School Based Strategies for Panic Attacks

In this episode Sarah Reeder (College and Career Readiness Counselor) and I cover the most common symptoms of panic attacks along with the various phases and timelines of a panic cycle.  We discuss specific strategies and techniques that are effective to reduce the overall level of panic. The strategies presented include focusing on underlying anxiety, remaining in the environment and accepting the panic attack, the physiological sigh breathing exercise, normalizing the panic symptoms and dealing with automatic negative thoughts.  The skills and techniques are provided to students for use while in school, but the strategies can be applied in most other settings as well.   

Transcript

Intro: Welcome to Mr. O’s Podcast episode 2: Panic Attacks

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Hello and welcome to Mr. O’s podcast!  I am Doug Olszewski, School Social Worker at NHSD. As a licensed social worker, I have provided over 20 years of counseling supports to students in grades K-12, with the majority of my time being spent in the high school. 

With me again is Sarah Reeder, College and Career Readiness Counselor. Thank you for joining me. How are you today? The last time we were together it was during spirit week and now we are approaching spring break! The year is going by so quickly! (Small talk) It definitely is - and once we return from spring break, the rest of the year really flies by.  Yes, with all of the testing in May and the seniors leaving to complete their APEX projects, the rest of the year will go by very quickly. 

In the previous podcast, we talked about Generalized Anxiety Disorders along with the common school based strategies and techniques recommended for managing it. In today’s episode, we will continue our conversation about anxiety issues in school and focus on the topic of Panic Attacks.  But before we get started, I have another joke for you.

Joke: Why is Anxiety is like a GPS? Because it recalculates every five seconds, but you’re still lost.” 

Better or worse than the previous joke? I feel like people with anxiety could relate to that one! 

As we mentioned in the last episode, we have seen lots of students in the high school experience a variety of anxiety related issues in school, and this certainly includes panic attacks. 

I feel that panic attacks are the 2nd most occurring anxiety issue that students experience after generalized anxiety.  For those people who have never experienced a panic attack, consider yourself lucky. For those of you who have, you know you never want to have one ever again!  Like most people, I have certainly experienced my share of anxiety throughout my life, along with some mild panic before, but I wouldn’t say that I’ve ever had a full blown panic attack. So I consider myself pretty lucky. 

Sarah, have you ever experienced a panic attack? Thankfully, I have not experienced a panic attack myself - but I’ve sat with students as they have experienced panic attacks, so I’ve witnessed the stages and impacts of panic attacks. 

Awful experience isn’t it? Definitely. 

Panic attacks come on fast and furious and make the person suddenly feel like they are going to pass out, have a heart attack or that they are going to die if they do not escape from the situation or environment causing the distress.

So why do people experience panic attacks? 

Panic attacks are a type of fear response. They are an exaggeration of your body’s normal response to danger, stress or excitement.  When the brain perceives danger, the autonomic nervous system orders the body to prepare the heart, lungs, and muscles for combat or for running away, the so-called fight-or-flight response, which happens very fast.  With a panic attack, the body can go into fight, flight or freeze mode, even when there is no excessive stress, trigger, or actual danger present.

Sarah asks: Is there specific criteria for a panic attacks?

Yes. Just like GAD, there is a set of diagnostic criteria for panic attacks that are defined by the following:

With a panic attack, there is an abrupt surge of intense fear or discomfort that reaches a peak within minutes and during which time four or more of the following symptoms occur:

●        Palpitations, pounding heart, or accelerated heart rate

●        Sweating

●        Trembling or shaking

●        Sensations of shortness of breath or smothering

●        Feeling of choking

●        Chest pain or discomfort

●        Nausea or abdominal distress

●        Feeling dizzy, unsteady, lightheaded, or faint

●        Chills or heat sensations

●        Numbness or tingling sensation

●        Feelings of unreality or being detached from oneself

●        Fear of losing control or “going crazy”

●        Fear of dying

That’s a pretty scary list don’t you think? Yes - my heart really goes out to people who experience panic attacks! 

