If we suddenly encounter a danger or a threat, we will fight, try to get away or be in such fear that we are immobilized and freeze. The fight, flight or freeze responses are daily experiences in the animal world. A gazelle lives its life grazing in the field and propagating for species survival, while simultaneously being on the alert for predators. Anxiety is an alarm system to keep an animal on its toes, to maintain a look-out for possible life threatening danger. The nervous system is fine-tuned to anticipate danger or threat so that there is time to escape danger.

These responses are normal in the human condition. Something may trigger our alarm system and we are thrown into the emergency alert mode. If the internal alarm goes off when there is no obvious danger or threat, how does one handle this internal warning? You really cannot completely ignore it. You will try to find an explanation to account for it. Your mind may start building up a scenario to account for such fear and anxiety. It may be a subliminal flashback of memory that is the trigger.

More fear will feed on that initial intangible fear, and perhaps a bodily sensation gets misinterpreted. The alarm system will convince you that something is wrong, that there is still danger. And then, you get into a full response mode of fight, flight or freeze. Even if we are getting a clearly false signal of impending danger, we may have already set into motion those patterns of getting ready to fight, running away, or becoming frozen with fear. This is a primitive reaction that is in our genes. It is a reaction cycle that kept our ancestors alive for tens of thousands of years.

The problem is that this kind of response behavior is usually no longer adaptive for survival in modern life. In most cases we do not have a natural predator lurking behind the tall bushes in the park to prey on us. However, as is clear from the statistics on early childhood abuse, there are predators out there, sometimes in the child’s own home. In later life, if some past trauma for which our body has been keeping the score raises its ugly head as a fragment of implicit memory, we receive the same alarm signal warning us of possible life-threatening predatory danger.

Traumatic memory does not function like narrative memory in our ordinary life, like remembering coffee yesterday with a friend. Traumatic memory is often cued by sights, smells, tastes and the feeling tone in an environment. The memory often arises in a pre-verbal way. So, not conceptually remembering the specific trauma doesn’t mean that we have not experienced it, nor does it mean that we don’t carry that trauma in our mindstream.

Therapists in clinical practice see that anxiety comes in all forms. The purest form is anxiety that emerges seemingly out of the blue, without an identifiable reason. When a person reacts to a small triggering sensation, often without even identifying the sensation, the associated traumatic memory of fear itself will emerge quickly into a full blown panic. The sensation can be as small as the tinge of an odor similar to one that was experienced in trauma, or the passing twinge of a painful sensation. The mind is brought back to a danger of the past. The entire body shifts into “battle station” mode. It is not that one is not afraid of something unknown, rather one is on the lookout for something familiarly frightening.

It is very instructive for a therapist to watch anxiety developing right in front of them. I have had the experience of watching a patient developing a panic attack right in front of me in a hospital when I was the psychiatrist on call one night. While remembering that  any physical discomfort or symptom such as chest pain may actually have a real pathological rather than psychological basis – which will be left to the Emergency staff physician to handle – but with respect to a possible psychologically based anxiety attack, there are a series of steps for the therapist to take.

1. The first thing is to convey to the patient of your empathic understanding of the magnitude of fear the patient is experiencing. The worst thing is to make light of the patient’s panic, saying that there is really nothing to worry about.

2. Once you have their confidence, you will have to ascertain that the condition is really a panic disorder, not some physical problem that mimics a panic attack.

3. The preferred treatment depends on the orientation of the physician as well as the time available. In my experience, the efficacy of medication is uncertain. I believe the effects are often largely a matter of how much the patient trusts the therapist. In purely relying on the pharmaceutical effect, one runs into the danger of having to use a colossal dose to suppress the physiological arousal of a panic attack. At best, medication is useful as a short-term temporary intervention.

Panic disorders are related to the patient feeling loss of control over his/her bodily power. I characterize it as a disorder of “dis-empowerment.” The patient is thinking, ” Why is my heart racing so fast when I am sitting down, not even walking.” He/she does not realize it is the response reaction that has spun out of control, with the mind and body setting itself up in preparation for dealing with some as yet unseen but monumental threat. Whether that threat is a present danger or artifact from the past, the physical response is entirely understandable and beyond self-control.

The test of the therapist’s skill is how to suggest or assist the patient in reversing that escalating panic response. Stopping something when it is already in motion is very hard. For example, if a car is moving at 100 miles per hour, and the driver’s foot is pressed down on the accelerator, it is exceeding difficult to stop the car. The first thing to do is to let him/her  regain confidence that the car is still controllable. It is easier to let the person continue speeding while gently steering it in a different direction, perhaps up a hill, rather than insisting to the person that they get their foot off of the accelerator and stop short. The patient is already overwhelmed by the intensity of the panic, it is impossible for them to stop doing whatever their body response dictates.

