PMS and nocturnal panic attacks.

October 4, 2019 10:01 AM

I'm 39 and, as per a doctor, moving into peri-menopause. The last few days of my cycle, I'm getting pretty terrible middle-of-the-night panic attacks. Any advice on how to cope with this?

I've been prone to nocturnal panic attacks on and off since I was a teenager. After a particularly bad bout (understatement) in 2016, I've mostly had them under control, with a few flare-ups here and there.

During one of the flare-ups in 2017, it became clear that I was consistently having nocturnal panic attacks on (approximately) days 24-28 of my cycle. After consulting a doctor, she said I was probably moving into peri-menopause and should expect more anxiety near the end of my cycle. I worked with my psychiatrist to increase my Lexapro the last week of the month, and also followed the doctor's advice of eating cleanly and exercising more during that week. By and large, this has staved them off.

Unfortunately, for the last 3 or 4 months, the Lexapro and good habits have stopped working. Exercise can definitely make them less intense, but they're still happening like clockwork on those last few days of the cycle. Benzos definitely help; I've been taking anywhere from 0.125 mg (I have a REALLY good pill cutter) to 0.5 mg of Ativan when necessary. I don't think my psychiatrist is concerned about this, but I have an appointment with him on 10/29 to discuss.

My questions are:

1) Besides using Ativan or similar, do my fellow hormonal anxiety sufferers have any tips for decreasing the probability of these kind of attacks at the end of my menstrual cycle? I eat quite well, exercise regularly, and use a SAD lamp this time of year, so all of those bases are covered.

2) Even if I have to live with the panic, perhaps I can improve my emotional/cognitive reaction to them. I find these kind of attacks more frightening than non-hormonal ones (e.g. panic in response to external stressors) because of some vague notion that my hormones are out of control and menopause will just bring even MORE discomfort, and this is going to be my life for the next decade or whatever. Like there's some sinister chemical storm brewing in my body that's completely out of my control and unpredictable and maybe it will cause even more extreme panic than I'm used to. So, any advice to combat these kind of thoughts would be very welcome.

posted by leftover_scrabble_rack to Health & Fitness (13 answers total)

I think the key here is taking a cognitive-behavioral approach, rather than a medication approach (I am a clinical psychologist and researcher -- I have treated many many patients with CBT for panic). As you note, panic attacks are an unpleasant cycle where a real physical sensation (once you are oversensitized to physical sensations, even very normal fluctuations in physiological arousal can kick off this cycle) are followed by anxious thoughts which drive up physiological arousal and then you're off to the races. The key is to use exposure therapy (e.g., deliberately evoking the physical sensations you are afraid of, in a gradual way) and cognitive restructuring (e.g., challenging catastrophic thoughts like "this is going to be my life for the next decade") to break the cycle. Benzodiazepines are actually not considered first-line treatments for panic and in fact contribute to the cognitive errors around panic because patients begin to feel that they NEED the medication to survive the uncomfortable physical feelings.

A self-help book that is available and walks you through a very simple, very well-tested treatment protocol is called Mastery of Your Anxiety and Panic. Best of luck -- you can conquer this!
posted by Bebo at 10:11 AM on October 4, 2019 [3 favorites]

I have two suggestions -- as a former panic attack sufferer.

I cannot recommend Sharon Salzberg's Real Happiness: The Power of Meditation highly enough. After 3-4 weeks my anxiety levels plummeted. I notice that I do have to continue to meditate daily or on alternate days to keep the effects, but I've been listening to the same 4 tracks from this book for going on 3 years and they haven't let me down yet.

I also really enjoyed (from a practical perspective) Dr. Clare Weekes' Hope and Help for your Nerves. This is an older book, but I've read SO MUCH about anxiety, meditation and depression... and I find this one to be one of the most readable and helpful for very practical and sustained change. It helped me specifically to become "friends" with discomfort and panic, and to calmly lean into the panic instead of trying to calm myself enough to stop it.

