Stress, Anxiety and Panic Attacks

Anxiety is a feeling of unease, worry, fear, or dread and it can range in intensity and severity. We all experience anxiety from time to time, however, when it becomes persistent and strong enough to interfere with daily activities it is diagnosed as an Anxiety Disorder, and at its most severe, as a Panic Disorder. Left untreated, anxiety can negatively affect mental and physical health, reduce quality of life, productivity, and ability to function; and impact the sufferer and society at large.

The way you breathe is one part of this picture that you can work with directly. Anxiety is shaped by many factors – psychological, emotional, physical, and lifestyle – but learning to calm your breathing can help many people feel more settled, respond differently to the physical sensations of anxiety, and better manage panic attacks, alongside appropriate professional support.

Later we will share 10 general guidelines and 4 breathing exercises for panic attacks, anxiety attacks, and general anxiety. First, however, we will take a deeper look at Anxiety Disorders, panic attacks, the stress response, and how the breath is an important influence on all 3.

TYPES OF ANXIETY

Anxiety Disorders affect all races, genders, and age categories and are one of the most common mental health disorders affecting nearly 30% of the population at some point in their lives. Anxiety Disorders cause physical and psychological discomfort and symptoms such as nervousness, tension, fear, avoidance, restlessness, irritability, fatigue, disturbed sleep, memory problems, muscle tension, rapid heartbeat, poor focus, and panic attacks.

There are 5 major types of Anxiety Disorders and they include: Generalized Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), Post-Traumatic Stress Disorder (PTSD), Social Anxiety Disorder (SAD), and Panic Disorder (PD).

PANIC DISORDER & PANIC ATTACKS

The Diagnostic and Statistical Manual of Mental Health Disorders (DSM) defines panic attacks as: “an abrupt surge of intense fear or discomfort”. These episodes typically occur without any real danger or apparent cause, come on suddenly, and are incredibly scary.

Panic attacks can happen to people without a Panic Disorder or other type of Anxiety Disorder, however, when a person experiences recurrent episodes, a persistent fear of a potential recurrence, and there are no other medical causes of the attack, they are diagnosed with Panic Disorder.

Most panic attacks peak within just a few minutes and subside within 5 to 20 minutes. They are accompanied by symptoms such as a pounding heart, rapid heart rate, trembling, feelings of choking or suffocation, sweating, breathlessness, chest pain, nausea, dizziness, light-headedness, chills or heat sensations, numbness, tingling sensations, or fainting. There may also be derealization (feelings of unreality) or depersonalization (being detached from oneself), fear of losing control or ‘going crazy,’ and fear of dying.

ANXIETY ATTACKS

The symptoms of anxiety attacks are similar to panic attacks but not as intense. In contrast to Panic Disorder, anxiety attacks are not a documented mental illness and there is usually a clearly identifiable trigger. Also, unlike panic attacks which happen abruptly, anxiety attacks typically build up gradually over time and follow a period of excessive worry.

SUBCLINICAL ANXIETY

You can suffer from anxiety’s negative consequences and not have a diagnosable disorder. One 3-year study of Generalized Anxiety Disorder (GAD) in the general population found that 11.4% of people were dealing with a ‘subthreshold’ Anxiety Disorder.

This means that their anxiety was not severe enough to be clinically diagnosed, but it was a constant factor in their lives. By the time these patients were reassessed at the end of the trial, the condition had progressed to a full-blown Anxiety Disorder in 13.8% of those with anxiety. Wherever your anxiety lies on the spectrum, working with your breath is one practical tool that can help you manage it.

ANXIETY & STRESS

Anxiety and stress often get confused as the same thing and while the symptoms can be similar, stress is a reaction to an outside trigger, whereas anxiety is a person’s specific reaction to stress; which means its origin is internal.

While the causes differ, both anxiety and stress trigger the same response in the body. More specifically, they activate the Sympathetic Nervous System (SNS), which is a branch of the Autonomic Nervous System (ANS). The other branch of the ANS is the Parasympathetic Nervous System (PNS), and both operate unconsciously and automatically without our control.

Throughout human evolution, we have relied on the immediate bodily responses of the SNS whenever we were confronted with danger. Known as the ‘fight or flight’ response, the automatic reactions of the SNS result in certain physical reactions, including an increase in blood pressure and rate of breathing, and a release of adrenaline to help us run faster or fight harder. In our evolutionary past, the SNS was typically only activated for short periods of time in response to fleeting danger e.g. a predator attack.

