BioMed Central
BMC Psychiatry
Open Access
Research article
Development of mental health first aid guidelines for panic attacks:
a Delphi study
Claire M Kelly*†, Anthony F Jorm† and Betty A Kitchener
Address: ORYGEN Research Centre, University of Melbourne, Australia
Email: Claire M Kelly* - ckel@unimelb.edu.au; Anthony F Jorm - ajorm@unimelb.edu.au; Betty A Kitchener - bettyk@unimelb.edu.au
* Corresponding author †Equal contributors
Published: 10 August 2009
Received: 19 January 2009
Accepted: 10 August 2009
BMC Psychiatry 2009, 9:49
doi:10.1186/1471-244X-9-49
This article is available from: http://www.biomedcentral.com/1471-244X/9/49
© 2009 Kelly et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background: Panic attacks are common, and while they are not life-threatening events, they can
lead to the development of panic disorder and agoraphobia. Appropriate help at the time that a
panic attack occurs may decrease the fear associated with the attack and reduce the risk of
developing an anxiety disorder. However, few people have the knowledge and skills required to
assist. Simple first aid guidelines may help members of the public to offer help to people who
experience panic attacks.
Methods: The Delphi method was used to reach consensus in a panel of experts. Experts included
50 professionals and 6 people who had experience of panic attacks and were active in mental health
advocacy. Statements about how to assist someone who is having a panic attack were sourced
through a systematic search of both professional and lay literature. These statements were rated
for importance as first aid guidelines by the expert and consumer panels and guidelines were
written using the items most consistently endorsed.
Results: Of 144 statements presented to the panels, 27 were accepted. These statements were
used to develop the guidelines appended to this paper.
Conclusion: There are a number of actions which are considered to be useful for members of the
public to do if they encounter someone who is having a panic attack. These guidelines will be useful
in revision of curricula of mental health first aid programs. They can also be used by members of
the public who want immediate information about how to assist someone who is experiencing
panic attacks.
Background
For someone who has experienced a panic attack, there are
Panic attacks are common, with a US survey showing a
a number of factors which increase the risk of developing
lifetime prevalence of approximately 28% and 12-month
panic disorder or agoraphobia. Catastrophic misinterpre-
prevalence of approximately 11% [1]. Panic attacks may
tations (for example, fear that one is having a heart attack
lead to the development of panic disorder or agoraphobia
or other medical emergency) in relation to panic symp-
which have prevalence rates in the range 1–5% [1-5]. Both
toms predict the onset of panic disorder and agoraphobia
disorders are associated with a high degree of impairment
[10]. Severity of panic attacks, as measured by number of
and co-morbidity with other psychiatric disorders [6-9].
physical symptoms, as well as number of catastrophic cog-
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nitions, appears to increase the risk of developing agora-
has passed or the person has chosen to seek appropriate
phobia among adolescents [11]. The presence of a specific
professional help.
cognition, 'fear of going crazy or losing control', during
the first panic attack predicts the onset of agoraphobia
We chose the Delphi method, a technique used for reach-
rather than panic disorder [3]. Pre-existing high trait anx-
ing consensus in a group of experts or across expert
iety and the presence of other psychiatric illnesses, partic-
groups. Our aim was to get consensus within and between
ularly depression, predict the onset of either panic
panels of professionals, carers and consumers, so that the
disorder or agoraphobia among those who have had a
guidelines would be respectful of the needs of all three
first episode of panic [12]. A focus on the possibility of
groups. This method is relatively inexpensive and simple
future panic attacks, hyper-vigilance about physical symp-
to conduct, and can be done on the Internet, making it
toms and catastrophic cognitions increase the risk of
possible to include participants from English-speaking
developing panic disorder or agoraphobia [10].
countries across the world without lengthy postal delays.
