Panic attacks and agoraphobia

1. Before you begin

You were queuing at the checkout. Within seconds your heart raced, your head went light, your hands tingled, and the thought crossed your mind that you were going to faint, have a heart attack, or lose control in front of everyone. You abandoned your basket and went out. Outside, after a few minutes, everything settled.

Since then you have been thinking about it. You monitor your heart. You avoid that shop, then queues, then transport, then going out alone. Your world has shrunk, quietly, and those around you have not really understood what was happening.

Four things, straight away.

A panic attack is not dangerous. It is extremely unpleasant, but it causes neither a heart attack, nor madness, nor loss of control. It is a normal alarm reaction, triggered at the wrong moment.

It always stops. The body cannot sustain that level of activation for long. In general the peak is reached within a few minutes, and then everything comes back down, whether you do something or not.

It is not panic that spoils a life, it is what people do to avoid it. The detours, the precautions, the being accompanied, the places given up: that is what shrinks an existence, and that is precisely what keeps the problem going.

This responds very well to treatment. Cognitive behavioural therapy with exposure — a practical therapy in which you learn, one step at a time, to face the feared sensations and situations deliberately — is one of the best established psychological treatments in the whole of psychiatry. This guide describes its content, step by step.

2. What a panic attack is

A sudden rise, a peak, a fall

A panic attack is a surge of intense fear that rises very fast, reaches its maximum within a few minutes, then comes back down. It is accompanied by a set of physical sensations and catastrophic thoughts.

The most common sensations:

• A heart beating hard, fast, or seeming irregular.
• Short breath, a feeling of suffocating, of not getting enough air, a lump in the throat.
• Tightness or pain in the chest.
• Sweating, hot flushes or chills.
• Trembling, legs like cotton wool.
• Light head, dizziness, the feeling of being about to faint.
• Tingling in the hands, the feet, around the mouth.
• Nausea, a knotted stomach, the urge to go to the toilet.
• The feeling of being detached from yourself, or that the world is becoming unreal.

The most common thoughts:

• "I am having a heart attack."
• "I am going to faint."
• "I am going to suffocate."
• "I am losing my mind."
• "I am going to lose control, scream, make a scene."
• "I am going to die."

What it is not

It is not a heart condition, even when it imitates the symptoms of one. It does not make you lose your reason: panic has nothing to do with psychosis, an illness in which a person loses contact with reality. It almost never makes you faint: fainting happens when blood pressure drops, whereas in panic, it rises. There is an exception for certain phobias of blood and injections, where faintness is possible; outside that case, the fear of passing out practically never comes true.

It is extremely common

A large share of the population has at least one panic attack in their lifetime without ever developing a disorder. What distinguishes the disorder is not having had attacks, it is what comes next: the fear of having more, the monitoring of the body, the avoidance.

3. Panic, panic disorder, agoraphobia

These three words are often confused, and telling them apart helps you know what to work on.

The panic attack

This is the event: the surge of fear described above. It can occur in an identifiable context (an argument, a lift, a sleepless night) or arise for no apparent reason, including at rest.

Panic disorder

We speak of a disorder when the attacks repeat and, above all, when a fear of fear sets in: the permanent dread that an attack will return, the monitoring of the slightest sensation, and changes in behaviour to guard against it. It is that layer, and not the attacks themselves, that makes the disorder.

Agoraphobia

This is the avoidance of situations from which it would be difficult to escape or to be helped in the event of feeling unwell: transport, shops, queues, crowds, bridges, tunnels, the cinema, the motorway, but also, for many, going out alone or staying at home alone. So the word does not denote a fear of open spaces, as is often believed, but the fear of being trapped far from any help.

How they follow on from one another

The usual sequence is this: a first attack, often during a period of stress or tiredness; then the fear that it will return; then the first avoidances; then the gradual spread of avoidance to situations that have nothing to do with the first. Within a few months, a person can go from a single attack in the supermarket to a life organised around safe routes, quiet times of day and being accompanied.

4. What happens in the body

An alarm, not a breakdown

Everything you feel during an attack corresponds to a normal alarm reaction, designed to make you flee or fight a real danger. The body releases adrenaline, and:

• The heart speeds up to send more blood to the muscles.
• Breathing speeds up to bring in more oxygen.
• Blood is redistributed towards the large muscles: hence cold hands, tingling, pallor.
• Sweating increases to cool a body preparing for effort.
• Digestion pauses: hence the nausea and the knotted stomach.
• The pupils dilate, and vision sometimes becomes blurred or too bright.
• The muscles tense, hence the trembling and the feeling of weakness.

Every symptom has a function. None is a sign of failure. The problem is not that the alarm is working badly, it is that it goes off in the absence of danger.

Hyperventilation

When breathing speeds up without physical effort, you breathe out too much carbon dioxide. This drop alters the balance of the blood and produces exactly the most frightening sensations of an attack: dizziness, light head, tingling, blurred vision, chest tightness, a sense of unreality, clenched hands.

This is a crucial point: breathing more does not bring relief, it makes things worse. Many people take large deep breaths in order to "get more air", which heightens the hyperventilation and prolongs the symptoms.

