PANIC

PANIC STATIONSSTATIONS

Panic Stations
Module 2More about Panic
Introduction

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How do panic attacks happen?

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How does panic disorder develop?

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How is panic disorder maintained?

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What can be done about panic disorder?

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Monitoring your panic attacks

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Module Summary

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About This Module

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Module 2: More about Panic

Page 1PANIC STATIONSIntroduction
As we discussed in Module 1, panic attacks are surges of intense anxiety and fear. In panic disorder, panic
attacks seem to occur unexpectedly and cause considerable distress.
The aim of this InfoPax module is to provide you with some more detailed information on how panic
attacks actually develop. This module will also describe how panic attacks develop into panic disorder andwhat treatment strategies may be useful.

How do panic attacks happen?
In Module 1, we discussed how a panic attack can be described as a “false alarm”; a spontaneous surge offear without a real, physical threat. You might be wondering why panic attacks happen.
A particular person may have an initial panic attack (a false alarm) for a complex mixture of reasons. This
mixture probably includes a person’s biological make-up, their personality, and the tendency for the bodyto initiate a fear response. While these factors provide the setting for the possibility of a panic attack, one
thing that often sets the stage is a person’s experience of stress. Many people recall that their first panic
attack happened after a stressful period in their lives, such as after negative life events, or relationshipdifficulties, or significant loss. In people who have a greater likelihood of experiencing the fear response,going through this kind of stress can make a panic attack more likely. So for some people then, their
physical response to negative events may be similar to how they would respond to physical danger – as athreat to their well being.

PANIC STATIONS
At other times, panic attacks may begin to build when there is an internal or external trigger that isperceived as threatening. External triggers may be situations in which you feel a little apprehensive. For
example, going into a room that feels stuffy, or onto a train, or in a supermarket from which it may difficult
to escape. You can probably think of a few situations right now in which you often feel apprehensive.
Internal triggers might be thoughts, images, memories, and even bodily sensations. These triggers may be
ordinary events until you interpret them as somehow threatening. For example, have you ever felt tightness
in your chest, felt your heart beat faster, and thought “What’s wrong with me?” - which then leaves you
feeling quite anxious? Remember, it is our belief that something is threatening that leads to anxious feelings.
When we perceive a situation, thought, image or a sensation as
PANIC
somehow threatening, we begin to feel anxious or apprehensive.
ATTACK
More anxious
sensations
So, when we start to feel anxious, we may notice some physicalMorechanges, such as, accelerated heart rate, shortness of breath,worry
tightness in the chest, dizziness, etc. Normally these signs ofMore anxious
anxiety will soon subside or fade away on their own if the threat
sensations
Worry
is not a real one. However, what do you think would happen if,
about
sensations
before these sensations subside, you start worrying intensely
Anxioussensations
about the meaning of those sensations, such as thinking it might bea heart attack, or perhaps, that you are losing control or going
Anxiety
crazy? Such thinking would add to your fears and in response youranxiety would continue to build up? You can probably guess that
this extra layer of thinking produces a rush of increasing anxiety and it’s “PANIC STATIONS!”.
Think about it this way: what do you think would happen if you started thinking that you were going tohave a heart attack or going to faint? Your anxiety about these anxious sensations would probably increase,which makes the anxiety sensations stronger, which would increase your anxiety about those sensations,and so on. You can probably see where this situation is leading. The anxiety would rise so quickly that a“panic attack” would result.
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Page 2PANIC STATIONS
Restoration of the systems
Once the immediate danger has abated, the body begins a process of restoration back to a more relaxedstate. As a result, the heart rate begins to slow, breathing rate slows, the body’s temperature begins tolower and the muscles begin to relax. However, the systems involved do not return to normal straightaway. In primitive times, if a wild animal confronted us we would still need to remain prepared in case it
came back. Full restoration to a relaxed state happens slowly. This can leave the individual feeling ‘keyed up’for some time afterwards. This helps to understand why it is that people can feel anxious for ongoing
periods of time when no obvious stressor is present.

How does panic disorder develop?
As we mentioned, many people have panic attacks, but it becomes a problem when a person cannot
function adequately in their daily life due to the frequency and severity of symptoms. Now that we've talked
a little about how a panic attack develops, you may be wondering how someone develops panic disorder.
There’s no simple answer, of course, as everyone is different. However, there are some important factorsthat have been identified. These factors can generally be divided into biological and psychological causes.

BIOLOGICAL FACTORSNo single gene has been associated with anxiety or panic disorder, although based on twin studies andfamily studies, it does seem that individuals may inherit a vulnerability to developing an anxiety disorder. As
we mentioned earlier, some people may be physically more prone to experiencing a panic or fear response,
be it in response to physical threat or negative life events.