The Delphi methodology has been used in health research
An appropriate response by a member of the public,
in the past, mainly to reach consensus amongst medical
whether a friend, family member, co-worker or other per-
practitioners, but also with consumers of health services
son, may in some cases decrease the likelihood that an
in some settings [15,16]. We have also successfully used
individual who experiences a panic attack will go on to be
this method to develop mental health first aid guidelines
hyper-vigilant about physical symptoms or fear future
for depression, psychosis, eating disorders, suicidal
panic attacks, thus decreasing the likelihood of develop-
thoughts and behaviours, traumatic events, and non-sui-
ing a panic-related psychiatric disorder.
cidal self-injury using panels of professionals, consumers
and carers [17-21]. No research using the Delphi method-
In this paper, we aim to improve one particular approach
ology to determine consensus on panic first aid guidelines
to public education – training of members of the public in
has been conducted previously.
how to give first aid to someone who is experiencing a
panic attack. One existing approach of this sort is the
Mental Health First Aid training program [13]. Mental
Health First Aid training [14] was developed to train
members of the public to assist others who are developing
a mental disorder or in a mental health crisis situation.
First aid givers can be almost anyone, however, they are
most likely to be friends, family members or colleagues,
simply because they are the people most likely to be
present at the time first aid is needed.
When the program was first in development, the authors
used evidence-based information wherever possible, but
very little research was found about how members of the
public, with no clinical training, could assist in these situ-
ations. Where no evidence was available, the authors
informally sought the opinions of clinical experts.
In order for these approaches to be effective, it needs to be
ensured that the first aid strategies taught are likely to be
helpful. Because controlled trials of individual compo-
nents of first aid strategies are not feasible, an alternative
is to use expert consensus to develop a set of guidelines on
strategies that are most likely to work. Such guidelines can
be used directly as a source of advice by members of the
public and they can inform the content of first aid training
courses. The aim of this project was to develop such guide-
lines. These guidelines needed to focus on the immediate
response to a discrete panic attack, and not on diagnosing
Stages in guid
Figure 1
eline development
or treating a panic-related psychiatric condition. The first
Stages in guideline development.
aid giver's role would be to assist the person until the crisis
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Methods
for the public, and (3) lay literature. The lay literature
This study had two phases: a literature search and ques-
included books written for the general public, particularly
tionnaire development, and the Delphi process. Please see
consumers' and carers' guides, websites and pamphlets.
Figure 1 for a summary of the steps.
The medical and research literature was accessed through
Literature search
searches of PsycInfo and PubMed. The search term was
The aim of the literature search was to cover the full
'panic attack AND intervention OR (first aid)' and all
domain of potentially helpful actions to assist someone
records for the 20 years leading to the search date were
who is experiencing a panic attack. It was not a literature
reviewed. Papers were excluded first on the basis of their
review and did not include literature outside of the scope
titles and then on the basis of their abstracts.
of first aid. The focus for the search was to find statements
which instruct the reader on how to respond at the time of
Papers which described interventions to decrease the
the attack, and how and when to recommend professional
severity or duration of a panic attack, or offered sugges-
help to someone who has experienced a panic attack. The
tions about when to recommend professional help, were
literature search was conducted across three domains: (1)
reviewed, giving a total of 37 papers. Most of the advice
the medical and research literature, (2) the content of
given in these papers was very clinically oriented, or
existing crisis intervention guidelines and relevant courses
required extensive training to be applicable. For example,
Items accepted, rejected and re-rated
Figure 2
at each round
Items accepted, rejected and re-rated at each round.
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some papers described clinical interventions in which a
Similar or near-identical statements were frequently
panic attack was induced in vivo and then de-escalated. A
derived from multiple sources, and they were not repeated
small number of papers did include brief advice and sim-
in the questionnaire. A working group comprised of the
ple intervention instructions. Statements were drawn
authors of this paper and colleagues working on similar
from 12 of the 37 relevant records. All statements felt to
projects convened at each stage of the process to discuss
be simple enough for lay people to use were included.
each item in the questionnaire. The role of the working
group was to ensure that the questionnaire did not
To find appropriate websites, we used the search engines
include ambiguity, repetition, items containing more
Google [22], Google Australia [23], and Google UK [24]
than one idea or other problems which might impede
using three sets of search terms; 'panic attack' and 'self
comprehension. The wording was carefully designed to be
help', 'panic attack' and 'first aid', and 'panic attack' and
as clear, unambiguous and action-oriented as possible. All
(care or carer or caring). The first 50 websites listed by
participants answered the questionnaire via the Internet,
each were reviewed; beyond the first 50 websites, most
using an online survey website, Surveymonkey [26].