However, modern-day living subjects us to unprecedented stressors which are much more insidious and enduring. On top of worrying about finances, relationships, and work, many of us have to cope with traffic, crowded communities, and a jam-packed schedule. Technology compounds this stress by keeping us constantly ‘online’, on the lookout for the next message or task, and preventing us from fully shutting off and resting. 

Our body’s Autonomic Nervous System has sophisticated mechanisms to deal with moments of stress and danger. But it would be an evolutionary miracle if these autonomic processes had developed fast enough to manage the constant influx of stressors we experience today, when only a few hundred years ago these things simply didn’t exist.

As a result, many of us have our ‘fight or flight’ button jammed permanently in the ‘on’ position. This prevents the Parasympathetic Nervous System (PNS) from activating, and we need the PNS to rest, digest, repair, and rejuvenate. 

Living under chronic stress creates emotional and physical exhaustion. Once we’re in this depleted state, the effects of stress become compounded, and our ability to cope becomes depleted. This can lead to several mental health problems including Anxiety Disorders such as Generalized Anxiety Disorder and Panic Disorder.

UNTREATED ANXIETY CONSEQUENCES

If you’ve ever experienced anxiety, you’ll know that it can have an extremely debilitating effect on your quality of life. It’s damaging to physical health too. Whether you have a diagnosable Anxiety Disorder or not, if you regularly experience anxiety, your body is being impacted by chronic stress. Chronic stress compromises the immune system and makes you more prone to infections, respiratory illnesses, and autoimmune diseases.

It also increases inflammation, and chronic inflammation contributes to many chronic diseases. Anxiety is additionally linked with a greater risk of several mental health disorders including Bipolar Disorder, Depression, and Substance Abuse Disorder. 

The effects of a Panic Disorder are even more profound than anxiety on its own. When you’re constantly on the brink of a panic attack, it becomes incredibly difficult to function, socially, at work, and at home. Patients with Panic Disorder have much higher lifetime rates of cardiovascular, respiratory, and gastrointestinal disorders; major depressive disorder; and suicide. Addressing dysfunctional breathing patterns, as part of a broader approach to care, may help ease symptoms of anxiety and Panic Disorder and improve quality of life.

RELATED & CO-OCCURING HEALTH CONDITIONS

Anxiety frequently occurs alongside other health conditions. For example, people with Sleep Apnea are more likely to have an Anxiety Disorder than those without. Chronic Obstructive Pulmonary Disease (COPD) is also frequently co-occurring, and one meta-analysis showed 40% of COPD patients had clinical anxiety. In another paper, scientists reported that 45% of people with Bipolar Disorder suffer from anxiety.

THE LINK BETWEEN STRESS, OVERBREATHING, ANXIETY, AND PANIC ATTACKS

Chronic stress and anxiety affect the body in many ways, and one that is often overlooked is the way we breathe. Breathing is influenced by many inputs – brainstem rhythm, chemical feedback, metabolic demand, movement, and emotion and behaviour – so it is no surprise that emotional states change breathing patterns. Increased breathing is a perfectly normal response to temporary stress or anxiety as a rise in heart rate and breathing rate are necessary to prepare the body to fight or flee. But when stress is sustained over the long term, breathing may not have an opportunity to settle, and for some people this leads to a habit of chronic hyperventilation (overbreathing).

It’s important to understand what hyperventilation is because it’s not quite what most of us think. Chronic hyperventilation happens subtly, without a single paper bag in sight, and much of it is habitual – we’re breathing more air than the body needs on an ongoing basis. Research has found links between hyperventilation, anxiety, and panic attacks. To understand how the breath can feed into these states, it helps to understand the effects of breathing on carbon dioxide (CO2) levels in the blood.

When a person breathes too rapidly from their upper chest it leads to hyperventilation and a greater volume of air being taken in than the body requires. This, in turn, causes levels of CO2 in the blood to lower. CO2 is not just a waste gas.

Lower CO2 causes blood vessels in the brain to narrow, reducing blood flow to the brain, and CO2 also plays a part in helping oxygen to be released from the blood to the tissues (known as the Bohr effect). These changes may contribute to the light-headedness, tingling, and difficulty thinking clearly that many people experience when they are stressed or anxious.

