Coping with panic

Updated August 2017

Pride in our care

A member of Cambridge University Health Partners

 Introduction
This manual is designed to help you overcome your panic attacks. It is essential
that you read and work through each of the sections in sequence from start to
finish. Also, when moving onto a new section, it is useful to re-read all of the
preceding sections so that you become very familiar with the material in the
manual.

Overcoming panic attacks requires hard work and perseverance. The more
effort that you put into the task, the more likely it is that you will get better,
which makes all of the effort worthwhile. But this does not mean that you
have to get everything right first time. Setbacks are a normal part of the
process and try to use them to further your understanding.

This manual is designed for you to use on your own or for you to use with the
assistance of a therapist. If you try this on your own and do not make the
progress that you desire, then speak to your GP and ask if you could be put in
touch with a cognitive therapist to guide you through the sections in the
manual.

Contents
Page 3 Section 1 Anxiety and panic

Page 12 Section 2 Thoughts and panic attacks

Page 20 Section 3 Distraction techniques

Page 21 Section 4 Controlled breathing

Page 24 Section 5 Challenging safety behaviours and avoidance

Page 31 Section 6 Final notes

2
Section 1: Anxiety and panic
If you have had some trouble with panic attacks, it is easy to forget that
anxiety, which can range from the mild feelings of being nervous, on edge or
frightened to sheer terror, is a normal – and essential – aspect of human
experience. Although the experience of anxiety is harmless, it is also meant to
be unpleasant in order to draw your attention to danger. If it were not so
unpleasant, we would be less motivated to avoid danger and place ourselves
at far greater risk.

To better understand this, imagine you are standing on the edge of an

unguarded cliff. Most of us would feel a bit anxious staring down a cliff face,
particularly if there were no barriers to prevent us from falling over. It is likely
that the experience of anxiety would motivate many of us to move back from
the edge or take extreme caution if we decided not to move away.

Yet anxiety is more than just our body’s natural alarm system. It also mobilises
our body to respond to the danger, which is known as the fight-or-flight
response. So part of what happens when we get anxious is that our body
automatically adjusts to respond quickly and decisively in the face of a physical
threat. Some of the things that happen are:

• Our mind becomes alert and focussed on the threat.

• Our heart rate speeds up and blood pressure rises, while blood is diverted
to the muscles which tense in order to prepare for action.
• We start to sweat more to maintain our body temperature.
• We start to breathe more rapidly, while our nostrils and air passages in our
lungs open wider to allow air in and out more quickly.
• Our liver releases sugar to provide quick energy.
• Hormones are released, particularly adrenalin.
• Blood clotting ability increases, preparing for possible injury.
• Non-essential processes such as digestion and saliva production slow down,
causing a dry mouth, butterflies in our stomach and, sometimes, nausea.
• Muscles at the opening of anus and bladder are relaxed.
• Pupils dilate causing blurred vision.
• Feeling of pins and needles parts of the body

This fight-or-flight response is very useful in the short term, to help us quickly
respond to immediate physical danger. However, when faced with ongoing
danger over the long term, the response is of less use. Also, the flight-or-flight
response is not at all helpful when the danger does not include some sort of
physical threat.

3
 Being physically primed to respond to a life-threatening danger, for example,
does not help when the danger is that you may feel uncomfortable in social
situations, are having relationship problems or that you may not be able to
pay your mortgage. However, because the fight-or-flight response was useful
in the distant past when humans had to deal with physical dangers all of the
time, this response is still an automatic part of our bodily make-up.

Another problem is that we sometimes interpret harmless events as being

dangerous, which results in unhelpful anxiety. This is exactly what happens
when we experience a panic attack. When we panic, we do so because we
interpret the symptoms of anxiety as being dangerous. For example, a man
who fears that he may have a heart attack could think that his pounding heart
(a normal symptom of anxiety) is the beginning of a heart attack. If he were to
think this, he would understandably become even more anxious and his heart
will beat more rapidly. Panic attacks, as will be explained in much more detail
in the sections that follow, are brought on by the catastrophic interpretation
of the harmless, yet unpleasant symptoms of anxiety.

In summary, it is important to remember that anxiety is a normal, harmless and

essential aspect of living. Anxiety is, however, a problem when it occurs in
situations when there is no real danger. This happens when we interpret
harmless situations as being dangerous and the most extreme example of this
is the panic attack. Fortunately, it is possible to overcome panic attacks. The
steps involved in overcoming panic include understanding exactly what
happens when you do panic, learning to change the catastrophic thoughts
that drive your panic attacks and, as you become more confident, slowly
confronting the situations that have caused you to panic.

This booklet is designed to help you do this.