new records were abstracts from journal papers. Since
most websites were listed by more than one search engine,
The Delphi process
and were retrieved for more than one of the search terms,
The aim was to recruit participants into one of three pan-
178 websites were reviewed. The websites were read thor-
els: professionals (clinicians and researchers), consumers
oughly, once again looking for statements which sug-
(people who had experienced panic attacks in the past)
gested a potential first aid action (what the first aid giver
and carers. The professional panel had 50 experts, the con-
should do) or relevant awareness statement (what the first
sumer panel 6, but no carers could be recruited. All panel
aid giver should know). Any external links to other web-
members were from developed English speaking coun-
sites were followed and the same process applied to each
tries (Australia, New Zealand, The United States, Canada,
of them.
Ireland, England, and the United Kingdom). Participants
were recruited in a number of ways. Professionals
The fifty most popular books on the Amazon [25] website
recruited were those who had publications in the areas of
which listed the word 'panic' in the title or keywords were
panic disorder or agoraphobia or experience in treating
selected. This site was chosen because of its extensive cov-
these patients. When letters were sent to professionals ask-
erage of books in and out of print, including works about
ing them to be involved, they were also invited to nomi-
mental health aimed at the public. Books which were
nate any colleagues who they felt would be appropriate
autobiographical in nature and clinical manuals were
panel members. Those active in clinical practice were also
excluded. The remaining books were read to find useful
asked to consider any former patients who might be will-
statements. The majority of these were carers' guides,
ing to be involved.
which do contain advice relevant for first aid, but focussed
on general caring for a mentally ill family member.
The 50 professional participants belonged to the follow-
ing (sometimes multiple) groups: 44 academics (research-
Any relevant pamphlets were sought and read, and state-
ers, lecturers and professors), 23 clinical psychologists, 21
ments were taken from these as well.
medical doctors of whom 12 were psychiatrists, 1 nurse
(also an academic), 1 clinical social worker and 1 drug
Only one training course for members of the public was
and alcohol counsellor working with anxiety patients with
found to be relevant, as most training in critical incident
tranquilliser addiction.
response is designed for professional responders such as
paramedics and the police. Material from the Mental
Consumers were recruited from advocacy organisations
Health First Aid Program [14] was reviewed and state-
and referral by clinicians. They were also identified if they
ments drawn from it.
had written websites offering support and information to
other consumers. Consumers were difficult to recruit for
Questionnaire development
this study. All six consumers were working in some form
The questionnaire was developed by first grouping state-
of advocacy role. In addition, 1 was an academic
ments into the following categories: general intervention
researcher, 1 was the convener of a mutual help group,
principles; de-escalating a panic attack; slowing down a
and 1 was a clinical psychologist who chose to participate
person's breathing; things to say during a panic attack;
as a consumer.
professional help during a panic attack; alternative
approaches to stopping a panic attack; seeking profes-
Many attempts were made to recruit carers from carers'
sional help, and self-help strategies.
support organisations and informal sources, but no carers
chose to participate in this study. It may be that many car-
ers for people with panic related conditions do not iden-
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tify themselves as such. They may be a group that is less
ing which items had been accepted, which had been
inclined to be involved with carers' organisations than
rejected, and which were to be re-rated. When an item was
those who are carers for people with schizophrenia,
to be re-rated by the panellists, they were provided with
depression, or eating disorders [19-21]. Similar difficul-
their own response and a table outlining how many peo-
ties were found recruiting carers for people who have been
ple in each group had endorsed the item. They were told
suicidal or engaged in non-suicidal self-injury [17,18].
that they did not have to change their responses when re-
rating an item, but that if they wished to, they would have
Three rounds of questionnaires were distributed as fol-
the opportunity to do so.
lows, with each statement being rated up to two times. In
Round 1 the questionnaire, derived from the process
Results
described above, was given to the panel members. The
Table 1 shows the continuity of participation across the
questionnaire included space after each of the sections to
three rounds.
add any suggestions for new statements that panel mem-
bers felt should be included.
Figure 2 shows the rates of inclusion, exclusion, and re-
rating of the items in each round of the questionnaire.
