© COPYRIGHT NOTICE

Caroline Stewart & Robin Hall

Overcome Panic Attacks & Agoraphobia
Workbook 1 - Understanding Panic Disorder

© 2010 Caroline Stewart & Robin Hall

website: www.cognitivetherapyonline.com
email: [email protected]

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3
 You may read this book and think

‘This doesn’t apply to ME

I am MUCH worse
It COULDN’T be this straight forward
I have some other problem’

I know you feel UNBELIEVABLY unwell

I know it seems like more than ‘anxiety
I know you are seeking an ‘answer’
something that will ‘take it all away’

I too tried every ‘remedy’ ever invented

and I just stayed stuck
until I implemented the principles in this book

Even just READING the book every day WILL help

but doing the PRACTICE will CURE you!

READ it - then APPLY it

the answer is SIMPLE (not easy)

When you lose your fear of panic

IT WILL STOP HAPPENING

4
FOREWORD

I had panic disorder many years ago

I know EXACTLY what you are feeling right now
It’s a very very scary place!

The following techniques cured me COMPLETELY. I know with certainty that

I can NEVER have Panic Disorder again

Once you uncover how panic ‘works’ you simply can’t get caught up in it
to the same degree ever again. I can still get anxious like everyone else -
sometimes I even feel slight panic - but now I KNOW how to nip it in the bud
and it’s all over within minutes.

These workbooks will take you to complete recovery too if you follow them
carefully and DO THE PRACTICE.

Panic can seem like hell on earth - but it has changed me in ways I couldn’t
have imagined - for the better might I add. Someday you will feel this too.
You WILL be FREE from panic but more than that, the experience and
the recovery process will give you a strength and peace you never thought
possible.

You may think some of the explanations and advice about panic presented
here are too simple. How could something that feels so complicated be
treated so simply?

Just bear with it - read the text carefully - even if you

have come across some of these concepts before -
read it again. The more you read it the more sense
it will make

Even if you just read these workbooks book every

day that will go a long way to alleviating your
symptoms. Knowledge is a powerful thing.

Robin Hall (Cognitive Therapist and co-author) 5

A 3 Step Recovery Plan
STEP 1 - UNDERSTANDING PANIC
When you lose your fear of panic IT STOPS
HAPPENING.. The first step is to learn as
much about panic as possible - why it
happens and what keeps it going..

STEP 2 - RAPID RECOVERY SKILLS

Learn Cognitive and Behavioural
techniques that will enable you to
dramatically change the way you think,
react and behave towards panic

STEP 3 - RAPID RECOVERY PRACTICE

Behavioural Practices that will help you
put all your new skills and understanding
to the test so that you will prove that you
CAN be free of panic disorder - for GOOD!

6
 Step 1.
Understanding
Panic
“Knowledge is the antidote to fear.”
Ralph Waldo Emerson

7
 DSM Criteria for Panic Attack & Panic Disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published
by the American Psychiatric Association.

A Panic Attack
A discrete period of intense fear or discomfort, in which four (or more) of the
following symptoms developed abruptly and reached a peak within 10 minutes

• Palpitations, rapid heart rate

• Nausea or abdominal distress

• Sweating
• Derealization (feelings of unreality) or

• Trembling or shaking Depersonalisation (being detached

• Shortness of breath from oneself)

• Feeling of choking • Fear of losing control or going crazy

• Chest pain or discomfort • Fear of dying
• Feeling dizzy, unsteady, • Numbness or tingling sensations
lightheaded, or faint • Chills or hot flushes

Panic Disorder (without Agoraphobia*)

A. Recurrent unexpected Panic Attacks / at least one of the attacks has been
followed by 1 month (or more) of one (or more) of the following:

(a) persistent concern about having additional attacks

(b) worry about the implications of the attack or its consequences (e.g., losing
control, having a heart attack, "going crazy")
(c) a significant change in behaviour related to the attacks

B. The Panic Attacks are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical condition
(e.g., hyperthyroidism).

C. The Panic Attacks are not better accounted for by another mental disorder
such as Social Phobia, Specific Phobia, Obsessive Compulsive Disorder, Post-
traumatic Stress Disorder or Separation Anxiety Disorder.