I've been prescribed Ativan on and off for anxiety, and I can honestly say that I haven't needed it in over a year, and that now meditation works faster and more effectively then Benzos. YOU GOT THIS! GOOD LUCK!!!
posted by Dressed to Kill at 10:20 AM on October 4, 2019 [2 favorites]

Best answer: The thing about this kind of panic is that it's not actually mental. CBT is great and I've worked on it a lot and it's helped a lot for my day-to-day anxiety/panic stuff over the years, but it does not, in my experience, do a lot for the fact that sometimes your nervous system is just on a hair trigger because hormones. I was able to largely divorce the attacks from my thought processes... but still felt like garbage and woke up in the middle of the night with heart palpitations over nothing. Ativan does fix the root of that problem, if only temporarily, but I think it is useful to think about taking it on a prophylactic basis for this kind of thing--small doses before bed on the couple nights that it is most likely to be a problem, not waiting to try to make it stop a panic attack already in progress. A beta blocker may also help for this and be better for routine use like that, but I wind up doing a combination of both at this point, a couple days a month.

I'm not saying don't look into the therapy, it's great stuff for a lot of things and very supportive! But if you're still regular enough to be able to predict this, it's like cramps--taking something after they've started is less effective than taking it beforehand. It now feels less like my brain is totally out of control and more like it's a finicky gadget that I need to occasionally thump just right to keep it running. I would not personally consider taking benzos consistently over long periods of time, but that doesn't mean I have to wait until I feel terrible.
posted by Sequence at 10:27 AM on October 4, 2019 [8 favorites]

Best answer: OK so disclaimer: I believe in therapy and have had therapists for basically 30 years now, but I am also 100% on team Fuck This Shit: Better Living Through Chemistry.


You have a lot of options. You can talk to your GYN or GP and stop your periods altogether. You can stop being adverseto .125 to .5mg of Ativan and just go with that -- addiction is not going to happen at that dose taken four days a month. You can see if HRT helps. You may need to substantially increase your Lexapro -- I don't know what dose you're on but 20mg during the Lutal phase is the baseline for this. Alternatively you can talk to your shrink about switching to Sertraline, which is the front-line drug for this bullshit.

If you get relief from meditation, that's great, but I just want you to know that there is ZERO shame in managing a life-impacting medical issue with drugs. This is not all in your head.

Also, if you're a Reddit user, feel free to come join us on r/TrollXMenopause!
posted by DarlingBri at 10:34 AM on October 4, 2019 [8 favorites]

Response by poster: Thanks for the advice so far. Just to clarify: I've been in therapy for 10+ years, and I have very effectively used CBT to manage catastrophic thought around panic at other times of the month. Sequence's description of "nervous system on a hair trigger" pretty much nails what I'm experiencing for 4-5 days a month. All my usual coping mechanisms fly out the window.
posted by leftover_scrabble_rack at 10:45 AM on October 4, 2019

If your periods have gotten heavier, it might be worth getting your iron/ferritin checked. I was having a lot of issues with anxiety tied to my cycle when my iron levels were in the basement. Bringing them back up to a normal level reduced my anxiety attacks to nearly zero.

Relevant info: Heavy Metal: Iron and the Brain
posted by burntflowers at 11:10 AM on October 4, 2019 [1 favorite]

Best answer: I'll just chime in once more and say that the exposure the physical sensations is key -- you need to train your BODY that these feelings aren't harmful. CBT isn't just about thoughts (although cognitive restructuring is great!). But I'm more of a "little c, big b" CBT person, and for panic those exposures (fancy term is interoceptive exposures) are so important for really trusting that these feelings are okay. You need to have practice riding out those physical feelings and learning that they subside on their own.