In each round of the study, the usefulness of each state-
From a total of 144 items, 27 were eventually included in
ment for inclusion in the mental health first aid guide-
the guidelines. (See Table 2 for a categorised list of
lines was rated as 'essential', 'important', 'don't know or
included items.)
depends', 'unimportant', or 'should not be included'. The
options 'don't know and depends' were collapsed into
Writing the Guidelines
one point on the scale because operationally, they are the
It was important to the research team to avoid making the
same response. Most of the statements were, very reason-
guidelines read like a list of 'dos' and 'don'ts'. The
ably, noted to be useful in some cases and not others,
accepted items were incorporated into a plain language
meaning they could not be generalised in guidelines,
document. To illustrate, consider the following state-
which is also true of statements participants did not feel
ments:
confident to rate.
1. The first aider should reassure the person that a
The suggestions made by the panel members in Round 1
panic attack, while very frightening, is not life threat-
were reviewed by the working group and used to construct
ening.
new items for the Round 2. Suggestions were accepted and
added to Round 2 if they represented a truly new idea,
2. The first aider should reassure the person that a
could be interpreted unambiguously by the working
panic attack, while very frightening, is not dangerous.
group, and were actions. Suggestions were rejected if they
were near-duplicates of items in the questionnaire, if they
3. The first aider should not belittle the person's expe-
were too specific (for example, 'focus on the guided med-
rience.
itation imagery negotiated between myself and my psy-
chologist'), too general ('just be there'), or were more
4. The first aider should reassure the person that they
appropriate to therapy than first aid ('remember to avoid
are safe.
using safety behaviours'). Unexpectedly, in Round 1, no
items describing techniques to control breathing were
5. The first aider should reassure the person that the
endorsed by the professional panel, although many were
symptoms will pass.
endorsed by the consumer panel. The working group
chose to add any new item about breathing techniques
These statements were incorporated to make the follow-
suggested by panel members, in spite of some being close
ing paragraph:
to duplicates of Round 1 items, in case one was felt to be
acceptable to the professional panel.
Do not belittle the person's experience. Acknowledge
that the terror feels very real, but reassure them that a
Items rated as 'essential' or 'important' by 80% or more of
both the professional panel and the consumer panel were
accepted for inclusion in the guidelines. If they were
Table 1: Study participation in each round
endorsed by 80% or more of one of the panels, or by 70–
Panel
Round 1
Round 2
Round 3
80% of both panels, they were re-rated in the subsequent
round. Items which met neither condition were rejected.
Consumers
6
5
3
Before Round 2 and 3 of the study, each participant was
Professionals
50
44
35
sent a summary of the results of the previous round, list-
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Table 2: Statements accepted as mental health first aid guidelines
General intervention principles:
Round:
The first aider should identify themselves if they are not known to the person.
1
The first aider should explain to the person that they are experiencing a panic attack.
1
The first aider should speak to the person in a reassuring but firm manner.
1
The first aider should remain calm and avoid becoming caught up in the panic.
1
The first aider should speak clearly and slowly.
1
The first aider should use short, clear sentences.
1
The first aider should be patient with the person.
1
The first aider should acknowledge that the person's terror feels very real to them.
1
The first aider should reassure the person that a panic attack will rarely last more than ten minutes.
2
The first aider should know the symptoms of a panic attack.
2
The first aider should ask the person if they know what is happening.
2
If the person says that they are having a panic attack, the first aider should ask them if they need any kind of help, and give it to them.
2
The first aider should ask the person if they have ever had a panic attack before.
3
De-escalating a panic attack
No items endorsed.
Slowing down the person's breathing:
No items endorsed.
Things a first aider should say during a panic attack:
Rather than making assumptions about what the person needs, the first aider should ask them directly.
1
The first aider should reassure the person that a panic attack, while very frightening, is not life threatening.
1
The first aider should reassure the person that a panic attack, while very frightening, is not dangerous.
1
The first aider should not belittle the person's experience.
1
The first aider should reassure the person that they are safe.
2
The first aider should reassure the person that the symptoms will pass.
2
Professional help in an emergency:
If the person loses consciousness, the first aider should apply regular first aid principles (check for breathing and pulse).
2
If the person loses consciousness, the first aider should call an ambulance.
2
Alternative approaches to stopping a panic attack:
No items endorsed.
Seeking professional help
The first aider should assure the person that effective treatments are available for panic disorder.
