This Manual is both a guide to treatment and a workbook for persons who suffer from panic disorder and agoraphobia. During treatment, it is a workbook in which individuals can record their own experience of their disorder, together with the additional advice for their particular case given by their clinician. After treatment has concluded, this Manual will serve as a self-help resource enabling those who have recovered, but who encounter further stressors or difficulties, to read the appropriate section and, by putting the content into action, stay well.
The nature of anxiety, panic, and agoraphobia
Since the time of the ancient Greeks there have been consistent reports of a disorder causing the most irrational fears in otherwise sane persons. It was not until the latter part of the nineteenth century that this came to be known as agoraphobia, which literally translated means “fear of the market place”. More recently, it has come to be known more generally as a fear of public places or open spaces. While fear of public places or open spaces does characterize the majority of sufferers of agoraphobia, recent evidence suggests that these situational fears are not the primary fears in agoraphobia. It is the fear of panic or anxiety attacks, regardless of where they occur, that is the primary fear in panic disorder and agoraphobia.
Many people have attacks of panic. However, only a few people continue to have frequent or distressing attacks of panic that begin to interfere with their day-to-day functioning. When panic attacks are very frequent or when a person spends a considerable amount of time fearfully anticipating the next attack of panic, that individual may be said to suffer from panic disorder.
Some people with panic continue their daily lives despite the attacks of anxiety that strike them out of the blue. For other people with panic, the attacks of anxiety lead them to avoid situations for fear of panic. Typically, people who panic do so for one of three reasons. First, they may avoid situations because they see a link between the various situations and their panics. For example, panic attacks may occur regularly in shopping centers, so the person comes to avoid these places. Second, people with panic can avoid situations where a panic may occur because of the physical or social effects of panicking in that place. For instance, someone who fears urinating during a panic may avoid places where people easily may observe the consequences of such a loss of control. Finally, individuals may avoid situations where they perceive that they do not have the resources to manage a panic. For instance, a person may avoid driving if they fear that a panic may rob them of the capacity to drive safely.
The avoidance of situations for fear of panic typically includes crowded areas, open spaces, buses, trains, closed-in places, and being a long way from home or help. Remember, these fearful avoidances are secondary to the basic fear: the fear of panic. It is, therefore, more appropriate to describe agoraphobia as a fear of panic attacks that may lead a person to avoid any situation or activities that they think will provoke these attacks or prevent escape or hinder help arriving.
The distinction between primary and secondary fears is important. For individuals with panic disorder it will be necessary to learn to control the primary fear, the panic attacks. For individuals with panic disorder and agoraphobic avoidances, the fact that the fear of situations is secondary to the fear of anxiety means that to overcome the problems of agoraphobia it is necessary to learn to control the anxiety and panic attacks. Once this primary fear is controlled, an individual with agoraphobia can learn to overcome the situational fears. As individuals learn that they can control their anxiety and their panics, they can confront those situations that they have previously avoided, secured by the knowledge that they can prevent panic attacks.
This primary fear in agoraphobia is often described as a fear of fainting or collapsing, having a heart attack, going crazy, losing control of bowel or bladder, or in any other way losing personal control. The secondary or situational fears are many and varied. These fears include any situation that an individual believes will provoke or is associated with high anxiety. The important point here is that one does not actually have to experience an anxiety attack in all of these situations, but need only believe that the situation might provoke an attack. In this sense it is not only the attacks of anxiety but the way in which an individual thinks about the attacks that determines which situational fears develop. In our experience, almost all people with a long-standing panic disorder come to avoid some situations for fear of panic. The extent of your avoidance will determine the amount of time and energy you will need to allocate to overcoming this problem.
Some disorders occasionally mistaken for agoraphobia include depression, schizophrenia, social phobia, and obsessive-compulsive disorder. However, a reasonable understanding of the nature of agoraphobia as previously described generally allows for easy classification of these disorders as not constituting agoraphobia.
How do panic disorder and agoraphobia develop?
Stress
For many people, the first panic attack occurs during a period of increased stress.
Stress can be psychological or physical.
Psychological stress: such as arguments with parents or partner, death or illness in the family, problems with others outside the home, financial problems, or work pressure.
Physical stress: resulting from personal illness, exhaustion from overworking, excessive use of alcohol or drugs, lack of sleep, low blood sugar as a result of dieting.
Anxiety
Both physical and psychological stress can produce an anxiety reaction. Becoming anxious is not the inevitable consequence of stress, but it is a common result. Often these stresses and the associated anxiety can be quite subtle, but it is in these situations that a person is more vulnerable to a panic attack.
At some time or another everyone experiences stress and reacts by becoming anxious. However, not everyone who experiences anxiety develops panic attacks. The question arises why some people develop panics while others don’t. Unfortunately, there is no single answer to this question as yet. There are, however, various possible explanations. First, there is some evidence that people who develop panic disorder and agoraphobia have been subjected to greater than normal amounts of stress just prior to their first attack, thus making them more vulnerable than others. Second, it may be the case that people who develop panic attacks are more vulnerable than others to stress and to worry about panic attacks.
Hyperventilation or overbreathing
To hyperventilate means to overbreathe, either by breathing too quickly or too deeply. The actual abnormal breathing often goes unnoticed by the sufferer; however, the effects of hyperventilation do not. The symptoms include dizziness, light-headedness, tingling sensations in hands or feet, weakness in the legs, palpitations, tightness and pains in the chest, and rising panic. These symptoms are the result of reduced carbon dioxide in the blood as a result of overbreathing.
Personality characteristics
Another possible reason why panic disorder and agoraphobia afflicts some and not others is that people have different natures. Most sufferers of panic disorder and agoraphobia have a tendency to worry. They are often overly concerned with many aspects of their lives, especially their health. When things go wrong, or do not turn out as expected, some of us consider that it is a more drastic or serious problem than is actually the case. Control of these worrying and self-defeating thoughts, which often contribute to anxiety, will be discussed in detail later in the Manual.
For the present, we shall turn our attention to the attack of panic.
