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Panic Attacks: New Understanding Of Causes And Treatment

Bert A. Anderson, Ph.D.

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People with Panic Disorder suffer from periods of intense fear or anxiety. Physical distress such as not being able to get their breath, racing heart and feeling weak and exhausted, are usually part of "panic attacks."

Panic attacks start without warning and last for minutes or hours. An afflicted person must cope with the possibility of an attack occurring while shopping, driving, attending church, or being with other people socially.

There has been no agreement among professionals about what causes them. Even today, most professionals who treat panic disorder patients will say that the cause is not really known. Many state that stress or anxiety is a factor.

Most people who have attacks believe that there is something physically or mentally wrong with them, that they are ill. It is a common misbelief that something has happened during the person's lifetime which was quite fearful, and this deep psychological fear reasserts itself during an "attack."

It is important to seperate conditions of a psychological nature, such as early life trauma or lack of assertiveness, from the physical manifiestation of panic attacks. Both in clinical practice and in correspondence with many people who have sought help by downloading "How to Treat Your Own Panic Disorder," there has been no evidence of an underlying psychological condition worthy of a diagnosis.


Only in the last decade has an explanation for panic attacks appeared which explains all the various symptoms. When this explanation is understood by the panic attack sufferer and applied to treatment, control is regained and panic attacks can be stopped. This explanation is based on evidence that panic attacks result from what has been called "Hyperventilation Syndrome." Panic attack sufferers all have one thing in common. They don't breathe properly. There is much to know about faulty breathing and having panic attacks.

People who suffer from panic attacks:

  • Breathe shallowly and rapidly.
  • Breathe using the muscles of the chest, neck and shoulders.
  • Make little or no use of the diaphragm in breathing.

Day in and day out, people who suffer from panic attacks breathe about twice a fast as normal breathers. Every person who has sought help in my office for panic attacks has been tested for these dysfunctional breathing habits using sensitive biofeedback sensors. Without exception, all have been found to breathe improperly. Their shallow, rapid breathing causes them to hyperventilate.

Hyperventilation occurs any time a person breathes in such a way that they breathe out more carbon dioxide than their body is manufacturing. Medically, this results in a condition known as "hypocapnia." When the blood's level of carbon dioxide gets below a critical point, the person begins experiencing apprehension and physical symptoms such as tingling arms and hands and rapid heart beat. If they don't know what to do at that point, the symptoms become more severe and a panic attack results.


The symptoms of hyperventilation are said to mimic the symptoms of organic disease. People who suffer from panic attacks are often put through a series of expensive medical tests only to find that there is no physical cause for their symptoms. The symptoms experienced during panic attacks are not "imagined," they are real. Hypocapnia (abnormally low level of carbon dioxide in the blood) upsets the normal chemical balance of the body. Changes in the regulation of the heart and breathing result. Blood flow to the brain has been shown to decrease by 30% to 40% in laboratory studies of hyperventilation. Oxygen transfer from the red blood cells to the tissues is inhibited, known as the "Bohr effect." The nervous system is over-stimulated at first, then under-stimulated as the condition worsens.

Fortunately, the body has numerous ways of protecting itself from death due to a complete loss of carbon dioxide, but the sensation of dying which many people experience during a panic attack has a physiological basis in actual fact.


Researchers now believe that the fearful symptoms of panic attacks are responsible for the development of phobias. It is not unusual for many people who suffer from panic attacks to take precautions about being too far from home, medical help or those who they trust. But phobias and rituals can become a disabling complication for people who have suffered panic attacks over a long time. They lose the confidence to carry on life in a normal way. They rarely leave the safety of their homes.

When phobias and avoiding any situation which might trigger an attack have become a way of life, they become the most serious obstacles to recovery. Even treatment which offers the promise of recovery is rarely carried through because of these fears. When treatment is sought, the patient, their family, doctor or psychiatrist, and therapist need to make careful plans to keep the treatment going until the patient feels strong enough to do it on her or his own.


  • Light headed, giddy, dizzy, vertigo
  • Faint
  • Headache
  • Blurred vision
  • Tremors, twitching
  • Numb, tingling, prickly feelings, especially in the face and arms
  • Chest pain or pressure
  • Nausea or vomiting
  • Abdominal pain or upset
  • Gas and abdominal extension
  • Lump in the throat
  • Dry mouth
  • Difficulty breathing
  • Weak, exhausted, fatigued
  • Apprehensive, nervous
  • Feelings of unreality
  • Fearful during an attack of dying
  • Going crazy
  • Doing something uncontrolled

These symptoms are essentially the same as those listed for Panic Disorder in the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association.


Although behavioral approaches such as desensitization are currently popular, panic attacks are best treated by teaching victims of this disorder to control their tendency to breathe shallowly and rapidly. Nearly all persons who learn to change their habitual and unconscious breathing pattern will experience considerable control over their attacks in the first few days, or at most, weeks of practice.

The anxieties, phobias or other disorders which may be preconditions or a complications of panic attacks should be treated as soon as the person has gained some control of the attacks. The help of a competent therapist may be needed but much can be accomplished through self-help publications listed in the Bibliography. Many people who use these materials, especially those whose onset of panic attacks has been recent and has interrupted an otherwise normal life, will need no further assistance. They should, however, continue breathing practice for some time after they have stopped having panic attacks. Those who have had panic attacks for many years and have become fearful of going places should not discount the possibility that these materials will give them the help in controlling their attacks. More patience and practice may be needed and help getting over the phobic part may also needed. Phobias should be discussed frankly with a therapist so treatment can be planned accordingly.


Medications can be both a help and a hinderance to overcoming panic attacks. A medical doctor should always manage a person's medications. In the beginning, medications can provide a level of comfort which makes practice easier.

