When Panic Attacks

When Panic Attacks

Module 1

Overview of Panic

Introduction 2
Panic and Anxiety 2
Panic Disorder 3
Anxiety Symptoms Worksheet 7
Module Summary 8
About the Modules 9

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 When Panic Attacks

Introduction
Panic attacks can affect any kind of person at any stage of their life. In fact, it is estimated that about 1 in
every 30 people experience panic attacks at some time in their life. Panic attacks occur as a part of many
different anxiety problems. However, in those other anxiety problems (e.g., generalised anxiety, social
anxiety), panic attacks are scary, but they are not the things that you are most worried about. If you have
panic disorder, then often the panic attacks become a major source of the concern and worry.
Ask yourself this, when you feel panicked do you sometimes get afraid that you
are sick or losing your mind? Does it feel as if your heart is racing, or you have
trouble breathing? Or maybe you feel dizzy or faint? You may even feel sweaty or
have flashes of hot or cold sensations. Do the feelings come out of the blue when
you least expect them? Are you worried about when these feelings will happen
again? Do these feelings stop you from doing things that you want to do?
If these descriptions apply to you, and you find you have repeated worries about experiencing a panic attack,
you may have panic disorder. If you are concerned about panic attacks, you may find it helpful to work
through this workbook. You can try this on your own or with the support of a clinician. The modules cover
strategies that research has shown to reduce panic attacks effectively. This module aims to provide
information about panic attacks and panic disorder and describe the types of symptoms common to panic.

Panic and Anxiety

Fear and anxiety are natural, necessary, and harmless emotions. They are experienced by everyone and part
of the experience of being human. In fact, anxiety can even be helpful. Would you feel scared if a dangerous
animal was coming straight at you? Of course, you would! In this case, anxiety and fear about being attacked
by a dangerous animal would help you get out of the way. This is called the fight-or-flight response. It helps
you avoid danger by recognising an immediate threat and making your body take quick action, either by
running away or defending yourself.
However, it can be challenging if you experience the fight-or-flight response when there is no danger present.
In these cases, anxiety can become unhelpful. Anxiety in the absence of danger or threat can make you feel
uncomfortable, especially if it occurs too frequently or is intense.
A panic attack is the same brief, intense episode of fear or uneasiness you might have in response to real
danger. Still, it happens in situations most people would not be afraid about. It is like someone ringing a false
alarm! Let’s have a look at some of the symptoms of a panic attack:

 Skipping, racing or pounding heart  Feeling dizzy, lightheaded, feeling faint

 Sweating  Tingling or numbness in parts of your body
 Trembling or shaking  Hot flushes or chills
 Shortness of breath or difficulty breathing  Feeling things around you are strange, unreal, or
 Choking sensations detached
 Chest pain, pressure or discomfort  Thoughts of losing control or going crazy
 Nausea, stomach problems or sudden diarrhoea  Fear of dying

Many people experience some of these sensations when they feel anxious about something, but a panic
attack is more intense than usual. It includes four or more of the above symptoms and peaks within about
ten minutes. As you can see from the list, many symptoms are like what you might experience if you were
in a truly dangerous situation. A panic attack can be very frightening, and you may want to escape the
situation or seek emergency assistance.

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 When Panic Attacks

It is essential to understand that fear and anxiety are just natural responses. It is a response to physical
feelings in your body, the thoughts that you have, or the situations you are in. It is unrealistic and unhelpful
to take away all your anxiety and fear. Just like getting out of the way of a dangerous animal, anxiety and
fear can help you in genuinely dangerous situations. The focus instead is on reducing the anxiety that does
not help you, which is often when we believe there is danger - despite nothing being there. The goal when
treating panic (and so the goal of these modules) is to understand when anxiety is not fear and learn that
we can cope with our feelings.

PANIC DISORDER
Panic disorder describes the condition where there are repeated, and often unexpected, panic attacks.
Importantly, someone with panic disorder is often afraid of having another attack or worries about the
consequences of their panic attacks. Many people change their behaviour to try to prevent panic attacks.
Some people are affected so much that they try to avoid any place where it might be difficult to get help or
to escape. When this avoidance is severe, it is called agoraphobia.
A typical list of situations someone may want to avoid because of agoraphobia can include:

 Transportation (e.g., driving, planes, buses, boats)  Being in large crowds

 Waiting in lines  Shopping centres
 Elevators  Theatres
 Long distances from homes  Escalators
 Lectures/seminars/auditoriums  Unfamiliar areas

Before we continue:
If your symptoms are very severe or a doctor has not checked them, it is important to have an
assessment conducted by a qualified health professional to ensure that these symptoms are the result of
anxiety and not caused by something else.

