With Reut Bar’el, Expert Psychologist at Mayanei Hayeshua’s Mental Health Center
Nava was just about finished collecting everything she needed at the crowded hosiery store. The saleslady rang up her purchase and then packed the items into two massive shopping bags. For a moment, Nava stood, contemplating whether to call a taxi or to send her daughters later on with a baby stroller to bring the bags home. Suddenly, her breathing began to quicken and a choking sensation grasped at her throat. Instinctively, her hands flew to her neck and she opened her mouth wide, struggling to get more air in. The more she struggled, however, the less air she felt entering her lungs. Nava desperately ran to the entrance of the store.
Nava was sure she was experiencing a heart attack, but when the medics arrived at the scene, they didn’t see any signs of a true medical emergency. They determined that Nava was experiencing a panic attack, triggered by the crowded conditions of the store. Nava was not reassured and asked to be taken to the emergency room. The doctor there repeated what the medics had told her, and encouraged Nava to begin treatment for anxiety.
Nava was hesitant to take the doctor’s advice. “If I just avoid places that are too crowded,” she reasoned, “I won’t have those attacks anymore.” But a few months later, she was at her sister’s wedding, and had to run out in the middle to curb an impending attack. It was then that she realized how much she was missing in life because of her anxiety. She had been avoiding so many places and experiences that would have made her life better, easier, and more meaningful—classes, stores, events of all kinds… and now her own sister’s wedding! The realization hit her hard, and the decision was quick to follow. She was going to get help. She was tired of being so restricted. She wanted to breathe and move freely through life again. Thankfully for her she discovered the Mental Health Center at Bnei Berak’s Mayanei Hayeshua.
About Anxiety and Panic Attacks
Reut explains that panic attacks are considered a type of anxiety disorder. They generally occur for the first time with no prior warning or obvious reason, and then recur in varying frequencies. Today, we know that the trigger for the first panic attack is generally a result of a stressful situation that has been repressed; a situation in which the gap between the desired state of calm and order and a given reality shakes the foundations of one’s sense of security or feeling of control. Recently, an anxiety gene responsible for anxiety and panic attacks in some parts of the population was discovered, which explains why some people might experience anxiety or a panic attacks in situations which may not cause the same kind of response in other people in the same circumstances.
Following the first or second attack, which are perceived as “random,” the person develops anxiety about a recurring attack. A person who experiences a panic attack is certain that he is experiencing heart failure and is on the verge of – or in middle of – a full-scale heart attack. Often, people arrive at the emergency room or visit their private doctors complaining of symptoms similar to a heart attack, such as those Nava experienced – rapid pulse, difficulty breathing, sweating, and sometimes uncontrollable shaking. Some also feel extreme dryness or temporary paralysis of the legs and an inability to move.
Why Do Panic Attacks Happen?
Reut describes how our bodies contain two autonomic internal systems. One is the “rest and digest” system, which operates at times of rest (imagine how you feel after a good meal with your loved ones), and the other – the “fight or flight” system – operates at times of arousal (try to recall how you felt after running on the treadmill or after chasing a bus). Both systems are equally crucial for our functioning in life. Panic attacks result from a “switching on” of the “fight or flight” system due to a psychological factor.
During an attack, a person may feel rapid pulse, high blood pressure, changes to his breathing, muscle tension that is sometimes accompanied by involuntary shaking, light-headedness, or other symptoms. As a result of these symptoms, a person suffering from a panic attack is usually certain that he is experiencing a heart attack or that he is about to lose consciousness. It is important to stress that the “fight or flight” response is working properly – just not at the right time. It’s like a Shabbos clock in which the pins were pushed in instead of out, so that it turns the appliance off when it is supposed to have been turned it on – yet the Shabbos clock is still in perfect working order!
What to Do During an Attack
Since the problem is the result of the wrong system being activated, the “rest and digest” system must be activated instead, Reut clarifies. Sound simple? It is and isn’t. It is, because the systems are healthy and working properly, and it isn’t, because a person experiencing an attack feels a sense of paralysis and light-headedness, loss of control, sometimes even near-madness. There are a few ways to activate the “rest and digest” system—skills that can be learned and practiced as part of a treatment plan. Some of these methods include muscle relaxation, breathing exercises, and bio-feedback.