The nature of panic
A panic attack is a sudden spell or attack when you feel frightened, anxious or terrified in a situation when most people would not feel afraid. During one of these attacks you may have noticed some of the following sensations:
• Shortness of breath
• Pounding heart
• Dizzy or light headed
• Tingling fingers or feet
• Tightness or pain in the chest
• A choking or smothering feeling
• Feeling faint
• Sweating
• Trembling or shaking
• Hot or cold flushes
• Things around you feel unreal
• Dry mouth
• Nausea or butterflies
• “Jelly legs”
• Blurred vision
• Muscle tension
• Feeling you can’t get your thoughts together or speak
• Fear you might die, lose control or act in a crazy way
When the panic becomes severe, most people try to get out of the particular situation in the hope that the panic will stop, or else they get help so that should they collapse, have a heart attack, or go crazy, there will be somebody with them who will look after them. Occasionally, some people want to go somewhere alone so that they do not embarrass themselves in some way.
The first few times that someone experiences a panic attack are usually very frightening because this is a new experience that is strange and abnormal. However, after many such experiences most people know deep down that they’re unlikely to lose control, collapse, die, or go crazy. At least, they haven’t up till now. However, many fear that the next time may be different, that the next panic may be the worst. Some people manage to resign themselves to the experience of panic, even though they never like the experience.
Panics rarely come truly out of the blue. Even the first attack usually occurs at a time when the individual is under emotional pressure, or unwell (e.g., recovering from the flu), or when they are tired and exhausted and beginning to feel at the end of their tether. A person’s first panic attack is very uncommon when someone is truly safe, genuinely relaxed, and free from stress.
The development of situational fears
Most people rapidly learn to predict the situations in which the panic is likely to occur. It is not that the situation is so dangerous; it is just that they can identify it as an awkward place to have a panic. Planes, trains, buses, elevators, or escalators are often seen as awkward places to panic, since you have to wait until they stop in order to get off. Having to wait in a line in a bank or a shop is often difficult for the same reason. Being truly alone, as in being at home with no neighbors to call, or driving on a lonely road, or being in a lonely place like a beach or a field can have the same effect: who would come to your aid if you panicked? Driving on your own and being caught in a traffic jam has all these problems: being alone, help can’t get to you, but you can’t really leave the car should you panic. Of course, for some, the fear of making a fool of yourself outweighs the need for help, and so you’d do anything to be alone.
When an event occurs in our lives, we seek an explanation for that event. Also, when a panic attack is experienced, an individual will seek an explanation for it. At the time of the attack, 90% of people with agoraphobia will have no true explanation of why the attack occurred. Stress, anxiety, and hyperventilation, which have in fact caused the attack, are not seen as the reasons by the sufferer. This is because stress, anxiety, and overbreathing develop gradually, and the individual is often unaware of their presence.
The individual with agoraphobia mistakenly explains the panic attack in terms of the situation in which the panic was experienced. One way that this association is made is by the process of conditioning. Because the experience of the panic and the place in which it happened both occurred at the same time, the conditioning process leads to an association between the two events being made in memory. Your memory of the attack is associated with your memory of the situation in which it occurred. It is this association that leads to the belief that the situation caused the attack. This belief leads to the development of the situational fears and the avoidance of certain situations.
As was mentioned previously, not all situations avoided by people with agoraphobia have necessarily been the site of previous panic attacks. These individuals need only think that a certain situation may provoke an attack to avoid it. This explains the often widespread fears and avoidances held by people with agoraphobia. It also explains the speed with which these fears can develop. In fact, in 30% of people with agoraphobia, widespread avoidance develops within one week of the first panic attack. The process by which these avoidance behaviors or fears spread is known as generalization.
It is important that you understand the concepts of conditioning and generalization because the successful treatment involves the breaking down of the associations between the panic attacks and the avoided situations that have been built up by these two processes.
Another reason why people with panic attacks develop avoidance of feared situations is because they see themselves as being unable to control a panic in that situation. Because the panic is out of control, the person begins to worry about the possible consequences of having a panic, the embarrassment or possible injury. For example, you may worry that people will think less of you if you collapse in public, or you may worry that if you were to lose control of your actions you may injure yourself or loved ones. Whatever the reason, it appears sensible to avoid situations in which the consequences of having a panic (such as driving a car) are frightening.
Remember, the primary fear in agoraphobia is the fear of panic or anxiety attacks, not the fear of certain places or situations. The situational fears are secondary. Successful treatment involves, first, learning to manage and control the anxiety and panic attacks and then, second, with that knowledge, learning to overcome the situational fears.
Subtle avoidances
We have already talked about avoidance of actual situations, but there are also other types of avoidance which, although more subtle, are nevertheless connected to panic attacks.
• Do you avoid medication of any kind even if your doctor prescribes it?
• Alternatively, do you avoid going out without medication?
• Do you avoid exercise?
• Do you avoid becoming very angry?
• Do you avoid sexual relations?
• Do you avoid very emotional movies such as horror movies or even very sad movies?
• Do you avoid being outside in very hot or very cold conditions?
• Do you hate being startled or frightened?
• Do you avoid being away from medical help?
• Do you keep an eye out for exit routes?
• Do you avoid standing and walking without structural support?
If so, these forms of avoidance may well be connected to panic attacks and will need to be overcome.
Distraction can act as another form of avoidance. Many people attempt to “get through” situations in which they are afraid of having panic attacks by distracting themselves. For example, if you feel yourself becoming anxious or panicky do you:
• Carry around something to read and then read it as intensely as you can?
• Open windows?
• Play loud music?
• Try to imagine yourself somewhere else?
• Tell somebody who is with you to talk to you about something – anything?
• Seek reassurance
• Play counting games?
If you have tried many of these tricks (or are still using them), then the chances are that they have helped you to get through a panic attack in the past and may well help you in the future. However, these tricks often become strong habits in themselves to the extent that many people come to depend on them. In the long run, these strategies, while not harmful, are not helpful, since they do not change the core element of panic attacks or your anxiety over the future occurrence of panic attacks.
In addition, if you are too busy distracting yourself, you will be unable to employ the techniques we will be teaching you to control worrying thoughts. During a panic attack, the thoughts and statements that one tells oneself involve the sense of impending doom, that something terrible is about to happen, and involve a great deal of worrying about the present and future. There is an anticipation of the worst and apprehension about what may be going to happen. In addition, there are feelings that events could proceed uncontrollably or that one may not have control over one’s own reactions. We will be looking at how such thoughts can trigger, intensify, and prolong our anxiety reactions.