4
What is a panic attack
How do you know if what you have had is a panic attack? Panic attacks involve
four features:

• During panic attacks people experience intense fear or terror;

• The attack comes on suddenly, often with little warning;
• The very intense feelings tend to pass relatively quickly, often within five
or ten minutes (although it may not feel like it when it happens, and
people usually feel very drained and unsettled for a long time afterwards);
and
• During the panic attack people think that something really awful is about,
or has already started, to happen. Often we think we are having a heart
attack, are about to suffocate, faint, vomit, go crazy, make a fool of
ourselves, or lose control of our bowels or bladder.

Panic attacks are common: approximately one out of every ten people
experiences at least one panic attack in their lives. Some people have ongoing
problems with panic and may require the help of a psychologist, GP or
therapist. This happens because our natural response to panic often makes the
situation worse. Fortunately, with some guidance, people are usually able to
make significant progress in overcoming panic attacks. This process of recovery
starts with understanding exactly what drives the panic cycle.

5
 Symptoms, thoughts and behaviours
In the left column below, you will find a list of the common symptoms,
thoughts and behaviours associated with panic. Now think about your most
recent panic attack and tick the boxes that apply to you. If you experience any
symptoms, thoughts or behaviours that are not listed below, then write them
into the space provided.

Common physical symptoms of panic

A racing heart.

Feeling faint and dizzy

Feeling short of breath.

Feeling sick or nauseous.

Feeling the need to get to a toilet in a hurry.

Experiencing hot flushes.

Experiencing numbness or tingling sensation in your fingertips or toes.

Feeling detached from your environment as if you are not really there, or your
environment is somehow different or strange.
Sweating, particularly on the palms of your hands, in your armpits and /
or on your brow.
Feeling shaky. Feeling of weakness in your legs.

Visual changes.

Any other physical symptoms:

6
Thoughts

I am going to have a heart attack.

I am about to collapse or faint.

I am suffocating / struggling to breathe.

I am about to lose control of my bladder or bowels.

I am going choke to death.

I am not normal, I am going ‘mad’.

I am about to vomit.

I am about to lose control and do something crazy.

I am about to embarrasses myself in front of others.

I have to escape.

Any other frightening thoughts:

Behaviours

An overwhelming need to escape the situation and return to a place of safety.

A desire to avoid the places or situations that I associate with panic attacks.

Sitting down or holding on to something.

Taking someone with you to places or situations associated with panic attacks.

Any other actions to reduce the risk of having a panic attack:

Any behaviours that are employed to prevent the terrifying thoughts that
you ticked above:

7
 Once a person has had one panic attack, he or she is often frightened of
having another one. In fact, after one panic attack people are usually very
sensitive to the normal symptoms of anxiety that we all experience from time
to time and worry that these are signs of another panic attack. This worry
results in greater anxiety that may result in another panic attack. In other
words, people get trapped in a vicious cycle where the fear of panicking may
increase the likelihood of having a panic attack.

In the next section you will be introduced to a model explaining what happens
when we panic that was developed by a British Psychologist, David Clark. His
model is known as the ‘vicious circle model’ of panic. Clark noticed that when
people panic it is because they interpret their physical or mental symptoms of
anxiety in a way that makes them more anxious. In the next section, you will
need to think about a recent panic attack that you have had to better
understand the sequence of events that occurred. The list of symptoms and
thoughts that you completed above will help you map out the sequence of
events that happen when you panic.

The vicious cycle of panic

Let’s begin with an example: Emily is a 25-year-old woman who is troubled
with panic attacks. A year ago she was on a crowded train between
Cambridge and London and felt faint and hot. She felt embarrassed that she
may faint or be ill so she got off the train at the next stop. After this event,
she noticed that she became very anxious in public places. Recently, at a
crowded work seminar, she began to feel anxious and nauseous. She began to
fear that she would faint in front of all her colleagues and had to quickly leave
the room. Emily was sweating, felt dizzy, her heart was pounding and she was
taking short breaths of air. She went to a bathroom and splashed some water
on her face while making sure that she took deep breaths. She is convinced
that had she not left at that time, she would have fainted and caused
catastrophic harm to her career. This type of thing is happening more and
more often to Emily.

Emily’s Panic Attack:

The triggers to Emily’s panic attacks seem to be anything that causes her to
become a bit anxious. In particular, she becomes anxious in social situations
where she cannot easily escape. Other triggers include normal sensations such
as feeling hot that most of us would hardly notice. Also, Emily has not been on
a train since the day she thought that she was going to faint.

As soon as she notices that she is starting to feel uncomfortable, she has the
thought: “What if I faint?” This makes her much more anxious.

