PANIC

ATTACKS
 WHAT IS A
2
PANIC ATTACK
▹ A panic attack is much more
than just strong anxiety or fear.
Panic attacks are basically your
body’s fight-or-flight system
going off unexpectedly.
▹ It is a “false alarm” (Bouton,
Mineka, and Barlow 2001).
▹ During a panic attack, your body
is essentially telling you that you
are in some kind of immediate
danger, even if a threat really
isn’t present.
3 SYMPTOMS
▹ Pounding heart ▹ Feelings of unreality
▹ Sweating or being detached
▹ Trembling or shaking from yourself
▹ Shortness of breath ▹ Fear of losing control
or going crazy
▹ Feeling of choking
▹ Fear of dying
▹ Chest pain
▹ Numbness or tingling
▹ Nausea or abdominal
distress ▹ Chills or hot flashes
▹ Feeling dizzy, unsteady,
lightheaded, or faint
 TRUE, FALSE, LEARNED ALARMS
4
▹ Barlow (1988) regarded panic attacks as
exemplars of the basic emotion of fear.
▹ The initial spontaneous panic attack/false
alarm is believed to occur in individuals who
have a biological vulnerability to such
reactions
▹ This is followed by classical conditioning of
introceptive cues with the original false alarm.
▹ This interoceptive conditioning strengthens
with anxious apprehension over future panic
occurrences leading to“learned alarms.”
 PSYCHOLOGICAL VULNERABILITY
5
▹ This vulnerability involves a poor sense of
control and predictability that are related to
negative events in general and emotions in
particular.
▹ It generally is believed to originate with
developmental experiences.
▹ Because of the anxious apprehension, there
may be an increased self-awareness or somatic
sensitivity in the development of panic
disorder.
 COGNITIVE MODEL OF
CLARK
6
▹ Panic attacks are said to arise from the
catastrophic misinterpretation of certain bodily
sensations (somatic or psychological).
▹ Stimuli that trigger the catastrophic process are
more often internal than external.
▹ It is not a fear of anxiety, but fear of certain
bodily sensations that drives the process.
▹ In such attacks, patients often fail to distinguish
between the triggering body sensation and the
subsequent panic attack and so perceive the
attacks as having no cause and coming ‘out of
the blue’.
7

ANXIETY SENSITIVITY
THEORY
▹ Fear of anxiety-related sensations, arising from
beliefs that these sensations have harmful
consequences
▹ AS is thought to precede and exist independently of
panic attacks, although it is likely amplified by panic
experiences.
 PHYSIOLOGICAL THEORIES
8
▹ SUFFOCATION FALSE ALARM THEORY : Klein
(1993) proposed that “many spontaneous
panics occur when the brain’s suffocation
monitor erroneously signals a lack of useful air,
thereby maladaptively triggering an evolved
suffocation alarm system.
▹ DYSPNEIC FEAR THEORY : Ley (1989, 1992)
states that “fear experienced during a
hyperventilaiory panic attack is a direct
response to the sensation of severe respiratory
distress (dyspnea) in the context of a situation
in which the sufferer believes that she has little
or no control over the conditions that give rise
to the dyspnea”
 9

