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Panic - A Self Help Guide

by S Black, R Donald, M Henderson, NHS Borders
Acknowledgement to Newcastle, North Tyneside and Northumberland Mental Health NHS Trust
Developed with assistance from: The National Programme for Improving Mental Health and Well Being
www.wellontheweb.net

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, late at night. You discover you have had your wallet stolen. You are sitting an exam, look at the paper, and think 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 the feelings are a lot stronger, seem to come 'out of the blue' and are not usually related to the sort of frightening situation described above. 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 medicines taken together, thyroid problems, drinking too much caffeine, pregnancy, low blood sugar, etc. If, after reading this page, 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.

Recognizing 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 realize this is what is happening. One of the most important first steps in overcoming panic attacks is recognizing 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. Think about when you feel panicky – what happens?

• YOU AVOID situations that have caused panic or that you fear might cause panic, for example going shopping.
• ESCAPE as soon as you can when panicking, for example, rushing round the supermarket to get out as soon as possible.
• 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.
• 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?
• 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.

While 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 experience quite a few of these symptoms, thoughts and behaviors, then it is likely that you are suffering from panic attacks.

Understanding panic:

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 set off 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. Quite the opposite. It is a system designed to protect us, not harm us.

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.
• 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. Was anything happening that might have caused you to think more about your physical health?
• 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 that you are thinking about a lot.
• 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 over-sensitive car alarm. Their alarm system is triggered when there is in fact no danger.

It is less important to know what causes panic attacks to begin and more important to know what keeps them going. As you will remember, panic affects your body, your thoughts and your behavior. All three work together to keep panic going. Firstly, the physical symptoms can be part of the problem. For example, 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 out enough. This is not dangerous but can lead to feelings of dizziness, and is often taken as further evidence that there is something seriously wrong. 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. 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, and often leads to avoidance. 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 behavior described earlier are all part of the vicious circle.

We have spent a lot of time looking at recognizing 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, 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?

Coping with and reducing 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 recognize and understand, and accept that they are not harmful. As we have seen, panic affects your body, your mind and your behavior. 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 straight away, but keep at it and you should see the benefits soon, when you've found the techniques that work best for you.

YOUR BODY:
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 therapist will be able to give 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 a leaflet on relaxation and some people find these very helpful. 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: breathe out, breathe in slowly to the count of four (one elephant, 2 elephant, 3 elephant, 4 elephant), hold your breath for the count of four, breathe out slowly to the count of four. 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:
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 favorite 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 on to 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? Distraction breaks the vicious circle, but it is important to remember that distraction is not preventing something terrible from happening. In fact, as distraction works, this is evidence that nothing awful was going to happen after all. For example, could the fact that the phone rang really have prevented 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. To do that, first 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. And then 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 these thoughts when you are actually panicking. Some examples of unrealistic and unhelpful thoughts, with more realistic alternatives are given below.

  Unhelpful or unrealistic thoughts:	More realistic thoughts:
  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 crazy	The feelings I am experiencing are panic – they are nothing like going crazy
  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

While 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 behavior 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 counselor (for example your doctor, nurse, practice counselor or psychologist).

YOUR BEHAVIOR:
Finally, challenging what you do is probably the most helpful way of overcoming panic. We have already talked about how avoidance, escape and safety behaviors keep panic going. It makes sense then that to reduce panic you need to reduce these behaviors. 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 true: a 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 is 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 behaviors 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 your 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 behaviors. 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, and afterwards what you found out, following the example below.
  

  Safety behavior and purpose:	What you do instead:	What did you learn?
  Lie down when panic comes on to prevent heart attack	Run up and down stairs	I did not have a heart attack even though I ran up and down the stairs
  Lean on shopping cart to prevent fainting	Walk without a cart, use basket instead	I did not faint even without the cart

  
  By testing out your fears in this way, and finding out that your worst fear never happens you will gradually become more and more confident. Your panic attacks should become fewer and fewer and less strong when they do come.