Panic Attack Policy

Template policy for Nightline volunteers where callers may be experiencing a panic attack.

Table of contents

1. Panic Attack Policy
2. Written by the Setup and Policy Team in 2020
3. Background
4. Resources & Research {#resources-&-research}
5. Options and Variations
6. Policy and Procedure Design
7. Example Panic Attack Policy
8. Scope
9. Aims of Policy
10. Responsibilities
11. Definitions and Notes
12. Offering Help
13. Techniques
14. Example Panic Attack Procedure
15. Step 1: Is it a panic attack? {#step-1:-is-it-a-panic-attack?}
16. Step 2: Offer help.
17. Step 3: Give information.
18. Step 4: Guided breathing exercise.
19. Step 5: After the panic attack.

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Panic Attack Policy

Written by the Setup and Policy Team in 2020

Background 2

Resources & Research 2

Good Practice Guidelines (GPGs) 2

NHS Advice 2

Charity Advice 3

Academic Research 4

Mental Health First Aid 4

Breathing 5

Sources 6

Options and Variations 6

Whether to Have a Policy 6

Extent of Help Offered 6

Roles & Responsibilities 7

Modes of Communication 7

Policy and Procedure Design 7

Example Panic Attack Policy 8

Scope 8

Aims of Policy 8

Responsibilities 8

Definitions and Notes 8

Offering Help 9

Techniques 9

Information 9

Breathing Exercises 9

Example Panic Attack Procedure 10

Step 1: Is it a panic attack? 10

Step 2: Offer help. 10

Step 3: Give information. 10

Step 4: Guided breathing exercise. 10

Step 5: After the panic attack. 11

Background

Some Nightlines may wish to have a panic attack policy and procedure. Your Nightline will likely come across callers experiencing a panic attack, so implementing a policy can provide guidance to your volunteers during a stressful situation.

This example policy and procedure has been developed by the Setups and Policies Team to provide Nightlines with a template and guide for developing a panic attack policy and procedure if you wish to have one. It is in line with the current Good Practice Guidelines (GPGs) Version 3.

Resources & Research {#resources-&-research}

The Setups and Policies Team has done in-depth research into panic attacks and current advice from the National Health Service (NHS) and national mental health charities.

Good Practice Guidelines (GPGs) {#good-practice-guidelines-(gpgs)}

A panic attack procedure is not necessary (nor mentioned) under the current Good Practice Guidelines (GPGs) Version 3. Therefore, you can have a specific approach to panic attacks or not, depending on what is most appropriate for your Nightline. However, any policies or procedures must be in line with Nightline’s core principles of running a non-directional, non-judgemental and non-advisory service.

This guidance may inform part of your policy when dealing with silent callers, where no meaningful dialogue is possible (GPGs 1.1).

NHS Advice

The National Health Service (NHS) describes panic attack symptoms as detailed below:

• a racing heartbeat
• feeling faint
• sweating
• nausea
• chest pain
• shortness of breath
• trembling
• hot flushes
• chills
• shaky limbs
• a choking sensation
• dizziness
• numbness or pins and needles
• dry mouth
• a need to go to the toilet
• ringing in your ears
• a feeling of dread or a fear of dying
• a churning stomach
• a tingling in your fingers
• feeling like you’re not connected to your body

It is important to note that these symptoms are also associated with other physical health conditions. Most panic attacks last between 5 and 20 minutes. Some panic attacks have been reported to last up to an hour.

During a panic attack, the NHS recommends to:

• not fight the attack
• stay where you are, if possible
• breathe slowly and deeply
• remind yourself that the attack will pass
• focus on positive, peaceful and relaxing images
• remember it’s not life threatening

… and also recommends the following breathing exercise:

• Let your breath flow as deep down into your belly as is comfortable, without forcing it.
• Try breathing in through your nose and out through your mouth.
• Breathe in gently and regularly. Some people find it helpful to count steadily from 1 to 5. You may not be able to reach 5 at first.
• Then, without pausing or holding your breath, let it flow out gently, counting from 1 to 5 again, if you find this helpful.
• Keep doing this for 3 to 5 minutes.

Charity Advice

The UK charity Mind recommends the following:

• Focus on your breathing. It can help to concentrate on breathing slowly in and out while counting to five.
• Stamp on the spot. Some people find this helps control their breathing.
• Focus on your senses. For example, taste mint-flavoured sweets or gum, or touch or cuddle something soft.
• Try grounding techniques. Grounding techniques can help you feel more in control. They’re especially useful if you experience dissociation during panic attacks.

