S3E11 Panic

Dr. Rubin introduces the education regarding panic symptoms and panic attacks, and how they are precipitated by a perceived threat. Drs. Rubin and Pete present the symptoms and present some mechanisms that people use to manage panic. Dr. Pete brings the Eastern teachings with the focus on anxiety and nonattachment. Tune into this episode to learn about the east and west perception of panic.




Nikki: So, Pete, I was going to say, we're going to get in some alliteration here. Pete, we're talking about panic. Pete. Panic.


Pete: Can you spell alliteration? 


Nikki: I can spell alliteration.  


Pete: Don't even know if I know what that means, but, all right. Who cares? 


Nikki: What alliteration?


Pete: Yeah.


Nikki: It's like the same watch; I'm like saying it wrong. 99% positive, when you're saying the same letter, it's the first letter of each word. 


Pete: Pete and panic got you. 


Nikki: Yes, Pete and panic. So, we're going to talk about panic because first of all, it's something that's really very common that people come to treatment for, right?


Pete: Yes.


Nikki: So a lot of people show up in our offices, pretty unpleasant. People are suffering a lot from it. Also, I think it's really important to talk about panic today because something I encounter a lot in my practice, I'm not sure if this is something you experienced as well. But there's often, I would say, a lot of misunderstanding or misconception around like, differences between a full panic attacks. And also just experiencing panic symptoms and the latter tends to be more common, honestly.


Pete: Yeah, totally. 100%. And actually, I don't let them use the word panic. So maybe we should start with, you know, trying to actually describe what panic is, you want to start with that? 


Nikki: Sure. When you say you don't let them use that word, you mean when you're trying to identify symptoms?


Pete: Yeah, so one of the things I do for diffusion is just not using the words panic. Not using the word or panic attack or anxiety, just really describing the physical sensations.


Nikki: Cool. Okay. 


Pete: I’m looking at your face…


Nikki: I'm like, huh Interesting choice. I'm like, alright. No, I'm not against it honestly. What was going through my mind as you were saying that was, it's always just kind of fun. I mean, obviously like talking to people for lots of reasons, but it's always interesting to see like, what are the things that, you as a clinician are like, this doesn't work for me because I have similar kind of like rules for myself where I'm like, I don't let people say X, Y, and Z. Like, I don't let people say should, you know?


Pete: Well, why Dr. Rubin?


Nikki: Because should are judgments and demands.


Pete: That's right. 


Nikki: And as the, you know famous second wave CBT psychologist, Albert Ellis used to say, “People should all over themselves.” So, I was not judging your choice that was my internal monologue as you were talking.


Pete: My brother would not have laughed that hard as we just did over Ellis's statement two psychologists walk into it.


Nikki: Yeah, right. I got a lot of my patients get a chuckle on that one.


Pete: That's a good one.


Nikki: So, let's define it. Yeah, let's start there.


Pete: Well, I got you, ready? Panic from APA is, ‘sudden uncontrollable fear reaction that may involve terror, confusion and irrational behavior precipitated by a perceived threat. I know you love that. 


Nikki: I do, I'm into that. I was like, please don't read from the Webster.


Pete: Not Webster. No, I'm not going to do that to you as much anymore. 


Nikki: Thank you. I appreciate that. We want some psychological definitions here. 


Pete: We’ll break that down for little bit.


Nikki: Yeah. Well, I think maybe we could start from there and we can say like, a panic attack is something very specific. So, you know, I would say out in the world people that, whether they've been in therapy or not, lots of people throw that word around. And I would also say they use it interchangeably with anxiety attacks.


Pete: Totally.


Nikki: Yeah. And so I think it's really important for listeners to understand an anxiety attack, again, totally okay to use that language if that works for you. But, that's not a clinical term.


Pete: That's right.


Nikki: It's sort of like a term that's evolved, you know, out in the world, but it's not something that clinicians use. It's not it's not a diagnostic right tool or language. So that's really important to understand because a panic attack is something that's a psychological phenomenon that we can diagnose. And a panic attack is also very discreet, which is something to know as well.


Pete: I think I'm right, but I'm not sure. I think it's panic disorder is the diagnosis technically. Is that right?


Nikki: Oh, so we could really go into this, there is a disorder called panic disorder. That's true but panic disorder is something that is different than a panic attack. You can have panic attacks outside of panic disorder.


Pete: Does the DSM have panic attack in it or not?


Nikki: It does, yes. So a panic attack is defined, but you can have a panic attack without a panic disorder. 


Pete: Got it.


