PANIC ATTACKS
Everyone knows what panic is, and it is common to feel panicky
from time to time: You get the sense that you are being followed
on your way home from a party late at night. You discover you have
had your wallet stolen. You are sitting an exam - you look at the paper
and realise you don't know the answers to any of the questions. Someone
runs in front of your car and you almost hit them
It would be normal in any of these situations to feel a sense of panic. The feeling would be understandable and would pass fairly quickly. A panic attack is a bit like "normal" panic, but different in a number of ways: The feelings seem to come "out of the blue" and are not usually related to the sort of frightening situation described above. The feelings are a lot stronger. As the feelings are UNEXPECTED and STRONG they can feel extremely frightening. Panic attacks affect people in many different ways, but there is usually a frightening feeling that something really awful is about to happen.THE TRUTH IS: NOTHING AWFUL IS GOING TO HAPPEN, AS PANIC ATTACKS ARE NOT DANGEROUS
Lots of people have panic attacks, although they can affect people in different ways. Some people have only one, others may have them for many years. Some people have them every day, some people only once in a while. If you were to ask all of your friends if they had ever had a panic attack, it is very likely that at least one or two will have had the same experience. They are quite common and NOT a sign of serious mental or physical illness. Some non-serious physical conditions can cause symptoms similar to panic attacks. For example: certain medicine taken together; thyroid problems; drinking too much caffeine; pregnancy; low blood sugar; etc. If, after reading this leaflet, you are concerned that your problem may have a physical cause and you have not yet had a check-up from your GP then it may be a good idea to make an appointment
SUMMARY: Panic attacks are very common. They are NOT dangerous and are NOT a sign of serious mental or physical illness. This booklet aims to help you reduce your panic attacks by helping you to: Recognise whether or not you are having panic attacks. Understand panic, what causes it and what keeps it going. Accept that panic cannot harm you. Learn techniques to reduce panic
How do I know if I am having a panic attack?
This may sound obvious, but it isn't. Sometimes panic feels so awful,
and comes so "out of the blue", that people can't quite
believe that it's only a panic attack, and think it must be something
more serious. The feeling of a panic attack can be so unusual that
you may not even realise this is what is happening. One of the most
important first steps in overcoming panic attacks is recognising
whether or not your symptoms are caused by a panic attack. Panic
affects your body, your mind and the way you behave. The following
are some of the most common symptoms experienced by people having
a panic attack. Some people have all of the symptoms, others just
a few
| SYMPTOMS |
| Your Body (please tick those
that apply) Heart pounding, beating fast or skipping a beat Heart seems to stop, followed by a big thud, chest pains Changes in your breathing, either gulping air, breathing fast or feeling short of breath Pounding in your head Numbness or tingling in fingers, toes or lips Feeling as though you can't swallow, feeling sick Feeling as though you're going to faint, wobbly legs |
| Frightening thoughts such as: You feel anxious in situations where you have had a panic attack before I'm going to have a heart attack will collapse or faint I'm running out of air I'm going mad I'm choking I'm going to be sick I'm losing control I'm going to make a complete fool of myself I've got to get out of here You feel anxious in situations where you have had a panic attack (Remember these things never actually happen in a panic attack, but people sometimes think they will) |
| What you do/your behaviour (please tick any of these that apply to you) |
| YOU AVOID: situations that have caused panic or that you fear might cause panic, for example going shopping |
| PREVENT what you think is going to happen, by doing something to make yourself safe, for example, gulping air if you think you are going to suffocate or sitting down if you think you are going to faint, or lying down if you think you are having a heart attack or scanning your body for evidence of something being wrong |
| COPE People often try to cope with a panic attack by doing things they have found or have been told are helpful, for example, distracting themselves or trying to relax |
| ESCAPE as soon as you can when panicking, for example, rushing round the supermarket to get out as soon as possible |
| SEEK HELP In one study a quarter of all people having their first panic attack called an ambulance or went to accident and emergency, they were so convinced something dangerous was happening to them. Perhaps you have done this, or called out the Doctor? |
Whilst all of these things can help to stop a panic attack, as we
shall see later, they can also become part of the problem. If you have
ticked quite a few of these symptoms, thoughts and behaviours, then
it is likely that you are suffering from panic attacks
SUMMARY: Recognising a panic attack. A panic attack is a strong feeling
of terror that comes on very suddenly. Physical symptoms include pounding
hearts, fast breathing , shaking, wobbly legs. People often have lots
of frightening thoughts and think something awful is happening. They
often try to avoid or escape the panic. But panic is not dangerous
or harmful
Understanding Panic - What causes it and what keeps it going?
