Panic Disorder 411

How To Overcome Panic Disorder - Text

My name is Reneau Peurifoy. The following presentation is an overview of the approach that I've used to help people with panic disorder return to a normal life.

This approach is the result of over twenty years of work with people with panic disorder. If you have not watched the companion presentation on what causes panic disorder, I would encourage you to view it first before watching this one. What Causes Panic Disorder

In this video, I'll began by describing three general levels of recovery and then outline the specific skills needed to achieve each level. Keep in mind that the following three levels are not distinct from one another, but represent three possibilities along a continuum. As I describe each, identify the level you are at.

When panic disorder first begins, there's usually little or no understanding of what is happening. While there is great variation as to how a particular person will react to the initial panic attack, people often begin to experience chronic anxiety and increasing episodes of panic attacks. They may also began to avoid situations associated with their symptoms and begin to become hypervigilant, that is, always on guard and watching for possible signs of anxiety or panic.

Levels of Recovery
The first level of recovery is basic symptom control. The focus at this level is on controlling symptoms. By the end of this level, anxiety symptoms are greatly reduced with only occasional episodes of intense anxiety or panic, and there is usually the ability to function comfortably in at least half of the everyday situations that were formally uncomfortable. In order to achieve this level, a person needs a good understanding of what has caused their anxiety to escalate out of control, and a broad range of coping skills for managing anxiety. While this person is no longer hypervigilant, he or she is still moderately on guard for possible signs of anxiety or panic. Medication can also continue to play a major role in symptom management at this level.

The second level is advanced symptom control. Individuals at this level have greater confidence in their skills, and there's an absence of most, if not all, avoidance behavior. Intense episodes of anxiety are now only rarely experienced. However, many still have a higher base level of anxiety than prior to the onset of their panic disorder. To at least a moderate degree, individuals at this level have come to terms with those aspects of their personality and childhood factors that contributed to the development of panic disorder and would present a genetic predisposition that makes them more prone to anxiety.

Anxiety no longer interferes with everyday activities, and there's a good understanding of how to avoid entering into the anxiety-panic cycle and how to use their skills effectively. There's also some understanding that their symptoms are messages that indicate there are important life issues that need to be dealt with. Many of those who relied heavily on medication while at the first level are now no longer using medication, others are using it at a reduced level or reserve its use for situations that are especially anxiety provoking, such as a long flight or a major presentation.

While anxiety is still a fearful thing, there is now more awareness of the issues that trigger anxiety. The focus has shifted, at least in part, away from the symptoms to the causes of anxiety. However, because this understanding has not been fully internalized, periodic flareups of moderate to intense symptoms that seem mysterious still occur. When this happens, some have relapsed and moved back to level one and again become preoccupied with symptoms and develop avoidance behaviors.

The final level and goal of treatment is long term recovery. Individuals at this level see anxiety as a natural part of life rather than something to be avoided. Thus, their focus is on living with little thought given to the possibility of experiencing anxiety. The core issues that cause problems can be easily identified, and when anxiety occurs, the message it brings is clearly understood. There is a solid understanding that has been internalized at a gut level that high levels of anxiety are supposed to occur when real life issues are present, so the focus is on the issues generating the anxiety rather than on the symptoms of anxiety. This internalization is different from a simple cognitive understanding. It is like the difference between individuals who are just starting to learn how to drive a car and those who have driven for years. The first group is constantly thinking about what they are doing. With the second experienced group, the mechanics of driving are now a natural and automatic part of their behavior.

The internalization of the knowledge and skills needed to overcome panic disorder allows individuals at this stage to experience high levels of anxiety without distress or escalation of the symptoms they're experiencing. People who formerly relied on medication for symptom control find it is no longer needed.

Symptom Control Skills
Now, let's look at what is needed to actually achieve each of these levels of recovery. The first thing a person needs to achieve basic symptom control is a clear understanding of what caused panic disorder to develop and what causes it to continue. Again, if you've not viewed the companion video on what causes panic disorder, stop and view it before going on with his presentation. What Causes Panic Disorder

If you've not done so already, be sure to write a short explanation of why you developed your condition. Having a clear and concrete understanding of the causes of your panic disorder is essential if you're going to use the following skills effectively.