1
The first aider should be aware of the range of professional help available for panic attacks.
2
The first aider should tell the person that if the panic attacks recur, and are causing them distress, they should speak to an appropriate
2
health professional.
The first aider should assure the person that panic attacks and panic disorder can be effectively treated.
2
The first aider should ask the person if they know where they can seek help and advice about panic attacks. If the person doesn't know,
2
the first aider should offer some suggestions.
Self-help strategies:
After the panic attack has stopped, the first aider should explain to the person where they can get more information about panic attacks.
2
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panic attack, while very frightening, is not life threat-
sages in the guidelines document. This is a criticism which
ening or dangerous.
could be made of all first aid approaches, and is a signifi-
cant concern. Physical first aid courses are usually accred-
When the guidelines were in draft form, they were sent to
ited and need to be renewed on a regular basis, and
all the panel members for feedback. Only feedback related
ultimately mental health first aid should be similarly reg-
to readability and structure was sought and incorporated.
imented.
The guidelines are appended to this article and can be
freely distributed (see additional file 1).
Finally, there were issues in regards to the items about
seeking professional help after a panic attack. Items about
Discussion
encouraging any person who had experienced a panic
Significant differences between the consumer and profes-
attack to seek professional help of any kind were not
sional panels were evident in this study. In particular, de-
highly endorsed, although it was felt that first aid givers
escalating panic attacks through breathing techniques was
should tell the person that effective treatments are availa-
seen as important by the consumer panel, but not by the
ble. Certainly, a large number of people experience a
professional panel. In total, 23 items relating to breathing
panic attack at some stage in their lives and do not go on
were rated by the panels. Of these, 6 were endorsed by the
to develop panic disorder or agoraphobia. The most sig-
consumer panel (5 in Round 1), but none were endorsed
nificant item included in the guidelines in regards to pro-
by the professional panel. This was very interesting to the
fessional help was one stating that, if the person
research team, as much of the lay literature about panic
continued to have panic attacks and felt distressed by
attacks emphasised the importance of controlled breath-
them, they should seek help from an appropriate profes-
ing.
sional. This item should assist those who are most at risk
of developing panic disorder or agoraphobia to get profes-
In Round 1, many of the professional respondents stated
sional help early.
that hyperventilation and other breathing difficulties were
not common in panic attacks. We thought this may be the
Limitations
reason for the low level of endorsement, and so, in Round
A significant limitation of this study is the small number
2, we altered the wording of the breathing-related items so
of consumer panel members and the lack of a carers'
that they each read "If the person is having trouble with
panel. Ideally, this study would have involved approxi-
their breathing, the first aider should..." followed by the
mately equal numbers of professional, consumer and
breathing technique. This made no difference to the rat-
carer panellists, but recruiting consumers was very diffi-
ings. Professional respondents also stated that a reliance
cult and recruiting carers even more so. As only six con-
on controlled breathing could cause difficulties later on
sumers were involved in the development of these
for people who sought help for their panic attacks, as
guidelines, it is possible that their opinions are not repre-
these could become 'safety behaviours' which interfered
sentative of people with panic disorder and agoraphobia
with real progress in coping with panic. Alternatively, it
more generally. This project should be conducted again at
may be that the professionals simply didn't think that
some stage in the future with a carers panel and a larger
breathing techniques were important enough to be listed
consumer panel.
in the guidelines. Our cut-off for inclusion was 80% – a
less conservative cut-off would have seen more items
It is important as well to reiterate that all panellists were
included. Only the most essential action are included in
recruited from developed English-speaking countries, so
the guidelines.
that the guidelines may not be generalisable to other
countries or to minority cultures within those countries.
Of great concern to many respondents was the idea that a
Furthermore, these guidelines cannot stand alone, as they
first aid giver could distinguish a panic attack from a heart
do not address the underlying psychological distress or
attack or other serious medical problem. The attached
mental illness which may predispose an individual to
guidelines do not encourage first aid givers to make any
begin experiencing panic attacks or go on to suffer from a
such distinction; rather, they are conservative, encourag-
panic-related psychiatric illness. Other guidelines in this
ing that first aid be given for a panic attack only if the per-
series may be useful in this regard [17-21].
son has experienced a panic attack before, believes they
are experiencing one now, and does not have symptoms
Conclusion
more indicative of a serious medical problem.
