Workbook 13

Panic
A self-help guide

Revised January 2024 v1

 Contents of
this booklet
 Introduction……………………………………………………3

 Panic attacks………………………………………………….4

 Stress and hyperventilation……………………………….....6

 Panic attack vs heart attack…............................................8

 What keeps panic attacks going?……………….…………10

 What might keep my panic attacks going…………......….14

 The vicious cycle of panic…………………………….........15

 My panic diary……………………..…………………….......18

 Facing your fears…………………………………………....19

 Graded exposure…………………………………………….21

 My graded hierarchy………………………………………...24

 My exposure diary……………………………………..........25

 Tips for dealing with panic………………………………….26

 Further resources…………………………………………....27

 Useful contacts……………………………………………....28

2
Introduction

Most people will feel anxious at some point in their

lives, but anxiety becomes a problem when it starts to Did you know?
negatively impact your day-to-day life.
1 in 6 people in the UK
This workbook will introduce tools in line with Cognitive Behavioural experience a common
Therapy, a treatment that is recommended by NICE (National mental health difficulty
Institute of Care Excellence) and backed by evidence as one of the like anxiety in any given
most effective ways to improve anxiety. week according to the
charity Mind.
What is anxiety?
Anxiety occurs when we perceive a situation or object as
threatening and we don’t feel we have the skills we need to cope
with it.

If something causes us to feel afraid or scared, then this can induce

physical symptoms known as the ‘fight or flight’ response.

This a response that has evolved to protect us from danger and

includes symptoms such as increased heart rate, feeling hot and
feeling a surge of adrenaline, among others. These physical
symptoms occur to help us either run away from danger or to
prepare to fight it.

The ‘fight or flight’ response is helpful if we are faced with real

danger but for most of us our daily lives do not present us with life-
threatening situations.

When we are faced with any situation that we don’t feel prepared to
deal with, the ‘fight or flight’ response can become activated. If
the situation is not physically threatening (e.g. giving a presentation
to a large group of people) this response is not helpful for coping
with the situation, and can actually be quite frightening.

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 What are
panic attacks?
How to recognise a panic attack
Fear and anxiety are normal emotions that most of us will experience
from time to time. Sometimes that anxiety can be so intense that we
experience a panic attack.

During a panic attack we may experience intense fear, terror and catastrophic
thoughts that occur suddenly and often peak within 5-10 minutes.

Panic attacks are not dangerous but often leave us feeling like something awful might
happen. If we have experienced a panic attack, we will want to avoid having another
one and so may change our behaviour to prevent it happening again.

Reflect
When you panic, can you relate to feeling any of the following:

• “I feel like I’m going crazy, like I’m going to lose my mind”

• “My heart is racing so fast”

• “I can’t breathe”

• “I feel so dizzy and lightheaded, I feel like I might faint”

• “I get sweaty or have flashes of hot and cold that leave me

clammy or cold”

• Do the feelings come out of the blue when you least expect them?

• Are you worried about these feelings coming back?

• Do you find these feelings stop you from doing things you want to do?

If you can relate to any of these feelings and are concerned about panic attacks, you
may find the strategies in this workbook helpful.

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What are
panic attacks?
How to recognise a panic attack
A ‘hot cross bun’ for a panic attack could look something like the below:

Thoughts
I’m having a heart attack
I’m losing control
I’m going to die

Physical
Feelings
Difficulty breathing,
Anxious, scared, dizzy, chest pains,
ashamed, frustrated, sweating, tingling,
upset nausea

Behaviours
Needing to escape,
avoiding/leaving
situations

Reflect
What thoughts cross your mind when you’re experiencing a panic attack?

How do you feel emotionally?

What physical symptoms do you notice?

What do you do?

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 Physical symptoms
of panic attacks
How panic attacks affect the body
An important part of changing our panic cycle is understanding why
our body responds in the way that it does.

Whenever we are anxious our mind tells our body to get ready to fight, take flight or
freeze in order to protect us.

Whether faced by physical threat where your life is in danger or another situation where
we feel anxious – that is not threatening – the same physical responses can be triggered.
This is known as the fight or flight response we touched upon on page 3.

