Mastery of Your Anxiety and Panic Workbook by David H. Barlow

Mastery of Your Anxiety and Panic
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EDITOR-IN-CHIEF
David H. Barlow, PhD
SCIENTIFIC
ADVISORY BOARD
Anne Marie Albano, PhD
Jack M. Gorman, MD
Peter E. Nathan, PhD
Paul Salkovskis, PhD
Bonnie Spring, PhD
John R. Weisz, PhD
G. Terence Wilson, PhD
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Mastery of Your Anxiety and Panic
FOURTH EDITION
Work book
David H. Barlow • Michelle G. Craske
2007
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ISBN-13 978-0-19-531135-8
ISBN 0-19-531135-3
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About Treatments ThatWork™
One of the most difficult problems confronting patients with various disorders and diseases
is finding the best help available. Everyone is aware of friends or family members who have
sought treatment from a seemingly reputable practitioner, only to find out later from
another doctor that the original diagnosis was wrong or that the treatments recommended
were inappropriate or perhaps even harmful. Most patients or family members address this
problem by reading everything they can about the patient’s symptoms, seeking out
information on the Internet, or aggressively “asking around” to tap knowledge from friends
and acquaintances. Governments and healthcare policymakers are also aware that people in
need do not always get the best treatments—something they refer to as “variability in
healthcare practices.”
Now healthcare systems around the world are attempting to correct this variability by
introducing “evidence-based practice.” This simply means that it is in everyone’s interest
that patients get the most up-to-date and effective care for a particular problem. Healthcare
policymakers have also recognized that it is very useful to give consumers of healthcare as
much information as possible, so that they can make intelligent decisions in a collaborative
effort to improve health and mental health. This series, Treatments ThatWorkTM, is
designed to accomplish just that. Only the latest and most effective interventions for
particular problems are described in user-friendly language. To be included in this series,
each treatment program must pass the highest standards of evidence available, as
determined by a scientific advisory board. Thus, when individuals suffering from these
problems or their family members seek out an expert clinician who is familiar with these
interventions and decides that they are appropriate, they will have confidence that they are
receiving the best care available. Of course, only your healthcare professional can decide on
the right mix of treatments for you.
This particular program presents the latest version of a cognitive-behavioral treatment

approach for panic disorder with or without agoraphobia.
There has been recognition in recent years that panic attacks are prevalent and that
individuals suffering from panic disorder with varying levels of agoraphobia constitute 5–8
% of the population of the United States, with comparable figures now available from other
countries around the world. As noted in this workbook, this means that one out of
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approximately every 12 people suffers from this devastating disorder at some time during
his or her lifetime. In this workbook, you will join tens of thousands of individuals who
have learned the skills to cope effectively with panic attacks and their devastating
consequences and to master the emotional rollercoaster that is panic disorder. Ideally, we
are all striving toward a goal of preventing the occurrence of panic disorder and associated
anxiety. But for the time being, governments around the world and their health services
have stipulated cognitive-behavioral treatments such as this one as the first-line approach in
relieving the considerable suffering associated with panic disorder. In this, the fourth
edition of this widely used workbook, further refinements are incorporated in order to take
advantage of our ever-growing knowledge of the nature and successful treatment of panic
disorder with agoraphobia. For example, focusing even more specifically on the
extraordinarily frightening physical sensations that accompany panic attacks which are also
associated with strong sensations of losing control are now an even more important part of
the exercises in this workbook. As with all programs such as this, this workbook is most
effectively applied under the direction of a clinician trained in this approach.
David H. Barlow, Editor-in-Chief,

Treatments ThatWork™
Boston, Massachusetts
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Contents
Chapter 1 The Nature of Panic Disorder and Agoraphobia

Chapter 2 Learning to Record Panic and Anxiety
Chapter 3 Negative Cycles of Panic and Agoraphobia

Chapter 4 Panic Attacks Are Not Harmful
Chapter 5 Establishing Your Hierarchy of Agoraphobia Situations
Chapter 6 Breathing Skills
Chapter 7 Thinking Skills

Chapter 8 Facing Agoraphobia Situations
Chapter 9 Involving Others
Chapter 10 Facing Physical Symptoms

Chapter 11 Medications
Chapter 12 Accomplishments, Maintenance, and Relapse Prevention
Appendix Answers to Self-Assessment Quizzes

References
About the Authors
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Chapter 1 The Nature of Panic Disorder and
Agoraphobia
Goals
To understand the nature of panic attacks, panic disorder, and agoraphobia
To learn about factors that cause panic disorder
To learn about this program for overcoming panic and agoraphobia
To determine whether or not this program is right for you
Do You Have Panic Disorder or Agoraphobia?
Do you have rushes of fear that make you think that you are sick, dying, or losing
your mind? When these panicky feelings happen, does it feel as if your heart is
going to burst out of your chest or as if you cannot get enough air? Or maybe you
feel dizzy, faint, trembly, sweaty, short of breath, or just scared to death. Do the
feelings sometimes come from out of the blue, when you least expect them? Are
you worried about when these feelings will happen again? Do these feelings
interfere with your normal daily routine or prevent you from doing things that you
would normally do?
If these descriptions apply to you, then you may be suffering from panic disorder
and agoraphobia. The rushes of fear are called panic attacks. Usually, panic attacks
are accompanied by general anxiety about the possibility of another attack.
Together, the panic attacks and general anxiety are called panic disorder.
Agoraphobia refers to anxiety about, or avoidance of, situations where panic attacks
or other physical symptoms are expected to occur. These terms are described in
more detail later. Here are some examples of how panic disorder and agoraphobia
can affect people’s lives.
Case Studies
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Steve
Steve was a 31-year-old sales manager who suffered from attacks of dizziness, blurred
vision, and heart palpitations. The first panic attack occurred at work, in the presence of
his coworkers, and began with feelings of weakness, nausea, and dizziness. Steve asked a
colleague to call a doctor because he was afraid that he was having a heart attack since his
father had recently died of one. In addition to this personal loss, Steve was dealing with a
lot of stress at work. Several months before the first panic attack, there were times when
Steve had been nervous and his writing had become shaky; but apart from that, he had
never experienced anything like this before. After a thorough physical examination, his
doctor told him that it was stress and anxiety. Nevertheless, the panics continued, mostly
at work, and in trapped situations. Sometimes they were unexpected or “out of the blue,”
particularly the ones that woke him out of deep sleep. Steve felt tense and anxious most of
the time because he worried about having another panic attack. Since his third panic
attack, Steve had begun to avoid being alone whenever possible. He also avoided places
and situations, such as stores, shopping malls, crowds, theaters, and waiting in lines,
where he feared being trapped and embarrassed if he panicked. Wherever he went, Steve
carried a Bible, as well as chewing gum and cigarettes, because glancing at the Bible,
chewing gum, or smoking cigarettes made him feel more comfortable and better able to
cope. In addition, Steve took medication with him wherever he went to help deal with his
panic attacks.
Lisa
Lisa was a 24-year-old woman who had repeated attacks of dizziness, breathlessness,
chest pain, blurred vision, a lump in her throat, and feelings of unreality. She was afraid
that these feelings meant that something was wrong with her brain, such as a tumor, or
that she was losing control of her mind. The problem began about five years before. While
at a party, Lisa smoked some marijuana, and within a short while, she began to feel very
unreal and dizzy. Never having had these feelings before, Lisa thought that she was going
insane or that the drug had damaged her brain. She asked a friend to take her to the
emergency room. The physicians did some tests and reassured Lisa that her symptoms were
due to anxiety. Lisa never touched marijuana or other recreational drugs after that. In
fact, she became nervous about any chemical substances, even ones prescribed for allergies
and sinus infections. The panic attacks waxed and waned over the years. At one point, she
had no attacks for three months. However, she continued to worry about having another
panic attack almost all of the time. She felt uneasy in situations where it would be difficult
to get help if another panic attack occurred, such as in unfamiliar places or when she was
alone, but she did not actually avoid many places. Her method of coping with panic was
to get as involved as she could in other things so as to keep her mind off panic.
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Judy
Judy was a 41-year-old, married woman who was unemployed because of her panic
attacks. Judy quit her job as a paralegal several years ago because it had become
increasingly difficult for her to leave her house. Judy’s panic attacks involved strong chest
pains and feelings of pressure on her chest, numbness in her left arm, shortness of breath,
and heart palpitations. Each time she panicked, Judy was terrified that she was dying of a
heart attack. In addition, Judy frequently woke up out of deep sleep with similar feelings,
particularly pressure on her chest, shortness of breath, and sweating. Judy lived with her
extended family, which was of Chinese descent and believed that the nighttime events
represented demons descending on her. Her grandmother convinced Judy that she would
die if she did not wake up in time. Consequently, Judy became very afraid to go to sleep.
She would spend many hours pacing the floors when everyone else was asleep. Instead, she
napped throughout the day, when other people were around. Her life had become very
restricted to the house, with occasional outings to stores and doctors as long as a family
member or friend accompanied her. Judy had seen many doctors and cardiologists, and she
had undergone several cardiovascular stress tests and a halter recording to measure her
heart over extended periods of time. Nothing was detected, and yet Judy remained
convinced that she would have a heart attack or that she would die in her sleep.
Diagnosis and Definition of Panic Disorder and Agoraphobia
The mental health classification system used in the United States and many other
countries, referred to as the Diagnostic and Statistical Manual for Mental Disorders,
fourth edition, text revision (DSM-IV-TR; APA, 2000), identifies the problem
addressed in this workbook as panic disorder with or without agoraphobia. The key
features of panic disorder are: (1) one or more episodes of abrupt, intense fear or
discomfort (i.e., a panic attack); and (2) persistent anxiety or worry about the
recurrence of panic attacks, their consequences, or life changes as a result of the
attacks.
Panic attacks refer to an abrupt rush of intense fear or discomfort accompanied by a

number of physical and cognitive symptoms, which are listed below. Occasional
panic attacks are common. However, not everyone who experiences occasional
panic attacks develops panic disorder. Details about the frequency of panic attacks
and panic disorder in the general population are described in a later section.
Panic Attack Symptoms
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Shortness of breath or smothering sensations
Heart palpitations or a racing or pounding heart
Chest pain or discomfort
Trembling or shaking
Feelings of choking
Sweating
Feeling dizzy, unsteady, lightheaded, or faint
Hot or cold flashes
Nausea or abdominal distress
Feelings of unreality or detachment
Numbness or tingling
Fears of dying
Fears of going insane or losing control
Panic attacks occur as a part of many different anxiety problems. However, in other
anxiety problems, panic attacks usually are not what the person is most worried
about. In panic disorder, the panic attacks become the major source of concern and
worry.
Continuing with the technical definition of panic disorder, at least one of the panic
attacks must be unexpected or occur for no real reason. In other words, the panic
seems to occur from “out of the blue.” A good example of an unexpected panic
attack is an attack that occurs when relaxing or when deeply asleep. For some
people, panic attacks continue to occur unexpectedly, and for other people, the
panic attacks eventually become tied to specific situations.
Another feature of panic disorder is avoiding, hesitating about, or feeling very

nervous in situations where panic attacks or other physical symptoms (such as
diarrhea) are expected to occur. Typically, these situations are ones where you may
not be able to escape or find help. A common example is a crowded shopping mall,
where it might be hard to find the exit and difficult to get through all the people if
one has to leave suddenly because of a panic attack. A list of typical agoraphobia
situations is provided in the list below. Avoiding situations because of fear when no
real danger exists is called a phobia. Avoiding situations from which escape might
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be difficult or where help may be unavailable in the event of a panic attack or other
physical symptoms is called agoraphobia. This is fitting because the agora was the
ancient Greek marketplace—the original shopping mall. However, as can be seen
from the list below, places and situations avoided by people with agoraphobia are
not limited to malls.
Typical Agoraphobia Situations
Driving
Traveling by subway, bus, or taxi
Flying
Waiting in lines
Crowds
Stores
Restaurants
Theaters
Long distances from home
Unfamiliar areas
Hairdressing salon or barbershop
Long walks
Wide, open spaces
Closed-in spaces (e.g., basements)
Boats
Being at home alone
Auditoriums
Elevators
Escalators
In most cases, agoraphobia develops after panic attacks, resulting in panic disorder
with agoraphobia. However, some people never develop agoraphobia; they have
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panic disorder without agoraphobia. Occasionally, agoraphobia is present without
panic attacks, in which case the official term is agoraphobia without history of panic
disorder. In this case, the person may experience one, two, or three symptoms from
the list of panic attack symptoms but never has had four or more symptoms at one
time (which is the technical requirement for a full-blown panic attack).
Nevertheless, one or two symptoms can be as distressing as four or more symptoms.
For example, lightheadedness is sometimes the only symptom experienced, but
anxiety about feeling lightheaded can be as severe and disabling as the anxiety
about having a full-blown panic attack. Putting it another way, the person who has
lightheadedness only may end up becoming as agoraphobic as the person who has
lightheadedness plus many other panic attack symptoms.
Another example of agoraphobia without panic disorder is when abdominal distress

is the primary symptom, resulting in hesitation about entering situations where
restrooms are not easily accessible. Abdominal distress may be part of irritable bowel
syndrome, which involves a chronic disturbance in bowel habits and includes nausea,
stomach cramping, constipation, or diarrhea. These types of symptoms are not due
to a medical condition and are often intensified by stress, such as the stress of an
agoraphobia situation.
Agoraphobia without history of panic disorder also refers to avoidance of situations

because of other bodily symptoms that are not on the list of panic attack symptoms,
such as visual disturbances. A list of these symptoms is shown here.
Other Physical Symptoms That Might Lead to Agoraphobia
Headaches
Tunnel vision or sensitivity to light
Muscle spasms
Urinary retention problems
Weakness
Fatigue
Diarrhea
Sensations of falling
The overriding notion is that agoraphobia comes from being anxious about
uncomfortable physical symptoms in certain situations. These situations are ones in
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which it seems difficult to cope with the uncomfortable feelings because of the
feelings of being trapped or of there being no way of getting help.
It is possible to be anxious about and avoid these types of situations for reasons
unrelated to uncomfortable physical symptoms. For example, many people refuse to
fly because of concerns about crashing or being hijacked. Or, difficulty driving can
be based on concerns about being hit by other drivers. Similarly, avoidance of being
alone or of leaving one’s safety zone can be related to concerns of being attacked,
mugged, or other external dangers. This workbook is not written with these kinds
of fears in mind. Instead, this workbook is for fear and avoidance behavior due to
uncomfortable physical symptoms and panic attacks.
Medical Problems
Certain medical problems can cause panic attacks, and controlling them eliminates
panic attacks. These medical problems include hyperthyroidism (overactive thyroid
gland) and pheochromocytoma (a tumor on the adrenal gland, which is very rare).
Other medical problems include extreme use of amphetamines (such as benzedrine,
which is sometimes prescribed for asthma or weight loss) or caffeine (10 or more
cups of coffee per day). However, these medical problems are different from panic
disorder. In panic disorder, the panic attacks are not caused by medical problems.
(We recommend that those who feel that they are suffering from panic attacks
undergo a full physical exam to decide whether the panic attacks are caused by
these types of medical problems or whether they are part of panic disorder.)
There are other medical problems that cause panic-like symptoms, but controlling
these medical problems does not eliminate panic attacks. These include
hypoglycemia (low blood sugar), mitral valve prolapse (flutter of the heart), asthma,
allergies, and gastrointestinal problems (such as irritable bowel syndrome). It is
possible to have one of these medical problems as well as panic disorder. For
example, low blood-sugar levels may cause weakness and shakiness and thus lead to
panic, but correction of blood-sugar levels through diet does not necessarily stop all
panic attacks. In other words, these types of medical problems may be a
complicating factor that exists alongside panic disorder, but removing these medical
problems does not always remove panic disorder.
If you have not had medical tests in the past year, it may be wise to undergo a full
medical examination to check for possible physical causes of panic-like symptoms
and to identify other physical conditions that might contribute to panic and
anxiety. These factors can then be taken into account during the treatment
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program.
How Common Are Panic Disorder and Agoraphobia?
Panic attacks and agoraphobia are very common. The most recent large-scale
surveys of the adult population of the United States show that from 5 to 8% of
individuals experience panic disorder and/or agoraphobia at some time in their
lives. This means that somewhere between 15 and 25 million people in the United
States alone suffer from panic disorder and/or agoraphobia. One out of every 12
people suffers from panic disorder and/or agoraphobia at some time in his or her
life.
In addition, many people have occasional panic attacks that do not develop into
panic disorder. For example, over 30% of the population has had a panic attack
during the past year, usually in response to a stressful situation, such as an
examination or a car accident. Moreover, a significant number of people experience
occasional panic attacks from “out of the blue” or for no real reason—estimates
range from 3 to 14% in the last year.
Panic attacks and agoraphobia occur in all kinds of people, across all social and
educational levels, professions, and types of persons. They are also present across
different races and cultures, although panics may be described and understood
differently according to specific cultural beliefs. Recognition of panic disorder in
other cultures has led to the translation of this workbook into several other
languages, including Chinese, Spanish, Korean, and Arabic.
Unhelpful Ways of Coping With Panic Attacks
We already mentioned a common way of coping with panic attacks: avoiding

situations where they might occur (i.e., agoraphobia). Although avoidance of
situations decreases anxiety in the short term, in the long term it contributes to
anxiety. The same is true for several others ways of coping with panic attacks,
including distractions, superstitious objects and safety signals, and alcohol.
Avoidance
In addition to avoidance of situations from which escape is difficult or help is not

easily available (i.e., agoraphobia), avoidance extends to avoiding activities and
other things. For example, consider the following behaviors.
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Do you avoid drinking coffee?
Do you avoid medication of any kind, even if prescribed by your doctor?
Do you avoid exercise or physical exertion?
Do you avoid becoming very angry?
Do you avoid sexual relations?
Do you avoid watching horror movies, medical documentaries, or very sad

movies?
Do you avoid being outside in very hot or very cold conditions?
Do you avoid being away from medical help?
Do you avoid being rushed?
Usually, these activities are avoided because they produce symptoms that are similar
to panic attack symptoms. Again, while avoidance helps relieve anxiety and panic in
the short term, it contributes to anxiety in the long term.
Distraction
Many people attempt to “get through” anxious situations by distracting themselves.

There is no limit to the methods used for distraction. For example, if you feel
yourself becoming anxious or panicky, do you:
Play loud music?
Carry around something to read?
Pinch yourself?
Snap an elastic band on your wrist?
Place cold, wet towels on your face?
Tell somebody who is with you to talk about something—anything?
Keep as busy as possible?
Keep the television on as you go to sleep?
Imagine yourself somewhere else?
Play counting games?
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Chances are that these types of distractions have helped you get through a panic
attack in the past and may well help you in the future. However, they can become a
crutch. For example, if you forget your reading material or your elastic band, you
may have to go home to get it. Also, in the long run, these strategies are not very
helpful. Distraction is like placing tape around a broken table leg without fixing the
break. We will discuss this further in chapter 5.
Superstitious Objects and Safety Signals
Superstitious objects or people are specific items or persons that make one feel safe.
(They are also called safety signals.) Examples include other people, food, or empty
or full medication bottles. If these objects or people were not around, you would
probably feel more anxious. The reality is these superstitious objects do not actually
“save” you because there is really nothing to be saved from. Other superstitious
objects are listed below.
Food or drink
Smelling salts
Paper bags
Religious symbols
Flashlights
Money
Cameras
Bags or purses
Reading material
Cigarettes
Pets
Portable phones
As with distractions, these objects become a crutch and can contribute to anxiety in
the long run.
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Alcohol
Perhaps you use a far more dangerous coping strategy—alcohol. We now know
that many men (moreso than women) drink to get through situations where they
might have a panic attack. In fact, from one third to one half of people with alcohol
problems began the long road to alcohol addiction by “self-medicating” anxiety or
panic. Using alcohol to cope with your panics and anxiety is extremely dangerous.
This is because while alcohol works for a little while, you are likely to become
dependent on the alcohol and require more and more of it. As you drink more and
more, the anxiety-reducing properties of alcohol become less and less. Instead,
anxiety and depression tend to increase. If you drink to control your anxiety, make
every effort to stop as soon as possible, and ask your doctor or mental health
professional for help.
How Does This Program Help You Cope With Panic and Agoraphobia?
Instead of relying on avoidance, distractions, superstitious objects, alcohol, or other

unhelpful methods, this program is designed to educate you and to teach
constructive ways of coping. This program focuses on ways of coping with panic,
anxiety about panic, and avoidance of panic. The kind of treatment that is
described in this program is called cognitive-behavioral therapy (CBT). CBT differs
from traditional psychotherapies in several important ways.
Unlike traditional psychotherapies, CBT teaches skills to manage anxiety and

panic. Specifically, you will be taught ways of slowing your breathing, ways of
changing the way you think, and ways of facing the things that make you anxious
so that they no longer bother you. For each set of skills, we begin with educational
information and then outline exercises to be practiced. Then, we build on the
previous practice by developing new skills. Finally, the skills are used to cope with
panic and anxiety.
Unlike traditional psychotherapies, you will be given homework assignments. Thus,

CBT is much like attending class and continuing to learn on your own by further
study between classes. In many ways, it is the self-study program that is the most
essential to your success.
Unlike traditional psychotherapies, we do not emphasize your childhood memories

and experiences (unless they are directly related to your panic attacks, as might
occur if witnessing someone die of a heart attack when you were a child led you to
fear that you will also die of a heart attack). Instead, CBT emphasizes interruption
of the factors that currently contribute to your panic disorder and agoraphobia. As
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you will see, it is this method that has proven to be highly effective.
A good beginning to CBT is education about what causes panic attacks.
What Causes Panic, Anxiety, and Agoraphobia?
The question of what causes panic, anxiety, and agoraphobia is very difficult, and
we do not know all of the answers just yet. We will discuss the subject in more
detail in chapter 2, but it is important to say several things here about the causes of
panic and anxiety.
Biological Factors
First, the research does not suggest that panic attacks are due to a biological
disease. Of course, there are the relatively rare examples mentioned above where a
medical condition does cause symptoms that resemble a panic attack, such as
hyperthyroidism or a tumor on the adrenal gland. However, common panic attacks
do not seem to be due to biological dysfunction.
Many people ask whether panic attacks are due to a chemical imbalance.
Neurochemicals are substances in the central nervous system, including the brain,
which are involved in sending nerve impulses. Neurochemicals that may influence
panic and anxiety include noradrenalin and serotonin. While these types of
substances may be present in greater amounts in the midst of anxiety and panic,
there is no evidence to suggest that a neurochemical imbalance is the original or
main cause of panic and anxiety. Some recent evidence using “brain scan”
procedures called Positron Emission Topography (PET) and functional magnetic
resonance imaging (fMRI) has shown that certain parts of the brain seem to be
particularly active in anxious patients. However, it is not at all clear whether these
findings are the effect of anxiety or the cause of anxiety.
On the other hand, certain biological factors that may be inherited or passed on
through genes may lead some people to be more likely to panic. Many believe that
what is inherited are overly sensitive parts of the nervous system which lead to a
tendency to experience all negative emotions, including anger, sadness, guilt, and
shame, as well as anxiety and panic. However, inheriting vulnerabilities to
experience negative emotions does not guarantee that you will experience panic
attacks or panic disorder. In other words, panic is not inherited in the same way
that, say, eye color is inherited. If you inherit the genetic structure for blue eyes,
then you will have blue eyes. You do not, however, inherit panic disorder in this
way. People probably inherit a tendency (or a vulnerability) to panic disorder—
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something that increases the chances of developing panic disorder but does not
guarantee it. Furthermore, even with a vulnerability to panic, it is possible to think
and act in ways that prevent panic attacks from recurring (which is exactly what we
teach in this program).
Biological factors (whatever they may be) probably help explain why panic disorder
tends to run in families. In other words, if one family member has panic disorder,
then another person in the same family is more likely to have panic disorder than
are others in the general population. That is, whereas 5–8% of the U.S. population
has panic disorder and/or agoraphobia, 15–20% of first-degree relatives (parents,
siblings, children) of someone with panic disorder themselves develop panic
disorder.
Psychological Factors
Psychological factors are important also. People who experience panic attacks tend
to have certain beliefs that lead them to be especially afraid of physical symptoms,
such as racing heart, shortness of breath, dizziness, and so on. The beliefs are that
physical symptoms are harmful, either mentally, physically, or socially. Examples of
such beliefs include thoughts that a racing heart could mean heart disease, that
lightheadedness could mean that you are about to pass out, that a growling stomach
could mean you will lose control of your bowels, that strong emotions mean that
you are out of control, or that a sense of unreality means that you are losing control
of your mind or going insane.
The sources of these beliefs are not fully known, but personal experiences with
health and illness may be one important contributor. For example, parents who are
overprotective about their child’s physical health may contribute to a general
overconcern about physical well-being in the child that gradually develops into
beliefs that physical symptoms are harmful. Or, the sudden and unexpected loss of
close family members to physical problems, such as heart attacks or stroke, may
increase the likelihood that someone believes that their own physical symptoms are
harmful. Another example is to observe another family member suffer through a
prolonged, serious illness.
However, beliefs are not the sole cause of panic attacks. As with the biological
factors described previously, beliefs that physical symptoms are harmful probably
increase the likelihood of panic attacks and panic disorder but do not guarantee
them. Furthermore, this type of psychological vulnerability can be offset by learning
to think and act in different ways.
Most likely, the vulnerability to panic is based on a complex interaction between
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psychological and biological factors. What we do know is that a panic attack is a
surge of fear that by itself is a normal bodily response. What makes it abnormal is
that it occurs at the wrong time; that is, when there is no real reason to be afraid.
Again, the response itself is normal and natural, and it would be the same kind of
reaction you would have if you were to face a real danger (such as being attacked by
a person with a gun). In addition, it is normal and natural to become anxious about
having another panic attack and to avoid places where you think that panic attacks
are likely to occur, if you believe that panic attacks are harmful to you.
What About Stress?
For most people, their first panic attack happened when they were under a lot of
stress. In addition to negative stressful events, such as job loss, stress can be positive
as well, such as moving to a new home, having a baby, or getting married. This
probably explains why panic attacks are more likely to begin in the 20s, since that is
when we tend to take on new responsibilities, such as leaving home and starting
new careers and relationships.
During stressful periods, everyone is more tense, and even little things become
harder to manage. Stress can increase overall levels of physical tension and can
lower your confidence in your ability to cope with life. Additionally, having to deal
with many negative life stresses can cause us to think of the world as a threatening
or dangerous place. For all these reasons, a situation that may normally be very
manageable becomes much more stressful when it occurs in the context of other
ongoing stress. Think of a woman who has recently lost her job and whose
marriage is breaking up. Within that background of stress, it may be much more
difficult for her to deal with traffic delays than if there were no background stress.
So, as a result, stress increases the chances of panic attacks. However, stress alone is
not an adequate explanation. Some people do not panic even though they are under
a lot of stress. Instead, they have other reactions to stress, such as headaches, high
blood pressure, or ulcers. It seems that stressful events increase the likelihood of
panic attacks in people who are vulnerable or susceptible to panic. These
vulnerabilities include the biological and psychological factors already described.
Furthermore, stress is rarely the reason why panic attacks persist. For example,
although panic attacks may have begun during a time of a lot of marital problems,
they are likely to continue even after the marital problems have been resolved. This
is because panic attacks and anxiety tend to take on a negative, self-maintaining
cycle of their own. This set of maintenance cycles is described in detail in chapter 2.
22
Is This Program Right for You?
The following list will help you to determine whether you can benefit from this
program.
Consider if you have experienced any of the following.
Episodes of abrupt and extreme discomfort or fear (i.e., panic)
At least some of the panic attacks include physical symptoms and fears, such
as:
Shortness of breath or smothering