The American organisation Mental Health First Aid, recommends the following:

If you suspect someone is having a panic attack… follow the ALGEE action steps:

1. ASSESS for risk of harm: Ask them if it’s happened before and if they think they’re having one now. If it’s something they’re familiar with and they suspect it is, ask them if they’d like help.

2. LISTEN non-judgmentally: Ask directly what they think might help … Don’t assume you know what’s best for them.

3. GIVE reassurance and information: Remain calm and reassure the person that they’re most likely experiencing a panic attack and that it’s not dangerous. Explain that while what they’re feeling is frightening, the symptoms will pass. As you talk, use short sentences and speak in a clear, firm manner. Be patient and stay with them throughout the attack.

   IMPORTANT NOTE: You might have seen on TV that people having panic attacks should breathe into a paper bag. This is no longer considered a best practice because the person ends up breathing in carbon dioxide, which could cause them to pass out. If someone is breathing rapidly, don’t call attention to their breathing. Simply stay calm and model a steadier breathing rate.

4. ENCOURAGE appropriate professional help: When the panic attack is over, provide the person information related to panic attacks if they don’t know about them…

5. ENCOURAGE self-help and other support strategies: Encourage the person to tap into other support sources, like family, friends or any communities they’re part of…

It is important to note that a Nightline volunteer should not force stages 4 and 5 into the call. A volunteer could ask whether the caller would like more information about panic attacks and in that case use the principles of an information call.

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Academic Research

Mental Health First Aid

A panel of experts were surveyed on their endorsement of mental health first aid techniques recommended in academic literature, existing guidelines, and advice for laypeople (Kelly, Jorm & Kitchener, 2009). The following was recommended:

What should I do if I think someone is having a panic attack?

If someone is experiencing the above symptoms and you suspect that they are having a panic attack, you should first ask them if they know what is happening and whether they have ever had a panic attack before. If they say that they have had panic attacks before, and believe that they are having one now, ask them if they need any kind of help, and give it to them. If you are helping someone you do not know, introduce yourself.

What if I am uncertain whether the person is really having a panic attack, and not something more serious like a heart attack?

The symptoms of a panic sometimes resemble the symptoms of a heart attack or other medical problem. It is not possible to be totally sure that a person is having a panic attack. Only a medical professional can tell if it is something more serious. If the person has not had a panic attack before, and doesn’t think they are having one now, you should follow physical first aid guidelines. Ask the person, or check to see, if they are wearing a medical alert bracelet or necklace. If they are, follow the instructions on the alert or seek medical assistance. If the person loses consciousness, apply physical first aid principles. Check for breathing and pulse, and call an ambulance.

What should I say and do if I know the person is having a panic attack?

Reassure the person that they are experiencing a panic attack. It is important that you remain calm and that you do not start to panic yourself. Speak to the person in a reassuring but firm manner, and be patient. Speak clearly and slowly and use short, clear sentences. Rather than making assumptions about what the person needs, ask them directly what they think might help. Do not belittle the person’s experience. Acknowledge that the terror feels very real, but reassure them that a panic attack, while very frightening, is not life threatening or dangerous. Reassure them that they are safe and that the symptoms will pass.

What should I say and do when the panic attack has ended?

After the panic attack has subsided, ask the person if they know where they can get information about panic attacks. If they don’t know, offer some suggestions. Tell the person that if the panic attacks recur, and are causing them distress, they should speak to an appropriate health professional. You should be aware of the range of professional help available for panic attacks in your community. Reassure the person that there are effective treatments available for panic attacks and panic disorder.

Breathing

Breathing, specifically hyperventilation (breathing too fast), has long been thought to play an important role in panic attacks (Lum, 1981; Ley, 1985). Patients improve when they learn to reinterpret hyperventilation as a normal reaction rather than a life-threatening event.

“Breathing retraining” (encouraging slow, abdominal breathing) leads patients to believe that they can control their panic symptoms. This belief, whether true or false, will generally reduce anxiety and panic (Wolpe & Rowan, 1988).

Encouraging panicking callers to breathe slower (when also explaining that panic is caused by hyperventilation) provides some relief (e.g. Clark, Salkovskis, & Chalkley, 1985). A case study recommends a pace of seven breaths per minute (Rapee, 1985), but other studies typically do not specify the rate at which participants were retrained to breathe.