PSYCHOLOGICAL FACTORS
Having this vulnerability does not necessarily mean that someone will develop panic disorder. A great deal
depends on the person’s lifestyle, types of life stressors and early learning. For example, perhaps as a child
you were taught that certain changes in bodily sensations, such as those due to anxiety, were negative or
dangerous. Or perhaps you learned that if you had such sensations that you should rest, or be very
cautious about them. If you have not had the opportunity to unlearn these patterns of thinking andbehaviour, they may have continued to develop, contributing to your distress about panic symptoms.
Now let's say that, with these patterns of thinking and behaviour, you experience a false alarm. It's nosurprise then that you might become even more anxious and apprehensive about these bodily sensations.
Panic attacks can be very intense! When this apprehension about physical symptoms develops, a number ofpsychological factors can also contribute to frequent and severe panic symptoms.

Anxiety sensitivity
When someone experiences panic attacks and is apprehensive about them, it can be easy to associate mild
physical symptoms (such as an increase in heartbeat) with the possibility of intense panic symptoms or
believe that such symptoms might signal the onset of a heart attack or "going crazy". As a result, the person
can become very attentive to bodily sensations such as tightness in the chest, breathlessness, dizziness,sweating because they are worried about having a panic attack. They scan the environment for any situationor sensation that may indicate a potential episode of anxiety, in the hopes to avoid it.
This situation is like a smoke alarm that is ultra sensitive. It is so sensitive that its alarm system gets
activated at the slightest possibility of smoke. In fact, it is so sensitive it basically activates the alarm whenno danger is present (eg, when someone is cooking, or even when hot air escapes from thebathroom!). Something similar happens with a person who is anxiety sensitive. They
continually find themselves becoming anxious (activation of fight/flight alarm system) at theslightest suggestion of threat (eg. “I’m feeling hot - I might have a panic attack”).
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PANIC STATIONS
Focus on internal sensations
As mentioned, being sensitive to anxiety symptoms often results in the person scanning their environment
for possible cues for anxiety. Often this means focusing inwards and noticing all the different physicalsensations. By focusing on your own body reactions, such as sweating or trembling, it can be easy toconvince yourself that you have a physical problem (eg, “I’m having a heart attack”) or a mental problem(eg, “I’m going crazy”). This can start the panic cycle that we described previously, leading to more frequent
panic attacks.
So, what’s the end result? Well, because there seems to be no obvious external reason for the panic
attacks, they appear to be unpredictable and to "come out of the blue". They can also be very distressing
because of the intensity of the symptoms, because they are unpredictable, or because it is difficult to escapefrom places where they might occur. As we discussed in Module 1, these are the markers of panic disorder.

How is panic disorder maintained?
Once panic disorder develops, several factors contribute to the maintenance of panic disorder.

ANXIETY SENSITIVITY AND FOCUS ON INTERNAL SENSATIONS
We have discussed how these factors might influence the development of panic disorder. They also help tokeep it going. The more a person learns that anxiety symptoms may signal an oncoming panic attack themore focused they become on monitoring internal changes. Perhaps by doing this, there may be adequate
warning about the onset of a panic attack so that it can be avoided. When people believe that these
symptoms mean physical or mental danger, it is no wonder that they start scanning for signs of threat!
However, we all have normal fluctuations in physical symptoms over the course of the day, which meansthat even normal changes in physical sensations can be mistaken for the possibility of a panic attack or the
potential for mental and physical danger. It is the belief that those symptoms are dangerous that contributeto the ongoing distress associated with panic, and which might even make panic attacks more likely.

AVOIDANCE
Many people who have become distressed about the possibility of having panic attacks often avoid
situations where panic attacks may occur or activities that may trigger symptoms associated with panic.
While avoidance of some situations may reduce anxious feelings in the short term, it also reduces
opportunities to prove to yourself that anxiety symptoms are not dangerous. In other words, avoidance
prevents people from disconfirming their fears. The more we don’t do something, the more we tellourselves we can’t do something.

SAFETY BEHAVIOURS
Even if you don’t fully avoid the situations where you think panic attacks may happen, you may go into
these situations and behave in ways to minimise those anxiety symptoms. In Module 1, we talked about
how you might use “safety behaviours” to prevent future panic attacks or symptoms of anxiety. For
example, you might sit in the chair closest to the door to make a quick escape if necessary. Perhaps you dosome breathing exercises to reduce your anxiety in the situation. In this case, although you’re not avoiding
the situation, you are avoiding the anxiety symptoms. However, in using this subtle avoidance, these safety
behaviours, you never lose fear of your panic attacks. This means that you continue to worry about them,focusing attention to them.
Do you recognise any of these factors in how your own anxiety has developed?

