How to Stop Panic Attacks

8 Steps to Stop Panic Attacks

  • Step 1: Understand the Physical Symptoms & Causes of Panic & Anxiety Attacks
    • Physical Disorders that Produce Panic Symptoms
    • Physiological Disorders with Panic-like Symptoms
    • Causes of a Racing or Rapid Heart Rate
    • Chest Pain with Anxiety Attacks
    • Physical Causes of Breathing Problems
    • Why You Get Dizzy
    • Physical Conditions that Cause Anxiety
    • Medications that Can Cause Anxiety
  • Step 2: Understand Your Body’s Emergency Response
    • The Body’s Emergency Response
    • Possible Symptoms During Hyperventilation
  • Step 3: Change Your Attitude
    • The Eight Attitudes of Recovery
    • Recovery Attitude Change #1: Shame & Embarrassment
    • Recovery Attitude Change #2: Become a Student of Panic
    • Recovery Attitude Change #3: Face Your Panic Symptoms
    • Recovery Attitude Change #4: Accept Your Anxiety During Panic
    • Recovery Attitude Change #5: Don’t Guard Yourself Against Anxiety
    • Recovery Attitude Change #6: Facing Panic is Practice, Not a Test
    • Recovery Attitude Change #7: Fear of Uncertainty
    • Recovery Attitude Change #8: Allow Yourself to be Anxious During Panic
  • Step 4: Practice Your Breathing Skills
    • The Calming Response (Parasympathetic Response)
  • Step 5: Practice Formal Relaxation Skills
    • Cue-Controlled Deep Muscle Relaxation for Anxiety
    • Guided Imagery to Help You Relax When Anxious
  • Step 6: Use Paradox
    • Use the Power of Opposites With Anxiety
    • Dr. Claire Weekes on Anxiety
    • How to Use Paradox During Panic
  • Step 7: Approach Your Goals through Small Steps
    • Set Your Long-Term Goals Against Panic
    • How to Create Short-Term Goals Against Panic
    • Create Short-Term Tasks to Beat Panic Attacks
    • How to Practice Your Skills at Overcoming Panic
  • Step 8: Handle Your Worries
    • How to Handle Worries That are “Signals”
    • How to Handle Worries That are “Noise”

Step 1: Understand the Physical Symptoms & Causes of Anxiety & Panic Attacks

This section identifies all the major physical problems that can produce paniclike symptoms. By no means should you use this section (or any other in this guide) for self-diagnosis. Only a physician has the resources to determine whether any of these disorders is the cause of your discomfort and to advise you of your treatment options. 

Physical Disorders that Produce Panic Disorder Symptoms

Everyone experiences the symptoms of anxiety from time to time, caused by any number of things — changes in our lifestyle, undue stress, tension. These symptoms often reflect a normal response to problems arising in our daily lives. In some cases, however, they may be the symptoms of a psychological or physical illness. The diagnosis of a serious medical problem is not always a simple process.

Because these symptoms are so difficult to assess, both patients and professionals can misdiagnose significant physical or emotional problems. Studies in recent years reveal that a number of physical disorders coexist in patients who have a psychological disorder, and some physical problem may cause 5 to 40 percent of psychological illnesses. In the majority of these cases the health professional fails to make the physical diagnosis.

Nowhere is this confusion more evident and diagnosis more difficult than with panic attacks. If the symptoms of panic are present, there are three possible diagnoses:

A physiological disorder is the sole cause of all the symptoms associated with panic. Treatment of the physical problem removes the symptoms.

A minor physical problem produces a few symptoms. The individual then becomes introspective and oversensitive to these physical sensations and uses them as a cue to become anxious. His heightened awareness and unnecessary concern will produce an increase in symptoms. If this continues, he can turn an insignificant physical problem into a major psychological distress.

There is no physical basis for the symptoms. Some combination of the following will help: education about the problem, reassurance, psychological treatment and medication treatment.

Through a comprehensive evaluation, your physician can determine which, if any, of these physical problems is associated with your symptoms. In most cases, curing the physical illness or adjusting medication will eliminate the symptoms. In some disorders, the symptoms remain as part of a minor disturbance, and you must learn to cope with them.

When a person suffers from panic attacks, one of the greatest obstacles to recovery can be the fear that these episodes are the indication of a major physical illness. And in some rare cases that is true. But predominantly, when a person continually worries about physical illness, that kind of worry intensifies or even produces panic attacks. In other words, the less you worry, the healthier you will become. For that reason, I strongly recommend that you adopt the following guidelines if you are experiencing anxiety attacks:

  1. Find a physician whom you trust.
  2. Explain your symptoms and your worries to him or her.
  3. Let your physician conduct any evaluations or examinations necessary to determine the cause of your symptoms.
  4. If your primary physician recommends that another medical specialist evaluate your problem, be certain to follow that advice. Make sure that your primary physician receives a report from the specialist.
  5. If a physical problem is diagnosed, follow your physician’s treatment advice.
  6. If your doctor finds no physical cause for your panic attacks, use the methods presented in the Panic Attack Self-Help Program to take control of your symptoms. If your symptoms persist, ask your physician or some other source for a referral to a licensed mental health professional who specializes in these disorders.

The most destructive thing you can do when faced with panic attacks is to steadfastly believe that your symptoms mean that you have a serious physical illness, despite continued professional reassurance to the contrary. That is why it is essential that you work with a physician whom you can trust until he or she reaches a diagnosis. No matter how many consultations with other professionals you need, allow one professional to have primary charge of your case and receive all reports. Do not continually jump from doctor to doctor. If you remain fearfully convinced that you have a physical ailment, even when there is a consensus to the contrary among the professionals who have evaluated you, then you can be certain of one thing: your fear is directly contributing to your panic episodes. In Part II you will learn how to control that fear and thereby take control of your symptoms.

Many physiological disorders produce paniclike symptoms. You will find them listed below.

Physiological Disorders with Panic-like Symptoms

Cardiovascular

  • Angina pectoris
  • Myocardial infarction (recovery from)
  • Arrhythmia
  • Postural orthostatic hypotension
  • Coronary artery disease
  • Pulmonary edema
  • Heart attack
  • Pulmonary embolism
  • Heart failure
  • Stroke
  • Hypertension
  • Tachycardia
  • Mitral valve prolapse
  • Transient ischemic attack
  • Mitral stenosis

Respiratory

  • Asthma
  • Emphysema
  • Bronchitis Hypoxia
  • Collagen disease Pulmonary fibrosis

Endocrine/Hormonal

  • Carcinoid tumor
  • Pheochromocytoma
  • Hyperthyroidism
  • Premenstrual syndrome
  • Hypoglycemia
  • Pregnancy

Neurological/Muscular

  • Compression neuropathies
  • Myasthenia gravis
  • GuillainBarr syndrome
  • Temporal lobe epilepsy

Aural

  • Benign positional vertigo
  • Meniere’s disease
  • Labyrinthitis
  • Otitis media
  • Mastoiditis

Hematic

  • Anemia
  • Iron deficiency anemia
  • B12 anemia
  • Sickle cell anemia
  • Folic acid anemia

Drug Related

  • Alcohol use or withdrawal
  • Side effects of many medications
  • Illicit drug use
  • Stimulant use
  • Medication withdrawal

Miscellaneous

  • Caffeinism
  • Head injury

Causes of a Racing or Rapid Heart Rate

Uncomfortable changes in heart rate are the most frequently reported symptoms of panic attacks. Over 80% of those experiencing panic list a rapid or irregular heart rate as a symptom.

Three complaints are common among patients who seek a doctor’s advice about their heart: “My heart feels like it’s pounding violently in my chest,” “My heart is racing, ” and “My heart feels like it skips a beat.” An arrhythmia is any irregularity in the heart’s rhythm. If the heart beats more rapidly than normal, this arrhythmia is called tachycardia. An unpleasant sensation in the heart, whether rapid or slow, regular or irregular, and of which one is consciously aware, is called a palpitation.

Physical Causes of Rapid or Irregular Heart Rate

  • arrhythmia
  • postmyocardial infarction
  • tachycardia
  • organic heart disease
  • palpitation
  • heart failure
  • extrasystole
  • infections
  • coronary artery disease

Heart palpitation is typically an expected sensation when the force and rate of the heartbeat are considerably elevated. After strenuous exercise we are apt to notice the thumping of our heart against the chest wall. As we begin resting, that sensation may continue briefly until we recover from our exertion.

People who are prone to anxiety may have palpitations more frequently when they find themselves in psychologically uncomfortable situations. In fact, the great majority of complaints about the heart presented to physicians indicate a psychological rather than a physical problem. An anxious person may turn his attention to his physical symptoms instead of learning to cope with the situation causing the symptoms. After several episodes in which he experiences his heart “pounding” or “beating too fast,” he fears it is a sign of heart disease or some other physical disorder.

It is possible to consciously notice a few minor disturbances of the heart rhythm. For instance, some people describe sensations such as a “flop” of the heart, the heart “skipping a beat” or “turning a somersault.” We call this sudden forceful beat of the heart followed by a longer than usual pause an extrasystole. These premature contractions of the heart are usually of no serious significance and occur in many healthy individuals.

In fact, because of several research findings, we now know that arrhythmias of all kinds are common in normal, healthy individuals. In one recent study published in the New England Journal of Medicine, Dr. Harold Kennedy found that healthy subjects with frequent and complex irregular heartbeats seem to be at no more risk of physical problems than is the normal population. In general, researchers are finding that the majority of even the healthiest people have some kind of rhythm disturbance such as skipped beats, palpitations, or pounding in the chest.

Tachycardia, or rapid heartbeat, is the most common complaint associated with the heart and one of the typical reasons that patients seek medical attention. For many normal healthy individuals it is a daily occurrence in response to physical exercise or intense emotion. Any kind of excitement or trauma, even fatigue or exhaustion, can accelerate the action of the heart, especially in overly anxious individuals. Too many cigarettes, too much alcohol, and in particular, excessive amounts of caffeine can cause tachycardia on occasion. Infections such as pneumonia, as well as acute inflammatory diseases such as rheumatic fever, may also produce a rapid heartbeat.

Although most complaints of palpitation reflect a minor cardiac problem or a sign of anxiety, it is possible that they involve some kind of coronary artery disease. A narrowing of the arteries to the heart causes such diseases.

Recovery and rehabilitation after a heart attack can be a difficult psychological problem. Many people become afraid that too much activity or excitement might produce a second attack. It is no wonder then, that postmyocardial infarction patients become fearfully preoccupied with the sensations of their heart. Many will return to their doctor’s office or hospital emergency room with complaints of palpitations. Fourteen percent of cardiac patients later suffer from panic disorder, which is the worried anticipation of having an anxiety attack or heart attack. Chapter 6 of the self-help book Don’t Panic describes the way in which panic complicates recovery from a myocardial infarction.

Complaints of a “racing” heart can signal certain kinds of organic heart disease and heart failure. More often, however, the symptom of these ailments will be breathlessness (see the section on difficulty breathing). Infections, such as pneumonia and rheumatic fever, may also produce a rapid heartbeat.

Chest Pain with Anxiety Attacks

Almost 40% of physically healthy people with panic attacks experience pain in their chest. The thought that this pain might be a serious heart problem sends many sufferers to the Emergency Room for help.

The predominant complaint of those suffering from coronary artery disease is most likely to be a pain or pressure in the center of the chest. They may also feel such discomfort elsewhere in the chest or in the neck, jaw, or left arm, and occasionally may notice tachycardia (as mentioned above).

Angina pectoris is an acute pain in the chest caused by interference with the supply of oxygen to the heart. It is a distinct pain, usually concentrated on the left side and sometimes spreading (radiating) to the neck and down the left arm. The feeling is of tightness, strangling, heaviness or suffocation. It is not a disease, but a symptom of some underlying disorder that reduces the supply of oxygen to the heart. Coronary artery disease or hypertension are the most common causes, with aortic stenosis, anemia or hyperthyroidism also possible causes.

Physical Causes of Chest Pain

  • coronary artery disease
  • angina pectoris
  • heart attack

A heart attack (myocardial infarction, coronary thrombosis) occurs when the blood supply to the heart is significantly blocked. The main symptom is usually a crushing pain in the center of the chest, which may continue into the neck, jaw, arms and stomach. The pain may begin during exercise or a stressful event. Unlike angina, this pain does not stop when the exercise or event ends. A heart attack is a medical emergency. Medical help is needed immediately.

Physical Causes of Breathing Problems

Complaints of difficult, labored, or uncomfortable breathing (called dyspnea) can be a signal of a serious emergency or of a mysterious medical puzzle. Seek immediate professional evaluation if this problem has never been diagnosed. Most often a person will describe it as “not being able to catch my breath,” or “not getting enough air,” even while appearing to breathe normally. Certainly the inability to breathe properly can be alarming, and many persons will immediately react with anxiety, fear, or panic.

Physical Causes of Difficult Breathing (Dypsnea)

  • bronchitis
  • pneumothorax
  • emphysema
  • hemothorax
  • asthma
  • pulmonary edema
  • pneumoconiosis
  • mitral stenosis
  • collagen disease
  • left ventricular failure
  • pulmonary fibrosis
  • aortic insufficiency
  • myasthenia gravis
  • pericardial effusion
  • Guillain Barre syndrome
  • cardiac arrhythmia
  • pleural effusion

Under normal circumstances, difficult breathing comes after any strenuous activity. If the degree of the problem seems out of proportion to the amount of exertion, concern is appropriate. Troubled breathing is sometimes experienced in pregnancy, since the uterus expands upward, reducing the possibility of a full inhalation. Severe obesity can also reduce the capacity of the lungs to inhale fully.

Most physical causes of dyspnea are associated with disorders of the respiratory and cardiac systems. Acute and chronic diseases of the lungs are the most common physical causes. Within the respiratory system, the problem usually stems from an obstruction of air flow (obstructive disorders) or the inability of the chest wall or lungs to expand freely (restrictive disorders). Each of these disorders makes the patient work harder to take each breath and decreases the amount of oxygen that he can absorb with inhalation. The three major obstructive disorders are bronchitis, emphysema, and asthma. In these problems a second common symptom is “chest tightness” upon awakening, shortly after sitting up, or after physical exertion.

anxiety breathing techniques

The primary symptom of bronchitis is a deep cough that brings up yellowish or grayish phlegm from the lungs. With emphysema, the shortness of breath gradually becomes worse over the years. The distinct symptoms of bronchitis and the gradual onset of emphysema will usually prevent these disorders from being misdiagnosed as severe anxiety or panic.

Those suffering from asthma will complain of difficult breathing, a painless tightness in the chest, and periodic episodes of wheezing. Severe cases can cause sweating, increased pulse rate, and severe anxiety. The primary trigger of an asthma attack is an allergy to such things as pollen, dust, or the dander of cats or dogs. Attacks can also be caused by infections, exercise, psychological stress, or for no apparent reason. Some asthma sufferers anxiously anticipate the next attack, since an acute attack of asthma can come suddenly “out of the blue” and last for an uncomfortably long time. This fear of an impending attack can actually increase the likelihood of the next attack and can extend the length of each attack. Asthma is a good example of a physical disorder that can increase in severity because of anxiety or panic.

Chapter 6 of the self-help book Don’t Panic will describe the manner in which panic can contribute to difficulties in patients with chronic obstructive pulmonary disease. Special attention is given to chronic bronchitis, emphysema, and asthma.

There are a number of restrictive disorders of the respiratory system that cause difficult breathing. Some produce a rigidity of the lungs (pneumoconiosis, collagen disease, pulmonary fibrosis); other involve the interactions of muscles and nerves (myasthenia gravis, Guillain Barre syndrome); and still others prevent the lungs from expanding to full volume (pleural effusion, pneumothorax, hemothorax). A restrictive deficit in pulmonary function can also be caused by pulmonary edema, which usually stems from heart failure or occasionally from toxic inhalants.

Dyspnea may occur in any of the various diseases of the heart and lungs, but it is more prominent in those associated with lung congestion. For example, mitral stenosis occurs when a small valve between the left upper chamber and left lower chamber of the heart (the left atrium and left ventricle) becomes abnormally narrow. As blood is forced through the heart, pressure backs up into the lungs and produces congestion. It is this congestion that causes breathlessness.

Other possible cardiovascular problems that can lead to difficulty breathing include left ventricular failure, aortic insufficiency, pericardial effusion, and cardiac arrhythmia.

Why You Get Dizzy

A broad range of complaints falls under the categories of dizziness and vertigo.

Dizziness is a broad term that can include:

  • lightheadedness
  • faintness
  • wooziness
  • a “swimming” sensation in the head
  • a floating feeling
  • double vision
  • a feeling of “everything spinning in circles” or of whirling in space.

Vertigo implies the more specific sensations of either the body or its surroundings turning or the head swaying or revolving. The physical causes of these two symptoms are numerous: problems of the middle and inner ear, dental problems, infections, head injuries, drug effects, and disorders of the cardiovascular, neurologic, and central nervous systems.

Physical Causes of Dizziness and Vertigo

  • Meniere’s disease
  • hypertension
  • labyrinthitis
  • postural orthostatic hypotension
  • nystagmus
  • stroke
  • benign positional vertigo
  • cerebral thrombosis
  • ear infections
  • cerebral embolism
  • dental problems
  • cerebral hemorrhage
  • head injury
  • transient ischemic attack

The ear is responsible for our sense of balance as well as hearing. The inner ear includes a structure called the labyrinth, which monitors the brain. When injury or infection disrupts the action of the labyrinth, vertigo may occur.

In Meniere’s disease, a common disorder of the labyrinth in adults, excess fluid builds up and increases the pressure within the inner ear, causing vertigo and occasionally a ringing or other noise in the ear (called “tinnitus”). Labyrinthitis is an infection of this same region, often caused by a virus, sometimes associated with an upper respiratory infection. This can produce severe vertigo, occasionally with some nausea and vomiting during the first episode. The individual may also experience a rapid flickering of the eyes (called nystagmus). Calcium crystals floating within the labyrinth can cause benign positional vertigo. In this condition, a shifting of position, such as rolling over in bed, can produce vertigo and nystagmus moments later, lasting no more than thirty seconds. Several kinds of ear infections, such as otitis media and mastoiditis, can cause vertigo but will additionally cause other distinguishing symptoms, such as drainage of fluid, fever, or redness of the eardrum. Dental problems, such as an abscessed tooth, malocclusion, or temporomandibular joint (TMJ) abnormalities, can also produce vertigo since the teeth are so closely aligned with the ear.

anxiety getting dizzy

Any head injury can cause a cerebral concussion or a labyrinthine concussion, which may result in vertigo or a sense of feeling dazed, unsteady, or faint.

A number of cardiovascular and neurovascular diseases may affect a person’s sense of balance. Hypertension, or high blood pressure, is often a symptomless disease. However, a swimming or woozy sensation may be the initial symptom that brings a patient into a physician’s office for evaluation.

If dizziness and lightheadedness are experienced rising in the morning or when changing from a lying to upright position, postural orthostatic hypotension may be the cause. This is a problem of low blood pressure, producing poor circulation of blood through the body. Typically, when a person shifts positions, the blood vessels reflexively contract to maintain proper blood pressure. In hypotension, this mechanism fails to respond appropriately. Since the needed pressure is not maintained, the flow of blood to the brain is temporarily reduced, causing dizziness and even fainting. Diabetes, minor complications in pregnancy, or hardening of the arteries can cause postural hypotension. It can also be a side effect of antidepressant medication, major tranquilizers, and even medications prescribed for high blood pressure (hypertension).

