Revised 2022

WOODFIELD TRAUMA SERVICE

CNWL

Panic protocol

Kerry Young, Zoe Chessell, Millay Vann, Francesca Brady, Sam Akbar, Amy
Chisholm,
2022

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Kerry Young, Sam Akbar, Zoe Chessell, Millay Vann, Francesca Brady & Amy Chisholm hereby assert
their rights to be identified as the authors of these materials
 Revised 2022

Panic Protocol – Only use in stabilisation if relevant

Aims:
• To help clients understand what causes their panic attacks and how to manage them when they
occur.

Achieve this by:

• Bringing their panic cycle to the client’s attention.
• Education on fight or flight.
• Discuss catastrophic thoughts and agree an alternative explanation for physical sensations.
• Teach a breathing technique.

This is a one-session protocol to be used once it has been established that the client experiences
panic attacks.

Before beginning this protocol, please check with your client and supervisor that what they are
experiencing is in fact panic attacks, as opposed to a severe physiological response to trauma
memories (though trauma memories certainly can be part of what causes panic attacks). A panic
attack is a sudden surge of intense fear which is accompanied by strong physical feelings (such as your
heart beating rapidly, or finding it hard to breathe) AND CRUCIALLY, catastrophic misinterpretations
of these symptoms (such as thinking that you will lose control or die).

Text in italics are what to say to the client.

Text highlighted in yellow tells you what materials are required at each point.

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Kerry Young, Sam Akbar, Zoe Chessell, Millay Vann, Francesca Brady & Amy Chisholm hereby assert
their rights to be identified as the authors of these materials
 Revised 2022

Session One

What you will need:

Physical symptoms diagram
Blank panic cycle

1. Introductions and setting up the session

‘Previously you have told me that you experience panic attacks/episodes/whatever term they used to
describe the attacks. Today, we want to focus on those panic attacks to try and help them occur less
often and to help you manage them when they occur. Does this sound like something that you would
like to do?’

Check if they have any questions.

2. Set agenda: (have this on the table between you and the client if a face to face appointment)
• Talk through a recent example of a panic attack and draw out a panic cycle.
• Explain fight or flight response.
• Discuss catastrophic thoughts and agree an alternative explanation.
• Teach a breathing technique.
• Is there anything else you would like to discuss?

3. Discussion of a recent example

‘Let’s talk through the last time you had an attack. When did this occur?

Ok, can I get you to cast your mind back to that day, what time of day was it? What happened before
the panic started/how were you spending your time? Once the panic started:
i. What was the first physical thing that you noticed inside your body?
ii. When you noticed this feeling in your body, what ran through your mind? (If appropriate) did
you get a picture of that inside your head?
iii. When you thought [repeat back what they said] how did you feel emotionally?
iv. When you felt [repeat back what they said] emotionally, what did you notice in your body?
v. When you noticed this feeling in your body, what thoughts ran through your mind?

Keep going, cycling through i-v until the vicious cycle joins back up – it may do so after the first time
you cycle through i – v or it may take more. Whilst talking through the recent example by asking the
above questions, fill in the panic cycle diagram. Follow the prompts in the boxes as a guide.

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Kerry Young, Sam Akbar, Zoe Chessell, Millay Vann, Francesca Brady & Amy Chisholm hereby assert
their rights to be identified as the authors of these materials
 Revised 2022

After you have done this, ‘This cycle is called a vicious cycle as it continues to go around and your
symptoms will keep getting worse. We need to interrupt the cycle and find a way to stop it repeating.
The way that these cycles work mean that you keep going around and around and the thoughts,
emotions, and physical responses get worse and worse. This results in you, understandably, feeling
terrible and afraid.’

SITUATION

What happened right before the panic attack? Where

were you? Did you notice any triggers? What set it off?

Physical Feeling: Alarm reaction

Then what happened to your body?

Thoughts Anxious Thoughts

So you were thinking [what they said] After you noticed those sensations, what
and your body was [what they said], thoughts went through your mind?
what ran through your mind then? If
appropriate - Did you get an image of (Give examples if they can’t come up with
that inside your head? them: eg ‘I’m having a heart attack, I’m going
to die?’)

Emotions
Physical Feeling
When you thought [repeat back what they said]
When you felt [repeat back what they said]
how did you feel emotionally?
emotionally, what happened to your body?
(Reinforce: “of course you were afraid, you were
thinking x would happen, that sounds terrifying”)

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Kerry Young, Sam Akbar, Zoe Chessell, Millay Vann, Francesca Brady & Amy Chisholm hereby assert
their rights to be identified as the authors of these materials
 Revised 2022

4. Explaining fight or flight

‘I want to explain to you the reason why our bodies have these physiological reactions when we
experience fear or anxiety. When we experience something that it perceives to be dangerous, our body
gets itself ready to act to keep us safe. We call this the ‘fight or flight’ response; your body prepares
you to fight or run (called ‘flight) when it believes that something is dangerous. If your brain thinks that
you can run away from the danger, it prepares you by increasing your heart rate, increasing your
breathing rate, and causing your arm and leg muscles to tense. This is so more blood can get to your
muscles, more oxygen can get into your blood and your muscles are prepared to run. It also stops any
inessential activity including digestion, contracting muscles in your bladder and bowel. This can lead
you to feel sick, get a strong feeling of needing to/or actually urinating or defecating. I would like to
show you this diagram to illustrate the ways that our body responds when it thinks there is danger.
Discuss the physical symptoms handout.

These processes are all in place to help you survive danger. These processes are very helpful if the
danger is a physical object (for example, a car speeding towards you or an attacker) but these physical
responses can also be triggered by a frightening thought, when you are not actually in danger. If what
you are frightened of happening is related to how your body is feeling, such has a racing heartbeat,
and then you have a fearful thought, this make your heart beat even faster. (For example, if you
think ‘my racing heart means I am going to die or have a heart attack’, then your panic response will
get even worse because of that thought).