FIGHT/FLIGHT RESPONSE
When there is real danger, or when we believe there is danger, our bodies undergo a series
of changes based on the fight or flight response. It helps us to respond to real physical
threats. Three major types of responses occur when our fight/flight response is activated.
These include changes to our physiology (what we notice in our body), behaviour (what we
do), and cognitions (what we think).

Physiology (what we notice in our body)

When we become anxious and afraid, be it in response to a physical threat or in situations where there is
no real danger, our bodies experience several changes. Some of these symptoms have already been
mentioned, such as heart pounding, breathing more quickly, sweaty palms, and light-headedness. These
are common reactions that occur when we become anxious.
Think about some of your own physical responses when you become anxious - what do you notice?

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 When Panic Attacks

You might think you are alone in reacting this way, but we all experience these types of reactions when we
experience fear and anxiety. Our bodies are designed to release certain chemicals when we believe a threat
exists, in case we need to either run away or stand and be ready to fight. There are important reasons why
these reactions occur.
 An increase in heart rate and strength of heartbeat enables blood and oxygen to be pumped around
the body faster, so you might feel like your heart is ‘pounding’.
 An increase in the rate and depth of breathing allows more oxygen into the body. You may start to
sigh, yawn, or notice breathlessness, choking or smothering feelings, tightness or pain in the chest. This
response also reduces the blood supply to the head, and while this is not dangerous, you might feel
dizziness, light-headedness, blurred vision, confusion, feelings of unreality, and hot flushes.
 A redistribution of blood from areas that aren’t as vital to those that are, such as away from the skin,
fingers and toes towards large vital organs. Your skin might look pale or you might feel cold, or there
might be a feeling of numbness and tingling in your fingers and toes.
 An increase in sweating causes the body to become more slippery, making it harder for a predator to
grab, while also cooling the body, preventing it from overheating.
 Widening of the pupils of the eyes lets in more light and enables you to better scan the environment
for danger. You may notice blurred vision, spots before the eyes, or just a sense that the light is too
bright.
 Decreased activity of the digestive system allows more energy to be diverted to fight/flight systems. A
decrease in salivation may leave you with a dry mouth and decreased activity in the digestive system
may lead to feelings of nausea or a heavy stomach.
 Muscle tension in preparation for fight/flight results in subjective feelings of tension, sometimes
resulting in aches and pains, and trembling and shaking. The whole physical process often leaves the
individual feeling quite exhausted.
As you can see, these physical responses are important when facing danger, but they can also occur when
there is no danger.
Cognitions (what we think)
Several thinking responses or cognitive changes are associated with anxiety and panic.
Firstly, as a normal part of the fight/flight response, our attention shifts to our surroundings and
looks for potential threats. This is a helpful response in physically dangerous situations but not
so helpful in other situations. Concentrating and attending to your ongoing activities becomes
difficult as you are scanning your environment for danger. When there are no external signs of
danger, you may start to scan internally for evidence of threat, focusing on physical sensations
such as a pounding heart or sweating. This often results in people thinking that there is
something wrong with them , e.g., that they are losing control, going crazy, or dying.
Secondly, some types of thoughts are often associated with panic disorder:
1. Catastrophic thoughts about normal or anxious physical sensations (e.g., “My heart skipped a beat - I
must be having a heart attack!”)
2. Over-estimating the chance that they will have a panic attack (e.g., “I’ll definitely have a panic attack if I
catch the bus to work”)
3. Over-estimating the cost of having a panic attack: thinking that the consequences of a panic attack will
be very serious or negative (e.g., “If someone sees me having a panic attack, they will think I am drunk
and judge me.”).
4. Under-estimating their ability to cope (e.g., “I won’t be able to handle it. It’ll be too overwhelming.”)

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 When Panic Attacks

When you become anxious, what kinds of thoughts do you have?

Behaviour (what we do)

When we feel anxious or expect to feel anxious, we often act in some way to control our anxiety. One way
you may do this is by keeping away from situations where you might have panic attacks. This is called
avoidance, and might include:
• Situations where you’ve had panic attacks in the past
• Situations from which it is difficult to escape or where it might be difficult to get help, such as public
transport, shopping centres, driving in peak hour traffic, places where medical help is not available
• Situations or activities which might result in similar sensations, such as physical activity, drinking coffee,
having sex, emotional activities such as watching horror movies or getting angry

What kinds of situations/activities do you avoid so as not to have a panic attack?

