Program 20



  1. What is Panic Disorder?
  2. The Causes and Treatment of Panic Disorder
  3. Identifying When You are Anxious
  4. Coping Techniques for Panic Attacks
  5. Altering Negative Thinking Styles
  6. Managing Physical Sensations
  7. Conclusion

  1. What is Panic Disorder?

Some anxiety is necessary for normal functioning but severe anxiety can be disabling. Panic attacks are sudden episodes of acute anxiety. Along with physical symptoms (e.g. difficulty breathing) there are distressing thoughts (e.g. I’m going to faint’). Panic attacks can be with or without agoraphobia, and can leave you feeling exhausted and confused. Some people seek medical help while others suffer in silence.

Panic disorder is when people suffer from repeated attacks or have had one or two severe attacks and fear another attack. In both cases the problem disrupts their lives. People with panic disorder often develop agoraphobia. The agoraphobic is concerned about being alone and unable to escape from crowded or vast open spaces. They tend to avoid circumstances where in the event of a panic attack, escape is difficult – or they put up with the situation only with a lot of worry. Some people may develop agoraphobia because they come to associate particular situations with panic; they have a fear of further panic attacks.

Physical and/or psychological vulnerability together with stress can set off panic attacks. Sufferers of panic attacks tend to lead constrained lifestyles and may become depressed. A sense of shame can exacerbate this and desperation may lead to overeating, alcohol and drug abuse, to try to forget the problems.

See Program 1: Coping Strategies Counselling Advice – Troublesome Emotions, Forgiveness, Program 6: Overcoming Anger, Program 8: Overcoming Anxiety, Program 12: Overcoming Depression and Program 15: Overcoming Grief And Bereavement.

One of the common symptoms of panic disorder is worrying excessively that there is a physical illness.

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2. The Causes and Treatment of Panic Disorder

Panic disorder can run in families due to genetic inheritance and/or the experiences of family life. Distressful early life experiences can lead to vulnerability to panic disorder as well as many other emotional problems.

Factors in later life include:

Psychological factors – sufferers of panic attacks tend to have a negative thinking style.

Social factors – people from all walks of life develop panic disorder but women are more vulnerable than men.

Physical factors – in panic disorder the ‘fight, flight, freeze or faint’ response to threat is set into action without an appropriate reason. Some people may have a lower ‘trigger’ threshold or their control mechanism to stop the ‘fight, flight, freeze or faint’ response may be less efficient.

You should check with your doctor that a physical illness is not the cause of your panic disorder. A person may suffer from both a physical illness and panic disorder and need treatment for both but usually there is no physical illness causing the panic disorder.

Hyperventilation is a trigger for panic symptoms as is misuse of alcohol, drugs and medications.

See Program 4: Overcoming Addiction.

Factors which may cause a vicious cycle to be set up that maintains panic disorder are:

Psychological factors – life stresses and poor coping ability, fear of illness and further panic attacks, negative thinking.

Social factors – pressures at work or at home, chronic stress, reducing leisure time for work, becoming socially isolated.

Physical factors – hyperventilation, insufficient sleep, overexertion, poor general health, misuse of alcohol, drugs or stimulants such as caffeine and nicotine.

Medications for the treatment of panic disorder are usually the minor tranquillizers (benzodiazepines) and the tricyclics (TCA's) under the direct supervision of a medical practitioner. The newer medications include selective serotonin reuptake inhibitors (SSRI's) and the reversible mono-amine oxidase inhibitors (MAOI's). Other medications include beta-blockers and Buspirone. In the short-term medications can be useful but in the long-term there may be side effects, dependence and they do not enable you to learn to control your problem.

Various psychological treatments can be used to treat panic disorder, in particular cognitive behaviour therapy. A combined treatment may be required in cases of severe anxiety where medication is needed to reduce the levels of anxiety so that psychological treatment can be applied. Over 80% of people find cognitive behavioural approaches produce noticeable and lasting improvement.

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3. Identifying When You are Anxious

It is important that you learn to differentiate between the symptoms of anxiety and those caused by physical illness. When a diagnosis is made several symptoms that occur in a regular pattern are identified bearing in mind that these symptoms vary slightly for each individual.

Write down your general pattern of symptoms when you are anxious. Make a list of your major symptoms of panic and in future remember these are symptoms of panic and not physical illness.

Monitor your panic attacks to identify panic triggers. For a few weeks note in a diary, the date, situation and the trigger. Rate your anxiety symptoms 0-10 (0 is the least possible symptoms and 10 is the worst possible symptoms). Rate your coping ability 0-10 (0 is worst level of coping and 10 is best level of coping). Also, note how you would have preferred to cope with each situation.

