Managing stress, anxiety and panic attacks

Definitions of anxiety, panic and worry

The Collins Dictionary defines these as:

• Anxiety - is a state of uneasiness or tension caused by apprehension of possible future misfortune, danger or worry
• Panic - is a sudden overwhelming feeling of terror or anxiety
• Worry - is to be or cause to be anxious or uneasy, especially about something uncertain or potentially dangerous

The three words above are all connected in various ways, and links will vary with the individual.

Panic is a normal reaction to sudden threat or danger, a reaction that can trigger the fight or flight response which is necessary for survival. Watch a YouTube video about the Fight Flight Freeze Response.

However, having once experienced a heightened state of panic, fear can set in about feeling panic again, leaving underlying anxiety and a heightened state of arousal. This makes us prone to more panic attacks, even when there is no imminent threat or danger.

Over time, we may become ‘worriers’, and find it difficult to let go of concerns, fears, apprehensions and ‘what ifs’ in our lives.

An underlying long-term state of worry or anxiety can make us prone to panic attacks for which there seems to be no rationally explicable trigger.

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The 4-prong approach

Overcoming panic attacks and managing anxiety requires a 4-prong approach:

1. Some understanding about the nature of stress, and how it affects us in physical, mental and emotional ways
2. Some skills in managing anxiety and panic attacks when they happen
3. Finding the causes
4. Regular self-care strategies

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Understanding the nature of stress

The first prong is to have some understanding about the nature of stress, and how it affects us in physical, mental and emotional ways.

In engineering terms, stress implies a load or force applied to a structure which will withstand it until some limitations inherent in the structure is exceeded and collapse occurs.

In human terms people have a capacity to withstand stress up to a certain limit – indeed, need stress up to a certain limit for best performance – they collapse or break down if this limit is exceeded.

This last point illustrates the fact that our minds and bodies are not designed to cope with consistently high levels of worry, stress and anxiety. Additionally, as we all have our own unique capacities for stress or ‘tipping point’, there is little point in comparing ourselves to others.

How the body responds and adapts to stress

The stress continuum has been explained by Hans Selye, as the General Adaptation Syndrome (GAS) which has three stages and presents a clear physiological/biological explanation of how the body responds and adapts to stress:

1. Alarm Stage

   In this phase, the initial reaction of the body to stress is that it labels the stressor (this can be a person, event, anything…) as a threat or danger to manage. That is why it immediately activates its fight or flight response system and releases “stress” hormones such as adrenaline, noradrenaline and cortisol.

   These hormones enable you to perform activities that exceed your usual capacity. For example, when we realise that our house is on fire, our body will shift to the alarm stage, releasing our stress hormones (particularly adrenaline) and meaning that we can run much more quickly or lift a very heavy appliance outside the burning house.

   Instead of the fight/flight response, there can be the ‘freeze’ response. This means that all the same physiological reactions are taking place, but we feel rooted to the spot, paralysed, and can feel incapable of acting or speaking.

2. Resistance Stage

   After the body has responded to the stressor, it is more likely that the stress level has been eradicated or reduced.

   Although the body has shifted to this second phase of the stress response, it remains on-guard and vigilant, particularly when the stressors persist, or we have been particularly impacted and frightened. Our body can remain ‘ready to respond’, although not as strongly as it did during the initial response.

3. Exhaustion Stage

   When the stressor has been persistent or perceived by us to be persistent for a longer period we move into this phase. The body starts to lose its ability to combat the stressors and reduce their harmful impact because our energy is all drained out.

   The exhaustion stage can be referred to as the gate towards burnout or stress overload, which can lead to health problems if not resolved.

Watch a YouTube video about the General Adaption Syndrome.

Physical effects

These can be:

• Dry mouth, maybe difficulty swallowing
• Digestion slows down, maybe ‘butterflies in the stomach’, nausea and sickness
• Adrenalin and nor-adrenalin are released to maintain body changes ready for fight or flight
• The heart pumps faster and blood pressure rises to move blood more quickly to muscles. There may be a feeling of racing or irregular heartbeat, or there may be palpitations
• Muscle tension increases – may be tension in the abdomen, throat, shoulders, neck, face or forehead. This tension can cause headaches, changes in vision, dizziness, insomnia and shakiness
• Breathing is faster and more gasping. This provides more oxygen to the body, but over-breathing and breathlessness may occur (hyperventilation)
• Sweating begins to allow rapid cooling in case of sudden exertion and, because of the changes in the flow of blood to the skin, there may be cold clammy hands or feet, blushing, flushing or hotness

These changes are normal, but prolonged stress can lead to other changes in the body such as constipation or diarrhoea, proneness to illness, lethargy or excessive tiredness.

