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QUESTION OF THE MONTH

We receive thousands of questions. The questions cover all aspects of the experience of an Anxiety Disorder. This question has been picked as the Question of the Month. It highlights aspects of recovery which will be of interest to many people. Read on and enjoy ....

Q. I have read many of the Q & As at your website. A lot of your answers refer people to CBT to deal with panic. I have wondered for quite a long time, why is it that the only way I have been able to block the panic is through medication? I take Prozac and Klonopin--medication was a last ditch effort to deal with the panic. I am on very low doses of both and through experience I have decided that the medication is the only way to block the panic.

I have read that you "deal" with and "accept" the panic attacks. Also I read that they "only last 30-seconds anyway." What about the residual chemicals stored in your body after a fight-or-flight response? What happens to those? I was told that the reason I feel as if I am in a state of panic for a couple of hours or days is because they aren't being metabolized before the next attack. So how do you get ahead of the production of chemicals so you can cognitively deal with this disorder?

I have seen several CBTs. They helped me feel more confident but I never seemed to completely block the attacks consistently. Now I am on the verge of tapering off of the Klonopin, but I won't give up the Prozac. I feel it is the only medication that has completely blocked the symptoms. Now, this is where I really get confused. How can a medication block the attacks if they are all brought on by my style of thought?--I still think the same thoughts to some degree.

Answer from Bronwyn Fox: There are a couple of issues in this. Firstly, this is what some medications can do for some people, ie., some medications can block the panic. Block being the operative word! Some people find as they begin to withdraw their medication, they may experience panic and anxiety as part of an overall withdrawal problem. In this instance their panic and anxiety is related to the withdrawal and not the original panic and anxiety. Other people may not have any withdrawal problems and may be panic and anxiety free, but find their original panic and anxiety returns a few months/year later.

Secondly, medication may not block some peoples' panic and anxiety completely. People can still remain symptomatic even while taking medication. The international research also shows this.

What I have found from my own personal experience of Panic Disorder / Agoraphobia, and also from 15 years of working in the field of anxiety disorders, those of us who recover and who stay recovered, are those who have used Cognitive Behavioral Therapy (CBT). The way I see recovery, it means recovery from the Disorder / Agoraphobia / depression / prescribed dug dependence. It does not mean we will never experience another panic attack or never feel anxious. Recovery for many of us is the loss of fear of our panic attacks and the loss of fear of our anxiety symptoms. Recovery means we may have an occasional panic attack, but if we do, we can manage it/control it so it does not impact on our life in any way. See below.

>I have read that you "deal" with and "accept" the panic attacks. Also, I read that they "only last 30 seconds anyway." <

While some people may only ever have a 30-second attack, many of us before CBT will have attacks that can last an hour to an hour-and-a-half. We know most researchers reject the hour / hour-and-a-half attack, but for many of us it is a fact! What I have found over the years, again both personally and professionally, in using CBT, people can bring the panic attack down from 60 - 90 minutes to 30 seconds.

The attack can be just as violent in those 30-seconds, but once you lose your fear of them you simply think 'So What' instead of 'What If' etc. We know people say, 'Well I don't even want a 30-second attack', but this is not being realistic. This is how we, as a group of people, react to stress. OK, it isn't pleasant, but what is thirty seconds now and again. And this is important. Many of us have repeated panic attacks day and night, along with ongoing, all-pervasive, anxiety even when taking medication! Using CBT, sometimes initially in conjunction with medication, we can reach the point where we are not only medication free, we may only have an occasional 30 second panic attack once every 6 -12 months and there is no residual anxiety.

You 'deal' with your attacks by simply letting them happen. That is you don't fight them, nor do you resist them. You simply let them happen. I know all the arguments about this one! 'How can I let my attacks happen, I am a nurse, school teacher, manager, bank officer, manager, CEO, sales assistant, student etc. What will people think etc etc'

What we don't realize is in worrying about 'what people think' we are giving our mental health away to the opinions of others. Our recovery needs to be the most important thing in our life, not other peoples' opinions. And we also miss the point of simply letting them happen. When we let them happen they are over as quickly as they started. Who is going to see? And if they do 'So What'! When we fight them/resist them they go on and on and on...and on! There is much more chance people are going to notice there is something wrong when we fight them. And people do notice sometimes! For people with panic disorder, it is not unusual for co-workers/family member etc to call an ambulance because we think we are having a heart attack etc. This may not just happen once, but quite a number of times!! Or people may notice because we are having time off from work or university/college etc. Yet when we give into our panic attacks they are over in 30 seconds.

We do need to accept our panic attacks and our anxiety. People go through various levels of acceptance, 'This is not me, I am not like this'....'What if the doctor has made a mistake?'....'What if the test results got mixed up with someone elses?'....'What if the Cat Scan, MRI was faulty' etc etc. We all need to reach the point where we know intellectually and emotionally that we are having panic attacks and/or anxiety and ....this is how we are supposed to feel when we have a panic attack and/or anxiety! We also need to accept that our panic attacks and our anxiety are not going to hurt us.