The next step is to learn four basic skills that can be used to reduce one's level of anxiety: Coping Self-Statements, Diaphragmatic Breathing, Cue Controlled Relaxation, & Distraction

Coping Self-Statements
The first skill involves learning to use what are called coping self-statements. People suffering from panic disorder tend to develop a wide range of frightening thoughts that become part of their daily thought life. Coping self-statements are used to counter the negative thoughts that accompany anxiety.

While people have a wide variety of disturbing thoughts that can accompany anxiety, there were two general negative thoughts that are very common. The first is the idea that what is happening is somehow dangerous. In order to develop effective counters to this frightening thought , you need to have a good understanding of what is causing your anxiety and that it is just part of your bodies fight or flight response. It is also important to consider that while panic attacks can be exhausting, they have never caused you any real physical harm.

As the understanding of the causes of your symptoms , and the fact that they are a normal response to fear becomes clearer, your coping self-statements will become more effective Since it is sometimes difficult to think clearly when experiencing strong anxiety, many find it helpful to write your coping self-statements on cards that you can carry with you. You can then pull out your cards and use them to counter your negative thoughts whenever you begin feeling anxious. Here are some examples of statements that others have used to counter the idea that your anxiety is somehow dangerous.

Anxiety is not dangerous; it's just uncomfortable. I've survived feelings like this and worse before. My body is functioning just as it is supposed to.

The scary things I have thought about my symptoms are lies. Anxiety is a nuisance and no more.

There is no need to fight what I am feeling. Even though it's uncomfortable, it's just adrenaline and will pass.

My current symptoms are just a type of conditioned response. They will lessen as I desensitize myself.

These symptoms are occurring because I'm like Pavlov's dogs; instead of salivating, I get anxious when certain "bells" ring. This conditioned response is normal and will fade with time.

The second common frightening thought is the idea that you might lose control in some way. While people often feel like they're out of control during a panic attack, in reality, they are able to do whatever they need to do and get to wherever they feel safe. Another thing to consider is that you've already experienced the worst panic attack you will ever experience. Let me say that again. You have already experienced the worst panic attack you will ever have.

This probably occurred when you're panic disorder first developed, and you had little understanding of what was happening and few skills for managing anxiety. While this experience was probably very frightening, nothing dangerous happened to you at that time, and eventually you were able to get yourself to where you felt safe.

Here are some examples of coping self-statements that can counter the idea that you might lose control in some way.

What I'm feeling is just an unpleasant body sensation. It is not dangerous. I don't have to let it stop me. I can continue to function even though I don't like what I'm feeling.

I can be anxious and still function effectively. I just need to stay focused on the task at hand.

Slow down and take one thing at a time. I know what to do and am able to do it even though my body is uncomfortable. Firefighters, police, and soldiers experience these feelings all of the time and are able to carry out their duties. I can too.

My body may be reacting strongly right now, but it doesn't really matter. It's just an old habit pattern that will pass with time.

Diaphragmatic Breathing
Since hyperventilation often plays a major role in the symptoms a person experiences, learning to take gentle, diaphragmatic breaths through the nose can help to greatly reduce the discomfort a person experiences. It turns out that there are two different general ways in which we breathe. The first is upper chest breathing, where the upper chest expands to take in the maximum amount of air. You use this when your body needs lots of oxygen such as when you were running or doing a strenuous activity. This has been exaggerated in this demonstration to help make it easier to see.

The second general breathing pattern is diaphragmatic breathing. With this type of breathing, there is little movement in the chest. Instead, the diaphragm just above the stomach moves down to draw air into the lungs. As it does this, the lower abdomen raises gently. Again, it's been exaggerated in this demonstration so you can see it more clearly. You use this type of breathing every night when you are in deep sleep.