Overbreathing can also produce unsettling sensations such as chest tightness, dizziness, and a feeling of not getting enough air. Breathlessness is not one single sensation – it can include air hunger (“I need more air”), a sense of effort, and chest tightness – and emotion strongly influences how unpleasant and threatening these sensations feel. Studies show that in people who are susceptible to panic attacks, feelings of suffocation can provoke a very strong fear response, leading to more air hunger, more hyperventilation, and further panic.

Compounding this snowball effect is the fact that emotions such as fear cause an increase in adrenaline and noradrenaline, and adrenergic stimulation has been shown to increase breathing. Research has also found that many people with Anxiety Disorders, particularly Panic Disorder, respond more strongly to CO2 than people without anxiety, although not everyone with anxiety shows this pattern.

The result can be a self-reinforcing cycle: fast, upper-chest breathing produces uncomfortable body sensations, those sensations are interpreted as threatening, fear increases, and increased fear leads to more overbreathing. CO2 chemoreception is one important part of this cycle, but it works together with emotion, attention, past experience, and breathing habits.

Research has also shown that people with Panic Disorder often react with fear, air hunger, and hyperventilation when exposed to raised levels of CO2. These findings are really interesting. They suggest that breathing, and how we respond to respiratory sensations, are an important part of susceptibility to anxiety and panic attacks – alongside psychological and other factors.

And this means there is something practical you can do that may achieve tangible results and allow you to feel more in control. This will feed back to your brain, and the feeling of control can lessen the psychological aspects of the problem – creating a positive feedback loop this time.

Worth noting here is that frequent sighing has been observed as part of the irregular breathing seen in people with Panic Disorder, and habitual sighing can help keep overbreathing going. Few healthcare professionals would pay much attention to the habit of sighing every few minutes, but to anyone trained in the Buteyko Method, it is an important sign of dysfunctional breathing. In our experience, reducing habitual sighing is an essential part of addressing dysfunctional breathing patterns.

CONVENTIONAL TREATMENT VS THE BUTEYKO METHOD

Current conventional treatments for anxiety and Panic Disorder include prescription drugs and psychological interventions such as Cognitive Behavioral Therapy (CBT). Noteworthy is that when scientists compared cognitive therapy to breath retraining in people with Panic Disorder, they found both had similar positive outcomes.

In the breath retraining group, raising low CO2 levels was one of the factors linked to improvement – suggesting breathing can be a useful, complementary part of care. Breathing exercises are not a replacement for medication or therapy, and you should not change any prescribed treatment without speaking to your doctor.

BUTEYKO BREATHING FOR ANXIETY

Evidence shows that people who are prone to anxiety and panic attacks tend to have dysfunctional breathing patterns, the most common of which is overbreathing. Research also shows that different emotions are associated with different forms of breathing, and changing how we breathe can change how we feel.

When it comes to anxiety, panic attacks, and depression, gentle reduced breathing exercises, which help you become comfortable with a light air hunger, are at the heart of the Buteyko approach. Before outlining how to do these exercises, it’s helpful to first understand what breathing patterns fuel the SNS stress and anxiety response, and what breathing patterns fuel the PNS rest and relaxation response:

SNS STRESS ACTIVATION BREATHING:

• Fast breathing
• Frequent sighing
• Breathing from the upper chest
• Breathing through the mouth
• Breathing in a more noticeable or louder way
• Erratic breathing

If you suffer with panic attacks or anxiety, chances are, you already breathe in the ways described above. This type of breathing becomes even more pronounced in moments of high anxiety or panic creating a negative, self-perpetuating cycle.

PNS RELAXATION BREATHING:

• Slow breathing
• Breathing from the tummy (as opposed to the upper chest)
• Suppressing sighs (if possible)
• Breathing through the nose
• Quiet breathing
• Gentle, light, and calm breathing

10 BUTEYKO GUIDELINES FOR REDUCING ANXIETY & PANIC ATTACKS:

1. SWITCH TO NASAL BREATHING

If you have a tendency to breathe through your mouth (and most of us do without even realizing it), it’s important that you retrain yourself to breathe through your nose and keep your mouth closed. If your nose is blocked, use the nose-unblocking exercise to clear it. Mouth taping at night will ensure to keep your mouth shut while you’re sleeping. You can also use MyoTape during the day if you have downtime at home. It’s additionally beneficial, to practice gentle walking daily while breathing through your nose with your mouth closed.

