Joe’s Experience of Panic

Joe is a 34 year old forestry worker. One day he had a panic attack out of the blue while queuing in a supermarket.  He started sweating, his heart was beating very fast and he was extremely dizzy.  He was convinced he was going to pass out and so he ran out of the supermarket, leaving his shopping behind.  As soon as he got out of the shop, he felt better.  Joe was very confused about why that had happened to him, and also embarrassed that he’d had to run out of a shop.  He began to worry that he might have another panic attack and started to feel anxious at the thought of going to supermarkets.  He decided that there was no need to go to supermarkets and instead went to his local shop when he needed something.  A couple of weeks later, Joe was driving to work on the motorway when he started to feel anxious and panicky.  As he was scared he might lose control of the car and cause a crash, Joe came off the motorway at the next junction.  Joe felt better straight away and decided that from then on he would not risk driving on the motorway.  Joe reasoned that since he might have a panic attack and need to leave places suddenly, it would be best to avoid busy places where it might be difficult to get out such as supermarkets, shopping centres, lifts, cinemas and the motorway. Joe’s wife began to get annoyed with him because the whole family had to make allowances for his anxiety.  In addition, Joe was becoming worried because he was avoiding more things over time and he wondered where it would end, and so he made the decision to come for a psychological assessment.

During the assessment, Joe and I discussed how his difficulties had progressed. We talked about what he wanted to gain from attending therapy and set his therapy goals, which included things like gaining confidence, using the motorway again and going for a date to the cinema.

Cognitive behaviour therapy (CBT) has a strong evidence-base for panic disorder and is recommended by the National Institute of Clinical Excellence (NICE) as the treatment of choice for this condition.  This approach was discussed with Joe and we agreed to meet for a course of CBT.

1)      Understanding the problem and what keeps it going

We began by considering what was causing and maintaining the panic.  We went through Joe’s experiences of panic in detail and learned that his panic attacks consisted of a) physical sensations and b) misinterpretation of those sensations as dangerous (this is called catastrophic thinking).  More specifically, the first time Joe had a panic attack, he was in a busy queue in a supermarket.  He was feeling stressed at the time because he had left work late and was worried he was going to be late home again, possibly resulting in an argument with his wife.  He was thinking about how he needed to get out of there as quickly as possible and he began experiencing a number of physical symptoms associated stress and anxiety, such as increased heart rate and sweating and dizziness. When this happened, Joe started to think about how faint he felt and how embarrassing it would be if he did so in front of the other people in the supermarket. These thoughts resulted in increased anxiety, further physical symptoms and further catastrophic thinking, with Joe thinking he was going to pass out for sure.  In order to prevent this happening, Joe left the supermarket and found that he felt better immediately, as he was no longer at risk of passing out and embarrassing himself.  While getting out worked to decrease his anxiety in the short-term, Joe then began to worry about going back to the supermarket, and so in the longer-term, the avoidance only served to increase his anxiety levels and likelihood that he would panic.  Therefore the areas we identified as important for intervention were catastrophic thinking and avoidance.

2)      Managing catastrophic thinking

We began by getting Joe to identify his thinking processes when he was stressed and anxious.  By doing so, Joe was able to recognise that when he noticed symptoms of anxiety, he started having a lot of catastrophic thoughts such as,“I am going to pass out”, “I am going to lose control”.  Next we looked at these thoughts in detail and considered how accurate these were.  For example, Joe was worried he was going to faint because his heart rate had increased and he felt dizzy. We investigated fainting and learned that people faint when their heart rate decreases and therefore it is almost impossible to faint when you are anxious and your heart rate is elevated (the one exception to this is blood-injury injection phobia so contact me if you wish to discuss this). As well as information about anxiety and panic, Joe was provided with techniques to help him evaluate his thinking and come up with more balanced alternatives and test these alternatives out.  Joe said he felt more in control as he realised that anxiety is a normal part of life and panic only occurs when thinking about sensations becomes distorted.

3)      Tackling avoidance

Now Joe had the necessary information and skills to manage his thoughts, the next step was for him to start doing the things he had been avoiding.  Joe was very anxious about the idea of this and so he did it in a graded way.  Joe was asked to think about all of the things he was avoiding and rate how anxious each one made him feel.  These were then placed on a list and Joe tackled them one at a time in order of difficulty.  Before doing each one, we would use the session to prepare for the task by predicting what he thought might happen and how he would manage if it did.  As a result of this preparation, Joe had the confidence to try things out as he had a detailed plan of what he would do to cope if he did become anxious.  He began by going into supermarkets when they were quiet and when he coped well with this, he went in at busier times.  Joe kept a record of his progress which also helped increase his confidence and spurred him on to try the next item on his list. When doing the early tasks, Joe continued to feel anxious but he learned that he could cope with anxiety and that it did not harm him.  By repeatedly doing the tasks, he became more confident in his ability to manage anxiety and panic and the sensations gradually reduced. By the end of his treatment, Joe had achieved all of his goals and felt confident in his ability to manage his mood.