For adults
Panic attacks and agoraphobia
Panic attacks follow a well-described pattern, and CBT for panic disorder is one of the most studied psychological treatments, recommended by NICE. This page explains the pattern and what treatment involves.
What a panic attack is
A panic attack is the body’s fight-or-flight response set off at full strength when there is no danger. Adrenaline is released within seconds, your heart speeds up, your breathing becomes fast and shallow, your hands tingle, the room feels unreal, and you may feel sure that you are about to die or lose control. It peaks within about ten minutes and subsides whether or not you do anything. The sensations are unpleasant, but they are not harming your body. It is the same healthy response that prepares you to run from danger.
Panic disorder develops when you start watching for the sensations. The body produces odd sensations all the time, such as a skipped beat after coffee or light-headedness on standing, and once you are watching for them each one reads as the start of an attack. That releases adrenaline, which produces the sensations more strongly, so fear of the next attack can itself become a trigger for one.
- Something feels wrong: A skipped beat or a light head feels like a warning
- Anxiety: Apprehension, and a surge of adrenaline
- Body sensations: Heart pounding, short of breath, dizzy, unreal
- What you think it means: “I’m having a heart attack” or “I’m losing control”
- Then back to the first step, and the loop runs again.
- Other situations that now set it off too: Supermarket queues, driving on the motorway, crowded trains, being far from home.
Where treatment steps in. You learn that you can stay with the sensations, without the precautions, and that they pass on their own. Bringing them on deliberately, for example by running up stairs, and dropping precautions such as sitting near the exit, also shows you what they lead to when you leave them alone.
New triggers. Over time, more situations become linked to the trigger and start the loop off too.
Why the precautions keep panic going
Most people with panic build up precautions, such as sitting on the aisle, carrying water or a tablet they rarely take, checking their pulse, or only shopping with a partner. They get you through, but they also stop you learning. You reach the supermarket with a way out planned, nothing happens, and you put that down to the precautions rather than to the fact that you could have managed the sensations without them. The learning comes when you start going without them, in graded steps that you choose. The worksheet on finding the things you do to feel safe helps you list your own and plan how to drop one.
How agoraphobia builds
Agoraphobia is rarely a fear of open spaces. It is the fear of being somewhere you could not easily leave, or get help, if the sensations started, such as motorways, trains, tunnels, a cinema, a supermarket queue or being alone in the house. Some people with agoraphobia have never had a full panic attack and fear being trapped or unable to cope. Each time you avoid a place the relief is immediate, which makes avoiding more likely, and the next similar place becomes harder, so the area in which you feel able to go shrinks over time.
What treatment involves
CBT for panic disorder is one of the most studied psychological treatments, and NICE recommends it (guideline CG113) for panic disorder, with or without agoraphobia. We start with a clear explanation of what adrenaline does, why over-breathing causes tingling and unreality, and why fainting during panic is very unlikely. Then you practise bringing the sensations on on purpose, by breathing through a thin straw, over-breathing for a minute, spinning in a chair or running up stairs, and staying put without your usual precautions. The main thing you learn is that you can have the sensations, feel the fear, and get through it without doing anything about it. Along the way you also see what the sensations lead to when you leave them alone, which is that they fade. Finally we return to the places you have stopped going. We build a list, such as the supermarket at a busy time, two stops on the train or the motorway junction, and you work through it, starting with a manageable step and dropping the precautions as you go. This part takes longer, and it is what widens where you can go.
When something else is in the mix
Where the fear is that the symptoms signal an undiagnosed illness, the picture overlaps with health anxiety. Where attacks only happen in social situations, it is usually social anxiety, and panic attacks also occur within specific phobias. The first session sorts out which applies, because the emphasis of treatment differs. If you take medication, please do not change it without speaking to your prescriber. I do not prescribe.
Sources
- Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470. doi.org (opens in a new tab)
- National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline CG113 (2011; checked 2020). nice.org.uk/guidance/cg113 (opens in a new tab)
Common questions
Can a panic attack actually harm me?
A panic attack is a full activation of the fight-or-flight response, with adrenaline, a fast heart, rapid breathing, tingling, dizziness and a sense of unreality. It is very unpleasant but it is not dangerous in a healthy person. You will not stop breathing, because breathlessness in panic comes from over-breathing. You are very unlikely to faint, because fainting requires blood pressure to drop and in panic it rises. It is worth getting new physical symptoms checked by your GP, and after that treatment focuses on the fear of the sensations.
What if I panic during a session?
Panic in a session is useful, because it gives us something real to work with and lets you practise staying where you are and letting it run its course, with me there. Later in treatment we bring the sensations on deliberately, through fast breathing, spinning or exercise, so that you can practise the same thing on purpose. Each step is agreed with you in advance, and you always know why we are doing it.
How long does treatment take?
There is no fixed number. NICE guidance (CG113) describes CBT for panic disorder as 7 to 14 hours in total, usually in weekly sessions over up to four months. Where agoraphobia has built up over years and the places you go have narrowed a lot, treatment can take longer, because each place is regained step by step. I give you an estimate by the end of the first session, and sometimes further assessment is needed before I can.
Free 20-minute call
Not sure whether this is the right fit?
Start with a free 20-minute call. We talk through what is going on, I answer any questions you have, and I tell you whether I think I can help. If I cannot, I will try to point you to someone who can. The call is free and there is no obligation to book.
Weekdays, 9am to 5pm. No GP referral needed.