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Understanding and Breaking Commuter Anxiety Why so many of us panic at the thought of going underground

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Panic attacks on public transport are a common problem – and a particularly debilitating one in a city like London where people’s working lives depend on navigating crowded trains, tubes and buses. L-SL offers several strategies for taming commuter anxiety.

By Sarah Graham

For most of us living and working in London, public transport is a fact of day-to-day life. Daily we tap our Oyster cards on the readers, run for the tube even though there’s another one just two minutes behind, squeeze ourselves into crowded carriages, between strangers silently tapping away on their smartphones or flicking through the Metro, until we reach our stop and emerge again back into daylight.

But, for some Londoners, the thought of using public transport to zip around the city is a daily source of anxiety. A recent study by bcalm, an innovative new company that has developed a discreet inhaler to help calm the symptoms of panic attacks, found that 20% of Londoners they spoke to suffer from infrequent panic attacks, more than 10% are affected at least once a month, and 3% suffer from panic attacks at least once a week. Perhaps unsurprisingly, public transport ranked as by far the most anxiety-inducing aspect of everyday life, with more than 50% of Londoners surveyed saying they thought crowded tubes, trains or buses could trigger them to have a panic attack.

For 23-year-old art consultant Emily, the fear of having a panic attack on public transport has a major impact on her daily life. She suffered an attack while travelling in London with friends as a teenager, and has struggled ever since. “I panic and get so worked up that I just avoid using the tube and all public transport now,” she says. “Particularly after the 7/7 bombings, I’ve found it even harder to get on the tube due to the fear of something happening and getting stuck.”

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Emily describes her panic attacks in vivid terms: “I feel as if I’m going to die, physically it’s like I’m not able to breathe, feeling as if I’m going to be sick; emotionally it feels like I’m losing control or going mad,” she says.

“I often drive, and have to pay a lot for parking and the congestion charge, or I’ll spend money on a cab, to avoid using public transport. If I have to go somewhere on public transport and I can’t cancel, I often have to travel with a close friend or family member. It is really hard for me to think about the future.”

Sophie’s* panic attacks began about six months after she moved to London as a student. Now 31, she recalls that first panic attack very clearly: “I’d been on the underground a million times before, so it wasn’t like it was scary or I didn’t know what to do,” she says. “I was stood on the platform at King’s Cross, waiting for the tube to arrive. I could hear it coming through the tunnel, and then all of a sudden my sight started to go, my hearing started to go, and my heart started racing.”

Her initial reaction was to bolt from the station and, once above ground, call her partner. When she returned to the tube for a second try, the same thing happened. “It didn’t feel as bad because I was expecting it. I remember sitting on the tube, trying to chill out, but feeling like everyone was looking at me,” Sophie says.

Panic attacks are widely believed to be a symptom of anxiety, caused by a psychological response to either a past traumatic experience or a specific phobia. However, bcalm has a slightly different take.

“Our research points clearly to elevated CO2 levels being a primary driver of panic attacks,” says founding director Dr Michael Sinclair, a former Registrar in Psychiatry at the Maudsley Hospital and London University’s Institute of Psychiatry.

“That’s not to say psychological triggers aren’t a major influencer on panic attacks, but we strongly believe they are a response to the physiological trigger,” he adds. “Our CO2 receptors trigger a central nervous system response when our CO2 levels become elevated. Two separate, double blind medical studies in two different countries, done by two different investigators, have demonstrated that carbon dioxide pollution filters [like bcalm] help reduce panic attacks.”

When it comes to public transport, he explains: “There are a number of factors at play, from anxiety associated with crowded and congested spaces to insufficient airflow and ventilation. As well as the obvious problem of increased CO2 from road fumes and the sheer volume of people in a small space, these environments tend to be hot, noisy and uncomfortable, which can make even the least panic-prone individual experience difficulties.”

And as Terence Watts, chair of The Association for Professional Hypnosis and Psychotherapy (APHP), points out, if you had a traumatic childhood experience such as being ill on a crowded bus or in a lift, that may also contribute to a panic response in busy or confined spaces.

