Written by Philippa Walsh

What Causes an Anxiety (or Panic) Attack?

Anxiety attacks can appear to come out of nowhere and can be extremely frightening. When you feel panic beginning to hijack your body, you may feel that you're not in control of yourself. Unfortunately fear of losing control or of embarrassing yourself in front of others, can intensify the physical symptoms of anxiety. By examining the actual causes of anxiety, we can regain control and learn how to minimise its impact.

Some of the most common physical signs of an anxiety attack are: an increased heart rate, shortness of breath, feeling too hot or cold, sweating, trembling, light-headedness, momentary disturbances to vision or hearing, a sense of 'unrealness' and muscle tenseness. This is usually accompanied with a need to 'flee' from the upsetting situation or feeling frozen to the spot despite having a desire to escape.

When we become overwhelmed by anxiety, our body reacts by releasing adrenaline. Also known as epinephrine, adrenaline is a hormone produced from our adrenal gland which is located near our kidneys. Its production is regulated by the sympathetic and parasympathetic nervous systems, designed to aid control of our bodies movements and adrenaline production.

Adrenaline activates the fight or flight mechanism needed for survival. This is one of our most basic default settings and is activated when we're under an intense amount of stress or when we perceive threat.  Adrenaline is designed to increase our mental alertness and fuel us with sufficient energy needed to fight or run from danger.

When our brain gets the message that we're in danger, adrenaline is quickly pumped into our bloodstream and causes our heart rate to increase (this allows oxygen to circulate around our body quicker), it will dilate pupils (to enhance our vision), increase sweat production (to regulate our temperature if we need to run), suppress our immune system (which is not needed in dangerous situations) and will create an acute feeling of fear.

The reality is that 99% of the time, our bodies are responding to an imagined danger, and so the fuel that our bodies have created is completely unneeded. The frightening part of an adrenaline rush is that it can happen so rapidly, we become convinced that we're in serious trouble. 

Fear of Having a Heart Attack

An anxiety attack is one of the greatest imitators of a heart attack. 

The chest pain experienced during an anxiety attack is very real and certainly not imagined. But thankfully this is caused by tense chest muscles, not our heart. Our chest muscles will hurt when we are breathing incorrectly and subconsciously tensing them.

Fear of Suffocation

The release of adrenaline can significantly impact on our breathing. Because of our increased heart rate and shallower breathing, we may feel that we're not getting enough air to breathe. Whilst this can be extremely uncomfortable, it is NOT dangerous. We have more than enough air to live on, and can use it to talk at the same time!

Fear of Fainting

For people experiencing anxiety attacks, fainting is a very common fear. It is however extremely rare, but we need to understand what actually causes fainting to understand why.

Fainting is caused by a sudden drop in blood pressure. When blood pressure drops significantly enough, this can cause a lack of blood supply, thereby reducing the oxygen supply to our brain. When our body is unable to get enough blood to the brain because of low blood pressure; it will protect us by bringing our brain down to the blood. Fainting ensures a blood supply to the brain by actually bringing our head down to the ground.

If our brains were located lower down, we would probably never faint! So how does this relate to anxiety? 

In an anxiety attack, our blood pressure is increasing not dropping. Not an awful lot, but it's doing the opposite of what you need to faint. This makes it extremely difficult for you to faint during an anxiety attack.  In order to physically faint during a panic attack, you would need to have some other physical condition which lowers your blood pressure to such an extent that it would counteract the blood pressure increase.

Please make sure that you speak to your GP to rule out any serious underlying conditions that might need further attention - particularly if you are experiencing symptoms that are unexplained by anxiety.

Once you have been reassured by a medical professional, be confident that although an anxiety attack feels uncomfortable, that it will not cause you any serious physical harm. Although it can be hard to accept, an anxiety attack is simply our mind and body working in unison as a result of a false alarm. This alarm is triggered by fear - or as therapists like to think of it:

F - FALSE

E - EVIDENCE 

A - APPEARING 

R - REAL

Causes of Unwarranted Fear

So now that we understand the physical causes of an anxiety attack, what on earth is going on in our heads to provoke the release of so much adrenaline? Remember - an adrenaline rush is caused by a perceived threat, so all of our bodily sensations result from what we are telling ourselves to watch out for! 

This can seem impossible, because when anxiety kicks in it can do so suddenly with no warning or obvious reason. I have had clients tell me that they can't understand why they became anxious at a particular moment; but once they start examining the situation and recalling their thoughts prior to having an anxiety attack, it usually becomes clear that they were telling themselves that there was something to fear.

Fear falls into two main strands: learned fear and anticipatory fear. We can learn to be afraid of something through personal experience or vicariously from what we witness or hear from others. We may also anticipate that something bad will happen, which can trigger anxiety and fear before it has actually happened.