Because many anti-anxiety medications interfere with learning and memory, it is necessary to withdraw from them as soon as some control has been regained over the attacks. Those who have participated in this program have expressed a desire to be off medications as soon as possible. Only minor relapses have been reported by persons who no longer take anti-anxiety medications. By continuing breathing practice, the possibility of relapse is minimized. Paradoxically, failures to achieve recovery have been among those who stayed on even low doses of benzodiazapine medications.


We live in a fortunate time for those who suffer from anxiety, panic attacks and agoraphobia. The decade of the 1980's saw advances in research and treatment in two major areas.

The first was in the devlopment of high-potency tranquilizers, notably alprazolam (Xanax), which is powerful enough to ward off panic attacks, but does not cure them. They are the most frequently prescribed drugs in this country. In spite of the widespread use of drug therapy, it has been shown by well-conducted surveys that the public and agoraphobic patients don't like drug treatments and would like to find some other way to deal with mental and emotional problems. The relapse rate is close to 100% for those who want to get off drug therapy.

The second development has come from the research into which non- drug treatments are effective and which are ineffective. Several effective interventions have resulted, and, in combination, are the core of treatment programs around the country. Finding the right program located near enough to home to be practical, however, can be almost impossible.

So, what is the good news? It is this. All the most effective treatment procedures can be learned and practiced at home. One of the things which was sorted out by researchers studying clinic programs was that those which encouraged home practice were the most effective.

The idea behind this book is that it brings what you would learn in a clinic into "the safety and comfort of your own home." Especially for those who have developed substantial fears of going out, this can be quite important.


Over the years experimental evidence indicates that what is known as exposure based treatment for panic disorder, avoidance and agoraphobias is only successful when it is accompanied by an actual reduction in panic attacks. Leading researchers now believe that panic is the central feature of agoraphobia (and panic disorder) and that avoidance is a resulting complication of panic attacks.

Whereas many programs concentrate on helping patients with their avoidance behaviors or catastrophic thinking, but ignore or downplay panic, this book targets panic directly.

How it helps the sufferer to rid him or herself of panic attacks is the unique part of the treatment or training detailed in this book. It is by fully embracing the evidence that panic attacks are caused by improper breathing habits which brings on a condition, for some people, known as Hyperventilation Syndrome.

The proposition is simple: "If panic is the root cause of phobias, agoraphobia and panic disorder itself, and breathing is the root cause of panic, then the best place to start is with breathing." Studies have shown that when breathing retraining is added to conventional treatment, the individuals receiving such training were significantlly better after six months than those who had not.

When dozens of patients who suffered from panic attacks were tested in my office for breathing problems, all fit the criteria which could lead to having attacks.

Better yet, those who stayed for breathing retraining overcame their panic attacks.

There were some who did not completely overcome panic attacks, and from them I learned some important lessons. The most important lesson, was that drug treatment, particularly with alprazolam (Xanax), prevents recovery. The reasons for this and the best way to withdraw from drug treatment are contained in the chapter on drug therapy.

Note: The Chapter on the usefulness of medications in treatment is not yet available on these pages.

This book begins with breathing but is not only about breathing. It contains all of the breathing awareness, reinforcing, early sign recognition, and exposure exercises which have been proven so effective in helping people who have suffered from panic attacks. It therefore presents a complete treatment plan for the agoraphobic and panic disorder patient.

I have tried to write this book from the patient's point of view. The most help to my understanding was my association with Joni. Joni was a true victim of panic and agoraphobia, who in spite of her fears, ventured out and found the answer to her seven year quest. In the process, she taught me most of what I know of the real suffering and agony the victims of panic go through. For this reason, I dedicate this book to Joni.


Chapter One

Take a minute and think about it. What do you believe, indeed, what have you been forced to believe about Panic Attacks? If there is anything in the world which effects you so powerfully, and seems to be completely beyond your control, it is Panic Attacks. One of the things people feel who have Panic Attacks is that they are out of control of their own mind and body.

For this reason, a lot of what is in this book is about getting in control. As reasonable and logical as it seems to believe that Panic Attacks are an inevitable part of your life, I want to begin by assuring you that just the opposite is true. Panic Attacks are not inevitable. They can be controlled. For a very few people who read the first few chapters of this book and do the exercises, success (meaning they will not longer have panic attacks) will be almost immediate. For most people it will take a little longer.

This is written for those for whom it will take a little longer.


Joni started having panic attacks when she was 28 years old. She's now 36. With the help of her husband she's raised a son, but for most of the last eight years she stayed at home.

Determined to get out, she took a job at an agency which used computers to keep track of credit reports. The first day, she sat at her work station nearly paralized -- for about a half hour -- then ran out and frantically drove home were she stayed for several years.

Joni tried everything, including alcohol, to find some relief from the attacks which were a daily occurance, often more than once a day. The list of medications for anxiety is impressive. She has been to emergency rooms more than once. She experienced so much dizziness that her doctors gave her a CT Scan to check for inner ear problems. When medical tests revealed nothing she began to believe she had a tumor of the adrenal glands that was causing the attacks.

A few years ago Joni again tried to go to work, and as it happened she was in front of a computer again taking care of the billing in an office. She wouldn't admit that anything was wrong, but at times staying at work must have been real agony. It so happened that Joni was working for me when I was serendipitously introduced to the idea of Hyperventilation Syndrome and the treatment which would help panic attack victims.

Together we found some people who were looking for help and started a group in the next few months.

I asked Joni a few months before this was written how she was doing. She replied in writing:

"I DO NOT have panic attacks anymore . . .for almost a year now. A solution to this problem was and is a Godsend. Miracles can really happen in the most unusual ways!!"

Joni mentions a miracle. If your are looking for the miracle that Joni is talking about, it is the one which brought her together with the knowledge of what to do. You too, now have that miracle. It is in the words which are before you at this moment.

The real secret to Joni's success was just plain hard work. Since everything else had failed to help her, she threw herself into the exercises with a vengence. Like all the others I asked about their success, Joni still practices, as of this writing, her breathing as she learned in the group.