All of the panic symptoms described above are nothing more than an
extreme form of fear. Fear is our body's natural response to a situation
perceived as threatening. Fear can range from mild anxiety (which
can be helpful when there is a goal, like passing an exam) through
to full blown panic. But why have fear at all when it's such an unpleasant
feeling? In a way, it is a bit like pain. If you were to break your
ankle, it would feel very painful, which would be a warning to you
not to walk on it. If you heard a noise downstairs at night, you
might feel frightened, which is a warning that you might have to
deal with a dangerous situation. Fear is very useful. It prepares
your body for action. This has been called the "fight or flight" response.
So that when you feel fear, what is happening is that your body is
preparing to fight or run away from the thing it feels threatened
by, or possibly to stay completely still and wait for the threat
to pass
If we take the example of the noise downstairs. Let us suppose it
is a burglar, as you fear. You may wish to stay absolutely still, so
as to prevent the burglar from attacking you. You might want to go
and challenge him or you might need to run away should he come after
you. Your fear response would help with any of these. When you are
frightened you breathe more quickly so that you can get lots of oxygen
to your muscles. Your heart beats faster to pump the blood faster round
your body. Your digestive system closes down to allow your body to
concentrate on the more immediate threat. This is your body's normal
healthy reaction to situations where your body feels under threat.
It is your body's alarm system. The problem with panic attacks is that
usually they occur when there is no obvious physical threat there at
all. Your body is reacting as though it was about to be attacked when
in reality it is not. In other words it is a false alarm. It is a bit
like the annoying smoke detector which goes off at all the wrong times,
because it is sensitive to small amounts of smoke. Or the burglar alarm
that goes off because of the cat. Or even more annoying, the car alarm
that is triggered by the wind. These are all alarms that can be triggered
when there is in fact no danger. The same can be the case with your
body's "alarm" system. Sometimes it can be triggered when
there is no real danger. The problem is that our body's "alarm
system" was designed many, many years ago, when people had to
cope with dangers in order to survive. Nowadays, we are rarely faced
with the sort of life or death threats our ancestors faced. We have
very different threats, mainly related to stress. Financial worries,
overworking, moving house, divorce for example, can all be stressful,
and can raise our anxiety levels to the point where our "alarm
system" is triggered. It is a bit like a "stress" thermometer
- which when it reaches a certain level results in panic. Whilst a
panic attack may be unpleasant, it is not dangerous but quite the opposite.
It is a system designed to protect us, not harm us
SUMMARY: Understanding Panic. Panic is a form of fear. It is our body's
alarm system signalling threat. It prepares our body to fight or run
away from danger. But as there is no physical danger it is a false
alarm. A panic attack may be unpleasant but it is not dangerous
What causes panic attacks to begin?
Panic attacks can start for a number of reasons:
STRESS - As mentioned, stressful events can cause
anxiety to go up, which may lead to the alarm system being triggered.
Are you aware of any stress in your life over the last few years? For
example, work stress or being out of work, relationship problems, loss
of a loved one, financial difficulties. Please list any stresses that
you are aware of: If you feel you have had a lot of stress in your
life recently, it might be useful to read our booklet "Stress,
a self help guide"
HEALTH WORRIES - Panic attacks often begin when a
person becomes over-concerned about their health. This can happen for
various reasons. Sometimes people with panic attacks have recently
experienced the sudden death of someone they know or are close to.