Heart palpitations or racing or pounding heart
Chest pain or discomfort
Trembling or shaking
Feelings of choking
Sweating
Feeling dizzy, unsteady, lightheaded or faint
Chills or hot flushes
Nausea or abdominal distress
Feelings of unreality or detachment
Numbness or tingling
Fears of dying
Fears of going insane or losing control
At least one panic attack was unexpected or came from out of the blue
Persistent anxiety or worry about panic attacks, their consequences, or life

changes as a result of the attacks
Avoidance of different situations (such as driving, being alone, crowded areas,

unfamiliar areas) or activities (such as exercise) in which you expect to panic
The panic attacks are not the direct result of physical conditions or diseases
As already mentioned, panic attacks can be a part of all types of anxiety problems,
such as social phobia, obsessive-compulsive disorder (OCD), generalized anxiety,
posttraumatic stress disorder (PTSD), and specific phobias. Panic attacks may also
occur in mood disorders, such as depression. The distinguishing feature of panic
disorder is that the panic attacks themselves become the main source of anxiety and
concern. If you experience panic attacks but are not anxious about having panic
23
attacks, and instead, you are worried about other things, then consult with your
mental health professional to learn if a different treatment is more appropriate. You
fit this program if your main concern is the panic attacks themselves and, of course,
if the panic attacks are not the direct result of physical conditions or diseases.
Are You Receiving Other Psychological Treatments?
This program may be appropriate for you even if you have had contact with other
mental health professionals in the past for panic and anxiety. We have used this
program time and time again with people who have been through many different
forms of treatment. However, some consideration must be given to other treatment
that is ongoing with your participation in this program. We recommend that this
program not be combined with other psychotherapy that specifically addresses your
panic and anxiety. The reason for this is that messages from different treatments
for the same problem can become mixed and confusing. We find it much more
effective to do only one therapy for panic disorder at a time. On the other hand, if
you are receiving ongoing general therapy or therapy focused on a different
problem area (such as marital problems), then there is no reason why you cannot
participate in this program as well.
If you are involved in another psychotherapy that specifically addresses your panic
attacks and anxiety, we recommend that you pursue that treatment until you are
sure that either it is effective (in which case, no more treatment is needed) or that it
is ineffective (in which case, our program can be tried). As you will soon see, our
program has been shown to be very effective for many people, but that does not
mean that other psychotherapies should not be given a fair trial. Different forms of
therapy are more or less effective for different people. You must make this decision
if you are involved in another treatment for panic disorder and agoraphobia. To aid
this decision, the National Institute for Mental Health published an official
statement in 1991 in which it was recommended that decisions about whether
psychological treatments for panic disorder are beneficial or not should be made
after about six weeks, when the beginnings of improvements should be evident.
Furthermore, they recommended against continuing for years in psychotherapy for
panic disorder when there is no evidence for improvement.
Are You Taking Medications?
This program will be appropriate even if you use medications to control your
anxiety and panic, assuming that despite the medication, you continue to be
24
anxious about panic attacks. We say this because medications are not always fully
effective. For some people, medications are only mildly to moderately effective or
not effective at all. For others, medications are effective initially, but then relapse
occurs when the medication is stopped.
Fortunately, medication treatments can be successfully combined with this

program, and we discuss ways of achieving this in chapter 10. In addition, this
program has been found to be helpful for persons who want to stop their
medications. For those who have an interest in stopping their medications, we
make some suggestions in chapter 10 that can be combined with direct medical
supervision of the withdrawal process. It is definitely not wise to stop taking
medication on your own.
Brief Description of the Program
In this program, you will learn how to manage your panic attacks, anxiety about
panic, and avoidance of panic and agoraphobia situations. The program is divided
into 11 chapters, and several of the chapters have a number of different sections. In
each chapter, you will learn specific skills. An outline of the content of each chapter
is presented below. The skills build upon each other, so that in each new chapter or
each new section, you will use skills that you have learned previously. The program
is obviously structured, but there is room for individual tailoring.
A self-assessment section at the end of each chapter or each section lets you test
whether you have understood the information. If you have not, go back over the
material again. This is important, because each new step is based on the previous
steps. If you have understood the material presented in the chapter or chapter
section, then continue to the next. In addition, homework exercises are outlined at
the end of each chapter or section. Their importance cannot be emphasized
enough, as the success of the program is based largely on your completing them.
The pacing is somewhat up to you, but we recommend the following general pace.
The first phase, called the Basics, takes one week, in which you are to read chapters
2–4 and the first section of chapter 11. These chapters provide all the necessary
background information for you to begin learning specific strategies and will also
get you going in terms of recording your panic and anxiety. After at least a full
week of recording, you begin the Coping Skills phase that is devoted to developing
your hierarchy of agoraphobia situations (chapter 5) and learning regulatory
breathing (chapter 6) and thinking skills (chapter 7). The Coping Skills phase
should take about three weeks. Then, the subsequent six weeks or so should be
25
devoted to the Exposure phase, which involves repeated practice in facing
agoraphobia situations (chapters 8 and 9) and facing frightening physical symptoms
(chapter 10). The amount of time in the Exposure phase is very much dependent on
the number of agoraphobia situations and the number of symptoms which cause
you to feel anxious. Considerations about how to stop medication (chapter 11,
section 2) and strategies to maintain your progress in the long term (chapter 12) are
covered in the last phase, Planning for the Future. Here is the list of chapters:
Mastery of Your Anxiety and Panic Treatment Program Outline
Chapter 1. Introduction
Basics
Chapter 2. Learning to Record Panic and Anxiety
Chapter 3. Negative Cycles of Panic and Agoraphobia
Chapter 4. Panic Attacks Are Not Harmful
Coping Skills
Chapter 5. Establishing Your Hierarchy of Agoraphobia Situations
Chapter 6. Breathing Skills
Chapter 7. Thinking Skills
Exposure
Chapter 8. Facing Agoraphobia Situations
Chapter 9. Involving Others
Chapter 10. Facing Physical Symptoms
Planning for the Future
Chapter 11. Medications
Chapter 12. Accomplishments, Maintenance, and Relapse Prevention
The following outline presents a recommended pace, although you should once
again recognize that the pace is likely to shift based on your own profile of panic,
anxiety, and agoraphobia. For example, you will spend much less time on chapter 8
if you avoid only a limited number of agoraphobia situations.
Week 1 Chapter 2: Learning to Record Panic and Anxiety
26
Chapter 3: Negative Cycles of Panic and Agoraphobia
Chapter 4: Panic Attacks Are Not Harmful
Chapter 11, Section 1: Medications (Education)
Week 2 Chapter 5: Establishing Your Hierarchy of Agoraphobia Situations
Chapter 6, Section 1: Breathing Skills (Diaphragmatic Breathing)
Chapter 7, Sections 1 and 2: Thinking Skills (Basics; Realistic Odds)
Week 3 Chapter 6, Section 2: Breathing Skills (Slow Breathing)
Chapter 7, Section 3: Thinking Skills (Putting Things Into Perspective)
Week 4 Chapter 6, Section 3: Breathing Skills (Coping Application)
Chapter 7, Section 4: Thinking Skills (Review; Memories)
Chapter 8, Section 1: Facing Agoraphobia Situations (Planning)
Chapter 9: Involving Significant Others
Week 5 Chapter 6, Section 4: Breathing Skills (Review)
Chapter 8, Section 2: Facing Agoraphobia Situations (Review and

Planning)
Chapter 10, Section 1: Facing Physical Symptoms (Assessment and

Practice)
Week 6 Chapter 8, Section 2: Facing Agoraphobia Situations (Review and

Planning)
Chapter 10, Section 2: Facing Physical Symptoms (Review and Practice)

Planning)
Chapter 10, Section 2: Facing Physical Symptoms (Review and Practice)

Planning)
Chapter 10, Section 3: Facing Physical Symptoms (Review and Practice,

Activities Planning)

Planning)
27
Week 10 Chapter 8, Section 3: Facing Agoraphobia Situations (Symptoms)

Week 11 Chapter 8, Section 3: Facing Agoraphobia Situations (Symptoms)

Week 12 Chapter 11, Section 2: Medications (Stopping Medications)
Chapter 12: Accomplishments, Maintenance, and Relapse Prevention
Finally, we recommend that you work on this program with your doctor or mental
health professional. That person can provide additional information, advice, and
guidance as you learn the various skills and conduct the different exercises.
Furthermore, your doctor or mental health professional can help to tailor the
program to your own needs.
For the period of time that you give to this program, it must become a priority. Just
as up until this time, fear has been your major focus, achieving mastery of your
anxiety and panic should now be your major focus.
What Benefits Will You Receive From This Program?
What should you expect to get out of this program? This information is important
in your decision to participate in our program. Research that we have conducted
over the last 20 years shows this treatment to be very successful. The percentage of
people who report that they are free of panic at the completion of a program similar
to this one is 70–90%. This rate of success has been replicated by other researchers
around the world who have tested treatments similar to this one. What is even
more exciting is that these results seem to persist over long periods of time—up to
24 months after treatment, which is the longest period we have examined. One of
the reasons for this long-term benefit is that the treatment is essentially a learning
program. When something is learned, it becomes a natural part of your reactions
and therefore is carried with you even after the formal program has been
completed. You may have ups and downs, but by completing this program, you will
be able to handle the downs much more effectively and return to normal
functioning more easily.
28
On the basis of results obtained as early as 1991, the National Institute of Mental
Health came out with an official statement recognizing that the treatments of
choice for panic disorder are either this type of program (CBT) and/or medication
therapy. Obviously, there is never a guarantee that this treatment will be the one
for you or that you may never panic again, but from the success rates, it would seem
that this program is worth trying.
These numbers refer to the success with which panic attacks are controlled.
Remember that many people who panic develop agoraphobia as well. Treatment
programs focused on agoraphobia per se produce significant improvements in 60–
80% of our patients. Again, this rate of improvement is maintained—and, in fact,
improvement usually continues—up to two years after treatment completion.
(Again, this is the longest duration that we have evaluated.)
What Is the Cost?
Knowing how effective these programs are, the question for you becomes, “What is
the cost?” Mainly, the cost is time and effort over the next 10–12 weeks. One (and
perhaps the only) factor known to predict the effectiveness of this program is the
amount of practice that is conducted. The more you put in, the more you will get
out of the program. It is not the severity of your panic and avoidance, how long you
have been panicking, or how old you are that predicts success; rather, it is your
motivation to learn to change. Do you have the motivation at this time to give it
your best shot? One point to keep in mind is that you are probably putting out as
much energy and effort into trying to manage your life with panic and anxiety as
you would by going through this program. But the big plus from this program is
that the energy and effort result in positive changes.
If you really do not have the motivation right now, then it is better to wait, because
you will be defeating yourself by beginning a program like this halfheartedly.
Finally, even if your fear and anxiety diminish quickly as you proceed through the
program, we recommend that you finish the program. It will prove more effective
in the long run to complete the entire program, in the same way that it is more
effective to complete a prescription of an antibiotic even if bacterial symptoms clear
up early on.
29
Figure 1.1.
Decision Tree
Homework
Read chapters 2–4 and chapter 11, section 1.
Self-Assessment
Answer each of the following by circling T (True) or F (False). Answers are given
in the appendix.
1. It is possible for people to have panic attacks but not have a

diagnosis of panic disorder. T F
2. In addition to the unpleasant physical symptoms, panic attacks

involve thoughts of going insane, losing control, or dying. T F
3. Panic attacks and agoraphobia are very rare problems, affecting

less than 1% of the population. T F
4. Children of parents who have panic disorder are at no greater

risk for developing panic disorder than children whose parents
30
do not have panic disorder. T F
5. Superstitious objects, distractions, alcohol, and methods of

avoidance have one thing in common—they contribute to
anxiety and panic in the long term. T F
6. You are born with panic disorder, and there is nothing you can
do about it once you have the genes for it. T F
31
Chapter 2 Learning to Record Panic and Anxiety
Goals
To learn the importance of record-keeping
To learn ways to record panic, anxiety, and other moods
Record-Keeping
This chapter presents the importance and method of record-keeping. For the rest
of the time that you are involved with this program, you are asked to keep ongoing
records of your panic and anxiety, among other things. Record-keeping is necessary
to the success of this program.
Why Take the Time to Record? I Know I Am Anxious!
There are many reasons why it is important to keep records of your anxiety on a
regular, ongoing basis. First, panic attacks, particularly those that seem to occur for
no real reason, make people feel as if they are out of control and victims of their
own anxiety. Learning to be an observer as opposed to a victim of your own anxiety
is a first step toward gaining control. Through record-keeping, you will learn to
observe when, where, and under what circumstances your panic and anxiety occur.
You will learn whether your panic attacks occur when you are alone or with others,
after a stressful day at work or on weekends, in the middle of the day or at the end
of the day; whether your panic attacks are brought on by feelings of excitement
from watching a sports event on television, feeling overheated by a crowded
shopping area, feeling suffocation from a steamy shower, thinking about horrible
things that could happen, or by relaxing and having nothing else to do but dwell on
your fears. Again, gaining an understanding of the factors that cause your panic and
anxiety to escalate will lead you to feel more in control and like less of a victim.
Second, you will learn to understand the way in which you experience panic and
anxiety, in terms of what you think, what you feel, and what you do. This is very
32
important, because this program is designed specifically to change anxious
thinking, anxious feelings, and anxious behaviors. They cannot be changed without
knowing exactly what they are.
Third, ongoing record-keeping provides much more accurate information than you
get by just asking yourself, “How have I been feeling lately?” If you were asked to
describe the last week, you may judge it to have been “very bad” when, in fact, there
may have been several times when you felt relatively calm. When anxiety is on your
mind so much, it is easy to forget about the times when you were not anxious. As
you can probably see, thinking about the previous week as “very bad” and
overlooking relatively “okay” times during the week are likely to make you feel
worse and more anxious. In fact, such negative judgments about how you have been
doing in general may contribute to ongoing anxiety. By keeping ongoing records,
you will not only feel more in control but also feel less anxious by being forced to
recognize that your mood state fluctuates and that there are times when you feel
less anxious than other times.
Finally, recording helps you to evaluate progress. For this reason, we recommend
that you continuously record throughout the entire program. Continuous recording
will let you appreciate the gains you make and will help to prevent occasional panic
attacks from overshadowing the progress you have made.
Let us review all of the benefits of ongoing recording, as well as the reasons why it
is crucial to this program:
to help you feel more in control, by being able to identify when and where
panic attacks are more likely to happen;
identify the specific ways in which you experience anxiety; your physical
feelings, your thoughts, and your behaviors;
to be able to judge your level of anxiety and panic more accurately;
to evaluate the success of your attempts to change.
What Is Objective Recording?
Sometimes, people are concerned that by continually recording their panic and
anxiety, they will be reminded of how anxious they feel, which in turn will make
them feel even more anxious. To address this concern, it is important to distinguish
between two ways of recording: subjective recording and objective recording.
33
Subjective recording means recording “how bad you feel,” how terrible the panic
attacks are, how much they interfere with your life, or how you cannot control
them. Examples include statements such as “I don’t feel well, I could panic today;
what if I get so dizzy that I have to go home?” Or, “I am really anxious. I wish
these feelings would go away. What if they get worse?” This type of subjective
recording tends to increase anxiety. Subjective recording is likely to be something
that you already do and, at the same time, may be something that you try to avoid
because it worsens your overall anxiety.
Objective recording, which is the technique that you will be learning in this chapter,
means recording the features of panic and anxiety in a concrete and nonjudgmental
way. You will learn to record things such as the number or intensity of symptoms,
the triggers of your panic, your thoughts, and your behavioral responses to panic.
At first, it may be difficult to switch from subjective to objective recording, and as

you start to use the records, you may indeed notice an increase in your anxiety
because you are focusing on your feelings in the old, subjective way. However, with
practice, most people are able to shift to the objective mode. To help you do this,
we have developed very specific forms on which very specific objective information
is to be recorded. These will be described soon.
What Do I Record?
Panic Attacks
You will record your panic attacks using the Panic Attack Record shown here. You
may photocopy the form from this book or download multiple copies from the
Treatments ThatWorkTM website (http://www.oup.com/us/ttw). Use this form
whenever you experience a panic attack or a sudden rush of fear. Remember, panic
is different from anxiety. Panic attacks are sudden rushes of fear, and they can
happen when you are fully relaxed or when you are already anxious. Panic attacks
peak quickly and then decrease within 10–30 minutes, although you may continue
to feel some of the symptoms and to feel generally anxious for quite a while
afterward. This is called residual anxiety. You may even panic again in the midst of
the residual anxiety. (See Figure 2.1.)
34
Figure 2.1.
Progression of Panic and Anxiety Over Time
In contrast, anxiety builds more slowly. At times, anxiety may be very intense and
severe, as it would be before a surgery or while waiting for the results of a test.
Anxiety is best described as worrying about something in the future, even if the
future is only an hour away. Panic, on the other hand, is a rush of fear with
thoughts of immediate catastrophe (e.g., “I am dying”).
Do not wait until the end of the day to complete the Panic Attack Record, as you
will lose the value of recording. Complete it as soon as possible after you panic. Of
course, some circumstances, such as driving or talking in a meeting, make it hard to
fill out the Panic Attack Record, but complete it as soon as possible.
35
On the Panic Attack Record, write down the date and the time that the panic
attack began, and also note the triggers that seemed to bring on the panic attack.
Triggers could include a stressful situation, an anxious thought, or an
uncomfortable physical symptom. Even if you do not know what brought on your
panic attack, list the thing that you noticed just before you panicked. You will also
record whether the panic was unexpected or “out of the blue,” as well as the
maximum level of fear you experienced during the panic attack. Use a 10-point
scale, where 0 = no fear, 5 = moderate fear, and 10 = extreme fear. You should also
record each symptom that was present to at least a mild degree, your thoughts
about what might happen, and your behaviors or what you did in response to the
panic.
Examples of Panic Attack Records completed by Jill are shown here. Jill is 29 years
old, married, and has one child. She began to panic one year ago, when her child
was a few months old. Since then, she has been afraid to stay home alone with her
baby and often spends the day at her mother’s place, while her husband is at work.
From Jill’s first record, it can be seen that this panic occurred at 5:20 p.m. on
February 16. She panicked while she was alone at home, waiting for her husband to
return from work. She noted that the panic was brought on because she was home
alone and felt short of breath. It was an expected panic; Jill was not surprised that
she panicked because being home alone is a stressful situation for her. Her
maximum fear rating was an 8, which is strong. Symptoms included racing heart,
difficulty breathing, sweating, trembling and shaking, feelings of unreality, and a
fear of losing control or going insane. Her thoughts were that she would lose
control or go insane, and her behavioral response was to call her mother.
36
37
Figure 2.2.
Jill’s Panic Attack Record (1)
38
Figure 2.3.
Jill’s Panic Attack Record (2)
As shown in her second record, Jill’s panic attack happened at 3: 00 a.m. on

February 19. This panic woke her out of sleep. In fact, the racing of her heart
seemed to wake her out of sleep, so she listed racing heart as the trigger. The attack
was unexpected. It took her by surprise. Her maximum fear was 7. Her symptoms
included racing heart, breathing symptoms, sweating, shaking, and fears of dying.
Her thoughts were that she would die, and her behavior was to wake her husband.
Anxiety and Other Moods
You can keep a record of your general feelings throughout the day as well, by
39
completing a Daily Mood Record at the end of each day. You may photocopy the
form from this book or download multiple copies at the Treatments ThatWorkTM
website (http://www.oup.com/us/ttw). Use a 10-point scale to rate your daily levels
of anxiety, depression (i.e., how sad, down, or lacking in energy you are), and how
much you worry about having a panic attack (i.e., how much is panic on your mind,
how concerned are you with the possibility of panicking).
For all ratings, 0 = none, 5 = moderate, and 10 = extreme anxiety, depression, and
worry about panic. These ratings are based on how you felt on average during the
day. In other words, considering the whole day, and combining all ups and downs
throughout the day together, what was your average amount of anxiety, depression,
and worry about panic?
Jill’s Daily Mood Record shows that over the course of the week, her patterns of
anxiety, depression, and worry about panic changed. On February 16 and 17, Jill
was quite worried about having a panic attack; these were the first two days after a
weekend spent with her husband. Notice how she was also generally more anxious
and depressed on those days compared to other days. In contrast, on February 21
and 22 (the weekend), she felt less anxious, less depressed, and less worried about
panicking because her husband was with her the whole time.
Over the course of several weeks, trends often become evident. One example is the
way in which moods fluctuate in relation to the frequency of panic attacks. It will
be important to learn this information to make your treatment as effective as
possible.
Daily Mood Record for Jill
Rate each column at the end of the day, using a number from the 0–10-point scale below.
40
Figure 2.4.
Jill’s Daily Mood Record
Progress Record
The Progress Record is a chart of your progress which is divided into the number
of panic attacks per week and the average level of anxiety per week. Of course, you
may also record your progress in other areas as well, such as worry about panic or
level of depressed mood. This Progress Record will allow you to see how you are
doing and to put things into perspective. It is helpful to keep this in a visible place,
such as your bathroom mirror or on the refrigerator. You may photocopy the form
from this book or download multiple copies at the Treatments ThatWorkTM
website (http://www.oup.com/us/ttw).
Daily Mood Record
Rate each column at the end of the day, using a number from the 0–10-point scale below.
41
Summary
We cannot emphasize enough the importance of recording. It must be done daily

to get the full benefit from this program. While at first you may have to push
yourself to record, it will become easier and even rewarding as time goes on. It
helps to give yourself feedback, and it is also beneficial for your mental health
professional if you provide this kind of information. These records will be
invaluable during the rest of the program, so it is definitely worth the effort.
Progress Record
For each week, plot the number of panic attacks you experienced and your average anxiety level for that week.
42
Homework
Record your panic attacks and daily mood levels for at least one full week using the
Panic Attack Record and Daily Mood Record.
Read chapters 3 and 4 and chapter 11, section 1, over the course of the week as you
record.
Self-Assessment
in the appendix.
1. Ongoing recording is important because it provides a more

accurate description of fear and anxiety than do vague
generalities or attempts to remember from the past. T F
2. Objective, matter-of-fact recording of anxiety and panic will

cause more anxiety and panic attacks. T F
43
3. Recording of panic attacks is best done at the end of the day. T F
4. Recording helps to identify the conditions and triggers that

provoke panic. T F
5. Recording of anxiety and other moods is done at the end of the

day. T F
44
Chapter 3 Negative Cycles of Panic and Agoraphobia
Goals
To learn about the purpose of anxiety and panic
To learn about the parts to anxiety and panic
To discover your own thoughts, behaviors, and physical symptoms
To understand the negative cycles that contribute to panic attacks and agoraphobia
To understand how this treatment interrupts the panic and agoraphobia cycles
The Purpose of Anxiety and Panic
Anxiety and panic are natural emotional states that are experienced by everyone—it
is part of the experience of being human. Anxiety is the reaction that we all have
whenever we think something bad or threatening could happen. This could include
physical threats, such as the possibility of illness, accident, or death; social threats,
such as the possibility of embarrassment, rejection, or ridicule; or mental threats,
such as the possibility of going insane, losing control, or losing one’s mental
faculties. The threats could be large (such as the possibility of losing one’s life) or
small (such as the possibility of being late for an appointment). Anxiety is our way
of preparing to meet the challenge posed by these threats. It helps to gear us up and
protect us from whatever is threatening.
Anxiety is not bad in and of itself, and it can be a productive, driving force. Years of
research have shown that having some anxiety enhances performance. That is, you
do better at what you are doing, whether in the classroom or on the job, when
anxiety is present up to a certain level. Imagine absolutely no anxiety about a job
interview—you would be less motivated to put your best foot forward to meet the
challenge of getting the job. However, anxiety can vary in severity, from mild
uneasiness to extreme distress. At the extreme end, anxiety can interfere with what
you are doing. Imagine extreme anxiety in a job interview which leads to poor
concentration and stammering. The notion that some anxiety is helpful for learning
and performance, whereas too much anxiety can interfere with learning and
45
performance, is shown above in the standard diagram of the Yerkes-Dodson Law.
Figure 3.1.
Yerkes-Dodson Law
Anxiety can vary in frequency, from occasional episodes to seemingly constant

unease. When anxiety is very frequent, it can interfere with daily life. The goals of
this program are to decrease the likelihood of becoming anxious unnecessarily and
to decrease the intensity of anxiety so that you can function normally. The goal,
however, is not to remove anxiety altogether.
How does this discussion relate to panic disorder? In the case of panic disorder,
anxiety is experienced because of the “threat” of panic. As described in more detail
in the next chapter, panic is regarded as threatening because of beliefs that panic
could cause you to die, lose control, or go insane. As you will see, these beliefs are
incorrect. Anxiety about the threat of panicking is unnecessary because panic
attacks actually are not harmful.
The Parts to Anxiety and Panic
There are three major parts to panic and anxiety: physical symptoms, thoughts, and
behaviors. The physical part involves the symptoms of rapid heartbeat, difficulty
breathing, nervous stomach, diarrhea, sweating, shaking, headaches, stomachaches,
a lump in the throat, frequent urination, fatigue, restlessness, visual disturbances, a
sense of pressure in the head, and many more. The physical symptoms can be
acute, lasting a short period of time (as in panic attacks), or can be prolonged,
lasting hours or days (as in general anxiety). Also, the acute physical symptoms can
shift from one panic attack to the next. On one occasion, you may notice strong
symptoms of shortness of breath, while on another occasion you may instead notice
a racing and pounding heart.
46
The thoughts are beliefs, or things that we say to ourselves, or images of impending
doom or of something terrible that is about to happen. We refer to these as
negative thoughts. Most often, thoughts during panic attacks are about immediate
physical catastrophes (such as fainting, dying, heart attack, brain tumor), social
catastrophes (such as ridicule or jeering), or mental catastrophes (such as going
insane or losing control). Thoughts during anxiety are about bad things that could
happen in the future, such as job loss or the worst panic attack ever.
The behaviors are things we do, such as pacing up and down, fidgeting, or escaping
from or avoiding places where anxiety and panic are expected to occur. An example
of escaping is to leave a shopping mall as soon as feelings of anxiety or panic
develop. An example of avoiding is to not enter a shopping mall at all because of
concerns about panicking once inside. Other behaviors include looking for exits or
ways out of situations, relying on objects that make you feel better (these are the
superstitious objects we described in chapter 1), or seeking help (such as at medical
centers).
These three parts often differ from times when you are anxious to times when you
panic. Thoughts during anxiety usually have to do with the future (e.g., “My boss
could give me a negative evaluation at the end of the year,” or, “It would be horrible
if I panicked at the party tomorrow”), whereas thoughts during panic attacks are
usually about the immediate situation (e.g., “I am going to faint right now,” or, “I
must be crazy”). Also, anxious behaviors include avoiding situations or extra
cautiousness (such as mapping out directions fully in advance), whereas behaviors
during panic have more to do with escaping or finding help. Finally, physical
symptoms during anxiety usually are long lasting and involve muscle tension,
restlessness, and fatigue; whereas panic attack symptoms are more abrupt and tend
to decrease more quickly than the physical symptoms of anxiety, and include heart
palpitations, shortness of breath, and other symptoms listed in the table in chapter
1.
Your Own Physical Symptoms, Behaviors, and Thoughts
Think about your own thoughts, symptoms, and behaviors when you are in the
midst of a panic attack, and consider your own thoughts, symptoms, and behaviors
when you are generally anxious (such as when you are worrying about having a
panic attack in the future).
Remember Jill? During her panic attacks, her most common symptoms were a
racing heart, shortness of breath, and feelings of unreality and numbness; her most
47
common thoughts were that she would lose control or go insane; and her most
common behaviors were to leave wherever she was and find either her husband or
her mother. In contrast, when she worried about panic attacks in the future, her
thoughts varied based on whatever she was worrying about; her most common
symptoms were an upset stomach, muscle tension, and fatigue; and her most
common behaviors consisted of biting her nails and seeking reassurance from her
husband that everything would be okay.
On the Parts of Panic and the Parts of Anxiety forms provided on pages 45 and 46,
record what you typically think, what you physically feel, and what you do when
you panic and when you feel anxious. You may photocopy these forms from the
book or download multiple copies at the Treatments That WorkTM website
(http://www.oup.com/us/ttw).
The Panic Cycle
Physical symptoms, thoughts, and behaviors contribute to each other in what is