Why these sensations seem abnormal

Two reasons. First, they arrive without context: the same heart at 130 is unremarkable when you are climbing stairs, and frightening when you are sitting on a bus, because nothing explains it. Second, attention amplifies them. What we monitor seems stronger, longer, more threatening: this is true of toothache, of tinnitus, and it is true of the beating of the heart. People who have panic attacks are often better than others at perceiving their own internal sensations; this is not a weakness, it is a sensitivity which, combined with an alarming interpretation, becomes a problem.

The effect of stress hormones

Adrenaline breaks down within a few minutes. That is why an attack cannot last indefinitely. What can last, on the other hand, is the state of alert that follows: you stay tense, you watch out, and a new surge can set off against that background of anticipation.

5. The panic circle

The most useful model, and the one best supported by research, describes a loop in four steps.

1. A bodily sensation appears. It can come from anywhere: caffeine, effort, heat, a bad night, emotion, digestion, a change of position, or simply an unremarkable variation that you notice because you are monitoring.
2. It is interpreted as the sign of an imminent catastrophe. "My heart is racing: I am having a heart attack." "My head is spinning: I am going to faint."
3. Fear increases, and with it adrenaline.
4. The sensations intensify, which seems to confirm the interpretation — and the loop closes, faster and faster.

What makes the loop so convincing

When you flee the situation, or take a tablet, or sit down, the attack eventually passes. You conclude: "thank goodness I went out", "thank goodness I had my tablet". In reality the attack would have passed anyway: adrenaline subsides by itself. But this mistaken conclusion protects the belief, and makes it impossible to refute through ordinary experience.

Anxiety sensitivity

Some people are quicker than others to regard bodily sensations as dangerous. This characteristic, which can be measured, predicts the occurrence of panic attacks. The good news: it can be changed. It is even one of the main effects of the work described in this guide.

6. What keeps the problem going

Five mechanisms, all understandable, all counterproductive.

Avoidance

No longer taking the underground, no longer doing the shopping alone, no longer going to the cinema. Avoidance brings immediate relief, and that is precisely what reinforces it. Above all, it prevents you from discovering that nothing catastrophic happens.

Safety behaviours

These are the precautions taken inside the situation: keeping a bottle of water, sitting near the exit, holding your phone, walking slowly, hanging on to the trolley, being accompanied, having a tablet in your pocket — often without ever taking it.

They are more insidious than avoidance, because they give the impression of facing the situation. In reality they maintain the belief: "if I had not had my bottle, I would have collapsed". The experiments conducted on this point show that exposure works markedly less well when these behaviours are kept.

Bodily hypervigilance

Monitoring your pulse, checking your breathing, watching out for the slightest dizziness. The more you look, the more you find: the body produces sensations all the time, and selective attention amplifies them. It is a machine for manufacturing triggers.

Reassurance seeking

Asking someone close "are you sure there is nothing wrong with me?", ringing a doctor for the third time, rereading a test report, looking up your symptoms on the internet: reassurance calms things for a few minutes, then the doubt returns, a little stronger. It works exactly like avoidance, with one deceptive advantage: it looks reasonable.

The mechanism is simple. A question put to someone else cannot answer a fear that comes from inside; and every answer obtained teaches you that it was right to ask. Those close to you, in good faith, exhaust themselves reassuring you without ever achieving a lasting effect.

The way out is to space out and then stop these requests, having warned those around you: "from Monday, stop answering me about my heart; just tell me you have heard me". It is uncomfortable for a week, and then the need decreases.

Anticipation

Between attacks, the mind runs through the scenarios: "what if it happened on the train?". This anticipation maintains a high level of tension, on which a new attack starts more easily.

7. What the research says

Attacks are common, the disorder less so

Large population surveys find that a substantial proportion of adults have at least one panic attack in their lifetime, and that a much smaller fraction develop panic disorder. In other words, the attack is not rare: what makes the difference is what follows.

The cognitive model holds up

The work arising from the catastrophic interpretation model has produced testable predictions: the people concerned are more inclined to interpret bodily sensations as dangerous, and changing these interpretations is accompanied by a reduction in attacks.

Cognitive behavioural therapy is the reference psychological treatment

Overall comparisons between psychological approaches place cognitive behavioural therapy, with exposure, in first position for panic disorder. The effects are large and are maintained after the end of treatment, which is less often the case with drug treatments alone, whose benefit can fade when they are stopped.

Exposure is the active heart of it

The analyses that compare the ingredients of programmes find that exposure to sensations (interoceptive exposure) and exposure to avoided situations are the components most closely linked to outcome.

How exposure works

The classical conception spoke of habituation: staying long enough for anxiety to come down. More recent work stresses another, more powerful mechanism: the violation of expectations. What counts is not that anxiety falls during the exercise, it is that the predicted catastrophe does not occur, and that you observe this clearly. Hence some precise instructions: state the prediction, vary the contexts, remove the safety measures, accept that anxiety sometimes stays high.

Safety behaviours get in the way

Experiments have compared exposure with and without safety behaviours: keeping them markedly reduces the benefit, even when the person does face the situation.