* Panic Disorder WITH Agoraphobia will be discussed later 8

Panic Attacks can be part of another disorder

THESE WORKBOOKS WILL DEFINITELY

HELP WITH YOUR PANIC ATTACKS

However - it is important to point out that Panic Attacks can

occur as part of another disorder.

For example:
Social Anxiety
Phobias
OCD (Obsessive Compulsive Disorder)
PTSD (Post-traumatic Stress Disorder)

If your life was NOT being significantly impaired by any other

problem BEFORE panic attacks then you are most likely ONLY
dealing with panic attacks / panic disorder

However - if you feel that your life WAS being significantly

impaired by some other mental health problem EVEN BEFORE
you had your first panic attack then it is recommended that you
talk to your doctor or get referred to a Cognitive Behavioural
Therapist for further assessment.

But - I repeat again..

Even if your panic attacks ARE part of another mental

health disorder - these workbooks WILL help you with
the panic attacks at least.

9
 Before we begin..

It is important that you check with your

doctor about your symptoms in order to
confirm that you are suffering from Panic
Disorder.

10
 TWO WEEKS TOWARDS FREEDOM
Tens of thousands of people worldwide go to their doctors every
day with symptoms of panic disorder CONVINCED they have
some serious illness.

They then go online and they read about chemical imbalances

and thyroids and glands and radiation and emotional problems
and on and on - the ‘panic forums’ are FULL of this.

Which just gets them more worked up than ever..

TRY THIS..

For two weeks, set aside ALL other ideas about what you think
MIGHT be wrong with you and STUDY and PRACTICE the
knowledge and techniques in these workbooks.

CBT is THE most effective treatment for panic in the WORLD.

and CBT keeps it SIMPLE ..

Panic is EASY to treat - even with people who are CONVINCED

they are ‘seriously’ ill.

At the base of panic is a ‘mistake’ - understand that and you are

half way home.

Put that understanding into PRACTICE and you will get ALL the
way home!

That’s where YOU come in - you must be willing to TRUST what

you are about to read - trust it enough to go out and TRY it.
11
 U N D E R S T A N D I N G PA N I C

Anxiety is a perfectly normal

and necessary part of life.
Most people will experience anxious feelings at some stage in their life if
put under stress - when afraid or in danger or upon hearing bad news.

Although anxiety is an emotion we generally prefer not to experience, a

certain amount of anxiety is actually very helpful to us.

PROTECTION - Anxiety helps protect

us from danger by stimulating our mind
and body to take ACTION very quickly.

PREPARATION
Anxiety can give
us extra energy
and focus our
minds to deal with difficult demands and challenges
- (performers often say that they would worry if they
DIDN’T feel anxious before going on stage because
anxiety helps them remember their lines.)

MOTIVATION - Anxiety can alert us to things

in our life that we would be better to change
- we may work too much or follow an
unhealthy lifestyle.

Our goal isn’t to eliminate anxiety altogether -

but to know how to deal with it when it arises.
12
 U N D E R S T A N D I N G PA N I C

But what about STRESS ?

Isn’t it a bad thing?..

Stress and Panic are two very different things.

Someone who has panic isn’t necessarily under a lot of ‘stress’

Panic is actually a fearful REACTION to frightening but harmless

symptoms that can arise from even a MODERATE amount of
stress.

Of course it seems desirable to have less stress but keep in

mind that this book WILL help you deal with panic so that WILL
reduce the amount of stress you feel.

At least remember that you ARE now doing something about it.
So any stress you are under WILL BE REDUCED.

13
 U N D E R S T A N D I N G PA N I C

Anxiety symptoms
stem from the very helpful
‘Fight or Flight Response’
Human beings evolved with a protective mechanism called the
‘fight or flight response’.