2. BUILD A TOLERABLE AIR HUNGER

The first thing we do with clients who come to the clinic with panic attacks is work on building a tolerance to light air hunger. We do this with gentle breathing exercises that create a slight, comfortable need for air (see below section ‘4 Buteyko Breathing Exercises for Panic Attacks & Anxiety’). With practice, many people find the sensation of air hunger becomes more familiar and less threatening. This change may involve how the sensation is perceived, changes in breathing habits, less anxiety about breathing sensations, and possibly changes in chemical sensitivity – most likely a combination of these.

3. REDUCE BREATHING VOLUME

The technique of observing and slowing down the breath has been shown to calm the mind and improve resilience in stressful situations. While many breathing techniques aim to slow down breathing, the Buteyko Method is the only breathing exercise to our knowledge that also intentionally reduces breathing volume in order to create a tolerable need for air. 

In essence, the idea is similar to gradual exposure – reducing breathing to create a light air hunger gives you a very small, controlled experience of some of the sensations that accompany anxiety. Over time, this can lessen the fear response to those sensations and help you feel less overwhelmed by them during a panic attack. The long-term goal is for calm, light breathing to become your normal resting pattern. Some people notice a difference quite quickly, while for others change is more gradual – responses vary, and consistent, gentle practice matters most.

Ideally, you will spend a cumulative 60 minutes per day practicing reduced breathing exercises. It’s also recommended that you work on reducing your breathing from the moment you wake up in the morning. For example, while lying in bed for a few minutes, reduce your breathing and create a slight air hunger. While driving to work, reduce your breathing by relaxing your chest and tummy and ensuring that your chest remains still. And while doing daily tasks such as showering, reduce your breathing by holding your breath after the exhale until you feel a tolerable hunger for air.

4. STOP BREATHING LOUDLY & SIGHING

Breathing loudly and sighing both fuel overbreathing. As such, it’s important that you ensure that your breathing is quiet 24/7 and that you stop sighing if you have a tendency to do so. If you notice a sigh is on the way, swallow or hold your breath. If a sigh slips out, compensate by exhaling through your nose and holding your breath for 5 to 10 seconds after the exhalation – this helps settle your breathing again.

5. EXTEND YOUR EXHALES

Aim to make your out-breath approximately 1.5 times longer than your in-breath in your everyday life. This way of breathing activates the PNS and research shows that a longer exhale is helpful for reducing anxiety, as well as physical and mental stress.

6. BREATHE INTO YOUR DIAPHRAGM

When things are stressful, we’re often told to ‘take a deep breath’. Ironically, contrary to everything you might think, this can be exactly the wrong thing to do. This is because many people equate taking a deep breath with taking a giant gulp of air into their upper chest and this leads to overbreathing and perpetuates hyperventilation. Breathing lightly, slowly, and deeply into the diaphragm on the other hand, has been shown to help induce a state of calm, reduce anxiety and its symptoms, and ease negative emotions such as depression and anger.

7. USE BREATHING EXERCISES FOR ANXIETY ATTACK & PANIC ATTACKS

In addition to addressing hyperventilation (overbreathing) over the long term, it is also very important to learn to control breathing during the early stages of an attack. A central feature of a panic attack is that the symptoms are cyclical, feeding back in on themselves and perpetuating the attack.

This is why it’s vital to address your breathing at the first sign of an anxiety or panic attack. If you notice symptoms coming on, practice either the ‘Many Small Breath Holds,’ ‘Cupped Hand Rescue Breath,’ or ‘Breathe Slow & Deep Breath’ immediately (exercises are outlined below).

8. PRACTICE MIND & BODY AWARENESS

Watch your thoughts and observe the antics of your mind. Pay attention to what is going through your mind and determine how your thoughts create your mood and how your mood creates your thoughts. Watch out for repetitive thought processes, especially the recurrent thoughts that take so much of your time, reach no conclusion, create anger, tension, and anxiety, and drain you of energy.

It’s also important to relax your body. If your tummy or chest are tense, encourage them to relax through mental commentary. Keep your breathing calm at all times and keep your chest still while breathing. When faced with confrontation, bring your attention immediately to your inner body. If you need to challenge somebody, wait until your anger has passed and approach the individual while keeping most of your attention on your inner body.

