CNWL Talking Therapies

Managing
panic
Workbook
My appointments:

…………………………………………………………
…………………………………………………………
…………………………………………………………
…………………………………………………………
…………………………………………………………

My main learning points:

…………………………………………………………
…………………………………………………………
…………………………………………………………
…………………………………………………………
…………………………………………………………

My weekly challenge:

…………………………………………………………
…………………………………………………………
…………………………………………………………
…………………………………………………………
………………………………………………………….

Crisis numbers:
Out of Hours Urgent
Advice Line: 0800
0234 650
Samaritans: 116 123
 What is panic?

Panic is a very high level of sudden uncontrollable fear or

anxiety. It is harmless though it serves an important
purpose; it makes our body respond and draws attention
to danger in what is known as the ‘fight or flight’
response. However, sometimes we can experience
feelings of panic out of the blue and may be unable to
identify a specific trigger.

Anxiety is a completely normal and natural response to

situations that we perceive as threatening. Everyone
experiences anxiety, although the level of anxiety and the
situations in which it presents itself can differ from person
to person. For example, some people are terrified of
speaking in front of a large audience, whereas other
people are able to do this and remain calm.

Fight or Flight

Anxiety serves a very important function – to

protect us from danger. When we are faced with a
threat our bodies produce a surge of adrenaline
that equips us to deal with that threat. This is
commonly referred to as ‘fight or flight’.

Imagine this scene: A

caveman is out hunting for
his dinner, when he is faced
by a hungry tiger.

What does he need to do in

order to survive?
He needs to either fight the tiger off or run
away!

In order to fight or flee, the body must prepare itself

in a number of ways:

 The brain sends messages to the body to

pump adrenalin into the bloodstream and
large skeletal muscles of the arms and legs
 As a result the heart pumps faster and needs
more oxygen
 The body needs to cool down so it may
sweat causing clamminess or capillaries
come to the surface of the skin resulting in
blushing
 To be as light as possible there may be a
need for the bowels to empty or frequent
urination to occur

In modern life it is very unlikely that we will be faced

with hungry tigers – but we are still exposed to real
or imagined threats or stressors in daily life and our
bodies respond to these with the same response. If
the situation is not physically threatening (e.g.
giving a presentation) then this response is not
helpful for coping with the situation and can actually
be quite frightening.
 What is a panic attack?

Panic attacks are common, they occur because we

interpret the symptoms of anxiety as threatening. During
a panic attack we may experience: intense fear, terror
and catastrophic thoughts that may occur suddenly
and often with little or no warning. The intense feelings
and unpleasant physical symptoms can peak within 5-10
mins and we may think that something awful is
happening or about to happen. We may behave in a
particular way to avoid these thoughts and unpleasant
physical symptoms returning.

Can panic feelings harm me?

The answer is no. They can feel extremely unpleasant
but we know that this is actually our body’s way of trying
to help us when we have identified something as
threatening. You may be more prone to panic attacks if
you have depression, anxiety, asthma, diabetes, are
taking stimulants (such as amphetamine or caffeine).
However, no one can die of fright no matter how
unpleasant the experience is.

The panic cycle

Once you’ve experienced a panic attack, you may be
frightened of having another one and become more
sensitive to the symptoms of anxiety. Focusing on slight
changes in our physical symptoms can increase our
awareness of them. Becoming more aware of these
changes can lead you to misinterpret a minor symptom
as a major threat, which can lead to a panic attack.
The situation is further complicated by the fact that when
most people have a panic attack, their natural reaction is
to try and leave the situation they are in as quickly as
possible, or avoid the situation if this can be planned.
This avoidance brings temporary relief in the short term,
but in the long term increases the likelihood of further
apprehension, negative thoughts, and unpleasant bodily
symptoms. This is because avoidance prevents you
from learning that the symptoms are not harmful.