A second action response may be to behave differently, or to use subtle avoidance behaviours called
“safety behaviours” to make yourself feel better or try to stop a panic attack from occurring. There are no
limits to strategies people try to feel better, for example you may:
• Distract yourself from anxiety (e.g., by playing loud music, keeping as busy as possible, talking to
someone, reading something intently).
• Plan an escape route ‘just in case’ or stay in a particular location of the room (e.g., leaning against a
wall or holding onto a handrail).
• Carry particular objects to make yourself feel better (e.g., food or drink, empty or full medication
bottles, religious symbols, mobiles)
• Stay around particular people (e.g., friends or family that we ask for help).

How do you behave differently as a result of your panic attacks?

These action responses may have been used so often that they have become a familiar way of life to you,
habits that you don’t think about. Although these habits can feel good initially, they can keep the anxiety
around in the long term. More often than not, we might feel like these ‘tricks of the trade’ are helping to
reduce our anxiety and prevent a panic attack. But they just stop us from learning that our fears are less
likely to happen than we think and less catastrophic when they happen. Suppose a situation goes well or
we do not have a panic attack. In that case, we attribute the success to our avoidance or safety behaviour,
rather than learning that the situation itself is safe and we can cope with our anxiety.

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 When Panic Attacks

These three types of responses – physical, thoughts, and behaviours - all combine to form the experience of
anxiety and panic. Some reactions may be more noticeable than others may, but they are all important
components and will be addressed throughout the modules.

PANIC DISORDER OR JUST PANIC?

Many people can relate to the experience of feeling extremely anxious or “panicked” in dangerous
situations (e.g., someone driving recklessly near us), or in situations where it feels like there is a lot at stake
(e.g., deadlines approaching for work or study). It can be really useful to think about whether what you are
experiencing is panic disorder or just a lot of anxiety.

Panic Disorder
We’ve briefly discussed that we use the term “panic disorder” when someone has panic attacks that seem
to happen unexpectedly, and when there is significant anxiety about having another panic attack. Unlike
the general feeling of anxiety, when talking about panic disorder, we usually refer to panic attacks that
don’t seem to be in response to dangerous situations. Panic attacks can happen when the person thinks
their internal symptoms signal that something dangerous or terrible will happen, perhaps a heart attack or
losing their mind. We will discuss this in further detail in the next module.

Nocturnal panic
Sometimes, people who have panic disorder have “nocturnal panic”, or panic attacks that occur during the
night when they are sleeping. These panic attacks similarly occur unexpectedly, rather than due to other
prompts such as nightmares or unexpected sounds. This may seem odd, because most people would think
that this is when they are most relaxed. In fact, studies have shown that nocturnal panic often occurs when
the person is falling into a deep sleep, when their bodies are beginning to relax and “let go”.
The brain can detect these changes in physiological sensations because our brains continue
to process information during sleep. For people with panic disorder, these changes may
be interpreted as a signal that something dangerous might happen, such as a heart
attack, resulting in a sense of panic that wakes them from their sleep.

Other Anxiety Disorders

In addition to being prominent in panic disorder, panic attacks can also occur in other anxiety problems.
You’ve probably heard about various phobias mentioned in movies and on television, where people show
an intense fear of things like spiders, elevators, or public speaking. For example, people with social anxiety
may have a panic attack when they must give a presentation to people because of their intense anxiety
about the situation. As with the description of panic attacks earlier in this module, this intense fear occurs
in the absence of actual physical danger. Instead, it occurs in the presence of a perceived threat. Even
though some phobias may seem to be in response to possible physical danger, such as with snakes, or
spiders, the “alarm” occurs even when the person is not directly confronted by the danger (e.g., the spider
is several metres away rather than in front of their face). So, people who are intensely afraid of situations,
objects, or animals may also experience panic attacks.
Now that we have talked a little about panic attacks and when they occur, we can begin to look more
closely at how they happen, how panic disorder develops, and what can be done about it. We will do this in
Module 2. On the next page is a worksheet where you can summarise your symptoms of panic, or if you
found it difficult to think of any, you can use it to track these symptoms over the next few days before you
continue with the modules.