Nikki: Yes. And maybe we'll leave panic disorder on the side for today because, you know, I don't want to confuse listeners here. But I think like, if we talk about panic attacks, that is something that you can have, you could have panic disorder. You could have a different anxiety disorder, like OCD or generalized anxiety disorder. You could have known anxiety disorder that something could bring.


Pete: None whatsoever, right.


Nikki: Yes. So I'm not going to just say a psychological, it's a physiological discreet experience that the body can undergo. And when someone experiences a panic attack, basically what happens is you start to experience physiological sensations where the brain then starts to go kind of like, what is this? Like, it tries to make sense or evaluate each sensation. And as your brain starts to evaluate each one, like let's say you start to feel really hot or like your heart rates increasing or you feel nausea. And your brain's like, what's going on? What is that? The questions like that tend to activate anxiety and what's anxiety made up of? More physiological sensations and so there's sort of an escalating climbing a ladder effect where the body then can start to get just more and more and more activated to the point where you can experience such intense sensations. You might think that you're going crazy or you're going to die, or people think they're having heart attacks that are a common thing people go to. 


Pete: That’s a common one, yeah.


Nikki: And I think also for listeners that haven't experienced them, it's important to understand panic attacks is not like a no big deal, it's like your body feels like it's being chased by a bear.


Pete: Yeah, and people are just looking to get away from it, and then people think it's not real. And that was the other thing I thought you were about to say, right? Where maybe if you're a loved one and your partner or someone in your family has this, you just sort of think that this is not real. And that usually the person that experienced a panic attack feels like that people don't get them, you know?


Nikki: Yeah.



Pete: Yeah. So, I think that's important that we put that out there because it is real. So while it is about what's happening in the brain often the physical sensation that one experiences is super real, which is why it does lead a lot of people to go to the ER, as you’ve mentioned.


Nikki: Yeah. I'm really glad that you're bringing that up because again, listeners that haven't experienced them, it's important to understand, it's a physiological experience. Sometimes I describe to people as like, you know, it can feel like a runaway train, right?. Like the cessations get more and more and more intense so the person experiencing it is not being dramatic or making it up or exaggerating. Again, like if you haven't had one, think of a time when you've been the most afraid in your life and think about all the sensations that can show up in your body, right. Sweating, nausea, heart palpitations, chest tightness, all these things, dizziness that's getting activated in like a 10 to 20 minute span and it can be unbelievably just like consuming.


Pete: Well, when you look up panic attacks, I've done a little research since we're talking, so to differentiate, ‘ it's a discreet period of time and often involves fears of going crazy, losing control, or dying.’


Nikki: Yeah.


Pete: And so, for listeners to like, understand that's the level that this gets to, and people really feel that they're nuts. And I'll just share because I know we don't disclose a lot as psychologists, but you know on the path train, I used to get that from time to time and so that's why I can sort of work with people. You know .  sometimes people will come to us and say, well, do you have children? Or are you this, or are you that? Because that's the only way you could treat us. It's not true. I mean, perhaps our level of empathy or sympathy might change depending on what our own personal experiences are. But, you know, having the experience of the path train really, really crowded on a hot day stopping and getting stuck you know, in between stations you know, certainly led to these feelings or these physical sensations.


Nikki: Yes.


Pete: And there's no way out, so you know.


Nikki: So what Pete's talking about are some of like examples of like, what can trigger a panic attack or panic symptoms, which is like very common when is like, you know, again, it can be cognitive, like you're afraid of being trapped. Or it's like your brain, that's sort of the flavor your brain doesn't like the idea of not being able to get away or get to safety. And it's important, I guess also to say that this is relevant to all the things that we'll talk about today with regards to panic, is that these all have evolutionary roots in them, right? 


Pete: Yes. Thank you Dr. Rubin.


Nikki: Yes. You're welcome. So, fear evolved to keep us safe. That's why I said it's like, it physiologically feels like you're being chased by a bear because all of those physiological sensations increase heart rate, you know, like this is all about, like, you're trying to run, you're trying to get blood pumping, you're trying to feel activated and energized to get away and stay alive. So 40,000 years ago, very, very helpful but in modern days, like that same mechanism can get activated in times when we're not actually in danger.


Pete: Yes.


Nikki: So before we kind of move into like panic symptoms, which is honestly not necessarily less intense than a panic attack but sort of like different in how long it lasts. Like, I don't know, is there anything else that you want to make sure of, or let's go talk about panic attacks?


Pete: Let's jump into the symptoms. 


Nikki: Okay, cool. 


Pete: We've mentioned many of them, but go ahead.