Panic attacks are maintained by:

 Stressful events (triggers) that we perceive as a

threat
 Apprehension of something awful happening
 Unpleasant physical bodily symptoms and hyper
vigilance (scanning your body for symptoms and
sensations)
 Catastrophic misinterpretation of bodily symptoms
and worry about the consequences
 Avoidance and safety seeking behaviour that
prevents you from discovering that the
symptoms are not harmful.
 An event triggers the initial anxiety. The physical
and psychological symptoms of the anxiety are
then misinterpreted as signs of a disaster that is
about to happen. This ‘catastrophic
misinterpretation’ increases anxiety which, in turn,
makes the physical and psychological symptoms
worse.
 Trigger

Perceived threat
Avoidance

Catastrophic Apprehension
Misinterpretation

Bodily
Sensations

An event triggers the initial anxiety. The symptoms of the

anxiety are then misinterpreted as signs of a disaster that is
about to happen. This ‘catastrophic misinterpretation’
increases anxiety which, in turn, makes the physical
sensations worse.

Supermarket

Notice heart rate

increasing
Avoid supermarkets

“I’m going to lose control” Apprehension, Anxiety

Heart pounding
more
Sweating
 Step 1: Understanding Panic Symptoms

It is important to realise that the actual catastrophic

misinterpretation is what drives the panic cycle. If
you can recognise that the uncomfortable physical
symptoms of anxiety are not harmful, the vicious
cycle is then broken and the anxiety does not grow
into a panic attack.

The table below explains some misinterpretations

that we may have when experiencing panic:

Panic symptoms Catastrophic Reason this is

misinterpretation happening
Heart palpitations, ‘I’m having a heart Increase flow of blood
attack’ in the body

Chest pain ‘I’m having a heart Muscles held tight,

attack’ ready to fight

Shortness of breath ‘I’m going to suffocate’ Body trying to take in

more oxygen to fight
or run away
Feeling dizzy, ‘I’m about to collapse
unsteady or having or faint’
jelly
Pins and needles or ‘I’m having a stroke’ Hyperventilation
numbness
Head pounding/ ‘I’m losing my mind’ Increase in the
headache pressure of blood
flowing through the
body to provide more
energy

Blurred vision/ tunnel ‘I’m going blind’ Eyes trying to focus to

vision fight danger
 Unhelpful thinking
Some of the thoughts that we have in response to our
panic are unhelpful and unrealistic. These kinds of
thoughts involve thinking that something awful will
happen such as fainting or losing control if the panic is
faced. By using avoiding situations and misinterpreting
our anxiety symptoms, our anxiety worsens and we
never get the chance to overcome our fears and learn
that the worst isn’t going to happen.

Distinguish between a panic attack and a

heart attack

It is understandable to experience thoughts that

accompany our panic attacks such as ‘I’m losing control’
or ‘I’m going to embarrass myself’ though it is important
to remember that they are ‘catastrophic
misinterpretations’, largely misinterpretations of what is
actually going on.

Some symptoms experienced in panic are also

experienced during a heart attack such as chest pain,
and it is understandable that these can get mixed up.
However, if your GP ruled out heart disease it is very
unlikely that the chest pain is caused by a heart attack.
Physical reaction Heart attack Panic attack
Pain May or may not be Pain usually described
present. as ‘sharp’.
If present, pain often The pain tends to be
described as a localised over the heart.
‘crushing’ feeling Pain is usually made
(someone standing on worse by breathing in
your chest). Not made and out rapidly and
worse by breathing or pressing on the centre
pressing on the chest of the chest.
Pain is usually Pain usually disappears
persistent and lasts within 5-10 minutes
longer than 10 minutes

Tingling Tingling, if present, Tingling usually present

usually in the left arm all over the body

Vomiting Common Nausea may be present

but
vomiting is less
common
Breathing A heart attack does not Breathing too quickly or
cause you to breathe too deeply
too quickly or too (hyperventilation) is an
deeply extremely normal panic
(hyperventilation) - response which
panic does. precedes
most panic attacks.
With a heart attack you
may feel a little short of
breath. It is possible,
however, to have a
heart attack then you
start panicking. In this
case, hyperventilation
is a symptom of panic
not of the heart attack.
 Step 2: Identifying avoidance and safety
behaviours
When we experience anxiety it is normal for us to want
to avoid the anxious situation, as it acts as a way of
protecting ourselves from panic attacks when we feel
that something bad is about to happen. This leads to us
adopting anxious behaviours otherwise known as safety
and avoidance behaviours.

