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A panic attack is a brief episode of intense fear. It is accompanied by multiple physical and cognitive symptoms that occur repeatedly and unexpectedly in the absence of any external threat.

People with panic disorder experience recurrent and unexpected panic attacks and persistent fears of repeated attacks.

People are diagnosed as having a panic disorder if they have had four attacks within a four week period, or following one or more attacks, have the persistent fear of having another attack. Anticipatory fears of having panic attacks in public places, or where no help or escape seems possible may lead to the individual becoming housebound and the development of agoraphobia.

While panic attacks are common, with up to 30 per cent of the population experiencing a panic attack during a given year, panic disorder is less common, affecting 2 to 3 percent of the population. 

Symptoms

A panic attack includes four or more of the following symptoms:

  • Shortness of breath or smothering sensation
  •  Feeling of choking
  •  Dizziness, unsteady feelings or faintness
  •  Palpitations, pounding heart or accelerated heart rate
  •  Trembling or shaking
  •  Sweating
  •  Nausea or abdominal distress
  •  Numbness or tingling sensations
  •  Flushes or chills
  •  Feelings of unreality and detachment from self or the environment
  •  Fear of dying
  •  Fear of going crazy or doing something uncontrolled. 

Treatment for Panic

Simple Techniques

1. Education

Many patients first seek help in a crisis or for incidental reasons often after suffering symptoms for many years. Lack of basic information and irrational beliefs about anxiety are common problems and require education. Detailed explanation of general aspects such as links between physical and mental fitness is vital. More specific information such as the panic cycle, the learned association between panic attacks and agoraphobia and the link between social phobia and physical and cognitive symptoms is also required. Simple information needs to be provided verbally, while reference to useful texts for information and self-help techniques is also recommended (see references).

2. Relaxation Training

Relaxation can be an effective way for patients to demonstrate to themselves that they have control over their symptoms while also helping other cognitive behavioural techniques. One of the simplest ways of achieving some relaxation is through planning enjoyable and relaxing activities and planning breaks in busy routines. Formal training is useful for some and a range of relaxation techniques is available. One of the best approaches is the applied relaxation (AR) method of Ost (1983) which starts with progressive muscular relaxation involving alternating tension and relaxation phases. This method directly teaches discrimination between the two states in order to allow a patient to become more aware of tense body parts. The later stages of AR focus more on slow regular breathing and self instruction to relax, whilst generalising the technique to everyday activities and later anxiety provoking situations. Demonstration of the technique in the sessions (and taping of it) is more effective than provision of pre-recorded tapes. Alternative methods include self-hypnosis, yoga and meditation.

3. Slow Breathing Techniques

This simple technique is of great benefit for those suffering from both generalised anxiety and panic attacks. It is based on the principle that anxiety and hyperventilation are commonly associated both in generalised anxiety (chronic hyperventilation 16 to 20 rpm) and panic attacks (acute hyperventilation 20 to 30 rpm), with recognition that decreasing respiratory rate decreases expired carbon dioxide, returns acid base balance to normal, decreases anxiety symptoms and increases the threshold for panic attacks. The method can be applied both acutely or chronically although is best learned by regular practice over 2 to 3 weeks, 4 times each day. The aim is for 10 respirations per minute (or less) and is achieved by 5 minutes of breathing using a six-second cycle of inspiration and expiration (Page 1993). Breathing should be slow, steady and involve abdominal musculature.

Link to Breathing Workshop information.

4. Pleasurable Activities

It has been well demonstrated that patients with anxiety and depression are no longer active or enjoying life. A simple behavioural approach involves monitoring activities, pleasure and mastery (often with other indices of mood and anxiety) and thereafter actively scheduling pleasurable activities or planning graded task assignment to increase activities and level of enjoyment.

5. Exercise

Similarly increased exercise is known to be associated with decreased anxiety levels, decreased depression and increased pleasure and enjoyment of life. Many patients who describe a recent increase in their anxiety have turned from their previously active lives to low levels of activity and exercise.

6. Supportive Psychotherapy

The standard support and counselling provided by psychiatrists, psychologists and other counsellors is an important adjunct to other CBT treatments.

Common to all anxiety disorders are irrational thoughts (cognitions) which are generally characterised by being automatic, involuntary, distorted, unhelpful yet superficially plausible. The content differs for each condition, although overlap does exist, but commonly includes catastrophisation, fear of internal or external disaster, fear of ill health or personal vulnerability, automatic assumption of danger. These thoughts are common in anxiety and phobic disorders and treatment needs to address the negative thoughts present during the panic attack (usually catastrophic thoughts of impending death or ill health), the thoughts associated with anticipatory anxiety when people are about to go into a situation where they fear a panic attack and finally thoughts linked to incomplete resolution of panic disorder and residual symptoms. It needs to be stressed that Panic Disorder is not so much a disorder of physical symptoms, but a disorder marked by misinterpretation of the importance of these symptoms.

