Anxiety Management

Worrying, a common manifestation of anxiety, illustrates anxiety’s diminishing returns in that, as it rises, its mental cost quickly surpasses its potential benefit. The Dalai Lama offers that “if there is no solution to the problem then don’t waste time worrying about it. If there is a solution to the problem then don’t waste time worrying about it”.  True to the source, it is a lovely approach, but it leaves room for more to be said about strategies for anxiety management.

In the following I will present two mental protocols, or cognitive algorithms, that can be useful in containing anxiety in general, and a breathing exercise that can help deal with a panic attack. The first step of these approaches is the same: The starting point is recognizing the anxiety and labeling it for what it is (i.e., bringing the anxiety into focus in consciousness). In other words, anxiety management begins with simply telling yourself “The discomfort I’m presently experiencing is anxiety”. This realization, which is simple but not necessarily easy to make, is a required first step. The steps that follow vary according to the protocol you choose to employ.

One last overarching point before we move on: Remember that the typical response to pain is automatic and habitual rather than deliberate and mindful. It is driven by sensations and emotions, which are important but not particularly reliable. Because they are not reliable, our sensations and emotions require deliberation before we let them guide our choices (as most adults know, and all should know, not every pleasure — not everything that feels good, is good for you, and not every pain — not everything that hurts, is necessarily bad for you). 

Our automatic emotional responses are seeded very deeply, evolutionarily designed to protect survival; it’s not surprising that we tend to be “attached” to them. These attachments (as do all attachments, according to the Buddhist world view) lead to suffering. It is therefore worth making the effort required for ‘letting go’ of them. Our emotional attachments can run so deep that ‘letting go’ of, or transcending, them may be experienced as ‘getting over yourself’. This can be difficult, but not necessarily a bad idea, especially in the all-too-common occurrence in which serving the needs of the ‘Self’ gets in the way of the pursuit of happiness.

In other words, the effort to replace the automatic, habitual tendency to follow the guidance offered by feelings with a mindfully designed and practiced alternative is likely to be rewarded with a reduction of suffering. Dealing with anxiety, the automatic response to the pain of anxiety is avoidance, of whatever the mind perceives to be causing the pain. In the non-survival arena the avoidance strategy is not only futile, over time, it generally makes the problem worse. (A reminder: This work is about the pursuit of happiness. It does not pertain to the management of existential threats. Expertise and practices relevant to survival threats should be sought elsewhere.)

Hence, showing up to the encounter with anxiety mindfully requires tolerance (of the discomfort of anxiety) that manifests with a willingness to overcome the reflexive tendency of avoidance. The therapeutic term denoting the opposite of avoidance is ‘exposure’. The therapeutic application of ‘exposure’, in the most basic terms, means that increasing the frequency with which an anxiety causing situation is experienced will lead to a reduction in the anxiety (and conversely, avoiding it will increase the anxiety). This is an imperative concept that should be kept as the backdrop to the approaches in the following discussion.

The First Protocol

The first protocol is based on the theoretical conceptualization of anxiety as evolution’s response to the perception of a potential threat (note the distinction between anxiety and fear). It consists of the following four steps:

1.  Identify the perceived threat.
2. Generate a realistic evaluation of the likelihood of the threat materializing.
3. Generate a list of the various scenarios that may result if the potential threat materializes, their relative probabilities and your ways to influence then.
4. Examine your levels of self-confidence and hope.

Permit me to elaborate:

1. To identify the potential threat you are facing, answer the following question as specifically and precisely as you can: What exactly is the threat that my mind is perceiving? Answering the question often requires resisting the temptation to amplify the magnitude of the actual threat and to refrain from following a hypothetical chain-reaction of events that may become future threats but are not present yet (as in “if this happens then that will happen and then that will happen” and so on). 

If you are facing an actual, imminent survival threat — don’t just sit there, do something! (As mentioned above, this work is about the pursuit of happiness; it is irrelevant to the management of existential threats.) In the encounter with all other types of threats, overcoming the impulsive reaction usually works better. Most of the time it is preferable to generate a strategy, a thought-out action plan, and to refrain from ‘just doing things’. It can be hard to resist the urge to react to a threat and, instead, ‘just sit there’ and think, but it usually pays off.  

2. Once you have identified the specific (potential) threat your mind is reacting to, try to assess the likelihood that it will actually materialize. 