Practicing proper breathing between attacks in case of hyperventilation (over-breathing) also helps tremendously during an episode. Performing breathing techniques in which air is not expelled immediately upon inhalation but first held in for a few seconds trains the brain to recognize a state of having “unclean air” for a short period of time and not view it as risky, thus preventing the development of an attack when it happens again in a crowded place. The brain becomes accustomed to this kind of situation and no longer identifies it as a danger.
It’s important to know that a panic attack generally begins suddenly, reaches its peak within a very short time – usually about ten minutes – and then dies down. The longest duration of an attack is about an hour, but most pass within 20-30 minutes at most. This information may help calm the individual and decrease the duration and intensity of the episodes.
A Vicious Cycle
From her extensive work at Mayanei Hayeshua’s Mental Health Center, Reut is able to observe that typically a person who has already experienced a panic attack may find that subsequent attacks are induced by the very fear that they will happen. In many cases, panic attacks have been linked to being in crowded places, or conversely, in closed places such as wedding halls, long lines, airports, and similar closed areas. These places are perceived as a threat or danger that if an anxiety attack would develop there would be nowhere to run to in order to get more air. A person who experienced a panic attack while away from his home may avoid leaving his house again, since he feels safe at home and figures he can protect himself from further discomfort and danger by staying there. Unfortunately, this actually exacerbates the problem by strengthening the erroneous link drawn in the person’s psyche between the places he is avoiding and the danger he perceives there. While behaviors such as avoiding those places, carefully planning escape routes (always sitting close to the exit) or relying on the presence of a companion to help him in case of an attack may relieve the anxiety in the short term, it proves debilitating in the long term. As time goes on and the disorder is left untreated, the person’s “safe” zone grows smaller and his avoidant behavior spreads into more areas and places.
Reut indicates that some people might sometimes suffer from a panic attack, yet cope well with it and do not change their regular daily patterns for fear of an impending attack. It is unclear whether this may decrease the frequency or intensity of the attacks, but these people’s quality of life is definitely not diminished in the same way as that of people who develop avoidance behaviors. Other people find that the panic attacks frighten them to the extent that each time they are certain that this time it is indeed a heart attack. Their quality of life is impaired, and like Nava, they may develop additional anxieties such as social anxiety, fear of flying, and more.
A person who finds that his panic attacks affect his lifestyle and limit his living space and movement in the world is strongly encouraged to seek help.
The first step is to get a clear diagnosis. Since panic attacks are a psychological disorder, they are generally diagnosed by psychiatrists. However, because panic attacks are so common, many family physicians undergo training to identify them and refer patients for effective treatment. Most family doctors will recognize the symptoms and use clear diagnostic tools to differentiate between anxiety symptoms, which may look and feel like a heart attack, and a physiological cardiac problem. Thorough testing should always be conducted, and physiological problems should not be ruled out without proper examination, but generally speaking, a panic attack is a sudden attack that looks like a heart attack, yet does not present any proof of cardiac problems in an EKG and other similar tests, so diagnosis is usually clear and easy to define.
Today’s mental health clinics offer excellent treatment plans for addressing panic attacks, including Mayanei Hayeshua’s Mental Health Center headed by South African born, Bet Shemesh resident Professor Rael Strous, including customized medication and cognitive-behavioral therapy (CBT). CBT changes the automatic, limiting thought patterns about the perceived “danger” that is inducing the attacks. The patient learns to “shut the false alarm” which the brain sounds in the triggering situations, and to feel safe despite the possibility of an impending attack.
During treatment, the person is gradually exposed to the “scary” places in a slow, controlled manner and using lots of relaxation techniques. To establish trust and make sure the patient is not over-aroused, exposure will only be done after establishing the relaxation techniques and only in levels that have been jointly agreed upon. This exposure, in essence, leads to a reeducation of the brain – the brain begins to link the trigger to feelings of safety and security instead of danger.
These treatment methods have been shown to be extremely effective, and allow people like Nava to live a better, more fulfilling and more joyful life.
Mayanei Hayeshua’s six-story Mental Health Center in Bnei Brak was founded by the late Dr. Moshe Rothschild—who was interviewed in a previous issue of Bizness Magazine—and prides itself in being the world’s first culturally-sensitive psychiatric facility.