called a negative cycle. In other words, they tend to snowball off each other. For
example, negative thoughts can directly increase physical symptoms. If we tell
ourselves that something dangerous is about to occur (e.g., “I am about to have a
heart attack”), then physical tension will increase because our bodies pump out
more adrenalin and operate at faster rates whenever we face danger. In turn, a
physical symptom, such as a racing heart, may lead to more negative thoughts. This
is particularly likely if you believe that normal symptoms of tension are dangerous
(e.g., “The fact that my heart rate has not slowed down must surely mean that
something is terribly wrong”). Behaviors of fidgeting, pacing, and escaping a
situation can increase levels of physical tension as well because of the physical effort
they involve.
Parts of Panic
Physical Symptoms
1.
2.
48
3.
Thoughts
1.
2.
3.
Behaviors
1.
2.
3.
49
Parts of Anxiety
Physical Symptoms
1.
2.
3.
Thoughts
1.
2.
3.
Behaviors
1.
50
2.
3.
Figure 3.2.
The Panic Cycle
More specifically, the thought that a racing heart is a sign of heart disease is
frightening and will produce more raciness of the heart. In turn, the continued
raciness may lead to stronger beliefs that something is terribly wrong with the
heart. It may also lead to attempts to get medical help. Such negative thoughts and
behaviors may again prolong the racing of the heart. In other words, negative
thoughts lead to fear, and fear leads to more physical symptoms and escape
behaviors that snowball into more negative thoughts, and so on. The end result is
intense fear or panic, as is shown in Figure 3.2. This is called a panic cycle. Another
example is to think that shortness of breath means that you are about to suffocate.
That thought will cause more physical tension and more symptoms of shortness of
breath, as well as attempts to breath more deeply, which in turn may contribute to
shortness of breath (for reasons described later), and so on.
In contrast, thinking that a racing heart is harmless and not reason for concern will
interrupt this negative cycle, with the end result that panic does not occur. This is
51
shown in Figure 3.3. Similarly, realizing that shortness of breath is not a sign of
impending suffocation will offset the chances of a panic attack.
Think about a recent panic attack and the physical symptoms, negative thoughts
and behaviors, and the ways in which they contributed to each other. What was the
first thing that happened? Was it a physical symptom or a thought? What
happened next? Did your physical symptoms increase, and what did that lead you
to think? How did you behave? How did your reactions influence your physical
symptoms? An example of this kind of step-by-step analysis is provided in the next
section.
Figure 3.3.
Interruption to Panic Cycle
Case Studies: Step-by-Step Analysis
The very first thing I felt was when I stood up—my head started to feel really weird, as
if it was spinning inside [physical symptom]. My reaction was to hold onto the chair
[behavior]. I thought something was wrong [negative thought]. I thought it could get
worse and worse and that I would faint and collapse [negative thought]. By then, I was
feeling very nervous. As the dizziness got worse and worse [physical symptom], I became
really concerned, because it was different from any other experience I had ever had. I was
convinced that this was “it”—that I was going to collapse and that nobody would find me
[negative thought]. That’s when I called my husband [behavior] and waited for him to
arrive [behavior].
Here is another example.
I was sitting in front of the television watching ER. They were showing a scene of
someone dying from a heart attack. I felt a slight pain in my chest [physical symptom] and
52
immediately started to wonder if something was wrong—maybe I was having a heart
attack [negative thought]. My heart began to pound and speed up [physical symptom],
and I became very nervous. My breathing was faster [physical symptom]. I took my pulse
and started to walk around to distract myself [behaviors]. But my heart rate was still
going fast, and I felt like I couldn’t get a deep breath of air [physical feelings]. I was sure
that I was going to collapse at any moment [negative thought]. I thought of calling 911
but decided to just sit by the phone for a while [behavior], and then eventually, the
feelings passed.
Use the Step-by-Step Panic Analysis of Panic Attack form (on page 50) to
understand one of your own recent panic attacks. You may photocopy the form
from this book or download multiple copies from the Treatments That WorkTM
website (http://www.oup.com/us/ttw).
By understanding these cycles (from negative thoughts, to physical symptoms, to

behaviors, to more negative thoughts and more physical symptoms, and so on), you
will develop a good awareness of what causes panic attacks. These records will also
help you to understand that the way to interrupt these cycles is to change the way
you think about and respond to physical symptoms.
Agoraphobia Cycle
If you are anxious about physical symptoms, it is likely that you are especially
watchful for those symptoms as you enter a situation from which escape is not easy
or in which help is not available. For example, you might be particularly attentive
to dizziness as you drive on an unfamiliar road. If you become afraid of the
symptom in that situation, then it is understandable how you might feel panicky or
that you would attempt to find an exit. However, by escaping the situation, you
may feel even more anxiety the next time you attempt to enter that situation, and
you may feel even less likely to enter the situation in the future. That is, the fear has
been reinforced because you did not learn that it was safe to continue in the
situation, despite the physical symptoms. This sequence of events is shown in
Figure 3.4.
Interrupting Panic and Agoraphobia Cycles
This program teaches you ways of interrupting the panic and agoraphobia cycles. It
consists of strategies to help you think differently about and to behave differently
toward physical symptoms. It teaches you how to no longer be panicked by physical
53
symptoms and to no longer avoid physical symptoms or the situations in which
they are expected to occur.
Step-by-Step Analysis of Panic Attack
Where were you and what was going on when the panic attack first started?
What happened first? A physical symptom, negative thought, or a behavior?
What happened next? How did you react to the first physical symptom or negative thought? Did you notice
more physical symptoms, more negative thoughts, or did you do something, such as seek help, lie down, or
exit wherever you were?
What happened next? Did the physical symptoms get worse, did you become even more scared about negative
things happening?
54
What was next?
How did it end?
Figure 3.4.
The Agoraphobia Cycle
55
You will be taught two coping skills. The first strategy is breathing skills. Breathing
skills are designed to regulate breathing and interrupt the panic and agoraphobia
cycles by providing a tool for you to continue in whatever activity you are engaging
and face your fear rather than avoid it. The second coping skill is directed at your
negative thoughts. Once you are able to discover exactly what negative thoughts
you have, you will learn to treat them as guesses rather than facts. You will develop
alternative ways of thinking that are more based on evidence than conjecture.
You will use these two coping skills to help deal with the situations that you have
been avoiding because of anticipation of panic attacks (i.e, agoraphobia). You will
learn to be less afraid of these situations and to realize that they are harmless. In
addition, you will use the coping skills to deal directly with physical symptoms that
make you anxious, such as shortness of breath, dizziness, or palpitations. You will
learn to be less afraid of those symptoms and to realize that they are harmless. You
will learn how to deal directly with the physical symptoms when they occur in
agoraphobia situations. Everything you learn in this treatment must be put into
practice over and over again until it becomes part of your natural method of
responding.
Homework
Continue to record your anxiety and panic for one week using the Panic Attack
Record and the Daily Mood Record.
Read chapter 4 and chapter 11, section 1, over the course of the week of recording.
Self-Assessment
in the appendix.
1. Anxiety and panic are made up of three main parts: physical

symptoms, negative thoughts, and behaviors. T F
2. One should never feel anxious. T F
3. What you think has absolutely no effect on what you feel

physically. T F
4. Panic attacks just hit you—there is no reason for them. T F
56
5. Anxiety is usually in anticipation of future dangers, whereas
panic is a sudden rush of fear in response to immediate dangers. T F
6. The treatment program presented in this workbook involves

positive thinking, meditating, and chilling out. T F
7. Avoidance of an agoraphobia situation has no long-term

negative effect. T F
57
Chapter 4 Panic Attacks Are Not Harmful
Goals
To learn about the causes of the physical symptoms of panic
To learn that the physical symptoms of panic are not harmful
To understand why panic attacks seem to come from “out of the blue”
Physical Symptoms of Panic and Survival of the Fittest
Because negative thoughts contribute to panic, and because the negative thoughts
often have to do with believing that the physical symptoms are harmful, it is
important to have an accurate understanding of the physical symptoms of panic.
This information will help you realize that the physical symptoms of panic are not
harmful.
Scientifically, immediate or short-term fear (i.e., a panic attack) is named the fight-
flight response. The effects of this response are aimed toward either fighting with or
fleeing from danger. The number-one purpose of panic is to protect us from
danger. When our ancestors lived in caves, it was vital that when faced with danger,
an automatic response would take over, causing them to take immediate action
(attack or run). Even in today’s hectic world, this is a necessary mechanism. Just
imagine if you were crossing a street when suddenly a car sped toward you blasting
its horn. If you experienced absolutely no fear, you would be killed. What actually
happens is that your fight-flight response takes over, and you run out of the way.
The purpose of panic is to protect us, not to harm us. It is our survival mechanism,
and it involves the following physical changes in our bodies.
Nervous and Chemical Effects
When danger is detected, the brain sends messages to a section of your nerves
called the autonomic nervous system. The autonomic nervous system has two
subsections, or branches, called the sympathetic nervous system and the
parasympathetic nervous system. These two branches of the nervous system are
58
directly involved in controlling your body’s energy levels and its preparation for
action. The sympathetic nervous system is the fight-flight system, which releases
energy and gets the body ready for action (fighting or fleeing).The parasympathetic
nervous system is the restoring system, which returns the body to a normal state.
Activation of the sympathetic nervous system is believed to cause most panic attack
symptoms.
The sympathetic nervous system tends to be an all-or-none system. When it is

activated, all of its parts respond. This may explain why most panic attacks involve
many physical symptoms and not just one or two. In addition, the sympathetic
nervous system responds immediately, as soon as danger is close at hand (e.g., think
of the rush that you experience when you think another car on the freeway is about
to hit you). That is why the physical symptoms of panic attacks can occur almost
instantaneously, within seconds.
The sympathetic nervous system releases two chemicals, adrenalin and

noradrenalin, from the adrenal glands on the kidneys. These chemicals are used as
messengers by the sympathetic nervous system to continue activity so that once
activity begins, it often continues and increases for some time. However, the
sympathetic nervous system activity is stopped in two ways. First, the chemical
messengers adrenalin and noradrenalin are eventually destroyed by other chemicals
in the body. Second, the parasympathetic nervous system (which generally has
opposing effects to the sympathetic nervous system) becomes activated and restores
a relaxed feeling. Eventually, the body will “have enough” of the fight-flight
response, and the parasympathetic nervous system will restore a relaxed feeling. In
other words, panic can neither continue forever nor spiral to ever-increasing and
damaging levels. The parasympathetic nervous system stops the sympathetic
nervous system from getting “carried away.”
Adrenalin and noradrenalin take some time to be fully destroyed. Even after your
sympathetic nervous system has stopped responding, you are likely to feel “keyed
up” or “on edge” for some time because the chemicals are still floating around in
your system. This is perfectly natural and harmless. In fact, there is a purpose to
this—in the wild, danger often has a habit of returning. So, it is useful for us to
remain in a “keyed-up” state so that we can quickly reactivate the fight-flight
response if danger returns.
Each physical effect of the fight-flight system is intended to prepare you to fight or
flee—that is, to protect you. The fight-flight system affects our hearts, blood flow,
breathing, sweating, pupils, muscles, and digestive system, as well as other parts of
our body.
59
Cardiovascular Effects
Activity in the sympathetic nervous system increases heart rate and the strength of
the heartbeat. This is vital to preparation for action (to fight or flee) because it
speeds up the blood flow, improving delivery of oxygen to the tissues and removal
of waste products from the tissues. The muscle tissues need oxygen as a source of
energy for fighting or fleeing. This is why a racing or pounding heart is typically
experienced during periods of high anxiety or panic.
Also, there is a change in the blood flow. Basically, blood is taken away from the
places where it is not needed (by a tightening of the blood vessels) and is directed
toward the places where it is needed more (by an expansion of the blood vessels).
For example, blood is taken away from the skin, fingers, and toes. This is useful
because, thinking back to our ancestral cave days, the extremities are the most likely
place to be attacked and injured. Having less blood flow there means that we are
less likely to bleed to death. As a result, the skin looks pale and feels cold, especially
around the hands and feet. Instead, the blood goes to the large muscles, such as the
thighs, heart, and biceps, which need the oxygen for fighting or fleeing. The big
muscles are most important for running or fighting.
Together, these physical changes cause the heart to race or pound and the skin to
feel pale and cold, especially around the toes and fingers, sometimes causing
feelings of weakness in the hands and feet. You might feel cold even though it is a
warm day. These are normal physical feelings under conditions of being afraid or
anxious. It is a sign that the body is preparing to take action.
Sometimes, people report feeling hot instead of cold. Hot feelings are more likely
to occur during the abrupt rush of panic, as soon as the sympathetic nervous system
is activated and before the blood flow is redirected. The cold chills that go along
with the redirection of the blood flow are more likely to occur with slow-building
or longer-lasting anxiety.
Respiration Effects
Another effect is for breathing to become faster and deeper, because the body needs
more oxygen to be able to fight or flee. Sometimes, breathing can become
unbalanced and cause harmless but unpleasant symptoms such as breathlessness,
choking or smothering feelings, and pain or tightness in the chest. Also, the blood
supply to the head may be decreased. While this is only a small amount and is not
at all dangerous, it produces unpleasant (but harmless) symptoms, including
dizziness, blurred vision, confusion, feelings of unreality (or, feeling as if you are in
a dream state), and hot flushes. These physical symptoms might be uncomfortable
60
but are not at all harmful and are not a sign that something is seriously wrong with
you.
Sweat-Gland Effects
The fight-flight response increases sweating. Sweating cools the body to prevent it
from overheating and allows you to continue fighting or fleeing from danger
without collapsing from heat. In addition, excessive sweating makes the skin
slippery, so that it is more difficult for a predator to grasp. Perspiration is a
common symptom of anxiety and panic.
Other Physical Effects
Also, the pupils (the center of the eyes) widen to let in more light. This helps us to
scan the environment for whatever is dangerous. Remember, panic and anxiety are
reactions to the perception of threat, and if a threat or danger is expected to occur,
then it makes sense for us to be on guard and looking for it by increasing our field
of vision. At the same time, the change in the pupils may cause symptoms such as
blurred vision, spots in front of the eyes, or sensitivity to bright lights.
Another physical effect is a decrease in salivation, resulting in a dry mouth. In fact,

the whole digestive system is decreased, so that energy that is required for food
digestion can be redirected to the muscles that are needed to fight or flee. This
often causes nausea, heavy feelings in the stomach, and sometimes diarrhea as
material that could “weigh us down” while attempting to fight or flee is evacuated
from the body.
Also, many of the muscle groups tense up in preparation for fight or flight, and this
results in feelings of tension. This tension can sometimes cause aches and pains, as
well as trembling and shaking. Another interesting effect is the release of natural
analgesics (i.e., painkillers) from the brain, so that we are less likely to feel pain
when we are afraid. The purpose of this is to enable you to continue fighting or
fleeing from danger even if you have been injured. Connected with this is the
release of coagulants and lymphocytes into the blood which helps to seal wounds
and repair tissue damage. In addition, there is a contraction of the spleen, so that
more red blood cells are released to carry more oxygen around the blood, and there
is a release of stored sugar from the liver, so that the muscles have more sugar
available as a source of energy.
Finally, because the fight-flight response produces a general activation of the whole
body, and because this takes a lot of energy, people generally feel tired, drained, and
“washed out” afterward.
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In summary, the physical changes that underlie the physical symptoms of panic and
anxiety are protective in that they are designed to help us escape from or fight off
danger. The symptoms are real, but they are not harmful. Interestingly, physical
symptoms are sometimes felt in the absence of actual physical changes. For
example, sometimes people feel as if the heart is racing when, in fact, it is beating
at a normal pace. Or, sometimes people feel hot, even though their skin
temperature has not changed. This occurs because an intense and anxious focus on
physical feelings can create the perception of a physical disturbance even when
none really exists. However, intense panic attacks are almost always based on real
physical changes. These are summarized in Table 4.1.
How Do Physical Symptoms Influence What We Think and Do?
When the sympathetic nervous system is activated into an emergency fight-flight

response, there are certain natural effects on our behaviors and our thoughts.
(Remember, anxiety and panic are made up of physical symptoms, thoughts, and
behaviors.)
Table 4.1. Physiology of Fear
Physical Change Purpose Symptom
Increased heart rate and Speed up delivery of oxygen Racing or pounding

strength of heartbeat. and removal of carbon heart.
dioxide.
Redirection of blood flow Provide the big muscles Pale and cold,
away from skin, toes, and with energy for fight-flight especially in hands
fingers and toward the big response, lose less blood if and feet.
muscles. attacked.
Increased rate and depth of Provide more oxygen for Fast breathing. Also,
breathing. muscles as energy for dizziness,
fight-flight response. lightheadedness,
shortness of breath,
feelings of hot or
cold, sweating, chest
discomfort, visual
changes, if the
increased oxygen is
not used.
62
Increased activity in sweat Cool body to prevent Sweating.
glands. exhaustion from
overheating.
Pupils (eyes) dilate. Increase visual field to scan Eyes more sensitive to
for danger. light.
Less energy to digestive Direct all energy toward Dry mouth, nausea,
system. fight-flight response. stomachache, cramps,
diarrhea.
Increased muscle readiness. Preparation for fight-flight Muscle tension, muscle

response. cramps, trembling,
shaking.
Release of natural pain Dulls pain sensitivity to Less sensitive to pain.

killers (opioids). allow continued fighting
or fleeing if injured.
The Behavior of Fight-Flight Response
The emergency fight-flight response prepares the body to either attack or run. It is
no surprise that the overwhelming urge to escape is associated with panic.
Sometimes, escape is not possible, such as when you are in church in the middle of
the pew or at an important meeting. At these times, the urge to escape may become
stronger or be shown through such behaviors as foot tapping, pacing, or snapping
at people.
The Thoughts of Fight-Flight
The number-one effect of the emergency fight-flight response on our thinking is to

alert us to the possibility of danger. One of the major effects is an immediate shift
in attention to search for a potential threat—we stop attending to ongoing chores
and scan our surroundings for danger.
If There Is Nothing to Be Afraid of, Why Panic?
It is understandable to have the fight-flight response if we are attacked, trapped in

an elevator, or experiencing any other major stress. But why does the fight-flight
response occur where there is nothing to be frightened of, when there is no obvious
danger? Remember, a panic attack is a normal bodily response to fear. What makes
63
it abnormal is when it occurs at the wrong time, when there is no real danger.
It appears that people with panic attacks are frightened of the physical symptoms of
fear. Panic attacks represent “anxiety about fear.” A panic attack follows a typical
sequence. First, unexpected physical symptoms are experienced. (They are
unexpected because they cannot be explained by any real danger at that moment.)
Second, those physical symptoms provoke anxiety and fear.
Reasons for Unexpected Physical Symptoms
Why do you have the physical symptoms in the first place? There are many possible
reasons for this. One is stress, including stress from work pressures, rushing to
appointments, relationships, and so forth, which leads to an increase in the
production of adrenalin and other stress-related chemicals. This is your body’s way
of staying alert and prepared to deal with the stress. However, these stress effects
will cause physical symptoms.
A second reason is being anxious about having another panic attack. Anxious
anticipation of anything contributes to higher levels of physical tension and more
physical symptoms of stress. Also, anxiety causes us to focus our attention on
whatever it is that we are anxious about. For example, anticipating social rejection
leads to an intense focus on facial expressions as we look for signs of rejection. In
the case of anxiety about panic, this means that attention becomes focused on
physical symptoms. You may find yourself scanning your body for unusual physical
symptoms and detecting symptoms that you might not have otherwise noticed.
Anxiety about having panic attacks causes more symptoms of panic and more
attention to those symptoms. Consequently, anxiety about panic causes more of the
very things (i.e., the physical symptoms) that the person with panic disorder is
afraid of and, therefore, more panic attacks.
A third reason is that normal physical symptoms happen to everyone, because our
bodies are constantly changing: heart rate, skin temperature, and blood flow
fluctuate greatly throughout the typical 24-hour day.
Effects of Being Afraid of Physical Symptoms
As discussed earlier, the emergency fight-flight response causes the brain to search
for danger. Sometimes, an obvious threat cannot be found, as is usually the case for
panic attacks that seem to occur for no reason. However, most of us cannot accept
having no explanation. When an explanation cannot be found, the search may be
turned inward. In other words, “if there is nothing to explain my feelings of panic
and anxiety, then there must be something wrong with me.” Then, the brain
64
invents an explanation, such as: “I must be dying, losing control, or going insane.”
As we have seen, nothing could be further from the truth, since the purpose of the
fight-flight response is to protect and not to harm us.
These types of negative thoughts about the physical symptoms of panic only
contribute in a negative cycle to more negative thoughts, physical symptoms, and
behaviors of panic. This was described in chapter 3 as the panic cycle. The negative
thoughts intensify the fight-flight response because the body reacts with an impulse
to fight or flee when danger (in this case, the possibilities of dying, losing control,
or going insane) arises. This is true even if the danger is based on a perception of
what could happen—it does not have to be a real danger. As long as we think that
we are in danger, our bodies will react accordingly. As a result, the very thing that
is feared (i.e., the physical symptom) is intensified. That is, a physical symptom is
experienced, the physical symptom is feared (because it is judged to be dangerous),
and as a result, the physical symptom intensifies. This lasts until the cycle is ended
by either physical compensations, which slow everything down (i.e., parasympathetic
activation), or by realizing that you no longer need to be afraid of the physical
symptom.
In summary, physical symptoms are feared because of beliefs that they are signs of
impending death, insanity, loss of control, embarrassment, and so on. In turn, these
beliefs generate fear, more physical symptoms, and a snowball of anxiety and panic.
What About Panic Attacks That Come From “Out of the Blue”?
After a number of times of being afraid of physical symptoms, the fear of physical
symptoms can occur “automatically.” The “automatic” quality is typical of much of
what we learn. Think of when you first learned to ride a bike or to drive a car.
Initially, it took a lot of concentration and self-instruction about what to do each
step of the way. Gradually, it became automatic, so that you could ride and drive
without consciously thinking about what you were doing. And yet, your automatic
thoughts are still guiding the behavior of how to drive. The same thing happens
with the negative thoughts associated with panic and anxiety. Over time, they can
become automatic, so that you are not aware of what you are thinking; and yet,
those thoughts still influence your feelings and behaviors. Because you are not
aware of your thoughts, it might feel like panic and anxiety comes from “out of the
blue”—you just feel afraid, and you do not know why.
Another automatic process is called interoceptive conditioning. This means learning

to be afraid of physical symptoms because of prior negative experiences in
association with those symptoms. For example, imagine that you were violently ill
65
every time you noticed a muscle spasm in your leg. Pretty soon, you would learn to
be afraid of muscle spasms in your leg in anticipation of being violently ill. The
same thing happens with panic; but in this case, the muscle spasm is a physical
symptom that happens during panic (such as a racing heart), and the violent illness
is the terror caused by beliefs that you might die, lose control, or go insane. Once
the possibility of death or some other catastrophe is linked to a racing heart,
changes in heart rate can cause automatic fear since the fear is conditioned.
Consequently, even minor changes in heart rate that are normal, and did not
bother you before you experienced panic, can cause you to become afraid. In fact,
the physical change may be so subtle that you are not fully aware of it, and yet it
still causes you to be afraid. This is another reason why panic attacks sometimes
feel as if they come from out of the blue—they are actually being triggered by
subtle physical changes of which you are not consciously aware but to which your
body has become conditioned to react.
When judgments about the physical symptoms being dangerous occur

automatically (or, without conscious awareness), or when the fear is conditioned to
physical symptoms of even the slightest intensity so that you are not aware of what
you are responding to, then panic attacks seem to occur from nowhere. Also,
remember that our fight-flight emergency response systems are designed in such a
way as to respond instantaneously. Without such a capacity for instantaneous
response, we would not be able to survive, because dangers can sometimes come at
us very quickly. The consequence in terms of panic attacks is that automatic beliefs
and conditioning can happen so quickly that the end result—the panic attack—
seems as if it happened without time for thought or reaction. However, in reality,
our fear is always triggered by something. That is, the physical symptoms, or the
negative thoughts about physical symptoms, are always present, even if not
immediately obvious.
This is even true for panic attacks that occur from a relaxed state and for panic
attacks that wake you up out of deep sleep (i.e., nocturnal panic attacks). During
relaxation, physical feelings are often different from normal, sometimes resulting in
feelings of floating or being in a trance. If you are afraid of physical feelings that are
different from normal, then the physical feelings you have during relaxation could
trigger a panic attack. Nocturnal panic attacks are experienced by about one half of
the people who suffer from panic disorder. About 25% have repeated panic attacks
out of sleep. You might ask, “How can nocturnal panic attacks be triggered by
physical feelings”? First, it is normal to have changes in physical rhythms during
sleep. For example, heart rates and breathing rates increase and decrease at
different times throughout the night. Second, we have the capacity to respond to
meaningful events throughout our sleep. Think of the mother of a newborn child
66
who wakes in response to the slightest sound from her baby while sleeping through
other, louder sounds. Another example would be soldiers in combat who have the
capacity to sleep through the sound of allied planes but wake to the sound of enemy
planes. Thus, if physical changes are meaningful (in other words, if they are
frightening), it is understandable that physical changes that normally happen
throughout sleep could cause someone to wake out of sleep in a panic attack, in the
same way that panic attacks happen during the day. This is especially likely to
happen if the physical changes happen at a time throughout sleep when it is easier
to be woken. For example, it is very hard to be woken out of deep sleep and out of
rapid eye movement (REM) sleep, but it is easier to be woken out of Stages 2 and 3
of sleep.
Thus, a simplified model of panic attacks looks like the depiction in Figure 4.1.
Figure 4.1.
A Simplified Model of Panic Attacks
In summary, panic is based on the fight-flight response, in which the primary

purpose is to activate the organism and protect it from harm. Everyone is capable
of this response when confronted with danger, whether that danger is real or
imagined. Associated with this response are a number of physical symptoms,
behaviors, and thoughts. When physical symptoms occur in the absence of an
obvious explanation, people often misinterpret the normal emergency symptoms as
indicating a serious physical or mental problem. In this case, the physical symptoms
themselves can become threatening and can trigger the fight-flight response again.
Typical Mistaken Beliefs About Panic Symptoms
As noted, when physical symptoms occur without an obvious explanation, we tend
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to search inwardly for an explanation; and in so doing, sometimes the normal
symptoms of fear are misunderstood as a serious physical or mental problem. Such
mistaken beliefs can result in a vicious “fear of fear” cycle. Common myths and
mistaken beliefs about the physical symptoms of fear include sensations of going
insane, losing control, suffering nervous collapse, suffering a heart attack, and
fainting. Let us now evaluate each of these.
Going Insane
Many people believe that the physical symptoms of fear or panic mean they are
going insane. They are most likely referring to the severe mental disorder known as
schizophrenia. Let us look at schizophrenia to see how likely this is. Schizophrenia
is a major disorder characterized by such severe symptoms as disjointed thoughts
and speech (such as rapid shifting from one topic to the next), sometimes extending
to speech that does not make any sense; delusions or strange beliefs; and
hallucinations. An example of a strange belief might be the perception of receiving
of messages from outer space, and an example of a hallucination might be hearing a
conversation when there is no one around.
Schizophrenia generally begins very gradually and not suddenly, such as during a
panic attack. Also, because this illness runs in families and has a strong genetic
base, only a certain proportion of people can become schizophrenic, and in other
people, no amount of stress will cause the disorder. In addition, people who
become schizophrenic usually show some mild symptoms for most of their lives
(such as unusual thoughts). If this has not been noticed yet in you, then the chances
are that you will not become schizophrenic. This is especially true if you are over 25
years of age, because schizophrenia generally first appears in the late teens to early
20s. Finally, if you have been through interviews with a psychologist or psychiatrist,
then you can be fairly certain that they would have told you if you have
schizophrenia.
Losing Control
Some people believe they are going to “lose control” when they panic. They usually
mean that they will become totally paralyzed and not able to move or that they will
not know what they are doing and will run around wildly, hurting people, yelling
out obscenities, and generally embarrassing themselves. Or, they may not know
what to expect but may just experience an overwhelming feeling of being out of
control.
Even though panic attacks can make you feel somewhat confused and unreal, you
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are still able to think and function. In fact, you are probably able to think faster,
and you are actually physically stronger, and your reflexes are quicker. The same
kind of thing happens when people are in real emergencies—think of mothers and
fathers who accomplish amazing things (such as lifting extremely heavy objects)
and overcome their own intense fears in order to save their children.
Sometimes, the strong urge to escape is misunderstood as losing control. For

example, a patient at our clinic was driving to a job interview when she panicked,
changed direction, and headed for her husband’s office instead. She believed that
this was a loss of control. On the contrary, she was in complete control since she
was doing whatever she thought was necessary to get to safety. Given her fears (she
thought she was going to die), getting to her husband was a natural thing for her to
do. Most people would do the same if they believed that they were about to die. So,
the behavior was controlled. The problem was her mistaken belief that she was
dying.
Nervous Collapse
Many people believe that their nerves might become exhausted and that they may
thus collapse. However, this is not at all likely. As discussed earlier, panic is based
on activity in the sympathetic nervous system which is then counteracted by the
parasympathetic nervous system. The parasympathetic nervous system is, in a sense,
a safeguard to protect against the possibility that the sympathetic nervous system
may become “worn out.” Nerves are not like electrical wires, and anxiety cannot
wear out, damage, or use up nerves, although continuous anxiety may make you
more sensitive to negative events.
Heart Attacks
Many people misunderstand the symptoms of panic as signs of a heart attack. This
is probably because they lack knowledge about heart attacks. Let us look at the facts
of heart disease and see how this differs from panic attacks. The major symptoms
of heart disease are breathlessness and chest pain, as well as occasional palpitations
and fainting. The symptoms in heart disease are generally directly related to effort.
That is, the harder you exercise, the worse the symptoms, and the less you exercise,
the better the symptoms. The symptoms usually go away fairly quickly with rest.
This is very different from the symptoms of panic attacks, which often occur at rest
and seem to have a mind of their own. Certainly, panic symptoms can happen and
even intensify during exercise. However, this is different from the symptoms of a
heart attack, because panic symptoms occur equally often at rest. Of most
importance is the fact that heart disease will almost always produce major electrical
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changes in the heart which can be detected by an electrocardiogram (EKG)
recording. In panic attacks, the only change that shows up on an EKG is an
increase in heart rate. In and of itself, increased heart rate is not at all dangerous,
unless it reaches extremely high rates, such as over 200 beats per minute, for
prolonged periods, which far exceed the rates that occur during panic attacks. A
typical heart rate during a strong panic attack is around 120–130 beats per minute.
Vigorous physical exercise increases heart rate to around 150–180 beats per minute,
depending on your age and fitness level. The usual heart rate when resting is
anywhere from 60 to 85 beats per minute. Thus, if you have had an EKG and the
doctor has given you the all clear, you can safely assume that heart disease is not the
reason for your panic attacks and that panic attacks will not lead to heart disease.
Fainting
Fear of fainting is common in people with panic disorder, but actual fainting is very
rare. The fear of fainting is usually based on the mistaken belief that symptoms
such as dizziness and lightheadedness mean that one is about to faint. In fact, the
state of panic is incompatible with fainting. The physical tension (sympathetic
nervous system activation) of panic attacks is the direct opposite of what happens
during fainting. Fainting is most likely to happen to people who have low blood
pressure or who respond to stress with major reductions in blood pressure.
Other common myths or mistaken beliefs about panic symptoms include the ideas
that they may lead to an aneurysm, an epileptic attack, or to death from shock.
Where Do Mistaken Beliefs Come From?
Information given to you from other people about the dangers of physical
symptoms can be a very powerful agent for developing mistaken beliefs. For
example, we have come across a dictionary definition of panic (in a reputable
medical guide) as a state that can lead into psychotic depression.
That is misinformation, as there is no evidence to suggest that panic leads to