Can you see how this cycle is going round and round for you?

If no: find where the confusion is taking place and help them to understand it.

‘There are two main places where we can help to break the panic cycle. These are:

1) Right after your anxious thoughts (on the right of the cycle), before the following physical
responses (at the bottom of the cycle) – by challenging those thoughts.
2) Right after your first physical sensations (at the top of the cycle), before your first anxious thoughts
– by calming down our breathing.

5. Catastrophic Misinterpretation of Symptoms (‘Anxious Thoughts’ box)

Identify what the misinterpretation of the physical symptoms are (e.g. believes that increased heart
rate means heart attack rather than exertion/fight or flight response).

Signify these anxious thoughts on the panic cycle by using a red cross:

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Kerry Young, Sam Akbar, Zoe Chessell, Millay Vann, Francesca Brady & Amy Chisholm hereby assert
their rights to be identified as the authors of these materials
 Revised 2022

Then discuss the following information:

If misinterpretation is to do with the heart:

‘Do you know what causes heart attacks? Heart attacks are caused by blockages in the blood vessels
that supply the heart: they are not preceded by a racing heart.

When you experience a ‘fight or flight’ response, the body produces a hormone called adrenaline…this
sets off the whole reaction I have just shown you (refer to physical symptoms handout if needed).
Adrenaline causes your heart rate to increase. It is also what they give patients in hospitals to re-start
their heart in the case of the heart stopping. So adrenalin actually starts the heart not stops it, so this
means that it is not possible for you to die or have a heart attack due to your heart beating quickly
when you are afraid. It is really very normal and common that most people we work with have a racing
heart when they have frightening memories.’

If misinterpretation is to do with breathing:

‘As part of the fight or flight response, your breathing rate will also increase to get more oxygen around
your body. When we breathe too fast (often called hyperventilation), it can lead to feelings of anxiety,
dizziness, tingling in your hands and feet. These feelings are caused by a temporary imbalance in the
gases in the blood and are not dangerous – they cannot kill you. '

With regards to everything that I’ve just explained, what do you think will be helpful to tell yourself
next time you experience a panic attack?’

Validate their answer and suggest any of these if needed:

I’m not having a heart attack.
My heart is not going to stop.
It is physically impossible for me to have a heart attack because of adrenaline in my body.
I am not going to suffocate.
I am getting a lot of oxygen meaning that it is not possible for me to die.

Write this helpful alternative explanation next to the red cross on the diagram.

6. Teach breathing technique

Signify panicked breathing on the panic cycle by using a red cross (if relevant):

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Kerry Young, Sam Akbar, Zoe Chessell, Millay Vann, Francesca Brady & Amy Chisholm hereby assert
their rights to be identified as the authors of these materials
 Revised 2022

‘Now, I am going to teach you a breathing technique which you can use to help regulate your breathing
and bring your oxygen levels back to normal. I will do it with you so don’t worry. I want you to hold
one nostril closed with your finger, close your mouth and breathe through the open nostril. The key
is to try and breathe without making a noise. This controls the flow of oxygen into your body and stops
the hyperventilation symptoms, like dizziness and tingling.

Do this together for 2-3 minutes.

What did you notice in your body whilst you did that?

Validate answer.

This technique slows your breathing down which also has the effect of slowing your heart rate down.
It will also rebalance all of the gases in your blood stream, which will help you to stop feeling dizzy or
tingly. Next time you feel like you might have a panic attack, why don’t you try using this breathing
technique and by telling yourself [whichever helpful thought they had agreed on].

Ending the session:

• Review what was discussed and answer any questions
• Check that they know what to do if they experience a panic attack and ask if they are comfortable
doing this
• Schedule next appointment and confirm that you’ll check in with the panic attacks in the next
session

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Kerry Young, Sam Akbar, Zoe Chessell, Millay Vann, Francesca Brady & Amy Chisholm hereby assert
their rights to be identified as the authors of these materials
 Revised 2022

Physical Symptoms Handout

Dizzy/Faint: increased heart rate

and breathing leads to extra
oxygen in our blood, which can
make us feel dizzy or faint.
Quick & Shallow Breathing: our
breathing increases in order to inhale
more oxygen to prepare us when we
think we are in danger. This can Increased Heart Rate: our heart
make us feel dizzy. beats faster to pump more oxygen
to the muscles needed when we
think there is a danger.

Stomach Butterflies & Feeling Sick: digestion Tense & Shaking Muscles: our muscles
of food in our stomach stops as energy is will automatically tense in order to
directed to our muscles to prepare us to fight prepare us to fight or run when we think
or run. This leads to a feeling of butterflies in we are in danger
our stomach or nausea.

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Kerry Young, Sam Akbar, Zoe Chessell, Millay Vann, Francesca Brady & Amy Chisholm hereby assert
their rights to be identified as the authors of these materials
 Revised 2022

Blank Panic Cycle Diagram

SITUATION

What happened right before the panic attack? Where

were you? Did you notice any triggers? What set it off?

Physical Feeling: Alarm reaction

Then what happened to your

body?
Anxious Thoughts
Thoughts
After you noticed those
So you were thinking [what sensations, what thoughts
they said] and your body was
went through your mind?
[what they said], what ran Images?
through your mind then? If
appropriate - Did you get an
image of that inside your
head?

Physical Feeling Emotional feelings

When you felt [repeat back what they said] When you thought [repeat back what they said]
emotionally, what happened to your body? how did you feel emotionally?

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Kerry Young, Sam Akbar, Zoe Chessell, Millay Vann, Francesca Brady & Amy Chisholm hereby assert
their rights to be identified as the authors of these materials