beginning this is practice for gaining control soon. Don't try to control panic attack symptoms right from the beginning; at first you are learning to catch the ball, not play baseball.

Stop practicing if you experience hyperventilation symptoms.

If you start to have symptoms during any exercise, stop doing the exercise. Use the "fall back" exercises to regain immediate control so that your symptoms don't escalate and get out of control. Get your mind off your breathing and come back to it later in the day.

This is so important! If you are phobic about other things and you allow symptoms to
build during breathing exercises, you'll soon be phobic about the exercises and not want to do them. That would be one more failure, and you and I want these exercises to be a success.

Build your strength gradually.

It's better to work with the exercises for just a few minutes when you begin and then increase your duration later as you develop more tolerance. When working with your breathing, always stay within the comfort zone. The comfort zone will expand as you practice. Just like with an exercise program, it may be a week or two before you notice improvement. Consider the first week or two an investment; don't give up the program without making an honest effort.

Give yourself some room to make mistakes.

In your trying, you may try too hard or may fail to follow the directions as given. You might provoke some symptoms or slow down your progress. Most people make some mistakes when they begin these exercises, because they are learning something that seems strange and unfamiliar.

Eat an adequate breakfast and a snack before you go to bed.


Many people who suffer from panic disorder seem to be prone to low blood sugar or tolerate it less well. This is stressful to the body and can cause hyperventilation. An adequate breakfast with protein, and a snack at bedtime that includes complex carbohydrates and protein will help level out your blood sugar between meals.

You do not have to do the exercises perfectly in order to feel that you can control hyperventilation symptoms or panic attacks. All you have to accomplish to get control is mostly breathe diaphragmatically and slowly when you are thinking about it. It's a downhill battle from there!

Plan for First Week

• Make an appointment with your doctor to discuss any antipanic, antianxiety, and
  antidepressant medications you are taking. Make a plan with your doctor to withdraw
  from the antipanic and antianxiety medications.

  
  
  

• Each morning before getting out of bed, practice three slow, diaphragmatic breaths. Continue to be aware of your breathing and breathe slowly as you get out of bed.

  
  
  

• Use the daily logsheets, which will help you to switch from upper chest to
  diaphragmatic breathing.
  

GENERAL INSTRUCTIONS

• Always wear loose clothing during the exercises
  
  
• Starting to learn diaphragmatic breathing the first week is easier if you are lying down. Lie on the floor (or bed if it's firm). If you use the floor, use a carpeted surface or get a pad. A bed sheet over the carpet is a good idea.
  
  
• The volume of breath to be taken in for an exercise is either seventy percent
  [70%] or one hundred percent [100%] of maximum. In the beginning you will have to estimate how much this is. If you experience symptoms, reduce the volume of the inhale and exhale more slowly.
  
  
• Unless you have a nasal obstruction, keep your mouth closed and breathe through your nose. If you have a nasal obstruction, breathe through pursed lips.
  
  

CAUTIONS

Be aware of the most common hyperventilation symptoms (especially dizziness). If you experience the symptoms, use the pursed-lips breathing technique explained below to increase the carbon dioxide level in your bloodstream.

Re-breathe air from a paper bag (instructions appear below) only if overwhelmed. Don't become dependent on this technique.

When beginning to use the diaphragm for breathing again, some people experience a fluttering or shaky sensation in their abdomen. If you experience this symptom, use the pursed-lips breathing technique.

Pursed-Lips Breathing Technique

Many people will experience hyperventilation symptoms when checking their breathing or beginning breathing exercises. If this happens to you, discontinue the exercise you are doing. Breathe in slowly and hold it for as long as 20 seconds if you can. Then breathe out slowly by pursing your lips, as if gently blowing out a candle. After only two or three breaths, you should no longer feel dizzy. Then, exercise a little by walking around as you maintain awareness of slow breathing. Come back later and complete the breathing check or exercise.

Instructions for Re-breathing Air from a Paper Bag


If at any time your symptoms escalate and you begin to feel out of control, breathe into a medium-sized paper bag and re-breathe the same air for a few minutes. This will help you replace the carbon dioxide your system has lost from over-breathing. This is a common "fix," but does not help you gain control of your breathing over the long run. Whenever you can, use pursed-lips breathing or the slow exhalation count, which do help you learn to gain control.

Instructions for Slow Exhalation Count beginning on Day Five

Step One

Make yourself comfortable in a recliner or on a couch, where you can lay back but still have your head and upper body raised up a little. Use the sweep second hand of a watch or other timer that shows you the time in seconds to help you gain control of your breathing.

Watching the second hand, gradually slow your breathing to 3 seconds for each inhale and 3 seconds for each exhale. Breathe with your diaphragm as you have been practicing. At this point in the exercise you may be inhaling only 30% of your maximum capacity.

Be sure to exhale completely by squeezing in the muscles of your abdomen at the end of the exhale. As you relax, extend the length of time for each inhale and each exhale to 4 seconds, then to 5 seconds. As you extend the time of each inhale and exhale you will need to take in more air with each breath. Keep at it until you notice that you have more control over your breathing.

Step Two:

Once you feel more in control and relaxed, you can progress to practicing deeper breathing by taking in the deepest possible diaphragmatic breath, pausing for a few seconds at the top of the breath, and then breathing out slowly and counting the seconds in a whisper until you have squeezed out all the air you can. So it's:

1. BREATHE IN SLOW DEEP DIAPHRAGMATIC BREATH [70% to 100%].
   
2. P A U S E;
   
3. BREATHE OUT (Counting) ONE, TWO, THREE, FOUR, FIVE, SIX, SEVEN; etc.

Give yourself a rest of a few normal breaths before you try it again. Then, when you are ready, take another deep, relaxed, diaphragmatic breath and count out to a higher number if possible. You will find that the more relaxed you are, the deeper the inhale and the higher the exhale count.

The idea is to gradually increase the time you take to exhale without getting too much or too little air. This means always staying in your comfort zone. As you work with the timer and the slow exhalation count, you should start feeling a lot more relaxed. These are good exercises to do in the evening before you go to bed, as they help you become relaxed and able to sleep well once you are under the covers.

Medications


Working with your doctor is important, because your need for many types of medications will change as you practice diaphragmatic breathing and your overall breathing becomes more functional. If you are diabetic and take insulin, and if your doctor has approved slow breathing exercises, your need for insulin may change; you may need less than you did before. As you overcome panic attacks, your need for antidepressant medications may also change, or you may no longer require them. Only a medical doctor or psychiatrist in consultation with you is qualified to determine your needs.

As mentioned before, many antianxiety and antipanic medications are known or suspected to cause treatment failures. If you have taken some of these drugs for many months or years, the prospect of withdrawing can be uncomfortable. Taking this type of medication on an "as needed" basis is not recommended. Be willing to put up with some discomfort and to use the breathing exercises you will be learning to control anxious feelings. You should not stop any drug on your own; in some cases doing so can even be dangerous.

Verbal Reward

Give yourself an automatic verbal reward every time you do an exercise. This is important even if you do not feel totally successful. Positive thoughts relax your mind and body and lower anxiety. Even doing an exercise in such a way that you induce some symptoms is a positive learning experience. Such self-talk as "Wow, I did it!" or "That's O.K., I know I'm just learning" sets you up to continue your improvement the next time you practice.


-- Bert A., M.Div., Ph.D.

Healing Panic: Chapter Three: Breathe In - Breathe Out

"Breathe in, breathe out!" I first heard this as a young man, from an old doctor who liked to relax his patients with corny jokes while he prepared an injection. "Do you want to know how to live forever?" he asked. "Sure," I naively took the bait. "Breathe in, breathe out," he said. "As long as you keep breathing in and out you can't die."

Some thirty years later I heard the same words again from another doctor, a Ph.D., who is in the forefront of developing a learning model for retraining people to breathe. The "diploma" which Dr. Erik Peper awards patients and professionals who attend his workshops in breathing bears the title "Breathe In, Breathe Out."

