In order to reimagine Panic Disorder, we need to explore the ordinary psychological processes that lie behind panic. To show how different this is from seeing it as a condition or disorder we will look at a mainstream Internet site, in this case NHS.uk. Such sites supposedly offer readers unbiased evidence-based information to help them understand their experiences. However, we will see that NHS.uk’s ideas about panic disorder make it more likely we’ll have problems. They shape and intensify the distress we experience.
The costs of this are enormous in terms of distress, loss of productivity and provision of NHS services which aim to undo the damage that it has helped create. In contrast when panic is described in terms of ordinary, normal psychological processes it becomes easy to understand. To do the argument justice this article is necessarily long. There is a summary box of the ordinary psychology of panic at the end.
Many of us will experience an episode of panic at some point in our life. We might wake very suddenly in the night with a feeling of dread. Our heart will be thumping and our breath coming in gulps. Equally we could be going about our everyday life and, out of the blue, feel extremely anxious. If you’ve had such an experience, you’ll know just how intense it can be.
If this ever happens, we may well be able to identify why we feel panicky; some issue or conflict we’ve been struggling with (illness, failure, break-up etc). If we can’t it’s quite logical to wonder what on earth is going on. This is where our problems can begin.
One episode like this wouldn’t qualify for a diagnosis of panic disorder. NHS.uk offers the following;
“Panic disorder is an anxiety disorder where you regularly have sudden attacks of panic or fear. Everyone experiences feelings of anxiety and panic at certain times. It’s a natural response to stressful or dangerous situations. But for someone with panic disorder, feelings of anxiety, stress and panic occur regularly and at any time, often for no apparent reason.”
“You may be diagnosed with panic disorder if you experience recurrent and unexpected panic attacks followed by at least a month of continuous worry or concern about having further attacks.”
“A panic attack is when your body experiences a rush of intense mental and physical symptoms. It can come on very quickly and for no apparent reason. A panic attack can be very frightening and distressing.”
COMMENTS: How do these ideas shape a reader’s understanding of their experience? Can they even shape the experience itself?
The first thing to notice is that the experience is described as a panic attack. At first sight this might seem to capture something of what it feels like. However, it suggests a comparison with viruses or some other outside agent doing something unexpected and unpredictable (feelings of anxiety, stress and panic occur regularly and at any time)
Does the word attack also suggest we should be ready to defend ourselves in some way? How would we do this? Importantly there is no mention that we should stop and try to think what issues and conflicts lie in the background of our panic. This implies that, not only do these feelings feel as if they come out of the blue, but they do, and they could do so regularly and at any time.
The second paragraph specifies a criterion for the diagnosis. However, this is, as with all mental health diagnoses, inevitably arbitrary (at least a month of continuous worry). Is this a lunar or calendar month and what could continuous worry possibly mean and who is to decide?
The criteria for diagnoses are set by a committee. They are implemented by an individual practitioner interpreting what the person tells them in the light of what the committee has laid down. The criteria are not fixed by a clear, unambiguous physical test. This means there is no absolute distinction between having a panic disorder and not having it. At the end of the day it is a judgement made in a social situation. If a person either wants or doesn’t want a particular diagnosis, they should find out what the criteria are.
The third paragraph seems to suggest the problem is physical; it excludes any mention of the mind (A panic attack is when your body experiences…).
NHS.uk hasn’t invented its view in a vacuum; it simply reflects the wider culture which generally prefers physical, mechanistic explanations to psychological ones. Reading NHS.uk you wouldn’t think that these “panic attacks” were the experience of active agents who were trying to deal with and make sense of complex lives. Even when NHS.uk mentions events that have a psychological aspect (It’s a natural response to stressful or dangerous situations) these are conceived of as events that happen to people and as if there is no psychology in how we see events as stressful or dangerous.
SOME BASIC PSYCHOLOGY: How problems start.
So how do things look different if we see ourselves as active agents dealing with complex lives?
Anxiety is natural and necessary. We feel anxious when we predict something that we don’t want. The more likely we think it is and the more we don’t want it to happen the more anxious we will feel. (see The Speeding Car under Thinking Tools)
Feelings of anxiety can feel as if they come out of the blue because we are not aware of a lot of the thinking we are doing. Sometimes we face a complex situation that we can’t see solutions to. We can’t think about it all the time; it pops into our mind now and then. It does this particularly when we are not doing something that takes our mind off it. At these times we may experience a surge of anxious feelings and not immediately recognise the thought that provoked the feelings.
If our concerns are strong enough the feelings can be extreme. However, the physical aspects of these feelings are only the body doing what it is designed to do; i.e., doing what the mind is telling it to do, preparing for action. At this point what matters is how we make sense of the anxious feelings. It is clearly helpful if we understand how intense fear works; how it is driven by our thoughts.