Mental effects

Moderate levels may be stimulating and encourage clear thinking, rationality, good decision making and creativeness.

As stress increases, however, there is increasing difficulty in thinking and analysing, with thinking either becoming obsessively focussed in one direction, or jumbled and confused.

Generally, there is an inability to consider alternatives and confusion about what decision to make. 

Emotional effects

Emotional effects of stress are variable and depend on the degree of stress. The following are common: 

Distress, unhappiness, depression, despair, despondency, insecurity, inadequacy, hopelessness, feeling overwhelmed, aggression, lack of caution, risk-taking, impatience, irritability, panic, fear, anxiety, overactivity, excessive sensitivity, emotional withdrawal, apathy, boredom, numbness, increased emotionality, repetition when talking, stuttering, mispronounced words, general lack of confidence

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Managing anxiety and panic attacks when they happen

The second prong is some skills in managing stress and panic in the moment.

The key to managing feelings of overwhelm, high anxiety and panic attacks is to breathe:

• Babies and animals know how to breathe, but many adults do not! If you watch a baby, young child, or animal breathing, you will notice that when they breathe in (inhale) the abdomen expands, and when they breathe out (exhale) the abdomen relaxes in

• As we grow, we are often encouraged to suck in our abdomen or wear tight clothes. It does not take long to lose the habit of natural breathing

• Natural breathing allows a natural amount of air and oxygen to be inhaled and exhaled. Shallow breathing that is breathing only into the top of the chest does not

• When panic begins, and fear is experienced, we tend to breathe faster, and over-breathing (hyperventilation), with shallow breaths, causes changes in blood chemistry which can cause feelings of dizziness, weakness etc

Natural Breathing Practice

Natural breathing will not feel natural if you are used to breathing incorrectly.

Try this test: Put one hand on your chest, and the other of your abdomen, and then take a deep breath in.  Which hand moves the most? If it is the one on your chest, you need to practice breathing into your abdomen.

You can try practising in any of these four ways:

• Imagine your belly is a balloon filled with air.  Empty the balloon by blowing out slowly and flattening the balloon (put your hand on your belly and imagine you are pushing it flat to your backbone).

  When all the air is gone, let go of your stomach muscles, open your mouth and you will feel the air as it automatically goes in to fill the balloon again. Try this several times noticing how it feels as the air goes out of your mouth and in again.

• Sit upright in a chair with one hand on your chest and the other on your abdomen, and breathe slowly and evenly, in and out until you are able to keep your chest and shoulders relatively still, and your abdomen is rising on the in-breath, and falling on the out-breath. Find your own gentle, even and slower rhythm.

• Lie on the floor with one hand on your chest and the other on your abdomen, and breathe slowly and evenly, in and out until you are able to keep your chest and shoulders relatively still, and your abdomen is rising on the in-breath, and falling on the out-breath. Find your own gentle, even and slower rhythm.

• Sit forward on a chair with your legs apart. Lean forward with your forearms resting on your legs, relax your shoulders. In this position, you will necessarily breathe into your abdomen as you breathe in, and this is the best position for noticing the feeling of natural breathing.

  Remember to focus also on keeping your shoulders relaxed in this position. Find your own gentle, even and slower rhythm.

It will take a few practices for you to be able to breathe naturally and correctly, without using your hands as reminders. You can practice anywhere, on the bus, in a restaurant, in bed, anywhere.

Practice this awareness on natural breathing as often as possible, so that you can do it whenever you choose to, and eventually, you will change your habit of breathing only in a shallow way.

When a panic attack begins, remember, BREATHE!

Some people find it helpful to say to themselves during this focus on breathing ‘I am taking control of my breathing I am in control’.

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Finding the causes

The third prong is detective work to find out what might be causing you to have a panic attack.

Sometimes there is an obvious cause, but other times there is not. This is where you need to explore everything about the situation.

Initially, this needs to be after the attack has subsided, when you have calmed down, and are able to think clearly about what set it off.

With the practice of natural breathing, as the attack begins, you may find you are able to identify the triggers as they are happening. This will help you to take control of the attacks in a different way.

Sometimes it is important and appropriate to avoid certain situations or people who trigger attacks. In these situations, your body is informing you that there is indeed some real threat of harm (this may be more emotional harm than physical, but it is real) and the time has come to let go of that situation or person.

The anxiety you feel may not be about the specific situation; it is just a coincidence the panic attack has happened there, and it is more about a cumulative effect of prolonged exposure to stress. In these circumstances you have exceeded your ‘tipping point’ and the panic attack is a symptom of physical exhaustion or burn out.