Susan is one of those people who succeeded right away. Susan was never in formal treatment with me for her panic attacks. She only heard me talk in a group of people ONE TIME about hyperventilation syndrome and was unable to come to succeeding weeks of the group in a mental health center because of vacation plans with her husband.

Mostly I'm going to let her tell her own story as it came to me in a letter a few months after she returned from her vacation and reported her success.

She wrote:

I am so happy with the results of learning how to breath diaphragmatically. I wanted to share my experience. It has changed my life for the better.

I have been a sufferer of panic attacks for over three years. I have tried everything. I have been to doctors, had all kinds of tests, even been into urgent care a few times. All they would tell me is that it was stress. I finally got so that I could go through life as long as I had my tranquilizers. But I would still experience panic, feel dizzy, sick, out of control and worst of all a feeling like was loosing my mind. The only thing that sort of worked for me was to take Ativan and not do all the things in life that I really wanted to do. It was while I was at a meeting in Redlands that I met Dr. Anderson. I was very interested in what he was telling us about diaphragmatic breathing. It made so much sense, I decided to give it a GOOD try.

I first started by diaphragmatic breathing before I got out of bed in the morning. I noticed that I seemed to feel less shaky and more calm right away. At the time I was on the highest dosage of Ativan that I had ever taken.

My family was planning a vacation so I took [the time] to practice my breathing. Every time I could I would practice. By the end of my vacation I had cut my medication down by two- thirds. I kept breathing diaphragmatically every time I would think about myself and how I was feeling, which is pretty often when you suffer from panic disorder.

When I returned to work, the stress returned too. But breathing really helped. It really works! I did not want to go back on medication.

I have had a few panic attacks since. But I try to catch it early. I know this is hard. But there are signs of stress coming. I also know after breathing diaphragmatically at least three times I could feel the panic lift. And the best feeling of all is the feeling that I am in control again.

I have been totally off medication now for one month. I am thrilled. I have even been tested pretty good -- a trip to the dentist. I just kept up the diaphragmatic breathing. I really believe in diaphragmatic breathing. It has changed my life for the better.


Susan H.

The wonderful thing about Susan's letter is that she carefully spells out the steps everyone who suffers from panic attacks should take. As spelled out in more detail in the remainder of this book, these steps are:

  • Decide to give it a GOOD try.
  • Practice diaphragmatic breathing before getting out of bed in the morning.
  • Practice several times during the day.
  • Begin cutting back on your tranquilizing medication right away. But with the help of your doctor.
  • Use inner cues to remind you to practice breathing.
  • Stay off medication even when the stress increases. Continue to use diaphragmatic breathing.
  • Become aware of the early signs and see how a few breaths will do the trick in turning the symptoms around.

There is a follow up to Susan's letter several months later which came in response to my inquiry. She notes that she has the same ability to control attacks as when "treatment ended" and that she doesn't have panic attacks now. Thinking of others, she wrote as follows:

A person needs to stop and think at the first sign of panic what might be triggering the attack and breathe to slow down the increasing panic.

Since the TENDENCY to have panic attacks may remain for some time after the skills of controlling them have been mastered, it is important, as Susan found on her own, to stay aware of early signs and breath to stop the symptoms.

All of the former patient's who responded to my questionaire about their success noted that they continued to practice breathing as a way of controlling their tendency to have attacks.


Be Willing To Take One Step At A Time

No, I won't say, "Rome wasn't . . . .", but I will say that like a lot of things, what might seem simple at the outset turns into something requiring persistence in the long run. As you've seen, Hyperventilation Syndrome is a complicated interaction of many things. Several things must be brought together in order to gain control and live without attacks.

You don't have to learn "perfect" diaphragmatic breathing to be able to go on to the next step, but you should be able to mostly do it when you are thinking about it before taking the next step. So give yourself some time and reward yourself for a little progress at a time.

Learn To Work Within Your Limitations

For many people, having panic attacks and the fears and phobias which go with them is severly disabling. They have a lot of limitations which have been built up over the years.

Working within your limitations means that you will practice at those times you feel best. If that's not very good, then accept it as your best time and do what you can. Go slowly, if you're in this situation, it's been a very long time since you felt anything close to normal.

The same applies to medications. What's good about them is that they allow you to function, at least somewhat. You can taper off the medications that you now take when you have gained some skills to recognize and control attacks. Right now, the medications provide a window of opportunity which is helpful.

Don't Ignore The Spiritual Part Of This Problem

When Joni and I would rap about the struggles which she went through and how panic attacks became the focus on her life, we both recognized the after breathing, a Twelve Step program such as used by Alcoholic Anonymous would be helpful.

Breathing will stop panic attacks just like stopping drinking will lead to sobriety. Like the alcoholic, many panic attack victims suffer the consequences in terms of personal isolation, having to manipulate others to get their way, and being fearful of life in general. Don't overlook the self help groups available to you and the spiritual teachings of your religion to help you with these attendant problems.

"Spirit" and "air" mean the same thing. To inspire means to take in air or spirit, to expire means to let go of air or spirit. The physical fact that we all live together in a world filled with air, taking that air into our bodies several times each minute and giving it back again to the universe has spiritual meaning. No wonder breathing and being spiritual were seen by ancient people as closely related. Even today, in some religious traditions, right breathing is understood as an essential part of the spiritual life.

There is something else which comes to mind when I think of the problems faced by people who suffer from panic disorder. This comes from my own religous beliefs. It is "The pearl of great price." To obtain it, the finder has to go and sell everything that he has in order to obtain the pearl. There was no way to play it entirely safe. He or she had to take the risk.

How easy it is to play it safe. To stay at home. To do nothing. There must be some pushing at the boundaries which this problem imposes. But it must be a right pushing. To push too hard to function at a high level right away is one error. To not push at all or be willing to persevere will lead to no solution at all. Carefully follow the instructions outlined ahead. The Pearl of Great Price is freedom. Freedom from panic attacks and all the limitations which they have placed on your life for so long.