9. IMPROVE YOUR CONTROL PAUSE (CP)

Your Control Pause (CP) measures how long you can comfortably hold your breath after a normal exhalation before you feel the first clear urge to breathe. It is influenced by several factors, including chemical sensitivity, breathing pattern, how you perceive respiratory sensations, lung volume, and your psychological state. The CP is a practical feedback tool, not a diagnostic test. As your CP gradually improves, it indicates that you are responding differently to air hunger, and many people notice this as calmer breathing during rest, sleep, and exercise, and feeling better able to handle stress.

10. TRACK YOUR PROGRESS

You can measure your progress by using your CP score. Compare your CP with your own previous scores rather than aiming for a set number – a gradual rise over the weeks is a good sign. If your CP is not improving, pay more attention to your breathing during the day or do more of the gentle breathing exercises outlined below.

Always measure your CP gently: stop at the first clear urge to breathe and avoid pushing through discomfort, as a strong air hunger can bring on sensations similar to the start of a panic attack. You can also tell whether your breathing pattern is becoming healthier just by the way you feel. Signs include calmer, quieter breathing, fewer sighs, better sleep, and feeling more settled, energetic, and focused.

4 BUTEYKO BREATHING EXERCISES FOR PANIC ATTACKS & ANXIETY

Below are 4 breathing exercises that can help you calm your breathing and feel more in control of anxiety and panic. Exercises #1-3 can be used at the first signs of anxiety or panic to help settle your breathing before symptoms escalate. Exercises #2-4 can be used when you are not on the verge of a panic attack to improve your CP and help lower anxiety levels in general.

EXERCISE #1: CUPPED HAND RESCUE BREATH

Do this exercise immediately if you’re feeling symptoms of panic coming on. Cupping your hands over your face allows you to rebreathe a little of the CO2 you exhale, which can help counter the drop in CO2 that comes with overbreathing, while the soft, slow rhythm helps calm your breathing and your mind.

This exercise works on a similar principle to the old brown paper bag routine but it’s much safer, as fresh air continues to enter between your fingers so your oxygen levels are maintained. It is suitable for everyone, except those with serious health concerns or those in the first trimester of pregnancy.

Instructions

• You can do this exercise lying down on your back or sitting up straight.
• Cup your hands over your face. Make sure there are no big gaps between your fingers.
• Take a short, soft inhale and exhale through your nose.
• Breathe in softly through your nose and allow a calm, gentle, prolonged breath out.
• Don’t hold your breath or restrict your breathing. Just gently soften your breathing.
• You can time your breathing to breathe in for 3 seconds and out for 3 seconds.
• As you breathe in, imagine your lower ribs gently moving outwards.
• As you breathe out, feel your lower ribs gently moving inwards.
• Continue to breathe into your cupped hands for 2 minutes.

You should not feel any air hunger during this exercise. If your breathing rhythm becomes fast or chaotic, or you experience a need for air, take a rest for around 30 seconds and start again.

EXERCISE #2: MANY SMALL BREATH HOLDS

Do this exercise frequently throughout the day to keep your breathing calm, and also when you experience the first symptoms of stress, anxiety, or a panic attack. Don’t wait until the symptoms worsen, as getting your breath under control will be a lot more difficult. If you wake up during the night with attacks, then sit up in bed and do this exercise. It is gentle, suits everybody, and many people find it helps to ease their symptoms. The main objective of this exercise is to keep your breathing calm.

Instructions

• Breathe in, breathe out, and hold your exhale for 2 to 5 seconds. Do not attempt to hold your breath for longer than this, as this will only increase your breathing and possibly aggravate your symptoms. Your maximum breath hold should be no greater than half your Control Pause. For example, if your Control Pause is 4 seconds, then do small breath holds for only 2 seconds.
• After each breath hold, breathe normally for 10 to 15 seconds. Don’t interfere with your breathing.
• Continue to do a small breath hold followed by normal breathing for 10 to 15 seconds until your symptoms have passed.
• You can repeat this exercise hundreds of times per day and into the night.

EXERCISE #3: BREATHE SLOW AND DEEP

The objective of this exercise is to help alleviate air hunger and feelings of suffocation, by slowing down your breathing with lateral expansion and contraction of the lower ribs. You can use this exercise at the first signs of a panic attack and you can also practice it regularly to lower overall anxiety and stress levels.

Instructions

• Lie flat or sit up straight.
• Breathe into your diaphragm lightly to a count of 3.
• Place your hands on your sides to feel the ribs gently expanding and contracting as you breathe.
• Breathe out lightly to a count of 3 and notice your ribcage contracting.
• Continue this exercise for at least 5 minutes.
• If the feeling of air hunger becomes quite strong, breathe in slowly for 2 to 3 seconds and out slowly for 3 to 4 seconds. If this feels okay, you can slow down your breathing a little more, inhaling for 5 seconds and exhaling for 5 seconds.

EXERCISE #4: BREATH RECOVERY WALK

The objective of this exercise is to add small breath holds to physical exercise. This exercise is not meant to be used at the onset of a panic attack, instead, use it daily to calm your breathing whenever you are feeling anxious or stressed. You can also practice this exercise once per hour if you want to get your breathing under control.

It helps you become comfortable with a gentle air hunger while moving, can help with a stuffy nose, and supports a gradual improvement in your Control Pause and calmer, lighter breathing. Keep the breath holds short and comfortable – they should never create distress. If the air hunger feels too strong or brings on anxiety, stop and return to Exercise #3 instead. Please note, this exercise is not suitable if you are pregnant or have a serious health condition. 

Instructions

• While walking at a normal pace, take a normal breath in through your nose and out through your nose.
• Pinch your nose to hold your breath.
• Walk with your breath held for 5-10 steps.
• Let go of your nose and breathe normally through it.
• Stop walking, rest, and let your breathing settle for about 30 seconds.
• Between the breath holds, breathe low and slow through your nose and avoid interfering with your breathing muscles.
• Repeat the breath hold 5 times making sure you are breathing through your nose at all times.
• Rest in between each repetition and aim to do this exercise 4 times throughout the day.

ADDITIONAL SUPPORTIVE PRACTICES

Alongside a gentle program of breathing exercises, it’s also important to look at lifestyle factors. Getting enough high-quality sleep really helps with your quality of life and your ability to cope with stress. It’s also important to build awareness of physical tension and to slow down your breathing if you notice tension arising. Try to connect to and feel your inner body during many five-minute pockets throughout the day. You can also use the Buteyko breathing belt for assistance with learning diaphragmatic breathing.

Moving your body is additionally important and mindful movement exercises such as walking and yoga are particularly beneficial (try to do these with your mouth shut). Limiting sugar, alcohol, and caffeine, and balancing blood sugar by consuming a wholefoods-based diet and eating small meals spaced out throughout the day is also recommended. Finally, speaking to a therapist or mental health professional is strongly encouraged, as it can help you gain awareness around unhelpful thought patterns and belief systems which fuel anxiety. Breathing work and talking therapies can complement each other well.

GET YOUR COMPLETE BUTEYKO ANXIETY GUIDE

Learn to calm your breathing and support your mind and body with our online course. Discover simple, practical breathing exercises and tools you can use anytime. For additional support, download the ButeykoClinic breathing app for free breathwork coaching and guided meditations.

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CLOSING THOUGHTS

The breathing exercises and techniques outlined above are to be used in conjunction with normal day-to-day treatments, not as a replacement for them. Given the sensitive nature of anxiety and panic attacks, breathing exercises should be introduced very gently. It’s essential to avoid creating too strong of an air shortage during reduced breathing – or even during measurement of the Control Pause – as this could bring about sensations similar to the beginning of a panic attack.

Instead, begin with focusing on switching to nasal breathing and eliminating the habit of sighing. After a few days, when you are comfortable with nasal breathing, begin to incorporate gentle relaxation and the above-reduced breathing exercises. Everyone responds differently, so go at your own pace. 

Finally, if you would like more support with your breathing, we recommend getting the Buteyko Breathing app. This FREE breathing app offers breathwork coaching, exercises, and guided meditations to help support your mind/body health and it has a special section for supporting people with anxiety and Panic Disorder.

*For more help, speak to your medical doctor or find a certified Breathing Instructor. If you are struggling with your mental health, please reach out to your doctor or a mental health professional. If you are in crisis or feel unsafe, contact your local emergency services or a crisis helpline.

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