Unfortunately, many people with anxiety related problems tend to use upper chest breathing during the waking hours especially when they're anxious as it is part of the fight or flight response. Thus, they end up taking in too much oxygen and experience unpleasant symptoms associated with hyperventilation such as dizziness, light headedness, weakness, shortness of breath a sense of unsteadiness, tingling feelings around the mouth and finger tips, sometimes even muscle spasms in the hands and feet. One or more of these are often experienced during high anxiety or panic attacks.

Learning to use relaxed, diaphragmatic breathing can help reduce if not eliminate them. I usually suggest that individuals practice the following just before going to sleep as they are lying down and wearing loose fitting clothes of that time. As you lay in your bed comfortably on your back, take several gentle breaths that raise the area around the belly button slightly as the diaphragm moves down. There should be no real effort to do this. As your diaphragm moves down, it creates a vacuum that draws air into the lungs. As you exhale, pause for a moment before taking your next inhalation. Again, these should all be gentle, comfortable movements.

As you can see in this demonstration, there is very little movement in your abdomen. After a few days, you gain an internal sense of what feels right for you just as you have an average distance you step when you walk even though you don't think about it and have never measured it. Once you have a sense for this type of relaxed diaphragmatic breathing, take a few relaxed diaphragmatic breaths whenever you are anxious. This will not in itself eliminate your anxiety, but it will calm you and help to reduce any hyerventilation symptoms that you have. Keep in mind that if you've already begun to hyperventilate before doing this, it'll take a few minutes for the oxygen level in your blood to return to normal.

Cue Controlled Relaxation
The third skill that can be very helpful is cue controlled relaxation because anxiety is now being triggered by everyday objects in situations that have been tagged as dangerous by your amygdala. You can develop a relaxation trigger. To do this, practice any standard relaxation response technique while gently keeping your thumb and the first two fingers together. This will associate the feelings and physiological response of relaxation with this gesture in what is commonly called a conditioned response. Adding this to the other skills helps to reduce anxiety. If your unfamiliar with relaxation response techniques, there's a link to a free downloadable recording of the script I developed in the lower right of the screen. (If this link is missing, then refer to techniques presented in other videos on this page.)

Distraction
The fourth basic anxiety reduction skill is to distract yourself. The most effective form of distraction is externalization, focusing on something outside of your body as it is impossible to have a panic attack when you are fully externalized. Let me repeat this. It's impossible to have a panic attack when you are fully externalized. One of the key elements in panic disorder is this tendency to constantly monitor the body. Whenever anything that resembles anxiety is noticed , you react with fear and tell yourself scary things about what you are experiencing. This increases the symptoms, and you're stuck in the anxiety/panic cycle. Before the development of panic disorder, you, like most people, probably paid very little attention to what was going on inside of you. Most of your attention was on what you were doing, and what was going on around you.

This changes once panic disorder begins to develop, and people start to constantly monitor their body for signs that the dreaded panic attack is coming. There are many ways to both distract yourself and externalize at the same time. Doing something physical with your hands is usually the most effective. That's why people usually experience fewer symptoms when they are working.

If you're in a situation where you don't have an activity you can do such as riding in a car or sitting in waiting room, there are many other simple things that can be done. For example, many find it helpful to strike up a conversation with someone nearby. Others find it helpful to observe something carefully such as reading signs, examining the design on a nearby wall, clothing or carpet, or simply observing the activities of people around you. If you're in a car, observing the surrounding scenery, listening to a talk show or a recorded book can also be effective. Because most of the people I've worked with were not very good at managing stress, learning basic stress management strategies is also helpful.

This is too big of a topic to cover in any detail in a brief overview like this, however, there were three basic ideas that you'll find especially helpful. The first is the concept that your body is a machine with a limited supply of energy. On days when you are rested and feeling good, your energy tank is full. On days when you are ill, stressed, or experiencing lots of anxiety, your tank is empty. Therefore, on days like this, you need to prioritize activities and decide what is most important to focus on and ignore everything else. This can be hard to do because when you are stressed or anxious, small things can take on major importance. If this is true for you, take a moment to write a list of what needs to be done and focus on the one or two most important items. The less important items can wait until another time. Writing out a list often makes things seem more manageable than just running through them in your head.