8
When Emily starts to get very anxious, she begins to sweat more than usual,
her heart begins to beat much more quickly, she feels slightly nauseous and
has a dry mouth. She also notices that she gets shaky and can’t concentrate on
anything else but her anxiety. Emily feels short of breath and begins to
breathe more rapidly, which always makes her feel worse.

As Emily experiences these symptoms, which she associates with feeling faint,
she becomes convinced that she will faint. As soon as she believes that she is
about to faint, she becomes more anxious and her symptoms of anxiety get
worse, and so on.

At this point in Emily’s example of the panic cycle, she escaped the situation.
She had to breathe deeply and drink some water. Her recovery took around
ten minutes, but she felt very much drained for the rest of the day.
Interestingly, Emily has never fainted. Since then, she has avoided crowded
trains and other places.

The diagram below offers an illustration of Clark’s panic model. Some sort of
event triggers anxiety to begin the vicious circle. The anxiety includes various
physical and mental symptoms. These symptoms are then misinterpreted in a
way that increases anxiety, which of course, makes the physical and mental
symptoms even worse.

Trigger

Anxiety

Catastrophic
misinterpretation of
anxiety symptoms

Symptoms
of Anxiety

9
 Have a look at how Emily’s most recent panic attack is illustrated below:

Emily’s panic cycle

Emily experiences a catastrophic thought, which makes her anxious. She
misinterprets her symptoms of anxiety in a way that confirms her fear, result-
ing in even more anxiety.

Thought: What if I faint

in front of my work
colleagues

Anxiety

Catastrophic
misinterpretation:
Am I going to faint?

Symptoms:

• Sweats
• Racing heart
• Dizzy
• Nausea
• Dry mouth
• Shaky
• Unable to concentrate
• Rapid breathing

10
Your panic cycle
Now, you need to do the same thing for yourself to map out your most recent
or vivid example of a panic attack. Use the diagram below to help understand
exactly why and how the panic attack occurred. You could consult the checklist
on page 5 to help you complete the cycle.

Trigger

Anxiety

Catastrophic
misinterpretation:

Symptoms

Does this make sense to you? Can you see how your thinking may have made
the experience of anxiety worse, resulting in panic?

11
 Section 2: Thoughts and panic
The previous section introduced the role that our thoughts play in causing
panic. These thoughts are the catastrophic misinterpretations that we make
when we think that the harmless, though uncomfortable, symptoms of anxiety
are signs of a much more serious problem. Usually, there is a logical
connection between the most prominent symptoms of anxiety that we
experience and the catastrophic misinterpretations that we may make.
Consider the table below, the left column lists common symptoms of anxiety,
and the right column lists common misinterpretations that people make about
these symptoms.

Catastrophic misinterpretations

Prominent anxiety symptoms Likely catastrophic misinterpretation

Pounding heart, palpitations and chest I am having a heart attack.

pain.

Shortness of breath. I am going to suffocate

Feeling dizzy, unsteady or ‘jelly’ legs. I am about to collapse or faint.

Pins and needles or numbness. I am having a stroke.

Racing thoughts. I am losing my mind

Blurred vision. I am going blind.

Feeling of unreality, lack of I am going mad or I am going to have a

concentration or unusual mental stroke.
sensations.
Sudden urge to go to the toilet. I am going to lose control of my bowels
or bladder.

When our anxiety is triggered we become hyper vigilant to out bodily

sensations and start to focus on them more. However the more you focus on
bodily symptoms the more intense they may start to feel. This feed into your
panic cycle and supports your catastrophic misinterpretations.

12
As you know, the problem with these interpretations is that they lead to
further anxiety. Anyone believing that they are about to have a heart attack,
for example, will become even more anxious, and the symptoms of anxiety
may confirm the thought that they are about to have a heart attack. The same
is true of the other misinterpretations.

It is very important to note that it is the catastrophic misinterpretation driving

the cycle. If you are able to recognise that these often uncomfortable
symptoms of anxiety are harmless, there is nothing to escalate the cycle and
the anxiety does not grow into panic. The question, then, is how do we
challenge these misinterpretations? A good place to start is to consider some
facts about many of these common fears.

The fear of having a heart attack

As we have already noted, some of the symptoms of panic, particularly chest
pain, are similar to those experienced during a heart attack. It is therefore
understandable that a person who is having a panic attack may think that they
are in fact having a heart attack. It is worth remembering that heart disease is
very rare in young women, who also happen to be the group most likely to ex-
perience panic disorder. If you do experience recurrent chest pain, then you
should go and see your doctor as soon as possible. However, if your doctor has
already ruled out any heart problems and you have been told that what you
have experienced is a panic attack, then the next time you feel anxious about
your heart ask yourself, “Did I have a heart attack the last time I felt this
way?” If not, why is there any reason to think that it is different this time?

The fear of going crazy

Often when people have a panic attack they think that they are starting to
lose touch with reality and are going insane. This thought, naturally, will make
anyone anxious and so the cycle goes on. It is worth noting the difference
between panic and severe mental illness. Panic attacks and other anxiety
problems are very common and typically occur in the context of normal human
experience while severe mental illnesses such as schizophrenia or bipolar
disorder are rare. Panic attacks do not cause either of these mental illnesses.
People with panic are no more likely than anyone else to develop a severe
mental illness.

13
 The fear of fainting
It is very common for people to think that they are about to faint when they
have a panic attack. When people faint they do so because their blood
pressure is too low and not enough oxygen is getting to the brain. The most
obvious consequence of fainting is that you fall over. Once we are lying down
your heart is at the same level as the brain and no longer has to pump blood
uphill. Also, your muscles relax releasing blood for your brain. As a result, your
blood pressure quickly increases and you soon recover. Fainting is another way
your body protects you from harm.

Now, think about what happens during a panic attack: as soon as we become
anxious our hearts beat much faster than usual and our blood pressure
increases. This is exactly the opposite of what happens when we faint. It is very
common to think that you may faint while panicking, but this does not
happen.

There is one exception to this rule, which happens to people who have what
we call a blood-injury phobia. These are people who have an extreme fear of
blood, injuries, needles and surgery. Most people are frightened of these
things, but the phobia involves a much more extreme fear than usual. People
with this type of phobia react differently to others when they encounter their
fear in that their blood pressure drops. This probably occurs because if your
blood pressure drops, you would bleed less and are more likely survive if you
have been severely injured. There is a specific technique called applied tension
that increases blood pressure and that can be taught to people who have this
type of phobia. However, unless you have this rare problem (and you would
know it if you did), remind yourself that you are less likely to faint while
panicking than you are at any other time.

The fear of losing control

For some people the catastrophic fear is that they will lose control when they
become very anxious. Often by this people mean that they will run around
wildly, hurting themselves or others in the process while shouting obscenities.
According to the NHS National electronic Library of Mental Health, there
never has been a documented case of anybody doing anything ‘out of control’
in this way while experiencing a panic attack. If you have been worried that
you may lose control, then it may be helpful to ask yourself, "Did I really do
something completely out of control the last time I had a panic attack?"

14
The fear of suffocating
One of the most common symptoms of anxiety is to breathe rapidly so that
you can get more oxygen for your muscles to prepare to fight or to run away
from the danger as part of our fight-or-flight response. However, breathing
too quickly, while not harmful, can worsen the symptoms of panic, such as
feeling faint, tingling sensations, dizziness and being out of breath. In fact, for
many people, the worst symptoms of panic are a result of their breathing. This
happens because the rapid breathing changes the Oxygen (O2) and Carbon
Dioxide (CO2) levels in our blood. We inhale oxygen and exhale carbon
dioxide. The balance is upset when we breathe too quickly than what is
required by our bodies and we have too much oxygen in our bloodstreams. A
good way to restore this balance is to breathe in a controlled way which will
be explained in the next section.

People who worry about suffocating sometimes worry about being in small
rooms, or hot rooms, or rooms without ventilation, because they fear that
they will not get enough air. This fear may trigger a panic attack. My office,
which is probably a typical sized office for the NHS, is 6m long by 4m wide and
the ceiling is 2.5m high. This means that the volume of air is around 60 000
litres. This is more air than anybody would need to survive for many hours if
the room was sealed shut and airtight. The reality is that rooms that we
encounter in everyday life are not airtight. Test this by asking a friend to spray
some air freshener around the edge of a closed door to see if the smell of the
freshener leaks through. This will reveal that the air supply is in fact limitless –
air flows in and out through the narrow smallest gaps more quickly than we
need. Also, the temperature of the room makes no difference to how much
oxygen is available to us – warm air is still just as rich in oxygen. Opening
windows to let in the air may make us feel better, but this not necessary for us
to breathe.

The fear of losing control of bowels or bladder

Another common fear is that we will lose control of our bowels or bladder
while panicking. The feelings are common, yet in our clinical experience
nobody has reported ever actually losing control of their bowels – not unless
they have an awful stomach bug. The question to ask yourself, again, is if it
did not happen last time, why think that it will happen this time?