Breathing: a double-edged tool

Work on carbon dioxide shows that people prone to panic tend to hyperventilate, and that breathing training aimed at raising CO2 can reduce attacks. But other work shows that controlled breathing, used during an attack in order to stop the sensations, functions as a safety behaviour and holds back progress. The practical rule that follows: train yourself to breathe calmly outside attacks, and do not use it as a fire extinguisher.

Medication

Certain antidepressants (from the family known as "serotonin reuptake inhibitors") are effective in panic disorder. Benzodiazepines, a family of tranquillisers, bring quick relief, but pose three problems: dependence, the return of symptoms on stopping, and above all their use "as needed", which becomes a safety behaviour and hinders the learning that exposure aims at. Trials that combined exposure and benzodiazepines observed poorer long-term results.

Received ideas

"I am going to have a heart attack." Panic does not cause heart attacks. A medical opinion is nevertheless needed the first time, or if the symptoms change — urgently if it involves chest pain (see section 8).

"I am going to go mad." Panic has no link with psychotic disorders.

"If I do not get out, I am going to faint." Fainting requires a fall in blood pressure; in panic, blood pressure rises.

"It is psychological, so it is all in my head." The symptoms are physiological and real. What is at issue is their interpretation, not their existence.

"You have to breathe deeply." It is the opposite: large deep breaths keep hyperventilation going.

"As long as I have my tablet on me, I am fine." That is exactly what prevents the brain from learning that the situation is safe.

8. Ruling out medical causes

This is a preliminary step, and it is reassuring rather than worrying.

When to see a doctor first of all

Chest pain or marked breathlessness felt for the first time, or different from your usual attacks, and any loss of consciousness are a matter for the emergency services: call them, without waiting for an appointment. In other cases, see a doctor promptly if any of these points applies to you:

• A first attack, even one that has passed, especially after 40.
• Chest pain that has passed but was never examined, breathlessness at rest or on unaccustomed effort.
• Symptoms that last for hours, or that do not subside.
• Fever, weight loss, marked night sweats.
• A history of cardiac, respiratory or thyroid problems, or pregnancy.

What a doctor usually checks

A clinical examination, often an electrocardiogram, sometimes a blood test for the thyroid, blood sugar or anaemia, depending on the symptoms. The tests are generally normal: that does not mean "there is nothing wrong", it means the problem lies elsewhere, and that it can be treated.

What can trigger or imitate attacks

• Caffeine, particularly in sensitive people or after a bad night.
• Cannabis, frequently implicated in young adults. See our programme Cannabis: taking stock.
• Alcohol, especially on the rebound, the next day, or during withdrawal.
• Certain medicines and stimulant supplements, decongestants, corticosteroids.
• Lack of sleep, dehydration, missed meals.
• Hormonal disorders such as an overactive thyroid.

The trap of repeated tests

Having tests redone every two months brings relief for a few days, then the doubt returns. Beyond a properly conducted work-up, multiplying the checks itself becomes a safety behaviour. If you cannot manage without them, our programme The fear of being ill: health anxiety deals with this precise mechanism.

9. Taking stock: your map of panic

For one to two weeks, before changing anything at all, document what happens. This map will serve as the basis for everything else.

The attack diary

For each episode, note:

• The date, the time, the place.
• What you were doing just before.
• The first sensation you noticed.
• The thought that followed: what exactly were you afraid of?
• The intensity of the fear, from 0 to 100, at the peak.
• What you did: fled, phoned, took a tablet, held out.
• What actually happened afterwards.
• The time between the start and the return to calm.

The three lists

List 1 — The dreaded sensations. Rank them from the least to the most frightening: fast heart, breathlessness, dizziness, unreality, tight throat, tingling.

List 2 — The avoided situations. All of them, even the small ones: the supermarket at busy times, the underground, the motorway, the lift, the cinema, the hairdresser, flying, going out alone, staying alone, going more than ten kilometres away.

List 3 — The safety behaviours. Water, phone, medication in the pocket, being accompanied, a seat near the exit, checking your pulse, routes with pharmacies, driving in the left-hand lane.

What the map reveals

Most people discover three things. First, that attacks last far less time than they believed — often less than ten minutes at the peak. Second, that the dreaded catastrophe has never happened, not once. Third, that the list of avoidances is longer than they imagined.

10. During an attack: what really helps

The aim is not to make the attack stop. It is to get through it without doing anything that reinforces the belief in danger.

The four principles

1. Name it. "This is a panic attack. It is unpleasant, it is not dangerous."
2. Do not flee. If you can stay, stay, even feeling very bad. If you have to go out, come back as soon as possible and stay long enough to see that the catastrophe you fear does not happen.
3. Do nothing to make it stop. No emergency breathing, no checking of the pulse, no phone call for reassurance. Let the body do its work.
4. Wait. Adrenaline breaks down. The peak passes. It is mechanical.

What you can do instead

• Describe what you feel, mentally or under your breath: "fast heart, clammy hands, dizziness". Describe, rather than fight.
• Stay in contact with the outside: look at the objects around you, feel your feet on the ground, carry on with what you were doing if that is possible.
• Drop your shoulders, unclench your jaw, let the out-breath happen — without turning it into an exercise intended to stop the attack.
• Remind yourself of your prediction: "I believe I am going to faint; let us check".