Chapter II: "Panic and Hyperventilation Syndrome"

What is contained in this book is a new. It will teach you a way to control and overcome panic attacks which is not yet widely known. It is what I teach people who come to me who are overwhelmed by daily, weekly or monthly attacks which are sometimes so terrible they think they are dying, going crazy or will do something horrible.

People who suffer from panic attacks can't come up with enough words to describe to others how out of control they feel when an attack "hits". They feel overcome by some lurking inner madness which periodically reveals itself. They live in fear of the next attack, but also know that sooner or later they will be overcome just as if someone crept up behind them and put a black sack over their head, drew a tight cord around their neck and left them to struggle for air until they could claw the sack off and, exhausted, be free for awhile until caught once more.

Recently I attended a lecture on Panic Attacks presented by a psychiatrist. When he began the presentation he asked the people in the audience how many of them had ever experienced a panic attack. A scattering of hands went up. He then admitted that he had also suffered from these attacks. At the end of the lecture, when asked to pin-point the actual cause of the attacks, he did not have a ready answer.

This book does have an answer to the question, "Where do Panic Attacks come from?" Is it the right answer? Researchers don't yet agree. It's a simple question, but the answer, I'm afraid, is far from simple.

There is, however, one very good thing about the answer which is given in this book. The treatment based on that answer works for people who seriously try it. Most are able to completely prevent panic attacks from occuring. All but a small percentage are able to be in control and reduce the intensity of attacks, and prevent most of their attacks altogether.

I have been counseling people with emotional problems for over 25 years. Like 99.9% of my colleagues, I was as confounded by the problems of people who sought out my help for their panic and the numerous fears and other problems which accompany this condition.

Just like many other physical and emotional problems, panic attacks probably are not caused by any one thing, or for that matter cured by any one thing. Also, people who experience panic attacks for any length of time become fearful (phobic), learn to avoid any situation where the attacks might be triggered or where they can't get help. Other reactions to getting safely through life develop to, some of which are very disabling in themselves.

Panic sufferers have to look at a three step process that goes like this:


The conditions or situations which set-up the eventual victim of panic attacks may be multiple. Being an anxious person? Stress? (Many panic attack victims are told by the emergency room doctor that it's just their reaction to stress.) Diet? Bad breathing habits? Grief? A bad heart? Being a perfectionist? Unique brain chemistry? Tight girdles like women wore in the 1890's, or too- tight designer jeans nowdays?

All of the above have been implicated as possible existing conditions which make the person vulnerable to panic attacks.


There is some "thing" which triggers panic attacks. It might be an anxious thought or an anxiety producing situation. As I was making the notes to write this section I was sitting at the kitchen on a warm summer morning with the back door open, our Golden Retriever laying nose-on-paws looking languidly into the sunshine. Suddenly, without any warning, he was on his feet, rushing out the open doorway, barking loudly. I jumped in my chair in reaction, saw it was nothing and went back to my notes. For some people with the right preconditions, that might have been more than enough to start a sequence which would sooner or later lead to a panic attack.

Panic attacks are not preconditions or triggers. In the frame of reference of this book, the panic attack will come to be understood as something which comes about because of preconditions and triggers, but which can be treated by itself. As you will see in a few pages, attacks are undoubtedly physiological reactions, over which, when we know how, we have a lot of control.


The fears, anxiety, phobias, social isolation, need to control others and even ritualized obsessive-compulsive behaviors are the most destructive part of the panic attack cycle. Increased anxiety is to be expected at the very least. Anxiety, remember is one of the pre-conditions. In this way the cycle of preconditions, triggers, attacks and fears-anxiety are kept going.

People who have experienced attacks for any length of time usually consider themselves to be anxious people. But is anxiety the chicken or the egg? Was it a precondition which existed before the person ever had an attack? Or, is it the result of having been through emotionally wrenching experiences time and again, sometimes for years or decades? As you will see, it may easily be a result rather than a cause.

<> Now let's begin to look at some examples which makes all the theory understandable.


John was a patient who was referred to me to undergo therapy to help him with intense anxiety. His managerial job forced him to make presentations at meetings and before groups. At these times his panic became so intense, he was ready to quit his job. After John left my office, I reached for a new professional book which had just arrived in the mail. I opened it and began to read to see if there was anything new that would help me understand how to help my new patient. I was fascinated. The author of one of the chapters, Richard Ley, described John's problem exactly.

Lay's article was titled, "Panic Disorder, a Hyperventilation Explanation." It became clear that John hyperventilated and that led to his feelings of panic when he was called on to lead a meeting or talk to groups. He had begun to fear these attacks so much, he was willing even to quit his job to avoid being put in this position.

The Pre-existing condition for John was that he was, by now, habitually anxious because he good reason to fear a panic attack. He had developed that fear from the time he had the first attack. The pre-condition of the first attack probably was a faulty breathing pattern and not some underlying psychological condition.

The Trigger was knowing that he had to make a presentation or lead a meeting. John had come to fear the fear. His anxious breathing pattern was keeping him on the edge of hyperventilation and the Trigger was enough to push him into apprehension and finally Panic-Fear.

John's Coping Reaction was to protect himself from the Trigger. He had decided he would quit his managerial job and go into another line of work This was an instance when Science had finally caught up with a problem. Good science rarely makes startling discoveries. Ley had not "discovered" hyperventilation. His article contained an extensive bibliography of papers and books.

Many people who write today about panic attacks go back to an original scientific article titled, "Hyperventilation, The Tip of the Iceberg," written by Dr. C. M. Lum in the late 1970's. Over 2,000 patients had been admitted into his program at Papworth and Addenbrook's Hospitals in Cambridge, England, by the mid 1980's. 95% of these patients were not only helped, most were cured.

