The acute “fear of fear”, which develops after a first panic attacks, linked to the fear of certain physical sensations that accompany panic attacks (e.g, heart palpitation, dizziness, paresthesias). This fear is due to two factors.

The basis of the first of them is “interoceptive conditioning”, i.e. tentatively worked out the fear of certain internal sensations (eg, palpitations), which in the representation are associated with the expression of fear, pain or unpleasant feelings. The idea of conditioning is consistent with a traumatic origin of panic attacks, which are often seen by medical personnel in emergency, as well as vivid memories of the first attack of panic, even after 20 years.

Interoceptive conditioning quite resistant to fading and may be “unconscious”. Thus, interoceptive conditioned response to the fear does not depend on conscious perception of triggering this response factors. Consequently, panic attacks, which seem to arise suddenly, in fact, are based on minimal changes in the physical condition of the patient, which he did not immediately notice. Thus, minor fluctuations in blood pressure can cause fear, because a person has experienced the horror of a significant increase in pressure in the past.

The second factor is an erroneous interpretation of physical sensations (ie, interpretation of these sensations as harbingers of imminent death, loss, etc.). It can be seen as strengthening the already existing tendency to regard anxiety as harmful in itself.

Like interoceptive conditioning, there is an erroneous interpretation on the conscious and unconscious level. An individual may take the physical sensations of the warning signs of disaster, but without realizing it. Hence the impression of a sudden occurrence of panic attacks. Representations of the conditioned reflex nature of fear and erroneous interpretation of physical sensations as two separate constructs has its supporters (eg, LeDoux, 1996) and opponents (Rapee, 1991).

Nevertheless, the concept of “fear of fear” has empirical confirmation. Patients suffering from panic disorder, strongly believe in the inevitability of physical or mental damage due to bodily sensations associated with panic attacks, and fear it. Such people tend to interpret their own physical sensations as dangerous, and mostly use words related to physical threat (such as “disease” and “misfortune”) and words describing catastrophic events (such as “death” or “mental disorder”).

In addition, they are more afraid of the procedures associated with the emergence of physical sensations, reminding of the panic attack, including harmless loads on the cardiovascular, respiratory and vestibular system, and especially any invasive interventions (e.g, inhalation of carbon dioxide).

Moreover, these people are afraid of signs of excitation autonomic nervous system even in absence of the excitation, which explains the mechanism of false physiological feedback. This misinterpretation of symptoms cause fear, and reassessment of the situation reduces it.

For example, people with panic disorder and sub-clinical manifestations of panic reported a significant weakening of anxiety during the experimental procedures such as hyperventilation and inhalation of carbon dioxide when they deem the procedure safe and verifiable, if there is a credible person, and after cognitive-behavioral intervention, reducing the fear of bodily sensations.

Excitation of the autonomic nervous system caused by the fear intensifies frightening experience, completing a vicious cycle of fear and sensations. (This cycle continues playing until the complete exhaustion of the nervous system or to gain a sense of security.)

Thus, it is believed that the unpredictable nature of anxiety and panic enhances chronic sense of foreboding and maintain suspense about the recurrence of panic. A sense of foreboding increases the risk of panic, contributing to increased feelings that were fixed as a conditioned reflex signals to panic, and / or increasing susceptibility to these bodily sensations. That’s how the vicious circle of panic and a sense of foreboding is formed!

In addition, it is believed that the fear of bodily sensations enhanced by the avoidance of a frightening situation. As an example, the habit of sitting motionless for fear of a heart attack, move slowly or not active for fear of ridicule.

Finally, the anxiety is manifested in specific contexts where its effects may be particularly evident (for example, in situations involving a violation of operation, hit into the trap of negative evaluation and social insecurity). These concerns reinforce the manifestation of agoraphobia, which feeds the fear of bodily sensations.