Panic audio transcript

­­Panic – An NHS self help guide

What is a panic attack?

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 are a lot stronger.
• The feelings seem to come ‘out of the blue’ and are not usually related to the sort of frightening situation just described.
• The feelings often last longer than a few minutes.

As the feelings are unexpected, strong and often very physical, they can feel extremely frightening.

Panic attacks affect people in many different ways, but there is usually a sudden frightening feeling that something really awful is about to happen, with strong physical symptoms. This can cause people to feel that something more serious, such as a heart attack is happening.

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 over many years. Sometimes people have them every day, others 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 this experience. They are quite common and not a sign of serious mental or physical illness. However there can be some other causes for panic-like symptoms.

For example:

• certain medicines taken together;
• thyroid problems;
• drinking too much caffeine or alcohol;
• pregnancy;
• hormonal problems;
• asthma;
• low blood sugar;
• heart problems;
• Other mental health problems.

The symptoms of panic disorder may mimic or occur alongside many other medical conditions and/or mental health problems. For this reason it is very important to get yourself checked out by your GP before starting to work through this guide.

Summary: Panic attacks are very common. They are not dangerous and are not a sign of serious mental or physical illness. However, they can occur as part of another physical or mental problem so it is important to see your GP so that other causes can be treated or ruled out.

This guide 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 based on Cognitive Behaviour Therapy (CBT).

There is a lot of information in this guide and it may be helpful to listen to it several times, or to listen to it a bit at a time, to get the most from it.

Recognising 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 not 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.

Your body (write down those that apply)

• Heart pounding, beating fast or skipping a beat.
• Heart seeming to stop, followed by a big thud.
• Chest pains.
• Changes in breathing; for example: gulping air; breathing fast; feeling short of breath; sighing, yawning or panting.
• Pounding in the head.
• Numbness or tingling in fingers, toes or lips.
• Feeling faint, wobbly legs.

Write down any other symptoms

Your mind (write down any thoughts or feelings that apply)
Frightening feelings such as:

• Feelings of utter terror.
• Feelings of unreality, as though you are not really there.
• Feeling anxious in situations where panic has happened before.

Frightening thoughts such as:

• “I’m going to have a heart attack”
• “I 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”

Write down any other frightening thoughts or feelings.

Remember: These things never actually happen as a result of a panic attack, but people sometimes think they will. That’s not to say that these things won’t ever happen of course, but just that a panic attack won’t cause them to happen.

What you do/your behaviour (do any of these things apply to you?)
You avoid situations that have caused panic or that you fear might cause panic, for example going shopping.
You escape as soon as you can when panicking, for example, rushing round the supermarket to get out as soon as possible.
You 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. These are often called Safety Behaviours.
You 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.

 Write down anything else you do or don’t do as a result of having a panic attack.

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 recognised 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 heart, 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 is it, what causes it to begin and what keeps it going?

What is a panic attack?
All of the panic symptoms that have been described are nothing more than an extreme form of fear. Fear is our body’s natural response to a situation seen 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 “freeze, 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 heat. 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.

This is because 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.

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.

If you feel you have had a lot of stress in your life recently, you may find our ‘Stress self help guide’ useful.

Health worries
Panic attacks sometimes 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 may be 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? Are you perhaps suffering from health anxiety? If so you may find our Health Anxiety self help guide useful.

Mental health reasons
Panic attacks are often linked to other mood and anxiety disorders, including depression, anxiety, post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD). Guides on each of these are available in this series.

Physical health reasons
Sometimes panic attacks occur for the first time during a period of ill-health. For example some viruses can cause dizziness. Panic attacks are also common with certain other medical conditions, such as asthma, chronic obstructive pulmonary disease (COPD) irritable bowel syndrome (IBS) and sleep disorders. 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 lead to feelings of faintness or dizziness. Alcohol and/ or drug misuse can also cause panicky feelings. Can you think of any physical 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? Have a think about this and write down any problems you might 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 over-sensitive car alarm. Their alarm system is triggered when there is in fact no danger.

As can be seen, there are many reasons why panic attacks can begin. For this reason, it is important to see your GP in the first instance.

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.

Your body
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 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.