After thirty years and 2,000 patients, Doctor Lum concluded that "faulty breathing" perhaps along with being a perfectionist if you were a woman or a "Type A" if were a man, was the real root cause of hyperventilation and panic. After many years of faulty breathing ---> anxiety ---> hyperventilation ---> panic, you can hardly be blamed for thinking of yourself as "anxious". By now "anxious" has gotten to be a habit.


It was late in the day when a frantic mother called about her daughter. She had been having a panic attack for most of the day. She had gone into convulsions, the mother told me. They were afraid of going one more time to the emergency room of the local hospital. The doctors were definitely not sympathetic. Traci had been there more than once previously. A few weeks before, she was so agitated that she had been given injections of a powerful tranquilizer before she could calm down. She was told that unless she was able to get control of herself the sheriff would be called and she would be taken to the psych ward of our County Hospital. The tranquilizer affected her speech and she was uncoordinated from the effect of the medication when I saw her four days later.

When mother and daughter got to my office, Traci was gasping for air, she could hardly walk and the muscles in her face were twitching. Her eyes were glazed over from fear and exhaustion and her pupils were dilated. She was unable to concentrate on anything for more than a few seconds, and that made helping her very difficult. What she needed was to get control of her breathing. Little by little, I helped her slow down and deepen her breathing. After an hour, she was weak but calm. She had gained moderate control.

The panic had passed.

In the throes of a Panic Attack, people usually experience difficulty breathing. Usually, the breathlessness is thought to be caused by the attack. It is one of the many recognized symptoms of an attack. What is unrecognized is that actual symptoms of panic attacks are brought on by the way the person normally breathes. The breathlessness and gasping experienced during an attack is an extension of a problem which began very quietly and unawarely.

When Tracy first visited my office to begin her training in controlling the attacks, I could not see her breath at all. When I attached a stretch band around her abdomen and put some sensors on her neck and shoulders, all connected to a computer, I could then see her breathing. Only when I looked at the computer screen and saw the graph that was being made from what was being picked up by the sensors. Her breathing was shallow, rapid, erratic, and she was using only the muscles in her neck and upper chest. Her abdomen wasn't moving at all. She was breathing at a rate of 22 breaths per minute, about twice as fast as is considered "normal".

Tracy, like other victims of panic attacks, shows all the characteristics of hyperventilation syndrome which were recognized by C. M. Lum. Here's the list of breathing abnormalities:

They take air into their lungs by using their chest muscles.

They don't use, or only partly use their diaphragm when breathing.

They usually breath rapidly and shallowly, so it is hard to see them breath unless they sigh or are requested to take a deep breath.

HABITUAL rapid, shallow breathing (something of which the victim is usually not aware) keeps the important level of carbon dioxide too low all of the time.

Panic Attacks are triggered by anything which results in more rapid breathing and drops the carbon dioxide level below a critical point, causing increased apprehension leading to panic-fear symptoms.

A person is said to hyperventilate when the way they are breathing results in them loosing carbon dioxide from their blood faster than it is being manufactured by the body.


What most people don't know, is that breathing is what regulates the acid/base balance of the body. The amount of air we inhale and exhale is continually adjusting by the needs of the body to maintain a constant point on the scale between acidity and alkalinity. What the amount of carbon-dioxide we exhale has to do with the acid/base balance (base and alkali mean the same thing) is that when carbon dioxide is dissolved in water it makes the water more acid. Since the blood and the human body is 70% water, the right amount of carbon dioxide is essential to maintaining that balance at just exactly the right level.

Maybe you can see that this discussion is already getting too technical. Unfortunately, for the understanding of the people who have panic attacks, it can get a lot more technical.

Here's a summary of what you should know:

The right amount of carbon dioxide manufactured by the body remains dissolved in the blood before it is eliminated by breathing.

It is the amount of carbon-dioxide dissolved in the blood which regulates the acid/base level.

The acid/alkali balance of the blood is, normally, very slightly alkaline.

A slight shift either in the direction of the blood becoming too acid or becoming too alkaline can have serious consequences. The consequences can be, and too often are, panic attacks.


Panic attack sufferers are most interested in what happens in the body when too much carbon-dioxide is breathed away and the blood becomes too alkaline. Just to put it as simply as possible, the following are effected as the blood becomes more alkaline, a condition known as "blood alkalosis."

THE BRAIN: Breathing control centers are effected along with the panic victim's ability to think clearly. As the condition worsens, the brain processes information from the body too rapidly or not at all. Wrong signals or none at all are given as the brain shifts into "emergency". Clear thinking stops altogether.

THE SYMPATHETIC AND PARASYMPATHETIC NERVOUS SYSTEM: Adrenaline is discharged into the system, pupils tend to dilate, hands and feet get cold, and there is a tendency to sweat.

THE HEART: Reduction of the oxygen supply to the muscles of the heart, changes in the electrocardiogram, increase in heart rate, and increased blood output by the heart. Blood pressure may be affected (in either direction) to the point of causing the person to faint, a condition called Syncope.

THE OXYGEN TRANSPORT SYSTEM: The red blood corpuscles give up their oxygen to the muscles and organs of the body, including the brain, less easily. Starved of oxygen, the person feels weak, confused and, rightly, feels like they are suffocating.

That's probably more than enough to convince you that when the blood alkalosis gets serious, you are going to experience that a great deal is wrong. For more information on any or all of these points, there is a Bibliography of the references mentioned in this chapter which can be consulted for more complete information.


Panic attacks and Hyperventilation Syndrome are two terms for the same thing.

Over-breathing creates a shift in the acid/alkaline balance of body in the direction of being too alkaline.

The physiological and mental consequences of the brain, breathing, heart and oxygen carrying capacity of the blood and what results from all that are, in reality, what we call "Panic Attack!"


In spite of decades of research and successful treatment programs, your physician probably doesn't yet know about the promise which the methods discussed in this book hold out for you. A paper published in New England Journal of Medicine which focused on the increased risk of suicide among people who suffer from Panic Disorder did not mention hyperventilation or suggest treatment protocols which utilize this explanation for the symptoms.