Again, I hope you are able to get some relief.
posted by Bebo at 11:21 AM on October 4, 2019

Chiming in to say I also had this (tho not tied to my cycle) and it turns out it was sleep apnea. Just another data point, in case that's helpful. I would wake up mid-attack.
posted by Ink-stained wretch at 11:29 AM on October 4, 2019

Best answer: Panic attacks that come on in your sleep are adrenal misfires, you are free to pursue any chemical treatment that works. I am also in peri, with all the goddamn nighttime biological freakouts, and I get some overall relief (from the sweats, the leg cramps, the weird dreams/dread-wakes, plain old insomnia, etc) taking magnesium in the evenings (it can make you poop, so give yourself some leeway between dose and lights-out so you don't have to get back up half an hour later).

I think this is disruptive enough to talk to your doctor about hormonal support. I know this whole decision is complicated and fraught, and they're likely to take the broad-brush approach of putting you on the pill or mini-pill and that may not be what you want, but it's worth asking specifically about what your options are there and whether it's something you might only use part of the month.

But as far as managing the distress resulting from the panic attacks, it's so hard to do when you're IN the panic attack. There probably are CBT-type exercises very specific to this sort of "I am having an Event, it will pass" but it will take practice to get good at them in the middle of the endocrine monster mash, so don't write them off if they don't feel effective the first few times you try them.
posted by Lyn Never at 11:29 AM on October 4, 2019 [3 favorites]

Tdlr: 200mg of a Magnesium supplement and a spoonful of peanutbutter before bed .

Oh hey this kind of was me for the last couple of months (my beloved dog, who would sleep in my room every night, died recently and I would wake up with panic attacks several times a night). Cue weeks of getting shit sleep.

Coworker, who is going though peri-menopause, was recommended magnesium supplements by a doctor to help with sleep. Peanut butter was recommended by a friend whose bloodsugar would drop in the middle of the night and would wake up panicky.

Seriously, after trying those two things I can actually sleep through the night!

I am also on Lexapro
posted by littlesq at 3:02 PM on October 4, 2019 [4 favorites]

Apologies if this is off-track, but at the onset of menopause I started getting uncontrollable "twitchy legs" at night which prevent me from getting to sleep. 600mg Magnesium supplement didn't seem to do anything but when I added 100-200mg of Gabapentin about 2-3 hours before bedtime, they abated. I'm not sure if twitchy legs and panic attacks are triggered by the same mechanisms but I figured it would be worth suggesting.
posted by matildaben at 3:56 PM on October 4, 2019

I have this too! I'm perimenopausal as well. I don't have anxiety problems otherwise (I mean, no more than a normal stressed out person living in the hellscape of 2019) and this whole thing has just thrown me for a loop. Migraines have been involved as well, and none of my doctors so far have been able to offer any certainty about what's going on in my head.

My doctor prescribed a beta blocker (propanalol) to take as needed and I can't really figure out if it helps because it doesn't make the issue go away completely but I will say that I haven't had a total compete midnight freakout since I started taking one of those when I started to feel a bit off (I can often tell it's going to be one of those nights even before going to bed--I just feel...funny). But I've also started taking magnesium and I will say that since I've started that I have not had any more serious migraines (I started on the mag after two horrible weeks of migraine and migraine fallout) and not had any more major awful episodes, though I still experience mild issues that cause occasional sleep disruptions (I just got my period today and last night was not great but I did manage 5 hours of sleep which is better than the maybe 2 I'd get when these episodes were at their worst).
posted by soren_lorensen at 5:10 PM on October 4, 2019

Response by poster: Quick update: my psychiatrist is upping my Lexapro for the last week of my menstrual cycle, and is also comfortable with me taking some Ativan as needed. He'd like me to keep it under 3 mg per month, which is well more than I've been taking to cope with this. He also suggested that I talk to a gynecologist, since there's only so much expertise he has regarding perimenopause. I plan to do that in the next few months.
posted by leftover_scrabble_rack at 2:36 PM on November 8, 2019