psychosis. However, for someone without a background in psychological research,
that kind of information could easily provide the basis for a fear of becoming
psychotic during panic attacks. If someone is afraid of becoming psychotic, then it
is understandable that the experience of panic is terrifying, leading to anxiety about
the next panic attack.
Observing others be afraid of physical symptoms is another way in which one may
develop mistaken beliefs. For example, children who observe their mother or father
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show excessive concern over health issues are probably more likely to develop
mistaken beliefs about their own bodily symptoms.
Finally, traumatic events that you have personally experienced may contribute to
mistaken beliefs that physical symptoms are harmful. For example, surgeries
(especially ones that did not go smoothly in the recovery phase), dangerous allergic
reactions to drugs, or serious physical illnesses may contribute to tendencies to view
physical feelings with caution.
Homework
Continue to record your anxiety and panic for one week, using the Panic Attack
Records and Daily Mood Record.
Read chapter 11, section 1, over the course of the week.
Continue on to chapter 5 once you have completed at least one week of recording
your panic attacks and moods and have read chapters 2–4 and chapter 11, section 1.
Self-Assessment
in the appendix.
1. A panic attack is a medical problem over which you have no

control. T F
2. The symptoms experienced during panic, such as racing heart

and sweating, are indicative of a medical disease. T F
3. Panic involves activation of the fight-flight response, which is

intended to protect you from harm. T F
4. Panic attacks that seem to occur from “out of the blue” often can
be related to subtle physical changes, such as those caused by
changes in breathing or by excitement from other events. T F
5. A panic reaction could go on forever. T F
6. People do not go insane when they panic. T F
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72
Chapter 5 Establishing Your Hierarchy of Agoraphobia
Situations
Goals
Review information from recording panic attacks and moods
Develop a hierarchy of agoraphobia situations
Develop lists of superstitious objects, safety signals, distractions, and safety

behaviors
Review of Panic Attack and Mood Records
Did you complete a mood record every day and record panic attacks as they
occurred over the last week? If not, brainstorm ways of improving your ability to
record. Ongoing recording of panic and anxiety is essential to this program.
Remember that learning to interrupt your panic and anxiety depends on a complete
and accurate description. It is impossible to change without knowing exactly what
it is that has to change. In addition, accurate recording becomes more important as
you progress through the next few chapters. So, developing good recording habits
now will help you complete the rest of the program.
To help you remember to complete the records, place the Daily Mood Record in a
visible place, such as on the refrigerator, bathroom mirror, or next to your bed.
Also, carry your Panic Attack Records with you wherever you go.
If you have not done any recording, we strongly recommend that you use the
following week to record your panic attacks and anxiety before continuing with the
program.
If you have kept records over the last week, fill in the data for the first week on the
Progress Record: the number of panic attacks for the week, your average daily
anxiety rating for the week, and whatever else you decide to chart. Also, look for
any patterns from the week’s worth of panic attack records. For instance, do the
panic attacks typically occur when you are alone or when you are with someone
else? Do they occur at a particular time of the day, such as in the evening? Do they
73
occur more often during stressful portions of the day, such as when getting the kids
ready for school? Are the symptoms the same each time, or do they vary depending
on where the panic occurs? In addition, look for relationships between the Panic
Attack Record and the Daily Mood Record. For instance, does panic occur more
often when you are feeling generally more anxious or depressed? Does your anxious
worry about panic increase after a panic or before a panic?
Looking for patterns moves one closer to understanding that panic is a reaction to
something. Despite how it feels, panic is not an “out of the blue,” automatic
response.
Reminder of the Role of Avoidance
It is natural to avoid things that cause anxiety. Anxiety prepares us to avoid things
so that we stay out of the way of danger and harm. However, too much anxiety
leads to too much avoidance. Although avoidance provides relief from anxiety in
the short term, it also causes you to continually feel anxiety in the long term. The
longer we avoid the situations that worry or scare us, the scarier or more worrisome
they become.
Avoidance prevents corrective learning (i.e., learning something new). Avoidance

behavior is usually connected with overly negative thoughts. For example, if you
think you will faint if you drive on the freeway, it makes sense that you would avoid
driving on freeways. However, such avoidance prevents you from realizing that your
negative thoughts about fainting are wrong. Approaching rather than avoiding
situations or experiences is critical to overcoming fear and anxiety. But first, we will
identify the specific situations that you avoid and develop skills to help you to
approach those situations.
Establishing a Hierarchy of Agoraphobia Situations
Look at the list of agoraphobia situations on page 72. Put a check next to the
situations you currently avoid or are anxious about. It may be that there is
something you regularly avoid that is not on the list. Put this under
“other” at the end. Input as many “others” as is necessary. Now use the situations
you have checkmarked to create your own hierarchy of up to 10 items. The list
should include mildly anxiety-provoking (i.e., rated at around 3 on a scale of 0 to
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10), as well as very anxiety-provoking (i.e., rated at 9 or 10) situations. These will
be the situations that you will face over and over again. You may have only one or
two situations, or you may have many more than 10 situations that cause you
anxiety.
Conditions
Here are some of the conditions to keep in mind which may influence the level of
anxiety which you have in each agoraphobia situation. It is very important to
include the conditions that make you feel more anxious. For example, if you always
feel more anxious when you are alone, it will be essential to include items in your
hierarchy in which you are facing situations alone.
Distance From Home
For example, freeway driving may be divided into a number of different tasks,
depending on your distance from home (10 minutes from home versus one hour
from home). These could be different items on your hierarchy, and it will be
important to include further distances from home on your hierarchy if you typically
get more anxious the further you are from home.
Proximity to an Exit or Ease of Escape
For example, the task of going to movie theaters may be more or less anxiety
provoking, depending on how far into the middle of the row you are seated during
the movie. Sitting in the middle of the row may be a lot more anxiety provoking
than sitting on the aisle, if it is important to you to be able to get out of wherever
you are. Similarly, freeway driving may be easier or more difficult depending on the
distances between exit and entrance ramps. If this is the case, make sure that you
eventually face situations where exits or escape are very difficult, even though you
may start with situations from which there is an easy exit.
Typical Agoraphobia Situations
Check those that apply
Situations
You Avoid or
Are Anxious
About
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Driving ____________
Traveling by subway, bus, taxi ____________
Flying ____________
Waiting in lines ____________
Crowds ____________
Stores ____________
Restaurants ____________
Theaters ____________
Long distances from home ____________
Unfamiliar areas ____________
Hairdressers ____________
Long walks ____________
Wide-open spaces ____________
Closed-in spaces (e.g., basements) ____________
Boats ____________
At home alone ____________
Auditoriums ____________
Elevators ____________
Escalators ____________
Other ____________
Time of Day
For example, grocery shopping may be easier or more difficult, depending on

whether the shopping is done in the morning, afternoon, or evening. For example,
sometimes people are more anxious in the afternoons or evenings because they feel
more tired and less able to cope with panic.
Number of People
Whether the situation is crowded or not may influence your level of anxiety. So,
shopping during peak hours or driving at peak hours of traffic may be different
from shopping or driving when conditions are much less crowded. If this is
important to you, include items on your hierarchy that include crowded times.
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Accompanied or Alone
Of course, the presence of friends or family often makes a big difference. Relying
on certain other people is one form of reliance on a safety signal (as described in
chapter 1). If you feel less anxious when you have certain people with you, you may
begin facing your fear of agoraphobia situations with their aid, but it will be very
important for you to eventually face the same situations without those people. So,
your hierarchy should include facing situations without the help of others if being
alone makes you more anxious.
Summary
In the end, you will practice facing the situations listed on your hierarchy
repeatedly, without long intervals between each practice, and in such a way that you
derive information that proves your worries to be wrong. Therefore, the conditions
have to be the right conditions.
For example, if you worry about fainting only when you are shopping alone and not
when you are shopping with a friend or family member, then it will be best to
deliberately practice shopping alone. The goal is to provide direct experience that
shows that your worries are unrealistic.
So, now list your particular situations, including the conditions that make you most
anxious. Then, rate each situation from 0 to 10, where 0 = no anxiety/do not avoid
and 10 = extreme fear/always avoid; ideally, you should have a range of
anxiety/avoidance ratings from 3–10. The anxiety/avoidance ratings should be
made in terms of how you would feel right now if you were asked to face this
particular situation.
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Figure 5.1.
Example of Completed Agoraphobia Hierarchy
If you end up with a lot of items that are below 3 or a lot of items that are above 8,
use the list of conditions above to generate a broader distribution of situations. An
example of a completed hierarchy is shown here. A blank hierarchy is also
provided.
Unhelpful Ways of Coping
Now it is time for you to identify your own unhelpful ways of coping. Eventually, it
will be essential to eliminate all of these ways of coping because they are all
unhelpful in the long term.
Agoraphobia Hierarchy
78
As we had already discussed, superstitious objects and safety signals are objects or
people on whom you depend as if they are necessary for your survival. They provide
a “sense of safety.” Even though they seem to make life easier, in the end, safety
signals strengthen fear and avoidance because they reinforce the mistaken idea that
panic attacks are harmful. When you understand that there is no real danger, then
the need for safety signals is removed. In other words, safety signals do not actually
prevent danger because, in reality, there is no danger. However, realizing this
comes with experience. In the meantime, it is necessary to know your safety signals.
We have already discussed the roles played by other people. Additional

superstitious objects and safety signals include telephones, sunglasses, purses,
money (to call for help), paper bags (to breathe into), therapists’ phone numbers,
relaxation tapes, lucky charms, empty or full medication bottles, antacids, food, and
familiar landmarks when travelling. To help you identify your own safety signals,
ask yourself what you never leave home without. Or, to put it another way, consider
the things that make you feel more anxious if they are not with you. List these in
the space provided on page 77.
This list of superstitious objects and safety signals will be incorporated into your
hierarchy in one of two ways. One way is to face each item on your agoraphobia
hierarchy first with and then without your safety signals. For example, you might
drive two exits on the freeway first with a portable telephone, and then drive the
same distance without the telephone. The second way is to eliminate safety signals
from the beginning, facing the items on your hierarchy and always doing so
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without safety signals. The choice between these two approaches is up to you. In
fact, for some hierarchy items, you can do it the first way; and for other items on
your hierarchy, you can go the second way. Of most importance is that, eventually,
you face the agoraphobia situations without your safety signals.
Safety Behaviors and Distractions
Some styles of behaving may reduce anxiety in the short term but are unhelpful in
the long term because they interfere with learning mastery. In particular, we are
referring to examples of “holding on for dear life,” as if the situation that is being
faced really is dangerous. Examples include remaining close to structures (such as
buildings or rails) to provide a sense of physical support. This is particularly true for
persons who fear falling. Remaining close to structures, however, strengthens the
mistaken belief that collapsing is likely when “out in the open.”
Another example is to keep a tight grip on the steering wheel for fear of losing
control. In actuality, it would be quite safe to lessen your grip to a more relaxed
level. Other examples of safety behaviors include: placing the parking brake on at
traffic lights to keep yourself from losing control of the car and inadvertently
driving through a red light; driving very slowly on the freeway; or driving only in
the right-hand-side, slow lane and close to exit ramps.
Looking for exits is another safety behavior. For example, you might find yourself
searching for exit signs when out at a large nightclub or looking back repeatedly to
check on the visibility of the exit sign when shopping inside a mall. Again, the
search for an exit is based on the mistaken belief of some danger happening if the
situation was inescapable. Exit signs can also function as a safety signal.
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As mentioned earlier, distraction is another band-aid method that contributes to
anxiety in the long term. You must eventually face your agoraphobia situations
without the aid of distraction. Distraction can be obvious or subtle—but in all
cases, it is a way of avoiding the situation. A very common distraction technique is
81
to look away from the object of fear. For example, while you may face heights by
ascending to the tenth floor of a building, you may be avoiding them at the same
time by refusing to look out of the window or over the edge of the balcony.
Similarly, you may face your fear of elevators by using them; but at the same time,
you keep your eyes closed during the entire ride.
More subtle methods of distraction include using imagination to pretend to be

somewhere else or playing number games or word games until you are out of the
tunnel, or after the bridge has been crossed, and so on. Other more dangerous and
rare methods of distraction include self-inflicting pain or driving cars at high speeds
under the assumption that the fright or pain will overwhelm and wipe out the
panic. Of course, in the end, the latter methods of distraction are much more
dangerous than a panic attack.
The best results come from an objective focus on one’s reactions to a given situation
and on the situation itself. Objective self-focus is exemplified by the following type
of self-statement: “I’m in the elevator, I can feel it moving, I can see the doors and
the ceiling and the floor, I feel my heart beating, and my anxiety is moderate.”
Objective self-focus differs from subjective self-awareness, which is exemplified by
a statement such as: “I feel terrible, I will collapse, I can’t make it, I have to get out
of here.” Subjective focus is probably the style that you naturally engage in since it
is part of being anxious and afraid. Most often, attempts to keep distracted
alternate with brief but negative moments of subjective self-focus. For example,
using counting games or imagery to keep yourself distracted is likely to be
interspersed with momentary body-monitoring or questioning how bad you are
feeling at a given moment. This combination of distraction and subjective self-
focus is likely to contribute to continued anxiety. Your goal is to replace that style
with an objective focus that enables you to be fully aware of what is going on.
A goal of this program is to help you eliminate all of your safety behaviors and
distractions.
List your typical safety behaviors and distractions in the space provided on page 79.
Safety Behaviors and Distractions
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83
Recognizing your superstitious objects, safety signals, safety behaviors, and
distractions is not necessarily an easy task; indeed, we all get into habits of doing
things in certain ways without being fully aware of what we are doing. One solution
is to ask someone who knows you very well what kinds of things they have observed
you do. For example, a husband, wife, sibling, parent, or friend may be aware of
subtleties of your behavior of which you are not fully aware.
Homework
Continue to record using your Panic Attack Record and Daily Mood Record.
Read chapter 6, section 1.
Self-Assessment
in the appendix.
1. Avoidance increases anxiety in the short term but decreases

anxiety in the long term. T F
2. A hierarchy is composed of situations that currently make you

anxious and/or that you avoid, with situations ranging from
mildly to highly anxious or avoided. T F
3. Superstitious objects and safety signals are effective forms of

coping with anxiety. T F
4. Distracting yourself from anxiety is a sign that you are no longer

anxious. T F
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Chapter 6 Breathing Skills
Goals
To understand how breathing patterns contribute to panic and anxiety
To learn diaphragmatic breathing
To learn slow breathing
To apply breathing skills as a coping skill
We recommend that the information in this chapter be completed over a period of

three weeks. Use the table in the introduction to know when to do each section of
this chapter in relation to the chapters that follow.
SECTION 1 Education and Diaphragmatic Breathing
Am I Breathing Too Much or Not Enough?
Many people overbreathe when they panic—in other words, they breathe too
quickly. In fact, 50–60% of people who panic show signs of over-breathing. This is
also called hyperventilation. Technically, to overbreathe or to hyperventilate means
to breathe in more oxygen than is needed by the body. Overbreathing is involved in
panic attacks in two ways. First, over-breathing may produce an initial physical
feeling that frightens you and leads to a panic attack. Second, fear and panic may
cause you to over-breathe. The symptoms of overbreathing include dizziness,
lightheadedness, shortness of breath, blurred vision, cold sweats, hot flashes and
cold chills, feeling faint, a rapid heart rate, tightness or pain around the chest,
slurred speech. Although symptoms of overbreathing can be very intense, they are
not dangerous.
Let us consider whether overbreathing is an important part of your panics. To do

so, answer the following questions.
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1. In general, do you often feel short of breath, as if you are not getting enough
air?
2. Do you sometimes feel as if you are suffocating?
3. Do you sometimes experience chest pains or pressure around your chest,

including symptoms of tingling, prickling, and numbness?
4. Do you yawn or sigh a lot or take in big gulps of air?
5. When you are frightened, do you hold your breath or breathe quickly and
shallowly?
If you answered yes to any of those questions, then overbreathing may play at least
some part in your panic and anxiety. Of course, if you are like many people, you
may not be aware of your breathing patterns. Another way of knowing whether
overbreathing is relevant to your panic and anxiety is to conduct the following
overbreathing exercise. (Caution: Do not do this exercise if you have epilepsy,
seizures, or cardiopulmonary diseases.)
Sit in a comfortable chair, and breathe very fast and very deep, as if you are blowing
up a balloon. It is important to take the air right down into your lungs and to
exhale very forcefully. Continue for as long as you can, for up to two minutes.
When you have finished the exercise, close your eyes and breathe slowly, pausing at
the end of each breath. Continue the slow breathing for a few minutes, until the
physical symptoms have passed.
Now, think about what you experienced. Check off the symptoms from one of your
Panic Attack Records. Did you experience symptoms similar to your panic attack
symptoms? You may not have been as afraid as is typically the case because you had
an obvious explanation for the symptoms (i.e., you deliberately caused the feelings
by overbreathing). Nevertheless, were the physical symptoms similar to the
symptoms you experience during naturally occurring panic attacks?
If your answer is yes, then overbreathing probably contributes to panic attacks. If

not, then overbreathing may not contribute to your panics. Either way, however,
learning ways of regulating breathing can be a useful tool for helping you to deal
directly with the physical symptoms and situations that you fear and avoid.
Education About Breathing
Normal Breathing
86
This brief explanation of the mechanics of breathing and the symptoms of
overbreathing will help correct the mistaken belief that the symptoms of
overbreathing are harmful.
The body needs oxygen in order to survive. Whenever a person inhales, oxygen is
taken into the lungs, where it is picked up by the hemoglobin (the “oxygen-sticky”
chemical in the blood). The hemoglobin carries the oxygen around the body, where
it is released for use by the body’s cells. The cells use the oxygen in their energy
reactions. After using the oxygen, carbon dioxide is released back into the blood,
where it is transported to the lungs and, eventually, exhaled.
The balance between oxygen and carbon dioxide is important, and it is maintained
chiefly through an appropriate rate and depth of breathing. Obviously, breathing
“too much” will have the effect of increasing levels of oxygen (in the blood only)
and decreasing levels of carbon dioxide, while breathing too little will have the
effect of decreasing levels of oxygen and increasing levels of carbon dioxide. The
appropriate rate of breathing, at rest, is usually around 10–14 breaths per minute.
Hyperventilation is defined as a rate and depth of breathing which is too much for
the body’s needs at a particular point in time. Naturally, if the need for oxygen and
the production of carbon dioxide both increase (such as during exercise), breathing
should increase appropriately. Alternately, if the need for oxygen and the
production of carbon dioxide both decrease (such as during relaxation), breathing
should decrease appropriately.
Anxiety and Overbreathing
Anxiety and fear cause us to increase our breathing because the muscles need more
oxygen in order to fight or to flee from danger. If the extra amount of oxygen is not
used up at the rate at which it is inhaled (as would be the case if there is no actual
running or fighting going on), then the state of hyperventilation, or overbreathing,
results.
The most important effect of hyperventilation is to produce a proportionate drop in

carbon dioxide (meaning that the amount of carbon dioxide is low in proportion to
the amount of oxygen). Our nervous and chemical systems are much more sensitive
to levels of carbon dioxide than to levels of oxygen in the blood. A proportionate
drop in carbon dioxide in turn produces a drop in the acid content of the blood,
leading to what is known as alkaline blood. It is these two effects—a proportionate
decrease in the blood’s level of carbon dioxide and an increase in blood alkalinity—
which are responsible for most of the physical changes that occur during
hyperventilation.
87
One of the most important changes produced by hyperventilation is a constriction
or narrowing of certain blood vessels around the body. In particular, the blood
going to the brain is slightly decreased. Together with this tightening of blood
vessels, the hemoglobin increases its “stickiness” for oxygen. Not only does less
blood reach certain areas of the body, but also, the oxygen carried by this blood is
less likely to be released into the tissues. Although overbreathing means that we are
taking in more oxygen than necessary, less oxygen actually gets to certain areas of
the brain and body.
This causes two groups of symptoms. First are symptoms produced by the slight
reduction in oxygen to certain parts of the brain, including dizziness,
lightheadedness, confusion, breathlessness, blurred vision, and feelings of unreality.
Second are symptoms produced by the slight reduction in oxygen to certain parts of
the body, including an increase in heartbeat (in order to pump more blood around);
numbness and tingling in the extremities; cold, clammy hands; and, sometimes,
stiffness of the muscles. It is important to remember that the reductions in oxygen
are slight and totally harmless. Also, hyperventilating can produce a feeling of
breathlessness, sometimes extending to feelings of choking or smothering, so that it
actually feels as if there is not enough air.
Hyperventilation also causes other effects. First, the act of overbreathing is hard
physical work. It can make you feel hot, flushed, and sweaty, and after prolonged
periods, it will often cause tiredness and exhaustion. Also, people who overbreathe
often breathe from their chest rather than their diaphragm (the muscle beneath the
rib cage). When chest muscles are used predominantly, they become tired and
tender from overuse. This sometimes causes chest tightness or even severe chest
pains. Finally, many people who over-breathe have a habit of sighing or yawning.
Unfortunately, these contribute to the problem because yawning and sighing cause
large quantities of carbon dioxide to be dumped out of the system very quickly,
lowering the proportionate amount of carbon dioxide in the blood.
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Figure 6.1.
Physical Changes Caused by Overbreathing
Hyperventilation is not always obvious, especially with mild overbreathing for a

long period of time. In this case, there can be a large proportionate drop in carbon
dioxide. Due to compensation in the body, the blood-acidity level returns to
normal. Thus, symptoms are not present all of the time. However, because carbon
dioxide levels remain low, the body loses its ability to cope with changes in
breathing. Even a slight change in breathing (e.g., through a yawn or by climbing a
set of stairs) can be enough to suddenly cause the symptoms to appear. This may
explain the sudden nature of many panic attacks—a small change in breathing in
someone who has a general tendency to overbreathe, even if only mildly, causes
acute hyperventilation.
Probably the most important point to be made about hyperventilation is that it is

not dangerous.
Breathing Skills: Diaphragm Breathing
Next is a specific exercise to teach the skill of diaphragmatic breathing. The
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purpose of this exercise is to learn a method of regulating breathing that will help
you to deal directly with the physical symptoms and situations that currently make
you anxious. This breathing skill is not designed to control or prevent feelings of
fear and anxiety; rather, it is intended to help you face feelings of fear and anxiety
and the situations in which they arise.
The exercise involves a breathing component, in which you learn to slow your
breathing and to breathe using your diaphragm muscle more than the chest
muscles, and a meditation component. Meditation means to focus your attention
on the exercise of breathing. As with all skills, learning to meditate requires
practice.
The following exercise should be practiced at least twice a day, for at least 10
minutes each time. At first, the exercise may be hard, but it will get easier the more
that you do it.
Step One
The first step is to concentrate on taking breaths right down to your stomach (or,
more accurately, to your diaphragm muscles).
There should be an expansion (increase) of the stomach every time you breathe
in, or inhale. The stomach is sucked back in every time you breathe out, or
exhale.
If you are having trouble taking the air down to your stomach, place one hand
on your chest and the other hand on your stomach with the little finger about
one inch above the belly button. As you breathe in and out, only the hand on
your stomach should move. If you are correctly doing the exercise, there should
not be much movement from the hand on your chest. If you are normally a
chest breather, this may feel artificial and cause feelings of breathlessness. That
is a natural response—just remember that you are getting enough oxygen and
that the feelings of breathlessness will decrease the more that you practice.
Step Two
The second step is to breathe in normal amounts of air. Do not take in too much
air, as it should not be a big breath.
At this stage, breathe at your normal rate—do not try to slow down your
breathing. We will work on slowing your breathing later.
Also, keep your breathing smooth. Do not gulp in a big breath and then let it
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out all at once. When you breathe out, think of the air as oozing and escaping
from your nose or mouth rather than being suddenly blown out. It does not
matter whether you breathe through your nose or your mouth, as long as you
breathe smoothly.
Step Three
The third step involves meditation. You will count every time that you breathe in
and think the word “relax” as you breathe out.
That is, when you breathe in, think “one” to yourself; and as you breathe out,
think the word “relax.” Think “two” on your next breath in, and think “relax”
on the breath out. Think “three” on your next breath in, and think “relax” on
the breath out. Continue this until you count to around “10,” and then go back
to “one.”
Focus only on your breathing and the words. This can be very difficult, and
you may never be able to do it perfectly. You may not get past the first number
without other thoughts coming into your mind. This is natural. When this
happens, do not get angry or give up. Simply allow the thoughts to pass
through your mind, and then bring your attention back to the breathing, the
numbers, and the words.
Practice twice a day (or more, if you want to), about 10 minutes each time, in
relaxing situations, such as a quiet place at home where you will not be disturbed.
This new way of breathing may feel strange at first and cause feelings of
breathlessness. That is natural. Just remember that you are getting enough air and
that it will get easier the more you practice.
For now, do not use this new type of calm breathing at times of anxiety because
trying to use a strategy that is only partially developed can be more frustrating and
anxiety producing than not trying it at all. It would be like teaching scuba divers a
way of dealing with underwater emergencies one time and then expecting them to
use the skill successfully in an actual underwater emergency. Instead, scuba divers
must practice the emergency procedure on land over and over again before using it
underwater. So, for now, the breathing exercises should only be done in a quiet,
comfortable environment. Once you have become skilled in the basic exercise of
calm breathing, then we will apply it as a coping skill for anxiety.
After each practice, record your levels of concentration on the breathing and
counting and the success with which you are able to use your diaphragm muscle by
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using the Breathing Skills Record. You may photocopy this form from the book or
download multiple copies at the Treatments ThatWorkTM website
(http://www.oup.com/us/ttw). Each form should last one week. This will provide
feedback for you and your doctor or mental health professional.
Remember that even if you cannot successfully learn this breathing skill, you are
not in danger. This skill is helpful for the regulation of breathing, but it is not
necessary.
Homework
Continue recording your panic attacks and your daily mood using the Panic Attack
Record and the Daily Mood Record. At the end of each week, add the number of
panic attacks and your daily average anxiety to your Progress Record.
Breathing Skills Record
Rate your concentration on breathing and counting during the exercise and your success with relying mostly
on your diaphragm for breathing, on 0–10-point scales (where 0 = none and 10 = excellent), after each
practice (twice per day).
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Practice the diaphragm-breathing exercise twice a day, for 10 minutes each time, for
seven days. Keep a record of your practices on the Breathing Skills Record.
Continue with section 2 of this chapter after you have completed one week of
practicing diaphragm breathing.
Self-Assessment
in the appendix.
1. Overbreathing means breathing too much and too deeply for the
body’s needs at a particular point in time. T F
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2. Continuous overbreathing is potentially dangerous. T F
3. When practicing breathing skills exercises, one should focus on

completely unrelated material. T F
4. Feelings of dizziness and discomfort as you practice