As with the possible causes, opinions differ widely as to the best solutions for panic attacks. The NHS typically recommends cognitive behavioural therapy (CBT) and/or medication to treat panic disorder, while charity AnxietyUK recommends therapies including CBT, clinical hypnotherapy, counselling and acupuncture.

AnxietyUK-approved CBT therapist Barbara Salmon says her first step when tackling panic attacks is to reassure her client that they are not harmful, followed by addressing unhelpful thought patterns and helping the client to develop coping strategies, like controlling their breathing. “The less they fear it, the less likely it is that it will happen,” she says. “CBT doesn’t necessarily stop the panic attacks, but it’s about enabling the client to feel they could potentially manage them.”

After Sophie’s panic attacks started, her GP prescribed beta-blockers and referred her to 10 weeks of CBT. “For me personally, that helped quite a lot – when I could feel [the anxiety] building up, I felt like after [CBT] I was strong enough to talk myself out of it. Even though it was still hard being on that public transport and having to deal with those emotions, it stopped it from getting too much,” she says.

A similar approach in hypnotherapy, known as suggestion therapy, “teaches people how to manage the attacks, how to cope with and how to limit them,” Terence explains. “On rare occasions it will stop them happening altogether, but usually this simple form of hypnosis just works to help people cope with it and understand it more – in other words, to remain calm, to breathe steadily. It’s a little bit of a sticking plaster really; it’s a coping mechanism rather than a cure.”

“The other way is to go through regression therapy, to find out what triggered the attacks in the first place,” he adds. “Once they find the root cause and understand it, the associated emotion disappears because the panic is all about the brain trying to stop the client from dealing with a particular situation. I’ve used this method extensively over the last 30 years, and it’s very effective.”

Besides face-to-face therapies and coaching, there are also a number of technological solutions emerging – as in other areas of healthcare – to tackle anxiety and panic attacks. These largely use techniques derived from CBT, meditation or other relaxation practices.

Smartphone app Flowy uses a technique called Breathing Retraining, through a series of puzzle games, “to try and slow your breathing down to a slower rhythm, especially during panic attacks,” explains Toby Green of Playlab London, the developers behind Flowy. “This technique is widely deployed, but normally in pamphlet form. Flowy is the first application to gamify breathing retraining.”

The advantages of tackling panic through mobile gaming are obvious to anyone who’s ever sat idly flicking Angry Birds across their screen during their commute. “The whole world plays games! They really cross every demographic, so it’s a great way to engage with people’s health without taking them out of their comfort zone,” Toby says.

For former anxiety sufferer Charles Linden though, none of the traditional routes worked. “I was chronically flight phobic, I wouldn’t get on the tube, I wouldn’t have got in a taxi, I wouldn’t have gone on a bus – you wouldn’t even have got me in a car most days. I was absolutely horrendously agoraphobic,” he says. Charles’ personal experience led him to develop the Linden Method. He is now an anxiety coach to the stars, and widely regarded as a leading authority on the condition.

“Our take on this is unique. People who regularly have panic attacks are said to have a chronic panic disorder. These responses are systemic, because they come from the system of the emotions within the brain, which – just like the respiratory system or the digestive system – is autonomic and outside of conscious control,” Charles says.

“Once anxiety becomes set in the subconscious, the catalysts can be many but the responses are the same. So if you go down on to the tube and you feel like you’re going to be crushed or killed, you therefore go into fight or flight mode and develop a panic disorder related to that environment. Then you probably won’t go down there again because you’ll go into avoidance mode, and you’ll probably find alternative ways to go to work,” he explains.

Because the anxiety response is automatic, he says: “You can only do what the body expects. You have to remove the anxiety systemically, which is what we do. You put the Linden programme in place, and the physiological, emotional and chemical responses that happen as a result of doing that reset your emotional wellbeing. It’s almost like a brain reboot that sets you back to how you should have been, so that you no longer respond with anxiety.”

Of course, whether you tackle your commuter anxiety through talking therapy, breath strategies, CO2 filters, mobile apps, brain ‘reboot’ programmes or anything else, your progress towards recovery will be unique to you. Check out the Less-Stress London directory for support on your journey.

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* names have been changed