What is better avoided

• Large, deep, repeated in-breaths.
• Rushing out every single time.
• Phoning someone for reassurance, as a matter of course.
• Taking a tablet at the first sensation.
• Sitting down immediately, drinking immediately, immediately looking for the exit.

And if hyperventilation has set in?

If you are clearly breathing fast and shallowly, slowing the out-breath slightly helps restore the balance. The nuance lies in the intention: you slow down because it is more comfortable, not in order to prevent a catastrophe. If this manoeuvre becomes your lifebuoy, it will do you harm.

11. Working on catastrophic thoughts

Identifying the exact prediction

"I am going to panic" is not a useful prediction. "I am going to faint in the queue", "my heart is going to stop", "I am going to scream and someone will call the police": those are testable predictions. Write them down.

Examining them

For each one:

• How many times has this attack happened to me? And how many times has the catastrophe come about?
• What alternative explanation is there? "My heart is beating fast because adrenaline makes the heart beat fast."
• What contradicts my fear? For example: I ran up four flights of stairs last week, my heart was beating at 150, and nothing happened to me.
• What would I say to someone I love who described this to me?

Decatastrophising without reassuring yourself

There is a difference between examining a thought and reassuring yourself on a loop. Repeating "I am in no danger" a hundred times is a disguised check, and it stops working. The aim is to arrive at a more sober position: "I do not know what is going to happen, and I can bear it".

An example

"My heart is beating at 120, I am going to have a heart attack."

How long have I had this fear? Four years. How many attacks? About fifty. How many heart attacks? Zero. A heart attack that would set off fifty times and stop by itself after eight minutes — is that plausible? No. What makes my heart beat at 120? Adrenaline, as when I run for a train. So what is the simplest explanation? That my body is reacting as it is designed to react, at the wrong moment.

This conversation does not remove the fear. It opens up enough doubt to attempt the experiment in the next section — and it is the experiment, not the reasoning, that will do the work.

The prediction table

This is the central tool for the rest of the programme:

What I am going to do	What I fear	How likely I think it is	What actually happened
Stay ten minutes in the queue	I am going to faint	80 %	Very uncomfortable, no collapse

After a dozen lines, the gap between column 3 and column 4 becomes impossible to ignore. That is what neither reasoning nor willpower can produce on their own.

12. Exposing yourself to the dreaded sensations

This is the most specific exercise in this programme, and the most effective. Its principle: deliberately reproducing, in safety, the sensations you dread, until they stop being alarm signals.

Before you begin

Ask your doctor's advice if you have a cardiac or respiratory problem, epilepsy, glaucoma, back or neck problems, or if you are pregnant. These exercises are safe for most people, but this check is part of taking the approach seriously.

The classic exercises

• Breathing fast and shallowly for 60 seconds (deliberate hyperventilation): reproduces dizziness, tingling, unreality.
• Breathing through a thin straw for 60 seconds, with the nose blocked: reproduces breathlessness and tightness.
• Spinning round on the spot standing, or on a swivel chair, for 45 seconds: reproduces dizziness.
• Climbing stairs quickly or doing 40 squats: reproduces a fast heart and breathlessness.
• Holding your breath for 30 seconds: reproduces chest tightness.
• Staring at a point on the wall or at your own reflection for two minutes: reproduces the sense of unreality.
• Tensing the whole body for one minute: reproduces trembling and weakness.

The protocol

1. Choose the exercise that best reproduces the sensation you dread most.
2. Note your prediction: "after 60 seconds, I am going to faint — 70 %".
3. Do the exercise right through, without interrupting it at the first sign.
4. Then do nothing for two to three minutes: let the sensations subside on their own, without fighting them.
5. Note what actually happened, and the intensity of the fear.
6. Repeat three to five times in a row, once a day, until the exercise becomes boring.

What makes the exercise a good one

• Going as far as the sensation, not stopping short of it.
• Not cheating: no bottle of water, no phone in hand, no companion.
• Varying the places and the times: at home, then elsewhere, then before going out.
• Accepting that the fear does not always come down: what counts is that the catastrophe does not happen.

Then combining them

When the isolated exercises become easy, do them just before entering an avoided situation: spin round and then go into the shop, climb the stairs and then take the underground. This teaches the brain that these sensations, in these places, mean nothing dangerous.

13. Getting out of avoidance: the exposure ladder

Building the ladder

Take your list of avoided situations again and give each one an anticipated anxiety rating, from 0 to 100. You obtain a ladder. For example:

• 30 — Going to the small grocer's 100 metres away, alone.
• 40 — Travelling one stop on the underground at a quiet time.
• 50 — The supermarket, ten minutes, at quiet times.
• 60 — A full supermarket, a queue, without a trolley to lean on.
• 70 — Three underground stops at rush hour.
• 80 — The cinema, a seat in the middle of the row.
• 90 — A one-hour train journey, alone.

The rules

• Start around 40, not at 20: too easy teaches nothing.
• Stay until you have checked your prediction, not until you are calm.
• Repeat often: one exposure a day is worth more than a long one once a week.
• Vary the days, the times, the shops, the lines.
• Note each time the prediction and the actual result.
• Do not move up a rung until the current rung has become unremarkable; as soon as it bores you, move on to the next one without waiting.

What is not exposure

Crossing the supermarket at a run, headphones on full, looking at your phone, with your partner three metres away, is not an exposure: it is mental avoidance in a real setting. The instruction is to stay present to the sensations and to the situation.

When anxiety does not come down

This is not a failure. Recent work shows that the learning takes place even when fear stays high, as long as the dreaded prediction is disproved. What you are looking for is a clear disagreement between what you believed and what happens.

14. Giving up safety behaviours

Spotting them

Some are obvious (the tablet in the pocket), others are not: walking slowly, leaning on the shelves, avoiding turning your head too fast, keeping the car keys in your hand, choosing the checkouts with few people, never letting your phone run out of charge, locating the toilets as you go in.

Removing them, one by one

Draw up a second ladder, the one for safety measures, from the easiest to let go of to the hardest. Then redo the same exposures without them. The simple rule: one exposure without safety measures is worth three exposures with them.

The case of being accompanied

Being accompanied is the most frequent safety measure, and often the most organised: the partner does the shopping, drives, waits in the car. The usual plan consists of gradually reducing that presence: the other person goes in with you, then waits at the entrance, then in the car, then at home, then is not contactable. Each stage is an exposure in its own right.

The case of the tablet "just in case"

If you have a tablet on you at all times, the usual programme includes a stage where you go out without it — first for ten minutes, then for an hour, then for the day. This stage is prepared for and, if the medication is prescribed, discussed with the doctor. Never alter a maintenance treatment on your own.

15. Winning back places and journeys

Transport

Underground, bus, train: start with one stop, at a quiet time, with the possibility of getting off — then remove that possibility by committing to three stops. For the train, a journey without a stop is a harder rung, to be kept for later.

The car

The motorway, tunnels, bridges and traffic jams concentrate the fears: not being able to stop, being stuck. Take up driving again on short journeys, then lengthen them. Avoid systematically staying in the left-hand lane, which is often a safety behaviour. If you stopped driving a long time ago, a few lessons with an instructor help.

Shops and queues

Deliberately choose the longest queue, several times a week. Without your phone.

The cinema, the theatre, enclosed places

Sit in the middle of the row, not at the edge. That is an exposure in its own right.

Being alone

For many people this is the most dreaded situation. Progress in stages: alone at home for thirty minutes while someone is contactable, then two hours, then an evening, then a night, then with the phone switched off.

Going far from home

Some people have a safety radius. It can be measured, and then extended: five kilometres, ten, thirty, a weekend, a trip.

Flying

It concentrates several fears: being shut in, being unable to get out, the sensations connected with take-off. It is prepared for like the rest, last, and often with the help of a professional.

16. Night-time attacks

What they are

Waking in the middle of an attack, with no associated dream, early in the night. It is striking, and common in people with panic disorder. It is not a sign of any particular severity.

What helps

• Not getting up hurriedly or turning on all the lights: stay lying down, let it pass.
• Not watching out for it as you fall asleep: monitoring your sleep creates exactly what you dread.
• Avoiding alcohol in the evening: it fragments sleep and encourages awakenings with a surge of adrenaline.
• Treating sleep apnoea if it is suspected: heavy snoring, daytime sleepiness, pauses in breathing noticed by those around you. A medical opinion is needed.
• Regularising your hours: lack of sleep is a powerful trigger. See Getting your sleep back: the Psychotip® programme.

17. Medication

This guide prescribes nothing and does not replace your doctor's advice. Three landmarks, however, help you to have a useful discussion.

Antidepressants

Certain antidepressants have proved their effectiveness in panic disorder. They take a few weeks to act, may at first heighten anxiety — hence introductions at a low dose — and are taken every day, not as needed. They combine very well with therapy.

Benzodiazepines

They calm things within minutes. That is both their advantage and their trap: taken at every surge, they become the safety measure that prevents learning. Added to that are tolerance, dependence and a risk of seizures on withdrawal. Most guidelines reserve them for brief, specific situations.

The practical rule

If you are taking a treatment, do not alter it on your own, and talk to your doctor about the exposure programme: the aim is for the treatment to support the exposures rather than replace them.

18. The way of life that supports the work

• Sleep. A short night increases emotional reactivity and the likelihood of an attack the next day.
• Caffeine. It reproduces the sensations of panic. Cutting down gradually is better than stopping abruptly, which brings headaches and irritability.
• Alcohol. It soothes in the evening and wakes anxiety in the early morning. Many people panic more the day after one drink too many.
• Cannabis. A frequent trigger of first attacks.
• Physical activity. It deliberately produces the dreaded sensations — fast heart, breathlessness, heat — and for that reason constitutes a natural exposure, in addition to its effects on anxiety. Three sessions a week is a reasonable target.
• Meals. Skipping meals encourages faintness and dizziness, and therefore false alarms.