They then become very worried about their own health, and look for
signs that they may be developing the same illness. They are often
aware of medical 'mistakes' where serious illness has not been picked
up, and so become worried that there is something seriously wrong.
This leads to raised anxiety. They then think the anxiety symptoms
are evidence of a serious illness, which can result in panic. Think
back to when your panic attacks began. Do you know anyone who died
suddenly, for example from a brain haemorrhage or an asthma or heart
attack?
OTHER HEALTH-RELATED REASONS - Sometimes panic attacks
occur for the first time during a period of ill-health. For example
some viruses can cause dizziness. Pregnancy or the menopause can cause
changes in the way our body works that can lead to a first experience
of panic. Consuming large amounts of caffeine, or low blood sugar can
also lead to feelings of faintness. Can you think of any "health-related" reasons
for your panic attacks?
DIFFICULT EMOTIONS - Panic attacks often begin when
there are feelings from the past or present that are being "swept
under the carpet". Maybe you
have relationship problems, or something from the past you need to
deal with?
OUT OF THE BLUE - Sometimes we just don't know why
panic attacks begin. Some people even have their first panic attack
when they are asleep! It may just be that certain people, in certain
circumstances respond like the oversensitive car alarm. Their alarm
system is triggered when there is in fact no danger. In some ways it
is less important to know what causes panic attacks to begin and more
important to know what keeps them going
What keeps panic attacks going?
As you will remember panic affects your body, your thoughts and your
behaviour. All three work together to keep panic going
Physical - Firstly, the physical symptoms can be part
of the problem. For people whose breathing is affected by anxiety,
something called hyperventilation can occur.
This just means someone is taking in too much air and not breathing
it out. This is not dangerous but can lead to feelings of dizziness,
and is often taken as further evidence that there is something seriously
wrong
Thoughts - Secondly, the physical symptoms and anxious
thoughts form a vicious circle that keeps panic attacks coming back
again and again. Also, focusing your mind on your body can lead to
noticing small changes and seeing this as a threat. People often find
it hard to believe that our thoughts can produce such strong feelings
as fear. But if we believe something 100% then we will feel exactly
the same way as if it were true
Behaviour - Thirdly, how a person behaves before,
during and following a panic attack has a big part to play in whether
panic attacks keep happening. The avoidance, escape, and safety behaviour
described earlier all add in to the vicious circle
| THE VICIOUS CIRCLE |
| 1. THREAT |
| 2. Alarm bell |
| 3. I'm sure my heart missed a beat |
| 4. Physical symptoms of anxiety; for example heart thudding |
| 5. Thinks "oh no, something is wrong" |
| 6. Physical symptoms get worse |
| 7. Thinks "now I am really having a heart attack" |
| 8. Sits down "if I hadn't sat down I would have had a heart attack" |
Another way thoughts can affect panic, is when someone starts to
worry that they are going to panic in situations where they have panicked
before. This, unfortunately, makes it more likely to happen again.
People who have panic attacks often worry that the physical symptoms
mean something different from what they really do. Examples of some
of the most common misinterpretations are:
| What you feel | Reasons this is happening | Common fears |
| Eyes go funny Blurred vision Tunnel vision Feel unreal |
Eyes trying to focus to fight danger | Brain haemorrhage Going mad |
| Breathing changes | Body trying to take in more oxygen to fight or run away | Choking or suffocating running out of air |
| Chest pains | Muscles held tight ready to fight | Heart attack |
| Heart pounding | Increase flow of blood through body | Heart attack |
| Pounding in head Headache |
Increased pressure of blood flowing through body for extra energy | Tumour Haemorrhage |
| Numbness or tingling in fingers or lips | Blood diverted to muscles | Stroke |
Another way thoughts can affect panic, is when someone starts to worry that they are going to panic in situations where they have panicked before. This, unfortunately makes it makes it more likely to happen again. Fear is our body's way of coping with threat - preparing us to fight or run. Panic attacks can begin for a number of reasons: stress, health worries, during a mild illness, because of difficult emotions, out of the blue. Panic attacks are kept going because of the vicious circle of physical symptoms, thoughts, behaviour. By avoiding, escaping or preventing panic attacks, you may never find out that nothing terrible was going to happen may dread going back into the situation, because you fear another attack, lose confidence in your ability to cope alone
Can panic attacks really harm me?