Basically - if we are confronted with any real or perceived

threat or danger our body releases certain natural chemicals
(such as Adrenaline and Cortisol) which alter various nervous
functions, giving our body a burst of energy and strength so
that we are better able to ‘fight’ or ‘flee’.

This surge of ‘friendly’ adrenaline results in what could be

described as ‘anxious feelings’ - our nerves feel ‘on edge’ and
our mind is in a ‘worried state’ ready for action

It can also be called the ‘Fight, Flight or Freeze response’’

because in some dangerous situations staying perfectly still is
a useful response (like if a poisonous insect was nearby) 14
 U N D E R S T A N D I N G PA N I C

Let’s take a closer

look at HOW the
fight or flight response
works as it does..

and what sensations

we can feel as a result..

15
 U N D E R S T A N D I N G PA N I C

FIGHT OR FLIGHT RESPONSE RESULTING SYMPTOMS

Mind and body set on high alert Sense of danger, impending doom,
watching out for signs of danger. Agitation - uneasiness - can’t relax

Rapid breathing helps to Dizziness - Lightheadedness -

divert blood to vital organs Hyperventilation

‘Tunnel Vision’ - Peripheral vision Eye strain - Fear of going blind

is diminished so that sight is Blurred vision / spots in front
centrally focused (on any danger) of eyes - Sensitivity to light
Pupils of the eyes widen to let Feelings of unreality
in more light.

Adrenaline increases heart Rapid heart beat -

rate sending blood to Palpitations - Flutters - Feeling
major muscle groups - of ‘skipped’ or ‘missed’ beats.
to prepare for action. Tight chest - Choking sensation

Increase in sweat so that Sweating (even in cold)

the body does not overheat. Hot and cold flushes

Stomach produces extra acid Frequently needing toilet

and digestive juices. Muscle Nausea ‘Butterflies’
action increases to quickly Churning stomach Acidity
digest and eliminate food Indigestion - Diarrhoea

Muscles tense to prepare you Muscle tension - Shaking

for a quick departure and to Stiffness Trembling - ‘
make the body more resilient Jelly legs’ - Twitching
to attack. Even severe pain at times.

Blood vessels to skin constricted Cold clammy hands - ‘Pins and

reducing any potential blood loss needles’ - Tingling sensations
especially in hands and feet. or numbness in hands and feet
16
 U N D E R S T A N D I N G PA N I C

Now look at the typical symptoms

of a panic attack..
How does this compare to the sensations experienced when a person
is confronted with a clear threat of danger? Any similarities?

Sense of Dread
Headache
Dry mouth
Choking Sensation

Sweating
Tension
Shortness of Breath
Tight feeling in chest
Numbness
Rapid heart Beat

Stomach Pains
Butterflies
Bladder Weakness
Diarrhoea

Flushing hot - cold chills

Shakiness
Jelly Legs
Trembling
Pins & Needles

17
 U N D E R S T A N D I N G PA N I C

If Fight or Flight sensations arise due to a CLEAR

and REAL danger we realise that they are related
to the danger, are not harmful and will die down
once the danger is passed.

CLEAR or OBVIOUS real or

perceived threat or danger

Fight or Flight
Extreme physical or mental
anxiety SYMPTOMS

Realisation that the

symptoms are related to the
danger and are harmless
in themselves

Symptoms
die down
once danger
Body returns is passed
to normal NO PANIC

18
 U N D E R S T A N D I N G PA N I C

However.. if ‘fight or flight’ responses

suddenly happen ‘out of the blue’
and for no clear reason we ‘panic’
We evolved fight or flight to help us deal with life threatening danger.

However, our bodies can find it hard to distinguish between the

stress of real danger and everyday stress such as work deadlines,
rush hour traffic, bills, illness, relationship problems and so on.

So sometimes these fight or flight responses can be activated for

no obvious reason - ‘out of the blue’ and can be extremely
exaggerated and alarming. It can EVEN happen while we are asleep!

If we were being chased

by a Tiger we would
understand why we feel
so anxious but when
there is no clear or
apparent danger we
MISTAKENLY conclude
that we must be ill,
going mad or about to die..

This is why we PANIC..

19
 U N D E R S T A N D I N G PA N I C

We panic because we make

a MISTAKE!
We don’t actually ‘panic’ because of stress or anxiety (in fact
we may not even be aware of any obvious stress or anxiety)

We ‘panic’ because the very alarming SENSATIONS suddenly

produced by the fight or flight response for no obvious reason
FRIGHTEN us so much.

In ‘clinical’ terms -

we MISINTERPRET the symptoms

(mistakenly believe they mean something more serious)

and then we CATASTROPHISE (we ‘think the worst’)

20
 U N D E R S T A N D I N G PA N I C

Meet Miss-Interpretation
and Mr CATASTROPHE

Oh dear..
what on earth is happening to me?!
there must be something seriously wrong
These strange feelings must mean I’m ill
Maybe I should call a doctor
Now my arms are tingling..
maybe I’m having a stroke
What if I pass out
everyone will think I’m crazy!
I’ll never be able to show my face again
I’ll never be able to cope with this
I’ll never ever feel better ever again!
What if....

MISS INTERPRETATION

MR CATASTROPHE

21
 U N D E R S T A N D I N G PA N I C

This ‘mistake’ leads to a cycle of

fear - adrenaline - fear - adrenaline
The irony is - when we MISINTERPRET & CATASTROPHISE the
fight or flight sensations - the body receives a ‘false alarm’ that
we are in danger and tries to ‘help’ by releasing more adrenaline!

This again increases the FIGHT OR FLIGHT RESPONSE which

increases the sensations and we feel even more afraid.

We then become caught in a cycle

The PANIC CYCLE

Fight or Flight
Sensations
extreme physical
or mental
anxiety and fear
Additional fear Misinterpreting
body releases & Catastrophising
more Adrenaline the symptoms

‘PANIC’

22
 U N D E R S T A N D I N G PA N I C

The PANIC CYCLE

Not knowing they are harmless

Suddenly and for no obvious but exaggerated Fight or Flight
reason we experience very symptoms we assume we must be in
alarming symptoms of anxiety.. danger physically or mentally
we MISINTERPRET
and CATASTROPHISE

The more we panic the more we

send signals to the body that we
are in danger and in need of THIS IS WHEN WE

FIGHT or FLIGHT so the PANIC !!

symptoms increase..
23
 U N D E R S T A N D I N G PA N I C

Even though a panic attack

can feel terrifying it can NOT
cause you any ‘actual’ harm
Panic attacks can produce some of the most terrifying
sensations imaginable but they cannot cause you any actual
physical or mental harm.

No matter how extreme the sensations become you are

ACTUALLY in no danger in the slightest..

..it just SEEMS like it - its a MISTAKE

24
 U N D E R S T A N D I N G PA N I C

The body can only release a high

level of adrenaline for a short time
so the extreme symptoms of panic
HAVE to die down eventually..
We imagine that panic will last forever but the body can only
produce a high level of adrenaline (an adrenaline ‘rush’) for
short periods so ‘intense’ panic will ALWAYS pass quite quickly.
Afterwards however we may still experience a lingering low level
adrenaline which can make us feel uneasy and ‘jittery’. This is
unpleasant but still harmless.

MY NAME IS ?
CAPTAIN ADRENALINE
I’m HERE TO HELP!

I WILL HELP YOU FIGHT

I WILL HELP YOU FLEE
!!
I WILL KEEP YOU FROM DANGER
I WILL READY YOU FOR ACTION!
I WILL STAND BY YOUR SIDE!
I WILL...