The fear of vomiting

Similarly, the fear of vomiting is often implicated in panic attacks, yet very few
people ever claim to have vomited during a panic attack. We may feel bilious
when anxious, but that does not mean that we will vomit. Think about how
often you have felt bilious without vomiting. These are only some of the
common misinterpretations that we make when we panic, not all of them. The
section below will help you challenge these and any other thoughts that turn
normal anxiety into panic.
15
 The panic diary
In this section, you will be introduced to the Panic Diary. This is an excellent
way of collecting important information to help you challenge the thoughts
that turn ordinary anxiety into a panic attack.

Try to complete the panic diary after every panic attack. To start with, only
complete the first four columns. When you feel panicky, make a note of the
situation in the second column. Then list your symptoms of anxiety in the third
column before writing down the frightening thoughts in the fourth column.
Let’s do a quick example using Emily’s example of a recent panic attack:

Situation: Emily is attending a work seminar, when she notices that she feels
anxious.

Anxiety symptoms: Emily becomes sweaty, her heart races, she feels dizzy, she
feels nauseous, she has a dry mouth, she feels shaky, she is unable to focus on
anything else except how she feels, and she breathes rapidly.

Catastrophic misinterpretation: Emily believes that she is about to vomit in

front of all her colleagues. She expects that this would do irreparable harm to
her career. Using the diary, Emily could fill in the columns as follows:

The panic diary

Date Situation Anxiety Catastrophic Alternative

symptoms Misinterpretation response

25 Feb At work, Sweaty, I am going to

attending a Racing heart, vomit in front of all
crowded Dizzy, my colleagues.
seminar. Nausea,
Dry mouth,
Shaky,
Unable to
concentrate,
Rapid breathing.

16
Finding an alternative response to the catastrophic thought
The techniques described on the previous page will help you understand why
you panicked. Now you need to make a habit of generating an Alternative
Response to your catastrophic misinterpretations whenever you panic and to
write the response down in the final column of your panic diary. There are
many ways in which you can challenge these catastrophic misinterpretations
and generate a healthy, alternative response. To begin with, it is useful to
question the evidence for specific misinterpretations. Ask yourself:

I have had many previous panic attacks, so why has my worst fear not already
occurred?

Is there any reason to think that it will be any different this time?

Challenging the thoughts that cause anxiety is something that should be done
for as long as it takes to undermine the catastrophic misinterpretation
implicated in your panic attacks. As a practice exercise, think about Emily’s
situation: What could you say to her to undermine her catastrophic belief?

17
 In fact, another way to challenge your own thoughts is to ask yourself: What
would a close friend say to comfort me while I was having a panic attack?

Or, what would I say to a friend who described a panic attack to me?

If you know that you have anxiety, but still fear the catastrophic
misinterpretation, then you may want to ask yourself how anxiety causes the
catastrophe? (The catastrophe is the terrifying event that we think is going to
happen to us when we panic.) For example, how does being anxious cause me
to vomit, have a heart attack, faint etc?

18
 Date Situation Anxiety Catastrophic Response
symptoms Misinterpretation

When you feel panicky, make a note of the situation in the second column. Then list
your symptoms of anxiety in the third column before writing down the frightening
thoughts in the fourth column. The final column is there for you to write down a
helpful response to the catastrophic misinterpretation. It is useful to make a note of
the date and time of day in the first column.
19
 Section 3: Distraction techniques
A good method to reduce panic symptoms is to employ distraction techniques.
These techniques serve to reduce self-focus and anxiety. Instead of focusing
on your uncomfortable bodily symptoms you can for example turn your
attention to:

• What is going on around you?

• What you can see.
• What you can hear.
• What you can smell.
• Who is around you?

There are many types of distraction techniques, for example, thinking of a

holiday; imagine the sand between your toes, the sun on your skin and the
sound of the sea. Or you could picture your favourite place wherever that
might be.

Distraction techniques work because they break the panic cycle of thinking
and bodily sensations. These distraction techniques must be employed for at
least 3-4 minutes for them to be effective.

20
Section 4: Controlled breathing
Breathing exercise
Now, sit down in a comfortable chair and imagine that you are blowing up a
large inflatable mattress. Breathe in and out quickly, making sure that you
blow hard to fill the mattress. To start with, try to do this for 10 seconds, then
15 seconds and so on until you can hyperventilate for 30 to 45 seconds. This
will make you feel very uncomfortable. If you are not able or willing to do this
on your own, then it should be attempted with the help of a psychologist. Use
the list below to right down the sensations you experience when you breathe
much more rapidly than usual:

1..................................................................................................................................

2..................................................................................................................................

3..................................................................................................................................

4..................................................................................................................................

5..................................................................................................................................

What, if anything, do you make of this? Could some of the symptoms that you
have experienced during a panic attack be caused by the way you breathe?

....................................................................................................................................

....................................................................................................................................

....................................................................................................................................

The reality is that people often breathe faster or harder when they are very
anxious and hyperventilate. Hyperventilation plays an important role in most
panic attacks and controlled breathing is one way to counteract the symptoms
of incorrect breathing.

21
 You already know that there is a delicate balance between Oxygen and
Carbon Dioxide in our bloodstreams. Subtle changes to how quickly we
breathe can offset this balance and result in unpleasant symptoms including:

• Tingling face, hands or limbs;

• Muscle tremors or cramps;
• Dizziness and visual problems;
• Difficulty breathing;
• Exhaustion and feelings of fatigue; and
• Chest and stomach pains.

You can easily learn to correct over-breathing, which involves learning to

breathe gently and evenly. Controlled breathing may not be the answer for
everyone, but we will only know if you practice this two or three minutes as
often as you can, but at least three or four times a day.

22
Controlled breathing
Either sit upright or lie down on your back. If possible, breathe through your
nose in a gentle, steady rhythm. Your breathing should not be jerky and try
not or gulp or gasp.

• Place one hand on your chest and one on your stomach.

• As you breathe in through your nose, allow your stomach to swell. This will
mean that you are using your lungs fully. Try to keep the movement in
your upper chest to a minimum and keep the movement gentle. It is
helpful to imagine that you have four lungs: two in your chest and two in
your stomach area. Imagine the ‘lungs’ in your stomach filling up with air.
• Slowly and evenly, breathe out through your nose. Now imagine the
‘lungs’ in your stomach area deflating.
• Repeat this to establish a gentle rhythm. You are aiming to take eight to
twelve breaths a minute. This means that it should take around five to
seven seconds for each cycle where you breathe in and out again. But
don’t worry too much about the timing – you will find a comfortable
rhythm that is right for you.
• Try to relax your mind too. If possible, shut your eyes and concentrate on
pleasant, peaceful thoughts. Feel the tensions ease in your body.

Remember to practice this often. The more you practice, the more you will be
aware when you are not breathing correctly and able to correct this when you
need to.

Remember: even if you didn’t control your breathing nothing dangerous will
happen.

23
 Section 5: Challenging safety behaviours and
avoidance
It is a normal response to protect yourself when you feel that something bad
may happen. Safety behaviours are those things (and they can be just about
anything) that you do to prevent the catastrophe (the catastrophic thought
that we think is going to happen to us when we panic), while avoidance
behaviours are those things that you avoid to prevent the catastrophe.
Imagine a man who believes that he will faint while panicking (which is what
drives his frequent panic attacks). This person struggles to do his shopping
because he is frightened that he may faint in the supermarket. So, if he will
only go to the supermarket after a few pints of beer because the alcohol
makes him less anxious, then this is what we call a safety behaviour. And it
would be seen as a particularly problematic type of safety behaviour!

On the other hand, if the person refuses to go to the supermarket at all, then
this is something known as an avoidance behaviour. Usually we employ both
types of behaviours to protect ourselves. However, we are often more aware
of the avoidance behaviours than we are of the safety behaviours.

Sometimes the avoidance is extreme and the person is unable to leave what
they consider to be their ‘zones of safety’, usually the person’s home. Other
people have a very fixed routine from home to work and back again from
which they cannot deviate. These are examples of something that
psychologists call Agoraphobia, a condition that sometimes occurs as a result
of panic attacks. However, not everybody who has panic attacks will be
agoraphobic.

In panic disorder, because the danger is not real, these safety and avoidance
behaviours only make things worse. They prevent you from knowing that the
catastrophic misinterpretation is not true. Also, your brain responds to what
you do. So if you tell yourself that there is no real danger, but continue behave
as if there is a danger, your brain will cause you to be anxious. You have to
show your brain that the danger is not real by behaving as if the danger were
not real.

By employing safety and avoidance behaviours you are telling yourself that
you cannot really cope in anxiety provoking situations without them. This
undermines your confidence and is likely to make you more anxious.

24
So, to summarise, safety behaviours and avoidance are the strategies we use to
‘prevent’ our catastrophic misinterpretations from happening. Yet when we
do this, we deny ourselves the opportunity to learn that the catastrophic
misinterpretation will not happen.

Also, safety behaviours can make things worse. The best way to explain this is
by using an example: Jim, a 48-year-old builder, has a history of panic attacks.
During his panic attacks, he believes that he is having a heart attack. He
interprets his symptoms - usually a pounding heart, short breath and faintness
- as evidence that there is something very wrong with his heart. Frightened
that he may die of a heart attack, Jim avoids strenuous activity.

Because of this, he is less fit than he used to be and finds himself out of breath
after a short walk. When he notices that he is out of breath after very little
physical activity, he thinks that there must be something wrong with his heart.
His avoidance behaviour has directly impacted on his symptoms of anxiety.

The diagram below describes a typical panic cycle, including the role that
safety behaviours and avoidance have in maintaining people’s problems with
panic attacks.

Trigger

Anxiety

Catastrophic
misinterpretation of
anxiety symptoms

Symptoms
of anxiety

Safety /
avoidance
behaviours
25
 In Jim’s case, note how his avoidance of strenuous exercise makes his
symptoms worse and reinforces his belief that there is something wrong with
his heart. Because he is less fit, he is more easily breathless, which Jim assumes
is a sign that he is about to have a heart attack.

It should be clear that part of what you need to do to overcome panic attacks
is to confront the situations that you avoid. You need to do this without the
safety behaviours. Learning to give up these safety and avoidance behaviours
is probably the most important aspect of your therapy, but also one of the
more difficult. So proceed slowly. To start with, make a list of your safety
behaviours before listing the situations that you avoid.

Examples of Common Safety Behaviours

• Only going to places with someone else with whom you feel safe.
• Carrying anti-anxiety medication, such as diazepam, just in case you get
anxious even when you do not often use it.
• Resting frequently to prevent a heart attack.
• Carrying a paper bag with you in case you are sick.
• Carrying a paper bag in case you hyperventilate.
• Holding on to some type of support to prevent yourself from collapsing
when you become anxious.
• Open windows, or breathe deeply, to make sure you get enough air to
prevent suffocation.
• Using alcohol before entering situations that make you anxious.
• Sucking a polo mint in situations that make you anxious.
• Only sitting on an aisle seat at the cinema.

Make a list of your typical safety behaviours:

1..................................................................................................................................

2..................................................................................................................................

3..................................................................................................................................

4..................................................................................................................................

5..................................................................................................................................

26
Now, make a list of the places or things that you deliberately avoid in order
not to have a panic attack. Common examples include refusing to go to
particular situations, such as a busy supermarket, crowded restaurant, busy
meeting or cinema.

Situations that I avoid:

1..................................................................................................................................

2..................................................................................................................................

3..................................................................................................................................

4..................................................................................................................................

5..................................................................................................................................

6..................................................................................................................................

Graded exposure
The way to confront the situations that you have avoided is to start with the
situations that make you the least anxious and work up to the situations that
make you more anxious. This is what psychologists call Graded Exposure.

Dropping safety behaviours and confronting situations that you fear will
probably make you anxious. However, you do need to experience the anxiety
without the help of your safety behaviours to eliminate any lingering belief
that your catastrophic misinterpretation may actually happen.

Also, by staying in the situation for long enough so that your anxiety starts to
come down, you are showing your brain that it need not make you anxious
when you are in these situations. This is known as Desensitisation.

It is important that you are able to rate the intensity of your anxiety. Use a
scale of 0 to 100: a rating of 100 refers to the worst anxiety that you have ever
experienced while 0 is a state where you do not feel any anxiety whatsoever.
Have a look at how Emily ranked the situations that she would usually avoid:

27
 Rank Situation Anxiety rating
0 - 100
1 Presenting a seminar to boss and clients 95

2 Riding on a train to London 90

3 Attending weekly business meetings 85

4 Shopping at Tesco / Sainsbury’s 55

5 Going out for dinner 45

Now, using the list of situations that you avoid that you completed on the pre-
vious page, rate each of these situations according to how anxious you expect
you would be if you were in the situation and complete the table below.

Rank Situation Anxiety rating

0 - 100

You may need to adjust the list as you start confronting the situations. For
example, Emily found that shopping at the supermarket is worse on a
Saturday when it is very busy, while it is much easier during the week.

The important thing is to make progress, however slowly. If you cannot

tolerate a situation, then try again as soon as possible or attempt something
slightly easier.

28
When you do confront the situations that make you anxious, it may be helpful
to think of a coping statement that you can tell yourself as you get panicky.
For example, people find it helpful to remind themselves that the anxiety will
pass:

“This is just a panic attack. It will pass and I will feel better. When it does pass,
I will feel much more confident in dealing with these situations in the future.”

Also, remember to control your breathing when you confront the situations
that you have avoided. Controlled breathing prevents the symptoms of anxiety
from becoming any more severe than is necessary and is also a distraction from
the catastrophic thoughts that you have when you panic.

As you become more and more confident that panic attacks are harmless, it
will become easier to drop your safety behaviours as well as confront the
situations that you have been avoiding.