Safety behaviours are things that we do to prevent a

catastrophe that we think is going to happen as a result
of a panic attack. Avoidance behaviours are the things
that we try to avoid to prevent the catastrophe from
happening. It might make us feel better in the short term
by providing relief that we don’t have to be scared or
anxious, but in the long-term it reinforces the idea that
our panic is dangerous or a threat and should be
avoided.

Common Safety Behaviours

 Avoiding going into particular places such as
a busy supermarket
 Only going to places with someone else you
feel comfortable with
 Carrying anti-anxiety medication just in case
you become anxious (although you rarely
use them)
 Holding onto some type of support to prevent
yourself from collapsing when you become
anxious
 Opening windows to make sure you get
enough air
  Smoking a cigarette before entering an
anxiety provoking situation
 Seeking excessive reassurance or asking
others to make decisions for you

How am I going to overcome my panic attacks?

As we have already shown, our thoughts, behaviours,
emotions and physical symptoms are all interlinked and
affect each other. By targeting our avoidance and safety
behaviours it is possible to change how we think by
realising that the worst isn’t going to happen. This will have
a positive effect on how we feel physically and emotionally.
To do this, we need to gradually face our fear.

This can be a scary thought but this method of slowly

exposing ourselves to our fear is proven to effectively treat
panic. Here are some helpful hints before we get started:

 It is important to remember that anxiety can cause

people to think that they are going to develop a
physical or mental disorder or they will faint or lose
control. This is not the case; anxiety is a normal
reaction to something that we perceive as a
threatening situation.
 You will need to fill in a diary and record your
activities regularly
 It can be helpful to ask a family member or trusted
friend to assist you with the following exercises
Step 3: Recording your panic

A panic diary is a useful way of recording all the important

facts to help you challenge the thoughts that turn anxiety
into panic attacks. Try to complete the diary at the back of
the booklet after every attack or feelings of panic.

Step 4: Finding alternative responses for

catastrophic thoughts

Once you have filled in your diary, consider the last column,
‘alternative explanation for symptoms’ and reflect back to
the information at the beginning of this booklet. Consider
the following:

 Which of these symptoms can be attributed to anxiety

alone?
 Can you think of any ways that you are contributing to
making the physical symptoms worse once they have
started?
 Visit your GP if you feel there could be an underlying
physical health problem.

Tips for finding an alternative response:

 ‘Has my worst fear occurred with previous panic

attacks that I’ve experienced?’ Then consider: ‘Is it
likely that my worst fear will occur next time?’
 What would you say to a friend in your situation?
 Step 5: Graded exposure
When you use avoidance or other safety behaviours, your
anxiety drops right down. This works well in the short term,
but then the next time you enter that situation, your anxiety
is just as high as it was last time, if not even higher (see the
graph below).

1st time facing 2nd 3rd

fear
A
n
x
i
e
t
y

Avoidance

Exposing ourselves to our fear is a way of experimenting

and testing out whether what we think will happen is true or
false. Anxiety is a natural response to feared situations.
When we are in our feared situation for a sufficient amount
of time, our anxiety actually reduces. The more time we
spend exposed to our fear and the more often we do this,
the more that our anxiety reduces over time. This process is
called ‘habituation’ and is very effective for treating panic.