THANK GOODNESS!..
Z Z Z HE WAS REALLY
STARTING TO GET
ON MY NERVES!...

25
 U N D E R S T A N D I N G PA N I C

it is MISINTERPRETING and
CATASTROPHISING
that cause us to panic
and become locked in the cycle

Fight or Flight
Symptoms
extreme physical
or mental
anxiety and fear
Misinterpreting
Additional fear & Catastrophising
body releases the symptoms
more Adrenaline

We
‘PANIC’ the main
culprits!
te
rp
et r
at
ion

26
 U N D E R S T A N D I N G PA N I C

How we ‘misinterpret’
and ‘CATASTROPHISE’ the symptoms

SYMPTOMS CATASTROPHIC THOUGHTS

(effects of Fight or Flight Response) (what we mistakenly fear is happening)

Increased heart rate “I’m going to have a heart attack”

‘Jelly legs’ “I’m going to collapse”

Shortness of breath “I’m going to stop breathing”

Tightness in chest “I’m going to die”

Mind focussed on ‘danger’ “I am going insane”

Dizziness “I’m going to faint”

Nausea “I must be seriously ill”

Feeling of choking “I’m going to choke to death “

Hot flashes, or sudden chills “Everyone will see how anxious I am”

Tingling in fingers or toes “I can’t cope with this”

Trembling, sweating, shaking “I’m going to lose control”

27
 U N D E R S T A N D I N G PA N I C

Common Catastrophic Thoughts

“I’m going to have a heart attack”

“I’m going to pass out / collapse / faint”
“I’m going to make a fool of myself”
“I won’t be able to act normally / speak / walk”
‘I won’t be able to cope”
‘Maybe I have a brain tumour / MS / cancer etc”
‘I’m going to die”
‘I’m not going to make it out of here”
‘What’s happening to me”
‘I’ve got to get away from here NOW!”
“I'm going to completely lose control”
“Everyone is going to see how anxious I am”
“People will think I am crazy”
“I can’t let anyone see me like this”
“I can’t breathe”
“There must be something seriously wrong with me”
“This is never going to end / stop”

28
 U N D E R S T A N D I N G PA N I C

OK.. so that’s why we

have a panic attack

but why do we have

REPEATED attacks?!!

29
 U N D E R S T A N D I N G PA N I C

It is fear of the panic itself

that leads to further attacks..
If we worry about the consequences of having further panic
attacks this added fear produces a continuous feeling of
underlying anxiety or stress.

“What if the next attack is worse than the last one..?!”

“what if I collapse..?!”
“what if..?”

This worry causes a constant low level of adrenaline which

keeps the body on high alert which means the fight or flight
response is triggered more easily.

This is called ’ANTICIPATORY ANXIETY’

30
 U N D E R S T A N D I N G PA N I C

The
ANTICIPATORY ANXIETY
Cycle

PANIC
ATTACK

Fight or Flight AFTER the panic

Response triggered we live in fear of
more easily another attack

Body stays
on high alert.
Low level
adrenaline

We AGAIN
MISINTERPRET
& CATASTROPHISE
the imagined consequences
of FURTHER panic attacks

31
 U N D E R S T A N D I N G PA N I C

Remember.. whatever life situation led

to your first panic attack is NOT the
cause of repeated attacks
Each persons experience LEADING to a panic attack is different but after
the point of ‘panic’ everyone becomes caught in the SAME trap -

Fear of the IMAGINED consequences of

the extreme feelings of fear (Panic about Panic)

I'm sure you would agree that your worst fear NOW is of the fear that
these panic attacks bring. You are living ‘in fear of the fear’.

We all have different reasons But if we experience We ALL become caught in

why anxiety symptoms might arise PANIC the same ‘trap’

F
• long term stress
• family / relationship problems G
I
P
• debt
• work related stress
H
T
A PANIC
• illness
• a chemical imbalance
or
F
N about
PANIC
• genetics (runs in the family)
L
I
I
• A traumatic event
or maybe nothing obvious at ALL
G
H
C
etc T
32
 U N D E R S T A N D I N G PA N I C

So the good news is - you don’t need

to get rid of ALL your anxiety or stress
to overcome panic
People think that they have to eliminate all ‘stress’, rest, relax or get
help ‘emotionally’ to stop panic attacks.