The next few pages explain why we notice these symptoms, what those symptoms might
be and how these symptoms would be different from something like a heart attack.

Here are some common physical symptoms of anxiety and panic:

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Stress and
hyperventilation
Why do we experience physical
symptoms?
Overbreathing – or hyperventilation – means
breathing faster or more deeply than your body
needs.

The average adult will usually take around 15 breaths per

minute when relaxed and not engaging in physical activity.

When we are under stress, our ‘flight or fight’ response is

triggered and our breathing speeds up to inhale extra
oxygen and prepare our body for action.

As we are not actually running away from danger, we do not

use up this extra oxygen.

Because we’re inhaling more oxygen than our body needs, it

causes an imbalance in our body’s chemistry.

When we acquire more oxygen than we need, it builds up in

our blood stream over a period of time.

This build-up can happen gradually throughout the day while

we’re doing our daily activities, without us realising.

This can lead to a variety of symptoms such dizziness,

feeling faint, numbness or tingling, breathlessness or
tightness across the chest.

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Stress and
hyperventilation
Why don’t we always notice
hyperventilating?
When we may think of hyperventilation, we
imagine a person taking loud, rapid breaths;
however, it can also happen very slowly over a
period of many hours.

If we take a big deep breath in every hour during the day, it

could be that over many hours, we gradually take in more
oxygen than our body needs.

However, imagine that after a busy day, you are on the way
home and take a breath in, then start to notice these physical
symptoms.

This feeling might be due to the imbalance between oxygen

and carbon dioxide.

If you misinterpret these symptoms as a physical illness, you

could cause yourself further stress and distress and this
could lead to another panic attack.

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Panic attack vs heart attack
How do I know it isn’t a heart attack?
Some symptoms experienced during a
Physical Panic attack Heart attack
panic attack can feel similar to reaction
symptoms experienced during a heart • Pain usually described as ‘sharp’ • May or may not be present but usually is.
attack e.g. chest pain, so it’s If present, pain often described as a
• The pain tends to be localised over the
understandable that we may confuse heart
‘crushing’ or squeezing feeling (someone
Pain standing on your chest)
them.
• Pain is usually made worse by breathing in • Not usually made worse by breathing or
If your GP has ruled out heart disease it is very and out rapidly and pressing on the centre pressing on the chest
unlikely that the chest pain is caused by a heart of the chest
• Pain is usually persistent and lasts longer
attack. During a panic attack the symptoms than 10 mins
• Pain usually disappears within 5-10mins
usually last for up to 10 minutes and can be
Tingling • If present is usually present all over the • If present is usually in left arm or jaw
minimised with a slow breathing technique. If the
body
pain in your chest does not pass after ten
minutes of slow breathing, you are advised to Vomiting • Nausea may be present but vomiting is less • Common
seek medical advice. common
Breathing • Breathing too quickly or too deeply • Does not cause you to breathe too quickly
This table may be helpful in telling the symptoms
(hyperventilation) is an extremely normal or deeply (hyperventilation)
of a panic and heart attack apart. panic response which precedes most panic • May feel a little short of breath.
attacks
• It is possible to have a heart attack then
start panicking. In this case,
hyperventilation is a symptom of panic not
of the heart attack

Adapted from Andrews G and Jenkins, R, 1998, Managing Mental Disorders, (UK Edition) Sydney World Health Organisation Collaboration Centre for Mental Health and Substance Abuse.
 What keeps
panic attacks going?
Factors that keep panic attacks going
There are three main factors that can work
together to keep panic attacks going
1. Selective attention – scanning your body for symptoms
and sensations

2. Catastrophic misinterpretations – of bodily sensations

and what might happen

3. Safety behaviours – using avoidance or other

behaviours to help us cope

Selective attention
Research shows that those who experience panic attacks are
much more likely to notice physical changes in their bodies,
such as an increase in heart rate or a change in temperature.

Reflect
If you look for a symptom, the chances are that you will probably find it.

Try the following experiment:

Sit for two minutes and scan your body. See if you can find any part of your
body that is itching right now.