As discussed in the Theory section, by its design as a survival-protecting device, anxiety promotes an all-or-nothing, or binary, view of reality. Attending to the shades of grey between the black-and-white extremes is unaffordable in the face of an immediate survival threat. In contrast, it is an asset when facing all other (i.e., non-survival) threats.

The default response to the perception of a potential threat is to consider it imminent and immediate. The (survival) reflex is to treat potential threats as if they are for certain, a 100% done deal. The effort to correct this automatic overestimation with a rational, reality-based assessment may be considerable, but it is worthwhile. When facing a non-survival threat the overestimation of the likelihood of the threat to materialize makes matters worse not better; it is all cost, no benefit.     

For example, the potential threat posed by exposure to COVID-19 virus: A COVID-19 infection can result in a serious medical illness and may even be lethal. However, a serious medical condition is far from a done deal. Exposure to the virus is not a 100% guarantee of getting sick from it. A significant percentage of those who are exposed to the virus don’t acquire it (i.e., test negative for it). A majority of the people who do test positive for the virus do not develop any illness symptoms at all or experience only mild symptoms. Estimates of the probability of dying from the virus vary (depending on predisposing risk factors) between 0.1 – 0.2% (in the relatively young and healthy) up to about 15% (in the 80 years old and older, and in individuals with serious pre-existing medical problems). So, even for the most vulnerable, the likelihood of surviving the infection is much (more than eight-fold) greater than the likelihood of dying from it. For the young and healthy the mortality risk is mundane. Nonetheless, ruled by anxiety, it is easy to think of the threat posed by COVID-19 virus as an existential threat, which is not even close to a realistic assessment of the risk it poses. 

The same applies to the perception of potential threats that have nothing to do with health. For example, when a company announces “downsizing” plans some of its employees will register the announcement to mean an imminent loss of their job. The threat is inherent to the process but, to any individual employee, it’s not a done deal until it is a done deal. From an employee’s perspective, to manage the situation optimally, one needs to generate a rational estimate of the risk of losing their job. This can be done by considering relevant variables such as past job performance, duration of employment, and need for one’s particular skill set. Such an analysis may not yield a numeric answer — it may conclude with a risk range (e.g., low, medium or high) but any rational analysis is superior to the anxiety driven jump to the conclusion that one’s job is lost before it actually is.

3. List the possible consequences that can transpire if the perceived threat materializes; consider their relative likelihoods and practical ways by which you may exert influence over the process. 

Actual existential threats have two possible outcomes — life or death, black or whit. The outcome of non-survival threats is in the “gray-zone” between the extreme end-points. Under the rule of reflexive anxiety, the mind is attracted to the extreme end-points and tends to overlook the spectrum of possible outcomes that exists between them.

The likelihood of possible outcomes (of an encounter with a non-survival threat) typically exist on a ‘bell-shaped’ distribution curve: Outcomes close to the middle of the spectrum are most likely to materialize and more extreme outcomes are less likely to materialize. Conscious awareness of the ‘bell-shaped curve’ of possible outcomes, or in other words, the ability to list the different possible conclusions to an encounter with a given threat in order of their relative likelihoods, is essential for containing the anxiety a threat can elicit. As mentioned above, this may require effort; it may not be easy to identify and rank the variety of possible outcomes that may ensue following the encounter with a given threat, but the effort well is worth making.  

For example, let’s consider exposure to the COVID-19 virus again. As discussed above, it has a fairly broad spectrum of possible outcomes for any age and risk group: It may have no consequences at all, it may result in testing positive for the virus without experiencing any symptoms, it may result in mild symptoms, moderate symptoms, severe symptoms that may require medical attention, severe symptoms that require intensive care, and severe symptoms that end with death. 

Similarly, non-lethal threats, such as the threat of losing one’s job, may result with a variety of scenarios: It can lead to discovering one’s ‘true calling’ in a completely different field, a better job in the same field, a similar job, a lesser job, an eventual significant economic calamity, and the worse case scenario of permanent unemployment, homelessness and destitution. Any of these ‘outcomes’ is a possible scenario. As a general principle, the first and last scenarios (i.e., the extreme ends of the spectrum) are less likely and the ones closer to the middle have a higher probability to occur, thus producing the bell-shaped curve.

Led by anxiety, the mind is predisposed to focus on the worst-case scenario and ignore possible alternatives and their relative (higher) likelihood of materializing. This reflex is beneficial in survival situations but it makes matters worse in all others. In other words, a deliberate effort to maintain awareness of the range of realistic possible scenarios and their probabilities is required for optimal management of non-existential threats.  