The sequence and types of exercises in the pages to come are the fruits of Erik Peper's many years of careful research. The specifics, however, are the product of my helping people who suffer from panic attacks.

"Breathe In, Breathe Out" Knowing How We Breathe
The old doctor's joke isn't so silly, because it implies that we have control over our own breathing, unlike involuntary actions such as our heartbeat. It's easy to take a breath when we want to, or to blow out the birthday candles just when we're ready; we very consciously take a deep breath and blow hard. Most of the time, though, our breathing is on automatic and we don't think about it.

We humans have some breathing problems, probably because of this part-time conscious control over our breathing. We can easily learn to adjust or modify our breathing, just as singers, actors, and instrument players do. The problems come when we learn the wrong things, which don't have bad effects immediately but eventually become bad habits that create the symptoms of anxiety.

So now it's time to take a close look, from an anatomical standpoint, at how breathing is "supposed" to be done.

The Anatomy of Normal Breathing
The lungs are a complex maze of air passages and minute air sacs (alveoli), with an even more complex mesh of arteries, capillaries, and veins intertwining through the air passages and sacs. For our purposes, though, the lungs (there are two, one on each side of the chest) can be thought of as balloons. The balloons are emptied and filled not in response to their own actions, but in response to the actions of the entire torso, which encloses the lungs.

Breathing takes place through the air passages leading from the nose and mouth into the lungs. Although the bronchial tubes and lungs are lined with smooth muscles that regulate the flow of air, these are not the muscles with which we breathe.

The chest and ribs, which are attached to the spine in the back and the breastbone in the front, form a somewhat flexible cage enclosing the heart and lungs. The chest cage is narrower at the top, which has an opening occupied by the neck.
Looking at the illustration, turn your attention to the wide bottom of the rib cage. The bottom ribs are not connected to the rigid breastbone, but are held together by pliable cartilage. Attached to the bottom edges of the wide cage, from front to back, is a muscle called the diaphragm. The diaphragm is shaped like an inverted bowl or funnel. Through the middle of the bowl (or neck of the funnel) run the arteries and veins that carry blood from the heart, to the organs and lower extremities, and back to the heart. The esophagus runs through the same area on its way to the stomach, and major nerves run through here as well.

The diaphragm should be the main muscle of breathing, because its location in the body gives it the most room to move in a piston-like fashion. Below it are the soft organs and the belly, which can expand outward when a deep breath is needed. Above the diaphragm are the lungs, which are also soft and pliable.

The easiest way to understand how the diaphragm works is to make a relaxed, inverted bowl, with the tips of your fingers just interlocking.

With your fingers still interconnected, tense your hands and wrists, and, if you're doing it right, you'll see the bowl flatten down. That's almost exactly how the diaphragm works.

When it's relaxed, the bowl is most bowl-like (deepest). In terms of the piston illustration, the piston is up when the diaphragm is relaxed. At this position, the diaphragm is pushing up on the soft and pliable lungs, and the air in the lungs is forced out -- exhaled. If you pull in your abdomen at the same time you push up on the underside of the diaphragm, you force out even more air.
The inhale, of course, is the opposite. The diaphragm contracts, just as your fingers flatten out. That brings the piston down, creating more space in the cage. Air, naturally, is the only thing that can fill the space, so it moves into the lungs, filling them.

Other parts of the body also assist in breathing. If you tighten and pull in your stomach, you push more air out of your lungs, because you put pressure on the underside of the diaphragm-piston. If you let your stomach pooch out, the diaphragm has more room to move down into the area of the soft organs and you take in more air.

But the muscles between the ribs all up and down the chest, especially those between the more flexible lower ribs, can also work to make the rib cage bigger. Air comes in, again because there is more space to fill. Even the muscles of the neck, shoulders, and upper back assist in the breathing process.

When you're running hard or doing aerobic exercises, the idea is to breathe hard -- to inhale and exhale a lot of air. The more air the body needs, the more of the various breathing muscles go into action to create additional space for breathing.