The second idea is to delay major decisions when you're stressed or very anxious because you do not think as clearly during these times as you normally do. If you need to make a decision, talk to someone you trust who has good judgment. Bouncing your ideas off this person will help you make a better decision.

The third idea is to plan ahead. You ought to know when you're going to enter into a time of high stress, so plan to do the little mundane things of life either before or after this period so you can devote your energy to what is important at this time. Remember the idea that your body is a machine with a limited supply of energy. You have less energy during times of high stress so use your energy wisely. As I now focus on the things needed to achieve advanced symptom control, keep in mind that not everyone needs to work at all these areas. Different people will have different areas that contributed to the development of their anxiety related problems as detailed in the companion video to this one. What Causes Panic Disorder

Distorted Thinking
One common area for most people with panic disorder is the need to reduce the amount of distorted thinking they're using. 15 Styles of Distorted Thinking The way you think is a habit pattern just like the way you brush her teeth or tie your shoes. Habitual ways of thinking that distort reality are called distorted thinking or cognitive distortions. While everyone uses some distorted thinking from time to time , we tend to use more distorted thinking when we were upset, sick, hungry, or tired. The reason for this is that you lose some of your ability to reason during times like these. In addition, some patterns are especially troublesome for people with anxiety related problems. Learning to reduce the amount of distorted thinking you do can play a major role in reducing the overall amount of anxiety you experience. Since it would take too long to cover all of the various forms of distorted thinking in a brief presentation like this, I'll just highlight two that are common in people with anxiety related problems. The first is called should/must thinking. This refers to thoughts or self-talk characterized by words like should, must, and have to. Here are some examples :

Should/Must Thinking
I have to be on time. People should be more polite. That person should learn how to drive. This type of thinking transforms your preferences into rigid rules. When the rule is broken, it causes major distress.

You also to become problem focused rather than solution focused. This means that you focus on how awful the situation is rather than think about what you can do to make things better. Learning to counter such thoughts with rational self-talk helps you to calm down and focus on the choices you have. With practice, you find the rational self-talk becomes a new way of thinking in these types of situations.

Using our examples of should/must thinking, you can substitute words like want, like, or prefer and then follow them with a statement that represents reality. So when you catch yourself saying, "I have to be on time," you would tell yourself, "No, I don't have to be on time. I like to be on time. However, with this traffic, I'm probably going to be late. There's nothing I can do about it. So just relax and get there when you can. My friend will understand."

A possible challenge for the thought, "People should be more polite" would be, "It would be a great world if everyone had manners and was polite. Unfortunately, this is not the case. There are many rude and inconsiderate people in the world. I choose to focus on my behavior. I don't have to be rude in return." While it takes practice to become skilled and notice your distorted thinking, and then answer it with rational self-talk, it's amazing how it changes how you think and react to situations.

One other thing that happens is that you tend to be more in charge of your life. When you use should/must thinking, it feels like an invisible parent is making you do things you don't want to do. When you begin using the language of choice, you become the one who's deciding what's best for you. You begin to see more clearly that life is simply a series of choices. You choose things that you think will benefit you in some way and avoid things you feel will harm or not benefit you. As you begin substituting want, like, and prefer for your should's and musts, you will also probably find that you'll discard some of your should/must rules. You'll probably keep others, but now, you'll be able to break the rules when there's a good reason to do so without feeling anxious.

What-if Thinking
A second type of distorted thinking, common in people with anxiety related problems, is What-if thinking, which is more formally know as Negative Anticipation. This type of thinking is characterized by imagining a host of frightening possibilities. For example, When planning to go somewhere, people who tend to hyperventilate might have the thought, I might pass out. This thought then generates a host of frightening and images of passing out along with negative consequences that might follow.

When challenging what-if thinking, it's important to look at your track record. How often has this actually happened in the past? This is often difficult because what-if thinking tends to be accompanied by emotional reasoning. Emotional reasoning is when you use emotions to evaluate the possibility of something happening. In other words, if it feels like something might happen, a person then thinks that it's likely to happen. Unfortunately, this feeling is usually being fueled by anxiety and is not based on reality. When I ask a person who's thinking that they might pass out, "How likely is this?" they usually respond that it's very likely. What I then ask, "How many times have you actually passed out?" They usually respond, "I've never passed out." So based on emotion, it's very likely. However, based on past experience, it's very unlikely. The key point is that feelings are not facts. Sometimes, they come from rational thinking, and sometimes they come from very distorted and irrational thinking. You always have to evaluate your feelings with the cognitive or thinking part of your mind.

To summarize, challenging what-if thinking involves four steps. First, based on reality rather than emotional reasoning, how likely is it? Second, how bad would it be if this happened? Third, what is my plan to prevent this from happening ? And finally, what is my plan for coping with this if it were to happen? Let's continue with an example of a person who's going somewhere and thinks I might pass out. One, how likely is this? Based on the past, the odds are very low that this will happen because the person has never passed out. Two, how bad would it be? If a person is using emotional reasoning when thinking about this and saying something like, "This would be the worst thing i can think of," I usually have them imagine a scale from one to ten with ten representing having someone you love die, or you dying from a disease.

Next, consider that if you passed out due to hyperventilation, which is not very common. You would have time to sit down so you wouldn't hurt yourself. You would then also regain consciousness fairly quickly as your body readjusted the oxygen and carbon dioxide levels back to normal. The main consequence of passing out would be embarrassment. While embarrassment is unpleasant, it's way down the scale from truly catastrophic things that could happen.

Three, what is my plan to prevent this from happening? People often have things they can do to reduce hyperventilation such as diaphragmatic breathing. having their coping self-statements on a card they carry, or having something to eat and so on.

Four, what would I do if it were to happen? I usually go through the specifics of what a person could do if he or she felt like they'd pass out. First, you'd want to sit down so you don't hurt yourself. Second, you need to have something to say when you're feeling better in case there are people around such as, "I'm okay I've just felt a little weak lately. Give me a few minutes. I'll be fine." After thinking through a what-if thought like this in detail, you then need to compress it into a short coping self-statement you can use to counter it whenever it comes up. Often, a person writes this on a card if it's a particularly troublesome one. Here's an example of what a person wrote for the thought, "I might pass out." "I've never passed out so it's very unlikely that this will occur. Stop your emotional reasoning. It would not be the end of the world so stop catastrophizing. I know how to do relaxed diaphragmatic breathing, and I do better when I chew gum. I know what to say and can take care of myself." You can use this approach for any fearful thought or worry that causes anxiety. In fact, it's helpful to make a list of the fearful thoughts that you tend to have and create a card for each one.

Desensitization
If you have things that you are avoiding due to your anxiety or fear of having a panic attack, you will eventually need to go through a process of desensitization. This is where you create a list of the things you avoid, then you begin doing them starting with the easiest ones first and proceeding on to more the difficult ones in a systematic way.

If you have things that you are avoiding because of your anxiety, the only way you can convince yourself that you can face the situation you fear is to practice facing it. You need to demonstrate to yourself that you can function in the feared situation no matter how you feel. In essence, you're doing two things. First, you're proving to yourself that you can do things you once avoided or had difficulty with. Second, you are learning that you can tolerate distress and do whatever you want to do. Because the process of systematic desensitization is a very big topic in itself, it's the topic for a separate video. In addition to those already mentioned, there are several other areas that may need to be addressed to achieve advanced symptom control.

Perfectionism, Excessive Need For Approval
While these vary greatly from person to person, common areas include perfectionism, excessive need for approval, traits common in adults with abusive childhood, and negative core beliefs. Since these areas don't affect everyone, and I want to keep this presentation to a reasonable length, they're all topics for separate videos.