With this awareness it is possible to identify steps that may increase the likelihood of a favorable outcome. In the COVID-19 example steps that promote good general health (such as regular exercise, a healthy diet, a healthy sleep/wake cycle, stress reduction, weight loss and smoking cessation, if relevant) is likely to influence the outcome of exposure to the virus in the desired direction. In the employment threat example, the pending “downsizing” may spark a process of exploring alternative careers, lead to contacting prospective employers, and initiate a discussion with one’s employer to explore opportunities that may exist within the new structure. The idea is to identify common-sensical steps that can actually be implemented and thus increase the likelihood that the outcome that eventually materializes is in the desired range of the spectrum. 

4. Reflect on your self-confidence and hope.

In general, one should aspire to sustain a realistic notion of self-confidence. Neither overconfidence or under-confidence are mindful, and neither support the pursuit of happiness. 

The direct relationship between self-doubt and anxiety — i.e., the greater the self-doubt, the more intense the anxiety, is incontrovertible. The same can be said for the anxiety reducing effect of curtailing unrealistic self-doubts. The mindful aspiration is obviously to be realistic. 

Unrealistic lack of self-confidence is common and problematic (unrealistic overconfidence is less common but no less problematic). Self-doubt usually plays-out as doubting one’s ability to “handle” or “deal with” a perceived threat and its imagined consequences (as in — “I’m not sure I can handle it, or deal with it, if this were to happen”). It raises the question: What does the inability to “handle” or “deal” with something actually mean? Typically, the answer is vague and non-specific. Sometimes it comes down to the fear of not surviving, or somehow ‘ceasing to exist’ as a result of the encounter with the potential threat. Obviously, this complements the reflexive tendency to overestimate perceived threats or inflate them to an existential level. Sometimes the notion of the inability to “handle” or “deal” with an imaginable outcome is linked to the fear of losing one’s mind or ‘going crazy’ as a result of the encounter with the perceived threat. Ultimately, I think that this manifests a deep seeded, subconscious fear of losing one’s dignity. Specifics aside, the self-doubting mind is burdened by the notion that managing the perceived potential threat, in some ways, requires more than one has to offer. 

It is useful to start the process of ridding oneself of this undue burden by scanning the content of one’s thoughts or inner dialogue for evidence of self-doubting statements (once again — generating conscious awareness of an issue is the first step in managing it). These statements typically come in the form of “I don’t know what I will do if…”, “I don’t think I could handle it if….” and “I don’t think I could face it if…” ‘blank’ happens. 

Two approaches can be applied to contain or negate self-doubting statements, and thus reduce their anxiety-amplifying impact. The first is based on one’s personal experience. The second is based broadly, on the human condition. 

Starting with the personal-history option: When you discover self-doubting statements playing in your mind, look for past instances in which you have faced a similar threat or hardship. Recalling a time (or times) in which you encountered a similar situation and survived the experience without losing your mind or your dignity can serve as reference data to negate self-doubt.

I’ll use the previous examples to illustrate this. If the anxiety causing threat is related to COVID-19, it can be useful to recall a time you have dealt with a serious medical problem in your past. It is useful to make the distinction between hating an experience on one hand (which we usually do when it involves being sick) and not being able to “handle” it on the other. Or, when the perceived threat is of a potential loss, it can be useful to recall a past experience of a loss (similar, if such exists) which did not destroy you or result in loss of dignity. It brings to mind Nietzsche’s somewhat overused quote “That which does not kill you, will make you stronger.” In surviving hardship one earns the right to have confidence in surviving a similar hardship moving forward. If you have a reference point in your past that amounts to evidence of your ability to endure hardship, why wouldn’t you use it?

Moving on to the broader angle of reflection: When doubting your ability to “handle” the potential suffering your mind perceives as a threat, it can be useful to reflect on the suffering that ordinary humans have been able to deal with in the past, and sadly, are forced to deal with in the present. Nowhere does the ‘glory of the ordinary’ manifest more clearly than in the ability of regular folks, like you and me, to maintain dignity in the face of suffering, sometimes unimaginable suffering. If other people, who are just like you, have handled serious medical problems and heavy losses, why would you doubt your ability to do the same? (For more on this go to: https://wp.me/P7aKBB-on )

Lastly, there is the all important idea of hope (which I will discuss only briefly here; it will be discussed in greater detail elsewhere). Hope is required for maintenance of mental balance. Without hope it is a mistake to think about the future. 