Watches and apps that measure the heart

They deserve a paragraph of their own, because they have become one of the main things that keep the disorder going. A smart watch displays a heart rate permanently, flags up "anomalies", and offers measurements on demand. For someone who dreads their heart, it is a permanent checking device, available twenty-four hours a day.

Two problems. First, these devices get it wrong: wrist measurements are sensitive to movement, to cold, to how tight the strap is, and regularly produce false values. Second, and above all, even an accurate measurement tells you nothing about danger: a heart at 120 at rest is unremarkable during a strong emotion, and it comes back down on its own afterwards.

The rule, during the programme, is to stop measuring. Turn off the notifications, remove the heart-rate face, and put the watch away if the temptation is too strong. If a doctor has raised the possibility of a rhythm disorder, it is the doctor who decides on the monitoring, not you and not your app.

19. Those close to you: helping without reinforcing

What helps

• Understanding the mechanism: the fear of fear, the avoidance, the safety measures.
• Staying calm during an attack, without dramatising or minimising: "I am here, it will pass, we will wait".
• Encouraging the person to stay in the situation rather than flee, where that is possible.
• Gradually withdrawing from the role of companion, in agreement with the person and according to a written plan.
• Pointing out progress, including the small steps.

What does not help

• Doing the shopping in their place "to spare them that".
• Answering every request for reassurance: "are you sure there is nothing wrong with me?".
• Driving as a matter of course, waiting outside the door, staying contactable at all times.
• Reproaching, mocking, or treating the problem as a whim.

Useful things to say

"I am staying with you, we are not moving, it will come down."

"You have been through this before, and every time it has passed."

"I am not answering you about your heart, we have talked about it — we will wait together."

"Do you want us to stay another five minutes before we go out?"

A sentence said calmly, without haste, is worth more than well-meaning agitation: fetching a glass of water, throwing the windows open urgently, offering to call the emergency services silently confirms that something serious is happening. This applies to attacks already recognised as panic; in the case of chest pain or marked breathlessness felt for the first time, symptoms different from the usual attacks, or a loss of consciousness, call the emergency services.

An explicit agreement

The most effective approach is to agree on a plan together: what the person close to you does, what they stop doing, at what pace. Without that, the withdrawal is experienced as abandonment.

20. Particular situations

Pregnancy and the postnatal period

Attacks can appear or worsen at these times. Cognitive behavioural therapy is indicated, and questions of treatment are discussed with the doctor. Lack of sleep heightens everything.

Older people

A first attack after 60 makes it essential to rule out a medical cause and a medication effect carefully before concluding.

Adolescents

The problem is common, often triggered by a period of stress at school, and quickly accompanied by a refusal to go to class. It responds well to treatment, and it is better to intervene early to prevent avoidance from settling in.

At work

Meetings, open-plan offices, lifts and journeys are the places most often mentioned. A temporary arrangement can be negotiated, provided it does not become a lasting avoidance.

Panic and social anxiety

Some people dread above all that the attack will be seen. The work is then twofold: sensations, and the judgement of others. See Social anxiety: the eight-step programme.

21. When it resists

An associated depression

It is common, it cuts off the drive needed for exposures, and it can be treated. See Behavioural activation: fighting depression.

Alcohol or anxiolytics

Many people relieve themselves with one or the other, which makes exposures ineffective. Both problems need treating, in the order agreed with a professional.

Trauma

When attacks appeared after a violent event, with nightmares and hypervigilance, the work is different. See Understanding trauma and the window of tolerance.

Incessant checking

Taking your pulse, heart-measuring apps, repeated tests, internet searches. These checks keep the doubt going. See The fear of being ill: health anxiety.

Exposure that does not "work"

In the great majority of cases, one of the following three errors is responsible: the safety behaviours have been kept, the exposures are too brief or too far apart, or attention has stayed directed inwards instead of towards the situation.

22. Preventing relapse

What happens afterwards

Attacks become less frequent, then disappear, then sometimes come back — during a peak of tiredness, a bereavement, an illness. This is not a return to square one.

The maintenance plan

• Keep up regular exposures in situations you once avoided, even when everything is going well.
• Do not reintroduce the safety measures at the first signal.
• Do another week of the diary if anxiety rises again.
• Take up the sensation exercises again for two weeks if an attack occurs.
• Write your personal summary: what I believed, what I learned, what worked. Reread it at the first alarm.

The sign of a real recovery

It is not the total absence of unpleasant sensations. It is that they no longer change anything about what you do with your day.

23. An eight-week plan

This plan is not an obligation: it is a proven order of march. Adapt it to your own pace, but keep the progression.

Week 1 — Observe

Keep the attack diary described in section 9: after each attack, note the place, what you were doing, the first sensation, what you feared, the intensity of the fear from 0 to 100, what you did and what actually happened. Draw up the three lists in section 9: the dreaded sensations, the avoided situations, and the safety behaviours, that is, the precautions you take in order to feel safe (bottle of water, phone in hand, seat near the exit, being accompanied). Change nothing else this week: the aim is to observe what happens, not yet to act. Reread sections 2 to 6, which explain what an attack is and why it comes back.

