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My client has panic attacks as well as PTSD. What should I do?

Lots of people with PTSD also experience panic attacks. If they only have panic attacks in response to trauma reminders or when the trauma memory is activated, this wouldn’t meet criteria for panic disorder as such (according to DSM-5), but if they also have panic attacks out of the blue, this might constitute a separate diagnosis, if the other criteria are also met. This is helpful to know because you might approach the problem slightly differently.


Remember also that people use the term ‘panic attack’ differently. Distress and physiological arousal in response to reminders are common PTSD symptoms and people may feel panicky. However, a panic attack also involves a catastrophic misinterpretation of panic symptoms. For example, someone sees a person who looks like their ex-partner who assaulted them and physiological arousal is triggered. They feel hot and sweaty, and their heart rate increases. So far, this is typical of PTSD. However, if they then think ‘there must be something wrong with my heart, I’m going to have a heart attack and die’, triggering the panic cycle (Clark, 1986), the anxiety caused by the trigger spirals into a panic attack, fuelled by the catastrophic misinterpretation.


Sometimes panic symptoms, and coping behaviours, are also reminders of aspects of the trauma, perhaps because the person was also feeling or coping in that way during the trauma. For example, a very common physiological reaction to torture is hyperventilation. When a client then activates the trauma memories, and they get panic symptoms and feel breathless, they may start breathing very fast and hard, which then both worsens the sensation of chest tightness and also retriggers the memories of hyperventilating. In this way, the panic symptoms and trauma memories ‘fold over’ each other in a rapidly spiralling feedback loop (Otto, & Hinton, 2006).


Where memory work triggers panic attacks, you need to address these as no processing will happen if someone is in the midst of a panic attack and it may prompt them to disengage from therapy. If the panic attacks are triggered only by trauma reminders or are part of the trauma memories, practise stimulus discrimination with your client, and get them well- rehearsed at discriminating ‘then versus now’. For example, as in the case above where a panic attack is triggered by seeing someone who looks like their ex-partner, we ask our client to notice and focus on every details which is different between this person and their ex. We can do this in session by looking online at photos of people who look similar to their abuser (e.g. similar age, hair colour, ethnicity, weight, gender) and practising noticing differences. The client can then practise this for homework by deliberately looking for people with a similar appearance and consciously attending to differences. Once this is well-rehearsed, they should find it easier to recognise differences even when they see someone similar unexpectedly.


If someone is prone to panic attacks, we would also approach trauma memories gradually, for example, by first writing down a few keywords about what happened, and then gradually building up a narrative, switching to using ‘then versus now’ whenever the client needs to ‘lower the volume’ on a powerful memory. For most people, this is sufficient to get them through PTSD treatment and, if the panic attacks are secondary to PTSD, they should resolve by themselves. Where some of the panic symptoms and coping behaviours are also embedded within the trauma memories (e.g. they hyperventilated at the time), focus on these specifically in stimulus discrimination and when updating the trauma memory.


However, if someone has panic disorder, driven by catastrophic appraisals of their arousal symptoms, then further work may be required, drawing on techniques from cognitive therapy for panic disorder (Clark, 1986). These include developing a shared formulation for what is maintaining panic attacks, cognitive work on the threatening interpretations of symptoms, and behavioural experiments in interoceptive exposure tasks and with dropping safety- seeking behaviours. Where panic disorder developed after the trauma, we recommend only doing as much work on the panic attacks as is needed for you to work on the trauma memories as, once PTSD is successfully treated, the panic disorder may well resolve without needing further intervention. Of course, if it doesn’t, that can be a further target for treatment.

If panic disorder preceded the PTSD, we formulate the problems together and discuss with the client where to start. There are various options, including treating the problems concurrently or sequentially, which will depend on the client’s goals and whether treatment of one problem would impede the treatment of the other.

Key points

· Many people with PTSD experience panic attacks but not all will meet criteria for an additional diagnosis of panic disorder

· Physical and emotional arousal in response to trauma reminders are symptoms of PTSD and for some people can spiral into a panic attack when catastrophic thoughts also occur

· If panic attacks occur in response to trauma reminders, prioritise stimulus discrimination in therapy sessions

· Then approach memory work gradually, using stimulus discrimination as needed

· If they also have panic attacks out-of-the-blue, they may also have panic disorder and need additional focus on this, drawing on cognitive therapy for panic disorder models

· If panic disorder is secondary to PTSD, treat the panic just enough to get through PTSD treatment as the panic disorder should naturally improve



References

Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470.

Otto, M. W., & Hinton, D. E. (2006). Modifying exposure-based CBT for Cambodian refugees with posttraumatic stress disorder. Cognitive and Behavioral Practice, 13(4), 261-270

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