Panic Attacks
Ruth was 34 years old when she experienced her first full-blown panic attack. It was not long after she had her second child, following a difficult pregnancy and birth. She was in a crowded supermarket on a hot summer's day and could not stop the baby screaming. Suddenly, she felt herself getting hot and light-headed. She could feel her chest getting tight, her heart beating faster and faster and she could hardly breathe. She suddenly thought that she might be having a heart attack or a stroke, because of the physical difficulties she had during childbirth. Her hands and feet started to tingle and she was convinced that she would faint and it would be awful.
She left her shopping trolley and rushed out to her car with her screaming child. She sat in the car in an acute state of anxiety. Finally she was able to call her a neighbour who worked nearby and who, fortunately, was able to come and meet her and take them both home.
On several subsequent occasions, for no apparent reason, Ruth had suffered further panic attacks. By the time she came for therapy, it had reached the point where she was reluctant to leave the house without a friend or her husband, in case she had an attack somewhere and couldn't get home.
After an initial assessment of her panic symptoms and responses and taking a brief personal and medical history, Ruth and her therapist agreed on a course of 6-8 sessions, depending on how she progressed along the way. They drew up a formulation (see first case study above) capturing how she felt both emotionally and physically, what she thought and what she did as she felt a panic attack coming on. She agreed to keep a weekly journal, noting any instances where she felt panicky, along with the circumstances, any possible triggers, her thoughts, her levels of anxiety and behavioural responses.
Looking at the formulation with her therapist, Ruth started to grasp how the four areas (thoughts, feelings, physical sensations and behaviour) interacted in a way that led to a state of panic. She recognised that she was hyper-sensitive to any changes in her physical state since her first panic attack. As soon as she felt a slightly irregular heartbeat, or felt herself getting hot, she would immediately think, 'Oh no! I'm having a panic attack!' and her anxiety would inevitably increase. As she hyper-ventilated, her hands and feet would start to tingle. She became convinced that she was going to faint. As a result, she would rush out of the situation she was in and seek safety as quickly as possible, preventing herself from learning that it is almost impossible for someone to faint when their blood pressure rises as it does when they are panicking. [The only exception to this is when someone panics at the sight of blood, which causes a sudden drop in blood pressure.]
Having begun to understand the process, Ruth learned to interpret physical cues more accurately. She realised that the slightest anxious thought could lead to a physical response, but that she did not need to interpret these as catastrophic. Her therapist got Ruth to induce physical sensations identical to those she experienced in a panic attack, by clenching her fist (causing tingling), by jumping up and down on the spot (rapid heart-beat), by spinning on the spot (dizziness), none of which caused her anxiety. They worked together on her beliefs about what would happen and how people would react if she felt anxious / had a panic attack in public. They devised some experiments to test those beliefs: for instance, going out and monitoring how people react to someone looking odd. In this way, Ruth was able to revise her view on the worst that could happen.
Ruth also committed to overcoming avoidance / safety-seeking behaviours. She started going out on her own for short trips, gradually increasing the length of time as she gained confidence in her ability to cope. In the event, after 6 sessions, Ruth felt able to continue without therapy. She was now able to recognise that her key fear had been of the anxiety itself and, although it did not disappear entirely, she no longer interpreted her anxiety symptoms as a sign of approaching panic.