Rationale of the program
This program will teach you to alter your responses by learning to change the way you think and the way you react to certain events. In essence, you will be learning new methods of control. The program covers three basic strategies:
Techniques designed to modify what you say to yourself, Techniques designed to control physical sensations, and Techniques to help you to face more comfortably the things you currently fear and avoid.
We will begin by teaching you techniques to directly control many of your physical sensations. This will be done through control of your breathing and muscle tension. Many people breathe too much when they have a panic attack, even though it sometimes feels like the opposite. Overbreathing is a major reason for the worsening of the panic sensations that you experience and learning to control your breathing will help to reduce many of the panic symptoms. In addition, muscle relaxation exercises will lower your general level of stress and tension as well as relieving muscle tension when you get uptight.
Some people quickly begin to avoid the situations that might trigger the panics, particularly those situations from which there is no easy escape or in which help is not available should a panic occur. This avoidance seems to limit the panics in the short term, but in the long term most people need to avoid more and more situations and they may even become housebound or unable to be left on their own.
Avoiding situations in which panic has occurred at first seems to be a sensible thing to do because it initially reduces the number of panic attacks. One of the problems with avoiding situations in which panic has occurred is that each time a situation is avoided, the need to avoid it the next time is heightened or increased. In this way, the panics are no longer the only problem because the individual often structures his or her life around the panics, and spends considerable effort and anxiety planning what to do in case a panic should occur or how to avoid being in a situation where a panic is possible. In this way, agoraphobia can take on a life of its own.
The next part of treatment entails exposure or practice in the situations that you have been avoiding, which in the past have become associated with panic and anxiety. Another important component of treatment involves looking at the things you say to yourself before, during, or after a panic attack and looking at the specific kinds of misinterpretations and assumptions that contribute to your anxiety. You will be shown how to question and challenge these assumptions and misinterpretations by examining the evidence.
In addition, treatment will involve examining the physical sensations that have become part of your panic response and helping you to repeatedly experience those sensations so that they become less fear provoking.
It is important to realize that achieving control of your anxiety and panic is a skill that has to be learned. To be effective, these skills must be practiced regularly. The more you put in, the more you will get out of the program. It is not the severity of your panic or avoidance, how long you have been panicking, or how old you are that predicts the success of this program, but, rather, it is your motivation to change your reactions.
Hindrances to recovery
Another factor to consider is the maintenance of agoraphobia. In some cases, there are various hindrances to recovery that maintain the phobia. One particularly difficult situation is when the person with agoraphobia or some important person in his or her life actually gains something from the person remaining agoraphobic. For example, a person might be able to accept his or her partner’s agoraphobia quite readily because the person then feels confident that their partner will remain faithful since they are so dependent on them. A person with agoraphobia might prefer to remain disabled in order to avoid making decisions about what to do for the rest of his or her life. Such dependencies do not appear to cause the initial panic attacks, but they can make recovery difficult. In this program, you will be taught how to deal with panic attacks. It may also be necessary to consider whether there are any hindrances involved in remaining agoraphobic and how to deal with them. We will return to this factor later in the program.
The nature of anxiety: a true alarm
People who have suffered panic attacks soon become afraid of even small amounts of anxiety for they know that a rise in anxiety occurs at the beginning of a panic. But anxiety is useful.
Consider the following: just as you are about to cross the road, a bus hurtles straight through the intersection, just 2 meters away from you. You are startled and you run back onto the footpath. Yet even before you begin to run, your brain becomes aware of danger. Immediately, adrenaline is released to activate the involuntary nervous system. Activation of the involuntary nervous system instantly causes a set of bodily changes. Every one of the changes enables you to act quickly, avoid injury, and escape danger. By examining each of the changes in turn, the advantages of this alarm response can be made clear.
• Breathing speeds up and the nostrils and lungs open wider. This increases the amount of oxygen available for the muscles.
• Heart rate and blood pressure increase so that the oxygen and nutrients required by the muscles can be transported quickly to where they are needed.
• Blood is diverted to muscles, particularly the large muscles in the legs. Less blood is allocated to areas that do not immediately require nutrition. Blood moves away from the face and you may “pale with fear”.
• Muscles tense, preparing you to respond quickly.
• Blood-clotting ability increases so that, were physical injury to occur, blood loss would be minimized.
• Sweating increases to cool the body, stopping it from overheating when strenuous physical activity begins. Blood vessels expand and move towards the skin to cool the blood.
• The mind becomes focused. It becomes so preoccupied with the thought, “What is the danger and how can I get to safety?” that other things pass unnoticed.
• Digestion is put on hold. The stomach stops digesting food. The mouth dries as less saliva is produced. Food sits heavily in the stomach and nausea or “butterflies” may occur. Instead, glucose is released to provide energy.
• The immune system slows down. In the short term, the body puts all of its efforts into escaping.
• Sphincter muscles around the bowel and bladder constrict so that no trail is left by which a predator could track you down.
It is the automatic activation of this flight or fight response that allows you to run and escape. The flight or fight response is an automatic reaction that will first lead you to flee from danger. Only when escape is impossible will you turn and fight for your life. In contrast to this life-saving alarm, it is clear that not all anxiety is of the same intensity. The prospect of examinations or a job interview may increase anxiety but not usually to the same degree as if one were faced with a vicious dog. However, whatever the degree of anxiety experienced, it is controlled by the involuntary nervous system. Whether panic or vague worries, it is the flight or fight response being triggered. The alarm is triggered, but to a lesser degree.
Also consider that anxiety helps you perform any skilled activity. If you are totally relaxed when you take an exam, play a game, solve a quarrel between your children or discuss a problem with your in-laws you will not do your best. To do anything really well you need to be alert, anxious to do well, or “focused”. Anxiety in moderation can work well to make you more efficient. People with anxiety disorders often fear all anxiety, even anxiety that can help them to perform well. They often worry that it may spiral out of control, and they may panic, and hence try to avoid any anxiety.