SO TELL ME..
DID YOU HAVE
A HAPPY
CHILDHOOD?

All you need do is adjust your understanding.

• ‘Anxiety’ and ‘stress’ don’t directly cause ‘panic’.

• Panic arises when we MISINTERPRET and CATASTROPHISE

symptoms that may have arisen from anxiety or stress.

• This leads to frightening but harmless cycles of fear.

So to OVERCOME Panic we need to

• Understand that what is happening is not dangerous.

• REDUCE the belief in the MISINTERPRETATIONS.

• Learn how to break the frightening but harmless cycles of fear

by putting the above understanding into PRACTICE.
33
 U N D E R S T A N D I N G PA N I C

Misinterpretation, Catastrophisation
& Anticipatory Anxiety lead to cycles of fear

These fear cycles are MAINTAINED by

‘SAFETY SEEKING
BEHAVIOUR’

& ‘AVOIDANCE’

34
 U N D E R S T A N D I N G PA N I C

The
SAFETY BEHAVIOURS
trap

35
 U N D E R S T A N D I N G PA N I C

In an attempt to stop the panic we

adopt various ‘SAFETY BEHAVIOURS’
Even if we don’t completely avoid situations where we feel anxious we
sometimes adopt certain behaviours that we feel may STOP the panic.

Some examples of SAFETY BEHAVIOURS

Sitting or lying down Avoiding physical exertion (for fear

Leaning against a wall of increased heart rate)
Going out ‘for air’ Distraction - turning up the TV, radio,
Opening a window humming loudly, engaging in some
(indoors or in the car) activity to try to block out the panic
Getting a glass of water Practising relaxation or deep
Leaving a situation breathing in a frantic attempt to ‘get
Asking for someone's help rid of’ the panic
Phoning someone ‘Fighting’ or ‘resisting’ the feelings
Sitting near an exit in an attempt to control them
Avoiding crowds Constantly ‘scanning’ our body to
Carrying your mobile phone - see if the symptoms have gone
or a ‘reassuring’ object Making sure we eat a certain food or
Only visiting friends with whom ‘health’ supplement
you feel ‘safe’ Making sure we get the ‘exact’
Only going to places you feel ‘safe’ amount of sleep
Never going out alone Wearing loose clothing
(bringing a ‘safety person’) Avoiding warm rooms \ hot drinks
36
 U N D E R S T A N D I N G PA N I C

Safety Behaviours play a HUGE part

in maintaining panic attacks

• When we panic we imagine that a CATASTROPHE will befall us -

a heart attack - suffocation - collapse - going crazy and so on.

• In order to avert this imagined ‘CATASTROPHE’ we adopt ‘safety

behaviours’ - we may escape the situation, lie down, lean against
a wall, seek support from someone and so on.

• If this helps calm us down we then imagine that the ONLY reason
disaster DIDN’T happen was BECAUSE of the safety behaviour.

We think..
“Who knows WHAT might have happened !..”

• We then believe that should we ever feel this bad again the
solution is to REPEAT the safety behaviour that seemed to help.

• This means we NEVER get to learn that had we stayed with the
anxiety and done NOTHING to stop it - the disaster we predicted
wouldn’t have happened (because it was just anxiety which would
have died down in time.)

• This is why ‘safety behaviours’ play a big part in MAINTAINING

our fear of the consequences of the fight or flight sensations.