THE
CYCLE OF
PANIC
ATTACKS
10 PSYCHOEDUCATION
▹ Handouts and self-guided manuals are helpful
▹ As with other anxiety disorders, present CBT
model of symptoms (thoughts, feelings and
behaviors)
▹ Provide explanation for physical symptoms of
panic
▹ Introduces the role of catastrophic thoughts
▹ Addresses the role of “tense and protect” and
avoidance behaviors
▹ Introduces CBT strategies and their rationale
(this is really important as they are counter-
intuitive)
▹ Educates family members in addition to the
patient
 COGNITIVE
11 RESTRUCTURING
Increase awareness of thinking patterns
▹ – Over-estimating the probability of
negative outcomes
▹ – Assuming the consequence will be
unmanageable
Monitor relationship between thinking and
panic episodes
Generate more adaptive thought patterns
▹ – Evaluating evidence for the thought
▹ – Evaluating the cost of the feared outcome
Establish more neutral response to anxiety
symptoms
▹ – Mindful approach to thoughts and feelings
 INTROCEPTIVE
12 EXPOSURE
Test out negative predictions about physical symptoms (fear
extinction learning)
Increasing tolerance to and acceptance of sensations
(habituation)
▹ Headrolling – 30 seconds - dizziness, disorientation
▹ Hyperventilation – 1 minute - produces dizziness
lightheadedness, numbness, tingling, hot flushes, visual
distortion
▹ Running in place– 1-5 minutes - produces
breathlessness, a pounding heart, heavy legs, trembling
▹ Full body tension – 1 minute – produces trembling, heavy
muscles, numbness
▹ Chair spinning – several times around – produces strong
dizziness, disorientation
▹ Staring at bold pattern/mirror– 1 minute – produces
derealization
▹ Walking into steamy room – 5 minutes – suffocation,
dizziness, hot flushes
 IMAGINAL AND IN
13 VIVO EXPOSURE
▹ Provide new opportunities to
examine negative predictions
about feared outcomes
▹ Enhance sense of mastery and
competence
▹ Increase ability to tolerate
physical symptoms in different
contexts
▹ Facilitate generalization of
skills
 IMAGINAL AND IN
14 VIVO EXPOSURE
▹ Create a fear hierarchy with specific targets for
exposure
▹ Use imaginal exposure to situations that cannot
be targeted in vivo (or as a first step to in vivo
exposure)
▹ Identify and eliminate safety behaviors- actions
taken to avoid, prevent, or manage a potential
threat
– Avoidance
– Checking (pulse, exits, hospitals)
– Carrying rescue medications, cellular phones
– Safe people
– Mental avoidance; distraction
▹ Do not use relaxation to reduce symptoms during
exposure!
 IMAGINAL AND IN
15 VIVO EXPOSURE
▹ Create a fear hierarchy with specific targets for
exposure
▹ Use imaginal exposure to situations that cannot
be targeted in vivo (or as a first step to in vivo
exposure)
▹ Identify and eliminate safety behaviors- actions
taken to avoid, prevent, or manage a potential
threat
– Avoidance
– Checking (pulse, exits, hospitals)
– Carrying rescue medications, cellular phones
– Safe people
– Mental avoidance; distraction
▹ Do not use relaxation to reduce symptoms during
exposure!
16 GROUNDING
▹ Grounding is simply the action of
positively affirming what is known,
constant, and real about a situation,
drawing a clear line in the sand around
what is unknown, transient, and
imagined. This mental boundary stops
the individual from becoming
overwhelmed and effectively contains
the influence of a panic attack to within
that boundary.

▹ Grounding techniques can be sensory,

physical, cognitive, or emotional.
17 SENSORY TECHNIQUES
▹ Sensory grounding techniques
involve the client asking
themselves what they know for
certain from their senses; for
example, naming what they can
see, what they can touch, what
they can taste or smell, and so on.
▹ 5-4-3-2-1
▹ Ground with ice, water
▹ Apply pressure
 COGNITIVE
18 TECHNIQUES
▹ Cognitive grounding techniques
similarly involve identifying
what information is known for
certain, such as naming the
date, time, or location or
affirming that they’re in a safe
and controlled environment.
▹ counting backward
▹ reciting the alphabet backward
▹ playing a mental game.
 EMOTIONAL
19 TECHNIQUES
▹ Emotional grounding techniques
are sometimes referred to as
‘emotional labeling’ and involve the
client taking a detached perspective
to their emotions, describing to
themselves exactly how they’re
feeling in the same way they might
describe what the weather is like.
▹ Positive affirmations
▹ Labelling thoughts and emotions
▹ Noticing of emotions
 PHYSICAL
20 TECHNIQUES
▹ Move your body
▹ Box breathing
▹ Muscular Relaxation
▹ Breathing Training
 THANK YOU

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