Radically Genuine Podcast with Dr. Roger McFillin

Roger K. McFillin, Psy.D, ABPP (00:02.316)
Welcome to the Radically Genuine Podcast. I'm Dr. Roger McFillin. Today we're going to be exploring a topic that affects millions of people worldwide, but it's often misunderstood and mistreated. And that's panic attacks. Before we begin, some things I need to address. It's been deeply frustrating me for years as a clinical psychologist, because what is typical treatment has become the widespread practice of

prescribing drugs for when somebody experiences a panic attack. For example, benzodiazepines, which are like Xanax or Klonopin or Ativan or even SSRIs. And the drugs as I'll explain throughout the course of today's podcast is they're not just unnecessary. They are actively harmful to long-term recovery.

Now, with that being said, I completely understand how scary panic attacks can be. Many people believe that they're dying, they could pass out or some other catastrophic reaction to a panic attack. In fact, the fear of having a panic attack is what leads to panic disorder. But these drugs end up creating and maintaining a destructive cycle.

When you take a pill to stop a panic attack and a benzodiazepine is powerful, like that works. It is a true anti-anxiety drug. And there's a lot of drugs that diminish the experience of fear or anxiety, including alcohol, including cannabis. But when you take that pill, you're reinforcing the belief that your internal bodily sensations, you know, like a racing heart,

shortness of breath are dangerous and they must be suppressed. You're also externalizing the response. So you have to turn to something else to escape that experience. So this approach actually in the longterm is going to increase your hypervigilance to these reactions, including those of anxiety, which is on the spectrum of fear. So your body's fight or flight response.

Roger K. McFillin, Psy.D, ABPP (02:32.844)
you become more sensitized to monitoring your body for these cues, constantly scanning for any hint of discomfort that might signal an oncoming attack. So the very act of turning to these drugs teaches you that these sensations are threats that require chemical intervention rather than manageable experiences. The truth is that panic disorder

is one of the most treatable conditions that exists without any drugs. In fact, when I was in my doctoral program, a professor was conducting research on two session treatments for panic attacks. And to be honest with you, in my clinical experience over 20 years, what we do demonstrate, what we do see is that a person can overcome the fear of having a panic attack quite quickly and have the tools

in order to respond when they feel higher levels of anxiety. And so we're going to explore how breaking this cycle of hypervigilance and fear of internal sensations is really a key to that true recovery. By the end of our time together, and it shouldn't be too long of a podcast, you'll understand what panic attacks really are, why they persist, and most importantly, how to overcome them using

the safest and most evidence-based approaches that address the root causes rather than simply masking symptoms, reinforcing fear and entering into a cycle of dependence. You know, the one thing you have to know about benzodiazepines is they will create dependence quite quickly. And then you're going to require more and more of that drug just to get the same response. And there's something called rebound anxiety, which is the withdrawal.

once you start at a certain amount of milligrams of a Xanax, you'll require more to have the same response. Your body will actually crave it. withdrawal, experiences will mimic that of original anxiety. That's why it's a never ending loop. And I've seen people on benzodiazepines and even SSRIs for decades following a very treatable initial panic attack. So let's start with the basics. What is a panic attack?

Roger K. McFillin, Psy.D, ABPP (04:57.752)
Well, it's an intense surge of fear, extreme discomfort that reaches a peak within minutes. During this time, you might experience heart palpitations, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea, dizziness, chills or heat sensations, numbness or tingling, feelings of like disassociation or unreality, fear of losing control or even the fear of dying. So yes, it's quite scary if you've ever experienced one.

But here's what you need to understand. A panic attack in itself is not dangerous. It's your body's natural fight or flight response being triggered, potentially inappropriately. So what makes panic disorder unique and what we'll call it is it is a fear of fear. And that's what we see in the panic cycle. It starts with a misinterpretation of normal bodily sensations, often related to anxiety. So let me give you an example.

Imagine you're in a crowded store and suddenly your heart beats faster. Some people might think I'm anxious in this crowd, or maybe I feel a bit claustrophobic. Maybe I walk too quickly, whatever that sensation is with that attention to it in this understanding of it. But if you're somebody who might be prone to panic attacks or have had panic attacks, or maybe this is your first one, the initial interpretation might be, there's something wrong with my heart.