Other times it may be that something happened in your life which frightened you badly. This was a real threat then (perhaps having a bad experience in a classroom and subsequently feeling heightened anxiety in an academic environment) but does not need to be avoided. In these cases, identifying the stages of panic can help you in finding ways of remaining in control and calm.

Remember to be kind and gentle with yourself. It never helps to berate yourself for feeling out of control – it will add to the feeling of being out-of-control. Be gentle with yourself after an attack.

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Regular self-care strategies

This is the final prong.

As you are working to overcome panic attacks, and possibly long-term anxiety and worry states, some other skills will be essential.

Each individual will need to consider what is most helpful to them - yoga doesn't work for everyone! - but here are some simple starter self-care ideas:

• Ensure you focus on your natural breathing or meditation practice regularly

• Counselling can help you explore the reasons for anxiety and panic attacks. Even a few sessions can be helpful

• Try taking a yoga or relaxation class regularly - plenty are online

• More rigorous exercise also promotes feelings of calm and reduces stress. This may suit you more than slower forms of exercise

• Reading a non-work-related novel, something for fun rather than work

• Adding some items to your immediate environment that help you feel cosy and secure: a soft blanket, cushions, favourite photos pinned up

• Set aside time each day to do something you enjoy. Ten minutes listening to a piece of music, drinking a cup of tea, sitting in the garden or speaking with a good friend. Whatever helps you unwind will be very beneficial even for a short time

• Develop your own toolkit of things which help you unwind. Pin your list to the wall, and do something from your list every day

• Keep a diary of how you feel for at least a couple of months. Check-in with this three times a day at least, and add a note of any panic attacks. On a scale of 0-10 where 0 is completely relaxed and 10 is overcome with panic, note where you are on that scale. By keeping the diary you will see any emerging pattern, which might help with your detective work

• Consider whether any foods are contributing to your underlying anxiety state. For example, caffeine in coffee and other drinks are known to cause palpitations and shakiness. If you notice a connection avoid or reduce these

• Prioritise scheduling self-care activities in the same way you prioritise work appointments. Put ‘Appointment with self’ in the diary!

• Practising treating and speaking to yourself as you would a friend you care about. We are generally far too self-critical and it helps to try being kinder and gentler with ourselves.

  Our brains generally operate on the basis of 'what has gone before' so if we are in the habit of being mean to ourselves this often continues unless we make a conscious decision to change our 'script' and be more 'on our own side'. Counselling can also help with this if it feels too hard to do by ourselves.

In your detective work, you may have identified relationships which cause stress and anxiety. It can be useful to think about boundaries you may need to put in place so that you can protect yourself from the time and demands of others. You may need to access support with this if it feels too difficult to do alone and the Goldsmiths Wellbeing and Counselling Teams are here to help with these sorts of issues.

Meditation

Sometimes the sheer array of different online platforms to help us manage stress and anxiety can make us feel anxious and overwhelmed. Here is a simple meditation practice to get you started:  

1. Sit or lie down, ensuring that you will not be interrupted

2. Decide how long you will meditate for and then either set a timer or tell yourself when you will stop

3. Choose a phrase, a verse of a song or poem that you like.  Close your eyes, focus on your natural breathing for a few breaths and then, in your mind, say your phrase or verse

4. When you have finished, repeat it, and continue to repeat it until the time you have decided upon is finished

   You will naturally, from time to time, begin thinking about other things, or hear other noises and be distracted. Do not berate yourself or force your thoughts away, turn gently each time, back to your phrase or verse

5. Before going back to your usual activities, check how you are feeling

This simple technique can be useful even if practised for only five minutes and can be used anywhere. If practised for longer, say up to twenty minutes, you may find you fall asleep. That is fine too – meditation can put you in touch with what your body and mind really need.

Meditation is a discipline and needs practice. It is easy to give up when thoughts or feelings interrupt the focus of your attention (the phrase you are repeating). The trick or discipline is to accept that interruptions are natural and you just turn your mind again to what you have decided to focus on.

Conclusion

Fear of having further panic attacks increases underlying anxiety by worrying.

Through using your knowledge of how stress and anxiety manifest within us, focussing upon your own self-care, engaging your ‘inner detective’ to recognise the external and internal triggers and considering what can be done about these, perhaps with support, you will feel more in control and able to overcome them.

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Other sources of help

• Insight Timer - website with a range of free resources from professionals and celebrities
• Calm - app aimed at helping to still the mind
• Headspace – mindfulness and meditation to help combat stress

Videos from Goldsmiths Counselling Service:

• Grounding techniques
• Managing panic