diaphragmatic breathing are an indication that you should
discontinue the breathing exercises. T F
5. The goals of breathing skills are to eliminate fear and anxiety. T F
6. The goals of breathing skills are to help you deal directly with
the physical symptoms and situations that make you anxious. T F
SECTION 2 Review and Slowed Breathing
Review of Breathing Skills Practice
Did you feel as if you were getting the air down toward your abdomen, as you
would if you were mostly using your diaphragm muscle? Are you getting symptoms
of anxiety when you practice? If so, this is probably due to breathing a little fast or
becoming anxious about your breathing as you pay attention to it. Keep practicing,
and the anxiety will diminish. Are you having trouble concentrating on the
counting? Practice will help your concentration. Simply redirect your attention back
to the breath and the words (i.e., the numbers and the word “relax”) each time you
notice your mind wandering.
Breathing Skills: Slowed Breathing
This exercise is designed to slow your breathing rate by matching your breathing to
your counting. Practice two times per day, for 10 minutes each time, for seven days,
in a comfortable, quiet location.
Count the number, and then inhale; think the word “relax,” and then exhale. In
other words, put a little pause between each time you inhale and each time you
exhale.
Breathe at a rate of around 10 breaths per minute. This means to count (one
second), inhale (two seconds), think the word “relax” (one second), and then
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exhale (two seconds). Every breath will take a total of six seconds from when
you count to when you finish exhaling, which means 10 total breaths per
minute. This does not have to be perfectly timed, but aim for something close
to 10 breaths per minute.
You may continue to practice with one hand on your stomach and one hand on
your chest in order to encourage deep (i.e., diaphragm) breathing.
The main goals are to slow down your breathing while maintaining a smooth
and fluid flow of air and to use the diaphragm more than the chest.
Remember to think of the air as oozing and escaping from your nose or mouth
rather than being suddenly blown out, and remember to take a normal-size
breath rather than a big breath.
Homework
Continue recording your panic attacks and daily mood using the Panic Attack
Record and the Daily Mood Record. At the end of each week, add the number of
panic attacks and average daily anxiety to your Progress Record.
Practice the slowed breathing exercise twice a day, 10 minutes each time, for seven
days. Keep a record of your practices on the Breathing Skills Record.
Continue with section 3 of this chapter after you have completed one week of
slowed breathing practice.
Self-Assessment
in the appendix.
1. Skipping out on practices of breathing skills every now and then

is okay. T F
2. To slow my breathing means to count to 10 as I breathe in and

to count to 10 as I breathe out. T F
3. If it is not any easier by now, then breathing skills training is

never going to work. T F
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4. Breathing skills are not designed to eliminate physical symptoms
of anxiety or panic. T F
SECTION 3 Coping Application
Breathing Skills
Now that you are able to breathe at a slower rate, it is time to practice in different
places, not just in relaxing places. Do the breathing exercise when you are at work,
watching television, or out socially. Do as many mini-practices as you can during
the day. That is, instead of a full 10 minutes, practice for a minute or two wherever
you are, sitting at a traffic light, listening to someone else talk to you over the
telephone, or while you are in the shower.
Also, now it is time to apply breathing skills as a technique for helping you to face
anxiety and situations that bother you. In other words, as you feel anxious
symptoms building, begin to concentrate on slow, smooth diaphragmatic
breathing. Count on your inhalations, and think the word “relax” on the
exhalations. Continue by counting 1–10 and then 10 back down to 1, slowing the
breathing rate to about three seconds on the inhalation and three seconds on the
exhalation. Remember, the goal is not to eliminate anxiety but rather to regulate
your breathing, interrupt the panic cycle, and help you to go ahead and face the
things that are making you feel anxious. Breathing skills are intended to move you
forward, so that you can face and overcome your fears rather than hide from them.
Use the breathing skills to help you “breath through” fear and anxiety.
Also, remember that even if you do not control the symptoms of breathlessness,
you are not in danger. This is very important. To believe that you must slow your
breathing to prevent yourself from losing control, having a heart attack, or
experiencing some other catastrophe adds unnecessary anxiety to the breathing
exercise. Remember, hyperventilation is not dangerous.
You may discontinue the two daily, 10-minute practices of breathing skills at this
point, especially if you are easily able to breathe slowly from your diaphragm
muscle. However, it does not hurt to continue the two daily practices, alongside the
frequent mini-practices, especially if it remains difficult at times to achieve slow
and diaphragmatic breathing.
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Homework
Record and Daily Mood Record. At the end of the week, add the number of panic
attacks and daily average anxiety to your Progress Record.
Practice breathing skills in different, distracting environments, whenever possible.
Apply breathing skills to help you continue in whatever activity or situation makes
you anxious.
Continue with section 4 after you have completed one week of practicing breathing
skills in different environments and with moments of anxiety.
Self-Assessment
in the appendix.
1. Practicing breathing skills in different environments is designed

to prevent any anxiety or panic. T F
2. When I become anxious, it is important to leave the situation

that I am currently facing and practice slow breathing, so that I
can calm myself down and then go home. T F
3. Breathing skills are intended to help me face situations and

things that make me anxious. T F
SECTION 4 Review
Review of Breathing Through Anxiety and Panic
Did you use your breathing skills when you felt anxious as a way of helping you to
continue whatever you were doing? What was the effect? Were you able to pick up
on early signals of physical discomfort, or was it not until you found yourself
gasping for breath that you tried the breathing exercise? If this was the case,
become more aware of early signs that can prompt you to engage the breathing
97
skills. Did you try the breathing exercise with a sense of desperation, to escape or
prevent at all costs the symptoms of anxiety? If so, remember that the purpose of
the breathing skills is not to prevent fear and anxiety but rather to enable you to do
whatever you have to do, and continue moving forward, even though you may be
anxious or panicky. If you are using breathing control with desperation (e.g., “If I
don’t slow down my breathing, I may die”), you will only add fuel to the fire and,
therefore, increase your panic and anxiety. Remember, even if you never learn to
slow your breathing or to breath from your diaphragm muscles, you will survive.
The goal is to use the breathing skills to help you face whatever is making you
anxious; eventually, the anxiety will decrease.
Homework
Continue to practice breathing skills in different, distracting environments,

whenever possible.
Continue to apply breathing skills to help you continue in whatever activity or

situation makes you anxious.
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Chapter 7 Thinking Skills
Goals
To understand how thoughts influence our emotions
To discover your negative thoughts
To understand errors of jumping to conclusions and seeing things out of

perspective
To learn how to develop realistic odds
To learn how to put things into perspective
We recommend that the information in this chapter be completed over a period of

three weeks. Use the table in the introduction to know when to do each section of
this chapter in relation to the chapters to follow.
In earlier chapters, we discussed the importance of thoughts and, in particular, how

negative thoughts can contribute to the snowballing cycles of anxiety and panic. In
this chapter, you will build skills for changing your mistaken beliefs and negative
thoughts.
SECTION 1 Thoughts Influence Emotions
Imagine a friend walking toward you. Instead of smiling and saying “Hello,” this
person walks straight past you without even acknowledging you. What might you
think about this? If you think that the person is angry or upset with you, then you
might feel anxious or depressed. If you think that the person is stressed out by
something else and did not even notice you, then you might feel very little emotion
or, perhaps, even feel compassion for them. Of course, this is relevant to panic
disorder in that the ways in which you think about physical symptoms will
influence how you feel about physical symptoms. Below is an example of different
ways of thinking about the physical symptom of pain in your chest and about the
emotional effect, which is similar to the panic cycle that we described in chapters 3
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and 4.
Table 7.1. Examples of the Influence of Thoughts About Physical

Symptoms on Emotions
The same is true for different ways of thinking about agoraphobia situations, as
shown below.
Emotions Influence Thoughts
In addition, negative emotions cause more negative thoughts: feeling afraid

increases the likelihood of having negative thoughts. This is because the number-
one effect of the fight-flight system is to alert us to the possibility of danger.
However, sometimes an obvious threat cannot be found. It is very difficult for us to
accept not having an explanation for feelings of panic. (We talked about this in
chapters 3 and 4.) When people cannot find an obvious explanation for their
feelings, they turn their search on themselves. In other words, “If nothing out there
is making me feel afraid, then there must be something wrong with me.” In this
case, the brain invents an explanation, such as “I must be dying, losing control, or
going insane.” As you can see from the information provided in chapters 3 and 4,
nothing could be farther from the truth. The purpose of the fight-flight system is
to protect the organism, not to harm it—it is our survival mechanism.
Table 7.2. Examples of the Influence of Thoughts About Agoraphobia

Situations on Emotions
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Table 7.3. Examples of the Influence of Emotions on Thoughts
The effect of being anxious on the ways in which we think is shown above.
The fact that anxiety produces more negative thoughts helps explain why, when
feeling calm, many recognize that their panic attacks will not cause them harm; but
when in the midst of panic, the same people are convinced that their panic attacks
are harmful.
Emotions and Thoughts Cycle
So, panic and anxiety produce negative thoughts, and negative thoughts produce
panic and anxiety. In the end, a cycle of negative thoughts and panic and anxiety
develops. For all these reasons, learning to change the thoughts that contribute to
anxiety and panic is very important.
Discovering Your Own Negative Thoughts
101
At this point, you might think, “I don’t tell myself anything when I panic, it just
comes out of the blue.” There is a dimension of awareness to our thinking. That is,
sometimes we are fully aware of our thoughts; and at other times, our thoughts are
so automatic that we do not even know what we are thinking. As an example of the
latter, think of driving a car. There are many, many thoughts that go on as you pull
out from a parking place (e.g., put my foot on the accelerator, put my foot on the
brake, turn the wheel this way, look over my shoulder, pull out slowly, and so on).
However, you probably are not aware of those thoughts. Thoughts are more likely
to become automatic the more often we think them. So, for example, if you have
believed for a long time that panic attacks cause heart disease, then that thought
may occur without you being aware that that is what you are thinking—the
thinking becomes automatic. Nevertheless, by careful self-observation, we can
usually dig up our automatic thoughts.
Go to each item on your Hierarchy of Agoraphobia Situations and to each panic

attack that you have recorded over the last week. For each agoraphobia situation,
ask yourself, “What will happen if I am forced to enter and remain in that
situation?” For each panic attack, ask yourself, “What did I think could happen?”
Now it is time to be as detailed as you can. That is, rather than saying, “I thought I
could panic,” list the different negative possibilities that came across your mind,
even if only for a brief second, such as “If I panic, I might die from a heart attack.”
If your descriptions of your thoughts are general, such as “I felt horrible” or “I will
feel anxious,” ask yourself: “Why was it so terrible? What did I think could
happen?” Or, if your thought was “I could lose control,” ask yourself what could
have happened if you did lose control. In other words, be more specific than simply
stating that you are afraid of panicking or afraid of becoming anxious in a situation.
Panic and anxiety are emotional states in the same way that anger and excitement
and sadness are emotional states. They are not inherently dangerous. When you say
that you are afraid of having a panic attack, then it means that the panic signifies
something bad happening to you, such as physical injury (heart attack, stroke,
fainting), going insane, losing control, dying, or being shunned and embarrassed.
These are the negative thoughts—the catastrophes—that contribute to the panic
cycle.
Similarly, if your initial thought is that you are afraid of being trapped or that it will
be too difficult to get out of a situation, think more about the reasons why that
worries you. Remember, the need to escape from a situation is only relevant to the
degree that you think something bad will happen if you are forced to stay in the
situation. It may help to think of yourself as being literally trapped in your feared
situation (e.g., imagine yourself stuck in an elevator or on a very long plane trip),
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and ask yourself what motivates you to want to leave. For example, the fear of
being trapped might be based on fears of shouting, screaming, and hurting people
in order to get out.
Here is an example from a discussion between a therapist and a client with panic
disorder. The therapist is helping the client to identify the negative thoughts in as
much detail as possible.
T: What do you mean when you say that the feeling of a racing heart is horrible? What
is horrible about it?
C: Well—it makes me feel very scared.
T: What are you scared of?
C: It makes me worry about something going wrong—-physically. T: What do you

think could happen?
C: Maybe my heart will just keep going faster and faster, and eventually, it will stop.
T: And then what?
C: Well, then I’ll die.
T: What about your fears of totally losing control? What do you mean by that?
C: That’s hard to describe. I guess I don’t really know what it means. I just feel out of
control.
T: What do you think could happen if you were totally out of control?
C: That I couldn’t stop the way I was feeling.
T: And what would happen if you couldn’t stop that feeling?
C: Well, the feeling would get so intense that I wouldn’t be able to function anymore.
I’d just be a wreck.
T: And then what?
C: That would be the end of my life. I’d spend the rest of my life doing nothing.
Use this type of approach to discover your thoughts for each panic attack over the
past week and for each item on your Hierarchy of Agoraphobia Situations. List the
details on the Negative Thoughts form provided on page 103. Remember, the
method is to ask yourself, “What am I afraid of?” and to follow up with questions
such as, “And if that were to happen, then what?” or “And if that were to happen,
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what would that mean?” With this amount of detail, it is easier to eventually dispel
mistaken beliefs. So, continue questioning yourself until you find the specific
negative predictions that you are making.
Once you have identified the details of your thoughts in each agoraphobia situation
and in each panic attack, continue with Section 2.
SECTION 2 Jumping to Conclusions and Realistic Odds
Mistakes in Anxious Thinking
Years of research have shown that when we become anxious or panicky, we make
two mistakes in our thinking. The mistakes are: (1) to jump to conclusions about
negative events and (2) to blow things out of proportion. These mistakes lead us to
believe that events are more dangerous than they really are and to make us more
anxious. It is important to learn how to correct those mistakes.
Jumping to Conclusions About Negative Events
To jump to conclusions means to believe an event to be much more likely to

happen than it really is. Can you think of times when you caught yourself jumping
to a negative conclusion only to find out later that you were wrong? Maybe you
were sure that you would not get tickets into the theater because you were at the
end of the line, and then you did. Maybe you were convinced that someone was
going to be upset with you, and they were not. This means that you were inflating
the likelihood of a negative event. Now think about your panic and anxiety. How
many times have you thought that something terribly wrong would happen, and
how many times has it actually happened? Most often, you will find that what you
are afraid of has never happened or has happened only rarely. For example, how
many times have you thought that you might faint, and how many times have you
actually fainted? Or, how many times have you thought that you would lose control
and start screaming, and how many times has that actually happened? The fact that
these things do not happen shows you that you are jumping to conclusions.
Negative Thoughts
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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You might say, “Yes, I know those things are probably not going to happen, but I
still get frightened by the possibility.” Why do these mistaken beliefs persist? There
are several reasons why you might believe that bad events could still happen in
future panic attacks.
Perhaps you have consistently avoided what you are really afraid of, so that you
have not gathered evidence to the contrary. For example, perhaps you have avoided
driving on freeways because of the mistaken belief that you might lose control of
the car or pass out at the wheel. However, by avoiding driving, you have not given
yourself the opportunity to learn that those things—losing control of the car or
passing out—do not happen very often. This is one of the reasons why it is so
important to face your fears.
Maybe you think that what has happened in past panic attacks is not good evidence
for what could happen in future panic attacks. However, for the most part, past
experience is a good predictor of future experience. For example, if you have never
fainted up until now, then chances are that you will not faint in the future. This is
because the chances of fainting (or whatever else it is that you are afraid of) are
pretty much the same each time that you panic.
Or, maybe you think that the only reason why you have survived previous panic
attacks is because of luck or because of something that you or someone else did at
the time. This kind of reasoning leads to the belief that catastrophes could still
happen in the future. For example, some people think that the only reason why
they did not faint was because they managed to sit down just in time or to get help
just in time. In actuality, they would not have fainted even if they had remained
standing or if they had not gotten help. Other examples are: “I only made it
because I managed to get to the hospital in time”; “If my wife hadn’t been there to
help me, I could have died”; “I would have had a heart attack if I hadn’t lain down
and rested.” Taking the last example: in reality, the heart attack did not occur
because the real chances of heart attack at that moment of panic are very, very
small, regardless of how intense the symptoms are, regardless of whether you are in
a hospital emergency room or at home, regardless of whether you are alone or
accompanied, and regardless of whether you are lying down or remaining active.
Sometimes, people think that catastrophes have indeed happened to them when, in
reality, they have not. For example, sometimes the feeling of panic and the urge to
escape are seen as evidence for actual loss of control. (We discussed this before,
when describing common myths about panic symptoms.) In reality, actions are
guided by whatever is regarded as the safest thing to do at that moment, given
whatever it is that is feared could happen. For example, if you believe that you are
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about to stop breathing, then it makes sense to run outside into fresh air. If you
believe that you are about to have a stroke, then it makes sense to go to a hospital.
If you believe that you are losing touch with reality forever, it makes sense to pinch
yourself or even to pinch someone else to get back that feeling of reality. The
mistake is to think that these types of behaviors show that you are out of control; in
fact, what they do show is that you have mistaken beliefs about panic attacks.
Another reason is the mistaken belief that the stronger the anxiety or bodily
symptoms, the more likely it is that the catastrophe will happen. For example, “I
know I haven’t lost all touch with reality yet, but what if the feelings get worse than
ever before? Then I really could flip out.” Or, “If my heart races any faster, then it
will explode.” In reality, the intensity of the physical symptoms is not evidence for
them being more harmful. A similar belief is that the chances of harm increase over
time because the damaging effects of each panic attack add on to each other. For
example, some people believe that their heart is damaged with each panic attack
and, therefore, that their heart will eventually give way if the panic attacks
continue. As described in the previous section, there is no evidence that the body or
nervous system is worn down in this way. General stress and worry may eventually
have an effect on your body, but panic attacks themselves do not have this kind of
negative effect over time.
A final reason why beliefs in catastrophes persist is because of something that we

mentioned before—that negative thoughts become automatic, like a habit. That is,
negative thoughts will come into your mind when you are anxious just through
habit and despite the fact that your thinking is more logical at other times.
Some of these types of reasoning are illustrated below in the interaction between
Jane and her therapist.
JANE: I thought I was really going to lose it this time, that I would flip out and
never return to reality. It never actually happened, but it could still
happen.
THERAPIST: What makes you think that it could still happen?
JANE: Part of me feels like I’ve always managed to escape it just in time, by
either removing myself from the situation, or by having my husband help
me, or by holding on long enough for the feelings to pass. But what if, next
time, I can’t hold on?
THERAPIST: Have you ever flipped out and lost touch with reality?
JANE: I suppose you’re saying that, in reality, I can always hold on or that I can
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always escape in time.
THERAPIST: Not really, but rather, that you are jumping to a conclusion that if you do
not hold on or do not escape, then you will flip out and never return to
reality.
JANE: But it really feels like I will.
THERAPIST: The confusion between what you think will happen and what actually
happens is the very problem that we are addressing in this phase of the
treatment.
Examine the Evidence and Develop Realistic Odds
Treat Thoughts as Guesses
As we discussed before, fear and anxiety lead us to have mistaken beliefs; and, in
turn, those mistaken beliefs contribute to fear and anxiety. In other words, jumping
to conclusions about negative events and blowing things out of proportion make us
feel anxious and afraid. The first step toward change is to treat thoughts as guesses
rather than as facts. Once you recognize them as being guesses instead of facts,
then you are in a position to recognize that your thoughts may be mistaken and,
therefore, that they should be tested by looking at the evidence. Are your beliefs
supported by evidence or not? The goal is to develop more realistic ways of
thinking. This is not the same as positive thinking. In the long run, the “Don’t
worry, be happy” notion, where we pretend that everything is okay, is not very
helpful. But it does help to say, “Wait a minute, maybe I am thinking about this in
the wrong way—maybe the chances of me dying the next time I panic are small.”
Or: “Even if others did notice that I looked anxious, maybe it wouldn’t be as bad as
I thought.”
Evidence-Based Thinking
More realistic beliefs can be developed by considering all of the evidence—and

from obtaining additional information, where necessary—such as the information
covered earlier in this workbook. To consider the evidence, ask yourself, “What are
the real odds of this happening, has this ever happened before, what is the evidence
that it will or will not happen?” This means that you must look at all of the facts
before you judge how likely something is. Examining the evidence helps us to see
that negative events are less likely to happen than we first thought.
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For example, you may assume that you will fail a test; but in so doing, you have
ignored the fact that you have prepared carefully. Or, a friend may be acting coldly,
and you may think that they are displeased with you but overlook the possibility
that they are angry at someone else or that they have had a bad day. In terms of
panic attacks, you may think that tingling in the left arm is a sign of a heart attack
and thus overlook the fact that you are in good health and that you have
experienced the tingling many times before without having had a heart attack. Or,
you may worry about panicking at the meeting and overlook the fact that, despite
occasional panics in meetings, there have been many times when you did not panic
in meetings. Similarly, you may think that you are going to faint while overlooking
the fact that you have never fainted before and that people rarely faint during panic
attacks. Or, you may think that you will lose control and scream wildly while
ignoring the fact that you have never done that before. Also, you may think that
the panic will reach such an intense level that it never ends or cause you permanent
damage while ignoring the fact that this has never happened before and ignoring
the data about our inbuilt mechanisms, which restore balance (i.e., the
parasympathetic nervous system) so that panics never continue forever. Or, you
may think that the sense of disorientation you are experiencing means that you will
go insane like the other person you knew who also was disoriented and who had
become mentally ill; but you are overlooking the fact that there are many, many
differences between you and the other person.
Then, after considering the evidence, rate the actual odds of the event that you are
worried about. Rate the odds on a 0–100 point scale, where 0 = It will never
happen and 100 = It will definitely happen. This rating is based on the evidence
and not on how you feel. So, look at all of the data and evidence. The probabilities
are very helpful for developing more realistic ways of thinking. Odds are more
objective than a statement of “I think it could happen” or “I think it probably will
not happen.”
After you have recorded the realistic odds, generate alternative thoughts that are
based on the data and evidence to replace the negative thought. All the different
thoughts can be viewed as pieces of a pie. The example provided below shows
different ways of thinking about an increase in heart rate. The negative thought is
shaded. The greater number of alternative thoughts in comparison to your one
negative thought indicates the low likelihood of your negative thought actually
coming to pass.
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Figure 7.1.
Example of Completed Realistic Odds Pie Chart
The importance of looking at the evidence for the negative event is seen in the
following interchange between Jane and her therapist.
THERAPIST: One of your negative thoughts is that you will flip out and never return to
reality [negative event]. What leads you to think that this is likely to
happen?
JANE: Well, I guess it really feels like that.
THERAPIST: Be more specific, if you can. What feelings?
JANE: Well, I feel spacey and unreal, like things around me are different and that
I’m not connected [reasoning for negative event].
THERAPIST: And why do you think those feelings mean that you have lost touch with
reality?
JANE: I don’t know—it just feels as if I have.
THERAPIST: I see—let’s look at some of the evidence. Do you respond if someone asks
you a question at those times?
JANE: Well, I respond to you even though I feel that way sometimes in here.
THERAPIST: Okay, and can you walk or write or drive when you feel that way?
JANE: Yes, but it feels different.
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THERAPIST: So, it sounds like you perform those functions despite feeling detached.
What does that tell you?
JANE: Well, maybe I haven’t lost complete touch with reality. But what if I do?
THERAPIST: How many times have you felt detached?
JANE: Hundreds of times.
THERAPIST: And how many times have you lost touch with reality permanently?
JANE: Never. But what if the feelings don’t go away? Maybe I’ll lose it then.
THERAPIST: So what else tells you that this is a possibility?
JANE: What about my second cousin? He lost it when he was about 25, and now,
he’s just a mess. He can hardly do anything on his own, and he is
constantly in and out of psychiatric wards. They have him on a bunch of
heavy-duty medications. I’ll never forget the time I saw him totally out of
it—he was talking to himself in gibberish.
THERAPIST: So, you think you’ll be like your cousin. Are there things that are different
between you and him? It sounds like he may have something like
schizophrenia.
JANE: Yes, that is what I was told.
THERAPIST: So, let’s consider all of the evidence and some alternatives. You have felt
unreal hundreds of times, and you’ve never lost touch with reality because
you’ve continued to function in the midst of those feelings, and they have
never lasted forever. You are afraid of becoming like your cousin, but he is
suffering from schizophrenia, and your panic attacks are completely
different from schizophrenia. Also, keep in mind our previous discussion of
where feelings of unreality can come from—-from being physically tense
and from overbreathing. So, what are the realistic odds that you will lose
touch with reality permanently? Use a 0–100 point scale, where 0 = No
chance at all and 100 = Definitely will happen.
JANE: Well, maybe it is lower than I thought. Maybe 2o%.
THERAPIST: So, that would mean that you have actually lost touch with reality in a
permanent way once every five times you have felt unreal?
JANE: When it’s put like that, I guess not. Maybe it’s a very small possibility.
THERAPIST: Yes, so what is a different way of thinking about the feelings of unreality?
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JANE: Perhaps feeling anxious or overbreathing causes them, and they don’t
mean that I am losing touch with reality or that I am like my cousin.
Changing Your Own Odds
Look at your list of Negative Thoughts, and identify examples of where you were
jumping to conclusions. (i.e. concerns about a negative event that you frequently
worry over but that has never happened or has only rarely occurred.) Then, examine
the evidence for each example by completing the following steps, using the
Changing Your Odds form as you go. You may photocopy this form from the book
or download multiple copies at the Treatments ThatWorkTM website
(http://www.oup.com/us/ttw).
I. Has what I am worried about ever come true?
II. What are the mistaken reasons why I continue to worry?
Have I avoided the situations that would help me gain a more realistic
understanding?
Am I mistakenly thinking that evidence from past panic attacks does not
apply to future panic attacks?
Am I mistakenly thinking that I have been lucky or that things that I have
done in the moment of panic have actually saved me from negative things
happening?
Am I mistakenly thinking that the negative thing I worry about has

actually already come true, when in fact, it has not?
Am I mistakenly thinking that the risk of negative things happening

increases with the intensity of panic and anxiety?
III. What is the evidence?
Ask yourself the following.
a. “What is the evidence to suggest that it will happen?”
b. “What is the evidence to suggest that it will not happen?”
Remember to not confuse your behaviors with the evidence regarding

what you are most worried about. For example, if you believe that you are
about to stop breathing, then it makes sense to run outside into fresh air.
However, it is incorrect to view these behaviors as signs of a loss of
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control; they are logical actions, given the anxious thoughts.
Consider whether you are confusing low probabilities (odds) with high
probabilities (odds) or acting and feeling as if negative results are
guaranteed to occur, as opposed to being just possible.
IV. What are the actual odds?
Rate the actual odds of whatever it is that you are most worried about
after having considered all of the evidence.
Rate the odds on a 0–100 point scale, where 0 = It will never happen and
100 = It will definitely happen.
V. What are different ways of thinking that are more based in evidence?
Use a pie chart to list different ways of thinking.
Think of as many different ways of thinking as you can alongside your

negative thoughts as one piece (the shaded piece) of the pie chart.
Homework
Record and Daily Mood Records. At the end of the week, add the number of your
panic attacks and your average daily anxiety to your Progress Record.
Practice Changing Your Odds for each example of jumping to conclusions from
your list of Negative Thoughts, as well as for any panic attacks that occur over this
next week.
After one week, continue on to section 3 of this chapter.
Changing Your Odds
Negative thought:
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How many times has it happened?
Reasons why I continue to worry about it:
1. Avoidance behavior ___________
2. Mistaken belief that past evidence does not apply ___________
3. Mistaken belief that luck or my extra-cautious behaviors have prevented it from happening
___________
4. Mistaken belief that what I most worried about has come true __________
5. Mistaken belief that dangers increase with intensity of anxiety or physical symptoms _________
What is the evidence?
What are the real odds? (0–100) _________
What are different thoughts? (Fill in the pie chart, including your anxious thoughts as the shaded piece of the pie):
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Self-Assessment
in the appendix.
1. Thoughts have no impact on emotional feelings. T F
2. To change negative thoughts, you must first find out exactly

what you are predicting could happen, in as much detail as
possible. T F
3. To jump to conclusions means to believe that positive events are

never going to happen T F
4. A realistic odds judgment is made after considering all of the

data and the evidence and is not based on how you feel. T F
5. It is better not to think about negative thoughts and instead to

hope that they go away on their own. T F
6. Negative thoughts can occur so rapidly and automatically that

you may not be aware of them. T F
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SECTION 3 Facing the Worst and Putting Things Into Perspective
Seeing Things Out of Perspective
In the last section, we discussed jumping to conclusions. A second mistake that