Probably the reason that the medical profession is not up to speed when it comes to treating panic attacks, is that virually all medical practice for this disorder is focused on which drugs will do the job. Books written my medical doctors for people who have panic attacks, enthusiastically focus on the advances in drug therapy. The treatments used by those who have studied Hyperventilation Syndrome have nothing to do with drugs.

There are problems with some medications most used by physicians to treat panic attacks. They are physically addicting after a very short time. The side effects bother many people. And they interfere with the ability to learn or recall what you have learned.


The methods for overcoming panic attacks which are detailed in coming chapters are not the invention of any one single person, but have evolved over the years. These methods are based on observations, research and clinical practice which has taken place in hospitals, universities and the practices of many disciplines.

Now that you have been introduced to what is causing the symptoms which you experience and call "panic attacks", it is time to get down to how you breathe now, how you should breathe to prevent panic attacks, and what to do to train yourself to do exactly that.

These are the steps as presented in the chapters to come:


While you are practicing the beginning exercises, talk to your doctor about how to reduce medication particularly if you are using any anti-anxiety medication known as benzodiazapines."

WARNING: Don't discontinue any medication without your doctor's advice. Some drugs require supervised withdrawal in order to avoid withdrawal reactions such as seizures.

By now most people feel a little more in control. But it's not enough to overcome panic attacks. The next chapter will tell you how to:


Now it's time to read about integrating what you've learned into your lifestyle. The next chapter is about:


By now your Panic Attacks will be under control and perhaps even gone forever. It's time to concentrate on:



It wouldn't be fair to you to not warn you about some risks in undertaking the training in this book. Other than the strictly medical problems mentioned in the CAUTION AND RESPONSIBILITY section, there is a risk that you might temporarily increase your hyperventilation symptoms in the beginning.

It is impossible to foresee every eventuality for everyone who reads these pages and decides to "give it a go." Although learning diaphragmatic breathing is learning to breath as we are meant to naturally, in the beginning it may feel very unnatural. If, due to practicing something new, you start into anxiety or panic symptoms, stop practicing for that day. Come back to it tomorrow. You'll probably be able to handle it a little better.

There is one more risk which most people don't anticipate. If you have suffered from Panic Attacks for several years, you will have the problem of returning to a normal, non-anxious lifestyle. For this on-line publication, that is a chapter yet to be written. In the meantime be content to take one day at a time. The next chapter will get you started on observing your breathing patterns and beginning to change.

chapter three

"Breathe in, breathe out!" The first time I heard this was as a young man from an old doctor who liked to relax his patients with corny jokes while he was preparing an injection. "Do you want to know how to live forever?" he said. "Sure," I naively took the bait. "Breathe in, breathe out," he said. "As long as you keep breathing in and out you can't die."

Some thirty years later I heard the same words again from another doctor, a Ph.D., who is in the forefront of developing a learning model of retraining people to breathe. The "diploma" which Dr. Erik Peper gives patients and professionals who attend his workshops in breathing is titled, "Breathe In, Breathe Out."

The sequence and types of exercises in the pages to come are because of Erik Peper's carefully done research over many years. The specifics, however, are the result of my helping people who suffer from panic attacks.


The old doctor's joke wasn't so silly, because it implied that we have control over our own breathing. Unlike our heart beat, it's easy to take a breath when we want to or to blow out the birthday candles just when we're ready. We very consciously take a deep breath and blow hard. Most of the time, though, our breathing is on automatic and we don't have to think about it. It is likely that we humans have breathing problems because of this part-time conscious control over our breathing. So we can easily learn to adjust or modify our breathing just as singers, actors and instrument players do. The problems come when we teach ourselves the wrong things, which at the moment don't have bad effects, but eventually they become bad habits which create the symptoms of anxiety.

The information and instructions which follow are for the purpose of overcoming bad breathing habits. So now it's time to take a close look at how breathing is "supposed" to be done from an anatomical standpoint.


Although the lungs are a complex maize of air passages and minute air sacks (alveoli) through which an even more complex mesh of arteries, capillaries and veins is intertwined, they (there are two, one on each side of the chest) can be thought of for our purposes as balloons. The balloons are emptied and filled not because of their own actions, but by the actions of the entire torso which encloses the lungs.

Breathing takes place through the air passages leading from the nose and mouth into the lungs. Although the bronchial tubes and lungs are lined with smooth muscles which regulate the flow of air, these are not the muscles with with we breathe.

The chest and ribs which are attached to the spine in the back and the breast bone in the front comprise a somewhat flexible cage in which the heart and lungs are enclosed. The chest cage is narrower at the top, and the neck occupies the opening at the top.

Of particular interest to us is the wide bottom of the chest cage. The bottom ribs are no longer connected to the rigid breast bone, but are connected by pliable cartilage. Attached to the bottom edges of the wide cage, from front to back is a muscle called the diaphragm. It is shaped like an inverted bowl or funnel. Through the middle of the bowl (or neck of the funnel) run the blood vessels from and back to the heart which supplies blood to the abdominal organs and lower limbs. The esophagus on the way to the stomach and major nerves come through the same area.

The diaphragm muscle should be the main muscle of breathing, because where it is located in the body it has the most room to move in a piston-like fashion. Below it are the soft organs and the belly which when a deep breath is needed can expand outward. Above it are the lungs, which are also soft and pliable.

The easiest way to understand how the diaphragm works is to make a relaxed inverted bowl with the tips of your fingers just interlocking.

With your fingers still interconnected, tense your hands and wrists, and, if your doing it right, you'll see the bowl flatten down. That's almost exactly how the diaphragm works. When it's relaxed, the bowl is most bowl-like. To use the piston illustration, the piston is up when the diaphragm is relaxed. It is pushing up on the soft and pliable lungs, and the air in the lungs is forced out -- exhaled.