Did you find an itch? If yes, was that itch there before you looked for it?

The same applies to physical symptoms. If you search your body for the
symptoms, you will find something even if there is nothing wrong. Finding a
symptom will increase your anxiety and therefore increase your physical
symptoms.

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What keeps
panic attacks going?
Catastrophic misinterpretations
Symptoms of panic attacks are usually an
exaggeration of the normal bodily reaction to
a fearful situation.
As these symptoms can be very sudden, unpleasant and
frightening, people often misinterpret the symptoms to
mean that something catastrophic is happening. Common
thoughts might be ‘I am having a heart attack’ or ‘I am
going to pass out’.

The catastrophic misinterpretation is what drives the

panic cycle. If you can recognise that the uncomfortable
physical symptoms are not harmful, the vicious cycle is
broken and the anxiety does not become a panic attack.

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What keeps a panic attack going?
Panic symptoms Catastrophic Things to think about
misinterpretation
Pounding heart, palpitations, ‘I’m having a heart attack’ See page 9
chest pain

Shortness of breath ‘I’m going to suffocate’ or ‘I A common symptom of panic attack is rapid, shallow breathing. This can trigger other panic
can’t breathe’ symptoms e.g. dizziness, feeling faint and tingling sensations.
Feeling dizzy, unsteady or having ‘I’m about to collapse or Fainting happens when blood pressure suddenly drops. People who panic tend to experience
jelly legs faint’ high blood pressure and are unlikely to faint.
Pins and needles, numbness ‘I’m having a stroke’ This can be explained through ‘fight or flight’ and preparing our bodies for a threat. Our blood
rushes from our extremities to our vital organs to give them more oxygen
Racing thoughts ‘I’m losing my mind’ The thoughts occur as we focus internally

Blurred vision ‘I’m going blind’ Adrenaline causes our pupils to dilate to focus on long distances to help us plan as escape
(‘fight or flight’)
Feeling of unreality, lack of ‘I’m going crazy’ Feeling disconnected from your surroundings can make things seem different and sometimes
concentration people misinterpret this as a sign of a mental illness. Panic attacks don’t cause severe mental
illness
Sudden urge to go to the toilet ‘I’m going to lose control of This is unlikely to happen. Try considering if it didn’t happen last time, why would it happen this
my bowels or bladder’ time.
Nausea ‘I’m going to be sick’ Very few people have claimed to vomit as a result of a panic attack. Think about the number of
times you felt nauseous but didn’t vomit.
Intense physical symptoms ‘I’m going to lose control’ Did you do something completely out of control last time you had a panic attack? If not, why
would it be different now?
What keeps
panic attacks going?
Safety and avoidance behaviours
When a situation causes us anxiety, it is
completely understandable that we would try to
avoid that situation or adopt what is known as
safety behaviours to help us to cope.
Safety behaviours make us feel ‘safe’ in the anxiety-
provoking situation. They are behaviours that we perceive as
being helpful, as we feel that they make it less likely that
something bad will happen.

Avoidance and safety behaviours are helpful in the short

term, but in the long term they maintain our anxiety. This is
because we never have an opportunity to learn that nothing
catastrophic will happen. We begin to believe that the only
way we can cope with the situation is to use safety
behaviours and we rely on our safety behaviours more and
more. This reinforces the idea that our panic is dangerous
and should be avoided. This keeps the vicious cycle of panic
going. Examples of safety behaviours include:

• Over-preparing or over-planning to try and make the Reflect

situation more predictable.
A woman walks down
• Carrying anti-anxiety medication just in case you the road and sees a man
become anxious.
waving his arms in the
• Holding onto some type of support to prevent air.
yourself from collapsing when you become anxious.
“Why are you doing
• Always being close to an escape route, for example that?” she says.
sitting on the seat nearest the door on the bus/train.
“To keep away the
• Smoking a cigarette before entering an anxiety dragons” said the man.
provoking situation.
“But there aren’t any
• Seeking excessive reassurance or asking others to dragons” said the
make decisions for you. woman.

• Distraction such as listening to music, calling a friend, The man replies, “That
or trying to think about something else. just shows how well it
works”.

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 What might keep
my panic attacks going?
Take some time to think about the three factors that we have discussed
that keep panic attacks going.

What keeps my panic attacks going?

Selective attention –
scanning your body
for symptoms and
sensations

Catastrophic
misinterpretation –
of bodily sensations
and what might
happen

Safety behaviours –
using avoidance or
other behaviours to
help us cope

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The vicious
cycle of panic
How these factors can work together
We have talked about the role of catastrophic
misinterpretation, selective attention and
avoidance or safety behaviours. Now let’s look at
how these things work together to create a
vicious cycle of panic.

Example: Tim and transport

Tim had his first panic attack when he was on a
busy train.
He started to experience palpitations and became dizzy and
light-headed. He didn’t know what was happening and began
to feel very scared. He thought that he might be having a
heart attack and he thought he might die. Since this
happened, he has been avoiding public transport. Over time
he has started to avoid other situations too, such as busy
supermarkets.

See Tim’s panic cycle on page 16 and then use page 17 to

consider your panic cycle.

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 The vicious
cycle of panic
Tim’s panic cycle

Trigger
In supermarket notice my
heart has started racing

Perceived threat
There’s something wrong
Something bad is going
to happen

Anxiety

Catastrophic
misinterpretations Physical symptoms
“I’m having a heart Heart pounding, dizzy,
attack”. “I’m going to lightheaded
pass out”

Safety seeking
behaviour
Try to control breathing,
grip onto trolley, leave the
supermarket

16
The vicious
cycle of panic
My panic cycle
Trigger

Perceived threat

Anxiety

Catastrophic misinterpretations Physical symptoms

Safety seeking behaviour

17
My panic diary
Date Situation Physical Catastrophic Intensity of Behaviour – Alternative
symptoms misinterpretation panic (0- what did I do? explanations for
100%) symptoms
Example In town Heart palpitations, “I am going to die” 80% Left and went home Anxiety
fast breathing,
12th Oct shaking, sweating
Facing your fears

What do you think would happen?

What will happen to your anxiety if you face a
feared situation and stay in it?
Most people would say that they wouldn’t be able to cope,
the anxiety would just keep rising until eventually something
terrible happens such as passing out or having a heart
attack. We know this is in fact not the case.
We know that there is a release of adrenaline when we
become anxious which can impact our physical responses,
but we also know that we can only produce so much. So,
we also know that this adrenaline response and therefore
the physical symptoms will eventually reduce.
This graph shows what happens when we face an anxiety
provoking situation, and our response is avoiding the issue
– either by leaving or using a safety behaviour.
Each time we face that same situation our anxiety is equally
high the next time round:

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 Facing your fears
What would actually happen?
This graph shows what would actually happen if
we were to face an anxiety provoking situation
without the support of safety behaviours.

As you can see, anxiety goes up quickly when entering a

feared situation, but with time (usually after approximately
twenty minutes) will go down again.
With repeated exposure to the same feared situations, your
anxiety will become progressively less severe and more
tolerable. This process is known as ‘desensitisation’ or
‘habituation’, where the situation is so familiar that it no
longer appears threatening.
To overcome anxiety, you will need to actively let go of your
safety behaviours and confront the situations that you have
been avoiding. The thought of letting go of your safety
behaviours and avoidance may make you feel very anxious,
however by experiencing the anxiety provoking situation
without the help of safety behaviours and facing the
situation, you will begin to realise that you are able to cope
with it.

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Graded exposure
What is graded exposure?
Graded exposure is a technique that works by
breaking down our feared situations and confronting
them gradually.
By identifying situations which you avoid, and gradually
confronting them again and again, you can reduce the anxiety
associated with those situations. Using a graded exposure
hierarchy, we start with situations that are less anxiety provoking
and work up to more difficult situations. This helps us learn that
anxiety levels do come down if we stay in the situation and don’t
use safety behaviours.

See a graded hierarchy example on page 23.

The four rules of graded exposure

• Rule 1 – Graded
Exposure to anxiety provoking situations must be graded in
order of least to most anxiety provoking.
• Rule 2 – Prolonged
You need to ensure that your exposure to the situation is
prolonged. This means that you need to stay in that situation
until your anxiety has reduced by at least 50%.
• Rule 3 – Repeated
Repeat each exposure activity until your anxiety rating from
the start of the exercise has reduced by 50%. Once you have
achieved this, you can then move up to the next exercise on
your hierarchy.
• Rule 4 – Without distraction
It is important when using this technique to be aware of any
safety behaviours that you are doing, or anything that could
distract you from the anxiety. It’s important to truly feel the
anxiety in order to learn that your anxiety levels will reduce. If
it feels too difficult to drop safety behaviours initially then you
could start off by including them on the lower levels of your
hierarchy and gradually removing them within your hierarchy.

21
 Graded exposure
step by step
Step 1 – Plan your hierarchy
List all the things you are avoiding and rate how anxious or
uncomfortable those situations make you feel on a scale of
0-100 (with 100 being maximum anxiety).
Add these to the graded hierarchy template on page 24
to make your graded hierarchy.
Start with the easiest or least anxiety provoking situations
at the bottom, working up to the most anxiety provoking at
the top.

Step 2 – Begin graded exposure

The next step is to start deliberately exposing yourself to
the situations that you are avoiding.
Start with the easiest situation and keep repeating the
same step until your anxiety has at least improved by 50%.
Make sure you follow the four rules of graded exposure
from page 21.

Step 3 – Complete an exposure diary

Whilst completing your graded exposure, use the
exposure diary on page 25 to record how you find it.

Step 4 – Review and continue

Keep working up the graded hierarchy recording your
progress as you go.

22
Graded hierarchy example
See below an example of a graded hierarchy for anxiety when in
crowded places.

Situations Anxiety (0-100)

Going on a long train journey in rush hour 100

Going on a long train journey in the middle of the day 95

Going to a crowded train station 90

Going to a large supermarket at the busiest time of the day

80
and do my shopping

Going to a small supermarket at the busiest time of day to do

75
my shopping

Going to a large supermarket at a quiet time of day to do my

65
shopping

Going to a small supermarket at a quiet time of the day to do

60
my shopping

Going to a large café in lunch hour and having lunch 55

Going to a small café in lunch hour and sitting and having

50
lunch

23
 My graded hierarchy
Fill in the blank graded hierarchy below.

Situations Anxiety (0-100)

24
My exposure diary
Fill in the below exposure diary before and after you have placed yourself in an anxiety provoking situation. This can be
helpful so that you can see improvements with each repetition.

Date Duration Exercise/ Anxiety rating (0-100)

& (minutes) Situation Comments
Time Before At the start At the end
 Tips for
dealing with panic
• Remember panic feelings are normal symptoms of anxiety,
they are not dangerous

• Accept and face your feelings, notice that it is there and let
it go

• Monitor your level of anxiety: 10 (worst) to 0 (least), watch

the level go down

• Stay in the situation. If you run away, avoid or escape, it

will be more difficult in the future

• Take a few, slow, deep breaths from your stomach. Be

aware that this should not be used in relation to calming
yourself down during panic attacks; it should be used
regularly to help relax

• Make changes to your lifestyle, avoid stimulants such as

cigarettes, caffeine and alcohol and try to exercise regularly

• Eat regular meals and avoid processed foods and drinks as

this will keep blood sugar levels stable.

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Further resources

Workbooks
Centre for Clinical Interventions (CCI) – [Link]

A range of detailed resources and PDF workbooks available to download for free
focusing on a range of depression and anxiety related difficulties

Northumberland, Tyne and Wear NHS – [Link]

Self-help guides free to download by PDF and print on a range of difficulties including
anxiety and depression

Smartphone apps (found on Apple and Google Play store)

WRAP – Wellness recovery action app

Mood Tools – Depression aid

Fear Tools – Anxiety kit

Insight Timer – Meditation app

Websites
Mind – [Link]

Mental Health Foundation – [Link]

NHS – [Link]

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