happens in our thinking whenever we are anxious is to blow things out of
proportion or to think of situations as “insufferable” or “catastrophic” when, in
actuality, they are not. Typical examples are: “If other people noticed that I was
feeling very anxious or panicking, it would be terrible, and I could never face them
again”; “It would be disastrous if I fainted”; “I couldn’t cope with another panic
attack”; or “It would be horrible if I felt anxious.” If you stop to examine the
situation realistically, usually it is not as awful as it seemed at first. For example,
fainting, while extremely unlikely, is not such a terrible event. Fainting is actually
an adaptive mechanism designed to reestablish the “balance” of bodily functions.
Similarly, if another person noticed that you were anxious, the worst that might
happen is that they would feel awkward, not knowing how to respond, or feel
sympathy for you. Or, if someone did think you were weird, the worst that would
happen is that they would not think of you in the way that you would like.
Another common catastrophic thought is, “Anything could happen the next time I
panic. I don’t know what it is, but it is going to be something bad.” Again, this
kind of negative thought generates anxiety. But if you examine the evidence and
consider the worst that can happen, it is not as bad as you at first think.
Facing the Worst and Putting Things Back Into Perspective
Facing the worst and putting things back into perspective means to face whatever it
is that is scaring you and, in so doing, to realize that it is not as bad as you at first
thought. This is done by switching gears from focusing on “how bad it would be if.
. .” to considering “ways of dealing with....” When you come right down to it,
everything is manageable to some degree. No matter how intense your fear is, you
will survive. No matter how embarrassing the moment, it will pass. No matter how
bad the event that you worry about, there is a way of getting through it.
In other words, there is always a way of coping, and it is always possible to get
through even the worst situations.
For example, what if you actually did faint? What if others actually commented on
the fact that you appeared shaky and nervous? What if you did scream and draw
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attention to yourself? What if you actually did walk out of a room because you felt
trapped? Your first reaction to these questions might be something like “That
would be awful or terrible,” or, “I couldn’t stand it.” That is, however, blowing
things out of proportion. When you really think about it, you will find that you
have assumed them to be worse than they are.
In addition, there probably is a way of coping. Brainstorming ways of dealing with

negative events (which is sometimes called problem-solving) is much more helpful
than thinking only about how horrible it would be. For example, let us say that you
fainted in front of a group of people. Think of ways of coping. What would you
do? Picture what would happen to you as you woke up out of the faint; what might
you do, what might you say, what would happen next? Maybe people would help
you. Maybe you would ask for some water. Maybe you could say that you have not
been feeling well lately, or that you have been suffering a severe flu, or that you
were low on blood sugar, or even that you have been under a lot of stress—you can
say whatever you want! Then what would you do? Maybe you would go home for
the rest of the day. And what would you say to people the next day if they asked
how you felt? And so on.
The basic point is that we can stand any misfortune that happens to us. It is only
the belief that we cannot stand it that creates the anxiety. We can literally endure
anything that befalls us until the day we die—and then, it does not matter
anymore. Facing the worst and putting things back into perspective can be summed
up in one phrase: So what? (The “So what?” strategy, however, does not apply to
certain events, such as death, the loss of a loved one, or behaviors that conflict with
strongly held religious beliefs or values.)
Here are two examples of putting things back into perspective.
Example 1
C: I don’t like to be in a crowd because if I panic, I might faint, and I don’t know
what would happen to me then.
T: Have you ever fainted before?
C: No
T: So, how likely do you think it is that you would faint?
C: Okay, maybe not very likely, but I know I’d have to leave, and that would be
embarrassing.
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T: Have you ever been embarrassed before?
C: Oh, yes.
T: Well, you’re here, so I take it that you survived being embarrassed. How long does
your embarrassment usually last?
C: Well, it’s bad for a few minutes, then it kind of goes away. I don’t know. Maybe it
lasts a couple of hours in all.
T: Okay, so it’s not very likely that you would faint, but you might leave, and that
might be embarrassing, but embarrassment doesn’t really last very long.
Example 2
C: I am worried that I might lose control and do something crazy, like yell and scream.
T: Aside from the very low likelihood of that happening (as we discussed before), let’s
face the worst and ask what is so bad about it. What would be so horrible about
yelling and screaming?
C: I could never live it down.
T: Well, let’s think it through. What are ways of coping?
C: Well, I guess the yelling and screaming would eventually stop.
T: That’s right—at the very least, you would eventually exhaust yourself. What else?
C: Well, maybe I would explain to the people around me that I was having a really
bad day, but that I would be okay. In other words, reassure them.
T: Good. What else?
C: Maybe I would just get away—-find somewhere to calm down and reassure myself
that the worst is over.
T: That’s right. And maybe there are other things you could do, too.
Your anxiety may increase as you begin to focus on these kinds of images and
thoughts. However, the thoughts become less anxiety provoking the more often
you face them. Only by facing them directly can you learn that the worst is not as
bad as you first imagined. Remember, everything passes with time, and there is
always a way of managing even the worst situation.
In summary, deal with times when you blow things out of proportion by (1) facing
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the worst; (2) realizing that even the worst situations pass with time and can be
managed; and (3) thinking of ways of coping with the situation and with your
feelings in the situation.
Changing Your Own Perspective
Go back to your list of Negative Thoughts from Section 2, and identify examples of
where you were blowing things out of proportion. (You will know this if it feels like
what you are worried about is catastrophic or beyond your coping abilities.) Then,
face the worst, and consider ways of coping for each example by following the steps
provided and completing each section of the Changing Your Perspective form as
you go. You may photocopy this form from the book or download multiple copies
at the Treatments ThatWorkTM website (http://www.oup.com/us/ttw).
I. Face head-on whatever it is that are most worried about happening.
II. Recognize that whatever it is you are worried about is not going to last forever
and is survivable. (This does not, however, include events such as death,
significant loss, or behaviors that conflict with strongly held religious beliefs or
values.)
Develop different ways of thinking, and record that next to the section
titled “Will this pass and will I survive?”
Remember—the goal in doing this is not positive thinking but realistic

thinking.
For example, if you believe that you would never emotionally recover from
an embarrassing moment or from feeling afraid, think about the fact that
these feelings are temporary, and realize that you would in fact recover.
In general, the goal is to realize that you will be able to survive whatever
happens to you and that whatever it is you are most worried about will
not last forever.
III. Develop ways of coping
Switch gears from focusing on “how bad it would be if a difficult situation

happened” to considering “ways of dealing with a difficult situation.” List
actual coping steps.
Thinking Skills in General
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Sometimes your negative thoughts will be based on just one mistake—either
jumping to conclusions or blowing things out of proportion—in which case, you
would deal with just that one. Sometimes both mistakes are present, in which case,
you would examine the evidence to generate realistic odds and alternative,
evidence-based ways of thinking so that you do not jump to conclusions, as well as
face the worst, realize that even bad situations pass with time and are manageable,
and think of ways of coping with the situation and your feelings in the situation in
order to put things back into perspective.
Changing Your Perspective
Negative thought:
Will this pass, and will I survive?
Ways of coping:
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Do not be discouraged if this approach to thinking skills seems artificial at first. As
with other skills in this program, learning to change your negative thoughts takes
practice. With repetition, it will get easier, and the new ways of thinking will
become more natural. Eventually, it will become so natural that you will not have
to go through the entire process of finding negative thoughts and looking at the
evidence or facing the worst—instead, you will automatically think in less negative
ways.
Also, remember that the primary goal for thinking skills is not to eliminate anxiety.
Instead, the thinking skills are intended to correct mistakes in your thinking so that
you can continue to move forward and face the situations and things that make you
anxious; eventually, your anxiety will subside.
Summary of Thinking Skills
The first step is to know the details of what you are most worried about happening
in a specific situation.
For worries that involve jumping to conclusions (i.e., repeated worries about a
negative event that rarely or never happens), the steps include the following:
1. Ask, “Has what I am most worried about come true?” (If traumatized,
however, the question refers to the interval of time since the trauma.)
2. Consider mistaken reasons for why the worry continues.
3. Review all of the evidence.
4. Consider the realistic odds.
5. List different ways of thinking that are more evidenced based.
For worries that involve blowing things out of proportion, the steps for putting things
into perspective include the following.
1. Face the worst as if it were actually happening, and realize that even the worst
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situation is survivable.
2. Switch from thinking about how bad it would be to steps of coping with the
negative event if it were to happen.
Homework
attacks and average daily anxiety to your Progress Record.
Practice Changing Your Perspective for each example of blowing things out of
proportion from your list of Negative Thoughts.
Practice either Changing Your Odds and/or Changing Your Perspective for any
panic attacks that occur over this next week.
After one week, continue on to Section 4.
Self-Assessment
in the appendix.
1. The fact that I have thoughts about being overwhelmed or

collapsing means that these things actually are going to happen. T F
2. No one else has these kinds of thoughts. I must be really crazy. T F
3. Forcing myself to think about the worst will make me anxious

initially, but the more I think about it and put things in
perspective, the less anxious I will feel eventually. T F
4. Finding and changing negative thoughts is easy, and this process

should not take much practice. T F
5. A panic attack will not continue forever. It is time limited and

manageable. Even if I do nothing, it will pass. T F
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SECTION 4 Review of Thinking Skills and Dealing With Memories
Review of Thinking Skills Practice
Have you been able to pin down your negative thoughts in a lot of detail and
whenever you became anxious or panicky? Have you labeled the negative thoughts
such as jumping to conclusions or seeing things out of perspective? Were you able
to examine the evidence and put things back into perspective by looking at the
realistic probabilities and facing the worst, realizing that difficult situations and
emotions are time limited and that there always are ways of coping? Were you able
to say, “So what”? It might feel artificial at first to always examine and change your
thoughts. However, as you practice, this style of thinking will become more natural.
It is the same as when we learn a new language: initially, it takes a lot of effort and
seems unnatural, but with practice, it becomes more natural.
Keep in mind, also, that the goal of your work with your negative thoughts is not to
get rid of anxiety or the physical symptoms immediately. Instead, the goal is to
correct the mistaken thinking—the jumping to conclusions and the blowing things
out of proportion—which contributes to the snowballing spiral of fear and anxiety.
For example, let us say that you begin to feel dizzy and scared. You identify the
negative thought as, “This dizziness makes me feel as if I am about to faint.” You
use your thinking skills by realizing that “I have felt dizzy many times before, and I
have never fainted, so it is very unlikely that I will faint. The dizziness is just an
uncomfortable symptom probably due to a change in my breathing or my anxiety
level.” Then, you notice that you are still feeling dizzy. The persistence of physical
symptoms does not mean that your thinking skills have failed. Your new analysis
that the feeling of dizziness is harmless is still accurate. Dizziness just may take
some time to subside. Related to this, remember that some physical symptoms
occur no matter how anxious or afraid you are. All of us have times when we feel
off-balance, short of breath, lightheaded, trembly, or a racing heart. In other words,
even if you use your thinking skills properly, you may still have occasions when you
feel physical symptoms that remind you of panic attacks.
Also, watch out for the “don’t worry, be happy” syndrome. For example, compare
someone who says, “It will be okay, I’m fully in control, nothing bad will happen,”
to someone who says, “What am I afraid of? I’m afraid of fainting. How likely is it
that I will faint, given the fact that I have felt this way so many times before and
have never fainted? I know that I tend to jump to conclusions about the risk of
fainting. The feelings will pass.” The first person is trying for a quick fix, which
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does not really work in the long run. The second person is examining his or her
thoughts and looking for new ways of thinking based on real evidence. This is what
works in the long run.
Finally, remember that you are learning a new skill. Therefore, it takes time for the
new ways of thinking to become more powerful than the old ways of thinking. In
other words, “old habits die hard.” For this reason, it is not unusual for negative
thoughts to reappear despite previous successes in looking at the evidence and
putting things back into perspective. Treat the old negative thoughts in the same
way as you did the first time; that is, for each time a negative thought comes to
mind, even if it is the same one time and time again, repeat the strategy of looking
at the evidence, facing the worst, and putting things back into perspective.
Repetition makes the new way of thinking stronger and more natural.
Dealing With Frightening Memories
Whenever a past event is given a lot of significance (such as when thought of as

horrible), it is more easily remembered. In addition, the more frequently an event is
remembered, the more likely it will be remembered again. Frightening memories
then lead us to think of related future events as frightening also. Therefore, if you
tend to think of the worst panic that you have ever had as a terrifying, horrific
experience, something that you do not fully understand, and, in fact, it scares you
just to think about it, then that memory probably contributes to your anxiety about
future panics.
Many of our clients become less anxious and less on edge about the next panic
attack after they learn to understand their past panics rather than just being
horrified by them. This comes from forcing yourself to think about past panic
attacks using a matter-of-fact approach.
To do this, first, recall the worst panic and, as clearly as you can, remember the
context. This includes the people, the place, the sounds, the colors, the objects
around you, and anything else. Imagine it as clearly as you can by placing yourself
in the picture not as an observer, but as someone in the scene. Remember how you
felt. You might become quite anxious or fearful as you think about that event.
Statements such as, “I hate to even think about it,” “I hope I never experience
anything like that again,” “I couldn’t go through that again,” “I’m sure I nearly
died,” or “I was so lucky to survive” are a good indicator of the importance of the
next section.
Think about the worst panic again, particularly, the way you felt. Identify what, in
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retrospect, were the triggers for the panic: was it a physical symptom, was it a
negative thought, was it a time you were under a lot of stress? How did you react?
What was the first thing that happened? Did you have some negative thoughts, and
did they produce more physical symptoms? Use a step-by-step analysis: Did you
jump to any conclusions (e.g., did you think that you were going to die)? Did you
blow things out of proportion (e.g., did you think that everyone would notice and
think you were crazy)? What was the next thing that happened? Did you become
more frightened? What did you do? Did you go to a hospital, or try to escape, call
for help, or lie down? How did this add to the fear cycle? Furthermore, what was
the actual end result? In other words, you did survive, and you did not die, lose
control, or go crazy. Your goal is to think it through in a matter-of-fact manner, so
that it becomes understandable. In other words, come to the realization that the
reason you panicked is because, for example, you felt some unusual physical
symptoms, had negative thoughts that something was terribly wrong, and these led
you to become intensely afraid. Also, realize that, in the end, nothing was terribly
wrong and that the worst that happened was that you became afraid.
Continue to repeat this exercise of rethinking through a worst panic attack until
thinking about it no longer makes you feel anxious, until you have an
understanding of why it happened; and until you realize that you did survive. We
call this processing a past event, of which the goal is to have less-disturbing
memories about it and, therefore, to be less anxious about the same thing
happening again in the future.
Homework
Continue to practice either Changing Your Odds or Changing Your Perspective (or
both) for any panic attacks that occur over this next week.
Practice using a step-by-step analysis of your worst panic attack.
Self-Assessment
in the appendix.
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1. To rate the odds of a negative event means to realize that
negative events are always likely. T F
2. Thinking about ways of coping with worst-case scenarios should

be done for all examples of jumping to conclusions. T F
3. Thinking skills are not intended to eliminate anxiety but rather

are intended to help you deal with things that make your
anxious. T F
4. Thinking back over the worst panic attack and realizing the
sequence of events should be avoided at all cost. T F
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Chapter 8 Facing Agoraphobia Situations
Goals
To understand the value of facing agoraphobia situations
To learn how to optimally face agoraphobia situations
To review what is learned from facing agoraphobia situations
To continue to face agoraphobia situations
Completing this chapter will take a number of weeks (e.g., six weeks), although the
actual amount of time will depend on the number of situations on your Hierarchy
of Agoraphobia Situations and on the pace of your progress with those situations.
SECTION 1 Planning for and Practicing Facing Agoraphobia Situations
Value of Directly Facing Agoraphobia Situations
Up until now, our focus has been upon coping with anxiety. Now, it is time to
move into learning from direct experience. In many ways, direct experience is the
most powerful way of learning. It is essential that you eventually repeatedly face
and deal with all the situations on your hierarchy. By avoiding those situations, new
learning is prevented; instead, fear and anxiety are reinforced. The more you avoid
something, the more you will remain anxious about whatever it is you are avoiding.
You may choose to involve a significant other in this phase of treatment, in which
you will be directly facing the agoraphobia situations that make you anxious. If so,
read chapter 9.
Reasons Why Past Attempts May Have Failed
Sometimes people believe that they have already tried to face agoraphobia
situations, without any success. As a result, they mistakenly judge that this
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treatment approach does not work. However, it is likely that previous unsuccessful
attempts at facing the fear were not structured in exactly the right way. We review
the possible reasons why it may not have worked in the past as a way to present the
correct method of conducting exposure exercises.
Possibly, you believe that you practiced facing agoraphobia situations when, in fact,
you did not. For example, being forced into a situation is not the same as setting up
a specific task to practice over and over again. A onetime drive on the freeway to
visit a sick family member in an emergency is not the same as practicing driving on
the freeway three to four times a week in order to overcome a driving phobia. So, it
is important not to confuse difficult or negative one-time experiences with truly
facing your fear of agoraphobia situations.
Attempts to face agoraphobic situations may not have been done frequently
enough, meaning that there was too much time between one practice to the next.
For example, walking around a shopping mall once a month is much less helpful
than walking around the mall once a week. Related to this is the possibility that the
practice was not continued for long enough. For example, 90 minutes per day
practicing being alone is much more helpful than just 5 minutes of practice per day.
This is because a sufficient length of time is needed for new things to be learned.
Facing your fear for brief periods of time decreases the chances of learning
something new.
Most importantly, the practice may not have involved the right conditions.
Repeatedly facing agoraphobia situations only works if you learn what is critical for
you to learn. For example, if your fear of shopping malls is based on the notion that
you will go insane if you spend more than 15 minutes in the mall, then the practice
that will give you the critical learning is to shop for more than 15 minutes so that
you learn that you do not lose your mind. Repeated practice for less than 15
minutes will not provide critical learning.
Perhaps you relied too much on superstitious objects, safety signals, safety
behaviors, or distractions as you attempted to face agoraphobia situations.
Remember, these are unhelpful ways of coping because they interfere with
corrective learning and contribute to anxiety in the long term.
Systematic, frequent, and lengthy practices under the conditions necessary for
critical learning, without safety signals, superstitious objects, safety behaviors, or
distraction, will be much more successful.
The practices with agoraphobia situations are intended to do three things:
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1. Gather new information that will help you fully realize that what you are
worried about happening is very unlikely to happen or never happens, that
when you face the worst, it is not as bad as you first thought, and that there are
ways of coping, even with difficult situations.
2. Let you learn that you can handle and survive the feelings of anxiety and fear.
3. Show you that you can accomplish the things that you have been avoiding.
Use of Medication
The use of medication has to be considered: particularly, medications that either

block all of your feelings or medications that you rely on to reduce your fear in the
moment (the latter include fast-acting medications, such as Xanax and Klonopin).
If medications are so potent that they block all feelings, then they may interfere
with the benefits you can receive from actually facing your fear of agoraphobia
situations. That is, some anxiety is very helpful—we learn more when we are
anxious in comparison to when we are completely relaxed. So, if your anxiety and
panic are completely blocked by medications, it may be helpful to talk with your
prescriber about lowering the dosage of medication.
The second issue concerns the use of fast-acting medications. Initially, when you
first face agoraphobia situations, you may feel the need for Xanax or Klonopin
because those medications have been your usual coping tool. That is acceptable, as
long as you eventually become comfortable enough so that you can face these
situations without those medications. (We talk more about ways of reducing
medications in chapter 11.)
Your Practice Facing an Agoraphobia Situation Design of the Practice
Now it is time to design your practice with an agoraphobia situation. Choose the
first item from your hierarchy, and go through the following steps.
I. Identify what it is that you are most worried about happening in this situation.
This is called the Negative Thought. This could be a concrete outcome, such as
fainting, going insane, or having a heart attack, or it could be the idea that you
cannot handle the anxiety associated with the situation.
II. Think about the best conditions in which to practice so that you can truly
learn that your negative thoughts are unrealistic. These are called the end goals.
For example, if you believe that you could walk from one end of the mall to
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the other one time without fainting, but you are convinced that you would
faint if you were to walk to the end and back again, then of course the best
conditions for you to practice are to walk to the end and back again. Similarly,
if you believe that you could walk into the mall for 10 minutes one time only
but that to return into the mall three times would certainly cause you to faint,
then of course the best conditions to practice will be to return to the mall three
times. So, take into account how long you need to be in a situation or how
many times you need to face the agoraphobia situation in order to learn that
whatever you are most worried about either does not happen or that you can
cope. At the same time, learning that your negative thoughts are unrealistic
will require that you let go of all superstitious objects, safety signals, safety
behaviors, or distractions. So, go back to your lists of Superstitious/Safety
Signals and Safety Behaviors/Distractions from chapter 5, and plan for
eventually practicing each agoraphobia situation without anything on those
lists.
There is one possible exception to these objects, which is the cellular phone. In
today’s world, cell phones can sometimes be very helpful in the event of a true
emergency. We recommend traveling without them only to learn that you will
not die from a heart attack, faint, or be otherwise incapacitated if you do not
have your cell phone on hand. At the same time, we recognize that cell phones
can be valuable tools if your car breaks down.
III. Choose either to gradually work up to the end goals or to go directly to the
end goals.
For example, if the end goal is to walk around the mall for one hour alone
(because that is the point at which you currently are sure that you will faint if
you are alone), you may start by completing 20 minutes with a friend and then
20 minutes alone; 40 minutes with a friend and then 40 minutes alone; and 60
minutes with a friend and then 60 minutes alone. Or, you could go straight to
doing the full 60 minutes alone. Today’s goals are the conditions in which you
will practice on a given day as you work toward your end goals.
An example is shown here.
IV. Use your thinking skills.
In preparation for the practice, ask yourself the following.
Has what you are most worried about ever happened? (If it has not or
rarely has, then you are jumping to conclusions?)
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Figure 8.1.
Example of Part of Completed Facing Agoraphobia Situations Form
Figure 8.2.
Example of Part of Completed Facing Agoraphobia Situations Form Using Thinking Skills
What is the worst that can happen, and how would you cope with it? (If
the worst feels unbearable, and you feel as if you could not cope, then you
are blowing things out of proportion.)
Then:
a. look at all the evidence;
b. consider the real odds;
c. realize that the worst is probably not as bad as you first thought; and
d. think of ways of coping.
An example of using these thinking skills is shown above.
This situation is to be practiced at least three times over the next week (either
going straight to your end goals or gradually working up to your end goals across
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each practice). If your situation is very brief (e.g., riding four floors on an elevator),
then continue practicing over and over again on a given day until you spend about
an hour practicing.
You will continue to practice a given situation for the number of days necessary for
your maximum anxiety level to reduce to 2 or less. Whether your level of anxiety
decreases or not within a given practice is not important; what is more important is
that over each day of practice, the level of anxiety eventually decreases. Now, we
will consider ways of making the practice as effective as possible.
Moment of Fear
If you become afraid or nervous during the practice, use your breathing and
thinking skills to help you continue to move forward and complete the practice.
First, practice breathing by doing the following.
Focus your attention on breathing and counting.
Count for one second, inhale for two seconds, think the word “relax” for one
second, and exhale for two seconds.
Expand your stomach when you breathe in, and deflate your stomach when
you breathe out, keeping your chest relatively still, without taking big breaths.
Count up to 10 and back to one, one time.
Then, ask yourself the following key questions, so that you can use your thinking
skills.
What is it that I am most worried about happening?
What are the real chances of that happening?
What will I do to cope with and manage this situation?
Escape
If, while you are doing your practice, you feel as if you absolutely have to leave
because your fear and anxiety are so intense, the best strategy is to leave the
situation temporarily and, after using your skills, return to the situation again. Here
are some examples.
If you are driving on the freeway, pull off the freeway and find a place to stop.
Practice your breathing skills, and ask yourself the same key questions listed
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above to help you use your thinking skills. Then, get back on the freeway.
If you are in a shopping mall, find a place to sit down near the exit or just
outside the mall and, after you have used your breathing and thinking skills,
return back into the shopping mall.
The number-one rule is that if you escape from a situation and do not return to it,
you will end up back where you started and will not make progress. So, you must
always return to the situation.
After the Practice
After the practice is completed;
rate whether what you were most worried about occurred or not (yes or no);
rate your level of maximal anxiety during the practice on a 0–10-point scale,
where 0 = no anxiety and 10 = extreme anxiety.
Think about what happened, your accomplishments, and what you might do
differently next time. Watch out for unhealthy self-criticism. Remember, if you felt
anxious as you faced the situation, that is fine—in fact, it is expected, and it is
good. Learning is helped by anxiety, especially since two of the most critical things
to learn are that anxiety is not harmful and that you can handle anxiety. Also,
remember that whether your anxiety decreases within a given practice is not so
important; more important is that eventually, over repetitions of days of practice,
the anxiety decreases. Finally, remember what you actually accomplished. For
example, it is much more helpful to reward yourself for having driven two miles on
the freeway than to criticize yourself for not having driven further. It is the
accomplishments that are most important, no matter how small the
accomplishment may seem to be.
Homework
attacks and daily average of anxiety to your Progress Record.
Read chapter 9 over the next week to learn about involving family or friends.
Practice Changing Your Odds and/or Changing Your Perspective for any panic
attacks that occur over this next week.
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Practice facing an agoraphobia situation at least three times this week. You may
practice more than one situation from your hierarchy at one time.
Continue on to section 2 after you have practiced facing agoraphobia situations at

least 3 times.
Facing Agoraphobia Situations
Self-Assessment
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in the appendix.
1. It is essential that you do not think about your feelings when you
face agoraphobia situations. T F
2. Occasional practice with agoraphobia situations is acceptable. T F
3. Practice each agoraphobia situation only once. T F
4. Experiencing anxiety or fear when you are in the agoraphobia

situation means that you have failed T F
5. It is essential to eventually practice facing the agoraphobia

situation enough times and for long enough, and without
superstitious objects, safety signals, safety behaviors, or
distractions, so that something new can be learned. T F
6. The goal of facing agoraphobia situations is to learn that

whatever you are most worried about rarely happens or never
happens; that there is a way of coping with the worst; and that
you can handle fear and anxiety and accomplish something you
have been avoiding. T F
SECTION 2 Review and Continued Planning and Practice Facing Agoraphobia