What if I'm having a heart attack? I need to get out of here. I can't take this. And so this misinterpretation then triggers more anxiety symptoms. So now you're afraid of the original symptoms, especially if you're afraid you're going to pass out, especially if you're afraid you're going to have a heart attack. And you can see how these can come in association with other events in your life. Like if you really do have concern about your physical health or there's some other

anxiety provoking events that might be going on. And this can create a vicious cycle that spirals quickly into a panic attack. Okay. So how does a psychologist like myself understand and then help somebody who is in this vicious cycle? Well, it's essential for us to have a framework for understanding how panic attacks develop and then persist. a typical cycle works like this.

Roger K. McFillin, Psy.D, ABPP (07:26.102)
You experience an initial bodily sensation like a racing heart. You misinterpret it and it's not always very conscious. It's like very, very fast, right? this is dangerous. I don't feel well. Something bad's going to happen. I'm having a heart attack. I could vomit, whatever that may be. And then you become afraid of that. So that misinterpretation causes your anxiety to spike.

You are now in full fight or flight mode. It is now a crisis and that elevated anxiety exacerbates those physical sensations, which then in turn confirm, see, this is a heart attack, something bad can happen. Often people can go to the emergency room for that initial sensation panic attack intensifies.

so how, how do these develop for some panic attacks can develop through classical conditioning, which is associative learning. That means that the experience of anxiety becomes associated with a particular event, place, or even a trauma. For example, if you once had anxiety in an elevator, your brain might learn to associate elevators with this panic feeling, triggering the same response in similar situations in the future.

And then panic is maintained by these two factors. First, it is the catastrophic misinterpretation of those bodily sensations and then avoidance behaviors. The more that you avoid something, you're strengthening that fear. It's almost like you're communicating clearly to your reptilian brain that this is dangerous. I must stay away. So then at any time in the future,

when something is associated with it, you're going to have a panic response. You interpret these sensations as dangerous. So when we say fear of fear, it is really the dangerous experience of those internal sensations. Could even be a thought, could even be a memory. And you try to avoid even like thinking about it in the future. And that's the...

Roger K. McFillin, Psy.D, ABPP (09:51.394)
That's how the panic cycle becomes much stronger. So let's talk about avoidance because it's absolutely central to why panic persists. When you experience something frightening like a panic attack, your natural instinct is to avoid similar situations in the future. You know, we see this in PTSD responses as well. There's an overlap of all these diagnoses. you know, if something is associated with the past trauma,

the avoidance of those triggers strengthens their fear even when they're not related. So if you had a panic attack while driving, well, makes sense that you might avoid driving in the future. If it happened in a grocery store, you might avoid shopping or go only during specific hours, which again, reinforcing and strengthening the fear that there's danger there. So the problem is that this avoidance,

Although it may provide immediate relief, so it lowers the anxiety because you're not in a situation, but it's going to make things worse in the long run. Here's why. So first avoidance prevents you from learning that the situations you fear aren't actually dangerous. If you never drive again, after having a panic attack while driving, you're never going to learn that driving in itself didn't cause harm. Second avoidance.

reinforces the belief that these situations are truly dangerous and need to be avoided. So each time you avoid, your brain registers this as confirmation of danger. Third, avoidance always expands over time. What starts as avoiding driving on highways might gradually expand to avoiding all driving, then avoiding being a passenger, and so on. You can see where one's life becomes restricted

And now you would be experiencing what's panic disorder with potential agoraphobia, which is you are, your life is really restricted because you are afraid of having another panic attack. And this can lead to secondary problems, you know, like relationship difficulties or just depressed mood, right? Like to not live fully, you could feel really depressed. And this is part of the problem in the mental health.

Roger K. McFillin, Psy.D, ABPP (12:13.39)
field is that someone might present with some kind of emotional experience like depression, but everything that is underlying it and driving it are much more complicated than that. And so this brings us back to the problem with drugs as a primary treatment for panic. So, you know, Xanax or Klonopin, they work by really dampening the body's anxiety response. They can provide quick relief, which is why doctors prescribe them.