However, more recent studies have questioned the usefulness of breathing retraining, finding that Cognitive Behavioural Therapy (CBT) without breathing retraining was equally effective for treating panic attacks’ frequency and intensity (Schmidt et al., 2000).

This is not to say that breathing training is useless, but does not seem to add benefit to other treatments such as CBT or exposure therapy. A review by Meuret and colleagues (2003) found that although several studies testing the effectiveness of breathing training found an effect in reducing panic attack frequency and severity, studies with a control group generally found little to no effect.

Overall, one could argue that breathing training is possible to do over the phone with volunteers, whereas other evidence-based treatments require professionals. In summary, breathing exercises may be better than nothing, and are still recommended by the NHS.

Sources

For more information, check out these resources:

Clark, D. M., Salkovskis, P. M., & Chalkley, A. J. (1985). Respiratory control as a treatment for panic attacks. Journal of Behavior Therapy and Experimental Psychiatry, 16(1), 23–30.

Kelly, C. M., Jorm, A. F. & Kitchener, B. A. (2009) Development of mental health first aid guidelines for panic attacks: a Delphi study. BMC Psychiatry 9, 49.

Meuret, A. E., Wilhelm, F. H., Ritz, T., & Roth, W. T. (2003). Breathing Training for Treating Panic Disorder. Behavior Modification, 27(5), 731–754. 

Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, M., & Cook, J. (2000). Dismantling cognitive–behavioral treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417–424.

Options and Variations

Policies vary based on size of the Nightline, committee roles, what type of calls they get, and more. For this reason, each Nightline’s policy is a little different.

Whether to Have a Policy

As a panic attack policy is not necessary under the GPGs, some Nightlines do not have a panic attack policy. Assuming it is a panic attack and giving even simple instructions or information during a panic attack could be seen as being directive.

Alternatively, Nightline also offers information to callers. So, offering information on panic attacks is arguably appropriate and might be helpful if the caller is panicking. This is currently up to interpretation, and very much depends on how to write your policy.

For the sake of providing a sample policy, the example policy is designed for Nightlines that have chosen to have a panic attack policy. This does not mean that having one is recommended over taking a panic attack call like any other call.

Keep in mind when deciding whether to have a panic attack policy that you have to have the time and resources for training all volunteers on how to carry it out properly.

Extent of Help Offered

Your policy may be to offer simple guided breathing exercises, or a more complex set of information. This might depend on how much time you have available to train volunteers on panic attack procedures, and what proportion of your calls involve panic attacks.

Whatever your policy is, make sure you have adequate time to train volunteers. This should be covered during the new volunteer induction process.

Roles & Responsibilities {#roles-&-responsibilities}

Your Nightline might wish to mention a range of committee members in the Responsibilities section, depending on the committee structure.

For example, the Panic Attack Policy may be the responsibility of one individual on the committee, who ensures that it is regularly up to date and the policy is followed.

Modes of Communication

Your Nightline may offer several modes of communication (such as phone, IM, email, text, face-to-face), and you may have to adapt your policy to these. For example, you may be able to offer water face-to-face. In written modes of communication, you may only be able to tell that a caller is having a panic attack if they are able to write they are having one.

Policy and Procedure Design

Whatever you include in your policies, keep it simple – the use of short bullet points under each heading will enable greater clarity. If your policy is lengthy it may be useful to have a simplified guide (e.g. flow chart) for volunteers to refer to while they are on shift.

For the sake of providing a detailed example, this is a relatively complex Panic Attack Policy. You may prefer to take whole sections out, or not to have a policy on panic attacks (instead treating them like any other call).

Example Panic Attack Policy

Scope

Nightline endeavours to offer listening, support and information to all callers.

In the case where a caller is clearly suffering from a panic attack, it would be appropriate for the listening volunteer to offer some extra support and information.

Aims of Policy

This policy should cover:

• What we recognise as a panic attack

• What help we can offer when a caller is having a panic attack

• How we offer help when a caller is having a panic attack

In future, the committee may amend this policy, should such amendments be required to better meet these aims.

Responsibilities

The Coordinator is responsible for:

• Ensuring this policy and procedure are being effectively implemented;

• Reviewing and monitoring the effectiveness of the policy and its implementation, as part of a 5-yearly cycle of policy review.