37
 U N D E R S T A N D I N G PA N I C

Safety Behaviours
Example ‘Safety Behaviours’ Cycle
SAFETY BEHAVIOUR
We lie down to ‘rest’

Fight or Flight Sensation

PANIC DIES DOWN

eventually
(as it would have anyway)

FEAR of panic attacks

MAINTAINED

Didn’t learn that we COULD

HAVE coped with panic
that the feared consequence MISTAKEN ASSUMPTION
that lying down was reason
wouldn’t have happened
we didn’t have a heart attack
38
U N D E R S T A N D I N G PA N I C

The
AVOIDANCE
trap

39
 U N D E R S T A N D I N G PA N I C

You may start to AVOID

situations where you think
you might panic

You may think that certain places, people or things are the
cause of your repeated attacks - riding on the bus - driving the
car - the supermarket - the cinema.

Situations in themselves DON’T cause panic

People become afraid that they might panic in a situation
where they feel vulnerable and unable to ‘escape’ quickly.
They are also afraid of losing control in front of other people.

The MEMORY of any attacks then makes them fear the

situations they were in when the attacks took place and so
they AVOID those places from then on.

As time goes on they may find themselves avoiding more and

more situations.

The clinical term for avoidance or anxiety in public places for

fear of embarrassment or panic attacks is AGORAPHOBIA.

40
 U N D E R S T A N D I N G PA N I C

What exactly is Agoraphobia?

The Agora was an open "place of assembly" in ancient Greece.

The word Agoraphobia, the fear of potentially critical public
situations, derives from agora in its meaning as a gathering place.

DSM Criteria for Agoraphobia

The Diagnostic and Statistical Manual of Mental Disorders (DSM)
is published by the American Psychiatric Association.

A. Anxiety about being in places or situations from which escape

might be difficult (or embarrassing) or in which help may not be
available in the event of having an unexpected or situationally pre-
disposed Panic Attack or panic-like symptoms. Agoraphobic fears
typically involve characteristic clusters of situations that include
being outside the home alone; being in a crowd, or standing in a
line; being on a bridge; and travelling in a bus, train, or automobile.

B. The situations are avoided (eg, travel is restricted) or else are

endured with marked distress or with anxiety about having a Panic
Attack or panic-like symptoms, or require the presence of a
companion.

C. The anxiety or phobic avoidance is not better accounted for by

another mental disorder, such as Social Phobia, Specific Phobia,
Obsessive-Compulsive Disorder, Post-traumatic Stress Disorder or
Separation Anxiety Disorder.
41
 U N D E R S T A N D I N G PA N I C

Commonly Avoided
Situations and Places
Below are some of the most common situations and places that
people either avoid or (very bravely) ‘endure with marked distress’

Shopping Centres / Shops Doctors / Dentists / Hospitals

Restaurants / Cafes / Canteens Family gatherings

Cinema / Theatre Parties

Busy Streets Socialising

Buses / Trains / Subway / Planes Being alone

Driving / Motorways / City centre Open spaces

Elevators / Escalators Being too far from home

Walking outside / Running Holidays

Exercising Classrooms

Any activity that increases heart rate Recreation centres

Bridges / Heights _ _ _ _ _ _ _ _ _ _ _?

Work / Meetings _ _ _ _ _ _ _ _ _ _ _?

Talking to anyone in ‘Authority’ _ _ _ _ _ _ _ _ _ _ _?

42
 U N D E R S T A N D I N G PA N I C

Why AVOIDANCE
makes things worse..

Although avoidance can seem to help in the short term it

makes the problem worse in the LONG run.

The problem is that if all

feared situations are
avoided we never learn
that we CAN cope
with panic (and that our
catastrophic predictions
don’t happen) so the
fear continues.

We then become caught in yet ANOTHER cycle..

THE AVOIDANCE CYCLE

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 U N D E R S T A N D I N G PA N I C

Example ‘AVOIDANCE’ Cycle

PANIC ATTACK
in a Restaurant

AVOIDANCE
No opportunity to learn
that we CAN cope with
panic and that the
catastrophe we fear
doesn’t actually happen
Panic in other situations

Body and mind

on ‘High Alert’
Increased
easily triggered
Anticipatory Anxiety
fear of panic in other
situations

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 U N D E R S T A N D I N G PA N I C
REAL LIFE CASE STUDY..