When breathing is done correctly, the volume of the lungs is quite phenomenal. The diaphragm can move up and down as much as six inches. In the process, it gently massages the lower organs and aids in the blood's return to the heart. A large person can have a lung capacity of five quarts. Even a small adult can breathe in two or more quarts of air.

Habitual Diaphragmatic Breathing
When at rest, the correct way to breathe is with relaxed shoulders, upper chest, and stomach muscles, allowing the diaphragm and lower rib muscles to carry on the automatic breathing process. When you breathe in this way, your body continually adjusts the volume and breathing rate as needed to maintain the acid/base balance of the blood and other factors. Eight to twelves breaths per minute is normal breathing rate.

Habitual Thoracic (Chest) Breathing
Many, and that may mean most, people breathe in a slightly abnormal fashion. They tend to hold in their stomach, make little use of the diaphragm, and breathe using the muscles of the upper chest, neck, and shoulders. This style of breathing becomes automatic, and the body adjusts volume and rate as it does in diaphragmatic breathing.

Thoracic breathing depends on the more rigid system of muscle action in the neck, chest, and shoulder area. This means that the lungs are given less room to expand or contract and that the body must work harder. As breath volume is lowered, breathing must be speeded up in order for the body to maintain its chemical balance.

My own observations of the breathing of panic attack patients confirm what other researchers have discovered: people who have panic attacks chest-breathe. Their resting breathing rate has speeded up to twenty to thirty shallow breaths per minute. They also try to compensate by sighing frequently, sometimes as often as two or three times a minute, adding significantly to the loss of carbon-dioxide. Sighing is likely the result of the small air sacs' failure to expand, and the sigh allows enough air deeper into the lungs so as to keep the sacs and airways open. When sighing or taking a deep breath, the chest-breather visibly lifts the entire chest up away from the diaphragm, thereby creating more space in the chest cage, rather than allowing the diaphragm to pull the air in.

How Breathing Changes When You Become Anxious
So far we have discussed functional and dysfunctional breathing. Relaxed abdominal breathing is better. Tight thoracic breathing isn't as good and may lead to problems. Now, how did it get that way?

When a person becomes anxious, sad, scared, aroused, or angry, the body immediately begins to go through changes in order to cope with the new situation. Of course, we needn't concentrate only on the negative emotions; changes also occur when we are delighted, loving, excited, joyful, playful, and full of laughter. We increase the amount of air we breathe, by breathing faster and deeper. Our heart quickens its pace, more blood flows through the arteries and veins, our senses become more acute, we become more alert.

Human beings are capable of a great range of emotions and physical responses. We can be placid like the waters of a gentle pond, or raging like the ocean in a fierce storm. The change from placid to raging can happen in the twinkling of an eye. It's all part of being human, even necessary to being human. Problems arise when the emotional and physical responses can't be played out, when the storm has to be held inside, not unleashed in some civilized or uncivilized way.

It is the connection between emotions and physical responses that concerns us when we think about panic attacks. Recently I was watching a person whose breathing was being monitored as he was pretending to be angry with someone else. As soon as he began to work up some pretend-anger his breathing changed as if he were actually angry. His breathing became faster and deeper, and the carbon dioxide level of his body, as monitored in his breath, began to drop. I noticed something else: as this was happening, he didn't breathe out in the same way as when he had been relaxing a few moments before. As a result, he retained more air in his lungs each time he exhaled. His deeper and more rapid breathing was actually on top of the air remaining in his lungs. It was as if his body were trying to hold on to the carbon dioxide by preventing him from exhaling too much!

Actual experiments have shown that just imagining a stressful event will cause a person to breathe faster and retain many times more air in the lungs than when relaxed and unstressed. You can well imagine that if you've had panic attacks, just the thought of another attack can be enough to change your breathing and start you on the road to another attack, without you even being aware of it.