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Page 4PANIC STATIONSWhat can be done about panic disorder?
MEDICATION
Medication has been used to reduce anxiety symptoms and reduce the likelihood that you will have panic
attacks. While there are a number of different medications that may help to reduce anxiety symptoms, it isoften difficult to know which one will work the best. You should always speak to your doctor if you haveany queries about medication, and if your doctor prescribes them, make sure you follow all the
instructions, and report any side effects.

COGNITIVE-BEHAVIOURAL STRATEGIESAnother powerful treatment option for reducing panic attacks is cognitive-behavioural therapy (CBT).
Cognitive and behavioural strategies address the three components that specifically contribute to panic andintense anxiety. You may recall from Module 1that these components include cognitions, behaviours andphysiology. In this way, cognitive-behavioural strategies seek to change the anxiety habits that may havedeveloped around panic and anxiety.

Cognitions
For people who experience panic attacks, cognitions can occur in the ‘here-and-now’ of the situation, andmay include focusing on physiological sensations of anxiety and panic, and then interpretingthem in a catastrophic way. Importantly, it is our perception of particular cues as
dangerous that contributes to increasing anxiety.
These cognitions are also part of a bigger picture of thinking processes. People who
experience panic attacks often worry excessively about anxiety symptoms. They may
overestimate the likelihood of having a panic attack and overestimate the consequences of having a panic
attack. It is this continued fear of fear that starts the feelings of anxiety, which then prompts the search forevidence of threat and danger. In these modules, we will take a closer look at the types of cognitions andthinking styles that might contribute to anxiety about panic symptoms.

Behaviour
One of the most important factors that needs to be addressed when overcoming panic and anxiety is the
avoidance of symptoms of anxiety, avoidance of situations where panic attacks might occur, and the use ofsafety behaviours to try to prevent panic attacks. These modules will suggest some ways to gently confront
the things you are avoiding so that you can start to feel less anxious about symptoms of panic attacks. Afterall, if you didn’t want to feel less anxious and panicky, chances are you wouldn’t be reading this information!

Physiology
Remember the physical symptoms that our bodies experience in reaction to anxiety-provoking events?
These include rapid breathing, pounding heart, sweating, clammy palms, and muscle tension. For somepeople, changing breathing patterns can help to show that anxiety symptoms are not dangerous because
they are under your control. However, we don’t want you to use breathing strategies, like the calming
technique, as a safety-behaviour to avoid anxiety. We want to first focus on experiencing those panic
sensations so that you have real proof that they are not dangerous.
On the next page is a worksheet that you can use to monitor your panic attacks.
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Page 5PANIC STATIONSMonitoring your panic attacks
Date:

Time:

Intensity (0-100):

Expected: Y

Indicate prominent symptoms:

N

Describe trigger: eg Where were you? What
were you doing? What were you thinking?

 Skipping/racing/pounding heart Dizzy, lightheaded, feeling faint Sweating

 Tingling or numbness

 Trembling/ shaking

 Hot flushes or chills

 Difficulty breathing Thoughts of losing control/ going crazy Choking sensations

 Fear of dying

 Chest pain/pressure/discomfort

 Feeling things around you are strange, Nausea/stomach problems
Date:

Time:

Intensity (0-100):

Expected: Y

Indicate prominent symptoms:

N

Describe trigger: eg Where were you? What
were you doing? What were you thinking?

 Skipping/racing/pounding heart Dizzy, lightheaded, feeling faint Sweating

 Tingling or numbness

 Trembling/ shaking

 Hot flushes or chills

 Difficulty breathing Thoughts of losing control/ going crazy Choking sensations

 Fear of dying

 Chest pain/pressure/discomfort

 Feeling things around you are strange, Nausea/stomach problems
Date:

Time:

Intensity (0-100):

Expected: YN Skipping/racing/pounding heart Dizzy, lightheaded, feeling faint Sweating

 Tingling or numbness

 Trembling/ shaking

 Hot flushes or chills

 Difficulty breathing Thoughts of losing control/ going crazy Choking sensations

 Fear of dying

 Chest pain/pressure/discomfort

 Feeling things around you are strange, Nausea/stomach problems
Time:

Intensity (0-100):

Expected: Y

Describe trigger: eg Where were you? What
were you doing? What were you thinking?

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unreal, detached, unfamiliar, or feelingdetached from your body

Indicate prominent symptoms:N Skipping/racing/pounding heart Dizzy, lightheaded, feeling faint Sweating

 Tingling or numbness

 Trembling/ shaking

 Hot flushes or chills

 Difficulty breathing Thoughts of losing control/ going crazy Choking sensations

 Fear of dying

 Chest pain/pressure/discomfort

 Feeling things around you are strange, Nausea/stomach problemsforCentrelinical
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unreal, detached, unfamiliar, or feelingdetached from your body

Indicate prominent symptoms:

Describe trigger: eg Where were you? What
were you doing? What were you thinking?

