6

Coping with Panic Attacks

n
A y*d^l l^l (; - d- L! L! d' L-f .r. 'l :- d-. . c. r ru Lr rdL d
r r e n -s1u
u rrbs( e o
\ , rf rnr rrU, ur ru
r Lnr rf ritn
/rr-\.)r\rrvbrr
l rousal that can occlrr ''out
r r n l t v s i o l o e ' i c aa

of the blue" or il responseto encounterilig (or merclv thinking about) a pirobrc situation.
Bodily svntTttortts
that occur r,r'iththe onset of panic can irrclude ireart paipitations, tighterr-
ing in the chest or shorlnessof breath, chokrng sensations,dizziness,faintness,srveating,
trembling, shaking, and/or tingling in the hands and feet. Pstlclnlogicnlrcncfions that
oftcn accompanr these bodill'changes include fcelings of unrealitr', an iltense desire to
^f - -:-- ----,. l.-:-^- ^* J -:.^^ . ^noflrino rLr U
r rtnt n
lr .Ll lUn r u
, . rt \\ u\ .\2, \ . .t funr du tf L
n :q-l S ul 5ul.lt5 LIdz_\/ u\u15, ur uulrlS 5(rlllcLllulS L nI tFLr lnLl Il lf (b l g ,

Anrlone n'ho has had a full-fledged panic attack knon s that it is one of the most
intenseh' uncomfortabie states iruman beings are capable of experiencing. \'our ver\- first
nrni - :llrnL ^ -d- l l Il "l -d1\' rp ynrr
qL14LAL : fi rl :dt lLml :l fl il rd L l L il m
d l l nl P
a rqf L L , ll e( ,( 1i \r - ui nr ob )\'u Jf ececl li nu cr b t ocr lr ri (ut p
L l !r ul : r lr rdu
o lhtocl lr fr l, er cqc) ) , rrn\ ' il fLhl r
f,qrrrt
strong anticipatory anxiefi' about the possible recurrence of t'our panic sl.mptoms.
UnJortunately, in some cases,panic does come back and occurs repeatedir' \\rh1' some
people have a panic attack only once-or perhaps once ever)' fert' vears-n'hile others
develop a chronic condition u'ith several attacks a n'eek, is still not understood bt'
researchers in the fieLd.
TLregood nelt's is that r.ou can learn to cope u'ith panic attacks so r,r'ellthat thel' rvi1l
no longer have the pow,er to frighten you. Or-el tinre 1'ou can actua1l1.diminish the inten-
sity and frequency of panic attacks r/ yo, are r,r'illing to make some changes in )'our life-
style. Lifestyle changes r.r'hich are most conducive to reducirrg the severitv of panic
reactions are described in other chapters of this rt,orkbook. They include
o Regular practice of dcep relax.rtion(see Chaptcr 4)

. A regular protram of excrcise (see Chapter 5)

o E l i m l r a t i o n o f s t i m u l a n t s( e s p e c i a l l vc a f f e L n es,u g a r ,a n d n i c o t i n e tf r o m
1 ' o u rd i c t
(see Chapter 16)
o Learning to acknon'ledgeand exprcssvour fi,elings,especially'angerand sadlrcss
(see Chapter 13)
o Adopting self-talk and "core beliefs" n'hich promote a calmer and more accept-
ing attitude toward life (see Chapters 9 arrd 10)

These five lifestl,le changes vary in importance for different people. To the extent
that vou can cultivate all five of them, r'ou n'ill find that, over time, your problem rvith
panic reactions will diminish.
1.10 Tlrc Anxietu €t Phobia Workbook

Yet there are

The approach in this workbook is not oriented toward medication
to-take medication'
some peopt" *.ho suffer from panic attacks for whom it's appropriate
that they interfere
If you're havrng panic attacks with sufficient intensity and frequency
youl sleep' or if such
*,ith 1,o.,. abilit/ to work, your close personal relationships, or
grip" on yourself' then
attacks persistently give you the feeling that you are "losing your
med.ication may be an aPProPriate intervention'
attacksare minor
The trvo types of medications most frequentiy prescribed for panic
(sucir as Tofranil' Elavil'
tranquilizers (for instance,Xanax or AtiVan) and antidepressants
in treating panic
or Prozac).For more information on the use of prescription medications
attacks, see ChaPter 17.
for dealing with
The remainder of this chapter n'ill Present some specific guidelines
strategiesfor coping
panic attacks on a s/rorf-tu'rn, immediate basis. These are practical
rvitlr panic attacks nt thc uct'V1lnnlent tltey occln"

Deflate the Danger*

experience,br-rtit is abso-
A panic attack can be a very frightening and uncomfortable
ts an cntitely nntn'nl bodily
lutely not dangerous. You may be surpriied to learn that panic
the fight-or-flight
renctiorrtltnt simpty occul'sott't of corttcxt.Earlier chapters discussed
just humans) to physiologically
reaction-an instinctual response in all mammals (not
instantaneous reaction is
prepare to fight or flee when their survival is threatened. This
situations' It serves to
necessaryto ensure the survival of the species in life-threatening
their predators' And it
protect the lives of animals in the lt'ild when they are faced by
impulse to flee from danger'
ser\-/esto protect vour life bv informrnq and mobilizing your
tracks while a train
supjose, for example, that youl car stalled on the raiiroad
a sudden surge of
uppron.h"d. yo' from aiout 200 yards away. You would experience
adrenaline, i-rccotnpanieci by feelings of panic, and a very strong and sensibleurge to flee
rt'hole range of reactions'
your preciicament. In faci, yor-Lrbody would ttndergo a
including
in yrrltr heart rate
o An ir-icrci'rsc

o Au incre;rsein yottr respiratory rate

o A t c t t s i t r go f y o L r r r n r ' t s c l e s

o Constrictio. of vour arteries and reduced biood flow to your hands elnd fcet

o Increased biood flolv to your muscles

o Releaseof stored sugar from yoltr liver into your bloodstrearm

' lncrcased production of sweat

r'vhat
The very intensity of this reactitln and the strong urge to flee are preciseiy
to yt'rur muscles
wor,rlclensllre your st rvival. The sllrge of adrenaline and flow of blood
Your energy is mobilizcd and directed
increasesyotLr alertuess ancl physical strength'
might never get
toward escape.If these reactions rvere less intense or less rapid, you

* Some of the ideas are adapted from Davicl Barlow' Ph.D.' and Michelle Craske,
Presented i1 this section
New York: Gra)'wind Publications, 1989
Ph.D., Mnstery of Yow AnxictY ntrl Ptutic.Albany,
 Coping with Panic Attacks 771