Your 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 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 fears are:
Physical symptoms – your eyes go funny, you have blurred or tunnel vision, you feel unreal
Reasons this is happening – your eyes are trying to focus to fight danger
Common fears – a brain hemorrhage or that you’re going mad

Physical symptoms – your breathing changes
Reasons this is happening- your body is trying to take in more oxygen to fight or run away
Common fears – Losing control, Choking or suffocating

Physical symptoms – Chest pains
Reasons this is happening- your muscles are held tight ready to fight
Common fears – Running out of air

Physical symptoms- Heart Pounding
Reasons this is happening- Increased flow of blood through the body
Common fears – Heart attack

Physical symptoms – Pounding in head or headache
Reasons this is happening- Increased pressure of blood flowing through the body for extra energy
Common fears –  Tumor or brain haemorrhage

Physical symptoms- Numbness or tingling in fingers or lips
Reasons this is happening- Hyperventilation causes this
Common fears – Stroke

People often find it hard to believe that our thoughts can produce such strong feelings of 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.

Your 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.

These physical symptoms, thoughts and behaviours form a vicious circle which keeps the panic attacks occurring over time.

Imagine you feel a threat. This rings an alarm bell and you think “I’m sure my heart missed a beat”.

You feel physical symptoms of anxiety, for example, your heart thudding then you think “oh no something is wrong”. Your

physical symptoms get worse and then you think “Now I really am having a heart attack”. Your safety behaviour is to sit down because “If I hadn’t sat down I would have had a heart attack”

Understanding panic – summary

• Panic is a form of fear. It is our body’s alarm system signaling threat. It prepares our body to fight or run away from danger, but as there is no danger it is a false alarm.
• 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
  – dread going back into the situation, because you fear another attack
  – lose confidence in your ability to cope alone

Are panic attacks harmful?

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 write down what percentage you think  (0 -100%), for example, heart attack, stroke, fainting, choking, suffocating?

Next time you have a panic attack, write down the percentage rate at the time how much you believe something awful is going to happen?

The aim eventually is to reduce your belief that something awful is going to happen to 0%.

Do remember however, that although panic itself will not harm you, it is very important to get symptoms checked out by your GP, just in case there is something else going on, especially if things do not improve or you develop any new symptoms.

Summary: Panic attacks are not harmful. None the less it is important to look after your health and have symptoms checked out by your GP.

What techniques can help to 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 them, and accept 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 straight away, but keep at it and you should see the benefits soon, when you’ve found the techniques that work best for you.

It is really important to remember that these techniques are about managing panic and anxiety so you can ride it out, not about trying to stop it altogether. If you try to force yourself not to panic because you are frightened of it, this can make you more anxious. Whereas if you can learn to cope with the symptoms, gradually they will be much less frightening, and as a result will reduce.

Your body
There are at least three things you can do to help with the physical symptoms of panic:

• Relaxation and deep muscle relaxation
• Controlled breathing
• Exercise

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 practise regularly when you are not anxious. Look on it as getting into training. You would not enter a marathon 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. 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 practised. We have already seen that one of the things that happens when we panic is that our muscles tense up. Deep muscle relaxation can help you learn to relax your muscles whenever you start to feel anxious or when you become aware you are tense. There are relaxation CDs, downloads, and sometimes classes, which can help. Some suggestions of where you can obtain these for free are suggested in the written version of this guide but to get you started you may find the following useful.

Deep muscle relaxation
It is helpful to listen to the instructions first and then gradually learn them off by heart. Start by selecting quite a warm, comfortable place where you won’t be disturbed. To begin with choose a time of day when you feel most relaxed. Lie down, get comfortable, close your eyes. Concentrate on your breathing for a few minutes, breathing slowly and calmly: in two-three and out two-three. Say the words “calm” or “relax” to yourself as you breathe out. The relaxation exercise takes you through different muscle groups, teaching you firstly to tense, then relax.

Starting with your hands, clench one fist tightly. Think about the tension this produces in the muscles of your hand and forearm.

Now do the same with the other hand.

Study the tension for a few seconds and then relax your hand. Notice the difference between the tension and the relaxation. You might feel a slight tingling, this is the relaxation beginning to develop. Now do the same with the other hand.

Each time you relax a group of muscles think how they feel when they’re relaxed. Don’t try to hard to relax, just let go of the tension. Allow your muscles to relax as much as you can. Think about the difference in the way they feel when they’re relaxed and when they’re tense. Now do the same for the other muscles of your body. Each time tense them for a few seconds and then relax. Study the way they feel and then let go of the tension in them.