Date:unreal, detached, unfamiliar, or feelingdetached from your body

Module 2: More about Panic

unreal, detached, unfamiliar, or feelingdetached from your body

Page 6PANIC STATIONSModule Summary
Please remember that it is always important to ensure that you first have your symptoms
checked by a qualified health professional. Once you are sure that your symptoms are due toanxiety, then the information in the rest of these modules may help you to reduce your panic
symptoms and your anxiety about panic attacks.
•

Panic attacks are brief, sudden surges of intense anxiety, with symptoms that are very similar
to intense fear. Initial panic attacks, or “false alarms” can happen for a mixture of reasons
including biology, personality, and stress.
•

Panic attacks can be set off by internal or external triggers that the person believes issomehow threatening. The distress about having panic symptoms can creating an
increasing spiral of anxiety that builds quickly into a panic.

•

The body has mechanisms to naturally restore itself to a more relaxed state. However
this process is usually slow and can leave a person feeling “on edge” for quite some timeafterwards.

•

Many people have panic attacks, but panic disorder develops when it interferes significantly ina person’s life. Biological and psychological factors can influence the development of panic
disorder. Psychological factors include being sensitive to anxiety symptoms and focusing on
internal sensations.

•

Psychological factors also contribute to the maintenance of panic disorder. In addition toanxiety sensitivity and focusing on internal sensations, avoiding situations or activities, andusing safety behaviours to minimise anxiety symptoms all keep panic disorder going.

•

Medication can help to alleviate some of the symptoms associated with panic. Cognitive
behavioural strategies have also been effective in helping people to overcome panic disorder.
This includes targeting the thoughts and cognitions that fuel the maintenance of panic
disorder and addressing the behavioural aspect, such as avoidance and the use of safety
behaviours. In addition, once these strategies have been effectively used, some people mayfind changing their breathing patterns may help to reduce their overall anxiety.

•

It is important to monitor the frequency and duration of panic attacks so that you have someidea about whether these modules are helping you to overcome your panic.

In the next module wewill look at how
thoughts influenceemotions.

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About This Module
CONTRIBUTORSPaula Nathan (MPsych*)Director, Centre for Clinical Interventions
Adjunct Senior Lecturer, School of Psychiatry and Clinical
Neuroscience, The University of Western Australia

Dr Helen Correia (MApp Psych*; PhD)
Centre for Clinical Interventions*MPych/MApp Psych: Masters of Psychology (Clinical Psychology)

Some of the material in this module was taken fromNathan, P.R., Rees, C.S., Lim, L., & Smith, L.M. (2001). Mood Management – Anxiety: A Cognitive Behavioural
Treatment Programme for Individual Therapy. Perth: Rioby Publishing.

BACKGROUND
The concepts and strategies in this module have been developed from evidence based psychologicalpractice, primarily Cognitive-Behaviour Therapy (CBT). CBT for panic disorder is a type of psychotherapy
that is based on the theory that panic disorder is a result of problematic cognitions (thoughts) andbehaviours. There is strong scientific evidence to support that cognitions and behaviours can play animportant role in panic disorder, and that targeting cognitions and behaviours in therapy can help many
people to overcome panic disorder. Examples of this evidence have been reported in the following:
Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Panic
Disorder and Agoraphobia. (2003). Australian and New Zealand clinical practice guidelines for thetreatment of panic disorder and agoraphobia. Aust N Z J Psychiatry, 37(6), 641-56.

REFERENCES
These are some of the professional references used to create this module.
Barlow, D.H. (2002). Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic (2nd Edition).
London: Guilford Press
Craske, M.G., & Barlow, D.H. (2001). Panic disorder and agoraphobia. In D.H. Barlow (Ed.), ClinicalHandbook Of Psychological Disorders, Third Edition. New York: Guilford Press.

FURTHER READING
There have been many other information resources written for people with panic attacks and panic
disorder.
Barlow, D. H., & Craske, M. G. (2000). Mastery of your anxiety and panic (3rd edition). San Antonio, TX:
The Psychological Corporation. (ISBN: 0127850783)
Royal Australian and New Zealand College of Psychiatrists. (2003). Panic Disorder and Agoraphobia:
Treatment Guide for Consumers and Carers. Available: http://www.ranzcp.org/publicarea/cpg.asp (clickon “Panic Disorder and Agoraphobia”). Accessed Feb. 2004.
Zuercher-White, E. (1998). An End To Panic: Breakthrough Techniques For Overcoming Panic Disorder (2nd
Edition). Oakland, CA: New Harbinger Publications. (ISBN: 1-56731-3760)“PANIC STATIONS”
We would like to thank Uta Juniper for the title of the InfoPax that this module forms part of:Nathan, P., Correia, H., & Lim, L. (2004). Panic Stations! Coping with Panic Attacks. Perth: Centre for ClinicalInterventions.
ISBN: 0-9751985-8-0 Created: June, 2004.
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