For me the feeling of being detached from yourself or the fear of dying is probably the most worrisome. Which symptom is the most concerning for you (Sarah)?   The physical symptoms are most concerning to me, because they feel so similar to actual medical emergencies so it’s difficult to know how to respond in each situation. That can also be really scary for other people to witness if they don’t understand what’s going on. 

Yes, the physical symptoms are typically the most concerning for people who have panic attacks, so we will spend some time covering how to respond to those symptoms in a moment. You raise a good point about others witnessing it happening, it can certainly be a scary event to watch.

Sarah - is there a pattern or cycle to panic attacks?  

Yes, I’m glad you asked. The typical cycle of a panic attack can develop with either a slow increase of anxious thoughts or they can occur suddenly without much awareness as to why or what triggered it.  Sometimes people are unaware as to why they are occurring and can’t identify the trigger or what they were worried about prior to experiencing it.  Regardless of the conditions causing them, most panic attacks follow a similar pattern with 3 phases. 1. A buildup phase - where the length of the buildup can be either immediate or slow depending on the situation, 2. a peak phase - where the symptoms and fear are most intense, and then 3. a reduction and decline of symptoms.   Once an attack reaches a peak intensity level, it may last only a few seconds to a few minutes, but a typical panic attack can only last between 10-20 minutes. The heightened arousal level can only be maintained for so long before the body naturally starts to decrease and return to a more normal state. But to the person having it, those few minutes can seem like a lifetime!   

Sarah-we have definitely seen this with students before, and it’s true that they usually subside in about 20 minutes, but those are a seriously challenging 20 minutes.

Exactly! That is a very difficult and unpleasant time for anyone having a panic attack. To help students understand the cycle of a panic attack, I will often use a bell curve diagram to allow them to visually comprehend the sequence or pattern of a panic attack, where they can see the different phases and approximate timelines for each. It’s very useful for them to see that a panic attack is limited and will not last forever.    

We have both worked with students who were experiencing various levels of panic and suddenly felt like they were going to freak out, pass out, or have a heart attack, etc.  I feel this occurs when a triggering situation causes a student to experience intense fear. For instance, a mild example could be when a student is being called on randomly by a teacher to answer a question in front of the class or write out a problem on the board.  A more critical example can occur when a student needs to give a speech or formal presentation in front of the whole class, or even while they are taking a test.  They may already be experiencing some mild anxiety prior to the triggering event occurring, but in an instant, the student can have serious thoughts that they are unable to complete the task without something bad happening. Which then can trigger their flight, fight or freeze reaction.

As an example of this, a student stands up to give a presentation, and in a brief moment, they are instantly flooded with negative thoughts like: they can’t do it, and they are going to fail miserably! Their heart starts to race, they may feel nauseous, start to sweat and then they feel like they will freak out or pass out if they don’t leave immediately. The student feels that they need to get out right that second or else something extremely bad is absolutely going to happen. Whatever extremely bad means to them. 

Sarah, you know what can happen next right? Yes…they leave the situation, often very suddenly - and in a school situation, that can lead to other issues when the teacher doesn’t know where the student is or if they’re okay.

YES! Instead of melting down or freezing in class (both of which can happen at times), typically they flee… like as in leave the class. Immediately! Oftentimes they go to the bathroom, or sometimes to the guidance office or my office, but they go anywhere to be removed from the trigger. And you are correct that the teacher is left now knowing where the student is and if they are okay.  Once they leave, the student often feels a sense of relief, as they try to settle down their thoughts, regulate their emotions and attempt to calm down. After a few minutes of calming down, the person often thinks about what just happened and how scary they felt, along with the thought that they never want to feel that way again.    