Chelsea had recently started a new job. She enjoyed the work and
seemed to get on well with her work colleagues.

The job was in the nearest large town which was a route that she
was unfamiliar driving. Chelsea found herself becoming very anxious
at the thought of travelling to and from work.

One night the traffic was particularly slow moving as there had been an accident and as Chelsea sat
in her car she noticed that her heart had begun to race and she had started sweating, these
symptoms appeared to come from nowhere and she immediately thought ‘Something is wrong with
me’ She then began to feel a tightness in her chest and thought ‘These are the same symptoms you
have when you are having a heart attack.

Chelsea pulled over to the side of the road, the symptoms continued and she felt awful. Chelsea knew
that a classic symptom that would confirm her worst fear was if she felt a pain in her left arm. Chelsea
focused on her arm anticipating the symptom and she noticed that her arm did indeed feel strange, it
confirmed her worst fear ‘I AM HAVING A HEART ATTACK!’ Chelsea was distraught; she rang her Dad
for help. She knew she had to get to hospital and her next thought terrified her, ‘ I am trapped in this
car! ‘The traffic is too bad, they won’t be able to get an ambulance here in time to help me’ ‘I AM
GOING TO DIE!’

Chelsea rang her Dad again, he said he would not be long, she focused on the thought that help would
be here soon, and soon she began to feel a bit better.

By the time her Dad arrived Chelsea’s symptoms had died down but she still thought it was best to
get her heart checked at the hospital, because there must have been something wrong.

Chelsea did get her heart checked and all the results were clear.

Chelsea went to work the next day, but as home time approached she started to feel unwell again
and began to worry about the drive home, ‘What if the same thing happened again?’ ‘What if the
hospital had got it wrong?’ ‘What if there was something wrong with her heart and she didn’t get help
in time?’

Chelsea decided it would be safer if she got a lift home with someone when the traffic wasn’t going
to be so busy. She began to feel a bit better after re organising her travel arrangements. Whilst
Chelsea did still feel a bit unwell on the way home, it wasn’t nearly as bad as the night before, so she
concluded that it would be better if she continued to get a lift to and from work… just in case.
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 U N D E R S T A N D I N G PA N I C

The four main CYCLES in PANIC

It
all starts with
frightening but harmless
FIGHT OR FLIGHT
symptoms

ANTICIPATORY
PANIC Cycle ANXIETY Cycle
Leads to further attacks

MISINTERPRETATION
and
CATASTROPHISATION
are the reasons
we PANIC

SAFETY
AVOIDANCE
BEHAVIOURS
Cycle Cycle
Panic
is maintained
because we don’t learn
that the symptoms are not
actually harmful

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Summary of Step 1 - Understanding Panic

• Anxiety is a normal and necessary part of life.

• Human beings evolved with a protective response to danger .

If we sense danger adrenaline surges through our body
preparing us for ‘FIGHT OR FLIGHT’. The resulting bodily
sensations we call ‘anxiety’

• Most people have experienced these feelings of anxiety in

times of stress or fear.

• Sometimes however these feelings can come to us for no

clear reason which can be very alarming because we assume
there must be something seriously wrong with us.
We MISINTERPRET and then CATASTROPHISE the symptoms

• This causes us to PANIC which in turn activates the Fight or

Flight response which increases the symptoms - we then
become caught in a CYCLE of fear

• Regardless of what caused the initial fearful thoughts or

sensations the MAIN problem becomes the fear of the
sensations of panic itself.

• Fear of further panic attacks keeps our body on high alert

which means the Fight Or Flight Response is again easily
triggered leading to more panic attacks

• The biggest thing that maintains the problem is AVOIDANCE

and using SAFETY BEHAVIOURS
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You are now ready for
Workbook 2