The inhale is of course, the opposite. The diaphragm contracts, just like your fingers and flattens out. That brings the piston down, creating more space in the cage. Air, naturally, is the only thing that can fill the space, so it moves into the lungs, filling them.

Other parts of the body also assist in breathing. If you tighten and pull in your stomach, you push more out of your lungs because you put pressure on the underside of the diaphragm-piston. If you let your stomach pooch out, it gives the diaphragm more room to move down into the area of the soft organs, and more air can be taken in.

But the muscles between the ribs all up and down the chest, especially those between the more flexible lower ribs, can also work so as to make the rib cage bigger. Air comes in, again because there is more space to fill. Even the muscles of the neck, shoulders and upper back assist in the breathing process.

When running hard or doing aerobic exercises, the idea is to breathe hard -- to inhale and exhale a lot of air. The more air the body needs, the more of the various breathing muscles go into action to create more space for breathing.

The volume of the lungs is quite phenomenal when breathing is correct. The diaphragm can move up and down as much as six inches. In the process it gently massages the lower organs and aids in the blood's return to the heart. A large person can have a capacity of five quarts. Even a small adult can breathe in two or more quarts of air.


When resting the right way to breathe is with relaxed shoulders, upper chest and stomach muscles, allowing the diapragm and lower rib muscles to carry on the automatic breathing process. When breathing in this way, the body will continually adjust the volume and breathing rate as needed to maintain the acid/base balance of the blood and other factors. Eight to twelves breaths per minute is normal breathing rate.


Many, and that may mean most, people breathe in a slightly abnormal fashion. They tend to hold their stomach in all the time, make little use of the diaphragm and breathe mostly with the muscles of the upper chest, neck and shoulders. This style of breathing becomes automatic also and the body adjusts volume and rate as it does in diaphragmatic breathing.

Thoracic breathing, because it depends on the more rigid system of muscle action in the chest and shoulder area, means that the lungs are given less room to expand or contract. As breath volume is lowered, in order for the body to maintain it's chemical balance, breathing must be speeded up. Probably, most people who habitually breathe mostly with their chest and shoulders will never have panic attacks. Others, however, will.

My own observations of the breathing of panic attack patients confirm what other researchers have discovered, people who have panic attacks chest-breathe. Their resting breathing rate has speeded up to twenty to thirty shallow breaths per minute. They will also try to compensate by sighing frequently, sometimes as often as two or three times a minute. Sighing is likely the result of the small air sacks not being expanded, and the sigh allows enough air deeper into the lungs to keep the alveoli and airways open. When sighing, or taking a deep breath, it can be observed that the chest-breather appears to lift the entire chest up away from the diaphragm, thereby creating more space in the chest cage, rather than allowing the diaphragm to pull the air in.


In order to control panic attacks you will need to become aware of the way you breathe enough so you can begin to switch from chest breathing to diaphragmatic breathing.


You do not have to perfectly reach this goal in order to feel that you can control an attack. Is all you have to accomplish to get that kind of control is to mostly breathe diaphragmatically and slowly when you are thinking about it. It's a downhill battle from there.


Please read the materials about diaphragmatic and thoracic breathing patterns. Be sure you are clear about the following:

How rapid, chest breathing relates to a condition known as "hypocapnia", the root source of symptoms of panic attacks.

The mechanics of breathing: What the body does in order to get air into the lungs and out again, so another breath may be taken, and so on.

As you know, people who have panic attacks breath in a particular way. This way of breathing seems very natural, and even when demonstrated, its hard for them to believe that there is another way of breathing. It is so hard to believe, that you just have to "give it a good try", because the only way you'll really believe it is when you have learned to breath correctly and are able to control your panic attack symptoms.

Give yourself some room to make mistakes. In your trying, you may try too hard and provoke some panic symptoms. This is good only because it help proves the point, breathing is the problem. Its not good, of course, because no one wants to have more or worse attacks.

Important points to remember during these exercises.





You'll soon learn that whenever you think about your breathing you change it.

Don't expect to catch yourself breathing rapidly. All the exercises anticipate that you will change your breathing when you pay attention to it.

Exercise 1 Checking your current breathing mechanics.

For this exercise you will want to use the LOG OF BREATHING PATTERN It will help you if you print this log out right now so you can follow it as you continue to read this text.

Wear loose comfortable clothing. No tight belts or pantyhose around your middle to restrict your breathing.

Sit upright in a chair.

Place your left hand on your breast bone, just under the notch of the neck. Your hand will go across your chest so your left palm is laying on the left of center, and your fingers on the right. Relax your hand, don't press.

Place your right hand across your abdomen in the area between the bottom of the breastbone and navel. Don't press down. Relax.

Breath normally. As you do this, see which hand moves, or if they both move up and down as you breathe.

Take a few deeper than normal breathes. Take at least one breathe taking in as much air as you can. (More than one or two breathes could start panic attack symptoms. Be careful!) What you're looking for:

THORACIC BREATHING: Your left hand on your chest only will move up and down when you breathe. Your right hand will stay still.

REVERSE BREATHING: Harder to detect When you breathe in your left hand will move up and your right hand will move down or in. It's "reversed" because you pull your stomach in as you breath in, just the opposite of what you want to do.

COMBINED BREATHING: Your right and left hand both move up or out when you breath in, and down or in when you breath out.

SHALLOW BREATHING: Although your breathing is under control while you are doing these test exercises, you can detect shallow breathing.

LABORED BREATHING: When you take a deep breathe, you have to strain your upper chest, neck and shoulders to get the air into your lungs.


All of these breathing patterns are related to thoracic styles of breathing and are typical of the way people breath who have panic attacks or anxiety. Exercise 2 Checking for other breathing habits. The very first time you ever read this paragraph is the check for an important breathing habit. It is "not breathing". Are you not breathing or holding your breathe as you're reading this? At the same time you can check yourself for two other breathing habits.

What you're looking for:

NOT BREATHING: When you pay attention to something, start to do something, even to read this, do you stop breathing?