As we mentioned, when a student experiences a panic attack and leaves the environment, they will slowly start to experience a reduction of their panic symptoms.  Unfortunately, a negative cycle can develop where the student believes that it was their leaving the situation that actually caused the decline in symptoms. In reality, the symptoms would have likely started to reduce naturally on their own if they were able to remain in the situation, but they didn’t stick around long enough to experience that. This is a really important concept that we will talk about in a moment. 

Along with this, if a student leaves and the panic symptoms start to reduce, some students continue to want to avoid that class or situation again, for fear of experiencing another panic attack. Unfortunately the fear of having a panic attack can actually create more panic attacks. Because of this some people go out of their way to avoid the situations or environments where panic attacks have occurred, which then can cause the development of avoidance behaviors to those places. A cycle of avoidance can be triggered. We have had to spend a good amount of time working with students for them to feel comfortable enough to return to the classroom, take the test, or conduct the presentation.   

Sarah asks: So what can students do to help if they are having panic attacks?

As with GAD, there are a number of therapeutic methods, medications and various strategies someone could use to help treat panic attacks. From a school perspective, various proactive strategies can be used by students to reduce the severity or length of panic attacks while in school. I would encourage students to use a combination of the following:

●       Address any underlying anxiety that may be present. If there is some level of anxiety or fear that you are aware of, use coping skills, breathing techniques and visualization to reduce the heightened anxiety.  If the student has an idea as to what actually triggered the panic, it would be helpful to spend some time dealing with the fear around the trigger. We covered the strategies to reduce anxiety in the previous episode on Generalized Anxiety Disorders. 

●       This next one is really difficult to do but it is very effective to help with panic attacks. Remain in the environment and accept that you are having a panic attack. Don’t leave the classroom! Most students are shocked hearing that one.  They are like “What do you mean don’t leave?” which leads us to discuss the reasons why they need to stay.  We spend time talking about the cycle of panic attacks and how they will naturally start to reduce on their own. I acknowledge how extremely difficult it is to just stay where you are and experience the intense symptoms, but I will then explain how remaining allows you to condition yourself to see that you can actually tolerate experiencing these symptoms “in the moment” and that you can deal with it effectively.  I also want students to  understand that a panic attacks cannot kill you. No one has died from having a panic attack, so I work with student to recognize their worry about it being a more serious medical condition such as a heart attack. I encourage the student to practice acceptance and to tell themselves “I am having a panic attack, it is not life threatening and it will pass in a moment.” Which they should definately remind themselves during a panic attack. Ultimately you need to accept it and learn to allow a panic attack to run its course. 

So what are your thoughts on that?  It’s definitely easier said than done - but this is why it’s so important for people to practice mindfulness and coping strategies when they’re feeling absolutely fine, so that it becomes easier to put it into practice when they really need it.   Yes, thank you for mentioning that. This is definitely one strategy that benefits from some practice beforehand so that someone is familiar with it, and that can be prepared to actually put it in practice in the moment when they are experiencing a panic attack.  

●       Calm your central nervous system (heart rate, racing thoughts and blood pressure) with breathing techniques.  As I mentioned in the previous episode, one of the most effective breathing exercises is called the physiological sigh. The physiological sigh occurs when you double inhale, through your nose, and you fill your lungs to capacity, but then force yourself to inhale a little more before you exhale slowly through your mouth. Be sure to exhale longer then you inhale. I would demonstrate this breathing technique for students and suggest that they repeat it 5x’s in a row. This exercise has been proven to be one of the best techniques to reduce anxiety levels immediately.  And, as you pointed out when we first talked about it, you may not want to be looking at someone while you are doing this exercise!     True - it feels a little silly when you first do it - but I have practiced it myself since the last episode, and it really does work!  I’m really glad you tried it and that it worked for you! I still need you to show me how to use the Apple Watch mindfulness app.

