A panic attack is a discrete period of severe fear or discomfort that can last from several minutes to a few hours. Physiological symptoms include chest pain, dizziness, rapid heartbeat, breathlessness and choking feelings. Psychological symptoms include a sense of doom, an urge to escape from the current situation and difficulty in focusing which may extend to a sense of losing consciousness. You might feel afraid of losing control in some way such as fainting or being sick and ultimately of going mad or dying. It can be a terrifying experience.
Panic attacks are often the result of an anxiety-provoking situation, such as being in a confined space, although sometimes they may be triggered by something you are not aware of, for example, standing up too quickly leading to a feeling of dizziness. This can make you feel even more out of control as attacks seem spontaneous and unpredictable. The resulting concern about additional attacks can lead you to avoid situations where panic attacks have occurred. Approximately half of all panic sufferers develop the symptoms of agoraphobia, and research suggests that agoraphobia may be secondary to the fear of having a panic attack in a situation from which escape may be difficult (Gassner, 2004).
The Fight or Flight Response
Cognitive behavioural psychologists suggest that panic attacks result from the misinterpretation of normal symptoms of anxiety or the ‘fight or flight’ response. Everybody will at some time have experienced this. It is a survival mechanism which has evolved in humans to enable us to protect ourselves from harm, either by defending ourselves or by running away. It is automatically activated when an individual perceives danger, generating bodily sensations and temporary psychological disturbances which are unpleasant but harmless, for example:
* Our heart beats faster and harder to pump more blood to our muscles for running and fighting.
* Our breathing rate increases to take in more oxygen for the blood and muscles.
* Sweating cools the body down.
* Blood is pumped from the head and stomach to the arms and legs leading us to feel dizzy and sick, and we find it hard to think straight.
Problems arise when the panic sufferer interprets these sensations as symptoms of a more dangerous condition such as a heart attack. Frightening automatic thoughts like "I am having a heart attack and I am going to die" lead to further alarm and an increase in fight or flight symptoms. This reinforces the notion that something dangerous is happening and the sufferer becomes caught in a vicious circle. Some individuals hyperventilate when under stress, and as the effects of this are like those of anxiety they too are interpreted as dangerous.
Once the vicious circle has been established, the panic sufferer often develops further behaviours which act to maintain their difficulties. You may become hypervigilant, constantly scanning your body for physical sensations which you may otherwise have been unaware of. You may start to avoid situations where you have previously had a panic attack. This prevents you from disproving your predictions that you are going to faint or die, and in this way your assumptions that the fight or flight symptoms are dangerous are reinforced. You may also develop what are known as 'safety behaviours' - these are ways in which panic sufferers reassure or distract themselves when facing an attack, such as monitoring one's heart rate or reading a newspaper. You may begin to believe that you somehow prevented the imagined catastrophe by using your safety behaviour, for example, "if I hadn't monitored my heart rate I may have had a heart attack". This maintains the vicious circle in the same way as avoidance in that the catastrophic predictions are not disproved.
Research evidence indicates that cognitive behavioural therapy (CBT) is the most effective psychological treatment for panic disorder (Department of Health, 2001). The first step is to target the misinterpretations of physical symptoms. When working with panic, I start by mapping out together with you the sequence of a recent panic attack using the 'vicious circle' model. This is important in helping you to understand your symptoms and begin to accept them as a normal evolutionary function rather than as being dangerous.
Next, I will help you identify and challenge your assumptions about your symptoms. If you experience frightening images I may help you alter these using techniques from neuro-linguistic programming (NLP).
The next step is to focus on enabling you to disprove your predictions. I will help you to construct a hierarchy of situations that you have been avoiding since the panic attacks started. Over several weeks we will devise together some behavioural 'experiments' for you to try out between therapy sessions which involve gradually exposing yourself to your avoided situations, starting with the least anxiety-provoking. We will also try to identify together and work towards reducing any safety behaviours you have been using. For clients where hyperventilation is a key feature, I may include some training in how to control and deepen one’s breathing.
A final step in therapy will be to identify and challenge any underlying beliefs which may have predisposed you to developing panic attacks. This will take the form of a less structured exploration of your background and outlook on other problems. There may be common themes or assumptions which emerge, such as an assumption that problems always get worse and they last forever. Some people have learned "rules" about physical symptoms either from their parents, or as the result of past traumatic experiences such as the sudden death of a significant other. Helping you become more aware of your unconscious assumptions and beliefs can not only help prevent a recurrence of future panic attacks, but also improve your sense of wellbeing and emotional stability across many other aspects of your life.
American Psychiatric Association (1995). Diagnostic and Statistical Manual of Mental Disorders (4th edition, Text Revision). American Psychological Association: Washington, DC.
Barlow, D.H. (2002). Anxiety and its disorders: the nature and treatment of anxiety and panic (2nd ed.). New York: Guilford Press.
Department of Health. (2001). Treatment choice in psychological therapies and counselling: evidence based clinical practice guideline. London: Department of Health.
Gassner, S.M. (2004). The role of traumatic experience in panic disorder and agoraphobia. Psychoanalytic Psychology, 21, 222-243.
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