Using the table on the following page, list your situations that you prefer to
avoid and rate how anxious you expect to be in the second column. Start with
those that make you the least anxious and work towards those that make you
the most anxious. Then confront each situation, preferably without any safety
behaviours, and record how anxious you are at the start of the exposure
session. Stay in the situation, if you can, until your anxiety has come down to
at most 20 or 30 on your scale.

29
 Situation Expected anxiety Anxiety rating at Anxiety rating at
0 - 100 the start the end
0 - 100 0 - 100

30
Section 6: Final notes
By now, you will have learned the main strategies for overcoming panic
attacks. Complete recovery requires perseverance; so don’t be disappointed if
this takes some time. You will feel better as you become more confident that
panic attacks are harmless. With this growing confidence, you will notice that
your panic attacks occur less frequently and with less intensity. You should also
be able to approach situations that you have avoided with increasing
confidence. However, setbacks are a normal part of the gradual process of
recovery.

Setbacks
Expect setbacks. These are part of the process of getting better. Do not be
disillusioned if you experience a setback. Use the sections in your manual to
understand exactly what happened and how to turn the disappointment into
a helpful learning experience.

Medication
Your GP may have prescribed medication to treat your panic attacks. These
work in a number of ways, either by making you less anxious (some of the
anti-depressant / anti-anxiety medication work well to make us less anxious,
while the minor tranquilisers are used to reduce anxiety) or by suppressing the
physical symptoms of anxiety (the beta-blockers restrict the physical symptoms
of anxiety). Sometimes you will be told to take the medication when you feel
anxious, while others need to be taken everyday at around the same time each
day. Occasionally these medicines have side effects, but these usually pass in
time. If you have any problems with your medication, then discuss these with
your GP as soon as possible.

If after completing this self-help programme you still suspect that your ability
to cope is due to the medication and not because you feel that you have
overcome your panic attacks, then you should discuss this with your GP, who
will advise you accordingly. Medication can become a type of safety behaviour
that prevents you from realising that you are able to cope without any special
help. However, you should not make any changes involving your medication
without at least telling your doctor.

Physical exercise
A recent study suggests that exercise can reduce the symptoms of panic.
Researchers at the Cognitive Behavioural Therapies Centre in Newcastle found
that even a single bout of exercise can have benefits for people who
experience panic attacks. Once again, speak to your GP, psychologist or nurse
before attempting this, particularly if it has been a long time since you last
exercised.

31
 In fact, exercise is a useful antidote to stress that also serves to enhance our
sense of wellbeing. Thus, regular exercise may make you less vulnerable to
future episodes of panic.

Final task
As a final task, it is very useful if you write up everything that you have
learned so far. Give some thought to any difficulties that you anticipate. Keep
your written work with this manual and refer back to it from time to time.
Remember, your self-help should not stop when you reach the end of this
manual; you will need to continue confronting feared situations and
identifying and eliminating safety behaviours for as long as is necessary.

Good luck!

32
Further help
Psychological Wellbeing Service
If you are registered with a GP in Peterborough, Cambridgeshire, Wansford or
Oundle, you can access the Psychological Wellbeing Service via self-referral or
through your GP. Call 0300 300 0055. Lines are open from 9am to 5pm,
Monday to Friday, excluding Bank Holidays. it offers a range of support to help
you make changes in your life to improve your wellbeing and to help you cope
with stress, anxiety and depression. This includes self-help reading materials,
guided self-help (both over the telephone and face-to-face), one-to-one
therapies.

First Response Service

If you or a loved one is in mental health crisis, you can call our 24-hour First
Response Service on 111 (option 2). This service is for anyone, of any age,
living in Cambridgeshire and Peterborough. Specially-trained mental health
staff will speak to you and discuss with you your mental health care needs

Rethink
https://rethink.org/diagnosis-treatment/conditions/anxiety-disorders/types

Urgent Care Cambridgeshire

Dial 111

NHS Choices
www.nhs.uk/Conditions/Panic-disorder/Pages/Introduction.aspx

Leaflet updated August 2017

Leaflet review date: August 2018

Patient Advice and Liaison Service (PALS)

If you have any concerns about any of CPFT's services, or would like more information
please contact: Patient Advice and Liaison Service (PALS) on freephone 0800 376 0775
or e-mail [email protected]

Out-of-hours’ service for CPFT service users

Contact Lifeline on 0808 808 2121

7pm-11pm
365 days a year

en Elizabeth House, Fulbourn Hospital, Cambridge CB21 5EF.

q 01223 219400
c 01480 398501

ïïïKÅéÑíKåÜëKìâ