●       We touched on this one briefly, but the next strategy is to reassure yourself that you will be okay and that the panic attack will only last a little while. You may feel extremely uncomfortable given the various symptoms you are experiencing but remind yourself that you have felt heart palpations, sweating, and shortness of breath before and you made it through. I will often use the example of gym class with students. I ask them to think about a time when they were in gym, running sprints or doing a circuit, where they felt the same exact type of symptoms. When they had a hard time catching their breath, their heart was beating out of their chest and they felt like they were going to pass out. Usually students can completely relate they are like “yeah I remember that!”  We would then normalize the symptoms and talk about how they were able calm down and get through it.  It’s the same as when they are having a panic attack.  They need to remind themselves that they are safe and that they will be okay. I try to get them to practice thinking or saying ”Even though I am having heart palpations, can’t catch my breath, feel dizzy, etc, I have experienced these symptoms before and I will be okay”. 

Thoughts? I think it could be helpful to silently repeat a short mantra over and over while doing this exercise, something like, “I am safe, I am safe”  Yes, that would be a great way for them to remember that they are safe and that they will be okay.

●        We discussed this technique in the previous episode, but if a student has stayed in the classroom, tried to accept how they were feeling, normalized the symptoms they were experiencing, then the next step would be to try to catch the Automatic Negative Thoughts or ANTS they are having and try to prevent them from spiraling. This can be very difficult in the moment, especially during a panic attack when your mind is going in many different directions at the same time, but if you are able to, it is highly effective. As a summary, you first need to catch and identify that you are having a negative thought.  Say out loud if possible that “I am having the negative thought that…  I can’t breathe, I can’t do this, I’m having a heart attack etc.” Then challenge it by asking “Is this thought true? Am I really having a heart attack?” Reassure yourself that you are having a panic attack, and not some serious medical emergency.  Lastly, prevent it from spiraling downward by asking yourself “how likely is it that I will…” freak out, stop breathing or truly have a heart attack. Try to accept the fact that it is a panic attack as a more realistic outcome. Reiterate that “I may feel uncomfortable for a little while, but I am safe.  This is temporary and I will be fine.” That is definitely a higher level skill and a tough one to do in the moment.

●       If a student has tried the other strategies and would like another, the last point I would recommend is distracting your thoughts. This can also be difficult in the moment but try to think about anything else instead of focusing on your physical symptoms or that you are having a panic attack. Focus all your attention to the class lecture, or the notes you are taking or think of a happy or fun moment you experienced, picture a calming scene or place you went on vacation. Visualize how relaxed and calm you were in that moment, and try to feel it. It may help you disregulate the symptoms of the panic by focusing on something positive to increase your sense of calm. When you mind is calm, you body will follow.         

So Sarah, Which strategies do you think would be most helpful?

Sarah replies:  I think these are all helpful strategies. When I’m feeling anxious, it helps me to focus on one simple thing - I think I would focus on my breathing and repeating a simple mantra to myself.I would also try to remind myself that these feelings are temporary and will pass soon. Those are great strategies to use. I definitely use the physiological sigh and try to catch the negative thoughts.  There are times I am certainly better at using them effectively when needed, but not always. They all take a little practice to get comfortable with and then to use them at the appropriate times when needed. 

Those are the main techniques that I would discuss with a student if they were struggling with Panic Attacks.  Of course, we would review the details of their specific circumstances and modify the strategies to fit their personal needs, but generally speaking, these steps would be reviewed. I want to reiterate that this is not a comprehensive list of every anxiety treatment available, only some of which are most effective for in school use. 

So this concludes our discussion on Panic Attacks. The next episode will focus specifically on test anxiety, common symptoms and effective school-based strategies to help manage them. Thank you Sarah for joining me again and providing such great insight. I really appreciate you being here.  (Sarah responds)

I would love to have you participate with the next episode on test anxiety if you are willing. 

Sarah responds-

I am Doug Olszewski, school social worker as NHSD and I want to thank you for listening to

 Mr. O’s podcast. 

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