Anxiety and Chronic Pain: How To Cope In The Midst of a "Panic Attack"
Anxiety sucks. Eloquent, eh? But it's the truth. People who don't suffer from anxiety don't really understand the debilitating, life-altering effects anxiety can have and people who do suffer from anxiety can't figure out how the hell to communicate the devastating, breathtaking feelings. Anxiety is horrible on its own, but when you're suffering from chronic illness and/or chronic pain...well...it just sucks a little bit more.
Sadly, the good news is, you're not alone! In fact, anxiety and chronic pain go hand-in-hand. In a study published in 2014 by PLOS One entitled "The Association of Depression and Anxiety with Pain: A Study from NESDA" found that "chronic pain is common in up to 70% of patients with depressive and anxiety disorders" (1)
I have been pretty vocal about the depression and anxiety I have suffered throughout my illness, but the truth of matter is, I had never suffered from anxiety until I got sick. I can still remember my first "panic attack" - 11-years ago. I had no idea what was happening to me. I suddenly got warm from head to toe - like a wave of heat washed over me. Then, my heart started to beat quickly, which suddenly made me gasp for air. It was at that point I noticed that I had a hard time expanding my lungs and taking any kind of deep breath - it felt like someone was constricting my chest. My heart rate increased so rapidly that now I could hear it beating in my head. My mind began to race to try to figure out what was wrong with me... which only seemed to make each symptom significantly worse. And then...the crying began. What was truly incredible was the fact that I was surrounded by people...none of whom, had any idea that I was becoming increasingly fearful of my life. It was one of the most isolating feelings I've ever experienced.
Regardless of having a better understanding of anxiety and how it relates to my life today, I didn't know what suddenly brought it on then...and sometimes, I don't know what suddenly brings them on now. What is certain is from that day forward, my anxiety attacks would take the same shape...and show up when I least expect.
People experience anxiety disorder and panic/anxiety attacks in a myriad of ways - some people don't experience the sudden temperature change, hyperventilating, racing thoughts or crying and experience other awful symptoms but what most, if not all of us, do experience is the sudden, random, haphazard onset of anxiety. #yuck
So why do depression/anxiety and chronic pain have such high comorbidity? Well, the PLOS One study suggested a few possible reasons. "A possible explanation is that impaired functioning caused by pain can lead to social isolation, which in turn can lead to a negative effect on depressive symptoms, and vice versa. Furthermore, different brain areas, such as the amygdala and hypothalamus, play a role in both depression and pain. Also, when depression and chronic pain are co-morbid, recognition and treatment of depression are less effective, as patients mostly only present their physical complaints and receive treatment accordingly." (1)
Makes sense, no? Now, does it mean that these are the only "reasons" as to why there seems to be such high comorbidity between depression/anxiety and chronic pain? No, of course, not...but it's a great start.
Here's the way I describe why I believe these two illnesses run parallel so often. In most cases, chronic pain develops from an initial unexpected event - an injury, an accident, or an illness. If that initial unexpected event creates pain for just 12 short weeks, consistently...you are now a chronic pain patient. And now, everything you once knew, everything you once were, everything you once planned, has changed. And that sudden, random, haphazard event...causes...yep, you guessed it...depression and anxiety. Tada! I mean, is there anything else you'd expect someone to feel?
A lot of the advice I have read on anxiety discusses coping skills and tactics in handling anxiety BEFORE or AFTER the anxiety sets in...but what do you do DURING an anxiety/panic attack?
I think it's important before I go any further to note that I am a proponent of medications that can help manage anxiety disorders. Medications like, antidepressants and/or benzodiazepines - or medications that have off-label use like, beta-blockers and/or anticonvulsants, can be extremely helpful in managing anxiety.
As long as the identified patient takes the medication responsibly, understands that these medications don't resolve the underlying cause or root of anxiety, and seeks out nonpharmacologic, self-management coping skills.
With that said, here are my top 5 most effective, nonpharmacologic, and self-management coping skills I use when I'm in the midst of an anxiety attack:
1. ASMR Videos
ASMR has gained a lot of interest and traction in the last few years. ASMR (Autonomous Sensory Meridian Response) describes the experience of tingling sensations in the crown of the head, in response to a range of audio-visual triggers such as whispering, tapping, and hand movements.
ASMR has been touted to have therapeutic benefits for depression, anxiety, insomnia, and yep, even pain; however, there has not been much research to back up these statements.
I will admit, when I first watched an ASMR video, I was skeptical, but I decided to give it a valiant effort. Within 5 minutes, I noticed my body and mind relaxing. I continued to watch and looked at my smartwatch to notice my resting heart rate - when I began the video my RHR was in the high 80's - after 10 minutes of watching this particular ASMR video, my RHR began to fall - mid 80's...low 80's. I was shocked. And then, I was curious, really curious.