When people do get too anxious, the anxiety can interfere with performance, as they are focused on the symptoms of anxiety and want to escape. High levels of anxiety may lead to mistakes. The more difficult the task, the more important it is to manage anxiety carefully; ideally one should remain alert, tense and in control for maximum efficiency. The relationship between anxiety and skill is shown in the diagram. On this course we will teach a number of techniques for remaining calm when the situation is appropriate, and alert, tense, and in control in difficult situations.
Anxiety: a false alarm
Anxiety problems originate when the flight or fight response is too sensitive. Like an overly sensitive car alarm that goes off at the wrong time, if the body’s alarm is too sensitive, the flight or fight response will be triggered at the wrong time. If your anxiety alarm goes off too easily, you will be more likely to become anxious in situations where other people would not feel anxious. For example, someone with panic disorder and agoraphobia may become worried in the supermarket. Standing in a shopping line you may feel dizzy, light-headed, and slightly unreal. Having an easily triggered alarm reaction, you may then think, “What if I go crazy and I run amok in the local shops, shouting, swearing, and hitting people?”. As a result, you may find yourself retreating to the safety of your home.
If you have become anxious in situations in which other individuals would not be so anxious, it suggests that your anxiety “alarm” (the flight or fight response) is too sensitive. The alarm reaction, designed to protect you from dangerous buses, charging bulls and other physical dangers, has been triggered at the wrong time.
The flight or fight response is useful in the short term, especially if the danger can be avoided by physical exertion. But it is of no use in the long term and certainly of little use in most stressful situations in the modern world. It doesn’t help to run when the traffic cop pulls you over and it doesn’t help to fight physically when the boss threatens you. However, because the flight or fight response was useful to our ancestors, it is still a part of our bodily make-up. It is no wonder, then, that when we are threatened, we can’t get enough air, our hearts pound, we feel nauseated, and the muscles in our arms and legs tingle and shake, for all these responses would be useful if we could flee or fight.
The symptoms of a panic attack are, of course, very similar. This is because a panic attack is the flight or fight response being triggered at the wrong time. But as we know, there is no outside danger: the train is most probably not going to crash, the supermarket will not catch fire, we won’t suffocate waiting in the bank queue. We know our anxiety is unreasonable. So people with panic attacks come to fear themselves, fear that the panic will lead them to have a heart attack, lose control, or die.
Why do I have false alarms?
If panic attacks are false alarms, because your flight or fight response is too sensitive, why has this happened? What has made you more likely to react with the flight or fight response than other people? Psychological research has revealed three causes of a sensitive anxiety alarm. The first is stress, and we have already talked about how stress increases anxiety. The second is overbreathing (or hyperventilation), and we will discuss this soon. The third reason why false alarms may be more likely to occur is due to your nature or your personality.
The effect of personality
Personality refers to the usual way we react, feel, and behave year in and year out. Most people who seek treatment have come to regard themselves as nervous people in general. They consider themselves to be people who are usually sensitive, emotional, and worry easily. This has advantages including being sensitive to other people. But the emotionality and the proneness to worry can make you more vulnerable to developing panic disorder. People with a high degree of or general nervousness tend to respond to stressful events with more physical arousal. They may then tend to become overly aware of slight changes in body sensations and wrongly treat these as signs of panic. The thinking techniques and relaxation strategies that we will teach you will aid you to control this aspect of your personality.
Summary
When people find themselves in stressful or threatening situations, an automatic physiological response is triggered. This response has been part of our physiological make-up for perhaps thousands of years. It is a primitive response that prepares people to protect themselves or escape from the source of stress. It produces changes that prepare the body for vigorous physical action.
All of these changes are quickly reversed once vigorous physical activity has been carried out. This explains why many people report the desire to run or in some other way expend physical energy when placed in stressful situations. Today, however, it is often the case that we are unable to immediately engage in such physical activity and, therefore, are less able to reverse these changes.
This problem of reversing the flight or fight response is especially the case when the response is activated by stressful or disturbing thoughts rather than physically threatening situations. In this situation, the physical changes persist for longer than they would in other situations. For people who are prone to worry excessively, these changes can be quite disturbing and a source of considerable anxiety. This, of course, leads to further activation of the flight or fight response and the whole cycle is continued. Treatment must therefore aim to break this vicious cycle. One way is by controlling hyperventilation.
Hyperventilation
For the present, we shall turn our attention to one particular aspect of the flight or fight response that is of most concern in panic disorder and agoraphobia, namely the increase in rate of respiration, or overbreathing.
As we discussed in the context of the fight or flight response, the anxiety alarm involves an increase in breathing. This overbreathing can make many of the symptoms that occur in panic disorders and agoraphobia much worse than they otherwise would be. These symptoms are important because people fear the occurrence of the anxiety reaction even more than they fear danger in a feared situation. Overbreathing has the power to make anxiety symptoms worse. Let us see how this can happen. The diagram shows how the major components of breathing link together.
Whenever we breathe in, oxygen goes into the lungs. The oxygen travels to the blood where it is picked up by an “oxygen-sticky” chemical. This oxygen-sticky chemical, called hemoglobin, carries the oxygen around the body. Oxygen is then released by the hemoglobin for use by the body’s cells. The cells use the oxygen and generate a waste product – carbon dioxide. The carbon dioxide is released back to the blood, taken to the lungs, and breathed out.
The puzzle is, if hemoglobin is “oxygen-sticky”, then how did the oxygen become unstuck? What is the key that unlocks the oxygen? The key is carbon dioxide. Whenever the hemoglobin meets some carbon dioxide, the oxygen is unlocked so that it can go into the body’s cells. Therefore, while it is important to breathe in oxygen, it is just as important that there is carbon dioxide in the blood to release the oxygen. Overbreathing makes anxiety worse not because you breathe in too much oxygen but because you breathe out too much carbon dioxide.
Breathing “too much” has the effect of decreasing the levels of carbon dioxide, while breathing “too little” has the effect of increasing levels of carbon dioxide. The body works best when there is a balance between oxygen and carbon dioxide. When you overbreathe, you end up with more oxygen than carbon dioxide in your blood. When this imbalance happens a number of changes in the body occur.
One of the most important changes is a narrowing of certain blood vessels. In particular, blood going to the brain is somewhat decreased. Coupled together with this tightening of blood vessels is the fact that the hemoglobin increases its “stickiness” for oxygen. Thus less blood reaches certain areas of the body. Furthermore, the oxygen carried by this blood is less likely to be released to the cells. Paradoxically, then, while overbreathing means we are taking in more oxygen, we are actually getting less oxygen to certain areas of our brain and body. This results in two broad categories of sensations.
Some sensations are produced by the slight reduction in oxygen to certain parts of the brain. These symptoms include:
• Breathlessness
• Light-headedness
• Dizziness
• Body feels different or unreal
• Things around you seem unreal
• Confusion
• Increased heart rate
• Tingling, “pins and needles” or numbness in hands, feet or face
• Muscle stiffness
• Sweating hands
• Dry mouth or throat
It is important to remember that the reductions in oxygen are slight and totally harmless.
One of the most distressing sensations caused by hyperventilation is a feeling that you cannot get enough air. This can trick you into breathing even harder or faster, which will just make the symptoms worse. If overbreathing continues, further symptoms can appear such as:
• Vertigo
• Nausea
• A feeling of restricted breathing
• Chest pain, constriction or tenderness
• Muscle paralysis
• Increasing apprehension or fear
• Rising terror that something terrible is about to happen, for example, a heart attack, brain hemorrhage, or even death
When individuals hyperventilate, they use more energy than they need to. This may cause other symptoms:
• Feeling hot or flushed
• Sweating
• Feeling tired
• Muscle fatigue, especially chest muscles
Looking at the lists of physical sensations produced by hyperventilation, there is some overlap with symptoms commonly reported in panic attacks. It is also easy to see how individuals might mistake the sensations produced by hyperventilation as signs of some serious physical illness. When individuals do this, their anxiety increases, they hyperventilate more, and thus worsen or prolong their symptoms.
It is important to remember that hyperventilation produces physical sensations that are unpleasant (and, for some, frightening) but they are not dangerous. The physical sensations produced may be experienced as physically unpleasant, but will not harm you. When you stop hyperventilating (or when your body’s protective mechanisms step in), the sensations will go away.
Another requirement for survival is that the levels of oxygen and carbon dioxide in the body are balanced. The body has a number of protective mechanisms that prevent this relationship from becoming too unbalanced. When hyperventilation occurs for a while, the body takes steps to correct it. There are many examples of protective mechanisms in the body that maintain the body’s function. For example, there is a protective mechanism that maintains blood pressure at a stable level, thus preventing people from fainting every time they stand up. Other protective mechanisms exist to regulate eating, sleep, and temperature. These mechanisms are in-built, long lasting, and generally automatic.
Breathing has automatic and voluntary control. That is to say, when you are not thinking about it, your body maintains your breathing rate. When you want to, you can change your breathing rate, e.g., holding your breath under water. You will learn that you can take advantage of this voluntary aspect of breathing control to reduce the panic symptoms produced by hyperventilation.
Although people vary greatly in their response to overbreathing, the symptoms listed are those most commonly reported. It is these symptoms of hyperventilation that can make the symptoms of panic attacks much worse than they otherwise would have been. Mild hyperventilation can also cause an individual to remain in a state of perpetual apprehension.
At the risk of repetition, the most important point to be made about hyperventilation is that it is not dangerous. Even though it can feel uncomfortable and sometimes very unpleasant, severe anxiety alone does not harm you physically. Increased breathing is part of the flight or fight response and so is part of a natural biological response aimed at protecting the body from harm. Thus it is an automatic reaction for the brain to immediately expect danger and for the individual to feel the urge to escape.
Hyperventilation is often not obvious to the observer, or even to the persons, themselves. It can be very subtle. This is especially true if the individual has been slightly overbreathing over a long period of time. In this case, there can be a marked drop in carbon dioxide but, because the body is able to compensate for this drop, symptoms may not be produced. However, because carbon dioxide levels are kept low, the body is less able to cope with further decreases and even a slight change of breathing (e.g., a sigh, yawn, or gasp) can be enough to trigger symptoms.
Types of overbreathing
There are at least four types of overbreathing that you should learn to recognize. The first three tend to be episodic and are probably more common among people with specific phobias. That is to say, they occur only during episodes of high anxiety, such as when you are exposed to what you fear. The other is habitual: it occurs most of the time and is essentially a bad breathing habit or style.
• Panting or rapid breathing: Such breathing tends to occur during periods of acute anxiety or fear. This type of breathing will reduce carbon dioxide levels very quickly and produce a rapid increase in anxiety.
• Sighing and yawning: Sighing and yawning tend to occur during periods of disappointment or depression and both involve excessively deep breathing.
• Gasping: Gasping occurs when people think of frightening things such as doing something that they have avoided for a long time.
• Chronic or habitual overbreathing: This type of breathing involves slight increases in depth or speed of breathing sustained over a long period. Generally, this happens during periods of worry. It is not enough to bring on a sense of panic, but leaves the person feeling apprehensive, dizzy, and unable to think clearly. If such people are placed in the presence of what they fear and increase their breathing even by a little, this may trigger panic.
The relationship between phobic triggers and hyperventilation is summarized in the above diagram.
Common myths about anxiety symptoms
When fear is intense, people often worry about the possible consequences of extreme levels of anxiety. They may worry that anxiety will escalate out of control or that some serious physical or mental problem may result. As a result, the sensations themselves become threatening and can trigger the whole anxiety response again. It is therefore important to review the common misinterpretations about anxiety that some people have.
Going crazy
Many people fear they are going crazy when they experience the physical sensations of a panic attack. They may think they have the severe mental disorder called schizophrenia. However, schizophrenia and panic attacks are quite different. Panic attacks begin suddenly and tend to occur again and again. Schizophrenia begins gradually and once the symptoms are present, they do not come and go like panic attacks. The experience of panic is also quite different from schizophrenia. People with schizophrenia experience disjointed thoughts and speech, delusions or strange beliefs, and hallucinations. This is not the same as having your mind go blank or worrying about things that other people do not worry about. The strange beliefs might include the receiving of bizarre messages from outer space. Examples of hallucinations may be the hearing of voices that are not really there. Additionally, because schizophrenia runs strongly in families and has a genetic base, only a certain number of people can become schizophrenic and in other people no amount of stress will cause the disorder. Finally, people who develop schizophrenia usually show some mild symptoms for most of their adult lives. Thus, if this has not been noticed in you then it is unlikely that you would develop schizophrenia. This is especially true if you are over 25 years of age, as schizophrenia usually first appears in the late teens to early 20s.
Losing control
Some people believe that they will “lose control” when they panic. Sometimes they mean that they will become totally paralyzed and not be able to move. Other times they mean that they will not know what they are doing and will run around wild, hurting people or swearing and embarrassing themselves. It is clear where this feeling may come from when you remember our discussion of the fight or flight response. Your body is ready for action when the anxiety response is triggered and there is often an overpowering desire to get away from any danger. The problem is that when you do not use the anxiety response to flee or fight, you may feel confused, unreal and distracted. Nevertheless, you are still able to think and function normally. You are still able to decide what action to take in response to panic; that is, whether to stay or leave.
Heart attacks
At first glance it seems quite reasonable to worry that you might be dying of a heart attack when you notice that you have chest pains, tingling in your hands, shortness of breath, and so on. Fortunately, most people have never experienced a heart attack and therefore never know how this differs from a panic attack. Although the symptoms of a heart attack include breathlessness and chest pain, they tend to be related to effort and will go away once you rest. In contrast, the symptoms of a panic attack can happen at any time. While panic symptoms can occur during exercise and feel worse with exercise, they appear out of the blue and can even occur during sleep. Lastly, if a doctor has checked your heart with an electrocardiogram (a device which measures electrical changes in the heart) and has given you the all clear, then heart disease is unlikely to be causing the attacks. Heart disease produces obvious changes in the electrical activity of the heart; panic attacks just cause an increase in heart rate.
Relaxation training
The importance of relaxation training
Human beings have a built-in response to threat or stress known as the flight or fight response. Part of this flight or fight response involves the activation of muscle tension, which helps us to perform many tasks in a more alert and efficient manner. In normal circumstances, the muscles do not remain at a high level of tension all the time but become tensed and relaxed according to a person’s needs. Thus a person may show fluctuating patterns of tension and relaxation over a single day according to the demands of the day, but this person would not be considered to be suffering from tension.
If you remain tense after demanding or stressful periods have passed, you remain more alert than is necessary and this sense of alertness ends up turning into apprehension and anxiety. Constant tension makes people oversensitive and they respond to smaller and smaller events as though they were threatening. By learning to relax, you can gain control over these feelings of anxiety. In this program, you will be taught how to recognize tension, how to achieve deep relaxation, and how to relax in everyday situations. You will need to be an active participant, committed to daily practice for 2 months or longer.
Since some tension may be good for you, it is important to discriminate when tension is useful and when it is unnecessary. Actually, much everyday tension is unnecessary. Only a few muscles are involved in maintaining normal posture, e.g., sitting, standing, or walking. Most people use more tension than is necessary to perform these activities. Occasionally, an increase in tension is extremely beneficial. For example, it is usually helpful to tense up when you are about to receive a serve in a tennis game. Tension is unnecessary when (1) it performs no useful alerting function, (2) when it is too high for the activity involved, or (3) when it remains high after the activating situation has passed.
In order to be more in control of your anxiety, emotions, and general physical well being, it is important to learn to relax. To do this you need to learn to recognize tension; learn to relax your body in a general, total sense; and learn to let tension go in specific muscles.
Recognizing tension
When people have been tense and anxious for a long period, they are frequently not aware of how tense they are, even while at home. Being tense has become normal to them and may even feel relaxed compared with the times they feel extremely anxious or panicky. However, a high level of background tension is undesirable, because other symptoms, such as hyperventilation and panic, can be easily triggered by small increases in arousal brought on by even trivial events.
Where do you feel tension? For the next 12 days we want you to monitor the tension in your body. Use the following form to indicate the location of your tension and the degree of tension. Always choose approximately the same time each day to monitor your tension. Before your evening meal is usually a good time for this.
Progressive muscle relaxation
Progressive relaxation means that the muscles are relaxed in a progressive manner. This section will outline how to use both progressive relaxation and “isometric” relaxation. You should master both forms of relaxation, because the progressive muscle relaxation exercises are useful for becoming relaxed (before you confront your fears) and the isometric relaxation is useful for remaining relaxed (while you confront your fears).
Relaxation exercises should be done at least once a day to begin with, preferably before any activity that might prove difficult. Select a comfortable chair with good support for your head and shoulders. If a chair does not provide good support, use cushions placed against a wall. Some people prefer to do the exercises lying down, but do not use this position if you are likely to fall asleep. These relaxation exercises are not meant to put you to sleep, since you cannot learn to relax while asleep. Sleep is not the same as relaxation. Consider those times when you have awakened tense. When possible, it is advisable that you use a relaxation tape as a preparation before you expose yourself to what you fear.
You will need to commit yourself to daily practice in order to achieve really long-lasting effects. Some people continue daily relaxation many years after leaving treatment. If you can do this, we strongly advise it. However, not all people continue relaxation in this way. People who benefit most from relaxation either practice regularly, or practice immediately after they notice any increase in tension or anxiety.
Isometric relaxation
Isometric relaxation exercises can be done when you experience fear. Most of the exercises do not involve any obvious change in posture or movement. This is because “isometric” refers to exercises in which the length of the muscle remains the same. Because it stays the same length, there is no obvious movement.
The most common mistake that people make with isometric exercises is putting the tension in too quickly or putting in too much tension. These are meant to be gentle and slow exercises. The aim of the exercise is to relax you, not get you even more tense. If circumstances do not allow you to hold the tension for 7 seconds, you can still benefit from putting in the tension slowly over some period of time and releasing it in the same manner.
When sitting in a public place:
• Take a small breath and hold it for up to 7 seconds.
• At the same time, slowly tense leg muscles by crossing your feet at the ankles and press down with the upper leg while trying to lift the lower leg.
Or
• Pull the legs sideways in opposite directions while keeping them locked together at the ankles.
Or
• After 7 seconds, breathe out and slowly say the word “relax” to yourself.
• Let all the tension go from your muscles.
• Close your eyes.
• For the next minute, each time you breathe out, say the word “relax” to yourself and let all the tension flow out of your muscles.
Choose other parts of the body to relax, e.g., the hands and arms:
• Take a small breath and hold it for up to 7 seconds.
• At the same time, tense hand and arm muscles by placing hands comfortably in your lap, palm against palm, and pressing down with the top hand while trying to lift the lower hand.
Or
• Place hands under the sides of chair and pull into the chair.
Or
• Grasp hands behind chair and try to pull them apart while simultaneously pushing them in against the back of the chair.
Or
• Place hands behind the head, interlocking the fingers, and while pushing the head backward into hands try to pull hands apart.
• After 7 seconds, breathe out and slowly say the word “relax” to yourself.
• Let all the tension go from your muscles.
• Close your eyes.
• For the next minute, each time you breathe out, say the word “relax” to yourself and let all the tension flow from your muscles.
If circumstances permit, continue with various muscle groups. When standing in a public place:
• Take a small breath and hold it for up to 7 seconds.
• At the same time, straighten legs to tense all muscles, bending the knees back almost as far as they will go.
• After 7 seconds, breathe out and slowly say the word “relax” to yourself.
• Let all the tension go from your muscles.
• Close your eyes.
• For the next minute, each time you breathe out, say the word “relax” to yourself and let all the tension flow from your muscles.
Other exercises for hand and arm muscles:
• Take a small breath and hold it for up to 7 seconds.
• At the same time, cup hands together in front and try to pull them apart.
Or
• Cup hands together behind and try to pull them apart.
Or
• Tightly grip an immovable rail or bar and let the tension flow up the arms.
• After 7 seconds, breathe out and slowly say the word “relax” to yourself.
• Let all the tension go from your muscles.
• Close your eyes.
• For the next minute, each time you breathe out, say the word “relax” to yourself and let all the tension flow from your muscles.
Further isometric exercises
Various muscles that can be tensed and relaxed in order to make up additional isometric exercises. You need first to decide which of your muscles tense up most readily. (If you have difficulty deciding, consider what people say to you: “Your forehead is tense”; “You’re tapping your feet again”; “You’re clenching your jaw”.) Once you have decided on a muscle or muscle group, decide how you can voluntarily tense these muscles, and finally how you can relax them. In this way, you can design your own tailor-made set of isometric exercises.
Instructions
Some example exercises are given below. Complete the remainder by starting with those muscles that you rated as highly tense on the muscle tension rating form earlier in this section. Write down some suggestions for putting tension in the muscle area and then suggestions for relaxing that muscle. Give the suggestions a try, but remember to tense gently and slowly.
| Site of tension |
Manner of tensing |
Manner of relaxing |
| Shoulders and neck |
Hunching shoulders up towards the head |
Letting shoulders drop and let arms hang loose |
| Hand tension |
Make a fist |
Let all fingers go loose. Place hands palm facing upward on lap |
|
|
|
|
|
|
Important points about learning to relax quickly
1. Relaxing is a skill – it improves with frequent and regular practice.
2. Do the exercises immediately whenever you notice yourself becoming tense.
3. Develop the habit of reacting to tension by relaxing.
4. With practice the tensing of your hand and leg muscles can be done without any movement that would attract attention. It helps to slowly tense and relax the muscles.
5. When circumstances prevent you holding the tension for 7 seconds, shorter periods will still help but you may have to repeat it a few more times.
6. Do not tense your muscles to the point of discomfort or hold the tension for longer than 7 seconds.
7. Each of these exercises can be adapted to help in problem settings such as working at a desk or waiting in a queue. Use them whenever you need to relax.
8. Using these exercises you should in a few weeks be able to reduce your tension, prevent yourself from becoming overly tense, and increase your self-control and confidence.
Difficulties with relaxation
Some people report they can’t relax, or they can’t bring themselves to practice relaxation. Since all human beings share the same biological make-up there is no purely physical reason why relaxation should work for some and not others. The reason relaxation may not work for some people is usually due to some psychological factor or insufficient practice. These problems can be overcome. If you are experiencing difficulty in relaxing you should discuss this with your therapist. Some examples of difficulties are given below.
1. “I am too tense to relax.” In this case the individual uses the very symptom that needs treating as an excuse for not relaxing. Relaxation may take longer than expected, but there is no reason why someone should have to remain tense. It might be useful to consider whether there is some other factor getting in the way of relaxation.
2. “I don’t like the feelings of relaxation.” About 1 in 10 people report that when they relax they come into contact with feelings they don’t like or that frighten them. These feelings indicate that you are coming into contact with your body again and noticing sensations that may have been kept under check for many years. You do not have to worry about losing control during relaxation sessions. You can always let a little tension back in until you get used to the sensations. As you keep practicing these sensations will pass.
3. “I feel guilty wasting so much time.” You need to see relaxation as an important part of your recovery. Relaxation exercises take time, just like many other therapies.
4. “I can’t find the place or time.” Be adaptive. If you can’t find 20 minutes, find 10 minutes somewhere in the day to relax. If you do not have a private room at work, go to a park. You may need to consider whether other factors are preventing you from relaxing if you keep making the excuse that there’s no time.
5. “I’m not getting anything out of this.” Unfortunately, many people expect too much too soon from relaxation training. People often exaggerate the speed of recovery. You cannot expect to undo years of habitual tensing in a few relaxation sessions. Impatience is one of the symptoms of anxiety and often indicates a need to continue with relaxation training. Give the training time to take effect.
6. “I haven’t got the self-control.” You need to realize that quick, easy cures for panic disorder calling for no effort from you do not exist. The longest-lasting treatment effects occur when an individual takes responsibility for his or her recovery. Responsibility means self-control, but self-control is difficult if you are not motivated.
Producing panic sensations in your daily life
Once panic attacks become regular, individuals with panic disorder and agoraphobia can begin to misinterpret the physical sensations caused by everyday activities as signals of panic. You may even have found that you avoid certain activities because you are frightened by the sensations they produce. You might avoid aerobic exercise because it makes your heart beat faster. You might not lift heavy objects because it causes unpleasant physical sensations as a result of the increased blood pressure. If the activities cause the sensations, you can then misinterpret the sensations as signals of danger and a panic attack might occur. The aim of this part of the program is to reduce any anxiety associated with physical sensations produced by everyday activities.