It is useful to stick to the same order as you work through the muscle groups:

• Hands – clench fist, then relax.
• Arms – bend your elbows and tense your arms. Feel the tension, especially in your upper arms. Remember, do this for a few seconds and then relax.
• Neck – press your head back and roll it from side to side slowly. Feel how the tension moves. Then bring your head forward into a comfortable position.
• Face – there are several muscles here, but it is enough to think about your forehead and jaw. First lower your eyebrows in a frown. Relax your forehead. You can also raise your eyebrows, and then relax. Now, clench your jaw, notice the difference when you relax.
• Chest – take a deep breath, hold it for a few seconds, notice the tension, then relax. Let your breathing return to normal.
• Stomach – tense your stomach muscles as tight as you can and relax.
• Buttocks – squeeze your buttocks together, and relax.
• Legs – straighten your legs and bend your feet towards your face. Finish by wiggling your toes.

You may find it helpful to get a friend to listen to the instructions with you. Don’t try too hard, just let it happen.

To make best use of relaxation you need to:

• Practise daily.
• Start to use relaxation in everyday situations.
• Learn to relax without having to tense muscles.
• Use parts of the relaxation to help in difficult situations, e.g. breathing slowly.
• Develop a more relaxed lifestyle.

Remember relaxation is a skill like any other and takes time to learn. Keep a note of how anxious you feel before and after relaxation, rating your anxiety 1-10.

If at first you find relaxation exercises make you feel a little more tense and anxious, don’t worry.  This is quite common.  It may be you have got quite used to distracting yourself from your bodily feelings.  Try to learn relaxation techniques at first when

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 a few 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, practise while you are not panicking to begin with. This technique will only work if you have practised and if it is used for a few minutes. It works much better in the very early stages of panic. Practise 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 for about 4 seconds saying to yourself: 1 and, 2 and, 3 and, 4.

Then let the breath out slowly for about 4 seconds again saying to yourself: 1 and, 2 and, 3 and, 4. It may be helpful if you can, with practice, increase your out breath to 5 seconds.

Keep doing this until you feel calm. Once you have the rhythm nice and regular it may help to say to yourself as you breathe in ‘calm’ and as you breathe out ‘relax’.

Remember: even if you didn’t control your breathing, nothing awful is going to happen.

Exercise
There is a great deal of research to suggest that exercise works really well as a way of managing stress. Exercise helps to release tension in our muscles and uses up the stress hormones produced as part of the fight and flight response. There are also other great health benefits to regular exercise, including improved mood. Choose exercise you enjoy, and that way you are much more likely to keep it up.

Your mind
There are at least five things you can do to help with the way your mind fuels a panic attack:

• Stop focusing on your body
• Learn to be more mindful
• Distract yourself from frightening thoughts
• Question and test your frightening thoughts
• Try to work out whether something else is making you tense

Stop focusing on your body
Try to notice whether you are focusing on your symptoms, or scanning your body for something wrong as this can sometimes trigger a panic attack. Practice shifting your focus away from your body and focus on other things around you, for example try hard to focus on what someone is saying, or what you are doing rather than what is going on inside you.

Mindfulness
This is a slightly different approach to managing panic. Mindfulness is a form of meditation that involves being totally in the present moment. It involves observing what is happening with a calm, non-judging awareness, allowing thoughts and feelings to come and go without getting caught up in them. The aim is to concentrate only on what is happening in the here and now, not the past and not the future. When we panic, often it is because we have had a panic attack in a similar situation in the past, so have been worrying beforehand. Or we may have frightening thoughts about what our symptoms mean. By practicing Mindfulness regularly, we can become more accepting of our bodily feelings, which in turn makes us calmer and less anxious.