As you begin to check out your own breathing pattern and train yourself in more relaxed and functional breathing, remember how your thoughts and emotions can work for you or against you. Keep a positive attitude.

For many victims of panic disorder, thoughts, fears, and physical reactions become automatic and create a great deal of anxiety. There are proven methods for countering or neutralizing these thoughts and reactions, and these methods need to be part of every course of treatment. These will be found in the exercises you will be doing. Retraining your breathing and knowing positively that you can prevent attacks is essential to success in your recovery from panic disorder.


-- Bert A., M.Div., Ph.D.

Healing Panic: Chapter Two: Panic and Hyperventilation Syndrome

For more than 25 years, I have been counseling people with emotional problems.
Like most of my colleagues, for many of those years I was confounded by the problems of people who sought out my help for their panic and the numerous fears and other problems that accompany this condition.

A lecture I attended some years ago in order to learn some more about these attacks was of little value. The psychiatrist who presented it began by asking how many in the audience had ever experienced a panic attack. A scattering of hands went up. He said that he also had suffered from these attacks. But at the end of the lecture, when asked to pinpoint the actual cause of the attacks, he did not have a ready answer.

Medical treatment for panic usually consists mostly of anti-anxiety or anti- depressant medication and advice to watch stress. Even if the doctor understands that hyperventilation can lead to panic, he will likely do little more than recommend breathing into a paper bag for a few minutes to help re-establish the level of carbon dioxide in the bloodstream.

John

John came to me to get help with intense anxiety. As a manager, he often had to make presentations. When he was called on to lead a meeting or talk to groups, he would become so panicked that he was considering quitting his job just to avoid being put in this position. After John left my office, I reached for a new book that had just arrived in the mail. I began to read the chapter by Dr. Ronald Ley entitled "Panic Disorder, a Hyperventilation Explanation." I was fascinated. In it, Dr. Ley described John's situation exactly.

Ley did not "discover" hyperventilation. As his extensive bibliography showed, that had been documented about a century earlier. But it wasn't until 1975, in an article entitled "Hyperventilation, The Tip and the Iceberg," that Dr. C. M. Lum concluded that "faulty breathing" is the real root cause of hyperventilation and panic, perhaps along with being a perfectionist if you were a woman or a "Type A" if a man. By 1985, over 2,000 patients had been admitted into his program at Papworth and Addenbrook's Hospitals in Cambridge, England. Most of these patients were not only helped but cured.

Not all doctors agree with Dr. Lum's conclusions, but more and more scientists regard hyperventilation as the key to understanding panic.

Traci

Late one day a frantic mother called me about her daughter, who had been having panic attacks since morning. She had gone into convulsions, the mother told me, but they were afraid of going to the emergency room of the local hospital, where Traci had already been more than once. A few weeks before, she had been so agitated that she had to be injected with a powerful tranquilizer before she was able to calm down. She was told that unless she was able to get control of herself the sheriff would be called, and she would be taken to the psychiatric ward of the County Hospital.

When they arrived at my office, Traci was gasping for air. She could hardly walk, and the muscles in her face were twitching. Her eyes were glazed over from fear and exhaustion, and her pupils were dilated. She was unable to concentrate on anything for more than a few seconds. What she needed was to gain control of her breathing. Little by little, I helped her slow down and deepen her breathing. After an hour, she was weak but calm. She had gained moderate control. The panic had passed.

People experiencing a panic attack usually have difficulty breathing, a difficulty commonly thought to be caused by the attack, and one of the many recognized symptoms. But panic attacks are actually brought on by the way a person habitually breathes. That is, the breathlessness and gasping experienced during an attack is an extension of a problem that began before the first attack, sometimes long before.

When Traci began her training in controlling the attacks, I could not see her breathe at all. Only when I attached a sensor around her abdomen and others on her neck and shoulders, all connected to a computer, could I see her breathe, by watching the screen. Her breathing was shallow, rapid, erratic, and she was using only the muscles in her neck and upper chest. Her abdomen wasn't moving at all. She was breathing at a rate of 22 breaths per minute, about twice what is considered normal.