Contemplating the future when the mind is hopeless is guaranteed to make matters worse in a variety of ways, one of which is worsening anxiety. Upon recognizing that hope is absent from one’s take on reality, it is wise to stop all other mental processes and invest in recovering it. To recover and protect hope one must embrace uncertainty: Where there is uncertainty, there is hope. Conversely, where there is certainty, there is no hope (certainty about the future is almost always an illusion; the few exceptions are paradoxically, universally unattractive: Death, aging, suffering, and — uncertainty(!)). 

The problem inherent to maintaining calm awareness of uncertainty is that, by definition, it is an admission that the future can actually turn out to be worse than what one imagines. The undeniable uncertainty of the future means that not only can it be worse than the present, it can be worse than one’s worst imagination of it! Yet, the true nature of uncertainty also includes the inseparable fact that the future has the potential to turn out to be positive — not only better than the present, but better than that one’s best imagery.   

Anxiety tends to trigger a powerful (at times, insatiable) appetite for the fantasy of certainty — the illusionary notion of a guaranteed positive outcome. Most, if not all of us are familiar with the wish for an assurance, with certainty, that a perceived threat will not materialize. Or, that if it does, one will survive it — that “everything will be fine.” This illusionary assurance, sweet and seductive as it may be, comes at the expense of hope, which makes it, unequivocally, a lousy deal. 

The automatic wish for (the illusion of) certainty tends to intensify as anxiety rises and as it intensifies it increasingly undermines hope. The mindful approach to the conflict around hope is based on seeing reality as it truly is: In situations which, as a matter of fact, there is no uncertainty, there is no hope. Conversely, hope is inextricable from situations that, in fact, have an uncertain outcome. 

Resolving the ‘uncertainty-conflict’ mindfully is not necessarily easy. It often requires a level of fortitude, or mental firmness, which is perhaps what ‘courage’ is. A mantra that protects hope is simply: “You never know”. When the mind attaches to the notion that it knows the future, that the future is a foregone conclusion, repeating this mantra can trigger the correct (and corrective) line of thinking. 

The reminder that “you never know” should lead to a realistic examination of the uncertainty of the situation you are facing. If the outcome is indeed a ‘done deal’ then sustaining hope is irrational. However, if an honest assessment leads to the conclusion that there is uncertainty regarding the outcome of a given situation, the situation allows for hope. Embracing uncertainty means accepting that the future can actually be worse than what you imagine it might be (this is where self-confidence, as discussed above, will be useful). On the other hand, and inseparably, embracing uncertainty also means that the future can actually turn out to be as good as — or better than the best future you can imagine. This recognition amounts to recovering hope. It should also serve as a reminder of one’s influence, and an invitation to exert the right kind of influence that is likely to increase the odds of moving in a favorable direction, which is what being mindful is all about. 

If you are not able to turn on this (or any other) mindfulness practice, at the very least, in the absence of hope, refrain from thinking about the future. If you can’t employ a more sophisticated approach, when hopeless, distract your mind from thinking about the future. Call a friend, read, listen to music (or play music, if you can), workout, even watch something on TV. Almost any distraction, as long as it is not outright destructive, is likely to be better than thinking about the future while hopeless. Since nothing is permanent there’s always a chance that if all that you do is just manage to not make matters worse, things will get better. You never know!   

The Second Protocol 

The second protocol is based on the theoretical conceptualization of anxiety as the consequence of the wish to control something. More specifically: Anxiety is the product of the collision between the wish to control something and the knowledge that it can not be controlled. 

The wish to control is guaranteed to create an inner-conflict because — without exception, control is never an option and (consciously or subconsciously, sooner or later) the mind realizes it. The inner-conflict around control results with loss of inner-peace, which is synonymous with the subjective experience of anxiety. Given the value of inner-peace (both in-and-of itself, and as a prerequisite in the pursuit of happiness) any practice with a potential to protect it is worth serious consideration.   

Before we get to the business at hand, I’d like to touch on a few relevant insights  (that are discussed at some length in the theory section): Control is an all-or-nothing, or a binary, concept. There is no such thing as partial control. So, as a matter of fact, control — i.e., 100% influence, is never an option. It can be aspired to and imagined, but never fully achieved. At the same time, some degree of influence is unavoidable. Each and every interaction involves some degree of influence between the reactants. The level of influence may be infinitesimal but never zero. In other words, both the notion of complete influence (i.e., control) and zero influence (i.e., 100%, complete helplessness) are illusions and should be recognized as such in general and specifically when dealing with anxiety.