A typical example of vicarious fear:

Natalie's mum was a nervous driver. When she was growing up, she remembers her mum being very fearful of other motorists driving too fast. Her mum also used to confide in her that she was petrified of not being good enough to drive and that she dreaded causing an accident. Eventually her mum lost her confidence and was unable to drive again. 

When Natalie became old enough to learn to drive, she noticed that she was overly vigilant about what other drivers were doing and very hesitant about making simple manoeuvres. Her heart would race as she drove. Eventually Natalie passed her test, but she started to avoid long journeys and became fearful of driving on the motorway - she couldn't help thinking that she'd have an accident. As time progressed, Natalie drove to less places alone and told herself that it was safer to use public transport. 

Natalie has a driving phobia

A typical example of anticipatory fear: 

John is quite shy. He does not like being in the limelight or put on the spot. He takes his time thinking of what to say in conversations because he wouldn't want others to think of him negatively. On the whole, he prefers to go to smaller quieter shops and stay away from busy crowded places. He doesn't want to get drawn into chit chat with strangers and imagines that they'd find him boring anyway.

The more John thinks about what people will think of him, the more he believes that he will come across poorly and be thought of badly. One day John gets an invite to the pub from an old school friend. He starts to get sweaty and anxious just thinking about it. He tells himself that there's no point in going because he'll only feel too anxious to enjoy himself. Convinced that he'll make a fool himself by getting tongue-tied, he texts his friend with an excuse not to go. He feels safe now.

John suffers from Social Anxiety.

The Power of Unhelpful Thinking

Unhelpful thinking can be described as the anxiety trigger in the examples given above. Once that trigger was pushed, it set into motion anxiety. There are a number of unhelpful thinking styles people tend to use - often without realising it. We might 'catastrophise' and imagine only the worst outcomes of situations, or we may put pressure on ourselves by believing that we should always appear a certain way to others, by being 'interesting' or outwardly confident.

It is estimated that we have between 15,000 to 60,000 thoughts a day. Whichever figure is the most accurate, there is clearly a lot going on in our heads (whether we're conscious of it or not). Now imagine if we allowed EVERY single thought we have to control our lives and determine how we feel... this would not only be mentally draining, but time consuming and restrictive. 

Changing our Thinking

Thoughts can be extremely powerful and when given too much attention, they can be fused with reality and misinterpreted as facts. Let's rewind and imagine for a minute that Natalie - despite her upbringing; didn't pay as much attention to every unhelpful thought that popped into her head when driving. She may have had some self-doubt, but would have been able to tell herself that her thoughts were not enough evidence to prove that she is an incompetent driver. She may have been able to rationalise and remind herself that she had never had a collision whilst driving.

Similarly, If John was not focusing on the thought that he wouldn't enjoy himself or preoccupied in his belief that people would only think well of him if he were more chatty; he may have been able to shift his focus rather than get caught up in the meaning of his thoughts.

When we focus only on our interpretation of the thoughts because they scare us, this becomes our one way ticket to anxiety. Let's take a thought for exactly what it is...a THOUGHT. Just because we think we're not good at driving or people might judge us negatively, this does not make them facts. Where is our evidence? Are we discounting other important experiences to make our own erroneous 'facts' fit? 

Letting Thoughts Go

It is only when we explore our thoughts and label them as such, that they become defused from reality and therefore less threatening.Thought defusion is an effective technique that can be used to help reduce unwarranted fear and anxiety. Simply label the thought as a thought and NOT a fact, and commit to letting it go rather than trying to analyse its meaning. Imagine it as a temporary cloud and picture it drifting away. 

Refuse to feed your anxiety by getting tied up in your thoughts. View your thoughts as transient and unimportant; in time they will become so. Your thoughts will only cease to be powerful, when you choose not to engage with them.

Facing our Fear

We use safety behaviours because they are pretty effective at giving us what we need...in the short-term. But here's the downside: by continuing to avoid situations we fear, we are simply maintaining and prolonging our fear. How will Natalie disprove her theory that she is an incompetent driver if she stays away from behind the wheel of her car? Likewise, how would John build up his confidence if he continues to avoid socialising?

The problem with avoidance is that it never allows us to contradict our worst fears. By staying away from situations that make us feel anxious, we are only reaffirming our theory that the only way anxiety can be reduced is by avoidance.

The truth is that if we allow ourselves to stay in anxiety provoking situations, the anxiety WILL eventually pass. We know that the physical symptoms of anxiety are uncomfortable, but we also know that we're not going to faint or have a heart attack from them!

Think of exposing ourselves to anxiety like this: watch enough scary movies and we become less afraid. In other words, face our fears and over time they lose their impact. Our fear reaction becomes less responsive to certain situations only by remaining in them and learning that we are not in any real physical danger.