SIGHING: Do you notice a tendency to sigh frequently? By frequently, that means perhaps a few times every minute.

YAWNING: Do you yawn every so often? How often?


Not breathing, sighing and yawning are also typical of the breathing patterns of people with panic and anxiety. They are probably ways of compensating for imbalances caused by shallow, thoracic breathing.

EXERCISE #7 Verbal Reward for the Progress You've Made

If you've made progress, give yourself a verbal reward: "Nice going." "I did it." "I knew I could do it!" "I can't wait to write about this on the record form."

If you don't feel you succeeded, don't put yourself down. Encourage yourself instead by saying: "Rome wasn't built in a day. I'll keep trying until I get it." "Try, try again." "No one ever did it perfect the first time, why should I expect that of myself. I'll relax now and try again tomorrow."

If you do that, say those things to yourself and believe them, then you've assuredly have made progress. There's just as much of a change which needs to take place mentally as there is physically.

Many people have gained control of their panic symptoms having read on-line no further than the Introduction and the three chapters of "How to Treat Your Own Panic Disorder." You can practice the diaphragmatic breathing exercises described above for the next few weeks without further instruction. You may find that you can gain partial or complete control over panic attacks by doing so.

The next chapter to be brought on-line will be Chapter IV: DAILY PRACTICE IN BREATHING AWARENESS. As the materials in this chapter are still being organized it may be awhile before you find this material on the site. You might try again after two weeks of practicing what you have already learned.

Emergency Measures


Prepare for using these EMERGENCY MEASURES by printing out these instructions and putting them where you can easily find them the next time you have symptoms.

Take steps to control a panic attack as soon as you feel it coming on. The longer you wait, the worse it gets, and all the harder to get control of upward spiral of the symptoms. You can use the following suggestions in order or choose which are right for you at any particular moment:

Exercise. Go for a short brisk walk or use a treadmill or exercise cycle. While you're walking or exercising, breathe as deeply as you can rather than allowing yourself to breathe faster.

Distract Yourself. Try not to think about your symptoms . For instance, while walking, look at the scenery, listen for the sounds around you, say hello to the people who you pass on the way. Talk to someone. Become aware of your breathing. Splash cool water on your face.

Massage Your Neck. The carotid artery, which leads to the brain, when massaged, causes a reflex slowing of your heart beat. You can feel your pulse from the artery by pressing in just below the angle of the jaw. Gently massage one side at a time. Do this while sitting in a comfortable chair or laying back.

Slow Your Breathing

1. Use the sweep second hand of a watch to help you get control of your breathing. If your tendency to breathe is faster than 10 breaths per minute (3 seconds inhale and 3 seconds exhale) you are breathing too fast. Watching the second hand, slow your breathing gradually to 3 seconds for each inhale and 3 seconds for each exhale. Try to breathe so your stomach pooches out. As you relax, extend the length of time to 4 seconds, then to 5.

Slow Your Breathing II. Use the above technique, but hold your breath on the inhale for a count of 4. Slowly inhale and hold your breath, count to yourself 1,2,3,4, then slowly exhale. Don't gasp for air but inhale as slowly as you can and exhale in the same way.

If your symptoms return, don't get discouraged. It only means that you have allowed your breathing to speed up again, probably without knowing it. Each time you succeed in slowing your breathing and lessening your symptoms using these techniques, you move closer to your goal of controlling your panic attacks altogether.

Log of breathing pattern


EXERCISE 1 Observing faulty breathing patterns
With your left hand on your breastbone and right hand on your abdomen 
just below the ribs, check breathing pattern as instructed. Observe breathing 
pattern and check appropriate spaces below:

     _____All thoracic (chest) breathing
     _____Reverse breathing
     _____Combined, part diaphragm, part chest breathing
     _____Shallow breathing
     _____Labored breathing

EXERCISE 2 Checking for other breathing habits.

     _____Stop breathing

EXERCISE 3 First Steps to Learning Diaphragmantic Breathing

Write down your experiences as you practice converting to diaphragmatic breathing while laying down:

Does it help to have another person monitor your breathing by placing a hand on your abdomen?

YES NO (circle one)

Does stretching your arms back above your head help you to use your diaphragm more? 


EXERCISE 4 Stretching arms over head to increase diaphragmatic breath volume.

If another person is available have them gently place their hands over your lower ribs on each side of your body. If you Diaphragmatic Breathe they'll feel your ribs widen slightly. What do you experience with this exercise?

EXERCISE 5 Using a book as a reminder to continue Diaphragmatic Breathing

Place the book on your abdomen while laying down and practice raising and lowering the book as you breathe.

EXERCISE 6 Practice Diaphragmatic Breathing while laying on your stomach.

Stretch your arms over your head. Do you feel your abdomen press against the floor as you breathe? It's O.K. to skip this exercise if you find it too uncomfortable. What do you experience in this position?

EXERCISE 7 Verbal Reward for the progess you've made.

Don't forget the last part of these series of exercises. Reinforce the positive things you have done by telling yourself how well you've done.

by Bert Anderson, Ph.D.

Dearest Note: Anxiety, panic attacks and depression are common complaints during the menopause transition. Hormones and nerves all out of whack and your symptoms are all VERY REAL and often very frightening.

Don't let *anyone* tell you otherwise -- not even your doctor. Many of them know only enough about menopause to fill a thimble. And what's worse, they make you feel like an irrational, emotionally crippled, crazy woman and dismiss you with their, "It's just your nerves. Here, take this pill and you'll feel better" -- not unlike patting a child on the head and giving him a lollipop. Doctors probably have a few hours (if that much) of lectures about menopause during medical school - a few hours on a major health issue that often impacts every nuance of a woman's life for 10-15 years. The medical school required curriculum needs serious overhauling.

I hope those of you who made it to the end of this article have done so without having a panic attack from the length of it.

I hope you've found it helpful. I recommend reading the transcript of Dr. Bert Anderson's Guest Chat.



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