Remember the analogy of heading the speeding car uphill. Highways that run through mountains have special lanes for runaway trucks with failed brakes – they exit from the main road and head up a hill so that gravity, that invisible hand, acts as an environmental brake. How can a therapist use this analogy? Redirect the patient’s energy rather than confront it. Focus attention onto something for the patient to do that is not connected with denying the panic. There is the well known “Brown Paper Bag” method. This invites the patient to breathe in and out of a brown paper bag. I know of many patients who have successfully used this method. In fact, some carry a brown paper bag with them in case the panic returns.

The paper bag method is so simple. It is not asserting anything about the panic being correct or imaginary, therefore there is usually no obstacle to doing it. When someone is in a panic, the natural tendency is to “do something.” Just as with grounding exercises, this method fits into that protocol every well.

The reason it works is psychological, not physiological. Blowing into a paper bag is a simple task. The mind and body are engaged in a task. Through that engagement, the mind and body energies are redirected rather than suppressed.

There is another reason I like this method. It is because it is something the patient does which leads out of the panic. That is what counts. The best treatment is one that patients can do on their own, which engenders the confidence that they can control their bodily functions. This is re-empowerment.

Most psychiatrists advocate relaxation as the central focus in psychotherapy. This is difficult to apply, and generally not possible in the  midst of a panic attack. To ask a patient to try to relax during a panic attack is like saying to a drowning man, ” Relax, your body will naturally float.” It doesn’t work.

There is a proper time and place for discussion of the patient’s fears, whether they are seen as rational or irrational, but it is not during an attack. The cognitive or rational-emotive approach is appropriate only later, in the context of a supportive therapeutic relationship and environment. For example, a behavioral approach emphasizing graduated exposure to panic-inducing situations is only appropriate after the patient is taught methods of regaining self-control, that he is again the master of his body.

I do not have confidence in the long-term benefits of the textbook treatment of panic attack such as:

• Carrying items such as medication, water or a cell phone
• Having a companion (e.g. a family member or friend) accompany them places
• Avoiding physical activities (e.g. exercising, sex) that might trigger panic-like feelings
• Avoiding certain foods (e.g. spicy dishes) or beverages (e.g. caffeine, alcohol) because they might trigger panic-like symptoms
• Sitting near exits of a room.

All of these may be helpful short-term supports but they generally involve increasing the dependency of the patients, confirming that they are helpless and remain unprepared for the next time onslaught of panic. These methods are not based on, nor will they result in, re-empowering the patients.

I have practiced slow breathing long enough to be able to hold my breath for about 2 minutes. Given that, I was able to show and reassure my patients that it is quite safe to not breathe for 15 seconds. Then all I asked them to do is to slow down their breaths to say 4 times a minute. Once they were willing to try to slow down their breathing, even just by counting to 10 between each inhalation and exhalation, their panic dissipated.

No one can sustain panic when the breath is slowed down. The usual difficulty is convincing a patient to slow down their breath because they all feel they are struggling for air. By having them breathe along with me, they can see that they are able to work with their own breath. Then, they do it themselves. Once this is accomplished, the panic will usually not return in that intensity, and the patient will not become dependent on medication for anxiety .

After the panic is under control, find out what else needs attention. Is there past trauma? Is the current life-situation full of difficulties? Tell your therapist. In the absence of a therapist, or if you have yet to establish a safe therapeutic relationship, tell yourself by writing into your diary. Putting your troubles into words is always better than just stewing about it. In writing, it becomes something tangible with boundaries that can be worked with. Too much thinking often becomes a fruitless exercise – like a dog chasing its own tail.

Panic disorders are not something that you need to find a magic pill to cure. Even if there is such a pill, it will only work temporarily. I am generally against giving pills for this because on the one hand, they may not work and on the other hand, they most certainly will not re-empower you. Grounding exercises are critical for a patient’s re-empowerment. Practice them regularly before a panic attack arises so that you develop a personal panic toolbox to keep you centered in the present moment.

Panic attacks are self-perpetuating, tail-chasing, vicious cycles that distract us. What do they distract us from? Usually, they keep us from getting near a deep unhealed wound. A bacterial infection needs an antibiotic for healing, but panic attackes are not caused by an external agent like a bacteria. To eliminate a panic attack, one needs an inoculation of the present moment’s safety. Grounding is that specific inoculation.

Panic may be your body telling you that there is danger or that something needs to be fixed. Take heed of its warning—use your time and energy to deal with the real issue, rather than seeking a medication to suppress the alarm signal. If you cannot yet find the reason for your fear, through grounding, you have at least found a way to control your body, to re-own it again.

A famous psychotherapist in the mid 20th century, Frieda Fromm-Reichmann, wrote about a man, probably not her patient, who was suffering from severe anxiety. He underwent in-depth psychoanalysis. In this case, there was a real yet seemingly unrecognized reason for the anxiety, even though he was then at the peak of his wealth/fame/family bliss. Soon after he was “cured”, the Nazis took over and he was taken to the concentration camp to be exterminated.

There is an important lesson in this: Anxiety, like depression, is not always a symptom to be eliminated. Don’t limit your focus in therapy to turning off the alarm. Check to make sure whether or not the alarm signal is correctly assessing a present danger.