out of the way in time. Perhaps you can recall times in your life when the flight response
worked properly and served you well.
Irr a spontaneouspanic attack, your body goes through exactlythe samephysiological
flight reaction that it does in a truly life-threatening situation. Tire panic attack that
wakes you up at night or occurs out of the blue is physiologicallyindistinguishablefrorn
your responseto such experiencesas your car stalling on the railroad tracks or waking to
hear a robber going through your house.
\Alhat makes a panic attack unique and difficult to cope with is that these intense
bodily reactions occur in the absenceof any imtnediateor apparentdanger.Or, in the case o{
agoraphobia, they occur in response to situations that have no apparent life-threatening
potential (such as standing in line at the grocery store or being at home alone). In either
case,you don't know why the reaction is happening. And not knowing why-not being
able to make any senseout of the fact that your body is going through such an intense
response-only serves to make the entire experience even more frightening. Your ten-
dency is to react to sensationsthat are intense and inexplicablewlth even more fear and a
heightened sense of danger.
No one frrlly knows at this time why spontaneous panic atiacks occur-why the
body's natural flight mechanism can come into play for no obvious reason or out of con-
text. Some people believe that there is always somestimtius for a panic attack, even if
this is not apparent. Others believe that sudden attacks arise from a temporary physio-
logical imbalance. It ls known that there is a greater tendency for panic attacks to occur
when a person has been undergoing prolonged slress or has recently suJfered a signifi-
cant loss. Flowever, only some people who have undergone stress or loss develop panic
attacks, while others might develop headaches,ulcers, or reactive depression. It is also
known that a disturbance in the part of the brain called tlnelocusceruleusis implicated in
panic attacks; but it seems that this disturbance is only one event in a long chain of
causes without being the primary cause. A full understanding of what causes panic
attacks awaits future research.(For a more detailed account of what is known, see Chap-
ter 2.)
Becausethere is no immediate or apparent external danger in a panic attack, you
may tend to irrcent or attribute danger to the intense bodily sensations you're going
through. hr the absenceof any real life-threatening situation, your mind may misinter-
pret what's going on inside as being life-threatening. Your mind can very quickly go
through the following process: "IIl feel this bad, I must be in some danger. If there is no
apparent external danger, the danger must be inside of me." And so it's very corunon
when undergoing panic to invent any (or all) of the following "dangers":
In responseto lrcartpalpitatiotts:"I'm going to have a heart attack" or "I'rr. going
to die."
In responseto chokingsensations:"I'm going to stop breathing and suffocate."
"I'm going to pass out."
to dizzy sensations:
In response
to sengntiotts
ln response orfeeling"not all there": "I'm going crazy."
of disorientation

ht responseto "t'ubberylegs": "I won't be able to walk" or "I'm going to fall'"

ln responseto theouerallintensityof your body'sreactions:"I'm going to lose com-
plete control over rnYself."
112 The AnxietY €t Phobia Workbook

dangers,you multi-
As soon as you tell yourself that you're feeling any of the above
reactions even worse/
ply the intensity of your fear. This intense fear makes your bodily
upward spiral of mount-
which in turn createsstill more fear, and you get caught in an
ing panic.
your body is going
This upward spiral can be avoided if you understand that what
a product of your imagi-
through is not ctangirons.All of the above dangers are illusory,
panic' Thereis sim-
nation when you're undergoing the intenr" ."u.tior,s which constitute
by one'
pty no basisfor any of thei in reality. Let's examine them one
. A panic attack cannot causeheaft failure or cardiac srrest'
can be frightening sensa-
Rapid heartbeat and palpitations during a panic attack
up of very strong and
tions, but they ur" .,tt d*g"rorlr. Your heart is made
might thrlk Accord-
dense muscle fibers and can withstand a lot more than you
per minute for days-
ing to Claire weekes, a healthy heart can beat 200 beats
heart begins to race'just
even weeks-without sustaining any damage. so, if your
and that your heart will
allow it to do so, trusting that no harm can come of it
eventual$ calm down'
your heart during
There's a substantial difference between what goes on with
a panic attack' your
a panic attack and what happens in a heart attack. During
beats' Somepeople even
heart may race, Pound.,and-at times miss or have extra
left-upper portion of their
report chest pains, which pass fairly quickiy, in the
or increasedphysical
chest.None of these symptoms ls aggravuted by movement
symptom is continuous
activity. During a true heart attack, the most conunon
of your chest' Racing
pain and a pressured, even crushing sensationin the center
to the pain' Moreover'
o, pounding of the heart muy occ.ti but this is secondary
tend to diminish with
the pain and pressure get worse uPon exertion and may
and pounding may
rest. This is q.titu aiff"tlnt from a panic attack, where racing
get worse if you stand' still and lessen if you move around'
rhythm show up on
In the caseof heart disease,distinct abnormalities in heart
that during a
an electrocarcliogram(EKG) reading. It has been demonstrated
heartbeat. (If you want
panic attack therieare no EKG abnormalities-oniy rapid
doctor perform an
to gain ad.ditional reassllrance,you may want to have your
EKG.)
heart attacks and
In sum, there is simply no basis for the connectionbetween
panic' Panic attacks are not hazardous to your heart'
. A panic attsck will not causeyou to stop breathing or suffocate'
and your breathing
It is common during panic to ieel your chest close down
that you're going to suf-
become restricted. Tilis might lead you to suddenly fear
tightening and reducing
focate. Under stress your neck and chest muscles are
is nothing wlong with your
your respiratory capacity. Be assured that there
will pass' Your
breathing purrug" o. l.rrrg", and that the tightening sensations
you to breathe if
brain has a buiit-in reflex mechanism that will eventuaily force
you,rengtgettingenoughoxygen.Ifyoudon'tbelievethis,tryholdingyour
At a-certain point you'1l
breath fo.ip to a minr,rt" ur,d Lbr"rrr. what happens.
will happen in a panic
feel a strong reflex to take in more air. The same thing
gasp and take a
attack if yorl're not getting enough oxygen. You'1l automatically
pass out from a lack
deep breath long beiore reaching the point where you could
 C o l r n l , . i 1 ' 1li: i r i l t t c , l i l r a L . ' li:

of oxyget]. (And er-e1 if V6r-rdrd pass out, \'ott rt'onid immediatelv start breath-
ingll Iir sum, choki'g a.d se*satious of cot-rstrictionduling panic, ho\t'et'ct
al'e llot datrget'ou-.
LllrtrrlL'3trl'1,,

A pnnic sttsck cannot ctTtts(llolt to .fnirtt'