Find out what circumstances cause anxiety for most people by discussing this with others.

Some triggers of anxiety that may exacerbate your symptoms in particular situations are:

Inability to escape from a specific situation.

Embarrassment that others are aware of your distress.

Lack of possible help such as the company of a trusted friend.

Catastrophic thoughts such as ‘I’m going insane’.

Fear of losing control over your behaviour.

If you think of other triggers, list them on a separate sheet of paper. Make a list of situations in which you experience anxiety and identify the triggers that make your symptoms worse for each situation. List situations you have been avoiding or activities you are unwilling to participate in and rate them 0-10 (0 is no anxiety and 10 is severe anxiety).

See Program 1: Coping Strategies Counselling Advice – Problem-Solving and Planning an Activity Schedule.

A stressful and unhealthy lifestyle can increase your susceptibility to panic attacks. The panic attacks make the initial problems more difficult to solve and a vicious cycle is set up. You need to increase your resilience to daily stress.

There are two types of stress:

Mental stress – symptoms include worry, fears and low self-esteem.

Physical stress – symptoms include tiredness, headaches and stomach upsets.

Be aware that the mind and body are linked, so that you can improve your physical health to increase your resistance to stress.

See Program 22: Overcoming Stress and Program 23: Overcoming Stress At Work.

Regular exercise can build your resilience to stress. It is a good way of reducing your tension, meeting people and can help you sleep better. If you are just starting to exercise choose something you enjoy and do not overexert yourself – begin with gentle regular exercise and progress to more vigorous exercise when you feel ready. Try to have a routine and stick to it tolerating disruptions. Reward yourself for exercising. Agoraphobia may restrict you to exercising at home till you are confident enough to go out or you might ask a friend to accompany you.

Make sure that your diet is adequate and that you have regular meals. Reduce your caffeine, nicotine, alcohol intake and avoid drugs unless prescribed by a doctor. Eat enough fruit, vegetables and drink plenty of water. If you want to lose weight do this gradually.

See Program 1: Coping Strategies Counselling Advice – Nutrition, Exercise, Managing Your Time and Sleep Management.

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4. Coping Techniques for Panic Attacks

Use controlled breathing when you notice early symptoms of panic to prevent a full-blown panic attack. You need to practise this technique repeatedly for it to be effective.

See Program 1: Coping Strategies Counselling Advice – Controlled Breathing and Relaxation Techniques.

Another technique when you feel panicky is to place a small paper bag over your mouth and nose without any gaps so air cannot escape and breathe into it slowly and regularly until your panic subsides. Alternatively, you could try cupping your hands around your mouth and nose and breathing slowly.

Focusing on your symptoms worsens a panic attack – the following distraction techniques may be helpful:

Wearing a rubber band around your wrist and when you start to feel panicky, stretch it out and let it snap back onto the inside of your wrist. The pain caused by the band can distract you from the symptoms of panic and give you time to use some other technique if this alone in not enough.

You could try counting objects in your environment or multiplying numbers in your mind to distract yourself from the symptoms of panic.

On the early signs of panic try visualizing a pleasant or enjoyable scene in as much detail as possible. You will find it easier if you use the same scene every time.

Try intellectualizing the symptoms of panic by being objective about them – when anxious you could note your symptoms and fears rating their severity.

Everyday activities such as watching television can also be distracting.

List the distraction techniques rating them 1-10 for effectiveness (with 10 as most effective). This will clarify which techniques to use in future. Write down on a card all the techniques that help you to control your panic attacks and keep it close at hand for when you feel panicky.

Try to remain where you are for a while after your panic attack subsides so that you do not start avoiding the situation in future. Reward or praise yourself for coping with the panic attack. The occasional panic attack is to be expected and should be seen as only a minor setback and used to consolidate your skills.

See Program 1: Coping Strategies Counselling Advice – Distraction Techniques.

Develop your confidence.

See Program 1: Coping Strategies Counselling Advice – Assertiveness Training, Neuro-Linguistic Programming (NLP), Building Confidence I, Building Confidence II, Building Confidence III and Building Confidence IV.

Form a good support system.

See Program 1: Coping Strategies Counselling Advice – Social Skills Training, Communication Training, Negotiation Training, Troublesome Emotions and Program 13: Overcoming Destructive Relationships.

A positive body image will increase your self-esteem.