Nikki: Yeah. Well, I was going to say, panic symptoms. I think it's important to understand that you can experience panic symptoms without it rising to the level of a panic attack. So, sometimes patients come to me and they'll say, when I'm assessing, like, they've experienced panic attacks, and I'll ask like you know, how long did they last? And some people will say, I've had them for days at a time and when people say that they're not lying to me. They're not exaggerating. It's that again, they don't yet know the distinction between just panic symptoms and panic attacks. So it's really important everybody's clear that a panic attack is discreet, it's like a wave. It will reach a crescendo and then it will pass. So, it's like condensed, can be really awful to experience them. They're not going to hurt you. You can't be hurt by a panic attack. 


Pete: No one has died from a panic attack.


Nikki: No one's ever died from a panic attack. They're very unpleasant, but they'll be over relatively quickly even though they don't feel like that while they're happening right.


Pete: Right.


Nikki: But panic symptoms, and I explain this lot to people. Like sometimes I'll call them, it's like sub-threshold is what I'll say sometimes.


Pete: Yeah.


Nikki: Where sometimes what is really awful about those is because they never reached the apex right. Like a panic attack, they can stay like elevated for a really, really long time without relief. And that's something that's usually what's happening when someone's saying they're experiencing them for like days or hours on end. And they're experiencing some of these symptoms that Pete was mentioning. So, I'll say them again. So it could be dizziness, nausea any kind of GI symptoms, right? Sweating, increased heart rate, muscle tension shakiness. Any sensation of choking, that's a common one. 


Pete: Yep, shortness of breath.


Nikki: Shortness of breath.  But you know, like if you think of a scale of like 1 to 10, maybe they're hanging out at like a 7 Yeah. But they're never reaching that 10 to drop back down.


Pete: Yeah.


Nikki: Yeah. So is that what you experienced too clinically?


Pete: That's what I experienced that day on the path train yes.


Nikki: Yeah.


Pete: That's what you experienced when you were you know, working with people through that .  And so one of the things you said about scaling, so we'll use a liker scale often because in the moment what you start to realize and, you know, listeners I think play around with this. We all experience anxiety like Nikki said, it's adaptive and so it helps keep us alive. And if we can rate it from 1 to 10, it's likely to have less control over us because it might in our mind feel like it's a 10, but then if we actually observe it, it might only be like a 5 or 6 and not only because that's still annoying. And then what we try to do is work on some skills to, you know, breathe through or to keep lowering from over time. But like you said, like the wave is a big metaphor that I use often because it will come in and will go out, you can't stay in that. But the symptoms, you know, no matter where you're at, and especially anyone in performance, like you're about to give a presentation or, you know, you're going to have some of those moments. Sometimes when I was used to go live on air on like in a television studio, I would feel panic symptoms at times .  you know, right before the camera went live because, once you're on live TV, there's very and actually there's a very famous person who wrote about this Dan Harris, ‘10% and happier.’  And so he had, what he described as his first panic attack live on air, which anyone could Google and watch that or don't.


Nikki: Right. Well, I think he's really open about that. So I think what Pete's starting to get into, which we can talk a little bit about is, you know, some of the ways that we treat panic. 


Pete: Yeah.


Nikki: And there is a mix between east and west here. And maybe we could start with, with the west, well actually, let me be clear, this is important. We say this on this podcast, obviously, you know, we're not treating anybody on this podcast we are also not physicians. And so of course, like the thing with these kinds of physiological sensations, you know, it's always good to like be seeing your GP and get checked out a 100% right? 


Pete: Yeah. 


Nikki: So you know, that's just important to be clear about. 


Pete: Yes.


Nikki: But when it comes to panic attacks and panic symptoms, like, one thing that I often tell people is like, I can treat a panic attack in one session a lot of times.


Pete: That's right.


Nikki: And like, what do I mean by that? What I mean, is that a big reason that they tend to get activated. And again, this is not true for everybody. Doesn't mean every panic attack is going to stabilize after one session. But for a lot of folks, it's just this misunderstanding as to how to interact with the symptoms and you need to know what they are so the psychoeducation alone can bring them down. And so, you know, sometimes just teaching people that the reason panic elevates or anxiety increases in general is when you're misinterpreting your bodily sensations. So what I was saying a few minutes ago about, you know, you feel one of these unpleasant sensations, like you're getting overheated or your stomach's upset, and then your brain goes into that annoying problem solving cognitive evaluative mode and goes, what is happening? .  And then that triggers anxiety symptoms, and then all of a sudden you have more physiological sensation. If all of a sudden you say to yourself, wait a minute, there's nothing to figure out here. All that's happening is my stomach's a little upset. Or I'm on a crowded train and I'm getting a little overheated. That's all that's happening. That keeps the unpleasant sensation where it's at without escalating it.