We have succeeded in developing guidelines for first aid
for panic attacks which are acceptable to both profession-
In order to be able to effectively apply the recommended
als and people who have experienced panic attacks. Where
panic first aid strategies, individuals will need to have
the guidelines are used as the basis for first aid training,
either recently or consistently been exposed to the mes-
efforts need to be made to evaluate their impact on the
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first aid givers' helping behaviours and on the recipients
7.
Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD: The bur-
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Mathers CD, Vos ET, Stevenson CE: The burden of disease and
Competing interests
injury in Australia. Bull World Health Organ 2001, 79:1076-1084.
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Mathers CD, Vos T, Stevenson C: The burden of disease and
The authors declare that they have no competing interests.
injury in Australia. Canberra: Australian Institute of Health and
Welfare; 1999.
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Khawaja NG, Oei TPS: Catastrophic cognitions in panic disor-
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methodology. CMK did the literature searches and wrote
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to the development of later versions of the questionnaire.
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Schmidt NB, Zvolensky MJ, Maner JK: Anxiety sensitivity: Pro-
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CMK wrote the attached guidelines. All authors reviewed
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and suggested improvements to the guidelines. All
13.
Kitchener BA, Jorm AF: Mental health first aid training: review
authors read and approved the final manuscript.
of evaluation studies. Aust N Z J Psychiatry 2006, 40:6-8.
14.
Kitchener BA, Jorm AF: Mental Health First Aid Manual. Mel-
bourne: ORYGEN Research Centre; 2007.
Additional material
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Girgis A, Sanson-Fisher RW, Schofield MJ: Is there consensus
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Telford R, Boote JD, Cooper CL: What does it mean to involve
Additional file 1
consumers successfully in NHS research? A consensus study.
First aid guidelines for panic attacks. This file may be distributed freely,
Health Expect 2004, 7:209-221.
17.
Kelly CM, Jorm AF, Kitchener BA, Langlands RL: Development of
with the authorship and copyright details intact. Please do not alter the
mental health first aid guidelines for suicidal ideation and
text or remove the authorship and copyright details.
behaviour: A Delphi study. BMC Psychiatry 2008, 8:17.
Click here for file
18.
Kelly CM, Jorm AF, Kitchener BA, Langlands RL: Development of
[http://www.biomedcentral.com/content/supplementary/1471-
mental health first aid guidelines for non-suicidal self-injury:
244X-9-49-S1.pdf]
A Delphi study. BMC Psychiatry 2008, 8:62.
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Langlands RL, Jorm AF, Kelly CM, Kitchener BA: First aid for
depression: A Delphi consensus study with consumers, car-
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Langlands RL, Jorm AF, Kelly CM, Kitchener BA: First aid recom-
Acknowledgements
mendations for psychosis: Using the Delphi method to gain
consensus between mental health consumers, carers and cli-
The authors gratefully acknowledge the time and effort of the panel mem-
nicians. Schizophr Bull 2008, 34:435-443.
bers, without whom this project would not have been possible. Funding was
21.
Hart LM, Jorm AF, Paxton SJ, Kelly CM, Kitchener BA: First aid for
provided by Australian Rotary Health, who awarded CMK with the Hugh
eating disorders: Development of mental health first aid
Lydiard Postdoctoral Research Fellowship. Additional funding was provided
guidelines using the Delphi consensus method. Eating Disorders
in press.
by the Australian National Health and Medical Research Council (Program
22.
Google US [http://www.google.com]
grant 179805), and the Colonial Foundation, who provide infrastructure
23.
Google UK [http://www.google.co.uk]
support to Orygen Youth Health Research Centre. Thanks also to the
24.
Google Australia [http://www.google.com.au]
other members of the working group, Len Kanowski, Amy Morgan, Anna
25.
Amazon [http://www.amazon.com]
26.
Surveymonkey [http://www.surveymonkey.com]
Kingston and Laura Hart, for their assistance with the questionnaire devel-
opment. Thank you to Dr Kathy Griffiths for helpful discussion about the
Pre-publication history
design of the study.
The pre-publication history for this paper can be accessed
References
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