See Program 1: Coping Strategies Counselling Advice – Coping with the Need for Approval, Improving Your Self-Image and Combating Self-Harm, Criticism, Countering Self-Criticism and Program 16: Overcoming Low Self-Esteem.

For further coping strategies:

See Program 1: Coping Strategies Counselling Advice – Competitiveness and Perfectionism, Frustration, Procrastination and Persistence.

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5. Altering Negative Thinking Styles

Unhelpful thinking styles can make you susceptible to panic attacks. First you need to identify your negative thoughts, for example, ‘The pain in my chest means I am having a heart attack and will die’. Certain situations tend to be interpreted negatively.

See negative thinking styles in:

Program 1: Coping Strategies Counselling Advice – Modifying Maladaptive Thinking.

Next, challenge your negative thoughts by finding more positive alternatives. Consider the evidence for and against the negative thought, other possibilities and ask others how they interpret the situation. Write down the day/date, situation and related negative thought. Rate your anxiety level 0-10 (0 is no anxiety and 10 is extreme anxiety). Challenge the negative thought; consider an alternative – a positive/appropriate thought. Re-rate your anxiety.

Change negative thoughts to positive thoughts next time you come across a problematic situation. Think about and list the sorts of helpful thoughts you could say to yourself.

What advice would you give a friend in your situation? How would someone positive interpret the situation? Check your thoughts with a friend and look at your problem from different angles.

Try writing single positive thoughts on small cards to read when you feel you are reverting to negative thinking styles. Use your cards regularly until the positive thoughts become ‘second nature’.

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6. Managing Physical Sensations

Physical symptoms can trigger panic attacks and panic results in focusing on physical sensations – a vicious cycle is established. The individual with panic disorder tends to hold catastrophic beliefs about arousal-related sensations. They misinterpret benign arousal-related bodily sensations as indications of impending death, insanity or loss of behavioural control. Anxiety ensues leading to more vigilance over bodily sensations; escalated anxiety results, then a panic attack.

List the physical sensations that you link to symptoms of panic – nausea, dizziness, faintness, sweating, racing thoughts, palpitations, trembling, paraesthesia (numbness or tingling typically in the hands), stomach pain, chest pain, dyspnoea (laboured breathing).

Write down the activities or situations you avoid for fear of becoming too aroused and experiencing physical sensations that remind you of panic (e.g. you may avoid strenuous exercise or arguments).

Two methods to become less fearful of physical sensations that remind you of panic are:

Desensitization – consider your list of physical sensations associated with panic and think of ways of producing these sensations (e.g. rapid heart rate – physical activity, or dizziness – spinning with open eyes). Allow yourself to repeatedly experience the physical sensations while controlling your anxiety. As you do this and suffer no negative effects, your anxiety will dissipate. Excluding sensations produced by vigorous exercise, controlled breathing and shortened PMR can be used to control your anxiety levels. Implement a gradual step-by-step approach (e.g. increase your daily walking pace gradually until you experience some physical sensations then deal with these sensations).

Dealing with Catastrophic Thoughts – write down your physical sensation and related negative thought (e.g. rapid heart rate – ‘I am having a heart attack’). Note your challenging thought by questioning the evidence, looking for other possibilities and asking others for their interpretation of the situation. Try changing your negative thoughts to more positive, helpful thoughts.

Write down on small cards the techniques to use when you fear physical sensations, and keep these close at hand.

Practise both of the above techniques regularly to effectively challenge feared physical sensations. Note that your blood pressure must fall sharply for you to faint. During panic your blood pressure rises, so fainting and panic are incompatible – people with blood/injury phobia are an exception to this rule.

See Program 1: Coping Strategies Counselling Advice – Controlled Breathing and Relaxation Techniques, Eye Movement Technique (EMT), Mood Induction Procedure, Rational Emotive Imagery (REI), Imago Graded Exposure and In Vivo Graded Exposure.

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7. Conclusion

Your recovery will fluctuate but if you practise the techniques your anxiety level will gradually reduce so that the symptoms disappear completely. A relapse is a serious setback in contrast to the expected ‘ups’ and ‘downs’. The recurrence of external stresses is among the combination of factors that result in relapse.

To prevent relapse consider if there are new stresses in your life; if you are trying to progress too quickly; whether you are keeping a healthy lifestyle; whether you have stopped or changed your medication dosage; and is your thinking reverting to negative thinking styles?

If panic attacks continue seek advice from your doctor – remember you can deal with temporary setbacks by applying these techniques enthusiastically and can put yourself back on the road forward.

See Program 1: Coping Strategies Counselling Advice – Relapse Prevention.

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