Thinking errors can be effectively identified, evaluated, controlled and modified by cognitive therapy techniques in many cases. Most cognitions associated with panic and phobic disorders can be challenged effectively in contrast to the obsessions of OCD and thoughts in patients with severe comorbid depression which are very resistant. The process involves:

  • Becoming aware of negative thoughts – diary.
  • Answering/challenging negative thoughts.
  • Action to test negative thoughts and build up a body of contrasting evidence.

The use of pen and paper techniques is probably best either with the RET model of Ellis (ABC) or the dysfunctional thought record of Beck. David Burns’ book “Feeling Good” gives simple instructions on the use of such techniques to identify and challenge negative and dysfunctional thoughts. The final step involves behavioural experiments to build up a body of evidence to convince the patient that these thoughts are incorrect.

Graded Exposure

In theory, phobias can be overcome by facing the things that are feared. Treatment for both agoraphobia and social phobia involves reversing the vicious cycle by which a certain situation and anxiety were first linked, then the link consolidated by anticipatory anxiety and eventually avoidance. What has been learned must be unlearned and this is done by gradually re-introducing the patient to the situation in a slow and steady manner.

A detailed list of avoided or feared situations is constructed and then ranked in order to form a hierarchy of severity. Exposure commences at the lowest point on the hierarchy and needs to be graduated, repeated, prolonged and tasks must be clearly specified in advance. Tasks should be approachable and produce some anxiety but not excessive amounts. The patient needs to learn that they can “wait out” the anxiety, which naturally decays to lower levels over time. All exposure tasks require exposure until anxiety decreases significantly, usually 5 to 45 minutes is required but occasionally this may take some hours. Useful additional methods may include relaxation, distraction and challenging thoughts.

Interoceptive Exposure

A key aspect in the development of the panic attack is the cognitive misinterpretation placed on the physiological symptoms. The patients have an expectation of danger, medical catastrophe and/or a loss of control as has been demonstrated in the illustrated panic cycle. It needs to be emphasised that the physiological symptoms experienced are similar to those experienced in everyday situations such as exercise and excitement for any reason. Interoceptive exposure involves the controlled exposure to these symptoms in order to demonstrate to the patient that these symptoms are tolerable and not the harbingers of medical disaster.

Interoceptive exposure involves the careful production of symptoms followed by the control and then reduction of symptoms with techniques such as slow breathing and cognitive challenging/cognitive therapy. A good example is the production of panic symptoms by hyperventilation or running on the spot which often produce shortness of breath, palpitations, dizziness, derealisation and depersonalisation symptoms. After the patient produces these symptoms by hyperventilating for a short period of time, i.e. 15-30 seconds, the symptoms are controlled by slow breathing until they settle. The person then gradually increases the amount of hyperventilation as their tolerance to smaller amounts increases, resulting eventually in decreased reactivity to hyperventilation, the symptoms themselves and decreased cognitive misinterpretation the symptoms. This can be a frightening technique initially and should be firstly done with a therapist or helper before subsequently performing the activity alone. It can later be introduced to day-to-day life and maybe even into threatening situations to further improve the person’s ability to tolerate these physiological symptoms without catastrophic misinterpretation.

The above techniques are all valuable in the management of Panic Disorder and Agoraphobia. Treatment along these lines should lead to significant improvement within 4-6 weeks with major improvement by 3-6 months. Patients with high levels of symptomatology may feel uncomfortable with the idea of performing such techniques, including those which are sometimes anxiety provoking in themselves. In this context use of medications, specifically the antidepressant group, may help to lower the anxiety to a level to enable performance of these techniques. In this situation reduction and eventual cessation of the medication should be possible because of the ongoing use of these effective cognitive behavioural strategies. Whilst pharmacological treatments are known to be very effective in the management of anxiety disorders, they do not provide long term relief from these symptoms unless continued indefinitely. In this context Cognitive Behavioural Therapy for Panic Disorder and Agoraphobia must be regarded as the treatment of choice with addition of antidepressant medications a potentially useful adjunct to treatment. Combined treatment with pharmacological and psychological measures is usually very effective, often with one treatment improving both the compliance and effectiveness of the other.

Useful links: