Panic disorder

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Watch an interview on agoraphobia with Professor Salkovskis on the NHS Choices website

What is panic disorder?

A panic attack is a sudden episode of intense fear, accompanied by four or more symptoms from the following:

Different people have different combinations of symptoms, but the general pattern is usually the same:

Often people are afraid that they may collapse, lose consciousness, have a heart attack, lose control, go mad or even die.

Panic attacks usually come on very suddenly and reach their peak within 10 minutes. The peak generally lasts for 5-10 minutes, but it can take much longer for all the anxiety to subside. In a panic, normal fear reactions are happening at the wrong time: the body's "alarm system", which is designed to help you deal with emergencies, gets triggered off, exactly as if you were in real danger.

"Panic Disorder" means having repeated, frequent panic attacks. People with panic disorder are often very apprehensive about having more attacks, and may change their behaviour or lifestyle as a result of the attacks.

"Limited symptom panic attacks" are panic attacks with less than four symptoms. For example, a sudden episode of intense dizziness or nausea, accompanied by fear that something terrible is about to happen. Many people have a mixture of full and limited symptom panic attacks.

"Panic Disorder with Agoraphobia" is anxiety about being in places or situations for fear of having a panic attack or panicky feelings. Situations may include being away from home, queuing, travelling on public transport or using lifts. Some people avoid these situations completely. Others force themselves into feared situations, but feel anxious and panicky throughout.

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How Common is panic disorder?

Between 1 and 4 people in 100 have panic disorder at some stage in their life. It is twice as common in women as in men. It usually starts between the ages of 15 and 19 or between 25 and 30 years of age.

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Can panic disorder be treated?

Yes! Cognitive therapy has been shown to be a very effective way of treating panic disorder and agoraphobia relatively quickly. This therapy is very practical and active: it focuses on your thoughts and the way you behave. You and your therapist work together to find out what is keeping the problem going, and how to overcome it. You may already have started to make efforts in this direction. Cognitive therapy will offer you new techniques, and will strengthen your own efforts.

In cognitive behavioural therapy we usually spend the first two or three sessions making sense of how the panic problem works and what keeps it going. The idea is that if we can understand the factors that keep a problem going, we can then take the next step which is to think about alternative ways of viewing the problem and what we can then do to change it. Here is an example of how we might draw a problem out with someone in a therapy session. It is based on many different examples from people we have worked with in the past (all details are anonymised).

The team at our clinic have played a leading role in developing and improving cognitive therapy for panic and agoraphobia. We have an ongoing therapy and research programme which aims to increase the understanding and treatment of this condition.

We are currently offering cognitive therapy for panic disorder, and for panic disorder with agoraphobia. Treatment involves up to eight sessions with a therapist with one follow-up session at some point in the three month period following the end of therapy. Sessions are about one to one and a half hours long. You will be asked to keep written records of your panic attacks, and to carry out "homework" tasks between sessions to speed up your progress. One of the most important goals of therapy is to help you to become your own therapist in order to cope with and overcome panic permanently.

In addition to regular sessions with your therapist, treatment will be supplemented with a series of written 'modules', the first of which you will receive before your initial session. We have found that using these modules to assist treatment helps you make better progress, more quickly. Your therapist will discuss the use of the modules with you but, in general, it is helpful if you try to set aside time to read through the modules between your sessions. As well as providing information about panic attacks the modules ask you to write about your panic attacks in some detail and also suggests some things that you can do that might be helpful. Trying out these suggestions and discussing the outcome with your therapist in your sessions will be an important part of what happens in therapy.

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Are there support groups I could contact?

"No Panic" " is a voluntary charity, designed to help people with panic disorder and other related anxiety problems. It provides support to sufferers and their families and or carers, and uses cognitive & behaviour therapy as a basis for recovery.

No Panic has a confidential help-line (free phone 0808 808 0545, 10am to 10pm, every day) staffed by trained volunteers. It also offers pop-in centres, telephone recovery groups, support for people trying to give up tranquillisers, a telephone based one-to-one mentoring scheme. The address is 93 Brands Farm Way Telford Shropshire TF3 2JQ. Website: www.nopanic.org.uk

Anxiety UK (formerly National Phobics Society)
Zion Community Resource Centre, 339 Stretford Road, Hulme, Manchester, M15 4ZY
Tel: 08444 775 774
www.anxietyuk.org.uk

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Practical advice

Here are some important facts about panic attacks:

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Recommended reading about panic disorder

Understanding Panic by David Westbrook & Khadija Rouf. A short but practical self-help booklet for people with panic attacks, based on a cognitive model. Available through the Oxford Cognitive Therapy Centre, Psychology Dept. Warneford Hospital Oxford OX3 7JX ( www.octc.co.uk)

Overcoming Anxiety by Helen Kennerly (Robinson). A guide explaining how to overcome problem fears and anxieties of all kinds - from panic attacks and phobias to executive "burn out" - in order to regain confidence and self control. A step-by-step self-help plan is included.

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Current research

Several projects are running at the moment including research on previous treatments people have received, the way in which people suffering from panic have been referred (or not been referred) for specialist treatment, and projects on beliefs and behaviours in panic and other anxiety problems.

For further information please contact Lesley Anderson by e-mailing lesley.anderson@kcl.ac.uk

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Getting help

If you have panic disorder, or panic with agoraphobia, the first step is to VISIT YOUR GP. They will be able to refer you to a cognitive behavioural therapist or a clinical psychologist. They may also offer you medication.

If you live within the South London and Maudsley (SALM) catchment area, you can ask your GP to refer you to us, at the Centre for Anxiety Disorders and Trauma. (Please see the SLAM website to find out which areas it covers). Your GP can refer you to us directly and just needs to send a short letter. Occasionally, he or she may refer you to a community mental health team or to a psychiatrist first, for an initial assessment, and they may refer you on to us.

Once your referral letter is received, we will contact you to offer you an appointment for assessment. This will involve filling in some detailed questionnaires and attending an assessment interview. If the assessment shows that our treatment is likely to be helpful to you, you will be placed on our waiting list for therapy. We are usually able to offer people appointments for assessment within a few weeks of receiving the referral and you should not have to wait more than 18 weeks before beginning therapy. We are doing our best to reduce waiting times.

Information for health care professionals

Practical advice

Panic attacks are very frightening. It is important to be clear and unabmiguous in giving service users the following information:

It can also be helpful to explain that in panic, normal fear reactions are happening at the wrong time: the body's "alarm system" which is designed to help with emergencies, gets triggered, exactly as if there was a real danger. As there is no real danger, the person misinterprets bodily symptoms as evidence of impending catastrophe. These frightening thoughts then contribute to the fear, and affect how bad the panic is, and how long it lasts.

As a general rule, the more actively service users try to manage or fight panic, the more entrenched it becomes. During a panic, encourage them to

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Recommended reading about panic disorder

  1. Managing Anxiety: A Training Manual by Helen Kennerley (Oxford University Press). A practical guide for non-psychologists in primary care, designed to help them teach service users with anxiety self-help psychological skills.
  2. Panic Disorder: from theory to therapy. David M Clark, in Frontiers of Cognitive Therapy, P Salkovskis (ed) (Guildford Press). Sets out the cognitive theory, model and therapy for panic disorder.
  3. Understanding and Treating Panic Disorder: cognitive behavioural approaches. Steven Taylor (ed) (Wiley). A clinician's guide that integrates theory, empirical findings and treatment guidelines.

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Recent research

Panic Dissemination

The Centre for Anxiety Disorders and Trauma is a clinic that specialises in the treatment of anxiety disorders. A team of researchers from the Centre recently worked on a project aiming to disseminate the techniques and strategies employed at our specialist clinic to a primary care setting.

In the initial stage of the project, the team monitored the progress of service users receiving treatment for Panic Disorder from counsellors in GP surgeries across London and Essex. In depth assessments were conducted with every service user in the trial by one of our research team, before during and immediately after treatment, as well as at follow up points 3 months and 6 months after the end of treatment. Service users were also asked to complete various questionnaire measures which gave information about the frequency of their attacks, the thoughts associated with the attacks and how the attacks were affecting their lives.

After this 'treatment as usual' phase, the therapists participating in the trial were given specialist training on Cognitive Therapy for Panic Disorder, which is the leading empirically validated psychological treatment for this disorder. They were also given various research tools, such as questionnaires, panic diaries and 'Blue Prints' to help them to identify important beliefs and so that they could monitor any changes in the service user's beliefs and the frequency of their attacks. During this training phase, the therapists took on new cases and received weekly supervision. As with the previous stage, service users were given questionnaires and were assessed by one of our research team to gauge their progress. After several months, the therapists have refined their skills and are proficient with the new strategies and tools that they have acquired.

Treatment as usual led to clinically significant improvements in patients. However the results showed that training in cognitive therapy significantly improved the outcomes of the patients receiving treatment, over and above the prior usual treatment. In particular only 10% of people in treatment as usual became panic-free, while 60% of people receiving cognitive therapy became panic-free. The study has shown that brief training and supervision for primary care therapists can significantly improve the outcomes of those therapists' patients.

The published paper relating to this research can be found in Behavioural and Cognitive Psychotherapy: Grey, N., Salkovskis, P., Quigley, A., Ehlers, A. & Clark, D.M. (2008). Dissemination of cognitive therapy for panic disorder in primary care. Behavioural and Cognitive Psychotherapy, 36, 509-520

For further details please e-mail nick.1.grey@kcl.ac.uk

We are very grateful to all the service users and therapists who participated in this research.

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Getting help

Service users in the SLAM catchment area can be referred to our clinic, the Centre for Anxiety Disorders and Trauma. Service users living outside the SLAM area can be referred to their local clinical psychology department or community mental health team for cognitive therapy.

GPs in Southwark can refer to our service directly or they can refer via Southwark Psychological Therapies Service. Referrals from Lambeth and Lewisham go through central triage points. Please download the relevant referral form:
Lambeth referrals
Lewisham referrals

Please note that we do not accept referrals of people who have recently been prescribed medication in connection with their anxiety problems. Any medication of this type must have been at a stable dose for two months.

Service users referred to us are contacted when the referral letter is received and offered a choice of appointments for assessment. If the assessment shows that our treatment is likely to be helpful, they are placed on our waiting list for therapy. We are usually able to offer people appointments for assessment within a few weeks of receiving the referral and service users should not have to wait more than 18 weeks before beginning therapy. We are doing our best to reduce waiting times.

Questionnaires

Some of the questionnaires used by our clinicians for assessment and treatment of panic and agoraphobia can be found on our questionnaires for clinical use page.

 

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