How Hyperventilation Leads To Panic

Like other victims of panic attacks, Traci showed all the characteristics of hyperventilation syndrome recognized by C.M. Lum:

• She took air into her lungs by using her chest muscles.
  
  
• She didn't use her diaphragm when breathing, or only partly used it.
  
  
• She breathed rapidly and shallowly, so it was hard to see her breathe unless she sighed, or took a deep breath on request.
  
  
• Habitual rapid, shallow breathing (something of which the victim is unaware) results in breathing out more carbon dioxide than the body produces, keeping the carbon dioxide level always too low.
  

Over-breathing, or breathing in and out more air than is needed with each breath, creates the same imbalance. This is a more recently recognized cause of hyperventilation and panic attacks in some people.

A case in point is a person who works out at the gym or exercises regularly and whose breathing is unrestricted. The problem is the opposite of what Lum found, but the result is the same. Here it is "habitual deep breathing" that results in breathing out more carbon dioxide than the body is producing.

Without enough carbon dioxide to maintain the acid/base balance of the body, the blood becomes too alkaline, a condition known as "blood alkalosis." Alkalosis causes the arteries to constrict, with the result that blood flow is restricted, especially to the brain. Although the blood contains plenty of oxygen, alkalosis also prevents the essential transfer of oxygen from the blood to the brain, muscles, and organs, as has been frequently verified in panic attack victims who have gone to the emergency room. This is known as the "Bohr Effect" and has long been recognized by those who study hyperventilation.

Under these circumstances, the oxygen available to the brain is reduced drastically. At first vision begins to blur. The typical sufferer reports feeling dizzy, tense, anxious, jittery, and nervous. The sufferer often feels like crying, and feels weak and confused. Starved for oxygen, the sufferer feels as if suffocating. As the condition worsens, the brain gets more confused and sends the wrong messages. One wrong message is the need to breathe even more deeply, which worsens the problem.

The heart is pounding by now, increasing (or lowering) blood pressure, sometimes to the point of causing the person to faint. Pupils dilate, the face, hands, and feet become cold or numb, the hands tremble, and the sufferer sweats. Chest pain may be present. This is usually related to chest breathing and muscle spasms in the chest wall, but in some cases may be actual heart pain.

In brief, when blood alkalosis gets serious, the sufferer is going to experience that a great deal is wrong, even life-threatening.

Maureen

Maureen had been having severe panic attacks for only a few months when she sought treatment. Carrying on the normal activities of her life was becoming difficult, even with anti-anxiety medication. When she filled out the questionnaire I gave her, she checked off all of the statements about breathing: shallow breathing, rapid breathing, breathlessness, trouble catching her breath. She had trouble sleeping, often waking up in the middle of the night and unable to go back to sleep. She had headaches from the tension she carried in her neck and shoulders. Altogether, Maureen was a classic case of advanced hyperventilation syndrome.

Maureen's breathing was very erratic. I had difficulty helping her relax and slow down her breathing. Then, while being monitored for chest and abdominal breathing, Maureen had a panic attack. She had been working on relaxing her neck and shoulders and was making progress. Sometimes when a person relaxes it will bring on an attack, because less carbon dioxide is being produced as metabolism slows.

When this happened, Maureen became apprehensive and began to breathe more deeply. As she felt increasingly short of breath, she began to use her chest, neck, and shoulders as much as she could, causing extreme tension.

For about three minutes she was almost unable to breathe. This is the most frightening part of panic. Then she began to breathe out, but still with some difficulty. As she caught her breathe again at the end of the episode she was able to relax the tension from her neck and shoulders. It was a frightening experience and left her shaky, but at least able to breathe again.