The most serious vascular ailment, requiring immediate medical attention, is stroke. A stroke occurs when the blood supply to the brain is significantly altered, causing damage to the brain itself. Three types of vascular problems produce stroke: cerebral thrombosis, cerebral embolism, and cerebral hemorrhage. In thrombosis, some portion of an artery that supplies blood to the brain has reduced in size. A large deposit of fatty tissue in that portion allows blood to clot, causing a partial or complete blockage of the blood flow to the brain. An embolism occurs when a bit of blood clot or arteriosclerotic plaque from the heart or the wall of a large artery breaks off and travels to an artery within the brain, where it lodges and causes the stroke. In a cerebral hemorrhage, the artery leaks or bursts, causing blood to seep into the surrounding brain tissues.

A transient ischemic attack is usually caused by a small blood clot or piece of fatty tissue (embolus). While passing through the blood vessels in the brain, it briefly becomes lodged and reduces the blood flow through that area. These symptoms resemble those of stroke, but are temporary and do not cause serious harm, since the clot or embolus eventually is dislodged. Although emergency medical attention is not necessary, a transient ischemic attack does require medical evaluation and possible measures to prevent recurrence.

Dizziness alone is insufficient cause to fear stroke. However, if you experience one or more of the following symptoms, you should consult your physician: numbness and/or tingling in any part of the body, blurred vision, confusion, difficulty speaking, loss of movement in the arms or legs. These symptoms can also indicate a panic attack rather than stroke. If you have experienced such a reaction several times and your doctor finds no sign of a physical disorder, you should consider the possibility that some psychological disturbance is precipitating these symptoms.

Physical Conditions that Cause Anxiety

Many physical illnesses can produce nervousness in individuals who are not emotionally troubled. Certain other physical disorders — those discussed in this section — can cause a cluster of symptoms that resemble those of panic.

Physical Causes of Multiple Symptoms

  • hypertension
  • mitral valve prolapse
  • menopause
  • premenstrual syndrome
  • hyperthyroidism
  • hypoglycemia
  • pheochromocytoma
  • anemia
  • iron deficiency anemia
  • folic acid anemia
  • B12 anemia
  • sickle cell anemia
  • heart attack
  • hypoxia
  • carcinoid syndrome
  • compression neuropathies
  • temporal lobe epilepsy
  • caffeinism
  • amphetamines
  • cocaine
  • phencyclidine (pcp)
  • hallucinogens
  • marijuana
  • alcohol withdrawal
  • pulmonary embolism
  • withdrawal from antidepressants, narcotics, sedatives, barbiturates, benzodiazepines, or beta blockers

The predominant cardiovascular disorder that can produce multiple symptoms is hypertension, caused by a narrowing of the arteries. As your heart pumps blood through your body, it exerts a certain amount of pressure on the arterial walls. If these passageways become constricted for some reason, it requires greater force to maintain a steady flow of blood. The entire circulatory system is then under strain, and hypertension is the diagnosis. This, as mentioned earlier, is often a symptomless disease, but you might notice such symptoms as palpitations, nervousness, dizziness, and fatigue, as well as a general sense of ill health.

Mitral valve prolapse is a common condition found in approximately 5 to 15 percent of the adult population. In this disturbance a valve leaflet within the heart balloons into the left upper chamber (the left atrium) of the heart during contraction. About half of all people with mitral valve prolapse will complain of heart palpitation sometime in their life. Other possible symptoms are rapid heartbeat, shortness of breath, dizziness, and an increased awareness of the heart’s action. This is a rather minor cardiac problem, but people can erroneously blame it as the sole cause of panic attacks. More often, though, it is the patient’s fearful preoccupation with the action of his heart that produces panic. You will find a more extensive discussion of mitral valve prolapse in Chapter 6 of the self-help book Don’t Panic.

anxiety breathing techniques

Location of mitral valve and change in appearance after ballooning.

There is growing evidence that hormonal changes can dramatically affect a person’s physical disposition and mood. For instance, approximately 50 percent of women experiencing menopause report some major physical and/or emotional changes. Another 25 percent have uncomfortable, even distressing, symptoms that can include intense moments of palpitations, sweating, hot flashes, and anxiety. Premenstrual syndrome identifies a complex of symptoms, including panic, occurring in the days just before menstruation. You will learn more about premenstrual syndrome in Chapter 5 of the self-help book Don’t Panic.

A third hormonal problem is hyperthyroidism, the overactivity of the thyroid gland. This gland, located in the lower part of the neck, is controlled by a thyroid stimulating hormone produced in the pituitary gland. In hyperthyroidism, the normal control mechanisms are disrupted and the thyroid continues to produce an excessive amount of its own hormone, thyroxine. This overproduction causes a general speeding up of all chemical reactions in the body. The person may feel shaky and anxious, with heart palpitations, breathlessness, and increased perspiration — feeling as though he or she is experiencing a constant anxiety attack. Additional symptoms make this disorder easier to diagnose: increased appetite, but with weight loss instead of gain; thinning hair; chronic tension and a sense of needing to keep moving despite fatigue and physical exhaustion. Instead of feeling cold, as the anxious person might, the person suffering from hyperthyroidism will feel hot, and his skin will be warm to the touch. Your doctor may order a thyroid screening test for you if you have several of these symptoms.

Physicians treat hyperthyroidism in one of three ways: through anti-thyroid medication, by surgically removing either a lump in the thyroid or all the thyroid, or, more commonly, by administration of a radioactive iodine fluid that controls the overactivity of the gland.

Hypoglycemia is the experience of several unpleasant symptoms while there is a lower than normal level of glucose in the bloodstream. This state of low blood sugar generally produces a feeling of being uncomfortable, with cold, clammy skin and profuse sweating. Other symptoms can be dizziness, weakness, trembling, tingling in the lips and hands, palpitations, and fainting. The condition is most often found in diabetics who take insulin. However, many individuals erroneously believe that hypoglycemia is the cause of their panic symptoms and therefore fail to explore other possible diagnoses. For further information on hypoglycemia and panic, see Chapter 5.

The adrenal glands are located on top of each kidney. The adrenal medulla produces two hormones that play an important role in controlling your heart rate and blood pressure: epinephrine (adrenaline) develops within or near an adrenal gland and causes an increase in the production of this hormone. Tachycardia, sweating, anxiety, faintness, nausea and pallor — all resembling panic — can occur as a result of slight exercise, exposure to cold temperatures, or minor emotional upset. Typically the blood pressure will become extremely high, and the patient may have the frightening feeling of being about to die. This extremely rare disorder, called pheochromocytoma, is cured by surgically removing the tumor.

Anemia is the abnormal decrease of either hemoglobin or red blood cells. Red blood cells carry oxygen from the lungs to all parts of the body. Within each of these blood cells is the protein hemoglobin, which combines with the oxygen while in the lungs and then releases it into the tissues as the blood circulates through the body. Characteristic symptoms of anemia are lightheadedness, rapid heartbeat, difficulty breathing, and faintness. The anemic person may experience palpitations, because the heart is attempting to compensate for the lower levels of oxygen by pumping blood faster than normal. The diagnosis of iron deficiency anemia indicates that lower than normal levels of iron in the body limit the production of hemoglobin. Folic acid anemia and B12 anemia indicate that the body has insufficient amounts of these two essential vitamins, which are required for the production of healthy red blood cells. The inherited disease sickle cell anemia is found almost exclusively among people of African descent. In this condition, the red blood cells contain an abnormal hemoglobin, called hemoglobin S. This leads to deforming of the shape of each cell and thus impeding the smooth flow of blood into smaller vessels. Premature destruction of red blood cells, and anemia, results. A physician should diagnose and treat all forms of anemia.

Pulmonary embolism occurs when a blood clot detaches from the wall of a deep vein, moves through the bloodstream, and becomes lodged in the pulmonary artery close to or within the lungs. This reduces the volume of fresh blood returning to the left side of the heart and may produce sudden chest pain, rapid heart rate (tachycardia), rapid shallow breathing, and coughing up of bright red spit.

A heart attack often involves crushing chest pain as the predominant symptom, as mentioned earlier. Other symptoms can include dizziness, shortness of breath, sweating, chills, nausea and fainting.

Hypoxia means diminished availability of oxygen to the body tissues. It is a symptom of several possible underlying problems, such as altitude sickness or a pulmonary disorder. Symptoms can include difficulty breathing (dyspnea), rapid pulse, fainting and chest pain (angina pectoris).

A Carcinoid tumor, also called a argentaffinoma, is a small yellow growth occurring in the small intestine, appendix, stomach or colon. Carcinoid syndrome develops when a carcinoid tumor produces excess amounts of serotonin, a blood vessel constrictor. Exertion, intense emotion, or food or alcohol intake can trigger symptoms, which include one or more of the following: brief flushing of the neck and face, brief abdominal pain, diarrhea, racing heart (tachycardia), low blood pressure (hypotension), facial puffiness and difficulty breathing (caused by bronchoconstriction). Carcinoid tumors are rare.

Compression neuropathies, such as carpal tunnel syndrome, are disorders caused by some form of compression to localized nerves. Symptoms may include dysesthesia (a tingling or “pins and needles” feeling), similar to that which occurs during hyperventilation.

The symptoms of temporal lobe epilepsy (TLE) are highly variable, but in some cases sufferers experience them only as a sudden attack of immense fear or panic. In 60 percent of the cases, fear is the primary emotion. The patient may also have a feeling of unreality, as though he is far away from his surroundings (derealization), or may feel that his body is strange or dreamlike(depersonalization). Highly charged emotional responses such as these can lead to a misdiagnosis of the problem as a psychologically based one. A distinguishing feature of TLE can be the presence of an aura, a sudden experience that often takes the form of a strange aroma or taste at the moment of fear.

Caffeinism refers to the uncomfortable side effects that can occur with high intake of caffeine from coffee, tea, cola drinks, chocolate, and over the counter medication such as Excedrin and Anacin. Symptoms include anxiety, irritability, insomnia, headaches, stomach irritation, agitation, increased respiration, rapid heartbeat, and irregular heart rhythm. These side effects can occur with daily consumption between 250 mg to 500 milligrams. Between 20 and 30 percent of Americans consume more than 500 mg of caffeine a day (four to five cups of drip coffee contain a total of over 500 mg). Some panic prone persons are highly sensitive to caffeine, and symptoms can occur from less caffeine intake than the average person. If you experience any of these symptoms, you may wish to review your intake of all forms of caffeine. Use the following lists as a guide.

Caffeine in Medications*

  • Vivarin 200 mg
  • Fiorinal 40 mg
  • Caffadrine 200 mg
  • Medigesic 40 mg
  • Cafergot 100 mg
  • Triad 40 mg
  • No Doz 100 mg
  • Vanquish 33 mg
  • Excedrin (Extra Strength) 65 mg
  • Midol 32 mg
  • Amaphen 40 mg
  • Anacin 32 mg
  • Esgic 40 mg
  • Beta-Phed 32 mg
  • Fiorecet 40 mg
  • Empirin 32 mg
  • *milligrams per each tablet/capsule

Caffeine in Beverages

Coffees, teas and cocoa (5-6 oz.)

  • Drip Coffee, automatic 137 mg/cup
  • Drip coffee, non-automatic 124 mg/cup
  • Percolated Coffee 110 mg/cup
  • Instant Coffee 60 mg/cup
  • Decaffeinated Coffee 3 mg/cup
  • Tea, brewed 40-65 mg/cup
  • Instant tea 33 mg/cup
  • Decaffeinated tea 1 mg/cup
  • Hot Cocoa 5-13 mg/cup

Cola Beverages (12 oz.)

  • Coca Cola 45 mg
  • Dr. Pepper 61 mg
  • Mountain Dew 55 mg
  • Diet Mountain Dew 54 mg
  • Tab 49 mg
  • Pepsi Cola 38 mg
  • 7-up, Sprite, Fresca, Hire’s Root Beer 0 mg

Caffeine in Chocolate

  • Baker’s baking chocolate (1 oz) 25 mg
  • Milk chocolate candy (1 oz) 6 mg
  • Sweet dark chocolate candy (1 oz) 20 mg
  • Chocolate milk (8 oz) 5 mg

Amphetamines, whether taken for treatment of depression, for weight control, or illicitly for recreation, can cause severe anxiety to the point of panic. This extreme reaction is also possible with illicit drugs such as cocaine, phencyclidine (PCP), and the hallucinogens (LSD, mescaline). It is possible that these drugs stimulate brain receptors associated with anxiety, making panic attacks more likely. Marijuana causes increased heart rate that can lead to a severe anxiety reaction.

Alcohol withdrawal can produce nervousness, rapid heartbeat, confusion, high blood pressure, and panic as well as other symptoms. Too rapid withdrawal from antidepressants, narcotics, sedatives, barbiturates, benzodiazepines (Valium, Librium, etc.), or beta blockers can cause symptoms such as anxiety, rapid heartbeat, high blood pressure, and panic, especially after long-term use.

Medications that Can Cause Anxiety

Sometimes a medication may cause unwanted side effects along with its needed effects. If these occur, you should check with your doctor. In addition to other possible side effects, each of the medications listed below may produce paniclike symptoms. (All medications are listed by their generic names.)

Aminophylline relieves shortness of breath and wheezing in acute bronchial asthma and to reduce asthma-like symptoms in chronic bronchitis and emphysema. Side effects can include nervousness, rapid heart rate and dizziness.

Heterocyclic antidepressants are used to treat depression and, more recently, panic attacks (see our medication section regarding the use of tricyclic antidepressants within the treatment of panic). Possible side effects are dizziness and irregular or rapid heartbeat.

Antidyskinetics are used in the treatment of Parkinson’s disease. Side effects may include dizziness, irregular heartbeat, and anxiety.

Atropine is a medication used to dilate the pupil of the eye. It can produce an unusually fast heartbeat. (A number of drugs are atropine-like in their effects. These are usually called anticholinergic medications.)

Inhaler forms of beta-Z adrenergic agents, such as isoproterenol and metaproterenol (Alupent) relieve acute bronchial asthma and bronchospasms associated with chronic bronchitis and emphysema. Side effects can include general anxiety, dizziness, rapid strong heartbeat, and shaky hands.

Cycloserine is an antibiotic medication. Side effects may include anxiety, irritability, confusion, dizziness and restlessness.

Digitalis is a medication used to improve the strength and efficiency of the heart, or to control the rate of the heartbeat. It can produce an unusually slow or uneven pulse.

Ephedrine is a medication used for lung problems. Side effects can be nervousness, restlessness, dizziness, difficulty breathing, palpitations, and rapid heartbeat.

Epinephrine is a medication used in treatment of the eyes, the lungs, and allergies. Side effects can include faintness, trembling, rapid heartbeat, palpitations, nervousness, and difficulty breathing.

Insulin helps control diabetes. Increasing the dose of insulin can occasionally trigger a hypoglycemic reaction, which includes sweating, cold clammy hands, dizziness, palpitations and trembling.

Isoniazid, an antiinfection medication, may produce rapid heartbeat and lightheadedness.

Monoamine oxidase (MAO) inhibitors belong within the antidepressant family. Along with reducing symptoms of depression, physicians use them in the treatment of panic attacks (see Chapter 19). Possible side effects are dizziness or lightheadedness, especially when getting up from a lying or sitting position, and rapid or pounding heartbeat.

Nitrates are used to improve the blood flow to the heart and to relieve angina. Possible side effects are dizziness, lightheadedness, and rapid heartbeat.

Prednisone is the most commonly used of the corticosteroids and is prescribed to relieve inflammation. Its side effects can include irregular heartbeat, nervousness, muscle weakness, and mood swings. Other corticosteroid medications may cause similar problems.

Reserpine is used to treat high blood pressure and certain emotional conditions, as well as a few other problems. Side effects may include dizziness, faintness, anxiety, and palpitations. Some individuals have even developed phobic reactions while taking reserpine.

Synthetic thyroid hormones are used for treating hypothyroidism. Excessive levels of these hormones can cause rapid heartbeat, palpitations, shortness of breath, nervousness, unusual sweating, and anxiety.

Home Study

Chapter 2: Physical Causes of Paniclike Symptoms

Chapter 4: Agoraphobia and the Panic-Prone Personality

Chapter 5: Four Complicating Problems

Chapter 6: Panic in the Context of Heart and Lung Disorders

Step 2: Understand Your Body’s Emergency Response During a Panic Attack

Most people who experience panic attacks would describe themselves as feeling instantly out of control during panic. They primarily complain about losing control of their body: all of a sudden, physical symptoms come rushing into their awareness, and they feel overwhelmed. 

Although panic seems to occur instantaneously, in actuality there are a number of events that tend to take place within our mind and body leading up to panic. If we could magically slow down this physical and mental process, we would typically find that a person’s anxiety involves a number of stages. The tricky part is that some or all of these stages can take place outside your conscious awareness. And they can all take place in a matter of seconds. That’s why panic can feel like such a surprise: we are not consciously aware of the stages we go through prior to a panic attack.

Several of these stages also serve to instruct the body on how to respond. For instance, let me explain to you one possible way stage one — Anticipatory Anxiety — could unfold. The panic cycle begins as you consider approaching a feared situation. Quickly your mind recalls your past failures to handle similar situations. In the last example, Donna, while sitting at home, considered entering a grocery store. That thought reminded her of how she had experienced panic attacks previously in grocery stores.

Here is the first of four important pieces of information. When we become mentally involved with a past event, our body tends to respond to that experience as though the event were happening RIGHT NOW. All of us have had this experience. For instance, you might flip through the pages of your wedding album and begin to feel some of the same excitement and joy you felt that day. Or perhaps on another day someone mentions the death of a person he was close to. You are reminded of the death of someone you love, and you begin to feel sad again. Similarly, as Donna recalls her last panic episode, she unconsciously retrieves the feelings of that day as though it were today: anxiety.

So, first we contemplate facing our feared situation. That reminds us of our past failures. Since we are now recalling that we handle such situations poorly, we next begin to question our coping abilities. “Can I really handle this? What if I panic again?” These kinds of questions send a special message to the body.

And here is a second important piece of information. Unconsciously we answer these rhetorical questions: “No, based on my past performance I don’t think I can handle it. If I panic I will totally lose control.” These unconscious statements give this instruction to the body: “guard against the worst possible outcome.”

Simultaneously we can mentally visualize ourselves failing to cope with the situation, even though we may not consciously “see” the image. In our example, Donna pulls up to the store and imagines what it might be like if she “lost control.” Later, while filling her cart, she imagines how long it might take to go through the checkout line. And each time, her body responded to that image.

Here is the third important piece of information. Just as our body responds to memories of the past, it will respond to images of the future as though the future were occurring now. If our image is of ourselves coping poorly, the mind instructs the body to “protect against failure.”

What about the body? Exactly how does it respond to these messages?

Our bodies have been trained for millions of years to respond to emergencies. Ours is a finely honed response that answers with a moment’s notice to the instruction, “This is an emergency.” It responds the same way every time to any event that the mind calls an emergency.

Here is the fourth important piece of information in this step. Within the panic cycle, it is not the body that responds incorrectly. The body responds perfectly to an exaggerated message from the mind. It is not the body that needs fixing, it is our thoughts, our images, our negative interpretation of our experiences that we must correct in order to gain control of panic. If we never told ourselves, in essence, “I’ll lose control in that situation,” then we would not be flipping on that unconscious emergency switch so often.

In summary, here is the unconscious communication taking place between the mind and the body during the anticipatory anxiety stage. The mind considers approaching a feared situation. That thought process stimulates a memory of a past difficulty. At the moment the mind creates an image of that old trauma, it simultaneously instructs the physical body to “respond as though past difficulties are occurring NOW.” Using this information about the past, the mind now begins to question your ability to cope with this event. (“Can I handle this?”) These questions lead to an instant instruction to the body: “Guard against any of these worst possible outcomes.” Moments later the mind conjures up pictures of you failing to handle the upcoming event (consider them brief glimpses that don’t register in your conscious mind). A strong message is sent to the body: “Protect against failure!”

In other words, your mind says to your body: “The danger is NOW. Guard me! Protect me!” This is one reason why you begin to feel all those physical symptoms “out of the clear blue”: most all of the messages the mind sends the body before that moment are unconscious, “silent” ones.

In stage 2 — the panic attack — these messages are no longer silent, but their effects are the same. You notice those physical sensations that the body is producing, such as a rapid heartbeat. Then you become afraid of them and unconsciously instruct the body to protect you. The body begins to change its chemistry in order to guard against the emergency. Yet, since this is not a true physical crisis, you can’t properly use the body’s power effectively. You notice an increase in physical symptoms instead. This creates a self-reinforcing cycle during the panic attack.

Let’s look a little more closely at this physiology that is often misunderstood during panic. The table below lists many of the physical changes that take place when we flip on that emergency switch. (Technically we are stimulating hormones that engage the sympathetic branch of the autonomic nervous system.) All those changes assist the body in responding to an actual crisis. For instance, the eyes dilate to improve vision, the heart rate increases to circulate blood more quickly to vital organs, respiration increases to provide increased oxygen to the rapidly circulating blood, the muscles tense in the arms and legs in order to move quickly and precisely.

The Body’s Emergency Response

  • blood sugar level increases
  • eyes dilate
  • sweat glands perspire
  • heart rate increases
  • mouth becomes dry
  • muscles tense
  • blood decreases in arms and legs and pools in head and trunk

These are normal, healthy, lifesaving changes in the body’s physiology. And when there is an actual emergency we hardly notice these changes; we pay attention to the crisis, instead. However, since this is the “pseudo-emergency” of panic and not a real one, two problems develop.

First, we become stuck focusing on our fearful thoughts and our physical sensations instead of taking action to solve the problem. Since we are not expressing our body’s energy directly, our tension and anxiety continue to build.

The second problem has to do with our breathing. During an emergency, our breathing rate and pattern change. Instead of breathing slowly and gently from our lower lungs, we begin to breathe rapidly and shallowly from our upper lungs. This shift not only increases the amount of oxygen into our bloodstream but it quickly “blows off” an increasing amount of carbon dioxide. In a physical emergency we are producing excess carbon dioxide, so this breathing rate is essential. However, when we are not physically exerting ourselves, it produces the phenomenon called hyperventilation by discharging too much carbon dioxide.

During the anticipatory anxiety and the panic attack stages of the panic cycle, hyperventilation can produce most of the uncomfortable sensations that we notice, as listed in this next table. This is another important piece of information: simply by changing how we breathe during panic-provoking times we can significantly reduce our uncomfortable symptoms. However, our breathing is dictated in part by our current thoughts and the images we are currently focusing on, so we must also change our thinking and imagery.

Possible Symptoms During Hyperventilation

  • irregular heart rate
  • dizziness, lightheadedness
  • shortness of breath
  • “asthma”
  • choking sensations
  • lump in throat
  • difficulty swallowing
  • heartburn
  • chest pain
  • blurred vision
  • numbness or tingling of mouth, hand, feet
  • muscle pains or spasms
  • shaking
  • nausea
  • fatigue, weakness
  • confusion, inability to concentrate

Summary

Before you can learn to gain control over panic, you must first believe that you have the ability to take control. Many people feel helplessly out-of-control, experiencing panic as something that rushes over them from out of the blue. The truth is that many of the early stages of the panic cycle take place outside conscious awareness. In this step you learned what these typical stages are. By first identifying these stages, we can begin to design a self-help plan that accounts for the entire cycle of panic not just those stages we consciously notice during panic. As you continue exploring this self-help program, here are some important ideas to keep in mind:

Our body properly responds to the messages sent to it by the mind. If we label a situation as dangerous, and then begin to approach that situation, the body will secrete hormones that prepare us physically for crisis. Even if the situation appears relatively safe, if the mind interprets it as unsafe, the body responds to that message.

If we become mentally involved with thoughts of a past event, the body may respond as though that event were taking place now.

When we question whether we can handle a fearful situation, we tend to unconsciously predict failure. Our body responds to our fearful thought by becoming tense and on guard.

If we visualize ourselves failing to cope with a future event, our body will tend to respond as though we are currently in that event.

Within the panic cycle, the body is responding appropriately to unnecessarily alarming messages sent by the mind.

By changing our images, our thoughts and our predictions about our ability to cope, we can control our physical symptoms.

When we become anxious, our rate and pattern of breathing change. These changes can produce hyperventilation that may cause many of the uncomfortable physical symptoms during panic. By changing the way we breathe we can reduce all of those uncomfortable symptoms.

Home Study

Chapter 7: The Anatomy of Panic

Chapter 8: Who’s in Control?

Chapter 9: Why the Body Reacts

Step 3: Change Your Attitude

This section will help you feel more in control by giving you the Big Picture of how to handle panic. It will offer a way to organize all that you are learning into several common points of view. My intention from the beginning has been to give you as much information as you could possibly use, because you must become a student of panic to really take control of it. On top of that knowledge base you need to have many tricks and maneuvers to help with your anxiety. Yet every year that I work with people having panic attacks I become more convinced that you have one primary task. That is to manage your attitude. “Attitude” means your basic view of your relationship with panic and anxiety, your judgment of panic, your belief about how you should act in the face of anxiety.

As we approach any task, our attitudes and beliefs influence the degree to which we are willing to try to solve problems, our determination to persist in the face of obstacles, and the amount of time and energy we devote to the endeavor. So, pay attention to all the skills in this self-help guide, and practice those skills regularly. But when you are ready to take on panic, focus primarily on your attitude. That will be the driving force of your healing.

Few self-help approaches put most of their marbles on “attitude.” Typically they will direct you to make lists of your strengths, prioritize your goals, experiment with new behaviors and record your changes. These are excellent suggestions for a self-help approach, but it is the nature of panic that requires you to go beyond technique to modifying your attitude. I firmly believe — after talking with thousands of people in treatment sessions, training programs and public lectures — that it is attitude, not technique, that will take you across the finish line.

Consider the possibility that you can “inoculate” yourself with these eight statements. One of the greatest achievements in medicine began when William Jenner discovered that fluid from cowpox sores could immunize people against the deadly disease of smallpox. Physicians can now inoculate against dozens of illnesses, from polio, rubella, and yellow fever to tetanus, hepatitis B and rabies.

A vaccine consists of a dead or modified form of a disease-causing microbe. Once injected, it stimulates the body’s production of antibodies to the organism. If the microbe should then enter the body, the antibodies help neutralize and remove the microbe from the body before it can multiply and cause disease.

You inoculate yourself by taking in some of the causative agent in order to experiment with it or to become immune to it. Therefore, inoculations are paradoxical treatments: they take you close to what you want to avoid. That’s how you can use this section. Stop doing the activities that seem instinctual in the face of panic. Instead, go directly toward panic, drop your guard and let it touch you. Clearly you will be “experimenting” when you apply these inoculating attitudes. I predict that you also will become immune, which means “not affected by or responsive to” panic.

How valuable can your attitude be? I know some people who have applied no techniques — they didn’t control their breathing, they didn’t learn relaxation skills, they didn’t plan strategies for coping with symptoms — and they still brought their panic under control in a matter of weeks. They did that by focusing strictly on the eight attitudes presented in this section.

The reverse is not true. I have known many more people who have attempted to apply techniques without a shift in their attitude. They used the techniques while simultaneously thinking, “This better work! I can’t stand this anxiety. I shouldn’t be feeling this way.” They, unfortunately, continued to struggle with symptoms of anxiety and panic.

So, the point is . . . Especially when things aren’t working for you, when you apply suggestions and they just don’t seem to help, that is an important time to return to this section and check on your attitude. Also — after you recover from this problem — if you begin to experience a few symptoms of anxiety returning, again pay attention to applying these attitudes to your symptoms.

The Eight Attitudes of Recovery

Expected Attitudes

“I can’t let anyone know.”
“Panic is evil, bad, the enemy.”
“I want to avoid the symptoms.”
“I must relax right now.”
“I must stay on guard.”
“This is a test.”
“I must be certain (that there is no risk).”
“This had better work.”

Healing Attitudes

“I am not ashamed.”
“What can I learn as a student of panic?”
“I want to face the symptoms to gain skills.”
“It’s OK to be anxious here.”
“I won’t guard myself against anxiety.”
“This is practice.”
“I can tolerate uncertainty.”
“It’s OK if it doesn’t work.”

As you practice your skills to overcome panic, take a look at your basic attitudes and consider any changes that might make you more determined and committed to solving this problem. The kinds of statements people make about themselves or their behaviors often represent their attitudes.

In this section, two contrasting statements reflect each of these eight attitude shifts. The first self-statement in each pair reflects a personal position that undermines the task of controlling panic. It is the most likely way that any of us would think about such a difficulty, so it’s no surprise if you think this way. It comes quite naturally. The problem is, it doesn’t work. When put into action, it works against your desired goal of healing. The motto I go by is this: if what you are doing isn’t working, try anything else.

The second self-statement in each pair reflects the attitude I encourage you to explore. It moves you away from being a victim of anxiety and toward the freedom of panic free living. But I must warn you, it might feel quite unnatural to hold these attitudes in the face of panic or anxiety.

Now begin by learning more about Changes #1 through #8.

Recovery Attitude Change #1: Shame & Embarrassment

It’s hard to let others know of our problems. First, we can feel embarrassed to admit that we don’t have our lives together as well as (we fantasize) they have theirs. Then, if our problems are lasting awhile, we don’t want others to get fed up with our complaints. Or, we might explain what’s bothering us only to have others say, “I don’t get it. I don’t know what you mean.” Or, worse yet, “What’s the big deal?” In addition, people can start giving us advice on how to fix it and expect us to take action soon. Speaking to someone about a problem doesn’t mean that we are feeling courageous enough to try to fix it. These possible reactions can be good reasons to keep our problems to ourselves. 

There are at least two other reasons to be secretive when the problem is panic attacks. The first is the stigma around mental health problems. Think how easy it is for employees to call in sick because they have the flu, or even a migraine headache. But who’s willing to say, “I’m having a bout of depression that’s going to keep me out for a couple of days”? You can tell your boss you have to miss that cross-country trip tomorrow because your grandmother died. It takes more strength to admit you are afraid of flying. A mental health problem can be seen as a mark of disgrace.

Second, failure to control panic can heighten our own feelings of shame and low self-esteem. Not being able to travel in the same circles as our peers, or perform tasks that seem so simple to others and were once simple for us — it’s easy to see how that wears down our self-worth. And as our sense of self-worth diminishes, we become even more susceptible to the influence of panic. For instance, if you believe you are not worth much as a human being, then you will be less likely to try to help yourself. If you believe that this panic simply reflects your lack of basic skills necessary to cope with the world, then you will be less likely to face the stressful events of your life.

I think it is best to address all of these fears — social embarrassment, lack of understanding, stigma — by first addressing our beliefs about our own worth. This will help us touch our guilt and shame, and any feelings of personal inadequacy. I don’t expect to do a complete makeover of your personality in a few pages. However, I do want to instill in you the attitude that you deserve to feel self-respect.

Panic requires that you work on building up your self-worth, self-confidence and self-love, because panic has the powerful ability to wear away at your psychological vulnerabilities, to weaken your resolve. When you feel you have to hide your problem, then every time panic arises, you will begin to tighten up inside. You will try to contain it, not let it spill out, not let it be seen. When you attempt to contain panic, it grows. When you respect yourself, you can begin to make decisions based on what will help you heal, not what will protect you from others’ scrutiny. When you make that change, you starve panic by supporting yourself and letting others support you through this tough time.

Look over this list and see whether any of the statements reflect your negative beliefs about yourself:

“I am inferior to others.”
“I’m not worth much.”
“I’m disgusted with myself.”
“I don’t fit in with others.”
“I’m just no good as a person.”
“There’s something wrong with me, or inherently flawed about me.”
“I’m weak. I should be stronger.”
“I shouldn’t be feeling this way.”
“There’s no reason for all this anxiety I’m feeling.”
“I shouldn’t be having these crazy thoughts.”
“I should already be better.”
“I’m hopeless.”
“I’ve had this problem too long.”
“I’ve tried everything; I’m not going to improve.”
“My problems are too ingrained.”

Such self-critical attitudes support the first stages of restricting our options. We start to limit the way we act around others. If we feel as though we don’t fit in, or that we are not worth much to those around us, then we will tend to protect ourselves from rejection. We will think of others first and ourselves second:

“I can’t tell anyone.”
“I can’t bother other people with my problems.”
“I have to take care of others.”
“I can’t let people see me this way.”
“People won’t think I’m OK if they know I’m anxious.”
“I must hide my anxiety, hold it all in, not let anyone know my feelings, fight it.”

This attitude section focuses on the influences of our beliefs on our daily lives. These include the belief that we are worthy of success and happiness and the belief that we have a variety of positive choices available to us in our lives. These are attitudes that help us solve problems. They are convictions that affirm us.

An affirmation is a positive thought that supports us as we move toward our desired goals. Your greatest internal strength will come from the ways you affirm your worth as a person. There are two kinds of affirmations to explore. The first are beliefs concerning who you are, and the second are beliefs about what you need to do in this life to succeed. Consider the following statements. How might you change your approach to your life if you believed these words?

Accepting Who I Am

“I’m OK just the way I am.”
“I am lovable and capable.”
“I am an important person.”
“I’m already a worthy person; I don’t have to prove myself.”
“My feelings and needs are important.”
“I deserve to be supported by those who care about me.”
“I deserve to be respected, nurtured and cared for.”
“I deserve to feel free and safe.”
“I’m strong enough to handle whatever comes along.”

No one expects you to change a long-standing attitude overnight. But if you can continue to reflect on these attitudes until you begin to believe them, you will be on your way to overcoming panic. Building up our sense of self-worth increases our ability to confront the obstacles to our freedom.

The second kind of affirmation has to do with our expectations about how we must act around others. It reminds us that we don’t have to please everyone else and ignore our own wants and needs, that we all get to make mistakes as we are learning, and that we don’t need to view every task as a test of our competence or worth.

Supporting What I Do

It’s OK to say no to others.
It’s good for me to take time for myself.
It’s OK to think about what I need.
The more I get what I need, the more I’ll have to give others.
I don’t have to take care of everyone else.
I don’t have to be perfect to be loved.
I can make mistakes and still be OK.
Everything is practice; I don’t have to test myself.
I am not ashamed.

These attitudes give us permission to take the time we need to feel healthy, rested and excited about life. They insulate us against the paralyzing poison of shame.

Explore what obstacles stand in the way of these affirmations for you.  Sometimes discussing these issues with a close friend or a self-help group will help. Other times the causes of these blocks are not so clear or easily removed. If you feel stuck, consider turning to a mental health professional for insight and guidance.

Once you address those issues that block your willingness to support yourself, then pay attention to these affirmations. Find ways to accept these kinds of statements, then let your actions reflect these beliefs. (You may have to begin by acting as though you believe them — even when you don’t — before you discover how well they will serve you.) In addition to the support of friends and a mental health professional, look for courses in your community on assertiveness training. Such course teach you how to turn your positive beliefs into actions.

Recovery Attitude Change #2: Become a Student of Panic

Who wouldn’t be angry and rejecting toward something that produces such chaos in your life? Seeing panic as the enemy is a natural response. I assume that up to now that you have had plenty of practice viewing panic as the villain. Now try something new — consider panic your teacher. 

The martial arts, developed in Asia, teach self-discipline, physical combat technique and a philosophy, or attitude, about life. All but one are ancient schools. Aikido, a twentieth-century martial art based on love and dedicated to peace, puts a different spin on the art of self-defense. And “spin” is an appropriate expression. In the western world, we use boxing as the prototype for fighting. If someone punches, you punch back. You meet force with opposing force. On the other hand, the traditional martial arts axiom is “push when pulled and pull when pushed.”

As the attacker approaches you to push or punch, you learn to grab the forward moving hand and pull it. You don’t oppose the challenger with equal force. You take the attacker’s movement and energy and use it against him. As he pushes, you pull him past you and onto the ground, for instance.

In Aikido the axiom “push when pulled and pull when pushed” becomes “turn when pushed and enter when pulled.” You accept, join and move with the challenger’s energy flow in the direction it is going. You offer nothing for the challenger to resist. You turn and spin with the attacker instead of moving past him.

Imagine teaching an American the art of Aikido. It requires sincerely welcoming the attack and struggle, truly understanding the attacker’s intentions, loving the attacker. The moment the challenger begins to approach with an attack, the Aikido student shifts her position. She stands with open arms and open palms, “welcoming” the challenger. (If you try it for a moment — holding your arms out by your side with your palms open in front — you can notice how vulnerable you feel.)

I will leave the details of other Aikido moves to the masters. It is the basic attitude that I want to address. The attitudinal stance in Aikido is that each challenge is an opportunity to learn and practice, not something dangerous or frightening. The student views the challenge as a gift of energy, a creative system of joining rather than one of conflict. This view eliminates the notion of “enemy.”

Welcoming Panic

Let’s apply this to your relationship with panic. First of all, please know that I realize how frightening a panic attack is. You can’t simply “relax” in the face of panic, because your body is flowing with adrenaline-produced anxiety. This is a given: you begin with the normal human reaction of fear. What we are doing with this attitude shift is taking that state of fear and changing it. We are moving from an automatic reaction toward a designed reaction, one that brings you freedom and personal choice. The way we will change fear is by adding something to it, not by taking your fear away.

As you enter that restaurant, drive across that bridge, sit down in the middle aisle at the movies, or walk up to that group at the party, be curious about your anxiety. How is it expressing itself right now? What is it inviting you to be afraid of? What skills is it encouraging you to practice at this moment?

If you suffer from panic attacks, your best stance will be, “Panic, anxiety, you have something to teach me. What is it? Help me understand myself.”

Perhaps, over time, panic will teach you to stand up for yourself and be more assertive. Maybe it will lead you to be more self-revealing and vulnerable around those who love you. Or it might help you express your deeper desires for what is important in life, to take you out of the trap of playing the role of good mother, wife, employee. While I don’t know what you, in particular, will learn, I do know that every student learns once she focuses on her desire to learn.

I am not saying that panic always comes into people’s lives because they are missing some basic learning (although sometimes it does). Taking the stance of a student who truly wants to learn is a way to stop taking a resistant stance toward panic. The focus of our attention right now is how to get better. Choose to become a student of panic because it is the attitude that best moves you toward health. If you are paying attention to how you can learn from panic, then you will stop fighting against panic. As you reduce your fear and defensiveness, you influence the entire dynamic of your relationship with panic, and it can no longer rule your body.

Later, I’ll teach you a specific skill that uses this paradoxical stance.

Recovery Attitude Change #3: Face Your Panic Symptoms

Another common expression in the martial arts is, “Love the mat.” In other words, during the learning process you’ll find yourself, again and again, lying flat out on the mat after your opponent gets the best of you. By embracing challenging experiences as a necessary part of your training, you reduce your resistance to the learning process. “Love the mat” is a winning attitude of the student who knows that she doesn’t always get to be in control. 

The only way to get the best of panic is to face the symptoms directly and practice your skills. Many people make the error of designing practice sessions in which they enter the fearful situations until the point that they feel discomfort. Then they retreat. This approach makes their recovery process long, slow and arduous.

This task — of provoking your symptoms — requires courage. Think of courage as “being scared and doing it anyway.” This way, as you face panic, you don’t have to get rid of fear, you need to add courage. In fact, you only need courage in fearful situations!

Provoking your symptoms is exactly what I encourage you to do. Don’t wait until your weekly schedule puts you into a panicky situation. Set up events that will provoke your distress. Some would say that this goes beyond courage to stupidity. It’s like being in the jungle and running toward the lion’s roar. But that is the move, and the expression “run toward the roar” will be a useful reminder.

If your symptoms suddenly end without any effort on your part, that will be a wonderful experience. However, you will still be open to blackmail by panic because you have yet to learn how to respond to the symptoms when they come. If at any point in the future the symptoms return, you’ll be back at ground zero: reacting to panic with many of the eight expected attitudes. Although it is difficult to push yourself into situations that make you anxious, those efforts will help inoculate you against panic’s control of your future.

Your job here is to be proactive, not reactive. Don’t wait for the anxiety-provoking situations to arrive. Look around your world for ways to stir up trouble. Ask yourself, “What can I do to get myself anxious today?”

I can still remember Mary B.’s words: “Come on, panic, give me your best shot.” Here’s how she set the scene. “I was at the library gathering some research for a paper. After about twenty or thirty minutes I suddenly started feeling quite anxious and confined. I really wanted to run out of there. My body started shaking, I felt lightheaded and I lost all concentration on my work. Then, I don’t know how it came to me, but I decided to take the bull by the horns. I walked to the end of the row of shelves and sat down cross-legged on the floor. (I didn’t want to crack my head open if I fainted.) Then I said, ‘Come on, panic, give me your best shot.’ And I just sat there. I sat there and took it. Within two or three minutes all the symptoms stopped. I got up and finished my work, which required about three more hours in the library.”

That was quite a learning experience for Mary B. Before that night she would have left the building immediately upon noticing her symptoms, gone straight home, never finished that research and mentally kicked herself over the next two or three weeks for having failed at her task.

The nature of panic is that it produces involuntary symptoms in your body. By voluntarily seeking out those symptoms you begin to change panic. You take away its involuntary nature, and start to shift the control over to you. So as you accept this challenge of “I want to face the symptoms to gain skills,” remember to love the mat and run toward the roar.

Recovery Attitude Change #4: Accept Your Anxiety During Panic

Continuing our theme, once you choose to face your symptoms, then what do you do? You will see a lot of relaxation skills in this self-help guide. These are important skills. But equal to them is your willingness to stay anxious. (You are simply not going to escape this paradox: calm down, and let yourself stay anxious.) When anxiety hits, your instincts tell you to get rid of it. It’s the American way: “Don’t just stand there, do something!” The more powerful intervention is, “Don’t just do something, stand there.” 

Although you will train yourself to respond to anxiety using coping skills that include calming your breath and quieting your thoughts, do not make relaxation a demand. When you require yourself to relax, you add another demand to an already stressful situation. That will only add to your stress.

Instead, take the more permissive attitude of, “It’s OK that I’m anxious right now.” Accepting your anxiety in the moment when it occurs will reduce the anxiety. It takes away the internal demand and helps you build your tolerance.

Your accepting inner voice may go something like this: “It is really no surprise I am anxious right now. This is my first flight since I got scared during the trip to Orlando. I don’t like to feel trapped and out of control. This is harder than driving because I can pull off the highway when I need to. I can’t get off this plane whenever I want. So I’m going to practice all the skills I’ve brought on board with me. If I’m still anxious, that’s OK. I can handle those feelings, and as I do, I won’t be so worried on the next flight.”

So, shop in that mall, give that speech, go to that dinner, or climb that ladder . . . and use all your many skills to help you stay cooled out. Just add to those skills the important attitude of “It’s OK to be anxious here.”

Recovery Attitude Change #5: Don’t Guard Yourself Against Anxiety

Panic leads people to become vigilant. A panic attack hits suddenly, catches you by surprise and causes you pain. Our bodies and minds have trained over hundreds of thousands of years to guard against pain. A toddler doesn’t have to burn himself on a stove too many times before his built-in instinct trains him to watch out for stovetops. In that same way, when you’ve been “burned” several times by panic, your mind searches rapidly for danger signals any time you approach a panic-provoking situation. You are watching, listening, feeling with great attention, on guard in case something “goes wrong” in your body or your surroundings. Unfortunately, all this vigilance only contributes to your distress. You are tensing yourself up in anticipation of a problem. This is the definition of anticipatory anxiety. 

What about when a panic attack begins? Think about what you say to yourself. Even during panic, almost all your communications are anticipatory in nature: “I’m really feeling bad right now. What if this gets worse?” “I’m lightheaded and dizzy. What if I faint in a moment?” “My face feels flushed. What if people start seeing this?” On and on it goes. “I can’t let myself get any worse.” “I can’t let the symptoms increase.”

This natural, instinctual response to threat works against you. When you stay on guard as you approach events, you increase your tension and become more vulnerable to a panic attack. When you warn yourself to stay on guard in the midst of panic, you secrete even greater amounts of adrenaline into your bloodstream, causing more intense symptoms. You can’t remain anxiously on guard and simultaneously learn to control panic.

Daniel Goleman once said, “A person prevails over anxiety by sacrificing attention.” To come out on top you must let down your guard. You must not pay such close attention to what might happen next. You must clear your head of its constant and frantic analysis.

Now if you do this — if you stop being so vigilant — you run the risk that something might slip past your conscious attention. Some little twinge in your body might go unnoticed. You might not see that four cars are waiting in line ahead of you in the left turn lane at the stop light. So, as usual, here is an intervention into your problem that can at first make you more anxious, not less. When in the past you have kept your guard up as a way to stay in control, I am suggesting that you now let down your guard. So, you may feel that you are not protecting yourself. If you feel vulnerable, you’ll probably feel a little anxious in response. (This is another reason to become a student of attitude #4, “It’s OK to be anxious here.”)

There are two further considerations here. The first (no surprise) is a paradoxical one: when you are considering the possibility of confronting an anxiety-provoking situation, it is fine to plan out how you will take care of yourself. In Step 7 I will walk you through such preparations. But make those plans with the expectation that you may become a bit anxious, and not with the fearful dread that panic might strike. Include in those plans your decision to accept any anxiety as it arises, without holding yourself in a death grip waiting for its arrival. The paradox to play with is plan, and don’t stay on guard.

Second, let’s consider where you can place your attention when you pull it away from your anxious anticipation. If you will reflect for a moment, I think you can appreciate just how much time and attention you devote to dreaded anticipation. There are so many valuable things to be doing with your attention. The world outside you offers beautiful, warm, sunny days in the summer and the soft glow of fires in the winter, the embraces and laughter shared with those who love you, the challenges of solving problems at work and home, the stimulating interest of conversation, music, study. When you are anxious, turn your attention outside yourself. Become connected to life, and allow that rich healing contact to influence your feelings. Stop trying to figure yourself out! Be anxious and simultaneously become interested in your surroundings.

There is a second choice for your attention when you stop focusing on what terrible things might happen in the future. Pay loving, caring attention to yourself in this moment. By asking, “What do I need right now to handle these feelings?,” you will contribute to your self-control far more than by asking, “What will I do if that (terrible thing) happens next?” Start supporting yourself based on what you need at this moment, instead of becoming anxious about what will happen thirty seconds from now. The upcoming Steps will suggest what actions to take. Apply those skills with the attitude of, “I don’t need to stay on guard against panic.”

Recovery Attitude Change #6: Facing Panic is Practice, Not a Test

As you begin taking action to face a panicky situation, your attitude about the task will be an important factor in your progress. I instruct my clients to consider any activity they engage in as “practice.” I take a firm stand on this point. Never view a future task as a “test” of your progress or of your ability to overcome panic. Never look back at an attempted task in order to label your efforts a failure. Never invest your sense of self-worth in the positive or negative outcome of your plans. 

It seems that people who are prone to panic attacks turn many experiences into tests. When you decide to enter a previously difficult situation, do you say, “This will be a test of how well these new skills work”? As soon as you declare it a test, your body is going to secrete adrenaline, because you will be saying to yourself, “Uh oh, I’d better do well,” while you simultaneously imagine yourself failing. When you say, “Uh oh,” you secrete adrenaline through your body, and you will feel anxious. The more you set up future events as tests, the more you are going to feel anxious.

People declare, “This is a test” before events, and they declare, “I failed that test” after events. I have watched clients improve steadily week after week. Then, one week, they inevitably have a small setback in their progress. From this one episode they become dejected, depressed and demoralized. They are full of self-critical and hopeless thoughts. It is not simply that they say, “I failed,” but they then say, “. . . and I shouldn’t have,” or “. . . and that means I should quit trying,” “. . . what’s the point,” “. . . and that proves I’ll never change.”

When you decide that all your experiences are practice, you are, in effect, saying that you are both willing and able to learn from each of those experiences. You might fail to meet a certain goal by a certain time, but your intentions aren’t a failure, and your efforts aren’t a failure. They are the successful ways that people learn: setting goals and applying effort. No one knows everything about any particular subject. Our greatest scientists continually create new questions to ask about their field of expertise. These brilliant men and women would be the first to defend the importance of maintaining the open, curious, exploratory mind of a student.

When you test yourself during every activity, you inhibit your learning. If you say to yourself, “That action I took yesterday proves that I’m never going to make it,” you essentially have said, “Don’t bother learning from yesterday; it’s too late for you.” Of course, the truth of the matter is that making mistakes and studying them are among our best learning tools.

Since everyone who takes on a challenge has setbacks, you can assume you will too. When you hear your self-critical or hopeless comments rise up, let them go. They will only distract you from learning.

It’s true that if you set a goal of remaining at a party until 11 PM, but your discomfort caused you to leave at 9:30, then you failed to meet your goal. That is like throwing a dart at the bull’s eye from 15 feet and missing it by three rings. Let that experience be feedback to you as you take corrective action. What can you adjust for your next throw? Can you take aim at a different spot on the target? Give the dart more arc on the throw? Concentrate on your follow-through? Step closer to the target?

As you approach events, concentrate on what you can do to improve your outcome. Experiencing some worry and anxiety about the outcome is understandable. Just don’t let it consume your creative thinking. There are two important focal points for your attention when you leave a scene without meeting your goal. The first is, “What can I learn from my experience in that situation that I can apply next time?” The second is, “How can I take care of myself now that I am leaving this difficult situation?” Practice the skill of supporting yourself in the face of a disappointment. If your goal is improving your performance next time, how do you want to treat yourself after your difficulty this time? Stop being critical of yourself and begin developing a supportive voice within you.

Recovery Attitude Change #7: Fear of Uncertainty

Most problems with anxiety relate to a fear of uncertainty. 

My educated guess is that the brains of about twenty percent of the population have a more difficult time than the average person in tolerating uncertainty regarding risk. This, of course, can put them at a serious disadvantage, since living demands risk. It is no wonder, then, that so many people develop anxiety problems. They worry because their brain is demanding closure on a specific issue. Their mind says, “This is how it must turn out for me to feel secure. And I must feel secure. Do I know for certain it will turn out this way?” It is as though they require a 100% guarantee that they will encounter zero risk. That is simply too much to ask of life. If you intend to go up against one of the most powerful forces of the natural world — that is, continual change — you will have a tough time winning. Listen to these expectations of life and you will see what I mean. The person with panic attacks, phobias or social anxieties asks such questions as:

“Can I know for certain that I won’t have any symptoms?”
“Can I know for certain that I won’t have to leave?”
“Can I know for certain that I won’t feel trapped?”
“Can I know for certain that this isn’t a heart attack?”
“Can I know for certain that I won’t die on that plane?”
“Can I know for certain that I won’t cause an embarrassing scene?”
“Can I know for certain that people won’t stare at me?”
“Can I know for certain that I won’t have a panic attack?”

If we look at a different anxiety problem — obsessive-compulsive disorder — we find the same kinds of questions:

“Can I know for certain that this object is clean?”
“Can I know for certain that I won’t get contaminated if I touch the ground?”
“Can I know for certain that my family will be safe?”
“Can I know for certain that I didn’t run someone over?”
“Can I know for certain that I unplugged that iron?”
“Can I know for certain that I won’t kill my child?”

If it is true that some people’s brains cause them to feel a strong yet inappropriate need for certainty, then confronting that problem involves disrupting those demanding thoughts. It involves confronting them consistently and directly everyday to produce the change we want. This is where your new attitude comes in. You must find ways to accept risk and tolerate uncertainty.

Stay with me as I explain how this works, because this stance doesn’t seem very attractive at first glance. Whatever outcome you fear, work to find a way to accept that outcome as a possibility. For example, imagine that sometimes when you begin to have panicky symptoms you feel a pain in your chest that runs down one arm. Each time it happens, your first thought is, “This could be a heart attack!” Of course you have had one or more medical evaluations by a specialist. Let’s also say that all physicians you consult declare you have a strong heart, take good care of yourself and are not at risk of a heart attack.

Nonetheless, as soon as that pain shoots down your arm, you say, “This time it really could be my heart! How do I know? There’s no guarantee that this is only panic. And if it is a heart attack, I need help now!”

Further, let’s say that you’ve been learning to reassure yourself as a way to get some perspective on panic. “Look, guy, you’ve been to the emergency room twelve times in the last two years. One hundred percent of those visits have been false alarms. You know you suffer from panic attacks, and this is what they feel like, too. Take a few Calming Breaths, relax, wait a few minutes. You’ll begin to feel better.”

The reassurance lasts all of five seconds. Then you’re back in the saddle. “But I don’t know. I don’t know for certain. If this is a heart attack I could die! Right now! There’s always a chance.”

It’s the same with people’s fear of dying on a plane. Commercial flight is the safest mode of transportation we have. On average, about one hundred people die on a plane per year, while 47,000 motorists die on the highways and 8,000 pedestrians die each year. If you are looking for a risk-free environment, don’t stay at home; 22,000 people die of accidents a year without even leaving their house!

Even though your odds of dying on a plane are one in 7.5 million, the dialogue goes like this, “There’s still a chance I might die. And if I do, that will be the most horrible, terrifying death I can imagine.” You reassure, “Planes are safe. You’ll be fine. The pilot has gray hair; he has twenty-five years’ experience.”

“Yes, but how do I know? How can I be certain?”

This is what you do to yourself, in your own unique way. You ask, “how can I be certain someone won’t criticize me?”, or “how can I be certain I won’t have to leave the concert?” You might as well give it up, because you can never satisfy the demand for absolute confidence. No amount of reassurance will ever be enough.

Here, instead, is the attitude to strive for: “I accept the possibility of that (negative event) happening.”

For fear of heart attacks: “I accept the possibility that this time could actually be a heart attack. I’m going to respond to it as though it is a panic attack. I accept the risk that I might be wrong.”

For fear of dying on a plane: “I accept the possibility that this plane could crash. I’m going to think and feel and act as though this plane is 100% safe. I accept the risk that I might be wrong.”

For fear of having to leave an event: “I accept the possibility that I might have to leave the restaurant. I imagine I’d feel embarrassed, but I’m willing to tolerate that now.”

By making this decision — to accept the possibility of a negative outcome — you circumvent the requirement for absolute certainty of your future comfort and safety. There’s always a chance you will have a heart attack, regardless of your health. There’s always a chance you could die in a plane crash, regardless of the relative safety of air travel. There’s always a chance you will leave the restaurant and become embarrassed.

If you want to lower your chances of panicking and raise your chances of flying comfortably or feeling more at ease at the restaurant, you have work to do. Your job is to lower your risk of problems as much as makes common sense, then accept the remaining risk that is not under your control. You only have two other basic options. You can keep worrying about the risk while you continue with these behaviors. That leads to anxiety and the increased likelihood of panic. Or, you can withdraw from these activities. The world can get by with you never flying again. The world can get by if you never enter another restaurant. There are consequences to these behaviors, of course. (It may take longer to travel to your friends or relatives, and so forth.) But it’s your choice.

I encourage you, instead, to practice this idea of accepting uncertainty.

There is an interesting thing about many therapeutic interventions designed to help you control anxiety. Most actually make you more anxious at first. This one — giving up the requirement for complete confidence in the outcome — is a good example. For instance, you begin to feel that pain in your chest that shoots down you arm. Now you are saying, “I’m going to apply all my skills as though this is a panic attack. I’m not going to act as though this is a heart attack.” Do you think 100% of you is going to agree to this plan? No way! Some part of your mind is still going to feel scared, because, try as you might, some part of you will still be worried about a heart attack..

If worrying, or fearful monitoring, is one of our most common ways to stay in control, then if you practice letting go of your worries, your mind and body will feel out of control. That will make you anxious. This anxiety is the distress of positive experimentation and change. It’s a good kind of anxiety. Remember what Goleman said: “A person prevails over anxiety by sacrificing attention.” But expect to be uncomfortable at first anyway! Have faith that over time, this anxiety will diminish.

Reading about the next attitude shift will give you a better understanding of the value in accepting uncertainty.

Recovery Attitude Change #8: Allow Yourself to be Anxious During a Panic Attack

Thinking out loud with Camille helped me put a bigger piece of the puzzle together. 

Camille N. called me from Florida four years ago. She said she had suffered from panic attacks for many years and found the first edition of Don’t Panic in the library last year. She was wondering if, on her trip back to New York in a month, she could stop in for a consultation. We set up the appointment, and Camille arrived as scheduled.

Camille, it turns out, was similar to many of the people who see me from out of state. She was an impeccable student of the techniques. She practiced formal relaxation daily. She had her breathing skills down pat. She planned her practice sessions into the anxiety provoking situations and knew the most supportive self-talk during panicky times.

But she kept having trouble.

“Like last week, for instance . . . I was driving down the boulevard about 4:30, and the traffic was moderate. I needed to take a left so at the stop light I moved over into the turn lane, three lanes from the right curb, and pulled up behind four cars. Immediately three more cars pulled in behind me and the other two lanes filled with traffic. These lights are notoriously slow, and I’ve always hated getting trapped like that.

“When I felt my stomach get tense, I knew I had to work with my skills. First I reassured myself that I could handle this. If I needed to, I could even get out of the car, leave it right there at the light. I took a nice big Calming Breath, then started Natural Breathing. I dropped my hands from the steering wheel and let them relax in my lap. Nothing seemed to help!”

Outwardly I was attentive and positive, but inwardly I was frustrated, thinking, “Why? Why wasn’t that helping? That should be working!” I felt like the Wizard of Oz. This woman has driven so far in anticipation of this specifically arranged meeting with the expert that wrote the book she depends on to get her well. Now, here we are, face to face, and I’m about to say, “Hmm, I’m not sure what else to suggest.”

I’d love to say, “Then it dawned on me . . . .” In reality it took another thirty minutes of struggle to see the new opening. Both Camille and I were making the same error, and you can see it in our self-talk. She says, “Nothing seemed to help!” I said, “Why wasn’t that helping? That should be working!” Despite all our combined years of study, we were unknowingly committing a basic mistake. Our immediate goal was for Camille to stop being anxious. We thought if she applied enough technique — handle your negative talk, get your breathing straight, be willing to tolerate symptoms, wait — she would get “results” of diminished anxiety.

What’s wrong with that?, you say.

Here’s the answer, which may be tough to accept. While the long-term goal is to diminish your anxiety, the immediate goal is to continually monitor your attitude — to accept exactly what you are experiencing, as you experience it. As soon as you say, “This had better work,” you are moving against this important task. It is fine to observe, study and learn from your current experience, but don’t declare that your feelings must change on demand. Our bodies and minds simply don’t work that way.

This is paradox in its purest form. The attitude to aim for is, “It’s OK that I’m anxious right now. I’m also going to fool around with getting rid of this anxiety. I’m going to try every trick and gimmick I know. I’m going to apply all my concentration, my tenacity, and my commitment to the task of getting rid of this anxiety. I’m going to use what I believe is the best combination of skills and attitudes for this specific type of anxiety. If it works, that’ll be great. And if it doesn’t work — if I’m still anxious — that’ll be OK too.”

This is the attitude that even the best students of panic tend to miss. You must step up onto the platform of acceptance. Apply your skills from there. Maintain that stance through all the good and bad responses you get to your skills. And end up standing there in the end — accepting exactly what you are experiencing — regardless of the outcome.

The most important distinction here is that this position — “It’s OK if it doesn’t work out” — is not about passive resignation to the status quo. It is not surrendering to the fact that, “you have panic attacks and you better get used to it.” Instead, it is a part of an active, dynamic process of healing. Consider this attitude as though it is a technique that you apply throughout the moments you are either anticipating or having trouble. When you say, “This had better work,” you are testing yourself and you will respond by emotionally and physically tightening up. When you tighten up, you feed panic. By saying, “It’s OK if it doesn’t work,” you pull yourself out of this testing environment. Crazy as it sounds, this action of removing the demand for success actually increases the likelihood of your success.

Someone once said that if you want to hit the bull’s eye every time, throw the dart first and then draw circles around it. Say “yes” to every experience; that’s where you start. There will be plenty of hardships coming your way before the final curtain. You might as well get on friendly terms with them. Say “yes” to them when they arrive. Then begin to manipulate them actively and creatively. The fear of being trapped is a common concern for people with panic. Freedom comes by saying “yes” to whatever trap life puts you in, then doing something to get yourself out. Any time one of your attempts fails, begin immediately to do the really hard work: accept that you are still stuck in discomfort. Take time to complete that task — of accepting the dissatisfying outcome — first. Then re-double your efforts to change that outcome next time.

Prevent Panic Attacks: Eight Recovery Attitudes

These eight attitudes are not simply philosophical underpinnings. They are active workhorses in your healing process. Think of attitudes in a new way; think of them as technique. 

To find out their benefits for you, don’t wait until you are having a panic attack. Write these eight statements on an index card and carry them with you throughout the day. Pull them out when you’re feeling uncomfortable and stuck. Use them to influence what you do (or don’t do) next. That’s a good way to begin to learn of their benefits. It is also consistent with the metaphor of inoculation: you start by learning to accept a small amount of discomfort, and build your confidence on that experience. Nobody learns to drive by entering the Indianapolis 500. A much easier place to begin is the mall parking lot on Sunday morning, with your supportive parent sitting next to you. Master these attitudes gradually by giving them a chance in lower risk situations. Then gradually turn your attention to those panic-provoking situations.

Who knows . . . maybe these are the only “techniques” you’ll need.

Home Study

Chapter 9: Why the Body Reacts

Step 4: Practice Your Breathing Skills

During an emergency, our breathing rate and pattern change. Instead of breathing slowly from our lower lungs, we begin to breathe rapidly and shallowly from our upper lungs. If during this time we are not physically exerting ourselves, then it can produce a phenomenon called “hyperventilation.” This in turn can explain many of the uncomfortable symptoms during panic: 

  • dizziness
  • shortness of breath
  • a lump in the throat
  • tingling or numbness in the hands or feet
  • nausea
  • confusion.

The good news is that by changing your breathing you can reverse these symptoms.

By shifting your breathing rate and pattern, you can stimulate the body’s parasympathetic response. This is the body’s equally powerful and opposite system to the Emergency Response and is often called the relaxation response. For our purposes I will call it the Calming Response.

The table below lists the physical changes that take place in the Calming Response. As you can see, all of the primary changes of the Emergency Response are reversed in this process. One of the differences in these two physical responses is that of time. The Emergency Response takes place instantly in what is called a mass action: all the changes occur together. Once we flip on that emergency switch, it takes awhile for the body to respond to our calming skills. For this reason it is important for you to know what specific skills will reverse this emergency response and will help calm your body and clear your mind.

The Calming Response (Parasympathetic Response)

  • oxygen consumption decreases
  • breathing slows
  • heart rate slows
  • blood pressure decreases
  • muscle tension decreases
  • growing sense of ease in body, calmness in mind

You will now be introduced to three breathing skills. In later steps you will learn how to change your fearful thinking and your negative imagery, because each time you frighten yourself with catastrophic thoughts or images, you re-stimulate your body’s emergency response. To begin with, however, you need a solid foundation in proper breathing.

Calming Your Breath

People who are anxious tend to breathe in their upper lungs (upper chest) with shallow, rapid breaths, instead of breathing into their lower lungs (lower chest).  This is one contribution to hyperventilation: shallow, upper lung breathing.

The three breathing skills that I will describe next start with inhaling into your lower lungs.  This is a deeper, slower breath.  Below the lungs is a sheet-like muscle, the diaphragm, which separates the chest form the abdomen.  When you fill your lower lungs with air, the lungs push down on the diaphragm and cause your abdominal region to protrude. Your stomach looks as though it is expanding and contracting with each diaphragmatic breath.

Two kinds of breathing, upper chest (thoracic) above, and lower chest (diaphragmatic) below.

The first breathing skill is called Natural Breathing, or abdominal breathing. In fact, this is a good way to breathe all day long, unless you are involved in physical activity. In other words, you should practice breathing this way all day long, since it provides for sufficient oxygen intake and controls the exhalation of carbon dioxide.

It’s very simple and it goes like this:

Gently and slowly inhale a normal amount of air through your nose, filling your lower lungs. Then exhale easily. You might first try it with one hand on your stomach and one on your chest. As you inhale gently, your lower hand should rise while your upper hand stays still. Continue this gentle breathing pattern with a relaxed attitude, concentrating on filling only the lower lungs.

Natural Breathing

  1. Gently and slowly inhale a normal amount of air through your nose, filling only your lower lungs. (Your stomach will expand while your upper chest remains still.)
  2. Exhale easily.
  3. Continue this gentle breathing pattern with a relaxed attitude, concentrating on filling only the lower lungs.

As you see, this breathing pattern is opposite of that which comes automatically during anxious moments. Instead of breathing rapidly and shallowly into the upper lungs, which expands the chest, you breathe gently into the lower lungs, expanding the abdomen.

The second technique is deep diaphragmatic breathing and can be used during times when you are feeling anxious or panicky. It is a powerful way to control hyperventilation, slow a rapid heartbeat and promote physical comfort. For this reason we will call it the Calming Breath.

Here’s how it goes:

Calming Breath

  1. Take a long, slow breath in through your nose, first filling your lower lungs, then your upper lungs.
  2. Hold your breath to the count of “three.”
  3. Exhale slowly through pursed lips, while you relax the muscles in your face, jaw, shoulders, and stomach.

Practice this Calming Breath at least ten times a day for several weeks. Use it during times of transition, between projects or whenever you want to let go of tension and begin to experience a sense of calmness. This will help you become familiar and comfortable with the process. And use it any time you begin to feel anxiety or panic building. When you need a tool to help you calm down during panic, you will be more familiar and comfortable with the process.

The third technique is called Calming Counts. It has two benefits over Calming Breath. First, it takes longer to complete: about 90 seconds instead of 30 seconds. You will be spending that time concentrating on a specific task instead of paying so much attention to your worried thoughts. If you can let time pass without such intense focus on your fearful thoughts, you will have a better chance at controlling those thoughts. Second, Calming Counts, like Natural Breathing and the Calming Breath, help access the Calming Response. That means you will be giving yourself 90 seconds to cool your body out and quiet your thoughts. Then, after that time has passed, you will less anxious than you were.

Here’s how this skill works:

Calming Counts

  1. Sit comfortably.
  2. Take a long, deep breath and exhale it slowly while saying the word “relax” silently.
  3. Close your eyes.
  4. Let yourself take ten natural, easy breaths. Count down with each exhale, starting with “ten.”
  5. This time, while you are breathing comfortably, notice any tensions, perhaps in your jaw or forehead or stomach. Imagine those tensions loosening.
  6. When you reach “one,” open your eyes again.

As you apply these skills, keep two things in mind. First, our breathing is dictated in part by our current thoughts, so make sure you also work on changing your negative thoughts, as well as your breathing, during panic. And second, these skills work to the degree you are willing to concentrate on them. Put most of your effort into not thinking about anything else — not your worried thoughts, not what you will do after you finish the breathing skill, not how well you seem to be at this skill — while you are following the steps of these skills.

Home Study

Chapter 15: Your Mind’s Observer

Chapter 16: Find Your Observer

Step 5: Practice Formal Relaxation Skills

Now you will learn three methods that are useful in learning the general skills of clearing the mind and calming the body. Read through each of these four sections below. Then choose among these three techniques for the one that best suits you. 

Cue-Controlled Deep Muscle Relaxation for Anxiety

When a person thinks about a situation related to his anxiety, mental images activate the muscles into particular patterns of tension, as though bracing for a blow to the body. Dr. Edmund Jacobson was the first to propose that physical relaxation and anxiety are mutually exclusive. In other words, if one learns how to recognize which muscle groups are tense and can physically let go of that tension, then he will lower his emotional anxiety at that moment.

This first exercise gives you an opportunity to learn how you personally experience tension, and then to change that tension. Called Cue-Controlled Deep Muscle Relaxation (CC-DMR), it is based on well researched and time-tested methods for training your mind to notice the subtle cues of muscle tension — and to release that tension. CC-DMR, which takes approximately twenty minutes, trains your body’s large muscles to respond to the cues you give. Your task is to consciously notice what muscle tension feels like in specific areas of your body and to consciously release that tension. Learning this particular technique is not essential to conquering panic. It is, however, one of the best ways to learn about your tension and how to alter it. If you have learned a different technique that produces these results, or if you have already mastered this skill, feel free to move on to the next sections of the book.

When I teach a client this method, I give him or her a prerecorded audio-CD with these instructions. For your convenience, you may purchase this prerecorded CD. (See CD 1 – Relaxation) I suggest that my clients practice the exercise twice a day, every day, for one weeks, then once a day, every day, for four weeks.

Why so often for so long? Because this is a straightforward, mechanical exercise that physically trains the muscles to release their tension. At certain intervals during the exercise, you are asked to repeat a cue word, such as “loosen” or “relax.” It seems to take about five weeks of practice before the physical loosening of the muscles becomes associated with that cue word. (You will be creating new “circuits” between your brain and your muscles.) Once that learning has taken place, the muscles will be prepared to release their tensions rapidly when that cue word is spoken (along with several other “cues” that I will mention later).

There are three stages to this twenty-minute exercise:

Stage 1: Tense and then relax each muscle group. You will be instructed to tense a particular muscle group for a few seconds, then release the muscles and allow them to loosen. (ten minutes)

Stage 2: Allow all the muscle groups to loosen and relax. (five minutes)

Stage 3: Support and reinforce the muscle relaxation through imagery. (five minutes)

How to do it

Each day, find a comfortable and quiet place to practice. Take the phone off the hook or arrange for someone else to take calls. This a special time, just for you.

Begin by sitting comfortably in a chair; take off your shoes and loosen any tight clothing. Close your eyes and take three deep breaths, exhaling slowly. On each exhale, say the word “relax” silently. Or you may select a word that produces more comfort for you, such as “loosen,” “quiet,” “peace,” or “calm.”

First, you will tense and relax each muscle group once (Stage 1). During each relaxation phase, you will repeat the word “relax” (or your selected word) with every exhale.

Next you will follow in your mind a visual image of the sun warming and loosening all the muscles of your body (Stage 2). You needn’t feel frustrated if you don’t actually “see” the sun in your mind’s eye, or “feel” the sensations of loosening or warming. It is essential, however, that you maintain your attention on each muscle group as it is mentioned and imagine the possibility of warmth and loosening of the muscles. You may be surprised at your growing ability over time if you don’t try too hard. Just open your mind to the possibility of change.

During the last few minutes of the exercise you will be asked to “go to your safe place” in your mind’s eye (Stage 3). Take a moment now to picture a scene that symbolizes comfort, relaxation, safety, warmth, and the absence of outside pressures. You might imagine yourself in some location where you were relaxed in the past: a vacation spot, fishing, sitting on a mountain top, floating on a raft, soaking peacefully in the bath, or lying on a chaise lounge in the back yard. Or you could choose to create an image of your ideal vacation dream (like your own private South Seas island) or fantasy (such as floating on a cloud).

Regardless of the image you choose, spend a few minutes developing all your senses within that scene. Look around you in your mind’s eye to see the colors and patterns of the scene. Hear any sounds appropriate to the environment: perhaps birds singing, wind blowing, ocean waves crashing on the shore. You may even develop an aroma, such as honeysuckle or flowers, perhaps the salt air or the fresh odor after a rain shower. Enjoy all your senses in an easy, effortless manner. This is the kind of image you can use for your “safe place.”

At the end of the exercise, open your eyes, stretch your body, and slowly rise from the chair. Several guidelines will help you as you begin:

1. The more you practice a skill, the greater your ability. So, be dedicated to this project and practice, practice, practice.

2. During the ten seconds of tensing, tense only the muscle groups described. Let the rest of your body be relaxed and loose.

3. Always continue breathing while you are tensing a muscle group. Never hold your breath while tensing.

4. During each fifteen-second relaxation phase, focus on your breathing and mentally say your cue word — “relax” or “loosen” — with each exhalation.

5. Don’t evaluate or judge how well or how poorly you do during each practice. This is not a test. Simply practicing each day, no matter what you experience, will ensure progress. You are creating new, unconscious circuits in your brain. How you feel consciously is not a measure of your progress.

6. Some days you will find it quite hard to concentrate. Your mind will tend to wander to a variety of thoughts: “I’ve got to get back to my housecleaning.” “What should I make for supper?” “This isn’t working. I’m still tense.” “I’ve got to remember to pay those bills.” These kinds of distracting thoughts are normal; everyone experiences them. It does not mean that the process is failing.

As soon as you notice that you have drifted off course, let go of those distracting thoughts and return to your task. Do not feel angry or disappointed with yourself. Do not let that be a reason to quit the exercise. Your body and mind are still benefiting, still learning about control, still creating those new circuits. Stay with it.

7. You may do the exercise any time during the day or evening. It is best to avoid starting immediately after a meal, since your body is busy with digestion then and you are less alert mentally.

8. Do not expect immediate and magical relief from the practice. This process, repeated over time, trains your muscle groups to respond to a cue.

Some people will notice changes from the practice. You may find that you are more alert and rested, have an improved appetite and sleep better, are in a more positive mood and feel less overall tension. If any of these take place, consider them “icing on the cake.” Your primary task is to practice every day for five weeks.

9. Some people have difficulty developing images to use during the “safe place” visualization at the end of the program. An alternative to the “safe place”, called “One Hundred Counts”, is presented in Chapter 14 of the self-help book Don’t Panic.

Guided Imagery to Help You Relax When Anxious

Some people find that a passive technique to quiet the mind and relax the body is more suited to their personal style. You will have two choices if you prefer a technique of this nature. One is called Generalized Relaxation and Imagery, and the second is a meditation practice.

In Cue-Controlled Deep Muscle Relaxation, you rely on tensing the muscles first as a way to experience relaxation. As an option, or for an occasional change of pace, you may want to try this twenty-minute Generalized Relaxation and Imagery exercise. In this practice you will focus only on relaxing — not tensing — your muscles. In addition, several new visual images are added to help you increase your sense of comfort and well-being as you enjoy peace and quiet. A pre-recorded CD is available.

Home Study

Chapter 16: Find Your Observer

Step 6: Use Paradox

There are two primary ways each of us tends to battle our enemies. If we must face them, we gather our resources to fight them head-to-head. Or if we feel inadequately prepared to fight and win, we choose to steer clear of them, to avoid any kind of confrontation. With panic these two strategies seem to fail. The more you fight the symptoms directly, the stronger they seem to grow. The more you avoid panic-provoking situations, the more panic controls your life. The more you run from panic, the faster it seems to chase you. 

We encourage and strengthen the power of panic by treating it as our “enemy,” to be avoided or to be battled. If we place ourselves on guard, waiting and watching for the next signs of trouble, we are inviting panic to return sooner. How? By establishing a special “relationship” with panic, a relationship of opposites. To take control of panic you need to understand this special relationship and then learn how to alter it. That’s what you will learn in this step.

Use the Power of Opposites With Anxiety

First, let’s look at this relationship of opposites. All the activities of our world are built around a dynamic tension between opposing forces. There is a natural balance between rest and activity and between expansion and contraction. Examples abound: the ocean tides, a pendulum, summer and winter, day and night, our patterns of work and rest, and the movements of our heart and lungs. These are essential life-sustaining rhythms. The Emergency Response and the Calming Response also form a relationship between two equally powerful and opposing systems within the body that help to maintain our balance of health.

Polarity creates and maintains all types of activity. Every book, play, short story, movie, or TV show involves at least one basic polarity: antagonist “versus” protagonist, a detective “missing” the answers, a man “wanting” a woman, a teenager “struggling between” right and wrong, a poor family “seeking” food or shelter. Without this basic push-and-pull found in conflict, desire, struggle, decisions, or other differences, these “dramas” would not succeed. It is the tension of such unresolved problems that maintains our interest and involvement. In world politics, major activity is found only where a polarity exists, as was the ideological differences between the United States and the Soviet Union from the 1960’s through the 1980’s, or one country’s need to import what it is missing and another’s need to export what the other needs.

On a more personal level, all parents have experienced this same dynamic when you take a toy away from child, instantly the struggle begins, because now the child wants the toy. If you surrender and give the toy back, the child is soon bored with it and moves to some other activity.

Scientifically, opposites attract. Place the north end of a bar magnet next to another magnet. It will repel the other north end and attach itself to the south end. To make sure we continue to populate the earth, Mother Nature creates men and women as attractive opposites, producing desire.

In each of these examples there exists a complementary relationship between two opposites. Think of your own life and the lives of others around you. Whenever we set our minds to a goals, whether it is to graduate from school, achieve recognition, cook a meal, or take a vacation, we create this dynamic tension by choosing something we don’t already have. We produce our positive, goal-oriented drive by distinguishing between what we have now and what we want. We are “missing” that degree, that recognition, that supper, or that vacation. And we “seek out” what we are missing. Once we reach that goal, we stop working and come to rest. (Of course, moments later we have some new goal, large or small, because this process takes place constantly.) These polarities, and the ensuing tensions they create, are not bad or wrong; in fact, they are the driving force of all action. If activity is taking place within a given field, you will find a basic tension between two opposites.

Now let’s reverse the tables. How do you write a screenplay that will fail at the box office? Here is one way: make all your characters happy and content. Don’t let any character worry, or set a tough goal for himself, or realize that he needs something more in his life. Let no one struggle to fulfill a dream. How will your audience react? Zzzzz.

How could we reduce the hostile tensions between two opposing countries? One way would be to devote a greater amount of media and government attention to our similarities instead of our differences, thus reducing the degree of polarization. Or we could discover a foe that is more powerful than either county alone (a worldwide disaster, another Hitler, or aliens from outer space). This would shift the dynamic tension toward a new polarity, a new “them versus us.”

How could you make yourself depressed? By never setting any goals for yourself, by never striving toward the future. By not believing that things change or that you can change. By expecting that tomorrow will turn out just as badly as yesterday did. How could you deepen your depression? By creating a polarity in your mind between “everybody else” (who can change) and you (who can never be different).

How is this related to panic? In the most powerful ways.

Dr. Claire Weekes on Anxiety

Your most effective defense against anxiety and panic attacks will involve the use of paradox. Dr. Claire Weekes, in her book Simple, Effective Treatment of Agoraphobia, recommends four methods of managing symptoms of anxiety: face the symptoms – do not run away; accept what is taking place – do not fight; float with your feelings – do not tense; let time pass – do not be impatient.

Each of these is a paradoxical response, one that seems contrary to logic. Logic tells us that in a threatening situation we should flip on our Emergency Response, tense the body, and immediately begin fighting. Or if we imagine we will lose, run like the devil before we get hurt.

Instead, what I am suggesting is that you flip on your Calming Response, relax the muscles of the body, don’t fight your physical sensations, and don’t run away.

It’s much like those Chinese finger cuffs we played with as kids. Do you remember them? They were made from a cylinder of thin woven bamboo, just large enough to fit the first finger of each hand into each end. You would give the finger cuffs to an unsuspecting friend and instruct him to place his fingers inside. That was the easy part. When he attempted to remove his fingers, the cuffs tightened. The more he tugged, the tighter the cuffs were. Those darn cuffs defy all logic because they are created paradoxically. To remove your fingers your need to push the bamboo together again with your free fingers, not pull them apart. It is the same with quicksand. If you struggle, you sink. If you remain very still (going against all your instincts), you have your best chance of remaining on the surface.

One of my patients, Michelle R., became so fearful of panic that she stopped driving and avoided taking walks, staying home alone, or shopping alone. After a few sessions she realized that she was contributing to her panic symptoms by her negative comments, which I call her Worried Observer (see Don’t Panic, chapter 14) thoughts. One morning, just prior to a business meeting, she caught herself thinking questions such as, “What happens if you feel overwhelmed? Or if you get that panicky feeling?” While asking herself these questions she began to develop symptoms, and moments later she produced an anxiety attack. At that moment she recognized that her fearful thoughts of panic can lead directly to her actual panic symptoms.

From this awareness, Michelle made rapid progress. Several weeks later she began to practice driving alone and to take a few short walks. Her Worried Observer comments continued to hinder her:

“We agreed last week that I would return home from the session by driving on the freeway, and I did. Right before I got on the road I started to feel anxious. I thought, ‘What if I get a panic attack and I can’t get off the highway?’ I remained tense most of the drive, and my hands were perspiring. But I started thinking that I had an option to continue or to stop, and I really wanted to continue. I felt good that I made the progress. The worst part was anticipating the drive, not the drive itself.”

Notice how Michelle succeeded in switching from her Worried Observer comments to what I call a Supportive Observer stance. She said that her worst time was before starting the drive, because that is when her Worried Observer typically runs through a series of negative fantasies about the future. She began by worrying about some catastrophic event that might take place if she kept driving. Once she began the drive she shifted into a permissive attitude, giving herself choice. “It’s OK to stop driving if I need to. Or I can choose to keep going if I want.” By always giving herself supportive options, she gained the confidence to continue. And she was able to follow through on her desire, which was to complete her task.

To handle panic paradoxically is to go against our basic instincts. I knew that Michelle needed to experience some success in managing her anxiety before she would be ready for my next instructions. Now that she was able to persist through mild symptoms and continued Worried Observer comments, I presented the idea of paradox: if you stop fighting panic, it will disappear. For the coming week I gave her the following instruction: “The next time you have fearful thoughts about panic, I want you to try, at that very moment, to have a full-blown panic attack. Tell yourself to increase your heart rate, to become dizzy. Try to produce all your negative physical symptoms.”

As you can imagine, Michelle nervously laughed at my suggestion and questioned my seriousness. I explained the rationale behind this seemingly illogical advice. When we become afraid of symptoms we are supporting those same symptoms by establishing an oppositional relationship. The more fearful we become, the stronger they grow. By removing our fear we destroy this complementary relationship. We drain all the strength out of panic, because it requires our resistance in order to live.

In this same way, if you attempt to stop the symptoms or try to fight them, you are simply supporting and prolonging them. If you practice some kind of relaxation technique and then anxiously wait for it to reduce your symptoms, you will be disappointed. Techniques will not conquer panic; attitude will.

How to Use Paradox During a Panic Attack

In a paradoxical strategy your attitude must be this: “I want to bring these symptoms under voluntary control. I would like to increase all my symptoms right now.” Then consider each symptom that typically bothers you. “I would like to start perspiring more. Let me see if I can become dizzy or make my legs shaky, right now.” Through this attitude you accept your symptoms, and you permit them to exist. If you practice any relaxation techniques at that moment, you do so as a way to end your Emergency Response and reduce your Negative Observer comments so that you can continue to accept and encourage symptoms.

Fighting paradoxically is not only the instruction to increase your symptoms; it is an attitude and perspective to use whenever you face a panic-provoking situation. And it is a basic principle behind most of the practical skills in this self-help guide. For instance, in the Deep Muscle Relaxation exercise, you tense a muscle group to make it relax. In a panic-provoking situation, you calm your mind and relax your body. By calming yourself, you become more alert and better prepared to take control of panic than if you were to tense up for the fight.

Using Paradox During Panic

  1. Take a Calming Breath, then begin natural breathing.
  2. Don’t fight your physical symptoms and don’t run away.
  3. Decide if you want to use paradox.
  4. Observe your predominant physical symptom at this moment.
  5. Say to yourself, “I would like to take voluntary control of these symptoms. I would like to increase my [name the predominant symptom].
  6. Consciously attempt to increase that symptom.
  7. Now attempt to increase all the other symptoms you notice: “I would like to perspire more than this. Let me see if I can become very dizzy and make my legs into jelly, right now.”
  8. Continue natural breathing, while you consciously and fully attempt to increase all your symptoms of panic.
  9. Do not get trapped in worried, critical, or hopeless comments (“This better start working soon! I certainly must be doing this wrong. It’ll never work.”)

When you are controlled by panic you are run by your Negative Observer voice: “I can’t…” (“I can’t feel this way.” “I can’t get anxious, because someone will notice.” “I can’t handle this experience.”) As you begin to gain control over panic, you will notice that your voice shifts to that of the Supportive Observer: “It’s OK…I can…” (“It’s OK to feel this way.” “I can be anxious and still perform my job.” “I can mange these symptoms.”)

Using paradox, you progress to the opposite end of the continuum. You take full responsibility for your symptoms by inviting them: “I want to…” (“I want to make my heart beat faster.” “I’d like to see just how might I can perspire right now.” “I want to increase all of these symptoms immediately.”) Keep in mind that this shift represents more than just a difference in semantics-it reflects a new attitude.

Start by practicing the use of paradox when you are feeling just a few minor symptoms. If you have trouble mastering the approach, look first at your attitude. Once your attitude is set — your complete willingness to embrace the symptoms in order to diminish their power — your skill will improve dramatically.

Experiment with using humor, because humor can put some distance between you and the symptoms. Try to prove to the world that you are a champion fainter. See if you can tie your stomach in knots so tightly that even the butterflies want out of there.

Don’t be disappointed by early setbacks, because once this special attitude is in place, your entire perspective will have shifted. The goal of accepting and increasing anxiety is the object, rather than being free of anxiety. Panic comes when we try to control our anxiety and we fail. Since you are no longer trying to control your symptoms, it is much harder to experience a sense of failure. And when you don’t think “I am failing right now,” panic usually won’t set in.

Listen to Michelle’s description of her experience the week after she learned this approach.

MICHELLE: I took a long walk on Saturday. First I walked to a shopping mall and bought a few things. That only took about half an hour, so I decided to walk down some residential streets. I felt a little panicky because there were no stores, no telephone booths to turn to for help-unfamiliar territory. I took a few Calming Breathes and reassured myself. Again, I found that my anticipation of trouble caused me more problems than any actual symptoms.

Dr. W.: What kind of thoughts did you have?

MICHELLE: I would think, “Here I am…People don’t know me…What if I faint?…No one would help me…I could start feeling dizzy?” Than I would remember to do my breathing exercise and to say some positive things to support myself.

Remember the exercise you told me about last week, “Try to bring on the symptoms yourself?” I was surprised that the thought came to mind, but at one point I said, “Why don’t you go ahead, feel like you’re going to faint and see what happens?” And I sort of brought things back into perspective.

Dr. W.: How do you mean “brought things back into perspective?”

MICHELLE: Well, for a few moments nothing happened. Then I said to myself, “No, you know you’re not going to faint. You know this happens to you all the time. You can walk through this neighborhood, and you are going to feel good about that when you are done.” It was easy after that.

Something else seemed to change after Saturday. I’ve noticed an overall difference in my attitude…about myself. I seem to be staying away from criticizing myself. I’m not as down on myself. It’s as though I started accepting my symptoms and accepting myself. Then Tuesday I spent the night alone for the first time in ages. That went well, no problems.

Michelle’s experience with paradoxical intention is typical. When you completely and honestly request that your symptoms increase, they will usually diminish instead. It is important, however, that you don’t make a pseudo-request, such as, “I’m beginning to become anxious. Now, I’d like this anxiety to increase…but I hope it doesn’t, because then I’ll never be able to handle it. So this trick better work soon!” By fearing an increase in symptoms and hoping that they diminish quickly based on this “trick,” you fall back into the trap of opposing panic, and thereby encouraging and supporting those symptoms.

To win over panic, you stop fighting it. To rid yourself of panic, you let it exist. To conquer panic, you stop resisting. And that is the paradox.

Home Study

Chapter 19: Face Panic

Step 7: Approach Your Goals Through Small Steps

These guidelines are for anyone who desires to control anxiety and panic attacks and improve their ability to confront situations they currently avoid. This section will help those whose problems occur within panic disorder, a phobia, asthma, premenstrual syndrome, depression, or any of the other physical or emotional difficulties mentioned in this self-help program. 

Here are the topics we will cover. Begin at the first one – “Set your long-term goals” – and progress through the fourth one – “How to practice your skills”.

Prevent Panic Attacks: Set Your Long-Term Goals

Panic exerts a force over you. It attempts to push you into a corner, where you feel trapped and afraid. To confront this force you must place some target in front of you, some positive goal to reach.

Creating your own goal will give you a clear sense of purpose. When you feel lost or confused, this goal can remind you of your positive direction. Let’s decide to divide your goals into Long-term and Short-term. Long-term Goals represent your final desired outcome regarding your basic difficulties with anxiety. Short-term Goals focus your attention for only several days, weeks or months. Often there are several Short-term Goals for each Long-term Goal.

Identifying Your Long-term Goals

List all of the situations in which you have difficulty managing your anxiety and all the situations you avoid out of fear.

Re-write each item to create a positive Long-Term Goal.

If you have listed more than one Long-Term Goal, rank order them two times:

from the least difficult to the most difficult
from your most important, highest priority to your lowest priority.

Start by identifying your Long-term Goals. Take time to follow these instructions, writing down each of your answers. First, list all of the situations in which you have difficulty managing your anxiety and all the situations you avoid out of fear. Then, re-write each item to create a positive Long-term Goal. Here are several examples:

CHANGE “I don’t want to be scared in restaurants.”

TO “I will feel safe in restaurants and comfortably enjoy meals with friends.”

CHANGE “I’m anxious on planes.”

TO “I will be able to regularly fly in a plane across country.”

CHANGE “I avoid parties or large groups.”

TO “I will feel in control at parties and will enjoy myself without drinking alcohol.”

CHANGE “I’m afraid to drive far alone.”

TO “I will feel confident as I drive alone any distance I desire.”

If you have listed more than one Long-term Goal, rank order them two times: first, from the least difficult to the most difficult; and second, from your most important, highest priority to your lowest priority.

How to Create Short-Term Goals Against Panic

In addition to Long-Term Goals, mastering panic will require a smaller goal, which I call your “Short-term Goal.” This Short-term Goal will be your set of immediate tasks that moves you closer to your long-term goal.

Setting Up Short-term Goals

From your Long-Term Goal list, pick the two goals ranked least difficult, and the two highest priority goals.

For each of these Long-Term Goals, list up to five positive Short-Term Goals (what you wan to be able to do within several days or several weeks, stated in positive terms).

If you have listed more than one Short-Term Goal, rank order them two times:
– from the least difficult to the most difficult
– from your most important, highest priority to your lowest priority.

To understand the difference between a Long-term Goal and a Short-term Goal, consider this example. Imagine that you are thirty years old and have worked as a typist for the past six years. After much soul-searching you feel a strong need to become more independent in your life’s work. You decide to establish this as your Long-term Goal: greater job independence. Now what?

Your next step is to create a short-term plan that will help move you toward independence. You ask yourself, “What can I do today, this week, or this month about that goal?” The answer to this question is your Short-term Goal: “This month I will investigate what kinds of jobs might give me greater independence.” This Short-term Goal now gives you a concrete and specific set of tasks to accomplish in the immediate future. Once you set your Short-term Goal, you always have some positive tasks to direct your actions.

Let’s say that after a month of exploring options, you take another step closer to your goal: “I think there is room in this city for a word-processing service. With my experience I know what it takes to provide quality typing to customers. I think I am capable of managing a small staff of typists. But I don’t know much about business.” You set your next Short-term Goal: “I’ll take a ‘small business’ course at night this fall at the technical college.” Now you have a distinct focus. You must select the best course, register, buy the materials, attend class each week, complete your homework assignments, and so forth.

It is far easier to motivate yourself when your goal is almost within reach. Small decisions can now seem important, because they influence your immediate-future goals. If you have difficulty applying yourself to your studies because owning your own business seems so far in the future, then set your Short-term Goal closer to your reach: “By the end of this course I want to be able to say that I applied myself every week to complete the assignments of that week. Therefore, I will start by finishing my paper due this Friday.”

This is the process to use in overcoming panic. For instance, some people might have the positive goal of “looking forward to the adventures of life without fearing panic.” You will reach that goal by setting dozens of small goals, one after the other. As you accomplish one Short-term Goal you will set your sights on the next.

Don’t be in a rush to reach your Long-term Goal. By focusing too much of your attention on the distant future, you can feel demoralized and frustrated, as though you will never arrive at your destination. Instead, create images of your positive future, but work actively on accomplishing immediate tasks.

If you list more than one Short-term Goal, rank order them two times: first, from the least difficult to the most difficult, and second, from your most important, highest priority to your lowest priority.

At any point in your day, you should be able to remind yourself of your Short-term Goal and create some task that moves you along. Do this not as a way to evaluate your progress, to point out your failures or to criticize your weaknesses, but as a way to keep yourself motivated. Be careful of the Negative Observers, who are always just around the corner. The biggest troublemakers here are the Critical Observer and the Hopeless Observer.

Again, paradox comes into play as you set your Short-term Goals and work toward them. The paradox is this: you should set a concrete, specific immediate goal, with every intent to fulfill that goal. At the same time, it does not matter whether you actually reach your goal in the way you expected.

For instance, let’s say your Long-term Goal is to comfortably shop in stores again. You have been taking a number of steps to prepare, such as practicing the Calming Breath a dozen times each day, spending quiet, meditative time for twenty minutes each day, and learning to give yourself Supportive Observer comments during stressful times. Now you decide to set a new Short-term Goal: “to walk around inside South Square Mall today, looking in store windows with a friend, for thirty minutes.” Once you commit yourself to that Short-term Goal, you take as many steps toward that goal as you can manage. It is unimportant whether you accomplish that goal today. Your task is to set a Short-term Goal and move toward it to the best of your ability. And no further. Tomorrow you will simply review your learning from today and set a new Short-term Goal if needed.

We all deserve to feel a sense of pride and success. Don’t rob yourself of those good feelings by labeling yourself as a failure when you don’t accomplish a task. Do not define your personal success in terms of reaching your Short-term Goal. In conquering panic, you are successful any time you are actively moving toward your goal, regardless of whether you reach it.

Create Short-Term Tasks to Beat Panic Attacks

In this planning stage, the third step is to identify specific actions that will move you from your abilities today to the abilities needed to reach you goals. Practice this step now by picking one of your Short-term Goals. Think of and write down a list of related tasks, which gradually move you closer to accomplishing that Goal. The first item should be a low-risk experience that you can imagine accomplishing soon. Each successive item should include a little more risk-taking and should move you a little closer to your Goal.

Don’t worry about creating the perfect schedule. Later, as you begin using this schedule, you will revise it based on your experience. Simply outline a stepwise approach to accomplishing your Goal. Here is an example.


Example: Short-term Tasks – Driving

SHORT-TERM GOAL:
Comfortably drive a two-mile loop on the roads around my house.

SHORT-TERM TASKS:

  1. Map out a two-mile loop on the roads around my house.
  2. With a supportive person driving, ride as a passenger on this loop, noticing all the opportunities to pull over to the side of the road or to turn off on a side road, all the gas stations, stores, driveways, and telephone booths that are accessible to me.
  3. Drive this loop during a non-rush-hour time with a supportive person as passenger.
  4. Drive this loop during a rush-hour time with a supportive person as passenger.
  5. Drive this loop during a non-rush-hour time with a supportive person driving another car directly behind me.
  6. Drive this loop during a non-rush-hour time with a supportive person driving another car several cars behind me.
  7. Repeat #5 during rush-hour.
  8. Repeat #6 during rush-hour.
  9. Drive alone, with my support person waiting to meet me at a stopping point half-way along the route. Then have my support person leave before me and wait for me at the end of the loop.
  10. Drive the entire loop alone while my support person waits at the finish.
  11. Drive the entire loop alone while my support person waits by a telephone at another location.

FUTURE SHORT-TERM GOALS: Repeat all these steps for different loops and for longer distances, until I can confidently drive any distance I desire.

In order to look forward to the adventures of your life without fearing panic, one short-term goal must be to tolerate mild to moderate symptoms of anxiety. If you can accept those symptoms arising on occasion, and if you can trust in your ability to manage them, then your fear of them will diminish.

Once you set this Short-term Goal of learning to tolerate symptoms, you can establish short-term tasks. Practicing the breathing and Calming Response exercises in this book is a good first start. During this same early stage of learning you can begin listening for your Negative Observer comments (worried, self-critical, or hopeless thoughts) . Once you discover how your thoughts consistently reinforce your sense of fear, you can begin to practice Supportive Observer comments or other disruptive techniques. In this way you slowly chip away at panic.

Example: Short-term Tasks – Tolerating Anxiety

SHORT-TERM GOAL:
Learn to tolerate symptoms of anxiety

SHORT-TERM TASKS:

In the next five days, I will

Practice breathing skills 10 times a day
Listen for and write down Negative Observer comments
Practice Negative Thought Stopping daily
Practice Supportive Observer comments whenever anxious

Make Your Tasks Reachable

There is always a step that is within your reach. If you feel incapable of accomplishing any of your tasks, you must create smaller and smaller steps until you find one to which you can say, “I wonder if I can do that? It seems within my reach.” For instance, you don’t begin learning public speaking skills by placing yourself at the podium in front of a thousand people. You learn by talking into a tape recorder and then listening to your voice, by telling more stories to your friends during dinner conversations, or by imagining yourself comfortably addressing a small group of friends.

If you fear panicking while you drive, the thought of taking a cross-country trip might by overwhelming. What can you imagine doing? Can you sit in the driver’s seat of a car, with the ignition off, parked safely in the driveway, while you practice your Calming Response skills? If so, can you start the engine, back the car to the end of the driveway, then return it to its parked position, even if you feel somewhat anxious? Can you do that ten times? Once you feel in control of that step, can you drive around one block, with a supportive friend as a passenger? If not, practice driving to the corner and back. If that is not yet within your reach, let your friend drive the car to the corner, then exchange places and drive back yourself.

Hierarchy of Tasks for Short-term Goal

Create a list of related tasks that gradually move you closer to accomplishing your long-term goal.
 
Review the list to insure that:
– the first item is the lowest-risk item on the list that you can imagine accomplishing soon, and
– each successive item includes a little more risk-taking and moves you a little closer to your goal.

Regardless of what you fear, there is always a step small enough for you to take toward overcoming that fear. Whenever you run into difficulty, simply back up to a smaller step. The size of your step can never be too small. As the Chinese philosopher Lao Tsu wrote in the sixth century BC, “A tree as great as a man’s embrace springs from a small shoot; a terrace nine stories high begins with a pile of earth; a journey of a thousand miles starts under one’s feet.”

How to Practice Your Skills at Overcoming Panic

Now you are ready to begin working on the tasks you outlined above, while applying the knowledge and skills from all of these sections. The stages of this step are: preparing for practice, beginning practice, responding to worried thoughts, responding to uncomfortable physical sensations, and ending the practice.

As you begin your practice, remember to face tasks one at a time. Don’t look back to your last practice unless it is to remind you of your skills and capabilities. And don’t look ahead as a way to remind yourself how far you have to go. Continue to practice a specific task until you feel relatively comfortable (never wait until you are completely comfortable), then begin the next one. Don’t measure your progress by how quickly you improve your skills. Measure your progress by how persistent you are in your determination to reach your Short-term and Long-term Goals. Shaping your positive attitude each day, and developing a consistent schedule for practice — these two intentions will pay off with success.

Choosing a Short-term Goal

You will be practicing the Short-term Tasks listed under one or more Short-term Goals, so your first decision is to choose a beginning Short-term Goal. There are no rules for selecting the perfect Short-term Goal to work on; use your best judgment to pick one. You have rank ordered your Goals in two ways: how difficult they seem and how important a priority they are. Let those rankings help you make your decision. For instance, there may be a Goal that is moderately hard on your difficulty list but is a high priority. Your desire to accomplish that Goal may help motivate you to work on it now, even though there are easier items on the list.

You also can work on more than one Short-term Goal at a time. Perhaps you choose to focus both on the goal of driving comfortably to the mall and the goal of tolerating exercise that elevates your heart rate. You may have time in your week to practice driving skills every two days and practice cardiovascular workouts on the opposite days.

Preparing for practice

There is a great array of options for practicing Tasks. In the beginning weeks, I suggest that you follow a structure similar to the one I am presenting in this section. As you get more proficient at designing and implementing your practices, then feel free to take “short cuts” in the process. By the end, your practice can be as informal as this: “Hmm . . . I feel anxious about doing something like that. I think I’ll try it!“

For instance, one of my clients is working construction in an office building. One day last month his co-worker reported that one of the elevators had been temporarily stuck between floors for a few minutes. Upon hearing that, Alan became anxious and worried about getting stuck himself. Within a few minutes he excused himself, walked to the bank of elevators and rode one to the top floor and back. He simply would not allow his fears to begin to take hold of him anymore.

Before practicing any Short-term Task that moves you closer to your Goals, consider each of these questions in detail. You will benefit from writing your answers down, making them concrete.

Planning Each Task

  1. What is my task?
  2. When will I do this?
  3. How long will I take?
  4. What worried thoughts do I have about this task?
  5. What self-critical thoughts do I have about accomplishing this task?
  6. What hopeless thoughts do I have about this task?
  7. What can I say (in place of those negative thoughts) to support myself during this task?
  8. How can I increase my sense of commitment while working on this task?   (information about the setting or even, sense of options, willingness to take risks and reel uncomfortable, use of props such as a book or music, etc.)
  9. What support do I need from others?

Deciding how long to practice

Whenever possible, practice your task for 45  to 90 minutes at a time. It is true that shorter practices also will help your confidence, and some types of practices can only last a few minutes (such as looking people in the eye and smiling as you go through a reception line). However, from research we know that one of the most important purposes of Task practice is to develop habituation: during prolonged exposure to an anxiety-provoking situation, intense anxiety gradually decreases. As your anxiety diminishes, you can think more clearly. In the future, when these situations occur again, you will react with some anxiety, some distress, but not the terror that you once had.

So when you can, design your sessions for this 45- to 90-minute length, which promotes habituation as well as confidence. That may mean you will have to repeat the same behavior several times. Forty-five minutes will afford you many elevator rides. An hour’s shopping may require a trip to the grocery store then a walk next door to the pharmacy. Ninety minutes of aerobic exercise can mean that you run in place 5 minutes, then spend the next 15 minutes calming yourself down if you got too scared, then another 5 minutes of aerobics and 10 minutes of calming yourself, and so forth, until the time is up. The definition of “practice” means anything that you do while still facing the anxiety-provoking situation. For instance, you might enter the grocery store and stay only 5 minutes, then have to leave because of your distress level. For the next 30 minutes you may need to sit in your car, practicing your breathing skills to calm down enough to re-enter the store. Then you enter the store for another ten minutes before finishing your practice. That equals 45 minutes of practice — even though most of it was in the car — because all of that time you were working.

Creating supportive statements

Study your answers to questions 4, 5 and 6, above. These Negative Observer statements will be the most likely ways you will sabotage your efforts in the practice. Use them to design your supportive statements (question 7). Write these positive statements down on a card to carry with you during practice.

Increasing your commitment

As you plan your practice, consider what you can do to support your commitment. Certainly reviewing the eight attitudes is a positive step, because they will remind you that taking risks is the smartest way to get stronger.

You may also feel safer and therefore more committed if you gather information about the setting or event. If you are attending a party, know what the appropriate attire will be. If you are driving a new route, check the map in advance or take the ride first as a passenger. If you are spending a night in an unfamiliar hotel, call ahead to learn about their facilities.

Bring along any “props” that can help you manage the situation. For instance, if you are practicing eating alone in a restaurant, you might carry a novel to read as you wait for your food. For a long drive, bring your favorite music or borrow a book-on-tape from the library.

Receiving support from others

Decide if you would like one or more support persons to assist you in the practice. If so, choose people who believe in your worth and respect your efforts to improve yourself. They don’t have to have an intimate knowledge of anxiety problems; in fact, they might even be confused about the subject. They do need to be willing to follow instructions. Tell support people exactly how you would like them to help. What should they say to you before and during the practice? What should they do?

Visualizing success

In Don’t Panic, you will learn about the many visualizations that can help you prepare for practice. After you review that section, include any relevant imagery practices into your preparations.

Here are three brief visualizations to work with during the few minutes just before you begin your Task practice. (For example, if you are about to enter the grocery store, practice one or both of these visualizations while in your car at the store parking lot.) Each of them takes about three minutes.

Three-Minute Success Imageries

Successful Outcome. Close your eyes and see yourself after you have just finished your Task and it went perfectly, beyond your expectations. Don’t concern yourself at all with how you reached your goal. Just enjoy the pleasure of possible success.

and/or

Successful Task. Close your eyes and visualize yourself accomplishing your Task easily and without discomfort. Repeat that positive image a second time.

and/or

Successful Skills.* Close your eyes and visualize yourself moving through your Task. Let yourself experience two or three episodes in which you have some typical discomfort. Then rehearse what coping skills you want to use to take care of yourself during that discomfort. Imagine those skills working successfully.

* Always practice this one before a Task.

Beginning the practice

Now you are ready to enter the troubling situation. Remind yourself of each of your supportive statements. Take a gentle, slow Calming Breath after saying each one, giving yourself time to believe it.

Enter the situation with the expectation of responding naturally and easily to all that you encounter. Forget about yourself and pay attention to what you are presently perceiving with your five senses: what you are seeing, hearing, touching, smelling, and maybe even what you are tasting.

Use any of your skills to manage your thoughts and your physical symptoms. Continue to encourage yourself and ask for any needed support from others.

If you begin worried thoughts or if physical symptoms begin to bother you, use the two approaches below.

Responding to worried thoughts

In Step 8 you will learn the skills of responding to your worries. Here we are applying these skills to worries you have during your Task practice. The guidelines are simple: notice your worried thoughts, choose to stop them, then apply skills that support your decision. Which of these skills or combination of skills you use will depend on your Task, the nature of your worries and what has helped in the past. Sometimes you will need to explore several options before coming up with the most successful combination.

Responding to Worries

Notice your worried thoughts:
“I’m working myself up.”

Choose to stop them:
“These thoughts aren’t helpful. I can let them go.”

Take supportive action:
Practice any of these:

Supportive statements
Find something neutral or pleasant to do
Negative thought stopping
Postpone your worries
Sing your worries
Write your worries down
Take 3 Calming Breaths
Do Calming Counts
Move and loosen whole body
Turn attention elsewhere
Leave the situation and go to a “safe” place

Responding to uncomfortable physical sensations

Again, like with your worries, the best approach to uncomfortable physical symptoms is a simple one. First, mentally “step back” and notice the sensations without making worried comments. Second, reassure yourself: “It’s OK for these symptoms to exist right now. I can handle these feelings.” Then, third, ask yourself: “What can I do to support myself right now?”

Choose among the supportive actions listed, based on the nature of your symptoms, the circumstance, and what has helped you in the past. Here are some examples.

You can assure yourself that you can manage your task while experiencing these sensations. You then can turn your attention away from yourself and to the things around you. Involve yourself more actively in your surroundings (seek out a conversation or find something in your environment to study carefully) as a way to diminish your worried involvement in your body.

You can use Calming Counts as a way to support your physical comfort.

You can tell a supportive person about what you are feeling and what you want to do to take care of yourself. You can let that person support your efforts.

You can leave the situation for a brief period as a way to increase your comfort and control, then return to continue your practice.

You can leave the situation and not return at this time. As you continue to practice your skills, over time you will learn to remain in the scene.

As you study the chart below, you will notice how similar the actions are when your physical symptoms are your strongest concern. There is one primary difference. Can you see it?

Responding to Physical Symptoms

Notice your symptoms:
“I’m feeling uncomfortable.”

Accept them:
“That’s okay. I can handle this.”

Take supportive action:
Practice any of these:

Natural Breathing
Take 3 Calming Breaths
Calming Counts
Brief Muscle Relaxation
Supportive Statements
Paradoxically Increase Symptoms
Move and Loosen Whole Body
Find Something Neutral or Pleasant to Do
Turn Attention Elsewhere
Leave the Situation and Go to a “Safe” Place

As you can see, there is one distinct difference in how you respond to each of these problems. Once you notice your worried thoughts, you choose to stop them. You reject the negative messages they are giving to your mind and body. The actions you take support that decision. On the other hand, when you notice your physical symptoms, you choose to accept them. Resisting your symptoms will only increase your discomfort.

This decision — to accept your symptoms before trying to modify them — is a pivotal one. We have talked about it in several sections. Start to become curious about its value as you try it out during Task practice.

Ending the practice

Now is the time to support yourself for all your efforts. At the same time, review your practice session objectively. Assess what worked and what didn’t. Use that information to plan your next practice.

Remember that you are successful every time you decide to practice, regardless of how long you are able to stay in that situation. This is not a test of your ability to stop all sensations of discomfort. Nor is this a test of your progress. This, and every other thing you do, is an opportunity to practice your ability to support yourself. The more you practice supporting every effort and attempt, the stronger you will become and the more willing you will be to practice.

So LISTEN for any harsh self-criticisms or discouraged thoughts after your practice. (“I still get anxious. What’s wrong with me! I’ll never get better.”)

And REPLACE THEM with statements of support: “I’m working to change a lot of complex processes. I can’t do it all at once. And I’m not trying to do it perfectly. One step at a time; I’m going to get there.”

Home Study

Chapter 19: Face Panic

Step 8: Handle Your Worries

Let’s face it. Everybody worries some of the time. Some worries are important signal of tasks that need to be accomplished. Other worries are repetitious, unproductive thoughts that make you feel anxious or upset. They show up against your will, and you seem to have little control over them. Once you start worrying, it’s hard to stop. Often you’ll worry over things that others consider small or insignificant. And sometimes the more you try to argue against the worry, the stronger it becomes. 

Whenever you have worries, your task is to handle them, one way or another. And that is just what this section will teach you.

How to Handle Worries That are “Signals”

The first thing to do is to distinguish whether these worries are “signals” or “noise.” Are they “signals” that you have a legitimate problem to address or that true danger lies ahead? Are they alerting you to take some action? If they are “signals” then you want to pay attention to them.

Or are these worries simply “noise”: distractions, ways to make you uncomfortable. If they are noise, then you will need some special skills to stop them from intruding. You want to get that noise out of your head, to clear your mind so that you can have more enjoyable and productive days.

Any concern that you dwell on can be a signal or noise: you have a presentation due in three days; your son is late getting home from his date; you’ve been experiencing a headache for six hours; you’re not sure whether you turned the iron off after leaving for work. If you have been having anxiety traveling lately and if you are considering driving to a new location in a few days, then your mind will probably begin to dwell on the upcoming trip. If these become repetitious, unproductive thoughts, they are worries that you should respond to. But are they a signal or noise?

Remember, worries as “signals” means there is some action we need to take; we can ignore worries that are “noise”. If they are legitimate concerns (signals), we will handle them by studying the problem and taking action. If they are a noisy racket in our head, we will handle them by various techniques that reduce their annoyance. (That’s the next section.) The most direct way is to find out is by attempting to make these unproductive thoughts into productive ones. In other words, treat all worries as signals until you decide that they are noise. Begin to think in a structured manner regarding your concerns.

When you hear yourself worrying, turn your attention to the details of the worries. Assume they are asking you to take some kind of action. Assume that if they are important enough to be intruding into your mental time, they are important enough to address in a structured manner. Put your worries through these four steps that lead to action.

First, define specifically what the problem is. Sit down with paper and pencil to define the concern and its components — everything that worries you.

For example, your definition of the problem might be, “I am not prepared for the drive on Friday.” List the details under it:

“I’m not sure of all the places to pull off.”
“I don’t know where phones are along the route.”
“I don’t know how far it is between those two exits on I-40, and I’m not sure I can handle more than a 2-mile span without an exit ramp.”
“What if I have a panic attack while driving?”

Second, write down all possible solutions. Take the items on your list, one by one, and generate different ways to handle the concerns. These may include gathering more information, turning to experts or other knowledgeable people for advice, recalling your learnings from past successes, practicing skills. It can also include courageously taking actions even though you are uncertain of the outcome.

In this case, the items might include: taking a ride through the route as a passenger, identifying the pull-off locations, the phones, and the distance between those exits. Most importantly, it includes recalling any successes you have had in the past when responding to panic, identifying the specifics of how you would handle a panic attack in this situation, and practicing those skills ahead of time. Another obvious solution is to avoid the drive altogether.

Actively Responding to Worries as “Signals”

  1. Define your current problem, and list all the components of the problem.
  2. List all the possible solutions. What is necessary to handle each concern?
  3. Decide whether to go forward or retreat.
  4. Take action based on your possible solutions.

Decide whether to go forward or retreat. Most worries have this option: you either pursue or you pull back. Worrying offers you a way to sit on the fence and not commit to a decision. So if you want to handle most worries, you need to force yourself to choose a direction.

You have a presentation due in three days: you cancel it, or prepare for it.

Your son is late getting home from his date: you wait for another half hour, or you start calling his most likely locations.

You’ve been experiencing a headache for six hours: you take another analgesic and wait to evaluate the problem again in the morning, or you call the doctor.

You’re not sure whether you turned the iron off after leaving for work: you decide it is safe to wait until you get home from work, or you return home now to check.

You are considering driving to a new location in a few days: you go or you cancel.

You do not have to commit to the entire action from start to finish, only to walking along the path. If driving is your concern, you can decide to ride as a passenger through the route, identifying the pull-off locations, the phones, and the distance between those exits. You can then review your choices after you have experienced that step and decide whether to take another step toward your goal. You can outline the steps you want to take if you might panic while driving. You can plan to practice those skills and even list them on a cue card for the drive. You can then decide whether to take the next step of actually getting in your car and driving.

You have a right to decide to withdraw from the action. You may have to handle certain consequences of the decision — if you cancel a luncheon date, your intended guest might be upset — but you have the right to control your behaviors instead of being controlled by others or by some strict standard of action. You get to decide what is in your best interest at this time.

And, fourth, take action based on your possible solutions. Action gets you off the fence, where worries tend to sit. Move forward from identifying the problem, move forward from thinking about all the possible solutions. Begin to act on one or more of those plans. Again, remember that with certain projects you can commit to each stage of action without committing to the final task. Review your direction toward your goal anytime you think you have new knowledge or experience that will influence your decision.

How to Handle Worries That are “Noise”

Worries, like panic, take on a life of their own. When you have charted a path to walk and the noise of unhelpful thoughts follows you, then it is time to shake them. You must first take a firm stand against the worries: “These thoughts aren’t helpful. I’m not going to let them control me.” You can’t be wishy-washy about this decision.

For instance, if you believe that every panic attack is a potential heart attack, you must settle this issue before you can move forward against panic. Many people make this mistake. They have all their medical evaluations, ruling out any heart problem. They feel reassured. But each time symptoms begin, they say, “I think this is just anxiety.” Underneath that thought is, (” . . . but it could be a heart attack.”) A stronger voice is, “I’m going to treat these symptoms as anxiety. I’ve gotten a clean bill of health. I’m willing to risk the slight chance that this is something else.”

You will now learn about five ways to handle worries that are noise: stopping them, postponing them, modifying them in two ways and, surprisingly, increasing them.

5 Ways to Handle Worries that are Noise

1. Quiet That Negative Observer In Your Mind

I have adapted this technique from a procedure, called thought-stopping, that the field of behavioral psychology has applied for over twenty years. Use it when you want to dispatch quickly with intruding thoughts. This is how it goes.

  1. Listen for your worried, self-critical, or hopeless thoughts.
  2. Decide that you want to stop them. (“Are these thoughts helping me?”)
  3. Reinforce your decision through supportive comments (“I can let go of these thoughts.”)
  4. Mentally yell “stop!” (Snap rubber band on wrist.)
  5. Begin Calming Counts.

To break such a pattern, first you must begin to notice the moments when you are focusing on Negative Observer comments (See Don’t Panic, chapter 14). Often we are not aware that our minds are rushing through negative thoughts. As you begin to pay attention to such thoughts you will start to notice these moments more frequently.

The most straightforward way to stop your doubts and worries is to do it as quickly and powerfully as possible, before they get your mind caught up in them. Once those worries strike — when you become aware of repetitive, unproductive, negative thoughts — mentally step back and observe them. Are your worries a signal of something you should pay attention to right now? Or are they just more noise in your day?

Ask yourself, “Are these thoughts helpful to me right now?” This is a great question; it will help you in a powerful way by confronting your automatic, negative thinking. Please don’t ignore it! Simply by asking the question, you have momentarily disrupted your negative thinking, which is a good move. This is your Supportive Observer (See Don’t Panic, chapter 16) in action: it notices what you are thinking and decides if those thoughts are supporting you.

If the thoughts are not helpful — if they are noise — then consciously decide that you want to stop the racket. These thoughts are powerful and will draw you to them. They are drama, and your brain seeks out drama. Let your Supportive Observer reinforce your decision with statements such as, “I’m in control of my thoughts. I don’t need to be run by these ideas. It’s OK to stop focusing on this.”

You must make a firm decision of “not now.” One way is to yell, “STOP!” inside your mind. I know that sounds like a silly thing to do. But you yell “stop” as a way to disrupt the drama of your worries. You fight fire with fire. It derails your current thought process and permits you to begin a new one.

