From what we know of panic episodes roughly a third will occur for the first time in a public place. Around a third will occur at home and a third will occur in a car, either as the driver or a passenger.

In nearly all cases it is possible to identify a major source of stress in the lead up to the panic event. This may be a highly specific issue such as bereavement, or it may be more cumulative, such as work stress. Whatever the reason, the fact that this is the first experience of a panic event means the person has no prior experience to fall back on. Shortness of breath, a rapid pulse and a sense of great danger are the most common symptoms associated with panic. Not surprisingly, these symptoms are invariably mistaken for a heart attack and the person finds themselves being rushed to hospital for treatment.

Once the initial medical examination confirms there is nothing wrong with the heart a sense of relief follows. This is turn is quickly followed by anxieties. What if the doctor was wrong? If it wasn't a heart attack, what was it? For the person who suffers a panic episode their physical symptoms are profound and very real. So, the reasoning goes, ‘if I'm physically well, what's wrong with me? Am I going crazy?' In fact it may take more than one panic event before the dots are joined and the picture starts to emerge.

Following the first panic episode, and certainly subsequent episodes, the person often becomes more and more anxious and apprehensive. They frequently become irritable, restless and preoccupied with their health. Over time, and with successive panic episodes their attention begins to shift from the prospect of death towards the fear of another panic episode. The fear of panic itself (fear of fear) takes over.

I've helped in the treatment of various anxiety disorders. In one example, a middle-aged man (let's call him Mr. Brown) vividly recounted his first experience of panic. The episode occurred at home around 15 minutes prior to setting off for work. He finished breakfast, checked his watch and spent a few moments looking out at the garden. He said it was as if someone flicked a switch. He felt his respiration rate increase and he became very unsteady on his feet. He grabbed a nearby chair and tried to steady himself. After a few moments Mr. Brown felt slightly better but said he began to feel a strong sense of vulnerability. As he drove to work the symptoms returned. He was certain he might faint or lose consciousness behind the wheel. He fought to control his symptoms and not put himself or others in danger. Although nothing happened, it was the last time he drove a car for months. Mr. Brown sought answers from his doctor who runs blood tests, has an in-depth discussion and eventually concludes his experience was anxiety-related.

Two years on, Mr. Brown said he felt better. He had a few more anxiety-related moments but nothing as bad as his first panic episode. Having followed a course of treatment he became aware of what was happening and was able to cope with the symptoms more effectively. Mr. Brown still doubts he can ever return to the person he was prior to his first panic episode. His confidence, he says, was knocked sideways. Even today his sense of vulnerability returns in situations he finds personally stressful (crossing a busy street, crowded shops, crossing bridges, driving longer distances). Despite this