Pete: Yeah. And so that's going to sound, you know, to some people like super easy and perhaps even a little invalidating, but that's the practice. And so, you know, in the West and what we do in behaviorism is like, you have to have experiences to practice it. So you have to go on trains, you have to give presentations you know, the only way you can do this stuff is to lean into it. And I thought you were going to say you were going to start with the West because it works and it's really great.  


Nikki: Well, that too. It's more that I always think about like the power of like actual, just like having like knowledge about something. That sometimes some, again, like we, Pete and I talk about this all the time, right? Like, we don't know all kinds of things. There are lots of things that we don't know, but our brains really like certainty and they really like knowledge. And so sometimes, like in this case, just understanding what your brain's doing and knowing, oh, that's all that's happening, it's just a physical sensation that I don't like. That stops your brain from then trying to like, get you out of it. It stops you from trying to figure it out and interrupts that process of escalation that can happen really, really quickly. So Pete's right. It might sound like, oh, it's really easy. It it's not, but still, I'll say like, I've worked with lots of people where that alone ended up becoming such an elegantly simple intervention.


Pete: Oh, I love how you put that there. And I'll elegantly simply describe a little bit of the east before we wrap up because we’re out of time. But you know, the east doesn't have much to say about it because they don't really attach to any of those feelings. And so I think there's some things that I've read about it, what will you do is really welcome it and because sometimes people actually, when they're meditating  they'll have panic symptoms.


Nikki: It makes sense. Yeah.


Pete: Right, because it's a first time of stillness. It's a first time of quietness  and as we know you know, stillness speaks, it's very loud as Eckhart totally wrote and so you welcome it. And so one of the most eastern things is saying like, whatever's coming up on the cushion, you let it come up. It might be helpful to break it down into little pieces because again, in the eastern world, you kind of look at things for all of its collective parts. You know, rather than, you know, seeing things for at least like large thing. Again, because panic as we've read, is really about living, you know, or fear of dying in the east. Many of these cultural sort of teachings the inherently there's no fear of dying because the cultures are just more, you know, present or at least the teachings are. And so, again, it's going to sound elegantly simple but anyone that has felt this knows that it is quite the opposite.


Nikki: It's funny, I was like chuckling a little bit when you're like,  beast doesn't have a lot to say about it. I literally thought you were going to say the opposite. I'm like, no, I feel like it has so much to say because that's what some of the main practices that we work with are mindfulness practices exactly that of like, just allow what's coming up. And that paradoxically is actually what brings down the intensity. So like, when you're just allowing yourself to feel the sensations without engaging the story about them, that's what helps you move through them exactly, you know?


Pete: Yeah.


Nikki: Also, just interesting, it was just coming into my mind when you said, you know, obviously the, the concepts of like from some eastern philosophy like that there's not a fear of death right? Or there's not supposed to be, I guess.


Pete: Yeah. 


Nikki: But what's interesting here is that, where panic attacks or panic symptoms get activated is yes, when the mind starts to go into fear of death. Like, what is this what is happening to me?


Pete: That's right.


Nikki: Also, what's really happening is biologically our brains all have the capacity to activate fear as a survival mechanism right? And other mammals have this, like other animals as well. So when we are actually just with the sensations as they were designed by evolution, right?


Pete: Yeah.


Nikki: They don't overtake us, you know? So, I don't know, I thought you were going to say it has tons to say about .


Pete: Yeah. Well see, we remain surprised. And it comes back to some translation stuff that maybe wouldn't even be there because it's not translated.


Nikki: Right.


Pete: But here we are and it seems like we could have another episode on this for sure.


Nikki: Yeah. I mean, it sounds like maybe what we'll come down with is we'll break down the different diagnostic categories that can be associated with these, but hopefully listeners learning a little bit more about panic in general. How it may present, it might show up as a full-blown panic attack. It may be panic symptoms. All of them we get it's really, really unpleasant. And this is something that you have options about how to interact with it in a different way, move through it and hopefully begin to reduce the intensity of something that might be causing you a lot of strife. This has been When East Meets West. I'm Dr. Nikki Rubin.


Pete: And I'm Dr. Pete Economou. Be present. Be brave. This has been When East Meets West; all material is based on opinion and educational training of Doctors Pete Economou and Nikki Rubin.


Nikki: Content is for informational and educational purposes only.