However, there are several significant downsides. These drugs become a form of avoidance rather than learning to cope with the anxiety sensations, which ends up being the treatment. You learn to escape with the drug. And again, it reinforces the belief that these are dangerous and need to be avoided or suppressed. So when someone tells you that this is to take the edge off or to help

along with an evidence-based treatment. They don't really understand what the treatment entails. Nobody who really knows how to treat panic attacks and has success with them would suggest, go ahead, pop his annex to drink some alcohol, take SSRIs. It's nonsensical. It's actually incompatible with the treatment. Okay. Not to mention that benzodiazepines

are physically addictive and SSRIs create dependence as well. So you're going to require higher doses for the same effect and withdrawal can be quite difficult.

And then when people stop taking them, well, what are we going to see? That same panic is going to return. Okay. But I think what's most important. And if you follow me, I think turning to these drugs reinforces the harmful belief that emotions are dangerous, that these sensations are dangerous, that a memory is dangerous, that a thought is dangerous and they need to be controlled or eliminated. This is actually at the core.

Roger K. McFillin, Psy.D, ABPP (14:21.656)
Panic disorder, the idea that anxiety is dangerous and must be avoided at all costs. This is impossible folks. To live a life, a full one, is to live with anxiety. So what does actually work for panic disorder? The good news is that there are psychological treatments that have excellent, excellent success rates. Now, to be honest with you, I cannot even recall.

a time in my entire career going back to my training that when we did this that a person doesn't get better. This doesn't suggest that, you know, they're effective in 100 % of all cases because people are complex and I am working and have primarily worked outpatient. So at the very least someone can get to my office. There are people I think are burdened with this who just don't leave their homes, but I don't

understand or see any other way to really overcome panic without these key principles. So cognitive behavioral therapies involve a number of components. And when you look into the literature, you know, most people are getting better in somewhere six to 12 sessions. I guess if there's more complex factors like past trauma or other aspects that are contributing to it, obviously the therapy goes longer. So

This first involves identifying that the misinterpretation of these sensations is at the core of it. So for example, if you misinterpret a racing heart as having a heart attack, then your body is going to be certainly reacting to that crisis. So we learn to challenge such a thought and to be able to have more accurate interpretations of bodily sensations.

So for example, I've had this sensation many times before. I've never had a heart attack. I've been cleared medically. It's just anxiety, right? But this cognitive work is simply not enough. Okay. It is just the initial aspects of the educational piece and just another tool. Okay. We have to have this agreement before we move to the most powerful component, which is exposure therapy. and the initial

Roger K. McFillin, Psy.D, ABPP (16:45.442)
treatments which take, which occur often in office is what's called interoceptive exposure. In my work as a psychologist, I can tell you most people aren't getting this. You go into therapy, it's going to be a very traditional, typical talk therapy, and you're not going to be receiving the extent of exposure that is going to be needed both in office and out of office to

be able to overcome this. So I find it's like largely ineffective for the therapy to just be intellectualized or learned without doing interoceptive exposures and in vivo exposures. So interoceptive exposure involves deliberately bringing on the physical sensations you fear, but in a very controlled and safe environment. For example, if you fear a racing heart, it might run the stairs run in place.

for a minute to get that increase in your heart rate. So it's actually exposing you to what you're afraid of feeling. And people who have a very difficult time with racing heart because of that fear, you can understand like how debilitating it could be because you don't exercise and you try not to get too hot or a number of things that can impact it even just being out in public.

So we do have to face that and experience that. If you fear Disney, this we might spin in a chair or spin around. The goal is to learn through direct experience at these sensations while uncomfortable are in dangerous. And so you're going to see that you're going to have to learn how to self-regulate. And this is where someone who has expertise in the treatment of this area can help you self-regulate. These, these exercise eventually be compared with situational exposures where you gradually face

the situations you've been avoiding. So if you've been avoiding driving a car, you might start by sitting in a parked car, then driving around the block, building yourself up to back on highways. And so you're going to be then accepting and allowing in sensations, but also knowing that there's ways that you can respond. So some of the key principles here is that you need to experience the anxiety and stay with it long enough for you to learn. Okay.