The sensatiotrof lightJreadedtress)/ou nla\r feel r'r'itl-rtire'onset of panic calr et'okc'
is
a fear-gf fairrting. \\rhat is happenurg rs that the blood circulartiolrto 1's.,t'blain
(seetire sec-
slightlv reducecl,most likell'because \'()u are trreathingmore rapidl\'
tion on hl.pgrventilatior-rin Cirapter -1;.This is rlof dalrgerol-lsal'rd can be t'clievc'd
L-r\,5r'*"rnrrg siort,]1,and regulalh' from your abdomen, preferabll'througl'r t'oul
rt'alk
nosc.. It can also be hei;red L-,)'taking tl-re first opportulrit\' \'otl have to
arourrd a bit. Let tire feeiings of ligirt-l-readedness rise and subside rt'ithout fight-
ir-rg
" ' t ) t6em.
"" Beca'se \1our heitrt is pun-rpir-rgharder ar-rdacfuall)' irrct'easit'.gYoLll' cll'-
iravc a blood
culation, Vou are ven'utrlikeh'tcl fairrt (cxcept itl rare itlstanceSif \'ell
p1-robiaand irappen to be exposed to the sight of blood).
t A lose tlour balnnce'
Ttmticnttctck csnnot cause yott to
Sometimes )/oll may feel quite drzzY r'vhen pal-riccolrles on. It ma\r be that tensiotr
is affecting the sernicilcriol. canal sYsten in 1'our ittnet' eat, r'r'hichregulates Vour
thinqs
balance. Fclr a fert, moments Vou ma\r ieel dizzl'or it rnav eYell seem tl-rat
around \rou are spiruring. lnr-anabil' tiris sensation rt'ill Fass' lt is uot datrgerous
to be -sclstrong that l'ou rt'ill actuall)' lose )/oul balance' If sen-
ancl vert, r-urlike11,
nta\/
sations of pronoul ced dizziness persist for more than a fert' secotrds, \/ou
rvant to consult a doctor (preferal]1r'aIr otolar)'ngologist) to check rf infection'
allergies, or- other d.isturbances migl-rt be affectir-rg)/our illrrcI eat"
c Yott 71,o11't "zucak in tlte linees" durhrg n
fnll ouer 01'ce asel'o tttttlk u'lrcn Uottfeel
Ttanic sttsck.
Tl-readrenaline released during a panic attack can dilate the blood vessels in your
less' causins' t r blood
- ^- to accurnulate in )rour 1eg muscles and not fullv circr-rlate'
T l r i s c a n nf r- o. - c- l u* ' c e a s e n s a t i o t - ro f u ' e a k n e s s 0 1 ' " 1 e l i y l e g s , " t o r t ' h i c h ) i o u n l a y
respotrcltn'itl-,tl-t.fearthat)'c'ru$'on'tL-'ealrletor'r'alk'Beassuredtl-ratthissellsa-
to carry
tior-ris jusi tftat-a setrsation-and that Vour legs are as strong and able
u'eak sensatious to
you as ever' Ti-reytt'on't $ive rt'a1'!Just allorv these trembling'
pass ar-rdgi.,e you, lc.gs tl-rechancc to carrv ),ot-ttt,here yott need tO go.
o You can't "go cra:l1" futing a pnnic stttck'
Reduced blood flo* to your brain during a panic attack is due to at'terial cotrstric-
of dis-
tion, a ilorrnnlconsequenceof r:apidbreathing.This can resultin sensations
orientation and a feeling of unrealitv that can Lre frightening' lf tiris sensation
reduc-
contes on, reminci ,,o.,r.Llf that it's simpil' dr.teto a slight and tcnrpc'rrarv
rt'ith
tion of arterial .i...rlutiorl in your brain anci does t-tothave at-rythingto do
,'c,oinq,c.tazv."no rnatter how eerie ol strangeit r-uavfeei. No otre h.ts eYcl'gone
tr.,^..tr
bad as
,iuty fronr a panic attack, eveu thougl-i tl-refear of doilrg so is common' As
are completelv harm-
they feel, sensations of ul-irealitVrt'ill eventu;rlly pass and
less.
It mav be helpful to knort, that people do not "go ct'azy" irr a sudden olr sPon-
(sr-rch
taneous rn.or,.Mer-rtaldisorders invoiving behar-iorsthat are iabeled "crazy"
gradually orrer a
as schizophrenia or manic-d'eprressir-e Psychosis) develoP ver-v
 114 The Anxieht €t Phobia Workbook

started to
period of years and do not arise from panic attacks.No one has ever
where
hailucinate or hear voices during a panic attack (exceptin rare instances
such as LSD or
panic was induced by an overdose of a so-calledrecreationaldrug
no matter
cocaine).In short, a panic attack cannot result in your "goiog $azy:'
how disturbing or unpleasant yoff symptoms feel'
. A panic attack cannot causeyou to "lose conttol of yourself"'
it is easy
Becauseof the intense reactions your body goes through during panic,
'to losing
imagine that you could "completely lose it'' But what does completely
or running
it mean? Becoming completeiy paralyzed? Acting out uncontrollably
during
amok? I am awarJof no reported instancesof this happening' If anything,
a single goal:
panic your sensesand awareness are heightened with respect to
you
Running away or trying to run away are the only ways in which
"r.up". be likelli to "act out'l while panicking. Complete loss of control during
would
panic attacks is simPlY a mYth'
that they are
The first step in learning to cope with panic reactions is to recognize
intense' it's easy
not d.angerous.Becausethe Uoaly reactions accomPanyingpanic feel so
physioiogicai reac-
to imagire them being d.angerous,Yet in reality no danger exists' The
designedto panic so
tions underlyrng purri. are natural arrd,protectiae.ln fact,your bodyis
your survival'
that you .un q.ri.lty mobilize to flee situations that genuinely threatel
outside the con-
The problem occurs *hen this natural, life-preserving responseoccurs
can make headway
text ff any immed.iate or apparent danger. \fru1this happens,Yol
exist'
in mastering panic by leaining not to imagine danger where it doesn't

Breaking the Connection Between Body

Symptoms and Catastrophic Thoughts
those who
There is an important difference between people who have Panic attacks and
to interyret slightly unusual
do not. htdiaidtmlswho areproneto panichiae a chronictendency
or uncomfortableboclysensa'tions in a catastrophicway. For example, heart palpitations are
of breath
seen as ilgnats of al-rimpending heart attack, chest constriction and shortness
to fainting
are seen as signs of imminent suffocation, or dizzinessis seen aSa Preculsor
(and not particularly like)
or collapse.PIople who do not have panic attacks may notice
or dangerous'
having such body symptoms, but they do not interpret them as catastrophic
as portending some-
Iiyou have a tend.encyto interpret unpleasant body sensations
your body to
thing d,angerousor catastrophic, you will also tend to constantly monitor
tuned in to your internal
,"" if yorr;r" having those ,ur,ruiiotrt. You're probably very
o! unusual'
bodily states and oierreact easily if something begins to feel slightly "off"
you're more likely to
This increa sed internalization compounds the problem, because
that is slightly
notice and magn ify any sudden .huttg" in your body's internal state
unusual or unpleasant.
body's
The variety of circumstancesthat might cause a sudden aberration in your
lies outside of your body' For
internal physioiogical state are legion. Sometimesthe cause
hearing
example, an argument with your sPouse,seeing something unpleasant on TV,
could trigger an increase
yorr ulu.rr, cio& go off, or being in a hurry to get somewhere
of body
in heart rate, chest constriction, stomach queasiness,or any of a wide range

I
L
r
b.
 Cotitrr Tr,itl Pini. {l/,ri-l:s 115

s\'ll1Ptons asst)ciatL'dh'ith altxiet\'. At other times, tire cause resides irr somc. sulrt]c:
rrhYsiologicalsl-rift rt itirirr r .,r-rrI-,..,dr'-for example, ox\.gen deprilation clue to under.-
breathirrg, a spontaneous shift in therneurclendocrine st'sten-isof vonr Lrrain,an incl.ease
in nruscje teusittt-ritt votu' treck arrd shclulders, or a fall ir-r \roLrr blood sugar. ler,el.
\{lliethcr the initial callsc lies plimarilt' outsrde or r,r'ithirrvour bgd\', \,olr are ,suaily
unal\'arc of tl-rese phvsiologrcaishrfts urrtil vou actn;rllt'feel tite resultant svnrFtoms. The
abot'c exanlples illustrate' onlt' a feu' amons manv possibilities, anv of n'hich n-right ccx-r-
stitr-rtetlic- trigget'ittg evctrt ft)l'nn increast in ln..iett'. \Vhether or.rrot rrou actualh,
cievelcrp a fr-rll-Lrlorvlr
panic attack depgncl5on /rozr'tlou ltl'LriLit,tuttltL.sllr)t/d
tr; the par.ticu-
lar increase in bodr- s\rnlptoms that occnrs.
TO sum np, 1-resplc' r'r'ho l-ranicare likclv to experierrce:1) incrcased internalization
t)r preoccupationtt'ith subtle shifts in body symptoms or ntood arrd 2) a1 iucreased ten_
dencv to itrterpret slight abcrt'.ttionsor incrernerrtalchangesin boclv svnrptoms as dan-
gerous or cartastropiric.The diagran-rbclort' illustr"atesthis tcndenct':

Det,clopntent
of Pnnic Attock
r-rh:cc 1 Initrating Circumstances
(internal or external)

V
tllt3qp Slight increase irr unusual or
unpleasant bodv svmptoms
(i.e.,heart palpitations, shorhressof breatl-r,
fainhress or c-lizziness,su'eating, etc.)