Anxiety Management Techniques

Learning how to change our thinking and let unhelpful thoughts go is fundamental to effective anxiety management. We also need to learn how to manage the physical symptoms of anxiety once they kick in. Below is a list of practical techniques to try next time anxiety begins to take over:

Diaphragmatic Breathing

• Diaphragmatic breathing is a deep breathing technique that will help your body distribute oxygen to your body. This will aid in reducing your heart rate and regulate your racing pulse. It will also relax any muscles that have become tense from the sudden rush of adrenaline.

• Inhale through your nose for a count of four, hold for two and exhale completely to a count of four through your mouth. You can vary the counts according to your abilities.

• To get the most from this exercise, sit upright with your shoulders back and have your feet flat on the ground. Try and avoid slouching. Put your hands on your belly and practice breathing slowly - feeling your stomach move against the hands. When you exhale, tighten your stomach muscles and breathe out through pursed lips. Consciously feel the diaphragm move up and down as you breathe.

• This technique may feel uncomfortable at first and requires daily practice to perfect. Once you have learned this technique, this can be used when anxiety starts to surface.

Counting

• When you are feeling stressed, anxious or having an adrenaline rush, try and stay in the situation and count to 10 in your head. Counting can help your mind to refocus on something other than your current anxious state.

• Shifting the focus of your attention can help your body to return to its normal state by reducing adrenaline production.

• If necessary, count to 20 and repeat this method until your anxiety has passed.

Progressive Muscle Relaxation (PMR)

Anxiety can make us tense our muscle without us always realising it. Sudden muscle tenseness can cause pain. It is important to become aware of when we are doing it, so that we can train our muscles to relax when they become tense.

• If you notice stress or an adrenaline rush, practice relaxing your whole body to reduce the impact. 

• Lie down or sit somewhere comfortable and begin clenching and relaxing each muscle in your body.

• You will tighten and contract each muscle in your body for five seconds starting at your feet. Then let the muscles slowly ease into deep relaxation. 

Make Lifestyle Changes

Are you aware of what your own anxiety triggers are? We have already established that our thoughts play a huge role in how we feel. Perhaps it's time to sit down and think about the thoughts you're having that are making you anxious. 

If you're worrying about something in your life, are you able to make simple changes so that anxiety is no longer triggered? By this, I don't mean avoiding anxiety provoking situations, I mean dealing with the situation that is causing you to become anxious. 

For example, if you get anxious about speaking to your manager at work, can you prepare what you need to say beforehand so that you are less anxious when you speak? Or maybe you know that you have an issue around time management and meeting deadlines - so are anticipating that you'll be in trouble at work. 

Rather than feeding your anxiety by thinking about it, could you put something in place to resolve this problem? Can you keep a better diary or a to-do list? Maybe you have taken on too much at work and are afraid to let your manager know that you're struggling.  

Remember that sitting and thinking anxiety-provoking thoughts is not the same as problem solving.

If you realise that your anxiety is about hypothetical anxieties, use thought defusion to let them go. Since there is no problem solving required here, holding onto them only serves to feed your anxiety.

Exercise

The psychological benefits of exercise are rooted in neuro-chemistry. Endurance or aerobic activities have been shown to reduce our stress hormones (adrenaline and cortisol) and stimulate endorphin production.  Exercising regularly can improve mood and is effective in reducing anxiety.

I wish you luck on your journey to reduce your anxiety. Just remember that we will never lose the capacity to feel anxious - our threat system needs to be able to alert us to REAL danger and help us to survive it. 

Your aim should not be to eliminate anxiety completely, but to manage it so that it no longer impairs your life. Once you are able to stop seeing threat in everyday situations and no longer misinterpret the physical sensations of an adrenaline rush, your quality of life should significantly improve.  If you are unable to manage your anxiety alone, professional support can help. Find out more about how counselling and psychotherapy in Manchester can help you. Reach out and tell me your story. 

Here's a fitting quote...

"Anxiety is a thin stream of fear trickling through the mind. If encouraged, it cuts a channel into which all other thoughts are drained".  Arthur Somers Roche

References

Borkovec, T.D, Costello, E. and Beutler, Larry E. (1993). Efficacy of Applied Relaxation and Cognitive Behavioural Therapy in the Treatment of Generalized Anxiety Disorder. Journal of Consulting and Clinical Psychology, 61:4, 611-619.

Craske, MG; Stein, MB. (24 June 2016). Anxiety. Lancet (London, England). DOI:10.1016/S0140-6736(16)30381-6. 

Wells, A. (2009) Metacognitive Therapy for Anxiety and Depression. New York: Guildford Press.