We have spent a lot of time looking at recognising and understanding
panic, because this should give you all the information you need
to be able to accept that panic attacks are not harmful. If you can
do this then you have come a long way to being able to end your panic
attacks. To what extent, sitting here now do you believe that your
panic attacks mean that something awful is going to happen (0 -100%),
for example, heart attack, stroke, fainting, choking, suffocating?
Next time you have a panic attack, can you rate at the time how much
you believe something awful is going to happen (0 -100%)? SUMMARY:
Panic attacks are not harmful
What techniques can help me cope with and reduce panic attacks?
The good news is that panic attacks are very treatable. You may find
that your panic attacks have already started to reduce because you
have begun to recognise and understand, and accept that they are
not harmful. As we have seen, panic affects your body, your mind
and your behaviour. It makes sense to try to deal with each of these.
You may find some techniques more helpful than others. Not everyone
finds the same things helpful. Also, if you have been having panic
attacks for a while, it may take some time for these techniques to
work. Don't expect miracles straightaway, but keep at it and you
should see the benefits soon, when you've found the techniques that
work best for you
There are at least two things you can do to help with the physical
symptoms of anxiety: Relaxation, controlled breathing. These techniques
are helpful for a number of reasons: Panic attacks often start in periods
of stress. These techniques can help you to deal with stressful situations
better, and reduce overall levels of anxiety. They can "nip anxiety
in the bud" stopping the cycle that leads to full blown panic,
by reducing anxiety symptoms and preventing hyperventilation. They
can be used when avoidance is being cut down, to help you cope with
situations you fear. Being relaxed and breathing calmly is the opposite
of panic. To begin with it is best to practice regularly when you are
not anxious. Look on it as getting into training. You would not enter
the Great North Run without training for a while first!
Relaxation - People relax in many different ways.
It might be that looking at your lifestyle would be helpful. What do
you do to relax? Write down six things you do, or could do to relax;
for example, swimming, reading, walking. As well as finding everyday
ways of relaxing, there are special relaxation techniques which can
help with the specific symptoms of panic. We have already seen that
one of the things that happens when you panic is that your muscles
tense up. To help yourself you should try to relax your muscles whenever
you start to feel anxious. Relaxing in this sense is different from
the everyday ways of relaxing like putting your feet up and having
a cup of tea (although that is just as important!). It is a skill,
to be learnt and practiced. There are relaxation tapes, and sometimes
classes, which can help
Yoga - classes can also be helpful. Your doctor may be able
to lend you a relaxation tape, so please ask.
Relaxation tapes - teach you to go through the main muscle
groups in your body, tensing and relaxing your muscles. The tape will
come with instructions and some people find them very helpful. For
further details on relaxation please see the booklet in this series
on "Stress, a self help guide". Remember -Relaxation can
help to reduce symptoms of panic, but it is not preventing something
terrible happening - because nothing terrible is going to happen, whether
you relax or not
Controlled Breathing - As we saw earlier, when someone becomes
frightened they start to breathe more quickly, so that oxygen is pumped
more quickly round the body. However, breathing too fast, deeply or
irregularly can lead to more symptoms of panic, such as faintness,
tingling and dizziness. If breathing can be controlled during panic,
these symptoms may be reduced and so the vicious circle described earlier
can be broken. You must breathe more slowly. If you breathe calmly
and slowly for at least 3 minutes, the alarm bell should stop ringing.