And now, back to our protocol: Like the first protocol, this protocol begins with the awareness of one’s anxiety. The following four steps can be useful to contain anxiety as seen from our current point of view, i.e., as resulting from the wish to control:

1. Identify the nature and the details of the ‘control-wish’. 
2. Identify ways in which you can influence that which you wish to control. 
3. Implement your influence. 
4. Examine your levels of self-confidence and hope.

I will elaborate:

1. Bring the ‘control-wish’ into focus: Figure out what it is that your mind is trying to control.

The ‘control-wish’ may be subconscious, but typically it is not deeply hidden in it. Bringing it into conscious awareness is usually well within reach. It can be accomplished by simply asking yourself: “What does my mind demand to control right now?” Sometimes the control-wish can be exposed by asking yourself to imagine what you would wish for if you had a magic-wand that could fulfill any single wish you make (in the context of the anxiety you are dealing with). 

The idea is to bring the ‘control-wish’ into focus such that you can spell out to yourself first — what it is that your mind wishes to control and second — what it would look like if you had that imaginary control.

I’ll stick with the same examples I used above: A COVID-19 related ‘control-wish’ may be centered on the Corona virus itself (the ‘what’), and applied such that one’s self and one’s loved ones would not be infected (the ‘what it would look like’). In other words, the control-wish may be stated as: “I wish I could control this virus so that neither I nor my family members get sick”. 

The employment example ‘control-wish’ may be centered on one’s employer’s mental process (the ‘what it is that I wish I could control’) and applied such that one’s job remains secure (the ‘what things would look like if I had control’). It may be stated as: “I wish I could control my boss’s mind so that she decides to keep me employed”.  

‘Control-wishes’ tend to be like chains made of linked rings. A close examination typically reveals that the wish to control one thing is in the service of the wish to control another, more deeply seeded, thing. The individual links in the chain can be brought into conscious awareness by asking yourself: “On the assumption that controlling this [blank] will make it possible for me to control another thing, what would that ‘other thing’ be?

The ‘control-wish’ around the Corona virus is a fairly short chain: The wish to control the virus is subservient to the wish to control one’s own well being and the well being of the people they love, which, in turn, is subservient to the wish to control the way one ultimately feels — three “rings”. 

Controlling one’s boss’s mind may be subservient to the wish to control one’s job security which, in turn, may be subservient to the wish to control one’s financial situation which, in turn, may be subservient to wish to control the way one is perceived (by friends, relatives, neighbors etc.) which, in turn, may be subservient to the wish to control the way one feels about one’s self — a couple of links longer. 

Each link in the chain represents a point of potential influence. The more links that you can identify in the ‘control chain’ the more points of influence you will have.

The wish to control our own feelings is always one of the links in the chain, typically it’s the last one. The Corona virus example ultimately comes down to the wish to control one’s own feelings so that the fear, despair, sadness and other dreaded feelings that are likely to be precipitated by a serious infection will be avoided. The job example ultimately comes down to the wish to control one’s emotional experience to guarantee that being spared the feelings of failure and destitution and the other awful feelings one can expect to feel in response to financial ruin. 

One last observation before we move to the next step in the protocol: The fact that the wish to control our feelings is integral to the experience of anxiety underscores the immense importance that we automatically attribute to the way we feel. The fact is that we can not control our feelings anymore than we can control anything else. But, we can influence our own emotional process. To an extent, the practice of mindfulness is geared toward honing this influence. 

2. Examine and try to uncover the full range of your influence. When the mind is attached to controlling something (which is unattainable) it tends to overlook ways it can influence it (which is unavoidable). The operating principle here is that when you can’t get the deal you want, it is wise to take the best deal you can get. 

So, once you have a clear idea of the nature of your ‘control-wish’, ask yourself how you might influence that which your mind wishes to control; how can you get some of what you wish you could have gotten. If the ‘control-wish’ is the mind’s demand for a guaranteed arrival at some imaginable destination, the willingness to influence amounts to accepting a movement in that direction. The willingness to influence is the willingness to continue making an effort to move in the desired direction, regardless of the fact that there is no guarantee of the outcome.

Each link in the ‘control chain’ you identified in the previous step is a point of potential influence. Returning to our examples: The wish to control the Corona virus is obviously a non-sequitur. But influencing one’s well-being and the well-being of loved ones is within reach. For example, one can exert influence by keeping precautionary measures. One can offer their loved ones reminders and encouragements to follow the relevant risk reducing behaviors (without attempting to control, which would manifest as nagging and is likely to be annoying and counterproductive). 