V
L'l Ld>c -) Internalization
(increased focus on symptoms makes
them more noticeable and easily magnified)

i
r-llr: cp J
t - " ' - - ' Catastrophic Interpretatior-r
(telling vor.rrsc.lf
the symptom is dar-rgerr)us-i.c.,
"I'll lrave a hcart attack, " "I'll suffocate," "I'll go
completelrrout of coutrctl,""I must lc-at'eat once")

i
phase5 Panic

Thc. good rrcrt'sis that it's possiblc to intg.r'cne at any point rn this seclr.tcnce. At
pirase1 it may be gcrlt'r'rr/i:cd sfr.r'.ss
that leads to the initial unpleasant Lrodyset-rsatiens-
heatrtp;rlpitations, chest cr-rt.rstrictit'rn,
dizzitress,ancl so ctn. Incorpor.rtirrg legtrlar relaxa-
tiotl, exercise,lort'-stressnutritiotral habits, arrd otircr stresslnanagemer-rttechniques into
your lifestl'le (seeChaptels 1,5, 11, and 16) orr a daily basis can go a lor-rglt'ay tortar.d
reclttcilg the prol-rensitt,fol sudden iucreasesin your bodv's state of s).nrpatheticnenrous
s1'stemarousal associated rvith stress. Beyond generalized stress, vou may be abie to
identifu the p211i611arirritiating circlttnstancesthat cause your panic arttacksby noting
carefullv u'ltat 't't'asgoing on jr-istL-,efot'e-orin tl-reseveral honrs before-a panic attack

t
E
 'l-lte
116 Anxietv g p716btni{or*book

occurs. You can use the Pntic Attnck Ilecorddescribed in this chapter to help you deter-
mine what initial circumstancesma)/ have led to a particular panic attack. You can then
try to avoid or elirninate these circnmstances so they don't cause yotl trouble in the
future. Interrrentionsthat reduce the propensitS'for having unpleasantbody sensationsin
the first place (phases 1 and 2 in the chart) ali require making changes in your lifestyle
and attitudes.
Phase 3 of tl-repanic cycle is comprisecl of internalization-being too focused on
your internal body state. When voll actually feel panic coming on, yr)tt cau lcdttcc inter-
nalizatior-rby usrng any of the actir.e coping tecirniquesdescribed later ir-rthis c1'rapterin
the section, "Coping Tcchniqr-resto Counteract Panic at an Early Stage." These tech-
niques serve to distract your attentiorr avva1,from iuternal body symptours, aud also
havc a rlirectly t'el,rxingeffect.
Perhaps the most irnportant change )/oLlcan make to defuse panic attacks,howeveL,
is to inten,ene att pirase 4. That is, you can learn to stol-rinterpreting unpleasant body
sensationsas bcing dangcrous or potentially catastrophic.h-rfact, recent researchboth in
the United Statcs and Englarrd has determirred that c'limili;rting catastrophicinterpreta-
tions of body symptoms can, itt nrrdof itselfnlorut,be sufficient to relieve panic attacks. If
you cetn learn to tolertite serrsatiorrssltch arsdizzitress, tightness in your chest, rapid
ircartbeat, and so on as innocuons bod1, syn'tttoms-ratlrcr than as signs of imminent
dangcr-yotr will r'cry likely have fewcr', ii .rnt', panrc aitacks. That is not to say that
s t r e s sm r n a g c m e n t t c c h r r i t l t r r ' sr.rrd c o P i l i g s t r ' . r t c g i cfso r p . r n i c . t t ' cI ' t o ls t i l l i r n I r o r l , r r r it t;
does imply, though, tl-ratelimiuating catastrophic interpretations LrVitself ctrn go i-rlong
way to lclieve panic.
To assist you in bleaking the connection between body svmptoms and catastroprhic
interpletations, pleasc refer to the tr,r'o'uvorksheets belort'. The first worksheet is a list of
body syrnptoms that carr trigger panic attacks. Rate each bociy symptom on a 0-5 scale
accorditrg to horv mr,rchit affects vou when /oLr p'r.111i6. The second worksheet is a list of
common catastrophic sclf-startcmentsthat people whcl panic make iu t'esponse tcr
unpleasant body symptorns. Rate cach of these catastrophrc st;rtemctrtson rt 1-4 st:ale
according to irow mr-ich you feel it cotrtlibr.rtcsto yotrr panic attacks.
Finarlly,usc thc third lvorksheet to go b.rck .tnd conttect the two iists. For earcirtrolt-
blesornc.body symptom you rertedzl or'5, list thc specificcatirstrophicstatementslikely to
be trigger:ed by that symptom. For example, yor,rmight connect he.rrt palpitatiotrs with
"I'nr having arhetrrt attatck," ancl "I'm goit-tgto die, " or diz.zinesswitir "l'nr .r,ritrofn
pass out," or "I'm going to lose contrt-'I."
Whcn yoll're finisired, you shor-rldhave a better idea of r.t,hatparticultrr body synlp-
toms aud trssociirttdgxlnstlophic intclpretatioustrigger yotll'p;rnic attacks.This ktrort'l-
eclge will likely hclp yor"i break the farlseconuection yt)tt'r'e made bctwccn your body
symptoms turd mistaken it-rtcrpretations. Kecp in mind tht'otrghor-tt tiris excrcisethi-ttrirtrlir
tloLt'0c/isfr'dis nt'tttnllrldntrgarotts.
oJ fha ltotlrysryrr4ttttrtts Llttzt,cttcrtttrytlcnsntttsttcltstlntLttorrts
nigltt facl, tltt:y nrc conr.tlctclrl EqLrally
ltnrurlt'ss. itnpr6l1fnp1, kec'p in rnind tha'rt ttttnattf tlre
cntnstropltictlnrtglftsryrntlutut'cltcckt't1 off'is frut: ttr ztnlid,cttatrtltL'ntLjh
tlott nti,qlttlrilut:cortt,irrt:t'.tl
tltorrglrtsis sirrrytltl
otrc of tlrt'crrttrstrrtLtlic
yorLrsalftlrnt it is. Eztt,rry .ftilsc-tt ttrisfnl;ctr bclitJ-iltnt
you cmt lcnrrt to let go of,
How do you bleak the automatic connection between unpleasant body symptoms
and false, catastrophic thoughts? Three ways l-ravebeen found to be helpful:
 a-rr|/1r,( .'trlt ldntL .rlrilcli-. t1l

1. R
. ' e- "n 'n' o- "n -i f'i-n l r. - '

1 \ \ ' r ' i t i l r g d r r \ r ' 1 r. t l t e r t r . t t i r t ' u \ l . l . u t J t i ( ) n s o f s v r 1 1 ] r { l 1 ' 1 1 r

S v m t -f , ) n r i n d l r , - if o r 1 5
v _ , r
" f
! ! ' ,

I?.e
cogttitrou
lr-rstrecogr-riztng YoLrrtcnden.\'to Lrelievethat harmlc-ssbodv s\.nrpton-Is alr,signs ()j
imtt-Litrctrtdattgcl rs the ftlst stcp. {rr-aretressof spi:cific corrlectiot-rsbetr,r'ee1palticular
s\'IlPt()nls aitd particr-rlatcat.tsttoPlrrc tl-ror-rg1-rts, rt-hich \/olr n'li-r\har.e gaurcd fronr the
previotts excrcise,rvill lrerlpvou bt'gin diffusing tl-rcdangcr n'hctr those.sl,nlptot1sc6nre
L l i )i l r d ( t \- t . ' - d , t rl i i r ' .

r ^ / , . ; r ; , , ^D . . - { , / /A l t C n t n l i t , C F t t t l t u t r i li t t t r ;
i r / l l I l l \ L J I t L ( I l - 1 l I l L I I I l l l l ( ' L L - , t l t l t t t t L t t t l t l l . l

o.f Bodt7 Stlrrr1ttotrts

The catastrophic seif-statements),ou rnake in an atternPt to nrake sense of urPJe3=-
arlt bodt svtttprt.rnl5durilrg a panic attack are simplt'falsc. It's just 1ot true, for examl_r1e,
t i r . r tr . r p j d h c a t ' t b e , o
t lr ' I a l p ; 1 r l i o t t : o c c Lt r. b e C J u s p\ o u d l ' e h a v u r g a i i e a r t . r t f . r c k N . or. is
consfiction il I'our chest or shortnessol LrreathhaFPsllillg becauseyLlll're abont to suffo-
cate.Nor is dizzuressald light-he.rdedless occnrrirg L-'ecause I'c-ru'reabout to faurt or-"go
craz\'." hr eacl-rof tl'resecases,therc'is an alternafir'e erplanation that is notrcatastropiric
. u r d b a s t ' du r t a c t . A l t e n t . t t i re l o g i c , i le \ F 1 3 , ' . ' ' , ' , , 'mr : i q i r i q o s o n r c t l r L r gl i k e f l r i s ;

1. Alr incrcase in heartbeat and,,'or heart palpitatiorrSis ver1. likelr. caused fy

increased output of adrclraljue and st'mpathetic nerr-ous s\istent activitl' 111u1
accornparlv the earlt' staqe of an ar-Lxietvreaction. Sucl-rreactions are part of the
bod\.'s normal means of I'randlir-rgany Ttcrcaircdthreat-t1-rc)/ are part gf t6e
flight-or-fight lesponse. Thcv are il no \\'a\/ dangerous, c\ren if the1,coltillre for
some time. For erample, a healthy heart can Lrcatraprdll' for hours rt,ithorrt put-
ting 1'eu ;-tt atry l'isk.

2. An increaseiu chest constriction and sholhress of brcatli carr be crplainecl ir-r

tertns of coutraction of thc mr-rsclessnrlounding the chest cavitv, alsc'rdr-re tcr
increased svntPathetic ttt:rr.,rttssvstem actit'it1. Such syrnl-,totnshavc rrothilrg t.
do n,ith the process of suffocating. \'our chest mnscles cannot corrtract to tlre
point rt'here )rou rt'ould be at risk of suffocating, no matter hor,r'unpleasant t6c
tightness it.t 1'trul chest h.rp-'1-'t,ris
to feel.

3. Becor-niIrgdizzl'ol iiglit-hc'a,-led,conrrlon svrnptorrrs that ci-rr-r occllr rn'herr1,1y11

Lrecomeanxious,are not cansedbt' tl-rcfact that ),ou are abotrt to fairrt. Thel' 11."
caused L-rymiuor constrictions in the arteries of vour brain, r.r,hichlcad to a slrgl-rt
leductior-rin blood cilculation. It's ertremely uulikeh' that Yon r.t'onld faitrt, evcn
if vou feel quite light-headed. Fairrtir-rgtvpicallv occlu's dururg I rllop in blogd
Pressurei tt,hett Votl start ttl feel attlitlus, 1'c'luttsuatll)'erpgljgy-tCea. illcl'r'n-qc
i'
blood pressure due to iucl'easedadrenaline ;11161 sr;nrrr;rtl.rotir-
rrer'\,nltssyst.em
tolre.
r- C o p i r t nt r i t l t P n t r i r

Panic Attack I\/orkslrcet2

CatnstroTlric Tltough ts*

Catastrophic thougirts plav a major role in aggravating ;ranrc attacks. Using tl-re
belorn',rate each of the follor,r'rngthouglrts accordirrg to tire degree to rt'luclr von bel,
that each thought corrtril'rutes to vour panic ;rttacks.
' t -
Not at ali 3 * Quite a lot
Somer.r'l-rat 4 - \1ci'rlmucl-r

1. I'm gohg to die. - . 1 +

l . l ' n r tlro. ,i^t' .rt r] ^ .i.l"r* .\ a l r e . 2 3 I
3. I'n-r losing control. 2 3 I
4. This r,r'ill never end. 2 3 1
i. I'm rcallv scared. 2 3 4
6. I'm iraving a heart aitack. 2 3 4
7. I'm going to pass out. 2 3 1
8. I don't knort' n'hat 1-reo;'rie
rt'ill think. : , ) 1
9. I n.on't be able to get out of here. 2 3 +
1 0 . I d o n ' t u n d e r s t a n dn h a t ' s h a p p c n i n gi o n r e . : J 4
11. Peopie r,r'ill think I'm craz\.. : . ) 4
11. I'll alr.t'a1's
L-retlri: n ar . 2 3 1
li T'm o n i n o f n f.h. . r o \ \ 'u P .
o -.-.o "- 2 3 1
11. I must irave a brain tumor. ./- 3 4
15. I'11choke to deatir. a - a 4
i o . I ' m Dc -o- .i 'nD s t' "o a
' - -c t f o o l i s h . 2 3 4
17 I'n c'oirro lrlinrl
.)"....r"^^^.* 2 3 4
1E. I'll hurt someone. 2 3 4
19. I'm going to har.e a stroke. L , 1 4

20. I'm going to scream. 2 3 1

21. I'm going to babble or talk funrrv. r : J 1
n a
ll. l'11be ;'ra121y,2cd
by fc.r'. L , ) 4
23. Sometiring is really physicallv \^'r'ong r.t'ith nre. L J 4
?4. I won't be able to breathe. 2 3 4
f5 n a
S n m p- -l"l"r" it r1 r o fcrrihip rl Jn" '' i l l h : r r r r e* n" '
""1 -f
L , ) 4
lf,'. ]'m goinq to rrrake J scelte. L 3 4

* Ada;rlgi florn "Paruc Attack Cogmtior-rs in Co1,ir15

iritlt Pntric:A Drtrg-.frct,Approtchfo Dcnl-
Qr-rcstiururaire"
itrg \\titlt Anricttr Attncksbv G. A. Clurn. Copl'right O 1990 l.r'Brooks,/Cole lr-rLrlishirrgConr;r.1111',a division
of hrternational Thomson Publishing Irrc.,Pacific Cror.e, CA 93950 Reprurted lrl'prs111r15sj1rn of tl-Le
puLriisher.
120 The Antietrl & PircbiaWorkbook

ConnectingBody Symptomsand
CatastrophicThoughts

In the leffhand columlr beiow list body svmptoms you rated 5 or 4 on the first Panic
AttnckWorkslrcet.Describe your most troublesome body symptoms, one at a time' Then
iist catastrophic self-statements from the second r.t'orksheet, "Catastrophic Thoughts,"
whiclr you rated 4 or 3. List thosccntnstropl'ticstntenrcntsyou woultl bc nrosflikely to nnke in
rcspot.Ee For example, "Rapid heartbeat" is a body symP-
ts eachparfiuilnr body stlntTttont.
tom that might elicit such catastrophic self-statements as, "I'm irar.ing a heart attack,"
and "l'm soins to die."

Body Symptom: Thoughts:

Catastrophic

Body Symptom: CatastrophicThoughts:

I]^J-,
uu!t)
Q-,-..r^,-.
JlrrtlJt!rltt 6 . 1 1 5 1 1 ' t r p hTi ch o t t g l i i s :

Body Symptom: C a t a s t r' o

f n' l" r-i c T
^h" ' t' r"rror ' h t s :
122 Tlre r\niletv I Phobia Workbook

Accept zuhat your body is doing-don't fight against it.

When you try to fight panic, you simpiy tense up against it, which only makes yor-r
more anxious. Adopting just the opposite attitude, one of lettittg go and nllowirtg
your bodv to have its reactions (such as heart palpitations, chest constriction, sweaty
palms, dizziness, and so on) will enable you to move through panic much more
quickiy and easily. The key is to be able to zuntchor obseraeyour body's state of
physioiogical arousal-no matter how unusual or uncomfortable it feels-without
reacting to it with further fear or anxief.

Float zaith the "ware" of a pnnic attack rnther than forcing your xuay tfuough it.
Claire Weekes makes a distinction between fh'st fenr and secondfcnr. First fear con-
sists of the physiological reactions undellying panic; second fear is making yourself
afraid of these reactions by saying scary things to yourself like, "I can't handic
this!", "I'r,e got to get out of here right now!", "\{hat if other people see this hap-
pening to me!" While you can't do rnuch about first fear, you can eliminate second
fear by learning to "flow with" the rising and falling of your body's state of arousal
rather than fighting or reacting fearfully to it. Instead of scaring yourself about your
body's reactions, you can move with them and make reassuring statements to your-
self like: "This too n'ill pass," "I'11let my body do its thing and move through t1ris,"
"I've handled this before and I can handle it now." A list of positive, coping state-
ments you can use to help you float through a panic attack follows after tl-refourth
point below.

Allozo time to qtnss.

Panic is caused by a sudden surge of adrenaline. If you can allow, and float with,
the bodily reactions caused by this surge, much of this adrenaline will metabolize
and be reabsorbed in three to five minutes. As soon as this happens, you'll start to
feel better. Pnnic nttncksnre time limited.In most cases,panic wiii peak and begin tcr
subside within oniy a few minutes. It is most likely to pass quickly if you don't
asorrrr:fe
q6F)r(rv(rLL . . f' .i 4n, s a g a i n s f i t o r r o a c f i n o t o i t w i i h e v e r r n t o r e f e a r
ir !L' h. ' v_ / , ,f ti rr.-, h (caLtsius"sec-
"b..^.,

ond fear") by saying scary things to yourself.

Coping Statements
Use any or a1l of the follou,ing positirre statements to help you cultivate attitucles of
acceptinp;, "floailng," and allowing time to pass during a panic attack. You may find it
helpfLrl to repeat a single statement over and over the first minute or fivo when yor-rfeel
panic symptoms coming on. Yon may also want to do deep abdominal bleathing itr cotr-
junction with repeating a coping state'ment.If one statement gets tiresome or seernsto
stop working, try anoiher.

"This feeling isn't comfortable or pieasant, but I c.rn accept it."

"I can be anxious ancl still deal with this situation."

"I can handle these symptoms or sensations."

"This isn't an emergency. It's O.K. to think slowiy about what I need to do."
 Copittg rL,iiltPnnic ,i.ttncks 123

"This isn't the u'orst tirutg that could i-rapper-i."

"l'm going to go rt'ith tiris and rt'ait for mv anxiett'to decrease."

"This is an oPPoltlulitr'for me to learlr to cope rt'itl-iml'fears."

"I'11just let mt' bodr, do its thing. This n'ili Pass."

"I'll ride tiris througli-I don't need to let this get to me."

"I deserr.eto fecl O.K. right nort'."

"J can take ail the time I I-reedin order to let go and relax."

"There 's no need to 1-r11si'r

mvselt. J can take as small a step fortt'ard as i choose."

"I'\'e survived this bcfore and 1'll sun'ive t1-ristime, too."

"l can do mt' coping strategies and allort' this to Pass."

"This anxict)' rt'on't hurt me---<'r'enif it doesl-r'tfeel good'"

"This is just anxietv-I'm not gorng to let it get to me."

"Notiring serious is going to happen to me."

"Fighting and resisturg this isn't going to help-so I'11just let it Pass."

"These are just thoughts-not realiW."

"I don't need these thoughts-I can ciroose to think diffet'entir'."

"This isn't dangerous."

"So \4that."

" D o n ' t u ' o r r 1 ' - b e h u p f ] ' . " ( U s e t l r i s t o i n l e c ta l e l e m e t r to f l i g h f n e s so t ' h u m o r . )

I f i ' o u h a v e f r e q t r e n tp a u i c a t t a c k s 1, s L r g g e sr tr l ' i t i n gv o u r f a r o r i t e c o p i n g s t a t c m t ' t r t s

on a 3x5 card and carrf ing it ilr 1'our Furse or rn'allet.Bring ti-recard out and read rt tt'itet-t
rrnrr fpcl nrnir c . r ' r r' r- t 'r.r-f "n' m
" q r' n" n- r"i"t 'rbc ' o t - t" '

Explore the Antecedents of

Your Panic Attacks
You can increasevour mastely o\rer parric attackstrf irrvestig.rtingtJrt tt'ps5.1 circunl-
stancesrt'hich tend tt-rl.recede them. If vtru are agolaphobic, you are very familiar r'r'itl"r
these circumstances.You knor.n'that you are more iikell, to palric, fot' exanlPle, if you ale
fal from irome, drirring o\/er a Lrridge,or sitting in a t'cstaulant, and so )/ou systerrratically
avoid these particular situations. If Vou have spoutaueous p'ratric.-ttt.rcksthat come "ottt
of the blue," you miglrt find it helpfuL to monitor their occulrence {or trvo rt'eeks and
take careful note of rvhat rt'as going on immediatelv-as rt,ell as for several hours-
before each one occllrs. You might observe rt'hether any of tire follort'lng corrditions
rnakes a difference in ti-reiikelihood of 1'p,t,'har-ing a panic reaction:
124 The Anxiety E Plnbia Workl:ook

o Were you under stress?

r Were you by yourself or rt'ith someone?

o if with someone, lt'as it family, friends, or a stranger?

o What kind of mood were yoll in for sel'eral hours before panic came on? Anx-
ious? Depressed? Excited? Sad? Angry? Other?

o Wcre yotl engaging in negatirre or fearful thoughts just before you panicked?

o Did you feel tired or rested?

o Were you experiencing some kind of loss?

o Were you feeling hot or cold?

o Were you feehng restless or calm?

o Had you consumed caffeine or sugar just bcfore panic came ou?

o Are there at-ry other circumstances that correlate with your panic reactions?

Yotr can use the Pnnic Attnck Recttrtlto monitor every panic attack you experience
over a two-week period.* Make copies of the form and fili one out for each sepalatc
panic attack. Anstver a1l the tluestions for the entire day from the time yclu an'oke ttntii
th. ti*" you panickecl.If the attack happencd at night, ans\^/erfor the day precediug tirat
night.
By making the cffort to record your panic attacks and carefully observing any cir-
cumstances tirat consistently precede them, you are taking an import.rnt step. You arre
Iearning that yor.rneed not be a passive victim of an event that seemstotaily ontside yotttr
control. Instead, you can begin to alter the circumstancesof your daily life in a direction
t h a t s i g n i f i c a n t l yr e d u c e st h e o d d s o f h a v i n g p a n i c a t t a c k s .

Learn to Discriminate EarlY

Symptoms of Panic
With prarcticeyou carnlearn to identify the preliminat'y signs that a panic attack may be
imminent. For some individr,ralsthis might be a sudden quickening of the heartbeat.For
others it might be a tighteuing ir-r the chest, sweaty hands, or qltearsiness, Still others
might expcrience a slight dizziness or disorientation. Most people experiencesome pre-
liminary warning symptoms before reaching the "point of uo retltrn" when a ful.l-blort'n
panic attack is inevitable.
It's possible to distingtrish among different levels or degrees of anxiety leadir-rgup
to panic by imagi,ning a 1O-point sc.rle'

* The Pnnlc Attnck Recordis adapted from a sirnilar form developed by David Barlow and Micirelle Claske iu
tireir previously cited book,
 Cr,/,rirlitritl: Pnnt: Aftncl:s 115

Pnttic Attnck [lccord

(Fili out oue forrn tor e a c i r : c 1 ] a l ' d t t ' ; - r . 1 1 1'1r t6t a c l . d L r l i l r g a tn'o-r'r'eekperiod.)