Week 2 — Understand and prepare

Write out your catastrophic predictions, one per line ("I am going to faint in the queue", "my heart is going to stop"), and note next to each one how strongly you believe it, from 0 to 100 %. For each prediction, answer in writing the questions in section 11: how many attacks I have had, how many times the catastrophe has happened, and what other explanation is possible. Cut down caffeine gradually rather than all at once, to avoid headaches. Go to bed and get up at regular times, including at weekends, because lack of sleep triggers attacks. Turn off the heart alerts on your watch or app and stop taking your pulse: during the programme, these measurements keep the fear going (section 18). Make an appointment with your doctor if no examination has ever been done, or if you have a cardiac or respiratory problem, epilepsy, glaucoma, back or neck problems, or if you are pregnant: their advice is needed before the exercises of week 3 (section 12).

Week 3 — The sensations

If your doctor has yet to give their advice (see week 2), wait for it before starting the exercises. Choose from section 12 the exercise that best reproduces the sensation you dread most: breathing fast for 60 seconds, breathing through a straw, spinning round on the spot, running up stairs… Do this exercise once a day, three to five times in a row, that is, ten to twenty minutes in all. Before each repetition, write down what you fear and how strongly you believe it ("after 60 seconds, I am going to faint — 70 %"); afterwards, write down what actually happened. Do the exercise right through without stopping it at the first sign, then do nothing for two to three minutes while the sensations subside on their own.

Week 4 — The sensations, with variation

Continue with one exercise a day using the same method, but vary the conditions: move on to another exercise as soon as the previous one becomes boring, change room, do it standing, in the morning, just before going out. If you had been avoiding the exercise that reproduces your most dreaded sensation, do it this week: it is the most useful one. Build your exposure ladder (section 13): take your list of avoided situations again and note for each one, from 0 to 100, the anxiety you imagine you would feel.

Week 5 — First situations

Choose three situations rated around 40 on your ladder: no lower, because a situation that is too easy teaches nothing. Do one exposure a day, alternating between these three situations, and write down before each one what you fear, then afterwards what actually happened. Stay in the situation until you have checked your prediction, not until you are calm: the fear can stay high, what counts is that the predicted catastrophe does not happen (section 13). Keep your safety measures for now if you need them: the aim of the week is regularity.

Week 6 — Without safety measures

Rank your safety behaviours (your third list) from the easiest to the hardest to give up. Redo the same situations, removing one more safety measure each time, starting with the easiest: without the bottle, without the phone in your hand, without a seat near the exit. If you are accompanied, reduce the other person's presence in stages: they go in with you, then wait for you at the entrance, then in the car, then at home (section 14). If you keep a prescribed tablet on you "just in case", talk to your doctor about it before going out without it. When the situations around 40 have become unremarkable, move up one rung on the ladder.

Week 7 — Combine

Once a day, deliberately bring on the sensations just before entering a situation on your ladder, because this is the exercise closest to what you dread, and the most useful: climb the stairs then take the underground, spin round then go into the shop. Do it without the safety measures you have already given up, and note as usual your prediction, then what happened. When a rung has become unremarkable, move on to the next one without waiting.

Week 8 — The big rungs, and the review

Tackle two high situations on your ladder: the long journey, the evening alone, the cinema in the middle of the row. If the middle rungs still frighten you a great deal, stay on them for one more week: progress matters more than the calendar. Reread all your predictions and what actually happened, from week 2 onwards. Write your personal summary: what I believed, what actually happened, what I will do at the next alarm. Plan one maintenance exposure a week for the next three months, even when everything is going well (see "Afterwards").

Afterwards

Set yourself one maintenance exposure a week for three months, even when everything is going well. That is what anchors what you have gained.

How to tell whether the plan is progressing

Three indicators, more reliable than how you feel at the time: the number of situations you do without preparation, the number of safety measures you have given up, and the average gap between what you predict and what happens. The intensity of the attacks is the last indicator to shift — do not judge your progress on it.

24. When to seek help, and what to ask for

When

• The attacks are repeating and avoidance is setting in.
• You have given up important activities.
• You regularly take an anxiolytic or drink alcohol to cope.
• Depression or dark thoughts are appearing.
• You have tried on your own and you are stuck.

Who to turn to

Your general practitioner, to rule out a medical cause, to assess and to refer.

A psychologist trained in cognitive behavioural therapy, for a structured programme with exposure.

A psychiatrist, if drug treatment is being considered, in the event of associated depression or a complex situation.

Useful ways of putting it

"I have been having panic attacks for six months and I am avoiding more and more situations. I am looking for cognitive behavioural therapy with exposure."

"I have an anxiolytic treatment that I take as needed and I would like a plan for managing without it."

25. Frequently asked questions

Can a panic attack kill me? No. It is a normal alarm reaction, triggered without real danger. It is very unpleasant and not life-threatening. The sensible course is still to have a first attack checked by a doctor; if you feel chest pain for the first time, call the emergency services (see section 8).

How long does an attack last? The peak is reached within a few minutes and then comes back down. What can last longer is the state of tension that follows, and the fear that a new attack will occur.