This is the tragic irony. It is our various fears which create the disability/ies, Agoraphobia, depression, prescribed drug or alcohol addiction. We need to accept and take it back to the beginning point. A panic attack is a panic attack. It can feel violent, but that is all it is, a panic attack, nothing more. Lose the fear and all you have is a 30 second panic attack.

>What about the residual chemicals stored in your body after a fight or flight response? What happens to those? I was told that the reason I feel as if I am in a state of panic for a couple of hours or days is because they aren't being metabolized before the next attack. <

The 'residual' is being created by the way you are thinking. You have a panic attack and what are you thinking? 'Oh no not again, I am never going to recover'...'what if the next one is going to be the BIG one'....'what will people think'...'I am stupid, weak, a failure'....'I am letting everyone down'....'Why can't I get over this'.....'what am I going to do'...'what is my pulse rate'.....'what is that twitch, pain'...'I have never had that before' etc etc. The way we think keeps the fight and flight response turned on. These thoughts are telling our bodies that we are in 'danger'. The body doesn't know and can't tell the difference between our panic/anxiety disorder thinking, 'What if etc' and the thought 'Ahhhh here comes a Mac truck at 100 miles per hour with no brakes and it is heading straight for me!!' The body is doing what it needs to do to help us in 'dangerous' situation. It turns on the fight and flight response to enable us either to run from the danger or stay and fight it. Turn off the anxiety (danger) thinking and you turn off the fight and flight response.

>So how do you get ahead of the production of chemicals so you can cognitively deal with this disorder? I have seen several CBTs. They helped me feel more confident but I never seemed to completely block the attacks consistently. <

You stop the production of the 'chemical' (stress hormones actually) by learning how to become aware of your thinking. Not just when or after you have a panic attack, but before. We may not be thinking about our anxiety/panic but when we become aware of our thinking we see the 'internal conversations' we have in our head. Something may have or may not have happened, but we go over the situation in our mind in fifty different ways with fifty different outcomes...usually all negative and usually all 'threatening' to us in one way or another. We buy into the guilt trips, to the extent we worry and feel guilty about almost anything. We are forever mentally abusing ourselves. 'Stupid, weak, useless, dumb, hopeless, failure etc.' We are always worrying about what people think.

The more we become aware of our thinking, the more we can see how our thinking is turning on the fight and flight response. When we can see this, we can A. see how it is all being created B. see why there is nothing to fear and C. see we have a choice in what we think about. We become aware that if we keep on thinking the way we do we will end up in panic/anxiety 'city' so we can make a choice. We either keep on with our way of thinking or we chose to retrain our thoughts. This isn't easy, but it is worth the effort!!!

> I feel it is the only medication that has completely blocked the symptoms. Now, this is where I really get confused. How can a medication block the attacks if they are all brought on by my style of thought?--I still think the same thoughts to some degree. <

We do feel there is a biological component for some of the anxiety disorders, but for some people medication doesn't block the panic and anxiety. For you and other people it does. This is what happens. And to be honest we get confused about the whole medication issue per se. We have now spoken to or received email from over 30,000 people with an anxiety disorder and the whole issue is not as straight forward as it seems.

We do have a great deal of experience in what is happening or what is not happening for people with an anxiety disorder. Not only is there arguments about what the chemical imbalance is and what drug is best suited for the chemical imbalance, there are also conflicting experiences between people taking medication. For example Person A has panic disorder with a specific set of main symptoms and has been on a specific dose of XYZ medication for 10 months. The medication has 'blocked' all their panic attacks and anxiety. Person B also has the same specific set of main symptoms with their panic disorder and has been on the same dose of XYZ for 10 months as person A. But person B is still symptomatic. Researchers will say Person B is not complying with their medication instructions, but person B will categorically deny any lapse. We can understand the Researchers' point, because some people will not comply, but we see the person A & B scenario repeated over and over and over that there has to be more to it all than the 'non compliance'.

This difference is also highlighted in the withdrawal problems. Some people will have withdrawal problems, not just from the benzodiazepines, but from the anti depressants. Some people won't. Some people will have quite severe side effects when they begin taking anti depressants, some people won't. Again researchers will say those people who have problems are too 'sensitive' or are worrying about taking the medication. Again, while this is true to a point, some people are so severely effected, there has to be more to it.

The way we see it, if the chemical' imbalance theory was absolutely accurate, everyone would be taking the appropriate medication for their particular disorder and everyone would be leading normal lives. While we are not anti drug, (quite the contrary we know how beneficial they are, because we ourselves used them during the crisis of our own disorder), we do recommend Cognitive Behavioral Therapy for long term recovery. CBT empowers us as individuals. We can 'take back the power' from our anxiety disorder. Medication and the chemical imbalance theory can 'disempower' people. When people are told they will be on medication for the rest of their life it can be absolutely devastating for them. We see this over and over and over again. Many people are never even given a CBT option. They are told, 'learn to live with it!' Yet there is a choice in treatment and we feel everyone needs to be given the choice.

The bottom line though is we all need to do what we feel is right for us as individuals. This means some of us will use CBT as a way through to recovery, other people will use medication. There is no 'right' or 'wrong' way. It is individual and it is individual choice.

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