The final stage is long term recovery. There are two key things that I found to be essential to reach this level. The first is the internalization and application of the concept that anxiety is a messenger bringing the message that some important life issue needs to be dealt with. People with anxiety related problems often avoid dealing directly with issues that are difficult. While these vary greatly, one of the most common ones is relational issues, especially boundary issues, where another person is taking advantage of, or mistreating you in some way.

Another common issue is when a person needs to make a decision or take action that is difficult. For example, a person may be doing too much at work and needs to cut back because excessive stress is being experienced. However, this person is reluctant to set limits for fear of disappointing the boss, or because the feelings that others might see him or her as not being a team player or somehow being weak. The anxiety symptoms are simply saying, "You have a real issue to deal with, so deal with it." Not setting limits and not dealing with the real life issues often plays a major role in the development of panic disorder.

Thus, the life lesson is to learn to identify and deal with life issues as soon as possible when they come up. Delaying action tends to heighten anxiety and physical symptoms. Whenever you began to experience an increase in anxiety symptoms, ask yourself if there's anything important occurring in one of these areas: your relationship with your significant other, your children, your family, work, friendships, life goals, recent events.

When I ask this, people often describe something significant, but then add, "But it's not that big of a deal." Their symptoms are simply saying, It's important so deal with it. Usually, this is something that's a common and a real life issue that they've been ignoring. This is such an important point, it bears repeating. People with panic disorder need to deal with problems directly and honestly when they occur. This is especially true for relational problems. If you ignore or minimize them, it triggers anxiety that seems to be coming from nowhere.

Anxiety is the messenger for stress
At the same time difficult problems are often accompanied by anxiety. This is normal and simply a message that you have decisions to make or actions to take. Again, anxiety is simply a messenger. Focus on the message, the life issue, instead of the messenger, the anxiety.

You're not broken
The second key to a long term recovery is to normalize yourself. People with anxiety related problems often develop the view of themselves as somehow broken or abnormal. Sometimes, this is an old message from childhood. Sometimes, it's a direct result of the struggle with anxiety.

Clinical labels
The various clinical labels that have often been used to describe them by professionals can also add to the sense of being different or damaged. A key part of recovery is to see yourself as no different from anyone else. Yes, you do have some peculiarities, but we all have our individual weaknesses and strengths. The truth is that there is nothing wrong with you. You may have a sensitive body, childhood experiences, or some other things that people with anxiety related problems share. However, these are just normal variations from what are found in the general population. Some of them are your most valuable assets. Shedding the clinical terms and negative labels that you've used and adopted is an essential step in resuming a normal life.

During my years as a therapist, I've seen many people with severe panic disorder return to a normal life. In fact, they often have said that panic disorder was a blessing in disguise as it helped them learn to live life in a new and more effective and fulfilling way. While they do still experience anxiety, it is experienced as normal and a response to real life issues. This is something you can achieve as well.

All of the information in this presentation has been taken from the two books, Anxiety, Phobias, &, and Panic and Overcoming Anxiety. The first book is a detailed presentation of the basic ideas of this video. The second follows three people as they learn the skills and apply them to their particular situation and finally overcome panic disorder. Both have recommended activities at the end of each chapter to help you apply the ideas is to your particular situation. To learn more about these and other resources, click on the link in the lower right hand corner (You can click on the link below to view the books available). Thank you for viewing my presentation. My hope is that it will help you to take another step on your road to recovery. (Audio transcribed for educational and accessibility purposes.)

The video was written and presented by Reneau Peurifoy, a therapist, teacher, and author of several books. Please visit his channel for more information

THE ROAD TO FORT WORTH by Michael Jackson Smith: Very little was known about panic disorder when I had my first panic attack. There was no help available to teach me how to assuage the attacks, but I discovered that alcohol would dissolve my fear instantly. My website contains the kind of information that would have been a tremendous help to me in the early days of my illness as I searched for solutions for the panic disorder, agoraphobia, and alcoholism that incapacitated me. My book is the story of my journey into recovery. Read Chapter 8 | Top of Page↑