Why does it happen to me for no reason, sometimes at rest? Because the trigger is often an unremarkable bodily sensation — the heart speeding up after a movement, dizziness from tiredness — which attention picks up and interprets as dangerous. Rest does not prevent these variations: it even makes them more visible.

Should I breathe into a paper bag? No. This old recommendation is not without risk and is no longer advised. Slowing the out-breath slightly is enough when hyperventilation is obvious, provided you do not turn it into a ritual designed to prevent a catastrophe.

Do I have to give up coffee? Cutting down helps many people, especially at the start of a programme. Later, having a coffee even becomes a useful exposure: it reproduces the sensations you are learning no longer to fear.

The exercises that bring on the sensations — is that not dangerous? They are safe for most people, and they are the most effective ingredient of the treatment. Ask your doctor's advice if you have a heart or lung condition, epilepsy, glaucoma, back or neck problems, or if you are pregnant.

I have a tablet in my pocket that I never take. Does that count? Yes, very much so. A medicine that is never taken but is always there works like a charm: it maintains the idea that, without it, something serious would happen. Giving it up gradually is part of the programme.

Does it come back? Isolated attacks can reappear in periods of tiredness or stress. What counts is not to reintroduce the avoidances: a few exposures are generally enough to close the episode.

Why am I having attacks when my life is going well at the moment? This is very common. Attacks often appear after a difficult period rather than during it: as long as you have to hold on, the body holds on; it is when you let go that the alarm goes out of order. Besides, once the fear of fear has taken hold, it no longer needs external stress to keep itself going.

Is it hereditary? There is a degree of family vulnerability, as with most anxiety disorders: it increases the risk, it decides nothing. What turns a vulnerability into a lasting disorder is the interpretations and the avoidances — and both of those can be changed.

I have attacks in the car, should I stop driving? No, unless a doctor advises otherwise. A panic attack does not make you lose control of the vehicle. Stopping driving, on the other hand, installs a very costly avoidance that is hard to undo. Start again with short journeys, without a reassuring passenger, and lengthen them gradually.

Should I go to A and E during an attack? Yes, if you feel chest pain or marked breathlessness for the first time, if the symptoms are not like your usual attacks, or in the event of a loss of consciousness: call the emergency services. After a first attack that has already passed, a prompt appointment with a doctor is enough to rule out a medical cause. After that, for attacks similar to previous ones, no. Repeated trips to A and E bring relief for a few hours and lastingly reinforce the idea that the situation was dangerous.

My smart watch is flagging up high heart rates: should I be worried? Talk to your doctor about it once, with the data, and then stop looking. These devices often get it wrong, and even an accurate measurement says nothing about danger. Consulting them constantly is a form of checking, and checking keeps the fear going.

How long before I feel better? Structured programmes often last between eight and fifteen sessions, with clear improvements from the first weeks of regular exposure. The speed depends above all on how often you do the exercises, not on how severe things were at the start.

26. Key points

• A panic attack is a normal alarm reaction triggered without danger: it is very unpleasant and not life-threatening.
• The peak passes within a few minutes, whether you do something or not.
• The disorder does not come from the attacks but from the fear of fear, and from everything done to avoid it.
• Hyperventilation produces the most frightening sensations: breathing harder makes things worse.
• Rule out a medical cause once, properly, and then stop the checking, unless the symptoms change.
• Note your predictions and set them against what actually happens: that is the engine of change.
• Deliberate exposure to the dreaded sensations is the most effective ingredient.
• Exposure to avoided situations really pays off when safety behaviours are given up.
• What counts is not that anxiety falls during the exercise, but that the predicted catastrophe does not occur.
• Benzodiazepines taken as needed bring relief in the moment and hold back learning.
• A passing relapse is treated by taking up the exposures again, not by reinstalling the avoidances.

27. Sources and foundations

This guide is an original text written for Psychotip. It draws on published work, without taking material from any proprietary programme.

• D. M. Clark (1986), cognitive model of panic: catastrophic interpretation of bodily sensations.
• A. Goldstein and D. Chambless (1978), analysis of agoraphobia: fear of fear and conditioning to internal sensations.
• S. Reiss and R. McNally (1985) and S. Taylor et al. (2007), anxiety sensitivity and its measurement.
• D. Barlow (2002), theory of the false alarm and of anticipatory anxiety.
• P. Salkovskis (1991) and P. Salkovskis, D. Clark, A. Hackmann, A. Wells and M. Gelder (1999), the role of safety behaviours in maintaining panic.
• M. Craske et al. (2014), inhibitory learning: maximising the violation of expectations rather than habituation alone.
• C. Pompoli et al. (2016), network meta-analysis of psychotherapies for panic disorder; J. Sánchez-Meca et al. (2010), meta-analysis of effective components.
• A. Meuret et al. (2008), breathing training targeting carbon dioxide; N. Schmidt et al. (2000), controlled breathing used as a safety behaviour.
• M. Otto et al. (2005) and I. Marks et al. (1993), long-term results of combining exposure and benzodiazepines.
• R. Kessler et al. (2006), frequency of panic attacks and panic disorder in the population.
• M. Craske and D. Barlow (2007), protocol for interoceptive exposure and the treatment of panic disorder.

Content last reviewed: 2026.