This is not as easy as it sounds. Sometimes in the middle of a panic
attack, focusing on breathing can be difficult. One of the effects
of over-breathing is that you feel you need more air, so it is difficult
to do something which makes you feel as though you are getting less!
Again, practice while you are not panicking to begin with. This technique
will only work if you have practiced and if it is used for at least
three minutes. It works much better in the very early stages of panic.
Practice the following as often as you can. Fill your lungs with air.
Imagine you are filling up a bottle, so it fills from the bottom up.
Your stomach should push out too. Do not breathe in a shallow way,
from your chest, or too deeply. Keep your breathing nice and slow and
calm. Breathe out from your mouth and in through your nose. Try breathing
in slowly saying to yourself: 1 elephant, 2 elephant, 3 elephant, 4.
Then let the breath out slowly to six: 4 elephant, 5 elephant, 6. Keep
doing this until you feel calm. Sometimes looking at a second hand
on a watch can help to slow breathing down. Remember -Even if you didn't
control your breathing, nothing awful is going to happen
Your Mind - There are at least four things you can do to help
with the way your mind fuels a panic attack: Stop focusing on your
body. Distract yourself from frightening thoughts. Question and test
your frightening thoughts. 4. Try to work out whether something else
is making you tense
Stop Focusing - Try to notice whether you are focusing on
your symptoms, or scanning your body for something wrong. There really
is no need to do this and it makes the problem far worse. It may be
helpful to use the next technique to help you stop the habit. In particular
focus on what is going on outside rather than inside you
Distraction - This is a very simple but effective technique.
Again, you need to keep distracting yourself for at least three minutes
for the symptoms to reduce. There are lots of ways you can distract
yourself. For example, look at other people, and try to think what
they do for a job. Count the number of red doors you see on the way
home. Listen very carefully to someone talking. You can also try thinking
of a pleasant scene in your mind, or an object, like a flower or your
favourite car. Really concentrate on it. You can try doing sums in
your mind, or singing a song. The important thing is that your attention
is taken off your body and onto something else. Use what works best
for you. Distraction really does work. Have you ever been in the middle
of a panic attack when something happened that totally took over your
attention, for example the phone ringing, or a child falling over?
Remember - distraction breaks the vicious circle, but it is important
to remember that distraction is not preventing something terrible happening.
In fact, as distraction works, this is evidence that nothing awful
was going to happen after all. For example, could the fact that a phone
rings really prevent a heart attack?
Question your thoughts
Sometimes, rather than distracting yourself from your anxious thoughts
it is more helpful to challenge them. In the long run, it is most helpful
to challenge your worrying thoughts, so that you no longer believe
them. For thought challenging you need to do two things: Work out what
your anxious thoughts and worst fears are. Everyone's are different,
you should already have a good idea from the work done so far. Start
to challenge these thoughts and come up with more realistic and helpful
thoughts. Once you are aware of your thoughts and pictures in your
mind, ask yourself: What is the evidence for and against them? How
many times have you had these thoughts and has your worst fear ever
happened? Do your experiences fit more with panic or with something
more serious. For example, if thinking about panic brings a panic attack
on. Is it likely that a stroke or heart attack could be caused in this
way? If you can come up with more realistic helpful thoughts, write
them down and keep them with you. It is often much more difficult to
come up with thoughts you are actually panicking. Some examples of
unrealistic and unhelpful thoughts, with more realistic alternatives
are given below
| Unhelpful or unrealistic thoughts | More realistic thought |
| I am having a heart attack | I have had this feeling many times and am still here |
| I am going to faint | People having panic attacks are unlikely to faint. I have not fainted before |
| I am going mad | The feelings I am experiencing are panic - they are nothing like going mad |
| I will make a fool of myself | I have panicked before and no-one has even noticed. People are busy getting on with their own thing |
