Panic Stations...

When my colleague Joshua burst into my office that Friday morning, he was frantic, gasping for air with tears streaming down his face.?

Even as a mental health nurse with 20 years experience, I felt a surge of shock and after only??a second at most, I asked anxiously, what’s wrong?

Joshua looked like he was going to collapse and die any second. I tried to sit him down and asked him again what had happened. Joshua thought he was going to die too at that moment. He was incredibly agitated.

‘I can’t breathe…’ he croaked.

Was it a heart attack or a stroke??

There were so many thoughts passing through my head in those few seconds.

Joshua too confessed that he thought he was going to die later when I visited him in the Accident and Emergency department.

All tests were clear. He didn’t have a heart attack. But that??‘good news’ only made Joshua even more troubled. What had happened to him that day?

He was referred to a psychiatrist who, after eliminating all??possible physical causes, medication side effect or substance abuse concluded that Joshua had experienced a panic attack. The American psychiatric bible, aka: the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-V) describes a panic attack as: ‘an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four (or more) of the following symptoms occur:’

These symptoms are:

·??????Palpitations, pounding heart or accelerated heart rate

·??????Sweating

·??????Trembling or shaking

·??????Sensations of shortness of breath or smothering (Hyperventilating)

·??????Feelings of choking

·??????Chest pain or discomfort

·??????Nausea or abdominal distress

·??????Feeling dizzy, unsteady, light-headed or faint

·??????Chills or heat sensations

·??????Parasthesias (numbness or tingling sensations in the limbs or digits)

·??????Derealisation (feelings of unreality) or depersonalisation ( feeling detached from oneself – looking down on yourself)

·??????Fear of losing control or ‘going crazy’

·??????Fear of dying

??These symptoms can be classified into three categories:

1.?????Emotional Symptoms (fear, crying)

2.?????Psychological Symptoms (Feeling unreal or detached from??and not being able to think clearly)

3.?????Physiological Symptoms – (sweating, nausea dizziness, palpitations etc).

What cannot be underestimated, is just how really frightening such an occurrence can be.

As well as the fact that such an attack can occur??without warning from a state of calm or a slow build up , it can then result in the person changing their lifestyle as if to prevent a heart attack or lose control by avoiding stressful events (speaking in meetings) or partaking in exercise. The physical element of the attack can accelerate at astonishing speed. One other critical feature of such an incident , is that it is often almost impossible to isolate and identify the cause. Thus if we can’t find a trigger for the attack, how do we know how to prevent them and/or when will the next one strike?

Often panic attacks are linked to a condition known as Panic Disorder. Panic attacks can also affect people who experience Agoraphobia or generalised anxiety.

It is estimated that more than 10% of all people??may experience at least one panic attack during their lifetime, with 40% of young people having reported to have had occasional panic attacks during times of stress.

Many years ago I was about to be introduced to a famous boxer – his name was Herol ‘Bomber’ Graham. I was so anxious about meeting this hero of mine, that when I shook hands with him, I introduced myself as… Herol Bomber Graham! He laughed and said, ‘well who am I then?’ I blushingly muttered about swapping identities, prayed for the ground to open up and swallow me and scuttled off, cringing with shame.?

Even reading about panic attacks may cause some of you to feel anxious. Psychotherapist, Lisa du Plessis from Sunflower CBT tells her clients that a panic attack is simply a false alarm that activates a whole raft of physical, emotional and cognitive??(thinking ) responses.

The fight or flight reaction which takes place during a panic attack prompts the production of adrenaline which then precipitates a change reaction:??heart beats faster, breathing increases, but if we zoom in on the body there are other less obvious effects such as:

·??????Pupils of the eye dilate- so we can see more or become Hypervigilant.?

·??????Blood vessels dilate resulting in higher blood pressure and a faster flow of blood to the heart, muscles, lungs and the brain. This makes us stronger, more efficient and think faster – to survive.

·??????Breathing increases to allow faster movement of air in and out of the lungs

·??????Blood sugar rises as liver glycogen is converted into glucose to provide the body with extra energy.