Roger K. McFillin, Psy.D, ABPP (19:09.41)
you have to learn that the anxiety will naturally decrease over time. If you don't fight it, the catastrophic outcome you fear doesn't happen. And you can cope with these feelings even when they're intense. So yeah, some tools that are taught are breathing exercises, right? Ways to calm and slow down your body's stress response. So some people get very dizzy or fear passing out because there's the

deep, shallow breathing that's associated with a panic attack. And so certainly you can have the tools to respond to hyperventilating by just deep breathing through your belly and through your nose, out through your mouth. Usually it's a good breath in for six seconds and out for eight seconds, but it has to come along with what I call psychological acceptance, which is a powerful compliment.

to exposure therapy. So many people with panic disorder not only fear their symptoms, but they actively fight against them. So when they feel anxious, they try to suppress it or distract from it or control it. They'll pop a drug, they'll avoid the situation. It is that struggle that leads to a panic attack. And as I tell clients who I've worked with, who have panic attacks and panic disorder, I tell them,

that if you are fully willing to face and accept anxiety, you cannot panic. Because panic is the struggle. And it means allowing your emotions to be present without that struggle, without fighting with them. It doesn't mean you like it or you want more of it. It just means it's free to move. It just simply means you stop treating it as it is an enemy that must defeat it.

helpful metaphor is quicksand. If you fall into quicksand and struggle against it, you sink faster. And the counterintuitive solution is to kind of lie back, spread your weight and work with the quicksand rather than against it. Same thing with, you know, being in the ocean and getting pulled out by a riptide, right? Fighting with it's just going to lead to drowning instead of you kind of have to kind of just go with it. Simply when

Roger K. McFillin, Psy.D, ABPP (21:32.896)
Actually, that might be a bad metaphor. You might have to swim across the tide. Bad metaphor. Take that out. I actually don't know how you approach a riptide. So, but quick sands to write one. So very bottom line here is you fight against it. You're going to become more anxious in my office. I have Chinese finger traps, which is another good metaphor when your fingers are in there. And if you fight to get rid of them, it's going to tighten.

Right. But when you kind of give up the fight, everything loosens. So when you feel panic rising, instead of thinking on, this again, or I need it to stop. thoughts are it's anxiety. These are sensations. I can accept their presence. You know, they'll rise and fall on their own. In fact, I think we're forever going to challenge ourselves in life, which means we're going to get anxious because anything that's important is going to provoke some degree of anxiety.

have to allow anxiety to be a partner with us. A life partner that's a signal that there's something that's maybe really important or in the rare situations there is something that is dangerous and we have to react to it. This shift from struggling against emotions to allowing them to be present can dramatically reduce the intensity and frequency of panic attacks. Okay. So as a beginner and this episode is just a beginner episode.

If you do have questions, feel free to contact me through the website, drmcphilham.com or email me at roger at drmcphilham.com. These are always further topics because it does get a little bit more complicated, but without these foundations, there is no way. And most people are going to overcome this with these foundational principles. So I want to emphasize that overcoming

panic attacks is absolutely possible without having to turn to a benzodiazepine. And certainly I would never support an SSRI for somebody who's having a panic attack. So you need to understand the panic cycle. You have to understand the catastrophic thoughts and misinterpretation of bodily sensations and know how to respond to those accurately. But most importantly, it's facing feared sensations through exposure.

Roger K. McFillin, Psy.D, ABPP (23:53.59)
and practicing psychological acceptance. These are the evidence-based techniques with high success rates. So if you're currently experiencing panic attacks, I encourage you to make sure that these are key components with your mental health professional and provide education to them and to the doctors who are prescribing these drugs. Like I said, majority of people are going to see

significant improvement in just eight to 12 sessions and sometimes just one or two sessions of intero inceptive exposure and education around this certainly has a profound effect. If you're currently taking a benzodiazepine medication for panic or somebody put you on an SSRI, you know, make sure you do not stop these drugs abruptly. Make sure you're talking to your doctor.

about gradually tapering over time as a key and meaningful component of overcoming panic attacks. They remember the goal and no goal in life should ever be to never feel anxious again. So this complicated phrase that people are saying, my anxiety or I have anxiety is very, very unhelpful because we're reinforcing that idea that having those feelings

Having that natural human survival mechanism is somehow dangerous. And in creating that relationship of danger is the problem in why you are staying anxious and why you are experiencing panic attacks. So the goal is to change your relationship with anxiety so that it no longer controls your life. Thank you.