If we don’t have this understanding, we may well be alarmed by how we feel. Naturally we want an explanation. We might think the feelings mean there’s something physically wrong with us, even that we might die. We might think we’re losing control or going mad. We might think we are going to make a spectacle of ourselves or show ourselves up in some very embarrassing way. These are quite common ideas people have when they experience intense anxiety.
All of these are us doing our best to make sense of what is happening to us. They are all based on not understanding how our anxious feelings arise. They are all interpretations or guesses about what might be happening to us. If we think about each of these guesses, we can see they all contain predictions that for most of us would be intensely worrying.
All of them simply add more anxiety. They increase our physical feelings, so we’re likely to become more concerned what is happening. We’re caught in a vicious circle of thinking. The more anxious we feel, the harder it’ll be to recognise this at the time. It’s only later when nothing has happened to us and we’ve calmed down that we stand a chance of making sense of what how we felt. Then we might be able to see we were getting ourselves at it; that all of our predictions of disaster were just thoughts that only made us feel worse.
We need to know we can’t feel calm if we think these thoughts and take them seriously. And we can’t feel intense panic without entertaining some of these ultimate thoughts.
So, if we’ve had an experience like this and didn’t to recognise the issues and conflicts driving it, what do we do next? Well, increasingly people go online and look for answers.
BACK TO NHS.uk
“you may start to avoid certain situations because you fear they’ll trigger another attack. This can create a cycle of living ‘in fear of fear’. It can add to your sense of panic and may cause you to have more attacks.”
“Most panic attacks last for between 5 and 20 minutes. Some panic attacks have been reported to last up to an hour.”
“The number of panic attacks you have will depend on how severe your condition is. Some people have attacks once or twice a month, while others have them several times a week.”
“Although panic attacks are frightening, they are not dangerous……and it’s unlikely that you’ll be admitted to hospital. Be aware that most of these symptoms can also be symptoms of other conditions or problems, so you may not always be experiencing a panic attack.”
COMMENTS: The first paragraph appears to recognise some of the basic psychology involved (you may start to avoid certain situations because you fear they’ll trigger another attack). However, it again fails to mention any psychological reasons why we should feel suddenly anxious in the first place. Nor does it make it clear that avoidance is something we ‘choose’ to do because we are actively dreading something.
If we are not encouraged to look for the psychological reason why we panic in the first place it is entirely understandable that we’re likely to avoid situations like the one where we panicked. NHS.uk wants us to think our panic happened to us due to a condition or disorder that could happen to anyone.
This is reinforced by the next paragraphs. “Most panic attacks last for between 5 and 20 minutes. Some … have been reported to last up to an hour. The number….. will depend on how severe your condition is. Some people have attacks once or twice a month, others…. several times a week… they are not dangerous……and it’s unlikely that you’ll be admitted to hospital… most of these symptoms can also be symptoms of other conditions or problems…..”
Is this reassuring? Or does it encourage us to worry how bad the experience might become and to be concerned we might indeed be suffering from a physical health issue? If we think there is a physical cause it’ll be hard for anyone to persuade us to think about psychological explanations.
MORE PSYCHOLOGY: How we grow our problems.
All psychological problems grow because of the detail of our attempts to make sense of them. There is nothing mechanical about this. Our problems aren’t driven by outside factors or our brain biochemistry; they are driven by our in-the-moment thinking and how this develops over time. (see Thinking Tools; Two People on a Plane for an everyday example of the importance of our in-the-moment thinking.)
Recognising that it’s our thinking that matters doesn’t mean it’s easy to stop this thinking. One of the most important things to appreciate, and one of the most difficult, is just how complex and multi-layered our thinking is. But focusing on our thinking rather than thinking of our problems as a condition or disorder gives us a new direction to go in.
How do we grow our problems?
We can’t cover all the possibilities so let’s take an example.
When we have a surge of anxiety, we might notice our heart pounding (an ordinary part of the physical reaction to anxious thoughts). We might then assume there could be something wrong with our heart; perhaps, we’re having a heart attack. Even when the moment passes, and we feel better we can easily wonder what it was and whether and when “it might happen again”.
If we do this, we will unwittingly tune into how our heart is behaving. We watch for early signs that we might be in trouble. We might start checking our pulse regularly. We might find ourselves listening to our heart when we lie in bed at night. We might tune into sensations in our chest. We might feel uncomfortable in any situations that raise our heart rate. These things are sensible actions we take because we have misunderstood the nature of the problem. They are not things that simply happen to us.
Tuning into any sensation that could be an early warning sign can be unconscious and very subtle. Over time we can develop a remarkable sensitivity. We will notice not just signs of early anxiety, but we will tune into levels of activity that are entirely normal and which we have always ignored in the past. In this way the thinking behind our problem grows over time. (See Thinking Tools; The Red Mini for an ordinary everyday example of how the meaning we give things changes the way we unconsciously notice things and how this can lead to us becoming hypersensitive to harmless sensations.)