In June 2018, researchers from the University of Sheffield's Department of Psychology investigated whether ASMR is a reliable and physiologically-rooted experience with the potential to benefit the physical and mental health of those who experience it. They conducted two experiments - one of which, studied the physiological changes that occurred when participants watched two different ASMR videos and one control (non-ASMR) video in a laboratory setting.
The findings? "Those who experience ASMR showed significantly greater reductions in their heart rates when watching ASMR videos (an average decrease of 3.14 beats per minute) compared to those who do not. They also showed significant increases in positive emotions, including relaxation and feelings of social connection." (2)
I can (and probably will) discuss this study and ASMR in greater detail, but for the purpose of this particular blog, I'm simply going to refer you to the study, here, so you can learn more.
So where do you begin? There are more than 13 million ASMR videos on YouTube - a bit overwhelming. First, start by identifying what you like and dislike. Each creator has a different style, and each will typically focus on a few "triggers." For instance, you may find that you like the sound of tapping or scratching and may dislike the sound of whispering - click on a couple different videos to narrow down what sounds you find most relaxing - then you can further narrow your search to personalities you like best. Two of my personal favorite "ASMRtists" are Gentle Whispering ASMR and TingtingASMR.
2. Deep Breathing
There is massive information on the benefits of meditation and deep breathing in relation to managing anxiety but during an anxiety/panic attack, meditating and deep breathing seems ridiculous -after all, you want anything that removes you from the situation...not focuses on it. In fact, for a good portion of my illness, I believed the fact that breathwork was helpful in anxiety management but refused to believe breathwork could or would be helpful in the midst of an anxiety attack.
And then, my best friend introduced me to a little app on Imgur (an online image sharing community and image host). Instructions directed you to watch the little boxed image expand and collapse - inhaling as it expanded - exhaling as it collapsed. Though I couldn't find the original link, I was able to find one incredibly similar, here. Smartwatches like Apple Watch and Fitbit have guided breathing apps like the one above.
"Breathe" - 1 of 3 journals published by The European Respiratory Society released an article released in December 2017 entitled, "The physiological effects of slow breathing in the healthy human" discusses the history of controlled breathing. "The act of controlling one's breath for the purpose of restoring or enhancing one's health has been practiced for thousands of years amongst Eastern cultures. For example, yogic breathing (pranayama) is a well-known ancient practice of controlled breathing, often performed in conjunction with meditation or yoga, for its spiritual and perceived health-enhancing effects. Various forms of pranayama exist, such as nostril breathing (double, single or alternate), abdominal breathing, forceful breathing and vocalised (chanting) breathing, which are performed at varying rates and depths." (3)
But why is this so effective? Well, here is a simple explanation behind the science of why this works: "When your exhale is even a few counts longer than your inhale, the vagus nerve (running from the neck down through the diaphragm) sends a signal to your brain to turn up your parasympathetic nervous system and turn down your sympathetic nervous system."
"The sympathetics command your fight or flight response, and when they fire, your heart rate and your breathing speed up, and stress hormones like cortisol start pumping through your bloodstream, preparing your body to face a threat. If the threat is, "A lion is chasing me, and I need to run away," this is helpful. If the threat is, "I am late to work" or, "I'm so upset with my mom," this is not particularly helpful, and in fact it can be damaging – when cortisol is elevated for too long or too frequently it disturbs all the hormonal systems of the body."
"The parasympathetics, on the other hand, control your rest, relax, and digest response. When the parasympathetic system is dominant, your breathing slows, your heart rate drops, your blood pressure lowers as the blood vessels relax, and your body is put into a state of calm and healing." To read the rest of the article published on "mbgmindfulness.com" written by, Robin Berzin, M.D., please click here.
If you're familiar with the work that I do, you'll know I never suggest or recommend pain management/coping skills that I haven't personally tried and/or implemented on my road to recovery. If you introduce breathwork into your "self-management toolkit" understand it takes time, practice and patience.
Anxiety or panic attacks are awful- anyone who has experienced them can testify to that fact. Panic attacks feel like someone has hijacked your mind and body and glued them both to a violent rollercoaster. Seriously.
During one of my first panic attacks, my spouse began talking about... shoes!? I happen to love shoes and at the time, had an impressive collection of heels, boots, sneakers, and sandals. The conversation started very innocently..."Do you like the new pair of heels you just bought?" Suddenly, my mind was focused on the new pair of shoes, and through severely labored breath, I managed to say, "yes." I couldn't help but think, "Why are we talking about shoes when I feel like I'm dying?" But, the questions continued, "What do you like about them?" "Are they comfortable?" When my spouse saw the conversation was helping to calm me, the questions kept coming. "Do you want other colors?" "Is the heal too high?" It seems ridiculous, right? Unknowingly this helped to apply one of the most effective coping skills I have to this day...distraction!
Distraction can come in any form and touch on any topic - television, iPads, gaming, apps on our phones, or basic conversation. In other words, it can be anything that takes your mind off of your mind and blunts the spiraling thoughts, fears, and anxieties.
Today, if I feel like a panic attack is coming on, I will look at the person I'm with and say, "I'm about to have a panic attack, can we please talk about something senseless like, (insert any topic I suggest)?" Or, if I'm alone, I will turn on the T.V., go onto YouTube and watch a few of my favorite creators or Google something I'm interested in like medicine, space flight, theology, animals, etc.
In the above paragraph- I outlined 3 points I'd like to discuss further:
1. I am clear on the identified symptoms that act as an alert system to warn me when a panic attack is coming on.
2. Knowing that a panic attack is coming on, I have contingency plans - one, for when I'm with someone else, and one for when I am alone.
3. I give an example of how to best communicate with the person/people you are with, in the midst of an anxiety attack. You'll notice I give a statement that explains what is going on within me (i.e., "I'm about to have a panic attack") and then provide instructions on how they can best help me (i.e., "Can we please talk about something senseless like, (insert any topic I suggest?").
4. "Let It Go" ("Frozen" reference, anyone?)
The truth of the matter is when it comes to anxiety and/or panic attacks, sometimes, the "launch sequence" is initiated and there isn't an"abort mode" available. In other words, sometimes anxiety has a mind of its own, and before we can even identify we're experiencing it, we're in it.
So what do you do? Well, there are two self-management skills that you can do to help you in one of these situations:
1. Remind yourself that "it's just" a panic attack. Anxiety/panic attacks cannot kill you. You may feel that way, but I promise you will not die from having an anxiety attack. Keeping that perspective can dramatically help you cope in the midst of an attack.
2. My business partner, founder and Clinical Director of Hellenic Therapy Center, explains managing anxiety this way:
Think of your body like a window- particularly the center mass of your body. Then, visualize the anxiety, and it's energy being pent up behind that window. In order to feel better, you have to open the window and let that anxious energy flow out. Each time you take a breath, imagine more of that anxious energy flowing through you and out the window that is in the center of your body
Try practicing these techniques beforehand. You can even develop your own mantra like, "I know this is just an anxiety attack - I know it will not harm me - It cannot last forever."
5. Anxiety Malaise = Self-Care Phase
Lately, I've been suffering from what I call, "anxiety malaise" - this general, weird feeling of discomfort and uneasiness - like a little back cloud of anxiety that follows me around but never fully develops into a threatening thunderous cloud. Of late, anxiety has just been lingering all day, and the worst part is the fact that I cannot figure out where it's stemming from. All I know is that it feels horrible and I had to do something about it.
First, I sat down and pinpointed how this looming anxiety has been directly or indirectly, affecting me. My entire body is tense. I'm not sleeping well. My eating habits are off the wall - one minute I'll crave "comfort food" and the next, I can't bring myself to eat. My mind is constantly juggling the same five fears. And, perhaps worst of all, I can't seem to concentrate.
Next, I sat down and thought about what would ease the tension in my body, help me sleep, stop the looping thoughts, help me concentrate and balance my nutrition. The answer was simple: self-care. I went for a massage, slept in, taken a few baths, organized my office, snuggled up under my weighted blanket, started reading a new book and even taken a break from social media (regardless of business needs or not).
In conclusion, anxiety is a tough but manageable road. The more you understand yourself, the better you will be able to manage your anxiety. Don't be afraid to try new things. However, make an honest attempt to avoid the two biggest mistakes I see chronic pain and/or chronic illness sufferers make when trying something new - inconsistency and impatience. A lot of us try something new, for a few whole days...and if we don't see immediate results, we toss it out the window, throw our hands up in the air and say, "nothing works!" Anxiety is without a shadow of a doubt, tough...but I promise you...you're tougher.
Christina H Chororos founded Kairos Chronic Pain Coaching in the fall of 2017 after obtaining her Integrative Wellness Life Coaching certification from the Integrative Wellness Academy.
She is a decade-long deep infiltrating endometriosis sufferer, speaker and, suicide prevention + chronic pain patient advocate.
For more information, please visit kairoschronicpain.com
(1) de Heer, Eric W et al. “The association of depression and anxiety with pain: a study from NESDA.” PloS one vol. 9,10 e106907. 15 Oct. 2014, doi:10.1371/journal.pone.0106907
(2) Poerio GL, Blakey E, Hostler TJ, Veltri T (2018) More than a feeling: Autonomous sensory meridian response (ASMR) is characterized by reliable changes in affect and physiology. PLoS ONE 13(6): e0196645. https://doi.org/10.1371/journal.pone.0196645
(3) Russo, Marc A et al. “The physiological effects of slow breathing in the healthy human.” Breathe (Sheffield, England) vol. 13,4 (2017): 298-309. doi:10.1183/20734735.009817