The Training Officer is responsible for:

• Carrying out and maintaining training of all Nightline volunteers, especially providing volunteers tools to implement this policy

Volunteers are responsible for playing an active role in implementing this policy and developing their skills.

Definitions and Notes

In this policy “calls” and “callers” may refer to all uses of Nightline’s student support and information service whether in spoken or written communication.

“Panic attack” refers to when a caller describes a sudden overwhelming feeling of acute anxiety, which has some of the following symptoms, as stated by the National Health Service (NHS) at nhs.uk/conditions/panic-disorder:

• a racing heartbeat
• feeling faint
• sweating
• nausea
• chest pain
• shortness of breath
• trembling
• hot flushes
• chills
• shaky limbs
• a choking sensation
• dizziness
• numbness or pins and needles
• dry mouth
• a need to go to the toilet
• ringing in your ears
• a feeling of dread or a fear of dying
• a churning stomach
• a tingling in your fingers
• feeling like you’re not connected to your body

Offering Help

The listening volunteer must establish with the caller that they are indeed having a panic attack. When noticing three or more of the above symptoms, the listening volunteer will state “It sounds like you’re having a panic attack. Do you think that might be the case?”

Nightline is a non-directive service, and therefore the below techniques must be offered before implementing them. If the caller says they are having a panic attack, the listening volunteer will ask “Nightline can help with panic attacks. Would you like some help?”

If help is refused, the volunteer will carry on the call as with any other.

Techniques

The following are evidence-based techniques for combating panic attacks.

Information

The listening volunteer can acknowledge that the terror feels very real, but can inform the caller that a panic attack, while very frightening, is not life threatening or dangerous.

Breathing Exercises

The listening volunteer can guide the caller through the following breathing exercise recommended by the NHS at nhs.uk/conditions/stress-anxiety-depression/ways-relieve-stress:

• Let your breath flow as deep down into your belly as is comfortable, without forcing it.

• Try breathing in through your nose and out through your mouth.

• Breathe in gently and regularly. Some people find it helpful to count steadily from 1 to 5. You may not be able to reach 5 at first.

• Then, without pausing or holding your breath, let it flow out gently, counting from 1 to 5 again, if you find this helpful.

• Keep doing this for 3 to 5 minutes.

Example Panic Attack Procedure

Step 1: Is it a panic attack? {#step-1:-is-it-a-panic-attack?}

If a caller writes or says they are having a panic attack, skip to step 2.

If a caller is hyperventilating or showing other signs, say “It sounds like you’re having a panic attack. Do you think that might be the case?”

If a caller is unable to talk at this point, the volunteer may add “Could you tap the microphone or make a noise to confirm that you think you’re having a panic attack?”

If the caller responds negatively to either of these, the volunteer should carry on the call like normal, following the regular call procedures. If the caller is not speaking, it should be treated as a silent call.

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Step 2: Offer help.

** Speak calmly, slowly and clearly**

If the caller agrees they’re having a panic attack, offer help by saying: “Nightline can help with panic attacks. Would you like some help?” and “What would help?”

If a caller is unable to talk at this point, the volunteer may add “Could you tap the microphone or make a noise to confirm that you would like some help?”

Step 3: Give information.

Do as the caller asks. ** Speak calmly, slowly and clearly**

If the caller agrees they want help, give the following information to the caller:

“Even though the terror feels very real, it can be helpful to know that panic attacks are not life threatening or dangerous.”

Step 4: Guided breathing exercise.

“Breathing exercises can help. Would you like this?

We can guide you through one recommended by the NHS:

Let your breath flow as deep down into your belly as is comfortable, without forcing it.

Try breathing in through your nose and out through your mouth.

Breathe in gently and regularly. I’ll count while you:

• breathe in…2…3…4…5.
• breathe out…2…3…4…5.”

Repeat counting for 5 minutes or until the caller stops panicking. Check how they are feeling.

*if the caller is struggling to reach 5, it may be appropriate to adjust the breathing to fewer seconds (eg. 2..3. or 2…3…4.)*

Step 5: After the panic attack.

The volunteer should ask the caller “How are you feeling now?” or “How come you think that panic attack happened?” and continue the call as normal.

At the volunteer’s discretion, they may add “Nightline offers an information service, we can provide more information on panic attacks if you would like to know more about coping with them or where to seek further help.” if the timing and context is appropriate. This is not mandatory.

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