If you need a little more stimulus to draw your attention, then wear a rubber band on your wrist. When you yell “STOP,” snap that rubber band at the same time. “Ouch!” Exactly! Now what are you paying attention to? That stinging wrist. For a split second you have left your worries and shifted to some other experience. You have created a space for a new focus of your attention.

Take advantage of that moment! Fill that space by practicing Calming Counts. (Remember that breathing technique of one deep breath and ten gentle breaths?) This will be the most effective part of your intervention, because Calming Counts will accomplish two important goals.

First, it will disrupt your typical pattern of worry. Instead of continuing to worry, you have to stop and think about how to do this highly specific breathing technique. You have to exhale all the way, take a deep breath, exhale again as slowly as possible, loosen and relax your face. Then you have to follow the next ten exhalations, counting each one, but counting backward, and seeing that number in your mind. Boy, that’s busy work! And that’s exactly what we are looking for: something to keep your mind so busy that it doesn’t drift back to your worries. Calming Counts takes about a minute and a half. That’s a wedge of ninety seconds between you and your noisy worries.

Second, you will be busy performing a technique that actually calms down your body. Calming Counts can help reverse any anxiety that starts to build in response to your worried thoughts. As you get physically calmer and as time passes, you will gain perspective on your worries and have a much easier time resisting them.

Even if your negative thoughts return a minute later, you have briefly disrupted them. This is a method of bringing your Observer to the foreground during a time of trouble. Several minutes later you may want to disrupt those negative thoughts again with a second set of Calming Counts. Slowly, you will begin to “step back” and see your worries from a new perspective. You will become less preoccupied, and your tension level will have a chance to decrease.

This technique is adaptable to many public situations. For instance, you can begin Calming Counts while waiting to give a speech. Instead of dwelling on negative thoughts such as, “Everyone will notice that my hands are shaking” or “I know I’m going to make a fool of myself,” you can preoccupy your mind by keeping track of your counts.

This same negative thinking process takes place when we anticipate facing our fears. For example, imagine you plan to attend your neighbor’s party tonight. You usually avoid such parties because you become nervous in groups. But this week you decide you will fight your fears by attending this gathering of friends. It is now 11:30 A.M. You notice that you have spent the last thirty minutes repeating useless Worried Observer comments silently in your mind: “I can’t do this. I’ll never last. What if I get trapped there? I don’t want to get trapped. I can’t go. I just can’t handle it. I’ll never last.” At this moment your Observer breaks in.

OBSERVER: “I keep repeating the same thoughts in my head about tonight. I’m scared. I’ve decided to go, but I keep thinking about how to avoid it.”

SUPPORTIVE OBSERVER: “These thoughts are only making me more scared. They aren’t helpful. I need to stop them.”

ACTION: Mentally yells “stop!” Sits down for a minute and does ten Calming Counts.

OBSERVER: “Now that I am quieter, I notice how tense my stomach is. I’m still scared.”

SUPPORTIVE OBSERVER: “Probably I’ll be a little anxious all day. It’s OK to be somewhat tense since I’m taking on a challenge tonight. I need to pace my day and keep myself fairly busy until it’s time to get ready. That’s a good way to take care of myself. I also want some support tonight so I don’t feel like I’m going through this alone.”

ACTION: Makes a list of a few worthwhile projects for the day that require some concentration. Shares concerns with a supportive person who will be attending the party. Monitors stomach tensions periodically through the day, using the Calming Breath to relax the stomach muscles when needed.

Notice what happened at the beginning of this example. I described the Observer as “breaking in” during your negative, obsessive thinking. This is probably something that already takes place within you now. You will become entangled in some negative thinking, then all of a sudden, some part of your mind will “step back” and comment on what you are doing. This is the moment you want to seize; this moment is the opportunity for change.

Begin to listen to your Observer rising up. When you notice it, keep it! Let yourself gather the facts of the moment objectively, then shift to some suggestion or plan that will take care of you and at the same time support your positive goals. If you begin criticizing yourself or making comments of hopelessness, simply notice them and then let them go (“Thinking that thought isn’t helpful to me right now.”)

Chapter 16 in action: it notices what you are thinking and decides if those thoughts are supporting you.

2. Postpone Your Worries

An excellent stalling tactic is to postpone your worries for a bit. When you notice yourself beginning to worry, then mentally agree to pay attention to those worries. However, choose a specific later time when you will return to them.

  1. Mentally agree to pay attention to your worries
  2. Choose  a specific time in the future when you will return to them.
  3. As that time arrives, either start obsessing or consider postponing the worries to another specific time.  Whenever possible, choose to postpone.

This is like making a mental agreement with your fear. There’s a part of you that really believes that you need to pay attention to these worried thoughts. You are not about to say “no” to them. Your fear is there because it thinks it’s taking care of you. So you’re going to say, “OK, I’ll pay attention to you, just not now.” You’re going to keep the idea that you’ll actually worry. You’re going to change the idea that you have to instantly respond every time it beckons you.

How long can you postpone? Can you wait an hour? If you can’t postpone for an hour, try a half hour. Try fifteen minutes. Five minutes. Whatever it takes, try to break the automatic process of worry. That’s what postponing will do, by letting you take control over when and where you worry.

It really doesn’t matter how long you pick to start with. It’s relative to your capacity. As soon as you postpone even for 10 seconds, you’re taking voluntary control over an involuntary process. So start wherever you can, and support yourself in the effort. Use a stopwatch if you need to.

Continue to postpone as long as you can. When you feel incapable of postponing the worry any longer, then go ahead and address it. The key is to let at least some amount of time pass without worries dominating your thoughts during the practice.

Experiment with this technique a few times this week. Whatever your worries — whatever the unproductive noises are in your head — practice postponing them. In the process you will be practicing a skill that you can use in preparing for any new challenges panic offers you.

3. Learn Two Techniques That Change Your Worries

A momentary worry is not much of a problem. All of us experience them. The trouble comes with how we react to worries. If we follow those noises, if we embellish their story line, if we dwell on the details and let ourselves become upset, then we are bringing on trouble.

Here are a couple of techniques for reducing your attachment to your worries. Remember that the principle behind these techniques is that your are disrupting a thought pattern that is unnecessary, irrelevant and intrusive. You first declare that these worries are noise, then you intervene with one of these techniques. The primary benefit of these two techniques is to change your emotional response to the thoughts — to help you feel any other emotion beside anxiety.

Write down your worries

How might you change your emotions toward your worries? The first way is to write them down. Carry a pencil and a small pad with you throughout the day. When you begin the noisy worries, write down your exact thoughts. If you continue worried thoughts, keep writing. This doesn’t mean a summary of what you said in your mind. This means a verbatim transcript of exactly what you’re thinking. As soon as you finish writing down the worry, if you think it again, write it down again, even if it’s verbatim what you just wrote down. Act as though you are the stenographer in the courtroom.  Every single utterance goes on paper!  Don’t write down the theme, write down every single repetition of every single worried thought.

Now what’s the benefit here? When you worry, you tend to repeat the same content again and again, right? When you write down the worries, you recognize how repetitive and senseless they are. This perspective quiets the noise. After a while you will probably experience the task — of writing verbatim all the content — as a chore. Most of us know how easy it is to mentally repeat some worry, like, “I hope this (whatever) turns out.” It’s easy to say it in your head 400 times. It’s a lot harder to write over and over again, “I hope this turns out. What if it doesn’t? Gosh, I hope it turns out. But what if it doesn’t?” There’s no way you can write it 400 times . . . it loses its power. Writing it down makes worrying into an arduous task. It becomes more work to actively worry than to let it go.

That’s how the writing will help you. After several extended writing sessions you are more likely to say, “OK, I’m worrying. Now I’m either going to start writing it, or I’m just going to let it go. I can either go through all the bother of writing these worthless thoughts, or just stop worrying right now.”

One special note: Don’t wait until you want to do this task. Few people are ever in the mood to write out their worries. Start this and other interventions because you are ready to get stronger, regardless of your mood or interest.

Sing a worried tune

Another way to begin changing your emotional response to your noisy worries is to sing them. (OK, stop laughing and let me explain.) Pick up a short phrase that summarizes your worry. Ignore its meaning for a while. Continue to repeat the words, but do so within a simple melody. Keep up this tune for several minutes. Whenever you feel you are less emotionally involved with these thoughts, let go of the tune and the words. Turn your attention elsewhere.

That sounds pretty silly, doesn’t it? Here you are, suffering from very distressing thoughts, and I ask you to hum a few bars. But that’s the idea. The process of singing your worries makes it difficult to simultaneously stay distressed. Yes, it’s stupid. Yes, it sounds childish. Do it anyway!!

And here’s how to do it. Pick up a short phrase that summarizes your obsession. Ignore its meaning for a while. Continue to repeat the words, but do so within a simple melody. Keep up this tune for a few minutes. Whenever you feel less emotionally involved with these thoughts, let go of the tune and the words. Turn your attention elsewhere.

I don’t expect that you will start singing this little tune and instantly feel happy. In fact, it will probably be hard to feel anything but anxiety when you start singing. But stick with it. And while you’re singing, work to become detached from the content of your song. Remember, that’s our goal.

4. Try the Skill of Worry Time

Do you ever find yourself worrying for days, even weeks, before an event? Your mind thinks it is protecting you by reviewing your performance, checking to see that you are going to act properly. Perhaps you worry more often about someone else. My friend is in the pre-first-ever-prom-of-the-oldest-daughter syndrome. For the next three weeks Ginger’s mom will subject herself to the common obsessions regarding prom night. “Will she be safe? I trust her, but what about those other kids? Where exactly will they be? What about all those teens who drink? And I know she won’t have sex . . . will she?”

Creating a “Worry Time”

  1. Set aside two daily Worry Times of 10 minutes each.
  2. Spend this entire time thinking only about your worries regarding one issue.   (OPTIONS: speak into a tape recorder or talk to a “coach”)
  3. Do not think about any positive alternatives, only the negative ones.  And do not convince yourself that your worries are irrational.
  4. Attempt to become as anxious as possible while worrying.
  5. Continue to the end of each worry period, even if you run out of ideas and have to repeat the same worries over again.
  6. At the end of ten minutes, let go of those worries with some Calming Breaths, then return to other activities.

The problem is that your mind doesn’t know when to quit; the worry begins to intrude on your daily life. The more you think about it, the more anxious you become and the less competent you are at your other mental tasks.

When this occurs, start by addressing the worries as a signal. Identify and respond to the legitimate concerns. My friend already has her prom-readiness plans set, because her worries are not just noise. She will talk with Ginger of her concerns about drinking, defensive driving, and safe sex. She will have a serious talk with the young man and get a schedule of events. And the two mothers will compare notes.

It is possible that handling the legitimate concerns will end your worries. It may at least reduce them down to a manageable level. If you still have noise left, then apply any of the skills from above: thought-stopping, postponing, writing, singing. In many situations one of them will do the trick. But sometimes you may find that your worries are too intrusive and persistent, and these aren’t enough to help you gain control.

If you are troubled by such a worry that tends to preoccupy your mind throughout the day, consider using the technique of daily Worry Time. This is a paradoxical technique — meaning that it seems opposite of logic — in which you purposely worry more instead of less. (See how irrational that sounds! That’s how you know it’s paradoxical.) Let’s say for instance that you have been uncomfortable traveling by plane in the past and you have a flight coming up. You’ve already booked the flight. It’s now about two weeks away, and you begin to worry every day about the flight, or how you’re going to handle yourself on the flight. Here’s how you would use Worry Time in such a situation.

Set aside, twice a day, about ten minutes that you have designated solely to worry about your problem. Perhaps take the first Worry Time in the morning before you go to work. Sit down in a private place and pay attention to your worries. (I’ll describe how to do that in a minute.) Then, at the end of the day, perhaps right after you get off work, sit down again and designate this as your second Worry Time.

When you sit down for this special time, totally devoted to your worries, follow these guidelines. Spend the entire time thinking only of your worries about this topic. Think of nothing positive. Do not try to convince yourself that these worries are unnecessary, do not try to see the positive side or argue in any way whatsoever. Only introduce negative thoughts, and let those continue to come up. More and more of them! As many as you have about the topic! Every angle and aspect of your worries and fears! Just let them come up in your mind, and continue to look for more of them. And try to become as uncomfortable as possible as you review these thoughts.

If, after a while, you run out of worries, recycle the worries you have already stated. Go back to the first ones and repeat them. Your goal is to spend the entire ten minutes focused on your worries, even if you have to repeat them. It is not going to work if you say, “Well, five or six minutes have gone by, and I can’t really think of anything else to worry about, so I think I’ll stop here today.”

No! Don’t do that, because there is method to the madness here. I want you to experience, eventually, the kind of frustration that comes with not being able to generate any more new thoughts. People who worry feel as if they worry all day long, but that is not actually what happens. Their worries come in little spurts — they argue themselves out of the worries, they reassure themselves that things will be okay, or they tell themselves to shut up, or they get distracted — and then the worries become quiet. But a little later the worries come back, and this battle begins again.

In Worry Time you don’t fight or struggle with your thoughts. You clear away your slate, set aside other thoughts, and give total and full attention to your worries. The result is that your worries diminish.

Why does it work? Because it helps you begin to shift your emotions when you think of the problem. During your first few Worry Times, you will probably become upset with your thoughts. After all, you are dwelling on your worst fears, and you are going over them repeatedly (like you usually do in the back of your mind at other times). But what happens when you review the same material in detail twice a day for days? After several days, most people complain about how hard it is to fill the ten minutes. They run out of things to say. Instead of feeling anxious, they get bored. Now wouldn’t that be a pleasant change!

That is one of our primary goals. Instead of thinking about a worry and instantly feeling anxious, you begin to have other emotional responses. Your body’s emergency system stops kicking in reflexively. If your worry is about airline travel, after a few days you might even catch yourself feeling good about getting to your destination more comfortably (and three days sooner than you would if you took the train).

To make those changes in your emotions you need to follow the guidelines of Worry Time carefully. For instance, don’t spend any time during this ten minutes trying to convince yourself that your worries are irrational. Do just the opposite: go ahead and let yourself get worked up. Conjure up all the negative, uncomfortable and distressful feelings that coincide with these thoughts.

At the end of ten minutes, you can let go of your worries and begin to relax. Take a couple of Calming Breaths, shake off those tensions and go about your day.

Don’t use Worry Time just once or twice. Ideally, you should place it in your schedule for at least ten days in a row. (This means if you are concerned about an upcoming event, make sure you start to worry early enough!) Expect that after several days Worry Time won’t be able to stir up such strong emotions inside you. Don’t stop then! Keep up the practice, because that’s the kind of change we’re looking for. Part of this design is for you to practice even when, try as you might, you can’t get emotionally aroused.

There are three ways you can repeat your worries during this time.

The first way is to do it by yourself, silently, by mentally repeating all your worries.

The second way, which some people prefer, is to say your worries out loud, instead of silently, even if you end up talking to yourself. That seems a little silly to people, but of course you’ll be in a private place with the door closed, so no one will be listening to you. I recommend that my patients speak their worries into a tape recorder. Recording may help you feel as though you were talking directly to someone instead of talking to the walls. If you try it this way, you don’t need to listen to the tape when you’re done. Just flip it over and record on the other side the next time.

The third way is to use a “worry coach.” This is someone who is willing to listen to your worries and support you in a specific way. Here, the worrier’s goal is to keep talking with as little assistance as possible.

The coach’s job is to offer a question or a statement only if the worrier can’t think of anything else to say. So coaches should let a few moments pass to see if the worrier comes up with another worry. If not, there are a few specific comments or questions that he or she can offer. The first one is to ask you to “say more about being worried.” The second is to ask, “What else about this topic worries you?” And third, “What other topics worry you when you think about this problem?” You can see these kinds of comments or questions aren’t that different from one another. They simply bring your attention back to the topic at hand, that is, “Keep worrying.” The goal is to discuss your worries thoroughly and passionately.

If you run out of things to say, then the coach should say, “Tell me again about those worries you’ve already mentioned.” When you begin to talk about the positive side of things, then the coach should interrupt and remind you to only speak about your worries. (Don’t get me wrong. It’s fine to reassure yourself, just not during this exercise!)

Worry Time – What the Coach Says

“Say more about being worried.”
“How else does [this issue] worry you?”
“What else are you worried about?”
(If the person begins talking about the positive side) “Only talk about your worries, please.”
(If the person runs out of worries) “Tell me again about those worries you’ve mentioned.”

These statements and questions should be the only ones that the coach uses. Don’t let your coach get off the track by playing the “me-too” game: “Yeah, I’ve had that problem before, too. I can really understand how troubling that must be for you.” The coach should keep comments to a minimum; whenever possible he or she should just listen and nod and let you know when your time is up.

Let’s assume that you typically resist your worries or try to argue yourself out of them. How well is that working for you? If you’re like most people, it’s not working very well. It is an understandable approach, but resistance in itself may promote your worries. In Worry Time you actually support the worries. You give them space, you don’t fight them. And when you truly let them have all that space, noisy worries change. They may still be there; but if you are not fighting them, their intensity diminishes.

This is one of those techniques that you can never fully trust until you apply it. It sounds too simple to work. Let me tell you that it can work when you apply it to the “noise” of your worries.

Will Worry Time work for you? I challenge you to experiment with it just once. Choose any problem in your life these days in which you have repetitious, unproductive thoughts. Give yourself a full ten minutes of Worry Time, and see if you can even last the whole time without running out of things to say. (Follow the instructions; don’t think positively!)

I bet you won’t make it, even if it’s a problem you typically dwell on throughout the day! Because I’ll also bet that when you worry, you simultaneously struggle against the worry by trying to think more positively or by trying to stop the thoughts. When you stop struggling, and you voluntarily choose to worry, then thoughts that tended to last all day can’t even sustain themselves for ten minutes.

Worry Time and postponing can work together as a great team of skills during your day. If you have a designated Worry Time set up already, then when you begin to dwell on your worries at the office, you’ll know what to say. “At 5:15 I’m already scheduled to worry about this. I’m going to postpone this worry until 5:15. That’s the perfect time to pay attention to these thoughts.”

After you have been using Worry Time for a few days, then you may also have trouble filling that ten minutes with worries about that issue. So when your worries spring up unannounced at other times of the day, you might even end up saying, “Hey, I need this worry to fill my time at 5:15. I’m saving this thought!” By investing time twice a day to worry formally, you end up reducing the amount of time you worry during the rest of the day. And those worries begin to get so “old” that they just don’t have the punch to them anymore. It will be much easier then to say, “No, I don’t really want to think about that anymore. I’d rather [read my book, talk with friends, enjoy my day, get my work done].”

5. These 5 Skills Will Help You Control Worry

Each of these five options

– negative thought stopping
– postponing
– writing them down
– singing them, and
– taking “worry time”

will help you gain mastery over your thoughts. They give you the chance to control certain aspects of your worries instead of being controlled by them. Each of them prepares you for the next stage, which is to stop your worries and return to your daily activities.

Most people become physically tense and anxious when they worry. Once you choose to stop worrying, then be sure you take care of any physical tensions you are experiencing. Spend some time letting go of those tensions after you let go of your anxious thoughts. Practice some brief relaxation skills, like taking a few Calming Breaths or Calming Counts. Or, do something more physical, like taking a walk. Even taking a couple of laps around the outside of your house can help release some tensions and refocus your mind.

Home Study

Chapter 15: Your Mind’s Observer

Chapter 16: Find Your Observer

Chapter 17: Take a New Stance: Your Supportive Observer

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