Date:

Trnre:

Duration (minutes)

rate 5-10)
Lrterrsitvof patric olr anrietv scaie (see l-iert sectior-t,

,4rl ilccrJr

t . S t r e s : l e r t l d i t r i t t g l . r c c e d i r r gdar' (ratc or-rI -10 scalc)

? . -Alone ot' rt'ith sot-ueotte?

-t. if u'ith sotleolre, u'as it famil\', frtend(s1,stlar-igel?

4 . Your mood for tl-rreeirours precedrng palric attack' Ar-rxrous

TJcnrec..-d Excited A rr orv Sad
Other (specifr')

5 \\'ere vou facurg a c1-rallenge

--- or taking it easl' ?
--.-,,,----:^l-..J,
in ne5;ative or fearful thoughts before
6 Were vou engagir-r5; y LrLr
Pdl
rrLNf u :

Yes =-. No - If so, rt'hat i1-ror'rghts?

7 . \{ere vou tired - or rested

8 Were ,vou experiet-icingsome kind of emotitlual ul-set or loss?)'es

1\O

neitl'rer ?
\{erc' you feeling hot - cold -

10. \\lerc yor-t feclint restless ;rt-rdinrpatter-rt?)'cs .- Ntl

]1. \\'ere \/oll asleePbefole you panicked? \'es - Ncr

il. Did \-()LlconsLlrtreciiffcine t)r su,qar r,r'ithilr cigl-rt irours beforc )'olr Pi'rr-rickecl?
Ycs Ncr If Ves, hort' tlr-tch?

'1111 panic reac-

1 3 Have t'clr-rrroticed atrl' othe r circr-ttrrstances*,6icit correlate t lrt'rr_lr
ti.ons? ispecifl')
126 Tlrc Anxietv E PltobialNortr:book

Anxiety Scale*
7-70 Mnjor PnnicAttnck All of the srrrnrrlnnrq in lprrpl A nrac'oeraftrd: ierrnr

fear of going crazy or dying; compulsion to escape

6 ModerntcPm"Lic
Attnck Palpitations; difficultv breathing; feelrng disoliente'd
or detached (feclirrgof r"rnrealit!);1-r;11''i.
irr resl-ronsc
to perceived loss of control

5 Enrly Pnnic Heart pounding or beating irregr-r1.rr1y';

constricted
breathing; spacinessor dizziness; dcfinite fear of
l.n" c" i.n, a. b ronfrol' ann-rlrnlqinrr in .\(.-'ll.ln

4 Mnrkad Attxitty Feeling uncomfortable or "spracey";heart lreatinc

fast; muscles tight; Lrcginning to wonder about
mzrintaining control

3 Mttdtrnlc Atttitlr/ Feeling uncomfortalrle but stil1 in cor-rtrol;heart

starting to beat f.rster;more rapid Lrreathirrg;
sweaty palms

2 Mild Arnietrl Ilutterflies in stomach; muscle tension;

, ] pfirri tolrz 11ar\/^r r q

7 SliglttAnxicttl I'assing trvinge of anxiety, feeling slightlv nervr)Lrs

0 Rclttxntiorr ( , r l n r , r f c t ' l i r r go f l . ' t ' i r r !r,r r r d i s t r . r c t cadr r d . r t

[)t,act,

Thc syzrnplornsat various levels of this scale ale typical, although they may r-rotr:or-
respond exactly to yor.rrspecific symptoms. The important thing is to itlcntifl' n,hat con-
stitutes a Level 4 for yorL. This is the point at u'hich-wiratever sfml-rfpps volL're
expericncirlg-Vdu feel ryourcoutrol or)cr yoln' renctionbegirtrtntgto tlintitislt Up ttr arrcl
tirrotrgh Level 3, vt)Lrmary be feeling very anxious and Lrncomfort.rble,but yrru still feel
tlrat you're coping. Sttrrting at L,errcl4, yott begin to in,onderwhcther you can manilgr.
w
v r ll r
l (a
l (t ' s
J lhl (, lrFrr rf ;
, lrl o
l ln .v \ ll rl l i\ cl l h cL q, lrr n rl \rL' r, \rr , ' Jv| vpL ll r fl Uo fl \rl rl rt ltt h( ' nl r yr (rl ;l rl lr\ r. i r ^\v A
l t iSr, r r ' w
.--^ 'r:^^ "^'.
v l 'L: t rl ' 1 .
. t n l e , r t . nt t r
l ,
y t , t l
P l ( l \ L l L f

"catch yoursclf"-al.ort a panic lL'.rction bcforc it reachcs this point of no retr-rr:n. The
n r o r t ' . r d t ' 1 'yf t l r t b e c o n r ca t r c c u g t r i z i t r tgh c e , r r : l yw a r t t i r t gs i g n s o f P , l n i cr r P t l 1 1 1 r 1 1 g 1 1
Levcl 4 on the scalc, the more control you will gain o\rer yolrr panic reactions.l\4.rrkthis
page with a p;rper clip or in sonrc trther fashion,.rs rve rtill frequently rcfcl trr tire,4l-rir'lr7
Scnlchere and in subsequcntchapters

Coping Strategies to Counteract Panic

at an Early Stage
You must first lcarm to identify yollr own pre'litninaly rv.rlnirrgsigns of a potentral panic
attack. What are youl own I-evL.l4 synrptoms? Ther-rrt is time to do sontttliirr{'aLroLrt
them.

' T l r i s a r r r i c t l ' s c , i l ew . t s . r d . r p t e dfrorr .r sir-ni1arorre developed br, Dr. Arthtit' Flalrll, i1 the l'ERR,uiPPro{rnur
Mattrnl, Ivlenlo Park, Carlifolnia: T S C P t r b l i c a t i o n s 1, 9 8 1 ,
 13. RelteatPositiueCopingStatements
One of the central points of this chapter has been to emphasize the
roie of negative
self-talk tn aggravating a panic attack. While the physical
todily reactions associated
with panic (first fear) may come out of the blue, your emotional
reaction to these bodily
symptoms (second fear) does not. It is based on what you teIIyourself about
these symp-
toms' If you tell yourself that your physiological syrnptoms are horrible
and very threat-
ening, that you can't stand them, you're going to lose control, or that you
might die, you
will scare yourself into a very high siate of anxiety. On the other hand,
if-you accept
what's happening and make calming, reassuring statements to yourself,
such as, ,,It,s
only anxiety-I/m not going to let it get to me," "I've been through this before
and it,s
not dangerous," or "I can handle this until it passes,,,you can minimize or
eiiminate the
escalation of your symptoms.
Use any of the positive coping statements listed earlier in this chapter when
vou feel
the first symptoms of panic coming on. This will help divert yo,r, ,nlt d u*uy
bith fro^
the bodiiy symptoms of panic and from fear-inducing self-talk that can only
make things
worse. Many people find it helpful to write several coping statements down
on a 3x5
card which they carry with them at all times. Should syrmptoms start to come
on, you
simply pull the card out and repeat a particular statement over and over. Keep
this up
for several rninutes if necessary,until you feel the physiological intensity
of your panic
beginnrng to subside.
Learning to use coping statements effectively to overcome panic will take
practice
and perseverance, If you make the effort, you will be surprised how well
coping state-
ments can work to prevent your anxiety symptoms from going above Level
4 on the
Anxiety Scale.Positive self-talk also can help to limit a panic attack that has
already gone
above Level 4.
ln sum, the way you resPond to early physical symptoms of panic will
be cleter-
mined largely by what you say to yourself, as illustrated below.