By targeting our avoidance behaviours it is possible to change how we

think by realising that the worst isn’t going to happen. To do this, we
need to gradually face our fear. This can be a scary thought, but we do
this in a very gradual and manageable way.
Have a look at the following graph:

1st time facing fear

2nd
A
n 3rd
x
i 4th
e 5th
t
y

Time

The first time the fear is confronted, the anxiety is high

and it remains at a peak for a short while before it
gradually reduces. By the fifth time that we expose
ourselves to our fear, the anxiety levels are much
less, experienced for a much shorter amount of time
and they reduce much quicker. The anxiety
continues to reduce until the fear is manageable.

To overcome anxiety you will need to actively let go of your

safety behaviours and confront the situation(s) that you
have been avoiding. The thought of doing so may make you
feel very anxious, but by facing the anxiety-provoking
situation without the help of safety behaviours, you will
begin to realise that you are able to cope with it.

By gradually confronting situations you avoid again and

again, you can reduce the anxiety associated with those
situations. This technique is known as graded exposure.
This involves gradually facing your fears, starting with the
least feared situations, and working up to the more difficult
ones. You will need to stay in the situation and endure it
until your anxiety has dropped by half, otherwise this drop
may be attributed to leaving the situation and you won’t
learn that you can indeed cope with the situation.

Creating a list of feared situations or objects

The idea is to gradually expose yourself to the situation step

by step. So, if you feared going to particular places such as
the supermarket the first step might just be thinking about
going shopping alone. The final step might be going
shopping alone at a busy time.

Graded Hierarchy: Example

Situations Anxiety
(0-100)
Going to the supermarket alone at a busy 100
time
Going to the supermarket with someone 90
at a busy time

Going to the supermarket alone at a less 75

busy time
Going to the supermarket with someone 60
at a less busy time
Going to the local shop alone when busy 45

Going to the local shop alone when less 35

busy
Imagining going shopping alone 20
There are 4 principles to graded exposure that we need
to keep in mind:

 Graded: We don’t want to be putting

ourselves into our worst situation, as when we
experience high levels of anxiety, no new
learning can occur. We always want to grade
our exposure so that we are only provoking a
manageable level of anxiety.
 Repeated: Each stage of our hierarchy needs
to be repeated until our anxiety feels like it has
come down considerably when we enter the
situation. This usually can take between 4 – 8
times.
 Prolonged: Rather than setting a time limit for
how long we would stay in the situation, we
need to try and stay in the situation each time
until we feel our anxiety has come down by
half. Sometimes it is difficult to prolong the
situation, and if this is the case, then we need
to make sure our exposure to the situation
repeated more.
 Without distraction: We need to ensure we
are carrying out the steps on the hierarchy
with as few safety behaviours as possible.
Feared situations Anxiety (0-100)
 Key principles to remember:
Start with the easiest
Do it regularly each week
Stay in the situation
Drop the safety behaviours
Reconsider the worst that could happen
Avoid distraction
Remember useful ways to cope with
panic attacks

1 Remember panic feelings are only normal

reactions that are exaggerated, they are not
dangerous
2 Panic attacks and feeling of anxiety are not
harmful and nothing bad will happen
3 Notice what is happening in your body now, not
what you fear might happen
4 Stop adding to the panic with frightening
thoughts and where it might lead
5 Accept and face your feelings. Let them run
through your body and you will become less
intense. Try not to fight the panic, float over it

6 Monitor your own level of anxiety: 10 (worst) to

0 (least). What the level go down

7 Stay in the situation. If you run away, avoid or

escape, it will be more difficult in the future

8 Consciously relax your muscles and drop your

shoulders
9 Make changes to your lifestyle. Avoid
stimulants such as cigarettes, caffeine and
alcohol
10 Eat regular meals and avoid processed foods
and drinks as this will keep blood sugar levels
stable. Try to exercise regularly
 Panic diary
Copy and use the diary whenever you feel panicky.
Remember to complete the final column and record
a helpful response to catastrophic misinterpretation.

Date Situation Physical Intensity Behaviour Alternative

symptoms of panic – what did explanations
I do? for
0-100% symptoms