Panic disorder

1. Panic disorder

2. Strong physical component Strong anticipation of an impending attack

3. The symptoms of Panic disorder 1) Repeated unexpected “out of the blue” panic attacks 2) Dreaded anticipation of another panic attack 3) Avoidance of perceived triggers to a panic attack 4) Avoiding situations for fear of a panic attack coming and being unable to cope with it (for example public areas)

4. What is a panic attack? A person’s anxiety level peaks abruptly to the point that it is intolerable to the sufferer; it brings with it an array of physical symptoms.

5. Physical Symptoms of a panic attack: Pounding heart, palpitations and accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest Pain or discomfort Nausea stomach pain Feeling dizzy unsteady light headed or faint And Fear of Dying Fear of going Crazy, I will snap, I will lose control Fear of becoming detached Numbness or tingling sensation Chills or hot flushes

6. Apprehension about: • -dying • - Having a heart attack • Fainting • Losing their breath • Going “insane” • losing control • Embarrassing themselves in front of others • Choking

7. What is the way out of this? • Evaluation • Education about anxiety disorders • Understanding how the cycle of anxieties work and what fuels it. You are doing it to yourself! • Explain how exposure undoes it, create a hierarchy • the importance of accepting and living with uncertainty • Identify irrational beliefs • Identify distorted thinking patterns • Teach how to retrain the mind to think positively

8. Evaluation • Inventory – • which situations cause anxiety • How severe is the anxiety • How long has he been suffering for • How much is it disrupting the person’s ability to function • How much insight is there in realizing that this is a mind this order as opposed to a real social problem

9. Sholom Aleichem, so why do I deserve this honor to meet you today. • Bochur – it is a long story, I have to explain you about myself, I am not a regular person, I have a very deep mind and what I think about things I picture the very clearly. • Me – I hear and it’s wonderful to meet bright people, as a matter of fact I like dealing with bright people because they can understand where they are going wrong and get better much more quickly? • Bochur – I am telling you you have never met somebody like me • Me – and now I am really getting excited.

10. Me – So tell me a little of what is going on. • Bochur – okay but could I get a drink my throat is getting dry and it makes it hard for me to breathe, but that is not what I came for. • Me – sure, let me just ask you a few questions, how long ago was the first time that you realized that something was wrong? • Bochur – it was about a year ago, when I went to sleep at a friends house, it was a little bit cold, I was the only one in the room, and I was afraid that I would not be able to fall asleep, and all of a sudden I started feeling my heart pounding, and I felt like I was going to snap, I was sure it was a nervous breakdown.

11. Me – why didn’t you call an ambulance • Bochur – the truth is that it would have lasted a little longer I would have, but it kind of and went away. • Me – did you ever worry afterwards that maybe it would happen again • Buchur – as a matter of fact I never stop thinking about it. it does not give any warning – it is like standing on a trap door that can give at any minute • Me – so what have you done about it • Bochur – well I try to figure out what causes it and boruchhashem I have it pretty down packed. I try to avoid crowded areas, I make sure to sleep a lot and as soon as I feel a little weak I go eat or take a nap.

12. Bochur – I also make sure to always have a water bottle at hand, when traveling I always sit near the window. • Me – I hear, so if that was working so well then why did you come here? • Bochur – lately its getting worse – especially when I’m alone, I could get so frightened that I feel its not worth living like this. When youre in it – you feel like its all over. • Me – did you ever have such an anxiety attack in public? • Bochur – I make sure that if I would have one that I will be able to get out quickly • Me – for example,

13. Bochur – I don’t shop in big stores, I always take a seat near the door, I avoid waiting on line, you know those kinds of scary things. • Me – this sounds pretty miserable – and you probably wouldn’t wish it on anyone, but I must tell you that it is quite common. • Bochur – what do you mean, I never wanted to talk about because I thought that I was the only meshuganer. You don’t understand you really feel like its all over and you going to snap. • Me – people tell me that they can’t imagine any worse pain. But believe it or not, its relatively easy to fix and if you put your head to understanding and working the program you will be laughing at this one day. Hopefully very soon.

14. Education about anxiety disorders • They are very common • This does not show that there is something abnormal with you • It is something that is easily curable if you work for the program • Anxiety is not dangerous, it cannot cause any temporary or permanent damage to yourself

18. Understanding how the cycle of anxieties work and what fuels it • The problem: • When the brain • sends warning messages • to the body • When there is really no need to. • Similar to a false alarm • this is usually done by • Exaggerating the likelihood and the severity of the danger • This triggers very uncomfortable physical and emotional symptoms

20. ERP – affects cognition

21. Me - lets o back and try to reconstruct the first panic attack that you had that first night when it all started and lets try to understand where this led you and how this cycle all began. Then I will explain you how if you would have met me earlier we could have saved a lot of עגמת נפש. So tell me again “what was the first step in your experienceBochur - I had a hard time falling asleepMe – that’s sounds pretty normal to me, so where did the fear come from.Bochur – so I started worrrying that there must be a reason why, and I couldn’t figure it out?Me – ok but I still don’t understand why when you don’t figure something out does it become so scary – after all arent there many reasons why someone cant fall asleep – starting with the fact it’s a different bed and place so you may just not be used to it and feel a bit uncomfortable

22. Bochur – I will explain you the real truth, I did figure it out – my heart started failing – I literaly started breathing heavily I started sweating and I think I even felt some tingling in my left shoulder and I once heard that those could be signs of a real heart attack! Me – so what did you doBochur – I ran to the window for fresh air and got a drink, it got a little better so I didn’t go to the hospital but I still couldn’t sleep for the rest of the night because I was afraid that the heart attack would finish while I was sleeping. But it was endless gehinom. That night felt like a year.

25. Bochur – Its not so simple – when the panic comes you become so engrossed and scared of it – that you become paralyzedMe – its true that’s why you have to acquire a clear set of steps that you clearly understand that you can put into place as soon as the panicking sets into place

26. 1) Review the list of feelings and fears that are connected to panic attacks2) understand why a panic attack is not dangerous – trust your judgment.3) remind yourself about the cycle that brings the simple trigger, thought, and feeling to the level of panic attack.- accept the fact that you will be feeling anxious, acknowledge that something is bothering you, and you will deal with it

27. 4) Stop the cycle by “Defying the Fear”- observe the attack as an outsider - see how long it lasts – it always passes, just float with it. - see how tough can it get - tell yourself “I want it to get as bad as it can, I want to see what’s the worst it can get – I want more (after all its never dangerous)

28. 5) Relax yourself – deep breathing 6) Distraction – keep doing whatever you are doing. Physical activity is a good way of defiance and distraction.7) exposure to the feared situations8) don’t: fight it, don’t become upset, don’t try to gain control, don’t analyze9) be prepared to feel uncomfortable for some time after the anxiety subsides – there is still an increase of adrenaline in the system. It will get back to normal with time

29. Relax your breathing correct breathing. When overcoming high levels of anxiety, it is important to learn the techniques of correct breathing. Many people who live with high levels of anxiety are known to breathe through their chest. Shallow breathing through the chest means you are disrupting the balance of oxygen and carbon dioxide necessary to be in a relaxed state. This type of breathing will perpetuate the symptoms of anxiety

30. The correct breathing technique is called Diaphragmatic Breathing (stomach breathing). We automatically breath this way when we are born. Diaphragmatic breathing uses the diaphragm muscle (a strong dome shaped muscle) located under our ribs and above our stomach. When we breath in, we push the muscle down, and our tummy moves forward. When we breath out, the diaphragmatic muscle moves back to resting position and our tummy moves back in. There is little or no upper chest movement.

31. Diaphragmatic Breathing Diaphragmatic breathing is intended to help you use the diaphragm correctly while breathing to: Strengthen the diaphragm Decrease the work of breathing by slowing your breathing rate Decrease oxygen demand Use less effort and energy to breathe

32. Diaphragmatic breathing technique 1. Lie on your back on a flat surface  or in bed, with your knees bent and your head supported. You can use a pillow under your knees  to support your legs. Place one hand on your  upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe.

33. 2. Breathe in slowly through your nose so that your stomach moves out against your hand. The hand on your chest should remain as still as possible.

34. 3. Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips (see "Pursed Lip Breathing Technique"). The hand on your upper chest must remain as still as possible.

35. When you first learn the diaphragmatic breathing technique, it may be easier for you to follow the instructions lying down, as shown on the first page. As you gain more practice, you can try the diaphragmatic breathing technique while sitting in a chair, as shown below.

36. To perform this exercise while sitting in a chair: Sit comfortably, with your knees bent and your shoulders, head and neck relaxed.

37. 2. Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe. 3. Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips (see "Pursed Lip Breathing Technique"). The hand on your upper chest must remain as still as possible.

38. Note: You may notice an increased effort will be needed to use the diaphragm correctly. At first, you'll probably get tired while doing this exercise. But keep at it, because with continued practice, diaphragmatic breathing will become easy and automatic.