Staying Alive

A careful study of the chart made during Maureen's panic attack showed why she was unable to breathe. As her fear mounted she was not breathing out all the way. With each gasp for air she retained more air in her lungs, unable to breathe it out. At the height of the attack she could simply breathe in no more. Those frightening symptoms, however, are actually the body's way of staying alive. Before their appearance, Maureen had been breathing in such a way that she was exhaling too much carbon dioxide. If her nervous system had not detected what was wrong, she could have died. When she was prevented from breathing at the height of the attack,
it allowed her body to replace some of the carbon dioxide it had lost as she began to breathe harder. Although this was an agonizing experience, a semblance of balance was restored and life could go on.

Because we have for so long thought of panic attacks as an indication of a disease, we have failed to recognize that they prevent something far worse. Panic attacks are like the circuit breaker tripping to prevent a short in the wiring from burning
the house down.

The Habits of a Lifetime

Many panic attack victims are told by the emergency room doctor that they're just reacting to stress. Stress may be the most immediate cause, or trigger, for panic attacks, but many people cannot identify a unique stressor that preceded their first attack. John could identify that making a presentation in front of many people incited his attacks, but he had done this many times before without a problem. We have to assume, therefore, that John had an unrecognized problem that was building towards an attack. Hyperventilation was getting worse, but still did not induce symptoms until he had his first attack.

Bad breathing habits may begin for any number of reasons. Since flat tummy is part of our culture's idea of a good body image, people often learn to chest breathe in order to look trim and fit. Periods of grief, or anticipating harm over a period of time, can begin a pattern of shallow breathing that may later become serious enough to induce an attack.

The truth is that everyone hyperventilates to some degree on a regular basis. Being in a car going fast, being jammed into a crowded elevator, preparing for a dinner party, having a disagreement, going to the hospital, having blood drawn, being given an injection, reprimanding or protecting a child, being scolded, or going for a test where you might not know all the answers. Any or all of these can result in more rapid, shallow chest breathing. For most people, breathing returns to normal when the experience is over.

For people prone to panic attacks, the return to normal breathing and recovery from hyperventilation is delayed and usually insufficient.

The death of a spouse, divorce, loss of a job, being promoted, relocating, going off to college, retiring, buying a home, or starting a new career all can create a great amount of anxiety. None of us would be normal if we didn't hyperventilate while going through these experiences.

Whether stressful experiences will eventually result in panic attacks depends on whether the breathing pattern under stress becomes habitual. Some resilient folks seem to be able to go through many difficult circumstances and never have a panic attack. Yet, others who have difficulty identifying anything ever happening to them will suddenly be struck out of the blue.

The Triggers

Triggers depend on habitual and ongoing hyperventilation. John was habitually hyperventilating before he went to the meeting that triggered his attack. After repeated experiences, making a presentation or even thinking about standing in front of a group would trigger an attack. He started to anticipate the fear, and that made him more fearful.

When John noticed that he felt a little shaky, that his heart was beginning to pound, that his vision blurred, and that he began to sweat, he knew he was losing control. The resultant fear ensured that he would have an attack.

Because the physical symptoms are not actually dangerous, but only "feel" dangerous, there is no reason to fear them, and therefore no reason to panic. Many people have been helped simply by hearing this, but if they haven't solved the problem of habitual hyperventilation they keep on having physical symptoms, which frequently keep on getting worse. In some cases physical symptoms can trigger enough anxiety to cause panic. An example is a muscle spasm that feels like the pain of a heart attack.

Breaking the Habits

If you are reading this because you have experienced panic attacks, you probably already know what will trigger the physical symptoms that trigger an attack. Making a presentation, driving on the freeway, entering a market, going to church, being at work, exercising, excitement, relaxing, traveling. It's only logical that a person avoids trigger situations in order to avoid having panic attacks. The problem, of course, is that this limits your life to living only in the safety zone, places where you believe you are safe from attacks or can be quickly rescued by trusted family members.

The methods for overcoming panic attacks detailed in the coming chapters are based on observations, research, and clinical practice which have been carried out in hospitals, universities, and the practices of many disciplines.

Now that you know what is causing the symptoms you experience, it is time to examine how you breathe now, how you should breathe in order to prevent panic attacks, and what to do to train yourself to do exactly that.


-- Bert A., M.Div., Ph.D.