Situations
Review of Practicing Facing Agoraphobia Situations
What Did You Learn?
Did the practices help you to realize that you had been mistakenly jumping to
conclusions and/or blowing things out of proportion? Did your practices help you
to realize that you can handle fear and anxiety? Did your Answer each of the
following by circling T (True) or F (False). Answers are given in the appendix.
practices help you to realize that you can accomplish things that you have been
avoiding? Of course, these three goals will become more fully realized with
continued and repeated practice.
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Dealing With Escapes
Sometimes anxiety feels overwhelming, and you may choose to escape from the
situation without returning to it the same day. Treat this as a learning experience,
and if you did escape, spend some time now thinking about why.
What kind of symptoms did you feel?
What kind of negative thoughts were going through your mind?
What were you anticipating had you continued with the activity?
You were probably jumping to conclusions and/or blowing things out of

proportion, in which case, go back to your thinking skills by looking at the evidence
and putting things back into perspective.
Also, remember that these practices are not supposed to be associated with zero
anxiety or fear. That is, you should feel anxious at first, or else there would be no
need to do them at all. In fact, some anxiety is critical, as it helps you to learn that
the feelings of fear and anxiety are not dangerous in and of themselves and can be
handled. Furthermore, sometimes the anxiety increases at first before it decreases,
because you are facing things that you have been avoiding. However, with repeated
practice, the anxiety will eventually decrease.
If your level of anxiety remains high after many repetitions of practicing with the
same situation, it may be that you are putting too much focus on trying to prevent
yourself from feeling anxious in the situation instead of accepting the anxiety and
focusing on your breathing and thinking skills to help you face the situation.
Continuing to Plan for and Practice Facing Agoraphobia Situations
Choose the next item from your Hierarchy of Agoraphobia Situations, and apply
the same principles as described in section 1. Continue doing this for as long as it
takes for you to complete all of the items from your hierarchy.
Context of First Panic Attack
The contexts in which first panic attacks are experienced are likely to carry special
significance. For example, let us say that your discomfort about driving began with
a panic attack while driving home alone at night to an empty house. After that,
fears of driving expanded to driving in the day, on surface streets and on freeways.
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In addition to facing your fear of driving during the day and night, on surface
streets and on freeways, it will be particularly important to face your fears of driving
under the same conditions in which the first panic occurred; that is, to face the
situation of driving home alone at night to an empty house. Similarly, let us say
that your first panic attack occurred in a movie theater that was crowded and hot,
and when you were suffering from a cold. It would be particularly helpful to face
your fears of movie theaters under similar conditions of being crowded, hot, and
when you are feeling congested or experiencing other cold symptoms.
Homework
Record and Daily Mood Record, and at the end of each week, complete your
Progress Record.
Practice facing an agoraphobia situation at least three times a week, continuing until
you have practiced all of the items from your hierarchy. You may practice more
than one situation from your hierarchy at one time.
Consider ways to practice facing agoraphobia situations in the context of your first
panic attack.
Continue to section 3 once you have completed at least one half of your Hierarchy
of Agoraphobia Situations or when you have reached Week I0 of the treatment
program.
SECTION 3 Facing Physical Symptoms in Agoraphobia Situations
Facing Physical Symptoms in Agoraphobia Situations
It is conceivable (although unlikely) that you could face all of your agoraphobia
situations without ever experiencing a physical symptom that normally distresses
you. Think of a woman who is concerned about driving, especially when her arms
feel weak because she mistakenly thinks that the weakness means that she is about
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to lose control of the car. What would happen if she faced the situation of driving
the freeways each day without ever feeling weakness in her arms? That would be
okay, as long as she never felt the weakness ever again. But that is an unlikely
scenario. So, it is best to be prepared for the physical symptoms in agoraphobia
situations.
You would probably agree that the situations would be easier to deal with if you
were guaranteed never to feel the physical symptoms. But that is unrealistic,
especially if you are at all anxious about the situation; as we know, anxiety brings
about symptoms in and of itself. In addition, some symptoms will occur regardless
of your anxiety, such as the rise in body temperature which may occur in a crowded
shopping area, or the eyestrain that may occur due to driving, or the stomach
fullness that might occur after eating a meal in a restaurant. It is better to face
everything—the symptoms and the situation—rather than to wish that the
symptoms will never occur.
By this time in the program, you should have completed much of chapter 10, in
which you learn to face physical symptoms that make you anxious. Now, it is time
to incorporate your work from chapter 10 and accept and even exaggerate the
physical symptoms in your practices with agoraphobia situations.
Entering a situation with the intention of having physical symptoms is evidence

that you do not fear the symptoms. On the other hand, entering a situation with
the hope that physical symptoms do not develop is evidence that you still fear the
symptoms. There are many ways in which to purposely bring on the physical
symptoms as you face different situations:
driving your car with the heater on and windows rolled up (heat);
wearing woolen clothes, jackets, or turtlenecks (heat);
looking behind yourself quickly while walking (dizziness, loss of balance);
drinking coffee (racy feelings);
eating pasta or other heavy foods (fullness of stomach);
walking up flights of stairs (racing or pounding heart);
not wearing sunglasses on a sunny day (eye fatigue);
wearing a tie or scarf (tightness around the throat).
So, follow the next steps to design your next practice, using the Facing Symptoms
and Agoraphobia Situations form.
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1. Identify the situation from your hierarchy that you will practice. It may be a
new item that you have not yet practiced; or, if you have practiced all items on
your hierarchy, then practice the item rated with the highest anxiety rating
again.
2. Choose a symptom that you will intensify, and decide how and when you will
deliberately produce that symptom as you deal with your anxious situation.
This is called symptom exaggeration.
3. Think about the best conditions to practice in so that you can truly learn that
your negative thoughts are unrealistic. These are called the end goals.
Remember to exclude superstitious objects, safety signals, safety behaviors, and
distractions.
4. Choose to either gradually work up to the end goals or go directly to the end
goals. If you choose a gradual approach, your today’s goals will be different
from the end goals.
5. Identify what it is that you are most worried about happening in this situation
while experiencing the symptoms. This is called negative thought.
6. Then apply your thinking skills to the negative thought. (How many times has
it happened? What is the evidence? What are the real odds? What are some
ways of coping?)
7. After the practice, record whether what you were most worried about
occurred, and record your maximal anxiety.
Facing Symptoms and Agoraphobia Situations
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Homework
Use Changing Your Odds and/or Changing Your Perspective for any panic attacks
that occur over this next week.
Practice facing an agoraphobia situation and the symptoms in that situation at least
three times this week. You may practice more than one situation from your
hierarchy at one time. Continue this practice until you have repeated all of the
situations from your Hierarchy of Agoraphobia Situations with all of the symptoms
that make you anxious enough times, so that your maximum anxiety is no greater
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than a score of 2.
Once you have completed these practices and all of the material in chapter 10, then
move to the final phase of the treatment by reading chapter 11, section 2, and
chapter 12.
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Chapter 9 Involving Others
Goals
Understand reasons for including others
Plan effective ways for including others
In this chapter, we present ways for incorporating others, such as husbands, wives,
family, or friends, to help you confront your fears of agoraphobia situations. You
may skip this section if there are no others who can assist you in this endeavor or if
you prefer to work alone.
Why Seek the Help of Someone Else?
Research suggests that involving spouses, life partners, family, or friends in the
therapy process facilitates a pattern of continuing improvement, especially after
formal therapy is over. Therefore, we recommend that you seek the aid of a family
member, friend, life partner, or spouse whom you think would be willing to help
you.
It makes sense when you think about it.
First, agoraphobic behavior can impact others in your life. By avoiding situations,
certain tasks or chores that used to be yours may need to be taken over by others.
Although the other person may be doing this in order to help you out, by taking
over your normal activities, they may inadvertently reinforce your fear and
avoidance. For example, let us say that to help you with your fear of driving and
waiting in lines, your husband now stops at the store on the way home from work
to pick up the groceries. In turn, because you do not drive or stand in lines, you do
not have the chance to learn to be less afraid of those situations. Furthermore, you
may develop a sort of dependence on your husband. That is, you rely on him more
and more to take you places and to do the things that you used to do on your own.
As you might guess, such dependence brings a whole lot of other problems with it
—sometimes resentment on both sides and arguments—all because your husband
was initially trying to help you out and you thought that you were doing the right
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thing. Awareness of these patterns is the first step to change.
Another possibility is that your spouse, life partner, family member, or friend may
inadvertently reinforce your fear and avoidance by giving a lot of attention to you
when you are afraid. If the attention you receive (which is something we all like to
receive) is stronger when you are afraid than when you are not afraid, then it makes
sense that your fear may become motivated by attention from your spouse or life
partner. Of course, you might not be fully aware of this pattern, and it might be
subconscious. This is because we all tend to respond to attention by increasing the
behavior that produced the attention in the first place. So, let us say that your
girlfriend hugs you especially long, or is especially caring for you, when you are
anxious or that an argument is immediately forgotten when she learns that you are
experiencing distress; it makes sense that, in some way, you learn that such positive
attention can be obtained from being anxious. This is certainly not to say that all of
your anxiety is designed to receive positive rewards; the cost of anxiety almost
always outweighs the benefits. Nevertheless, this type of reinforcement can be a
contributing factor, and therefore, one that should be modified. It is even possible
for your significant other to find your dependence on him or her as reinforcing for
them, so that in the end, he or she takes over more and more of your
responsibilities.
Another possibility is that, due to their lack of understanding of the nature of panic
attacks and agoraphobia, a concerned husband, wife, parent, or friend could
exacerbate your own fears by overreacting to or by magnifying your panic
symptoms. For example, a reaction from them of “Oh, my, we better go to the
hospital as soon as possible” when you tell them that you feel as if you are about to
faint might only serve to increase your own distress. Again, awareness of these
patterns is the first step to change.
At the other end of the scale, your significant other may react to your difficulties
with anger, frustration, lack of understanding, and nonsupport. In some ways, this
is understandable, since your spouse, life partner, family member, or friend may feel
that they have to take on responsibilities and chores that they really do not want to
do or that they never expected to do. For someone who already has a busy schedule,
taking on extra tasks can be a burden. This situation can be exacerbated when the
significant other does not fully understand the nature of your problem. They may
even make accusations that your problem is not real, that it is all in your head.
Having an unsupportive or an accusing partner will add to your background stress
and, in turn, make your progress through the treatments in this workbook a little
slower and more difficult. Under these conditions, it is helpful to give the
significant other a description of the nature of panic and agoraphobia and of how
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they are treated.
So, as you can see, a balance needs to be achieved between an overly dependent and
reinforcing relationship with significant others and being shunned and accused by
significant others. Incorporating their help in your progress to recovery is a way of
achieving the right balance. By having them involved in your therapy, the
significant other (from now on, called the helper or the coach) can become an aid, so
that the two of you can work as a problemsolving team in applying all of the
principles outlined in this workbook.
Ways for Your Helper to Understand
Your helper can learn about panic and agoraphobia by reading this workbook, by
having a mental health professional explain things to them, or by asking you to
explain things to them in as objective a way as possible. The latter is probably the
most difficult, since strong emotions may have already been built up between the
two of you regarding your panic and agoraphobia and their impact on your
relationship.
Of course, the helper must have some motivation or willingness to understand

and/or help out. Unfortunately, some people may be unwilling, although they may
become interested and willing as they see you making progress. The best you can
do is to suggest that they either read the workbook or talk to a mental health
professional so as to better understand what you are going through. The fact that
change would help them, as well as you, is another important concept to convey to
your helper. In other words, your relationship will most likely get better when your
panic and agoraphobia lessen.
The rest of this chapter proceeds as if your significant other has agreed to learn
more and become a part of your recovery. In particular, this means that they
become a kind of coach or aid when you face agoraphobia situations.
Preparation for Working Together
Preparation for the two of you to work as a team so as to overcome your panic and
agoraphobia involves several steps.
The helper should learn about panic and agoraphobia. We recommend that your
spouse, life partner, friend, or family member read this workbook. Along with this
information is the understanding that your panic and agoraphobia are not
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consciously intentional and that this is not a problem that is “all in your head” or
that “everything would be all right if you just pulled yourself together.”
It is important that you recognize the way in which your helper’s life has been
impacted as the two of you have worked to accommodate agoraphobia. This means
having a discussion with your helper and listing the areas of his or her life that have
changed as a result of this problem. Of course, the goal of treatment is to alleviate
your own distress, as well as any stress that it has placed on your helper. Joint
recognition of problem areas is a good way to begin a process of change as a team.
Next, in continuing your discussion with your helper, it is helpful to identify which
of their behaviors might reinforce your fear and avoidance, albeit inadvertently.
Brainstorm together to identify the reinforcements. In particular, discuss whether
your helper gives you the most positive attention at times when you are anxious, as
opposed to when you are relatively relaxed. Also, identify which chores or tasks he
or she has taken over that used to be yours. Finally, identify ways in which your
helper might magnify your physical symptoms by overreacting to them. Reading
the beginning section of this chapter might help coaches to realize how their own
behaviors could be inadvertently maintaining their loved one’s distress.
The next step is for your helper to learn about ways of overcoming panic and
agoraphobia. In other words, they should understand the breathing and thinking
skills for helping you to face agoraphobia situations. Along with this, your helper is
to be discouraged from magnifying the experience of panic, such as believing that
you are at risk for dying if your heart rate speeds up. Instead, they will begin to help
you to use your thinking skills when you are anxious. At the same time, they are
encouraged to be supportive and patient, since progress is rarely always smooth, ups
and downs occur, and progress is dependent on a great deal of effort and
persistence.
Helpers can become familiar with the thinking skills by reading the relevant
sections of the workbook and by prompting you to use your thinking skills in
preparation for each time you face agoraphobia situations. In this way, your helper
can provide an objective focus that might be helpful to you when examining the
evidence and developing alternatives.
Ways to Communicate
The next step in preparing to face agoraphobia situations with the direct help of
your friend, family member, or life partner is to consider how to communicate
when you are in the midst of feeling very anxious. Sometimes, we say things that
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we do not mean or in ways that we do not intend when feeling distressed. For that
reason, it is useful to rehearse the most constructive type of communication before
you and your helper head off to face agoraphobia situations.
We recommend that you use a 0-10-point rating system to communicate with each
other about your own level of anxiety or distress as a way of diminishing the
awkwardness associated with discussion of your feelings, especially in public
situations. Furthermore, using a number scale helps to keep you on the track of
being objective as opposed to distracting from how you are feeling or, on the other
hand, being too subjective. It is much more effective to tell your helper that your
anxiety level is a 6 instead of saying “I feel terrible.” Similarly, it is much more
effective for your helper to ask for a number rating than to ask, “How bad you are
feeling?”
Of course, you may prefer not to let your helper know how anxious you are feeling
at all, for reasons of embarrassment or attempts to avoid your anxiety due to the
concern that your anxiety will intensify if you talk about it. Remember, attempts to
distract from or avoid your anxiety are not helpful in the long run—it is much
better to maintain an objective awareness of your reactions. The initial discomfort
and embarrassment about discussing your anxiety with your helper will most likely
reduce as the two of you become more familiar with discussing anxiety and its
management.
Also, significant others should attempt to be neither too insensitive nor too pushy.
For example, they may presume to know how anxious you feel or what is going
through your mind without asking for confirmation from you. Alternatively, they
may become angry or frustrated if you avoid or escape from a situation. Joint
discussion in advance about how the helper can best react should you show
hesitation or withdrawal is the best way to prevent negative communication during
exposure. So, again, take on the issue as a team. Discuss what each person will do if
you become very afraid or express an urge to leave. The two of you might decide to
use keywords to communicate crucial concepts, especially if in public. For example,
consider the following scenario.
YOU: My anxiety is strong—at a 6,I want to leave.
HELPER: Thoughts?
YOU: The same old thing—I’m hot and sweaty, and I think I’m going to faint.
HELPER: Jumping to conclusions?
YOU: Yes—but the feelings are stronger than usual.
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HELPER: How many times?
YOU: I know—I’ve never fainted.
HELPER: Sit?
YOU: Yes, let’s sit down so that I can think about this.
As you can see, the helper was using a few keywords that the couple had worked
out beforehand, to prompt the individual suffering from anxiety look at the
evidence and develop a coping strategy of sitting down versus escaping the
situation.
Here is another example.
YOU: I am terrified.
HELPER: Number?
YOU: It’s a 7—I feel like I can’t breathe.
HELPER: It’s a feeling—is it true that you cannot breathe?
YOU: I know—I am getting enough air, but it’s really difficult.
HELPER: Slow breathing?
Here is yet another example.
YOU: I don’t want to practice today—I am really tired. It’s too hard, and I’m worn
out.
HELPER: What were you planning to do today?
YOU: To go back to the bank lines. The same one I went to on Monday. I just don’t
feel up to it today.
HELPER: I know it’s hard, but it’s helping—you can go places that used to be almost
impossible for you.
YOU: Yes—but I just need a rest.
HELPER: Are you making any negative predictions about what could happen in the
bank line because of the way you are feeling?
YOU: Probably. I think that I really would pass out because I am so tired.
HELPER: Okay—what is the evidence?
YOU: I know... none. Okay, I will go.
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Support from the helper is important also. Support means recognizing attempts
you make to overcome your fear and avoidance and reinforcing these attempts. This
may differ from the usual pattern of reinforcement, which is to give most attention
to you when you are in distress. Occasionally, your own success can seem deflated if
the significant other in your life does not appreciate how hard you have worked or
what a major accomplishment it is for you to initiate an activity that you have been
avoiding for a long time. Let us say that you have been wanting to go out to dinner
at a restaurant with your partner, something that the both of you used to really
enjoy. Finally, you feel ready, and so you mention it to your significant other when
he or she comes home from work. However, you partner is tired and refuses to go,
suggesting that perhaps you do so another night. While it is understandable that
your companion might be tired and not in your mindset at that moment, it is
helpful if your partner realizes the significance of your initiative and reinforces your
progress by agreeing to eat out, despite personal tiredness. On the other hand, it is
also important for you to understand that your significant other may not always be
as supportive as you would like because of his or her own troubles and concerns.
Your Helper as a Coach
So with all of this information in mind, you can now proceed to include your helper
as a coach when you face agoraphobia situations. The helper may be a coach by
discussing the task before you attempt it and after it is over, prompting you to use
your thinking skills and breathing, and helping you to evaluate your
accomplishments objectively. Also, a coach can accompany you on the task.
However, remember that if your helper accompanies you, she or he could become a
safety signal. Therefore, it is essential that, eventually, you are able to face the
situation on your own, without your spouse, life partner, friend, or family member.
An example of how to wean yourself away from your helper gradually follows.
Drive I-90 five exits, with your coach as the driver.
Drive I-90 five exits, with your coach as the passenger.
Drive I-90 five exits, with your coach in a different car, one car in front of you.
Drive I-90 five exits, with your coach in a different car, two cars behind you.
Drive I-90 five exits, with your coach in a different car, one half a mile behind
you.
Drive I-90 five exits, meeting your coach at a destination point.
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Drive I-90 five exits, without the help of your coach.
Homework
Return to chapter 8, and continue with planning for and practicing facing
agoraphobia situations, either with or without the assistance of your helper.
Self-Assessment
in the appendix.
1. Family members or friends should never be involved in your

treatment, as they will only contribute to the pressure for you to
get better. T F
2. It is possible for your agoraphobia to be reinforced by attention

from your family or friends or by having them take over your
responsibilities. T F
3. If you do have a helper as you face agoraphobia situations, that

person should read this workbook, think about the ways in
which his or her life has been influenced by your agoraphobia,
how he or she may have reinforced your agoraphobia, and learn
the breathing and thinking skills. T F
4. In the midst of anxiety, it is better not to communicate with

your helper. T F
5. Make sure the coach is always with you and that you are never
left alone when you face agoraphobia situations. T F
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Chapter 10 Facing Physical Symptoms
Goals
To understand the value of facing physical symptoms
To learn how to optimally face physical symptoms
To review what is learned from facing physical symptoms
To continue to face physical symptoms and activities
Completing this chapter will take a number of weeks (e.g., six weeks), although the
actual amount of time will depend on the number of symptoms and activities that
make you anxious and on the pace of your progress with those symptoms and
activities.
SECTION 1 Facing Physical Symptoms
Face the Physical Symptoms: Why?
As you know by the now, fear of physical symptoms is central to panic disorder.
You have been learning to change what you think about the physical symptoms.
Now we will face the physical symptoms directly so that you can learn that the
symptoms are not harmful; that you can handle the symptoms and the anxiety; and
that, eventually, the anxiety about the physical symptoms will decrease. We have
discussed how being afraid of physical symptoms leads to more physical symptoms,
since the symptoms are the natural result of anxiety and fear. This is part of the
panic cycle.
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Figure 10.1.
Panic Cycle
As already mentioned, the reasons why fears of physical symptoms persist include:
avoidance behaviors (e.g., doing whatever you can to get rid of the symptoms or
avoiding places where you expect the symptoms to arise);
mistaken beliefs (e.g., that the physical symptoms mean you are going to die,
lose control, or go insane);
interoceptive conditioning, where your body has become highly sensitive to the
physical feelings of the beginnings of a panic attack.
The goal of this part of treatment is to help you directly face the physical symptoms
that make you anxious (i.e., decrease avoidance), replace your mistaken beliefs with
more realistic thinking, and interrupt the conditioning. To do this, we first identify
which physical symptoms make you feel anxious, using a series of exercises that
bring on symptoms similar to those that are typical of anxiety and panic. Next, we
repeat the exercises that produce the symptoms enough times and in just the right
way so that you learn that the symptoms are not harmful, that you can handle
them, and that you can break the conditioning.
What normally happens in your day-to day-life is probably very different—you

probably do everything possible to get rid of the physical symptoms, such as lie
down, distract yourself by getting engaged in other activities, leave wherever you
are, and so on. These actions are really avoidances, and they prevent you from
learning that the symptoms are not harmful. So, we will do the opposite of what
you normally do.
First, though, we would like to make a note about medical issues before we
continue. Most of the symptom exercises are relatively mild in intensity. You are
not being asked to run a marathon. However, they may be too intense for persons
with certain medical conditions, which is one of the reasons why we always
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recommend that a medical evaluation be conducted if you have not had one in the
last 12 months. If you do suffer from a medical condition (e.g., epilepsy, high blood
pressure) alongside panic disorder, we recommend that you undertake these
symptom-induction exercises under the guidance of your medical doctor. For
example, have your doctor look at the list of symptom exercises and ask the doctor
to indicate which ones are okay for you to do. Similarly, asthmatic sufferers should
obtain medical clearance for these exercises, as should women who are pregnant.
Symptom Assessment
Here is the list of exercises.
1. Run in place, lifting your knees up as high as you can, for up two minutes, to
produce racing heart and shortness of breath.
2. Spin around and around for up to one minute. If you have a chair that swivels,
such as a desk chair, this is ideal. Otherwise, stand up and turn around quickly
(about one turn every three seconds) to make yourself dizzy. Be near a soft
chair or couch to sit on after one minute is up. This will produce dizziness
and, perhaps, nausea as well.
3. Overbreathe for up to one minute—that is, breathe deeply and fast, using a lot
of force, as if you were blowing up a balloon. Sit as you do this. This exercise
produces unreality, shortness of breath, tingling, cold or hot feelings, dizziness
or headache, and other symptoms. In fact, you have already done this exercise
as part of chapter 6 when evaluating the role of overbreathing in your panic
attacks. (Do not do this exercise if you have epilepsy, seizures, or cardiopulmonary
diseases.)
4. Breathe through a drinking straw for up to 2 minutes. This will produce the
feeling of not getting enough air.
5. Stare at yourself in a mirror for up two minutes. Stare as hard as you can to
produce feelings of unreality.
6. Place your head between your legs for 30 seconds, and then sit up quickly, in
order to produce feelings of lightheadedness or a sense of blood rushing away
from your head.
7. Tense every part of your body, without causing pain, for up to one minute.
Tense your arms, legs, stomach, back, shoulders, face—everything. This will
produce feelings of muscle tension, weakness, and trembling.
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After each exercise, you will do the following.
List all of the symptoms you felt.
Rate your anxiety about the symptoms on a 0–10 scale (where 0 = none at all, 5
= moderate, and 10 = extreme).
Rate how similar the symptoms are to the ones you would feel in a natural
panic attack on a 0–10 scale (where 0 = not at all similar, and 10 = exactly the
same).
Now, go ahead and attempt each exercise, and complete the Symptom Assessment
form on page 157.
Here are Jill’s responses to each of the standard exercises.
1. Running in place: Jill stopped this one after 45 seconds.
“I feel like I have to stop—my heart is beating fast, and I feel sweaty and out
of breath. Usually, I try to avoid doing any exercise.” Jill rated this procedure as
producing symptoms that were very intense (8), very similar to what she felt
during her panic attacks (7), and, initially, that made her feel quite anxious (6).
2. Spinning: Jill stopped this after 30 seconds.
“Boy, I feel really dizzy. The room is spinning—I am spinning. And my heart
is racing, and I feel sweaty. It’s calming down now.” These symptoms were
very intense (9), similar to those she felt when she panicked (7), and they
caused some anxiety (5).
3. Hyperventilation: Jill stopped after 25 seconds.
“I feel really hot and sweaty, tingly in my face, lightheaded, and like I need to
take a deep breath.” Again, this procedure produced symptoms that Jill rated
as being very intense (9), similar to her natural panics (7), and that made her
feel very anxious (8).
Symptom Assessment
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4. Drinking-straw breathing: Jill stopped after 35 seconds.
“I feel like I can’t keep going, I have to take a deep breath.”
Jill rated the symptoms as strong (6), quite similar to her panic-symptoms (4), and
making her feel somewhat anxious (5).
5. Staring at herself in the mirror.
“This is weird. It feels a bit like the spacey feelings I get when I’m just coming
out of a panic attack. I don’t like this at all.” Jill rated the symptoms as being
moderate (5), fairly similar to her panic symptoms (4), and causing some
anxiety (4).
6. Head lift.
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“I feel a little dizzy—and lightheaded. This was not much at all.” She did not
report any fear (0) or much similarity (2), and she rated the symptom intensity
as being quite mild (2).
7. Body tension.
“I feel a little shaky and trembly and weak.” While the symptoms were quite
intense for Jill (6), she did not rate them as very productive of anxiety (1), and
she rated the similarity as being low (1).
Now, look at your own ratings on the Symptom Assessment form. Star (*) the
exercises that produced symptoms you rated as at least 2 on the 0–10 scale of
similarity. Next, rank the starred exercises in order of the level of anxiety (1 =
lowest level of fear, 2 = second lowest level of fear, and so on). We will begin doing
repetitions with the exercises that were rated with the least anxiety (instructions
follow).
If your anxiety ratings were never higher than 2, consider the following possible
explanations and solutions.
Maybe none of the symptoms of which you are afraid were produced by these
exercises. If so, be creative, and come up with other exercises to produce symptoms
that are most relevant to you. For example, if you are anxious about visual
symptoms, look at a bright light for 30 seconds, and then look at a blank wall to see
the afterimage. Or, if you are afraid of symptoms in your throat, put pressure
against the sides of your throat, or press down on the back of your tongue with a
pen. Another exercise is to sit in a hot, stuffy room for five minutes. You should
know by now which symptoms bother you most, so be creative, and invent some
ways to produce them. The goal is to deliberately bring on the symptoms that
worry you most, as long as it is safe to do. Add these to the “other” category on the
Symptom Assessment form, and try them out.
Maybe you stopped the exercises too soon in anticipation of strong symptoms. For
example, you might have stopped spinning after 10 seconds because you were just
starting to feel off-balance. If so, then repeat the exercises, and try to go for longer.
Maybe you have truly overcome your anxiety of the symptoms as a result of the
work you have done so far. If so, we still recommend that you continue with the
exercises described below. Overlearning is helpful in the long run.
Maybe you feel so safe in the setting in which you performed the exercise that the
symptoms did not scare you. If so, try the exercises when alone or in a place where
you feel less safe. Some of our patients note that if they had to do the symptom
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exercises alone, they would be more frightened. When accompanied, they feel safe,
because there is help should something go wrong. Note that this fear is based on a
mistaken belief that they would indeed be in danger if the symptoms occurred
when they were alone. In fact, these exercises are no more dangerous when alone
than when accompanied.
Maybe the knowledge of where the symptoms came from (i.e., the exercise) and the
knowledge that the symptoms will go away when the exercise ends decreased your
anxiety. Note that this, too, is based on the mistaken notion that unexplained
symptoms are necessarily harmful. In this case, continue with the practices, as they
should help you manage your fear of symptoms that do arise for no apparent
reason.
Repeated Practice With Physical Symptoms
The goals of the repeated practice are to learn something new, including:
the physical symptoms and anxiety itself are not harmful;
you can handle the symptoms and the anxiety.
As a result, eventually (although not necessarily immediately), the anxiety about the
symptoms will diminish.
You will practice with the exercises that you rated as having at least some similarity
(at least a 2 on the similarity rating). Of those, begin with the exercise that you
rated with the least anxiety on the 0–10-point scale, as long as the anxiety rating is
at least 3. (Do not bother practicing ones with an anxiety rating of 2 or less.)
If you are using benzodiazepine medications (such as Xanax or Klonopin) on an as-

needed basis, the temptation may be to take a pill just before you begin to face your
fear of the physical symptoms. This is certainly permissible, especially if the only
way you are willing to do the symptom exercises is with the help of the medication.
However, it will be essential to eventually face your fear and the symptoms without
taking the medication (which is described in chapter 11).
Remember, the goal of these exercises is not only to face the symptoms but also the
fear and anxiety initially produced by the symptoms, so that you can learn that you
can handle the symptoms, fear, and anxiety. Medications, especially short-acting
potent benzodiazepines, may actually prevent you from experiencing much fear and
anxiety, and in that regard, they become a form of avoidance.
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Here are the rules for the repeated practice with physical symptoms.
1. Decide what it is that you are most worried about happening as you practice
the symptom exercise, and record that next to the Negative Thoughts header
on the Facing Symptoms form on page 162. This may be a concrete outcome,
such as fainting, or it may be the idea that you will not be able to handle the
anxiety. You may photocopy this form from the book or download multiple
copies at the Treatments ThatWorkTM website (www.oup.com/us/ttw).
2. Begin the exercise, and continue the exercise for at least 30 seconds after the
point at which you first notice symptoms. By continuing beyond the point of
first noticing the symptoms, you are providing yourself with the chance to
learn that the symptoms and anxiety are not harmful—just unpleasant—and
that you can handle them.
3. Produce the symptoms as strongly as you can. Do not avoid the symptoms by
doing the exercise mildly or with hesitation. For example, while spinning, the
turning must be continuous, and when overbreathing, make sure that the air is
forced out with a lot of pressure and that the breathing rate is fast.
4. Remain focused on what you are doing and feeling in a matter-of-fact way.
You will use your coping skills of breathing and thinking after each exercise is
ended—not during the exercise—because there is not enough time, and it is
more important to focus directly on the physical symptoms.
5. When the time is up, stop the exercise, and then complete the Facing
Symptoms form to rate:
whether the outcome you were most worried about occurred;
your level of anxiety (0–10) under the section labeled First Exercise.
6. Now is time to use your coping skills. So, when you finish the exercise, take up
to 10 slow, diaphragmatic breaths, and then move into your thinking skills by
answering the following questions.
What will I do to cope with these symptoms and anxiety?
Be aware of negative thoughts, such as “I have to stop—I can’t handle these