Similarly, attempting to control one’s employer’s mind is futile, but influencing it is undoubtedly possible. Influence may be exerted directly, for example, by letting her know that the job is  cherished or by highlighting evidence of one’s productivity. A similar influence may be exerted indirectly, by working harder and increasing one’s productivity. The pattern remains the same as the different “links” in the ‘control-chain’ are followed: The wish to control one’s financial status is similarly futile, but influencing it is not. It may be accomplished by consulting a financial adviser, by reducing one’s spending or by taking on more work and increasing one’s income.   

3. The third step is self explanatory: Do the best you can to implement the influence that you identified within your reach. If your analysis is even partially accurate, you will experience a reduction in the level of your anxiety with each step you take that amounts to increasing your influence (if not, your analysis probably got off target somewhere, and you should start over).

One more thought about that ultimate wish — the wish to control one’s own feelings. As I said above, the practice of mindfulness is a way to cultivate the ability to influence one’s own feelings and thereby contain their impact on the perception of reality and choices of conduct. Meditation (in its various forms, including contemplative exercises e.g., contemplating compassion, hope, gratitude etc.) is at the core of the practice of mindfulness. One of meditation’s primary goals is to improve the practitioner’s ability to exert positive influence over their own emotional state. With growing experience in meditation practitioners sense a progressive ability to influence their feelings, an experience that inherently has an anxiety reducing effect. 

4. Reflect on your self-confidence and your level of hope (as discussed in the previous protoco).

 

The Breathing Exercise 

It is said that meditative-breathing and a panic attack are mutually exclusive: You can experience one or the other, but not both, at the same time. Furthermore, breathing is a remarkably popular and very low-risk endeavor. So even if the following breathing exercise doesn’t turn out to be as effective as advertised, it is still unlikely to set you back considerably, so why not try it?

The exercise presented here couldn’t be simpler: Consider each breath as consisting of three phases: Inhaling (through the nose), holding the air, and exhaling (through the mouth). The drill comes down to counting (mentally) each of the phases to a predetermined number. Typically, the inhaling phase is to the count of four, holding the air is to the count of three, and the exhaling phase is to the count of eight. I doubt that the specific numbers you count to (i.e. 3-4-8) are of particular importance. As long as you are always counting to the same three numbers and breathing comfortably, any three numbers (e.g., 5-5-10) will work just as well. 

What is important is that your breaths are smooth and steady. Your count should be slow enough to allow inhaling deeply, fully inflating your lungs, and exhaling thoroughly, clearing all the air out. Holding the air in your lungs between inhaling and exhaling it should be without stress or struggle. Meditative breathing should be very comfortable. If it isn’t, you need to adjust either your count, its pace, or both. 

Additionally, for this to work as an anti-anxiety measure it is important to rehearse this way of breathing many times in the absence of anxiety so that it can be ‘turned on’ effortlessly and without thinking about it in the face of high anxiety or a panic attack. As you undoubtedly know if you ever had one, a panic attack is not an opportune time to start developing new skills, even one as simple as counting your breathing.

My view of why meditative breathing works to negate anxiety is based on the model of anxiety as the product of the ‘control-wish’. As discussed in the theory section, each of the anxiety disorders identified in clinical practice can be formulated as centering on a specific ‘control-wish’. In panic disorder the ‘control-wish’ tends to center on the viscera, i.e., the internal organs; usually the heart and lungs. Panic attacks are typically linked to the wish to control the functioning of one’s internal organ(s) (a significant percentage of patients experiencing their first panic attack seek emergency care, convinced they are having a heart attack). Breathing in a premeditated way (as described above) is a demonstration (to one’s own brain) of the considerable level of influence they have over the functioning of their thoracic organs (starting with the lungs and usually, after a few breaths, involving the heart). As the anxious mind registers the level of influence demonstrated by the premeditated breathing, its insistence on control tends to ease; in turn, this results with a decrease in the moment’s anxiety level and often a resolution of the panic attack. 

And lastly, while we are on the topic, this breathing exercise has an additional potential benefit as a treatment for insomnia. This should not be a surprise, given the broadly recognized link between anxiety and insomnia. To optimize the insomnia treatment potential of the exercise, keep track of the number of breaths you’ve taken as you simultaneously keep counting the phases of each breath, as discussed above. Following two counters at the same time has the potential to “push” other (anxiety provoking) thoughts off the screen of consciousness which can decrease the mind’s arousal and support the initiation of sleep.