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 When Panic Attacks

Anxiety Symptoms Worksheet

Anxiety symptoms can often be grouped into 3 categories. Some symptoms are of the
physical or body type, for example, shortness of breath, tightness in the chest, light-
headedness, etc. Some symptoms are of the cognitive type which may include thought
responses such as, “I’m going to have a heart attack”, “I’m losing my mind”, etc. The third
category of symptoms is to do with your behaviours or actions, how you act and behave as
a result of your anxiety, for example: avoiding public transport, carrying something to read as a distraction,
not drinking coffee, etc.
Throughout this module, you have been asked about some of your body responses, thought responses and
physical/body responses. You can summarise your responses on this sheet.

PHYSICAL/ BODY COGNITIVE/ THINKING BEHAVIOURAL/ ACTIONS

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Module Summary
• Panic attacks are brief, sudden surges of intense anxiety, with symptoms that are the same
as intense fear.
• The term panic disorder is used when panic attacks seem to happen unexpectedly and where
there is excessive anxiety about panic attacks.
• The fight/flight response is a normal human reaction that occurs in response to fear when a
person is in physical danger. Sometimes it is also activated when there is no real danger. This
includes three major types of reactions:
• Physical responses such as increased heart rate, increased breathing rate, increasing blood flow
towards muscles and important organs, sweating, and muscle tension.
• Thinking responses such as searching for threatening information in anxious situations, which
can also reinforce the belief that you will be negatively evaluated by other people.
• Behaviours such as avoidance of feared situations or changing your behaviour in those
situations.
• Some people with panic disorder may awake from their sleep with a panic attack. Some
people may process physiological changes related to deep sleep, interpreting them as
dangerous, and awake in a panic.
• People who have phobias or other anxiety disorders may also have panic attacks in relation
to the feared situation or object – but they may not have panic disorder.

In the next module we

will look more closely
at how panic attacks
and panic disorder
develop.

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About the Modules

CONTRIBUTORS
Dr Adelln Sng (MPsych1, PhD2) Dr Joel Howell (PhD3) Melissa Burgess (MPsych1)
Senior Clinical Psychologist Clinical Psychologist Clinical Psychologist

Louise Pannekoek (MPsych1) Dr Bruce Campbell (DPsych4, MPsych1)

Clinical Psychologist Consultant Clinical Psychologist

1Master of Psychology (Clinical Psychology) 2Doctor of Philosophy 3Doctor of Philosophy (Clinical Psychology)
4Doctor of Philosophy (Clinical)

Some of the materials in the modules of this information package were taken from:
Nathan, P., Correia, H., & Lim, L. (2004). Panic Stations! Coping with Panic Attacks. Perth: Centre for Clinical
Interventions

BACKGROUND
The concepts and strategies in the modules have been developed from evidence based psychological practice,
primarily Cognitive Behaviour Therapy (CBT).

Craske, M.G., & Barlow, D.H. (2014). Panic disorder and agoraphobia. In D.H. Barlow (Ed.), Clinical Handbook Of
Psychological Disorders, Fifth Edition. New York: Guilford Press.

REFERENCES
These are some of the professional references used to create this module.

Barlow, D.H. (2002). Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic (2nd Edition). London:
Guilford Press

Pompoli, A., Furukawa, T. A., Efthimiou, O., Imai, H., Tajika, A., & Salanti, G. (2018). Dismantling cognitive-behaviour
therapy for panic disorder: a systematic review and component network meta-analysis. Psychological
medicine, 48(12), 1945-1953.

Reddy, Y. J., Sudhir, P. M., Manjula, M., Arumugham, S. S., & Narayanaswamy, J. C. (2020). Clinical practice guidelines
for cognitive-behavioral therapies in anxiety disorders and obsessive-compulsive and related disorders. Indian journal
of psychiatry, 62(Suppl 2), S230.

Stech, E. P., Lim, J., Upton, E. L., & Newby, J. M. (2020). Internet-delivered cognitive behavioral therapy for panic
disorder with or without agoraphobia: a systematic review and meta-analysis. Cognitive Behaviour Therapy, 49(4),
270-293.

“WHEN PANIC ATTACKS”

This module forms part of:

Sng, A., Howell, J., Burgess, M., Pannekoek, L., & Campbell, B. (2023). When Panic Attacks. Perth,
Western Australia: Centre for Clinical Interventions.

ISBN: 978 0 9757995 3 6 Created: February 2023

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