Just as we might worry about our sensations, we might also associate the panic with the situation in which it happened. This is another way in which we can grow our problem over time. For example, lets assume our first episode of intense anxiety occurs while we are waiting in the queue of a busy supermarket. We feel confused and embarrassed. Our first thought is to escape. When we next go out, we may be tempted to go to a different supermarket. We might avoid all supermarkets and any shops where we might have to queue. We might avoid banks and even small shops when they are busy. In time we might feel reluctant to go to a restaurant or, if we do, we might think we need to sit near the door, so we can leave quickly. Our thinking about situations can grow and grow in time until we don’t want to go out at all.
All of these things are reasonable if we fail to see our initial panic was understandable because of the psychological issues or conflicts we were facing. They flow from understanding the problem as NHS.uk would have us understand it. They are not things that happen to us, but things we are doing with the very best of intentions.
We may also develop a whole host of precautions; things we do because we believe they make us safer. We might only travel short distances from home. We might only go out if someone goes with us. We may feel we always need to know where we can get help. We may feel we have to have an escape route which we plan beforehand in great detail. We may only go to places by car so we can leave at any time and don’t have to rely on anyone.
We may feel desperate to find an answer and be willing to try all sorts of things that others suggest.
We may adopt all sorts of safety behaviours, things we believe will make us feel better if we start to feel anxious; eg having a paper bag to breathe into, water to drink to cool us down, a banana for energy, or medication or a herbal remedy. We may insist on sitting on the end of the row if we go to the cinema. There is an infinity of things we can come up with that we believe make us safer.
These precautions are all aimed at reducing the likelihood of a panic or helping us deal with the situation if we feel the first signs of anxiety. They ‘work’ because we believe in them. Over time we can add more and more of these safety behaviours.
But each time we enact any of these safety behaviours we are, in effect, telling ourselves there is something to be afraid of. If we have a lot of them, they keep our concern with whether we might panic at the front of our mind. So, the unintended consequence of relying on them is that they sustain and prolong our worries.
Psychological problems are not static; while in the early stages we are likely to grow them, later on they will ebb and flow. They grow as we add more ideas about what we should avoid or what our sensations might mean; they shrink as we learn to tolerate or ignore our sensations, or when we let go of our concerns with situations. They ebb and flow as we add or subtract safety behaviours. Our concerns and level of difficulty can change dramatically over short time periods.
At times we’ll forget all about it. We might be distracted by good things happening or our confidence might gradually grow over a period of time. However, if we carry on thinking of it as a condition that we suffered from, should life become difficult again for any reason, we might reactivate all our hypersensitivity, avoidance and precautions.
If we can understand the ordinary, psychological processes involved we can learn to become more aware of how we unwittingly allow the thinking to grow. If we can do this, we can learn to allow difficult times to pass. We may feel very anxious at times, but we’ll connect this with what we are facing and what we’re thinking.
When the difficulties pass we can get on with living our lives as best we can.
The message from NHS.uk is fundamentally unhelpful in many ways. It fails to see that we’re active agents in the business of dealing with and making sense of complex lives. Most individuals naturally use mainstream cultural ideas to help them make sense of their situations. NHS.uk is a primary site many will turn to. It spectacularly fails to offer a psychological understanding of how we panic. Instead it encourages people to think of themselves as suffering from a condition or disorder. It is, therefore, responsible for adding to people’s difficulties. Nhs.uk reflects wider cultural thinking. For this reason, so-called panic disorder should be seen not simply as an individual problem but as partly a problem of culture. The costs of this are enormous in terms of distress, loss of productivity and the provision of NHS services which aim to undo the damage that it has helped create.
SUMMARY: The psychology of panic.
We have feelings of intense anxiety when facing complex issues and conflicts that matter to us.
Messages in the culture mislead us. They do not recognise the ordinary psychology of panic. Because of these messages, it’s not easy to recognise the issues in our life; instead we’re encouraged to concentrate on how we feel.
We add to our anxiety and panic when we think our sensations mean something terrible is happening to us (death, illness, madness, social embarrassment)
We grow our problems by becoming hypersensitive to our sensations, avoiding situations and adopting precautions and safety behaviours.
Our problems will ebb and flow as our thinking ebbs and flows. At times we’ll be distracted or focused on other things. When this happens, we feel better.
If we appreciate how complex our thinking is and how it drives our feelings, we’ll have a new way of understanding panic. This changes everything and gives us a new direction to work in.
Ideas and habits can be difficult to change …..but they can be.
we can get on with living our lives as best we can.