Robert L. Leahy Ph.D.

Anxiety Files

Turning Panic Disorder on Its Head

Live your life free from the fear of panic attacks.

Posted May 11, 2009

If you have ever suffered from panic attacks then you know how terrifying they can be. Your first panic attack came out of nowhere-you suddenly found yourself shaking, trembling with fear, short of breath, feeling like you are going to collapse and then you thought that the end was coming. In my last blog on panic disorder-- Do You Have Panic Disorder?-- I described the process of developing panic disorder and agoraphobia. In this blog I will describe the steps to reversing this process so that you can live your life free from the fear of panic attacks.

What are the rules for having panic disorder?

In my new book, Anxiety Free: Unravel Your Fears before they Unravel You, I describe each anxiety disorder as a set of rules that you follow implicitly. For example, the general rules for developing panic disorder are the following:

1. Detect Danger - You focus on your sensations as a sign of danger
2. Catastrophize Danger - You interpret sensations as life-threatening
3. Control the Situation - You try to control your breathing or you use safety behaviors
4. Avoid or Escape - You avoid situations that make you anxious-or you escape

So, let's imagine that you begin breathing rapidly when you are anxious and you find yourself short of breath. You now become quite frightened that in the future you will become short of breath, so you begin watching your breathing to see if you are "losing your breath". You may also begin focusing on your heart-rate. When you notice your breathing has become more rapid you begin to think that you will stop breathing-and that you will collapse, have a heart attack or die. You then shift into "control" mode and try to catch your breath-perhaps by taking deep breaths-which makes you more short of breath. Or you use safety behaviors-for example, you slow down your pace of walking or you hold onto the side of a building so you won't collapse. And, if you have the chance, you will avoid exercise (which increases your breathing) or you avoid situations that "make you anxious"-such as sitting in a crowded theater. Now you have panic disorder and agoraphobia.

In Anxiety Free I give you the specific rules for your panic disorder. Do any of the following make sense to you?

The Panic Disorder and Agoraphobia Rule Book

  1. Focus on any sensations that don’t seem “normal.”
  2. Interpret these sensations as a sign of a catastrophe about to happen.
  3. Anticipate any situation where you might have these sensations.
  4. Avoid these situations if you can.
  5. But, if you can’t—then do something to make yourself feel safe.
  6. If you survive the situation, attribute your survival to your safety behaviors.

When you feel your anxious arousal increasing you may have some of these thoughts:

  • I'm going to throw up.
  • I'm about to pass out.
  • I must have a brain tumor.
  • I'm about to have a heart attack.
  • I'm going to have a stroke.
  • I'm about to choke to death.
  • I'm going blind.
  • I'm losing control of myself.
  • I'm acting foolish.
  • I may hurt someone.
  • I may hurt myself.
  • I'm going to scream.
  • I'm too scared to move.
  • I'm going crazy.

Take Away Your Catastrophic Thinking

The hallmark of your panic disorder is your belief that your physical sensations are dangerous. Anyone with panic disorder should have a full medical checkup before commencing with any cognitive behavioral therapy. But you can stand back and look at your sensations more rationally. Here are some more reasonable interpretations:

Rapid heartbeat, shortness of breath

  • Panicky thought: I am having a heart attack.
  • Rational response: I've just seen a doctor who's told me my heart is fine. I've had these sensations before and been none the worse. My brain is sending me a false alarm, telling me I'm in danger when I'm not. My reaction is simply the body's normal physical response to an alarm.

Dizziness, weakness, disorientation

  • Panicky thought: I'm about to collapse or pass out.
  • Rational response: This is a temporary phenomenon caused by the fact that my blood is circulating to different parts of my body away from my brain. If I sit quietly and breathe normally I'll return to a state of calm.

Racing mind, tension, shaking

  • Panicky thought: I'm going to start screaming and lose control.
  • Rational response: There's nothing to scream about. I have no clear idea of what "losing control" means. I can allow my mind to race without any danger; I can simply watch my thoughts and see where they go.

Rise in intensity of physical symptoms.

  • Panicky thought: My panic is going through the roof. If it doesn't stop, I'll go insane.
  • Rational response: Panic attacks are self-limiting. They eventually subside on their own. They are simply the result of arousal and pose no danger to me.

Eliminate Safety Behaviors

Research on anxiety disorders shows that you are probably doing something that you think "makes you safer". If you have panic disorder you may be using some of the following safety behaviors that superstitiously maintain your belief that panic is dangerous and needs to be controlled. Here are some typical safety behaviors: sitting near exits, having someone accompany you, walking slowly or rigidly, trying to catch your breath, holding onto the side of a building or a support, wearing sunglasses, having a drink or using an anti-anxiety medication, seeking reassurance, etc. You may also find yourself repeating self-assuring statements or praying. The problem with relying on safety-behaviors is that you can still do exposure to your feared situations, but believe that the reason you survived is that you relied on this magical thinking and behavior. Try to catch yourself and begin to give them up. Then notice if the world falls apart. Once you give up the training wheels you can ride the bike on your own.

Panic induction

In my book I spell out a number of ways that you can actually intentionally cause yourself to have the panic symptoms so that you can learn that they are not dangerous. Keep in mind that you should check with your physician before doing any of this. Be sure that you don't have a serious respiratory complication, asthma, or cardiovascular complications. Talk to your doctor if you are pregnant. However, your therapist can help you intentionally induce shortness of breath by breathing rapidly or induce a sense of derealization by staring into a light. You can spin around in a chair to learn to feel dizzy. Once you have induced the symptoms, under supervision, stand back and observe yourself and recognize that sensations go up and down in intensity. Breathe normally, relax your shoulders, sit and observe and describe to yourself what is happening. Notice that you become safe when you give up control.

Practice exposure

As with any anxiety disorder you should make a list of the situations that you fear and begin practicing exposure. You can begin with practicing the image of the feared situation. So, if you fear exercising practice the visual image of yourself on a treadmill getting your heart rate up. Then practice walking on the treadmill until your anxiety increases and then decreases. Gradually with more time increase the intensity and length of exposure. Watch for any safety behaviors and relinquish them.

Remember the rational, de-catastrophizing interpretations of arousal that I described above. Sensations are simply arousal, thoughts are often false alarms. Think of yourself as watching a movie-but you are not in it. It's simply a fiction, a make-believe. And nothing terrible is happening. The movie will come to an end.

Practice Discomfort

One of the concepts that I have used is "constructive discomfort"-that is, practicing doing things that are uncomfortable so that you can get things done that you need to do. You may already be doing this-for example, exercise and work may be uncomfortable, but you do them anyway. I suggest to my anxious and depressed patients to keep track of the constructive behaviors that are uncomfortable so that they can be proud of facing their fears and doing what is difficult to do. Much of anxiety involves attempts to avoid discomfort. Taking pride in tolerating discomfort is a way to empower yourself.

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