Whilst it is really useful to challenge thoughts in this way. Probably
the best way is to challenge the thoughts through the things we do,
which is the next section. Before looking at how we can alter our behaviour
to help reduce panic, it is useful to look at one other way in which
your mind may be contributing to panic. Not through unhelpful anxious
thoughts, but because there may be other things bothering you, as mentioned
earlier. Remember that panic can arise as a result of difficult feelings
not being dealt with. It may be helpful to work out whether anything
like that is bothering you. Is there anything from your past that you
haven't sorted out that is preying on your mind? Are there difficulties
in your relationship? Do you feel angry or sad? Has someone or something
upset you or is something troubling you? Panic is less likely to happen
if you face up to emotional difficulties, either through talking to
a friend or a professional counsellor (for example your doctor, nurse,
practice counsellor, psychologist)
Behaviour
Finally, challenging what you do is probably the most helpful way of
overcoming panic. We have already talked about how avoidance, escape
and safety behaviours keep panic going. It makes sense then that to
reduce panic you need to reduce these behaviours. Put simply, what
you need to do now is test out the situations you fear most to prove
to yourself that what is written here is time: panic attack cannot
harm you. This is best done, not all at once, but in a planned way.
It's probably best to start off with a small experiment. It's difficult
to believe something just by reading it, what you really need to do
little by little to prove to yourself what is really going on. It is
important to remember that whatever you do or don't do, the panic attack
will stop. Just like any other alarm would, First of all, work out
what behaviours you need to tackle:
Avoidance - For example, if you are frightened of being alone, or visiting
a supermarket, try gradually spending a little bit more time on your
own, or going to a small shop. Does you feared disaster actually happen?
Now you have some evidence that you didn't die/go mad/faint. The next
step is to spend a bit longer, more often. You will probably feel anxious
to begin with, as you have learnt to be anxious in certain situations,
and you may have been avoiding them for some time.
Escape - Note which situations you are escaping from. Do you stop eating
a meal half way through in case you are sick? Or leave the supermarket
without your shopping? Try staying in the situation until your panic
starts to go down. What will you have learnt?
Safety behaviours - Try to notice all the things you do to keep yourself
safe, big and small and gradually cut them out. Do you stand absolutely
still to stop yourself having a heart attack. Walk about instead. If
you normally sit down to stop yourself fainting, try staying upright.
What happened! What did you learn? Write down some experiments you
could try, find afterwards what you found out, following the example
below
| Safety behaviour | What you do instead | What did you learn? |
| Lie down when panic comes on to prevent heart attack | Run up and down the stairs | I did not have a heart attack even though I ran up and down the stairs |
| Lean on shopping trolley to prevent fainting | Walk without trolley, use basket instead | I did not faint even without the trolley |
By testing out your fears in this way, and finding out that your worst fear never happen you will gradually become more and more confident. Your panic attacks should become fewer and fewer and less strong when they do come
SUMMARY: Coping with Panic.
Practice relaxation, slow breathing, distraction and thought challenging
when not anxious until you have learned the techniques
Remind yourself during a panic that you have panicked many times before
and nothing awful is going to happen
Use distraction, relaxation and slow breathing to help you get the
panic to go away
Challenge your unrealistic thoughts during a panic, using some more
realistic thoughts you have written down
Try not to avoid, escape or use safety behaviours, instead test out
what really happens
Try to sort out any worries or troubles that you have. Talk about them,
don't sweep them under the carpet
Further help
Whilst the techniques in this book should help you to get better by
yourself, sometimes you may need professional help too. If you feel
you may need professional help, talk to your GP who might be able
to provide this, or who may refer you on to someone else who can
Source: Northumberland Mental Health NHS Trust
NHS
Direct 0845 46 47 www.nhsdirect.nhs.uk