So, in effect, our body is working hard to make us super efficient, energised and tensed up for action.

However if we are not in life or death situation then it doesn’t feel good and this in turn can result in misinterpreting fast pulse and hyperventilation as indicators of doom and death!

Mis-interpretation of an incident can often be the main factor that either precipitates a panic response, or maintains a high level of anxiety.

Most of us as children can re-call an event whereby a coat hanging on a door becomes a monster that terrifies us. Yet when the light is turned on, the ‘monster’ returns to being a coat once again. This is the essence of how??perception can make a huge difference to how we respond to situations. If we can learn to change how we see something it can change how we feel about it and ultimately how we behave towards it.

Geeta??often felt dizzy when she stood up from a sitting position, this made her feel she was going to faint and suddenly she was immersed in a full panic attack. However as part of her therapy, Geeta had her blood pressure recorded and she was found to have low blood pressure (Hypotension). Sometimes when we stand up quickly we can experience what is termed postural hypotension. In other words standing up fast means our blood pressure has to adjust and for a few seconds it can make us feel lightheaded and even unreal. Then, instead of recognising the experience as a quite normal phenomenon, we may instead perceive it as serious fainting and this can cause the panic to grow.??Helping how people change how they perceive such situations can make a massive difference to how they respond to a build up of anxiety.

So how can we cope with a panic attack if cannot identify the trigger factor?

For mental health first aiders, dealing with such an episode is a significant test.

In Joshua’s case, he??was in a frenzy, he couldn’t sit down or keep still and he certainly wasn’t responding??to my own shocked expression and/or questions.

I needed to de-escalate Joshua’s anxiety and I did??this by staying quiet at first and then slowly standing up and gently taking his hand. I guided him to a seat and whispering at first, I said to him, ‘its ok Joshua…you are safe here…you are in a safe place.’ The next stage was help??him regain control of his situation. ‘ Breathe slowly, breath deep Josh.’ I repeated these instructions several times. Then I demonstrated how to slow down and deepen my own breathing and encouraged him to align his breathing with mine. We did this for about two minutes. One of the common problems associated with panic, is the process of hyperventilation. One theory is that when we are anxious our breathing ceases being efficient and we breathe in a rapid shallow way that leads to a fall in the concentration of carbon dioxide in the blood and paradoxically despite breathing faster we are increasing the sense of not being able to breathe and feel like we are choking.

The next stage was to reassure him he was going to be fine. He wasn’t having a heart attack, he wasn’t going to faint or have a stroke. He was going to be fine. The calming??approach started to impact on Joshua and after about five minutes he was breathing normal once again and I took his pulse to show him that his heart rate was slowly returning to normal.

I was grateful my telephone did not ring during the soothing part of the intervention and nobody interrupted to disturb and distract our work.

So this was an??acute??and one of the biggest challenge to my mental health skill set. The??important lessons I learned that morning, was the??making sure that I was managing my own shocked??and probably anxious reaction to Joshua and his presentation.

That is the reality when dealing with mental health issues in the workplace, every now and then you have a situation that cannot be planned for or rehearsed.?

An American study in 1995 highlighted the impact of having a safe person with a person prone to have a panic attack. The main finding was that people who experience panic symptoms were much more likely to show symptoms of panic when a safe person was?not?with them! This is a fundamental response for mental health first aiders.

As part of the longer term plan for Joshua he learned to practice simple breathing exercises, mindfulness, progressive muscle relaxation and cognitive restructuring.

Anxiety can be reduced either by decreasing one’s perception of danger or increasing a person’s confidence??to cope with threat.

One of the most common difficulties people have when they try to understand panic is??failing to identify the trigger for the attack. Du Plessis adds, ‘even mild or apparently harmless events may be the trigger for a panic attack, including being hungry, having too much coffee or a hangover can be the precipitating factor for a panic attack.’

The really important part when dealing with a panic attack, is??to realise its not about finding something profound to say, its about being there, reassuring and supporting the person in their minutes of??acute need.