The following mindful breathing exercise may be useful:

• Find a quiet space where you won’t be disturbed. Sit comfortably, with your eyes closed or lowered and your back straight.
• Bring your attention to your breathing.
• Notice the natural, gentle rhythm of your breathing as you breathe in and out, and focus only on this.
• Thoughts will come into your mind, and that’s okay, because that’s just what the mind does. Just notice those thoughts, then bring your attention back to your breathing.
• You may notice sounds, physical feelings, and emotions, but again, just bring your attention back to your breathing.
• Don’t follow those thoughts or feelings, don’t judge yourself for having them, or analyse them in any way. It’s okay for the thoughts and feelings to be there. Just notice them, and let them drift on by; bringing your attention back to your breathing.
• Whenever you notice that your attention has drifted off and is becoming caught up in thoughts or feelings, simply note this has happened, and then gently bring your attention back to your breathing.
• Thoughts will enter your awareness, and your attention will follow them. No matter how many times this happens, just keep bringing your attention back to your breathing. If you are very distracted it might help to say ‘in’ and ‘out’ as you breathe.

The more you can practice this exercise the more it will help you to manage your panic attacks. At least 15-20 minutes a day is recommended. Some suggestions of where you can find more information about mindfulness can be found in the written version of this guide.

Distraction
Mindfulness can take time to learn. Distraction is a quick very simple but effective technique to manage panic in its early stages. You need to keep distracting yourself for a few 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 on to something else. Use what works best for you.

It sounds very simple but 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? What happened to the panic?

Remember: 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.

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 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, perhaps on a card. It is often much more difficult to come up with these thoughts when you are actually panicking so it is good to be prepared.

Some examples of unrealistic and unhelpful thoughts, with more realistic alternatives follow.

Unhelpful/unrealistic thought- I am having a heart attack
More realistic thought- I have had this feeling many times and still here

Unhelpful/unrealistic thought- I am going to faint
More realistic thought- People having panic attacks are unlikely to faint.  I have not fainted before.

Unhelpful/unrealistic thought- I am going mad
More realistic thought – The feelings I am experiencing are panic – they are nothing like going mad

Unhelpful/unrealistic thought – I will make a fool of myself
More realistic thought – I have panicked before and no-one has even noticed.  People are busy getting on with their own thing.

Unhelpful/unrealistic thoughts – I am going to lose control
More realistic thoughts – Panic is designed to keep me safe so it wouldn’t make sense that I would lose control

Whilst it is really useful to challenge thoughts in this way, it may also be helpful 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.

Is there something on your mind? 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 (for example your doctor, counsellor or psychological therapist).

Your 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 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 listening to 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 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 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 learned to fear certain situations, and you may have been avoiding them for some time. Writing out a simple anxiety ladder may be helpful here, starting with your least up to your most feared situation, and gradually working your way through this.

It may help to look at this example:

Peter has had a few panic attacks when shopping in the town centre, at the gym and while in the pub with friends. He has started to avoid things he believes trigger his panic. Peter has made an ‘anxiety ladder’ with his least feared situation at the bottom and his most feared at the top.

Peter’s least feared situation, step 1, is to spend an hour in the garden.
Step 2 is to walk along to the post box and back.
Step 3 is to go to the vegetable shop in the town centre with his partner.
Step 4, to go to the vegetable shop alone.
Step 5, to go to the gym with a friend.
Step 6, to go to the gym alone
Step 7, to meet friends in the pub on a quiet night
His most feared situation, step 8, is to meet friends in the pub on Saturday night

Once everything on the ladder is achieved a new ladder can be made. If steps are too big, a mini ladder between steps can help.

Try this for yourself. Make up your own anxiety ladder if you feel avoidance is a problem for you.

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, and afterwards what you found out, following these examples.

Safety behaviour and purpose – Lie down when panic comes on to prevent heart attack
What you do instead – Run up and down the stairs
What did you learn? – I did not have a heart attack even though I ran up and down the stairs

Safety behaviour and purpose – Lean on shopping trolley to prevent fainting
What you do instead – Walk without trolley, use basket instead
What did you learn? – I did not faint even without the trolley

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.

Summary: Coping with panic.

• Practise relaxation, slow breathing, mindfulness, 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 manage the panic.
• 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 guide may help you to get better by yourself, sometimes you may need professional help too.

If you feel you may need further help, talk to your GP who might be able to provide this, or who may refer you on. Help available may include someone guiding you through self help, online or face to face CBT, or other therapies. In addition, anxiety and panic attacks can sometimes be successfully treated by medication; usually in combination with the techniques described here. Discuss this with your GP who will be happy to give you more information.

A list of useful contacts, books and references are available in the written version of this guide.

Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.