Panic attacks and Panic Disorder: Fearing the false alarm

People with Panic Disorder have a complex experience of suffering that is sometimes misunderstood.

A panic attack, as I define it, is not just a moment of severe anxiety, but comes with a lot of physical symptoms, such as heart racing and pounding, hands tingling and sweating, feeling like you're going to have a heart attack.  Some of these symptoms are caused or worsened by hyperventilation.  Together, they feel like you're going to die if the symptoms continue.

For people with frequent panic attacks, they may have a "fight or flight or freeze" threat response system (mainly involving the ironically named sympathetic nervous system, as well as some hormones and parts of the brain) that is on overdrive, that can be set off randomly, or set off by a tiny trigger or action that elevates heart rate.  In other worse, our body reacts as if there is a threat when there is none.

For people with Panic Disorder, the real misery happens in between the panic attacks: worrying about the next one, and altering one's life in attempts to avoid an attack.  Worrying, and being hyperaware of any symptom related to panic (say, rapid heartbeat after climbing the stairs), can turn ordinary symptoms and situations into a panic attack about the fear of a panic attack.  Avoiding situations that might trigger an attack can escalate into Agoraphobia if the person seeks 100% certainty of never having an attack.

With my clients who are prone to panic attacks, I describe  an analogy to a smoke detector that is oversensitive, and goes off even when there is no smoke. There is a loud annoying alarm sound when there is no real threat.  Obeying the alarm just interrupts your life unnecessarily.  Avoiding the alarm means avoiding part or all of your home!  The key to dealing with a false alarm is to find it annoying rather than finding it threatening.  The key to dealing with a panic attack is learning to wait for the symptoms to pass rather than escalating them by worrying about them.
      Sometimes treatment includes intentionally raising your heart rate or making it hard to breath (breathing through a straw) to practice finding the symptom uncomfortable instead of finding it as proof that there is a danger that we need to run away from.   Treatment can also include gaining master over the symptoms by learning to slow down and deepen one's breathing (rapid shallow breathing messes with the body's O2/CO2 balance and can lead to tingling palms, palpitations, dizziness, and more).

In between panic attacks (for some people with severe panic disorder, there has not been an actual panic attack in a year, but still daily misery worrying and avoiding life):  The key to getting better is to realize that there never was real danger from outside; the real threat to a happy life is the worrying and avoidance itself.

Reversing this escalation of worry and avoidance is the key to treatment; trying to avoid panic attacks themselves is not treatment, it's the problem, it's what stresses people out and distorts lifestyles and relationships in between attacks.  If you've practiced handling symptoms of an attack itself, you can then practice not giving in to the alarms, not trying to avoid something that is just going to happen randomly, gaining confidence that if the sympathetic nervous system "burp" happened, you'd be able handle it, by waiting it out, not letting it gain power over you, not worsening it by shallow/hyperventilating breathing.

Panic Disorder, and its treatment, varies from person to person.  I hope that what you take away here is that full Panic Disorder is much more complex and troubling than a single panic attack itself.

One of the big Aha! moments of treating this or any other anxiety problem is realizing that the real problem, the misery that fills up the day, is the anxiety itself, and worse, the attempts to avoid anxiety.

The liberating "Aha" moment in Panic Disorder  Realizing that, although it's annoying to deal with, we don't have to fear, or obey, a false alarm.  We can occasionally be annoyed, and the rest of the time, freely live.

The myth of getting motivated

"Motivate me!"
   Some of my clients know of a change they want to make in their behaviors, relationships, thoughts, or ways of managing feelings, but ask "how can I get motivated to change?" 
   There are three related and often-confused concepts here:  Incentive,  Motivation, and "Should's" (often disguised as "goals"). 
     "I know I should exercise... I know I should work harder... I know I should be more supportive... I know I should get out of the house instead of brooding..."  I sometimes tell my clients that my office has a No-Should policy.  The main impact of these statements is often that we feel bad, incompetent, discouraged, knowing that we're not doing what we know is good for us.  "Shoulds" are shaming, not motivating.  For some people, shame can motivate change, just as anger can do so.  For people who are depressed, strongly anxious, or otherwise stuck in unhealthy habits of mind, behavior, and relating, these feelings of shame or anger at one's current state don't feel a "kick in the pants" of motivation, they only feel kicked while they're down. 
    "Incentive", I'm defining as: the payoff for changing, or the penalty for not changing.  Incentives don't work very well as motivators for any entrenched mental health problem.  The fact that life would be easier and more peaceful if you stopped your addictive or avoidant or vengeful behaviors doesn't make you magically able to do so, in fact doesn't do much to make you want to change. It can be easier to stick with the short-term reward of avoiding discomfort even if there is a potential payoff for change.  Avoiding punishment does not lead to increased positive behaviors.  Payoffs do sometimes increase desired behaviors, but are often ineffective in the long run, especially if the involve the efforts of well-intentioned people to reward your improved behaviors, because they don't usually build intrinsic motivation, the desire to change for my own sake. 
   "Motivation," in the sense meant by my clients seeking this feeling in psychotherapy, I'm defining as:  the the anticipatory excitement about carrying out an upcoming change or action.
     While it is true that having an incentive to change can help get you started, the emotion we call "motivation" doesn't usually show up until we are already having some success that feels good. Motivation is sometimes felt in a moment of insight when a change makes sense, when we've had a perspective shift; I've had clients leave sessions excited by a new way of thinking about their actions that leads directly to changes in their actions.  But in most cases, like the one we started with here where they change is obvious but seems foreboding, emotion isn't an emotion we can create out of faith that change will work; it is something that comes from already taking action and finding out what works.  Motivation comes more often from momentum than from contemplation.  
    Waiting for motivation, ironically, delays action, and thus delays your chance to feel that great feeling of motivation.  Find a small change in your pattern of behavior that you can rehearse mentally and then carry out.  Plan for how you'll manage the forces that will pull you back into your current habits, reactions, sequences of thought and action.  Then just get started first even though you're not feeling it yet; motivation will come later.  
     There's a reason they say "Fake it 'till you make it." You can act confident and later acquire confidence; similarly, you can act in other new ways and then acquire motivation to continue.  To get started, you can use incentives, incremental change, habit analysis as in the book The Power of Habit.  However you start, don't wait around for motivation to come first; be committed enough to change that you'll start even if it feels hard, uncomfortable, unnatural, almost not worth the effort.  Then, once you're started, if you want a bit of that motivation feeling, pay attention to your success, not just the road far ahead.  Then keep rolling, keep building momentum.  
     Enjoy the change after it happens, rather than expecting to always feel excited before you start.  Want an emotion to feel before you start?  How about anger, just enough anger at the way things are, to motivate you to act.  Anger can even emerge from depression; that irritability can be channeled into change.  Or anxiety, just enough worrying about the future to get you to strategize.  Or love, just enough to commit you to something outside of your current stuck state.  But motivation:  if the excitement isn't there at the beginning, it might come later, or you might not need it at all, you may simply change, and keep things going in a new way, because it works better. 

Welcome to MHK with Jim

Well, Through the magic of Google, my post on DMDD got a few page views without any action on my part to link other people here.

Now I'm committed.

After 25 years of helping people as a psychotherapist, counselor, teacher, supervisor, organizer, I've picked up a few things about mental health conditions, learning and developing some strategies for mental healh diagnosis/understanding and treatment.  I've been leading workshops, writing articles, and teaching courses for ten years, and have been doing some writing and editing for a psych textbook publisher.  I've been answering people's questions on .

I'd like to help you understand yourself and other people, and what happens in a therapy office.

Questions are welcome, but after answering a lot of questions for clients, people at my workshops, and on Quora, Academia.edu, and ResearchGate, I've got some insights and information to offer that hopefully will be useful to someone.

Topics coming up:  Anxiety, autism spectrum disorders, anger, bullying, teamwork, ADHD, psychotherapy,  ethics, supervision, sleep and sleep disorders, stimulants, hoarding, OCD, Body Dysmorphic Disorder, adolescence, the brain and body, and the mind-body interaction (including the science of embodied cognition, why holding a warm cup makes you feel more "warm" toward people).

So it begins!

Will tantrums be overdiagnosed as DMDD?

There are many controversial changes to the Diagnostic and Statistical Manual of Mental Disorders, which recently had its first full revision in 19 years.  One of these changes is the new diagnosis of DMDD, Disruptive Mood Dysregulation Disorder.
     DMDD is one of many changes that has generated alarming statements based on inaccurate information.  I cannot claim that I know the alarming predictions are wrong, but on this and other issues I can at least help the discussion start with important information we can agree on, such as what the diagnostic criteria actually say.  Whether people will misuse the manual and ignore the criteria and overdiagnose tantrums as a mental disorder depends on getting accurate information out there.

The work below is based on my summary of the criteria; others have posted the full criteria but I will choose not to violate APA's copyright nor use more words than necessary.  The words below will be published in a different form in one of the "Controversy Boxes" I wrote for Abnormal Psychology by Robin Rosenberg and Stephen Kosslyn (Worth/MacMillan, 2014).  I have more material available about how to differentiate DMDD from ODD, ADHD, Bipolar, Intermittent Explosive Disorder, if anyone is interested.

Disruptive Mood Dysregulation Disorder:  Overlabeling of tantrums?

Disruptive Mood Dysregulation Disorder, or DMDD, is a diagnosis designed to be a more accurate description of kids who have out of control rage episodes and were getting inappropriately labeled as having bipolar disorder.

The criteria for using this diagnosis, which is brand new in the DSM 5:

A.       Temper outbursts, including verbal or physical aggression, with a duration or intensity that is out of proportion to the situation and inconsistent with developmental level.

B.       These outbursts happen 3 times a week or more.

C.       Even between outbursts, mood is persistently irritable or angry.

D-H.  This pattern starts between ages 6-10 in at least two settings, continue for at least a year with no 3 month break, and does NOT include more than a day of mania, nor does it happen exclusively as a function of Major Depressive Disorder or other mental disorder.

The controversy, the critique:   Just as bipolar disorder diagnosis was overused to describe these kids with out of control rage episodes, this diagnosis might be used to label kid who merely have a lot of tantrums, including those with tantrums that are just manipulation of adults.  Or, it might focus blame on kids when the problem is in the family. This diagnosis might give those kids an excuse for their behavior or lead to overmedicating the kids.

The other side of this issue:   The severity, duration and frequency criteria are designed to prevent diagnosing kids who are sometimes grumpy and tantruming. To apply this diagnosis, there must be a persistent daily irritable mood that exists even when there is no reward as there might be for a tantrum.  The rages must also show up at school and home and not be an expected response to a home or school situation.  This diagnosis will theoretically lead to FEWER kids being medicated, since they will no longer be considered to have bipolar disorder unless they have the symptoms and duration of a true manic episode.

Critical thinking questions:  Even with narrow criteria designed to prevent overdiagnosing, won’t some people just associated this diagnosis with a grumpy tantruming kid and overuse it?  How can we prevent this? Was there a better solution to the problem of overdiagnosing bipolar besides adding another diagnosis?