First Fear NegatiueSelf-Tnlk Second Fear

"Oh no-here it comes." Emotional
"I'm losing control." ----> Reactionto --) panic
"I can't stand this." Bodily Symptoms
"What will others think
if I lose it?"

Bodily Symptoms
Rapid Heartbeat
Sweaf Palms
\
ConstrictedBreathing \
Dizzrness

PositiaeSelf-Tnlk
or CopingStatements
,,I can handle
these ____) Detachment -+ Coping
symptoms.""This is Flowing with Bodily
just anxiety-I'll iet it pass." Symptoms
"I can ride this through."

The choice is up to you.

 L34 Tlrc Anxictrl I Plnbio Workbook

74. Use Bresthing (or Relaxation) in Coltbit.tatiol,r

roith Coping Statenlents
You might find tl'rat a contbhmtionof abdominal breathi'g (or progressiyemuscle
relaxation) and repeating a positirte coPing statement will work best in limitilg yssr
panic. Generally it's best to address the physical se'sations of panic first with an
abdominai breatiring exercise(or muscle relixation), and to follow up shortly thereafter
with methodical repetition of a coping statement.you may prefer.to compleiely o'erlap
tire two types of teclrniques or, alternativelv, yo,, may want to r,rrork exclusirrely on
reducing your physiological arousal for a minute or two and then start working with a
positirrestatement.Experiment to see what works best for you. I suggestthat you gain
some skill and familiarity with each type of strateg! by itself, first, before attempting to
put them together.With practice,you may develof-a combinationof breathing (or rmrs-
cle leiaxation) and self-talkthat is rrery effectiveagainstall qrpesand degreeso?panic.

Learn to Observe Rather Than React

to Bodily Sensationsof Anxiery
You can take a major step forward by learning to detach emotionally from the first
physical symptoms of panic: simply obseraeth;. To the extent that you are able to
watch the intense reactions your body goes through when aroused without interpreting
them as a threat, you wili be able to save yo.rrrilf considerable distress. Slrategies 11
through 14, describedin the prer,'ioussection, can help
Vou to adopt this d,etachedstance.
By doing deep abdominalbreathing or-the calming breath exerciie,you can slow down
the physiological mechanisms responsible for p*i., giving yourseli time to garn some
detachment. By using positive self-talk, you repiace tie scare talk which can aggravate
your anxiety with coping statementsspecificalty designed to foster an attitude of detach-
ment and "flowirrg" with the experience.
You'll find that it takes some Practice to learn ilow to use breathing (or relaxation)

['H':;""'#*iTiH:;:l',:l:.ff
x'Jr:Hvfi
T]?^yTlJt"J,ff
HJ*:::*:n;
with panic rather than just reacting. This kind Jf detuch-ent is tl-Lekey to bei'g able to
master your panic.

What to Do When Panic Goes

Above Level 4
If you are unable to arrest a panic reaction before it goes
beyond your personal point of
no return, observe the following guidelines:
o Get out of the pa*ic-pro'oki'g situatio. if possibre.
' Don't try to control or fight your symptoms-accept them a1d "ride them out,,;
remind yourself tl-rat panic is not dangerous and will pass.

o Call someone-express your feelings to them.

F
f-

zuithPanicAttacks
CoTtitrg L35
':

o Move around or engage in physical activif.

o Focus on simple objects around you.

o Touch the floor, the phvsical objects around you, or "ground" yourself in some
other way.
o If you are in a place r,r'hereyou can do so, discharge tension by pounding your
C:^L- ^-,,:*^
ilsts/ cryrng, or screammg.
o Breathe slowly and regularly through your nose to reduce possible symptoms of
hyperventilation.
. Use positive self-talk (coping statements) in conjunction with slow breathing.
o As a last resort, take an extra dose of a minor tranquilizer (witir the general
approval of your doctor).

During an intense panic attack, you may fecl vcry confused and disoriented. Try
asking yourseif the follon'ing questions to increase your objectivity (you may want to
write these out on a 3x5 card which you carry with you at all times).

I'rtt feelhtg trtily dnngerorrs?(Answer: No)

7. Are thesesymTttonts

2. Whnf is the nbsohLtezuorstthing tlnt cotLldhappenZ(Usual answer: I might have to

leave this situation quickly or I might have to ask for assistance.)

3. Am I tellfug ntyselfanything thnt is mnking this zuorse?

4. Wlmt is the ntost supportiue thirtg I cotild do for nryself right nozu?

Putting It All Together

To sum up, there are three approachesyou can use to deal with the oncoming symptoms
of panic:

7. Rctrcst

2. Distrnction

3. BraLttlting(or muscie relaxation) and Ttositiueself-tnlk

The first technique is useful for dealing with panic that arises in the processof con-
fronting a phobic situation; the latter two carnbe used for phobic panic or for spontane-
-.-:- ^!r^-1.^
I'Lt> F'<lrtrL ctLLctLA).

Retrent
If panic symptoms begin to come on when you're approaching or dealing with a
phobic sitr.ration(such as driving on the freeway, entering the grocery store, or staying at
home alone), then retreat if your symptoms exceed Level 4 on the Anxiety Scnle,

L
 Tlte Anxiettt €t Phobia Workbook

Bodily symptoms of panic arise u'hile entering a phobic situation

V
I
Retreat from the situation

Y
I
Recover from the symptoms (altow anxiety to faII to a Level 1. or ))

+
Reenter the situation

The last step is very important. Not attempting to return to the situation after symptoms
of panic have subsided will only reinforce your fear.

Distrnction
If panic symptoms come on spontaneously, apart from any pirobic situatiory you
may find it helpful to try distraction first. Distraction can also be helpful in managing
your anxief, up to Level 4 while you are confronting a phobic sifuation.
Bodily symptoms of panic

+
Divert your attention from bodily symptoms
(use any of the strategies described in this chapter)

l-. Talk to someone.

2. Focus on objects in your sunoundings.
3. Do simple, repetitive tasks (count change, time a stoplight, read your list of
affirmations, and so on).
4. Engage in physical activifY.
5. Express anger physically or at the panic itself.
6. Do something pleasurable (get a backrub, eat a delicious snack).
7. Practice thought stoPPing.
I
t
Stay involved with the distraction until symptoms
of panic subside (down to Level 1)

DeepBrroihing (or Relaxntion)and PositiaeSelf-Tatk

\Mrile distraction techniques can be very practical and effective, you may prefer to
get at the "root" of a panic attack by practicit',g un arousal-reduction tecl-urique
 Coping witlt Panic Attack 1.37

(abdominalbreathing or musclerelaxation)md/or repealrngpositive coping statements.

For many people, these are the most powerful strategiesfor counteractingpanic. They
can be used separatelyor in combinationand are useful for spontaneouspanic attacksas
well as for panic encounteredwhile attempting to confront a phobia.
Bodiiy symptoms of panic

I
Do deep breathing (see Chapter 4), either:
(7) Slo'w, abdominal breatlung, preferably through your nose, for up to 3-5 minutes

or
(2) Calming breath (inhale to 5, hold to 5, exhale to 5) up to 10 Limes
or

Do abbreviatedversion of progressivemuscle relaxation (seeabove)

and/or

Repeat a positive coping statement over and over (during or

following deep breathing or muscle relaxation),for example:

"I can handle tfris,"

"This will pass and I'll relax,"

"This is just anxief-it's not dangerous."

I
Y
Continue deep breathing and/or positive seif-talk
until symptoms of panic subside (down to Level 1)