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.
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