As you begin these activities, it is important to note a difference between the panic sensation exercises done previously and the activities outlined in this chapter. When you did the exercises to produce the panic sensations, you would have noticed that the sensations started and stopped roughly when the exercises started and stopped. In contrast, when panic-like sensations are generated by daily activities, their onset and offset will be less clear. Do not worry about this. The more natural the activity is, the less likely it is that the sensations will start when the activity begins and stop when the activity stops. Take, for example, going out on a hot day. It takes some time to become hot and sweaty when you go outside and it will take some time to cool down once you come inside again. This is just what happens with natural everyday activities. However, if you worry about the fact that the sensations are no longer as predictable as before and do not stop the instant you stop the activity, you are just going to make the symptoms worse and make it more likely that you will have a panic attack.
Following is a list of activities or places that may produce panic-like sensations. Consider these activities and decide whether you avoid, or find uncomfortable, any of these activities for fear of having a panic attack. There may be other activities of your own that you wish to add to the list.
• Heated vehicles or public transport
• Hot stuffy shops or shopping centers
• Watching medical programs
• Watching suspenseful TV programs or movies
• Watching sporting events on TV or in person
• Eating rich or heavy meals
• Arguments
• Amusement park rides
• Riding on boats or ferries
• Sexual activity
• Bushwalking
• Jogging or exercising of any kind
• Going to the gym or lifting weights
• Sports
• Dancing
• Surfing or swimming
• Getting up quickly from lying down
• Running up hills or stairs
• Walking in hot or humid conditions
• Heavily air-conditioned places
• Having showers with doors and windows closed
• Hot or steamy rooms
If you avoid any of these activities or places for fear of panic you should apply your anxiety-management techniques, specifically graded exposure and straight thinking. Begin with exposure to the least anxiety-provoking activity. The goal is to repeat the activity a number of times until only mild anxiety is experienced. Then move on to the next most anxiety-provoking activity.
Now choose one goal you would like to start working on in the near future. Write down the goal in the space provided, then break it down into steps. Also, write down any anxiety-provoking thoughts you may have about doing this activity, and then challenge and replace those thoughts.
Anxiety-provoking thoughts Helpful thoughts
As with the graded exposure tasks you have been carrying out the important points to remember are:
1. Clearly specify the task you are to attempt in advance.
2. Continue the activity until a decrease in anxiety is experienced.
3. Use your anxiety-management skills such as breathing control, relaxation and thinking straight (of course you will not be able to slow your breathing if you are engaging in an activity that requires increased oxygen, e.g., walking quickly).
4. Make sure that you practice some activity every day.
Keeping your progress going
Coping with setbacks or difficulties in making progress
Setbacks or difficulties in making progress are generally the consequence of either poor management or poor planning of goals and steps. If you should experience such difficulties, you must carefully analyze the way in which you carry out these two exercises.
Managing anxiety and hyperventilation
• Are you regularly monitoring your breathing while performing activities?
• Are you using the isometric relaxation exercises and the slow-breathing technique when you experience the first signs of anxiety?
• Are you regularly practicing the progressive muscle relaxation exercises, especially prior to entering a situation?
• Are you too obsessed about having anti-anxiety medication with you?
• Are there mounting background stresses in your life that need to be defused? For example, marital, family, or financial problems.
• Are you suffering from any form of physical stress? For example, illness, premenstrual tension, poor diet, lack of sleep, overwork.
Planning of goals and steps
• Are you trying to progress too quickly or too slowly?
• Is the difference between levels of difficulty at each step too great?
• Do you need to develop in-between steps of gradually increasing difficulty that
lie between the last step you completed successfully and the step with which you are now having difficulty?
• Do you need to practice new steps more frequently and for longer periods before moving on to more difficult ones?
• Is your level of certainty of success too high or too low?
• If your objectives are too easy or too difficult you will not make progress. Are you sure that you are not expecting too much of yourself?
• Make sure that you give yourself sufficient praise for your achievements. Remember that the key to success is gradual but regular progress.
Emotional problems during setbacks
Setbacks do occur occasionally, even in persons who are making excellent progress. When this happens, some people become alarmed and despondent, fearing they have gone back to their very worst. Remember, no matter how badly you feel during a setback, it is very rare for you to go all the way back to your worst level of incapacitation. For most people, the apparent setback is only a passing phase, due to factors such as outside stressors, the ‘flu, or school holidays. In such cases, the setback is often viewed as devastating because it has a lot of emotional meaning for the person who has put considerable effort into recovering. This effort is not wasted, and after the stressors pass you will find it easier to get yourself out and about again. This pattern has been demonstrated again and again. Therefore, if you have a setback, don’t add to the problem with all the old catastrophic, emotional, and self-destructive ideas. Keep practicing all the techniques you have been taught and you will be able to make progress.
If you feel that you have genuinely lost the skills necessary to control anxiety and panic, then you may want to consider retreatment. Most people do not lose the skills but need some fine-tuning of their skills.
“Booster” sessions or follow-up meetings are the best way to receive this form of assistance.
Expect lapse occasionally
Here, a lapse means that you stop listening to your relaxation tape, start to worry about having a panic attack, or stopping slow breathing. Most people will have some sort of lapse when they are trying to change their behavior.
The trick is not to turn a lapse into a relapse and exaggerate the lapse into being bigger than it really is. If you have noticed that you have stopped using your panic control skills, don’t say things to yourself like “I’m really hopeless, I’m right back where I started from, I’ll never be able to change”. Instead, you should view your lapse in the following light: “I’m disappointed that I have let things slip, but I can cope with that and I’m not going to turn it into an excuse for giving up altogether. Now I’ll get out my Manual and start again.” Of course, some people do stop things like relaxation training or slow breathing when they have been feeling okay for some time.
This is fine, so long as you keep aware of any stress or anxiety that may be creeping back into your life, and restart the training as soon as you become aware of any increase. Also, it will be important to reinstate such techniques if you have recently experienced any stressful life event.
Conclusion
You now have three skills that you have been taught and now need to practice. You need to use the various exposure tasks, working up the graded “stepladders” of anxiety, to reduce your fear of your panic. Relaxation exercises will help to reduce your general level of tension before the exposure task and the isometric exercises will regulate tension during exposure. Slow breathing will help to keep control of any anxiety you may experience. By thinking straight you will be able to stop anxiety from spiraling into panic.