feelings.” That is a prediction that you are making which is based on nothing
but fear. You can, in fact, handle the symptoms and continue the exercises. If
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you have thoughts about the symptoms becoming more intense or lasting
longer, or about how they might affect the rest of your day, go back to looking
at the real odds, facing the worst, and ways of coping.
7. Wait until your symptoms have abated, and then repeat steps 1–6 two more
times.
At the end of each repetition, complete the section on your Facing Symptoms form
for the second exercise and then for the third exercise.
Remember to keep in the mind the goal of these exercises. By facing the symptoms
and anxiety, you are learning that the symptoms and anxiety are harmless and that
you can handle them. As a result, eventually your anxiety over the symptoms will
decrease, and eventually, the symptoms will occur less often in your day-to-day life.
(Although there will always be some symptoms—remember, everyone has
symptoms some of the time.)
Facing Symptoms
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Do not anxiously wait for the symptoms to abate—that will only fuel your anxiety.
Use your thinking skills to help you realize that it does not matter how long the
symptoms last, because they are not harmful, and they are tolerable. Anxiously
waiting for the symptoms to subside means that you are still worrying about the
symptoms. Use the symptom exercises to learn that what you are most worried
about in relation to the symptoms does not happen.
Practice the first symptom exercise three times each day over the next week.
Continue daily practices of the symptom exercise until your anxiety rating on a
given day is no more than 2. That is, it is not so important whether your level of
anxiety decreases with each repetition on a given day but whether your anxiety level
decreases over each day of practice.
Homework
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attacks and average daily anxiety to your Progress Record.
Practice the Facing the Symptom exercise for your first symptom three times each
day, continuing until the maximum anxiety on a given day is no more than 2.
Continue on to section 2 after one week of practice facing symptoms.
Self-Assessment
in the appendix.
1. You should bring on the symptoms to the fullest to get the most
benefit out of the symptom exercises. T F
2. Stop the symptom exercises as soon as you feel anxious. T F
3. The point of the symptom exercises is to learn that the

symptoms are not harmful and that the symptoms and anxiety
can be handled. T F
4. It is best to minimize anxiety by concentrating on slow

diaphragmatic breathing and thinking skills as you practice each
symptom exercise. T F
5. Facing the symptoms will only make you more afraid. T F
SECTION 2 Review of Practice and Continued Practice in Facing Symptoms
Review of Facing Symptoms
Your task for last week was to practice facing your fear of symptoms every day. By
bringing on the symptoms, did you learn that whatever you were most worried
about either did not happen or was something you could cope with and that you
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could handle the symptoms and the anxiety?
Remember to produce the symptoms fully. Also, remember not to distract yourself
while you are bringing on the symptoms. An example of distraction would be to
think about other things, such as how to manage a difficult situation at home or
what to eat for dinner. It is much more helpful to keep a very matter-of-fact
attitude in which you are fully focused on what you are doing and on the symptoms
that you are producing.
Distraction is similar to avoidance, and avoidance is to be prevented. The best way

to learn to be less afraid of symptoms is to face them directly. Usually, avoidance
happens because of the continued mistaken belief that the symptoms are harmful
(e.g., “I don’t want to hyperventilate because I’m afraid that I will pass out and that
no one will be there to help me”). Remember, the symptoms are not harmful.
Examples of indirect avoidance include keeping the symptoms at a very mild

intensity by doing the exercises only slightly (e.g., breathing only slightly faster
than normal during hyperventilation, or spinning at a very slow pace). Or maybe
you practiced the symptom exercises only in the presence of someone with whom
you feel safe, at times when you felt relaxed, or with the aid of benzodiazepine
medications. Either way, these actions represent avoidance. In the end, it will be
essential for you to face the symptoms and the anxiety directly, even at very intense
levels, or when alone, or at times when already feeling anxious, or without the
influence of benzodiazepines, because these are the conditions in which symptoms
happen in normal day-to-day life, now or in the future.
Continue to Face Symptoms
From your Symptom Assessment list, progress to the starred (*) exercise that you
rated with the next-highest level of anxiety. Practice facing that symptom,
remembering the following rules.
1. After you have identified what it is that you are most worried about with the
particular symptom exercise (whether that be something concrete, such as
fainting, or the idea of not being able to handle the anxiety), begin the
exercise.
2. Continue the exercise for at least 30 seconds after the point at which you first
notice symptoms. By continuing beyond the point of first noticing the
symptoms, you are providing yourself with a chance to learn that the
symptoms are not harmful—just unpleasant.
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3. Produce the symptoms as strongly as you can. Do not avoid the symptoms by
doing the exercise mildly or with hesitation.
4. Remain focused on what you are doing and feeling in a matter-of-fact way.
You will use your coping skills of breathing and thinking after each exercise is
ended—not during the exercise.
5. When the time is up, stop the exercise, and then rate:
whether the outcome you were most worried about occurred;
your level of anxiety (0–10) under the section labeled First Exercise.
6. Now is the time to use your coping skills. So, when you finish the exercise,
take up to 10 slow, diaphragmatic breaths, and then move into calm thinking
by answering the following questions.
What will I do to cope with these symptoms?
7. Wait until your symptoms have abated, and then repeat steps 1–6 two more
times.
At the end of each repetition, complete the section on your Facing Symptoms form
for the second exercise and then for the third exercise.
Continue in this way until you have practiced each starred (*) symptom exercise
three times a day and for enough days so that the maximum anxiety rating on a
given day is no higher than 2.
Homework
Record and Daily Mood Record. At the end of the week, add your number of panic
Practice facing the starred symptom exercises three times each day for the number
of days necessary for your anxiety rating on a given day to be no more than 2.
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Continue in this way until you have sufficiently practiced each starred symptom
exercise.
Move to section 3 when you have completed at least one half of your starred
symptom exercises.
Self-Assessment
in the appendix.
1. As you face the physical symptoms, keep your mind preoccupied

with other things. T F
2. Stop the symptom exercises when your maximum anxiety is no

higher than 5. T F
3. The purpose of facing the symptoms is to become less anxious

about the symptoms, but it is not to eliminate the symptoms. T F
SECTION 3 Facing Symptoms in Activities
Facing the Fear Out There: Activities
Up until now, your efforts have been directed at artificial exercises, such as
hyperventilation and spinning—activities that are not common in day-today life.
Now, it is time to move to more common activities that you have feared or avoided
because of the physical symptoms they cause. Examples include: drinking coffee
(because of the stimulant effect), eating chocolate (because of the stimulant effect),
aerobic activity (because of the cardiovascular effect), lifting heavy objects (because
of the heightened blood pressure and dizziness effects), and so on. A more
comprehensive list is provided below in the Activities Hierarchy. As you look
through the items on this list, you may realize that you have been avoiding these
types of activities, and only now is the reason clear—because these activities bring
on bodily symptoms that remind you of panic attacks.
Rate each activity from 0 to 10, where 0 = no anxiety at all and 10 = extreme
anxiety. Any activities that you rated as 3 or above will now be part of your
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Activities Hierarchy, and, as with the symptom exercises up until now, the goal is
to repeat each activity as many times as needed to learn that the symptoms are not
dangerous (i.e., that whatever you are most worried about never happens or rarely
happens and that you can cope with whatever happens) and that the symptoms and
anxiety can be handled. You will know this when the next time you practice a given
activity, the maximum anxiety level is 2 or less.
This takes a lot of work, because these activities often take more time than the
symptom exercises. However, the more you put into it, the more you will improve.
Also, there is a difference between the symptom exercises and some of the activities
that you are just beginning. With the symptom exercises, the symptoms generally
build up quickly after starting the exercise and subside quickly after you stop the
exercise. This not always true with the activities. For example, symptoms may not
come on right away after drinking coffee because it takes time for caffeine to have
its peak effect (about 45 minutes). Similarly, the symptoms may not go away
immediately after drinking coffee. The important point to keep in mind is that
even though you do not know exactly when symptoms will come and go, the
symptoms are not harmful.
Activities Hierarchy
Activity Anxiety (0–

10)
Running up flights of stairs _________
Walking outside in intense heat _________
Attending meetings in hot, stuffy rooms _________
Driving in hot, stuffy cars _________
Shopping in hot, stuffy stores or shopping malls _________
Walking outside in very cold weather _________
Participating in aerobics _________
Lifting heavy objects _________
Dancing _________
Engaging in sexual relations _________
Watching horror movies _________
Eating heavy meals _________
Watching exciting movies or sporting events _________
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Getting involved in “heated” debates _________
Showering with the doors and windows closed _________
Using a sauna _________
Hiking _________
Playing sports _________
Drinking coffee or other caffeinated beverages _________
Eating chocolate _________
Standing quickly from a sitting position _________
Getting angry _________
Riding fairground or amusement park rides _________
Snorkeling _________
Taking antihistamines or other over-the-counter medications _________
Looking up at the sky and clouds _________
Drinking diet cola and other sodas _________
Reading while a passenger in a car _________
For persons who frequently panic out of sleep:
Deep meditative relaxation _________
Fatigue from staying up late several nights in a row _________
Alcohol or antihistamines _________
Abrupt wakening from sleep by an alarm that goes off in the

middle of the night _________
Hot sleeping conditions due to central heating, windows closed,

no air conditioning or fans, on warm nights, or from wearing
warm clothes to bed _________
Facing Your Own Activities
Choose the activity that you rated about 3 in terms of anxiety, and then follow the
steps below.
1. Identify what it is that you are most worried about happening in this activity.
This is called Negative Thought. As with the Facing Symptom exercises, this
might be a concrete outcome, such as dying or fainting, or it might be the idea
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that you cannot handle the anxiety associated with the activity.
2. Think about the best conditions in which to practice, so that you can truly
learn that your negative thoughts are unrealistic (these are called End Goals).
For example, let us say that your task is to have a shower with the windows
and doors closed, so that the room fills up with steam. In the past, you may
have avoided doing this because the steam led you to feel a sense of
suffocation. So, the plan might be to close the doors and windows before you
turn on the water, run the hot water for a few minutes before you get into the
shower, and then stay in the shower for a particular period of time, such as 10
minutes, even if you feel a sense of suffocation. (Remember, a sense of
suffocation does not mean that you are actually suffocating.) Then, get out of
the shower, and dry off in the steamy room for a couple of minutes before
opening the door. Another example is deciding to overcome your fear of hot,
stuffy areas. In the past, you have avoided wearing heavy clothes, especially in
crowded places such as shopping malls. So, your goal is to wear a coat or a
thick sweater in an already warm mall.
Figure 10.2.
Example of Part of Completed Facing Activities Form (1)
As with facing agoraphobia situations, learning that your negative thoughts are
unrealistic will require that you let go of all superstitious objects, safety signals,
safety behaviors, or distractions. So, go back to your lists of
Superstitious/Safety Signals and Safety Behaviors/ Distractions from chapter
4, and plan for eventually practicing each activity without anything on those
lists.
3. Choose either gradually to work up to the End Goals of the activity or to go

directly to the End Goals of the activity. For example, let us say that your plan
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is to drink a cup of coffee, and you decide to take a gradual rather than a direct
approach. Therefore, your first step is to drink a full cup of decaffeinated
coffee, since usually you avoid even the small amount of caffeine in
decaffeinated brews. The next step is to drink a mixture of decaffeinated and
caffeinated coffee. Finally, you drink a full cup of caffeinated coffee. Or, if you
wanted to take a direct approach, you could just go straight to drinking a full
cup of caffeinated coffee. Today’s Goals are the conditions in which you will
practice on a given day as you work toward your End Goals.
In preparation for the practice, ask yourself the following questions.
Has what you are most worried about ever happened? (If it has not happened
or rarely has, then you are jumping to conclusions.)
What is the worst that can happen, and how would you cope with it? (If the
worst feels unbearable and you feel as if you could not cope, then you are
blowing things out of proportion.)
Figure 10.3.
Example of Part of Completed Facing Activities Form (2)
Then:
a. look at all the evidence;
b. consider the real odds;
c. realize that the worst is probably not as bad as you first thought; and
d. think of ways of coping.
This activity is to be practiced at least three times over the next week (either going
straight to your End Goals or gradually working up to your End Goals across each
practice). If your situation is very brief (e.g., looking up at the clouds moving across
the sky), then continue practicing over and over again on a given day until you
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spend about one hour practicing.
You will continue to practice a given activity the number of days necessary for your
maximum anxiety level to reduce to 2 or less. Whether your level of anxiety
decreases or not within a given practice is not important; what is more important is
that over each day of practice, the level of anxiety eventually decreases. Now, we
will consider ways of making the practice as effective as possible.
Moment of Fear
If you become afraid or nervous during the activity, manage your anxiety so that
you can continue the activity by first using your breathing skills.
Focus your attention on breathing and counting.
Count for one second, inhale for two seconds, think the word “relax” for one
second, and exhale for two seconds.
Expand your stomach when you breathe in, and deflate your stomach when
you breathe out, keeping your chest relatively still, without taking big breaths.
Count up to 10 and back to 1, one time.
Then, ask yourself the following key questions so that you can begin your thinking
skills.
What will I do to cope with and manage this situation?
Remember, the goal of the breathing and thinking skills is not to eliminate the
symptoms or the anxiety but to help you to continue moving forward in facing your
fears and completing the activity.
Incomplete Practice
If, while you are doing your activity, you feel as if you absolutely have to leave
because your fear and anxiety are so intense, the best strategy is to leave the activity
temporarily and, after you have used your coping skills, return to the activity again.
So, for example, if you are in an aerobics class, you may leave the class in order to
practice breathing, ask yourself the same key questions listed above to help you to
use your thinking skills, and then return to the class. Or, if you are dancing, hiking,
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or looking up at the sky and clouds, you may take a break, use your breathing and
thinking skills, and then return to the activity. (Of course, there will be some
activities from which it will be impossible to temporarily leave.)
The number-one rule is that if you escape from an activity and do not return to it,
you will end up back where you started and not make progress. So you must always
return to the activity.
After the Practice
After the practice is completed:
rate whether what you were most worried about occurred or not (yes or no);
Facing Activities
169
rate your level of maximal anxiety during the practice on a 0–10-point scale,
where 0 = no anxiety and 10 = extreme anxiety.
You may photocopy this form from the book or download multiple copies at the
Treatments ThatWorkTM website (www.oup.com/us/ttw).
Jill’s activities for her first two weeks were to attend a fitness class (10 minutes each
time, first with a friend and then alone) and to have a shower with the curtain
drawn and the door closed. The first time she attended a fitness class, she was very
anxious before the class but practiced slow breathing and reminded herself that
although she may feel out of breath, hot, sweaty, and a suffering from a pounding
heart, she was not in danger. As soon as the class started, Jill wanted to leave, but
then she realized that by going at her own pace, she could handle the feelings, and
so she stayed for the full 10 minutes. After the first practice, it became easier, and
Jill stayed for longer periods in the class. Then she went to class alone. Her fears in
the shower were related to negative thoughts about suffocating from a lack of air.
She gradually increased the length of time in the steamy shower room.
Medication Issues
As with the symptom exercises, the use of medication has to be considered:

particularly, medications that either block all of your feelings or that you rely on to
reduce your fear at the moment. (The latter are the fast-acting medications, such as
Xanax and Klonopin.)
If medications are so potent that they block all feelings, then they may interfere
with the benefits that you can receive from facing your fear. That is, some anxiety is
very helpful—we learn more when we are anxious in comparison to when we are
completely relaxed. Also, it is important to learn that physical symptoms and fear
and anxiety are not harmful. So, if your anxiety and panic are completely blocked
by medications, it may be helpful to talk with your prescriber about lowering the
dosage of your medication.
The second issue concerns the use of fast-acting medications. Initially, when you
first face activities that bring on bodily symptoms, you may feel the need for Xanax
or Klonopin, because those medications have been your usual coping tool. That is
okay, as long as you eventually become comfortable enough so that you can do
these activities without the fast-acting medications. That way, you will really get
the chance to learn that the bodily symptoms produced by the activity are not
harmful. Ways of weaning off medications are described in chapter 11.
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General Issues
Some of the activities will take special planning, and it may take some time to
accomplish all of the activities on your list. However, it is important to practice
regularly—do not put it off!
Given the timing issues, it sometimes makes sense to work on two activities at one
time. For example, you could exercise every second or third day, building up your
fitness level, while at the same time practice getting used to steamy showers once or
twice a day.
Homework
Practice your first activity at least three days a week, and continue to do so until
your anxiety rating on a given day is no more than 2. You may work on more than
one activity at a time.
Continue to section 4 once you have completed at least one week of practice with an
activity.
Self-Assessment
in the appendix.
1. I should avoid caffeine and any other stimulants. T F
2. It is dangerous to make myself feel unpleasant physical feelings

by sitting in a sauna or by weight training. T F
3. If I become anxious as I face an activity, I should stop and try a

different activity. T F
4. I should always complete the activity to its fullest degree and
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never proceed gradually. T F
5. I should continue the activity with the aid of breathing and

thinking skills, even if I experience symptoms. T F
SECTION 4 Review and Planning for Continued Facing Activities
Reminder of the Value of Facing Activities
As a reminder, the purpose of the activity practices is for you to learn that the
symptoms that are produced by these activities are not harmful, that you can handle
the symptoms and the anxiety, and that you can accomplish something you have
been avoiding. Consequently, your anxiety over the activities will eventually
decrease.
Review of Practicing Facing Activities
Did you practice an activity at least three days last week? If you have not practiced
regularly, we encourage you to make these practices a priority. It takes effort, but
the more effort you expend, the more benefit that you will gain. Remember to keep
records of your practices on your Facing Activities form, so that you can learn that
the symptoms produced by the activity are not harmful and that you can handle the
symptoms and the anxiety. Eventually, with repetition, your anxiety will decrease.
Did you try one of your activities, become frightened, and escape? For example, did
you sit in a sauna and leave as soon as you felt too hot, or did you stop drinking
from your cup of coffee after the first sip or two? If so, then spend some time
thinking about why. What led to your escape? What kind of symptoms did you
feel? What kind of negative thoughts were going through your mind? What
catastrophe were you anticipating had you continued with the activity? After
identifying the mistaken negative thought, look at the evidence, and put things
back into perspective. Then, repeat the activity so that you can confirm that the
symptoms it causes are harmless. Let us say that you left an aerobics class before the
designated time. After some thought, you realize that you left because you thought
your heart rate was far too fast, that it was reaching a dangerously high speed, and
that you might pass out or collapse. Then you looked at the evidence and realized
that heart rates are supposed to go fast when people exercise; that it probably was
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not going as fast as you thought; and that even if it was going very fast, the chances
of passing out or collapsing were very slim. After that kind of analysis, you felt
more able to go back and complete the aerobics class.
Remember that these practices are not supposed to be associated with zero anxiety
or fear. That is, you should feel afraid at first, or else there would be no need to do
them at all. Furthermore, sometimes the fear increases at first before it decreases,
because you are facing things that scare you. However, with repeated practice, the
anxiety will eventually decrease.
Continued Facing Activities
Continue to practice with each activity that you rated with an anxiety level of 3 or
higher in section 1, using the steps outlined in section 1.
Homework
Practice each activity at least three days a week, and continue to do so until your
anxiety rating on a given day is no more than 2. You may work on more than one
activity at a time.
Self-Assessment
in the appendix.
1. I should practice each activity the number of times necessary for

me to learn that the symptoms are not harmful and that I can
handle the symptoms and the anxiety. T F
2. If the symptoms continue for a long time after an activity such as

drinking coffee, that does not mean that the symptoms are
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dangerous. Instead, it means that I am probably preoccupied
with the symptoms. T F
3. It is not terribly important for me to record what I was worried

about happening on my Facing Activities form as long as I
complete the activities. T F
4. The activities should be discontinued if they create too much

anxiety or too many symptoms. T F
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Chapter 11 Medications
Goals
To learn about medications for anxiety and panic
To learn ways in which medications can be used in combination with the methods
outlined in this program
To learn ways of weaning yourself off medications
SECTION 1 Medications for Anxiety
Many people with anxiety and panic attacks have had doctors prescribe
medications. If this is true for you, you may take this medication regularly or
perhaps only when you feel you need it. Many people go through this program
without ever starting medication; others would just as soon not take the medication
but are doing so on the advice of their physicians. However, there are a number of
people who want medication for their anxiety and /or panic attacks. For some, the
anxiety and panic are so severe that they feel they cannot handle even one more day
and need relief as soon as possible. Even the medication that takes the longest to
act would begin to take effect in three weeks. Some of the shorter-acting
medications can work within a day or two. Others may not feel that they have the
time to devote to mastering the information in this workbook right now. Still
others may believe strongly that medication is the best treatment for their anxiety.
In any case, almost 60% of the people who come to our clinic for psychological
treatment are taking some kind of medication for their anxiety. Some have been
taking it for quite some time. For others, their physician has given them a
prescription to get them through a few weeks but has told them to come to our
clinic as soon as possible.
As we mentioned in chapter 1, we do not recommend that these people stop taking

their medications before starting the program. Eventually, many people stop taking
medication on their own. About one half of the people stop taking medications by
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the time they finish this program, and others stop sometime during the first year
after finishing. Below, we describe ways to stop taking medications if you want to
do so.
At this point, the evidence seems clear that some types of medications, if prescribed
at the right dosage, can be effective for at least the short-term relief of anxiety or
panic for some people. Many of these medications, however, are not effective in the
long term unless you continue to take them. Even then, they may lose some of their
effectiveness unless you learn some new, more helpful methods of coping with your
anxiety and panic while you are on the medication. Nevertheless, there are some
people who begin a course of medication therapy and stop several months later
without any need to go through a program such as this. Whether the particular
stress they were under has resolved, whether there were some changes in their
sensitivity, or whether they developed a different attitude toward their anxiety and
panic, medication for this short time was all they needed.
For all of these reasons, it seems useful to review the ways in which medications
work and the different types of medications prescribed for anxiety and panic.
How Do Medications Work?
Medications are believed to decrease vulnerability to experiencing panic and

anxiety. Medications seem to make it harder for the body to have a full fear
reaction. In addition, medications reduce general anxiety and, therefore, reduce the
severity of daily worry about panic attacks. Because the symptoms of general
anxiety are reduced, there are fewer symptoms to become afraid of in a “fear of fear”
cycle.
Medications decrease panic and anxiety by changing the proportions of

neurotransmitters (i.e., chemicals) in certain parts of your brain and nervous
system. This process of adjustment in the brain chemistry often takes several weeks,
which is why many medications do not work immediately (although some do).
During this adjustment, the brain “rebalances” itself. Therefore, medication is not
giving your brain something extra that it lacks, nor is it taking away something that
the brain has too much of. Rather, it is helping your brain rebalance and work more
efficiently doing the job it has to do.
Imagine that the brain has a stress “thermostat” that keeps it in balance, like a
thermostat keeps a room the same temperature when the temperature gets too hot
or too cold. Panic and anxiety may occur when the “set point” that determines the
ideal level (i.e., temperature) gets moved too high or too low. For example, stress
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can move the set point. So can certain substances, such as caffeine. The process of
rebalancing moves the set point back to the middle so that the brain can work more
like it has before. After some time, medication may no longer be needed, provided
that you can develop better ways of coping with stress so that future stressful events
do not move the thermostat set point out of balance again.
Different Types of Medications
Antidepressants
There are several classes of antidepressants which control anxiety and panic attacks.
Antidepressants called serotonin-specific reuptake inhibitors (SSRIs) include
medications such as fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox),
and paroxetine (Paxil). Related antidepressants called serotonin-norepinepherine
reuptake inhibitors (SNRIs) include venlafaxine (Effexor) and serzone
(Nefazodone). These two classes of medications have become first-line drug
treatments for panic disorder. In general, they are less toxic and cause fewer side
effects than older medications such as tricyclic antidepressants and monamine
oxidase inhibitors (described next). Nevertheless, some people still experience
stomach upset and other gastrointestinal symptoms, headaches, and other side
effects—particularly, sexual dysfunction—with these medications. In addition,
there may be some initial worsening of anxiety, although this can be decreased by
starting with lower doses (such as 5 mg of Prozac). The most effective doses for
controlling panic and anxiety for drugs most often prescribed are 20–40 mg of
Prozac, 75–150 mg of Luvox, 20–40 mg of Paxil, and 100–200 mg of Zoloft (see
Table 11.1).
Tricyclic antidepressants include imipramine (Tofranil), clomipramine (Anafranil),

desipramine (Norpramin), nortriptyline (Pamelor), and amitriptyline (Elavil).
Tofranil was formerly the most commonly used antidepressant for anxiety and
panic but has been largely supplanted by SSRIs, as noted above. These medications
are generally helpful for panic and anxiety when administered in the range of 150–
300 mg of Tofranil or its equivalent. There may be some worsening of anxiety
initially. However, the initial worsening is only small when beginning with small
doses (such as 10 mg of Tofranil). These doses are gradually increased to effective
levels. Also, the initial worsening goes away after the first week or so of treatment.
Other side effects include dry mouth, constipation, blurred vision, weight gain, and
lightheadedness. However, these side effects are generally harmless and go away
after a few weeks. It usually takes several weeks before the medications control
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anxiety and panic. So, getting through the first few weeks is critical. It is difficult
because the first few weeks are when the side effects are the strongest, but the
medication is not yet having a positive effect on reducing panic and anxiety. After
that, the side effects decrease, and so do panic and anxiety.
Another type of antidepressant medication is the monoamine-oxidase (MAO)

inhibitors. The best-known medication in this category for anxiety and panic is
phenelzine (Nardil). Others include tranylcypromine (Parnate) and isocarboxazid
(Marplan). MAO inhibitors can cause side effects such as lightheadedness, weight
gain, muscle twitching, sexual dysfunction, and sleep disturbance. As with other
medications, treatment usually begins with low doses, such as 15–30 mg per day of
Nardil, and is gradually increased to effective levels, such as 60–90 mg per day of
Nardil. The MAO inhibitors are seldom used for panic disorder these days because
there are severe dietary restrictions when on this medication. For example, you
cannot eat cheese, chocolate, or other foods containing tyramine, and you cannot
drink red wine or beer. If you do, you risk dangerous symptoms, including high
blood pressure.
The antidepressant medications seem to be about equally effective for panic attacks,
anxiety, and agoraphobia. One thorny problem with antidepressant medications is
the side effects during the first few weeks. In addition, the side effects are
sometimes similar to symptoms of panic and anxiety. For that reason, many people
do not want to continue taking the antidepressant or at least do not want to
increase the dosage to the levels that are needed to reduce panic and anxiety (this is
called the therapeutic dosage). And yet, research has shown that it is important to
take enough of this medication to get the full benefits. Therefore, it is best to stick
it out through the first few weeks until reaching the therapeutic dosage. To help
you stick it out, remember the following.
1. Side effects are not an indication of something wrong or harmful happening to

your body. That is, the side effects do not indicate that physical damage is
occurring to your body. Nor do they indicate a physical disease. In fact, side
effects indicate that medications are having their intended chemical effects.
2. Side effects are not an indication that your anxiety is increasing. Instead, side
effects indicate that your body is going through a period of adjustment to the
medication, and sometimes, the side effects of this adjustment are symptoms
that are similar to panic anxiety—but they are not actual panic and anxiety.
3. Side effects usually go away after a few weeks.
4. Strategies described in this treatment will help you to be less afraid of the side
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effects and achieve therapeutic dosages of medication.
It is much easier to stop taking antidepressants than benzodiazepines (described

below). In other words, there are usually fewer withdrawal symptoms when
antidepressants are ended than when benzodiazepines are ended. Therefore, the
relapse rates are much lower for antidepressants (around 40–50%) than for
benzodiazepines.
Benzodiazepines
Medications commonly prescribed for anxiety and panic in the past, but less
frequently now, are the minor tranquilizers. Two of the most common are
diazepam (Valium) and chlordiazepoxide (Librium). Typically, these medications
are prescribed for short-term relief of anxiety. They are generally believed to be
unhelpful for panic attacks unless they are prescribed in very high dosages. For
example, you might need 30 mg or more of Valium per day to make a dent in your
panic attacks. At this dosage, chances are that you would feel very sedated (i.e.,
sleepy). For this reason, minor tranquilizers are not usually prescribed for panic
attacks by psychiatrists and physicians knowledgeable in the medication treatment
of panic. Also, over time, you may need increasingly larger dosages of the
medication to obtain the same effects. This is called tolerance. Unless you work
carefully with your physician, there is a danger that with long-term usage, you may
become psychologically and physically dependent on medication (i.e., suffer
addiction) that had been intended only for short-term treatment of anxiety.
High-potency medications have stronger effects per dose than lower-potency

medications. High-potency benzodiazepines alleviate panic attacks without causing
such side effects as extreme sleepiness, which are seen with higher doses of lower-
potency benzodiazepines (e.g., Valium). These medications work very quickly; their
effects are usually noticeable within 20 minutes of ingestion and are still the most
frequently prescribed medications for panic and anxiety. The best-known high-
potency benzodiazepines are alprazolam (Xanax) and clonazepam (Klonopin). To
give you an idea of how strong Xanax is, 1 mg of Xanax equals approximately 10
mg of Valium. The therapeutic dose of Xanax for panic attacks varies from person
to person and also with the nature of the panic attacks. Usually, 1–4 mg per day
would be the best dosage for panic attacks, but a dosage of more than 4 mg per day
is sometimes required for severe agoraphobia avoidance. With these doses, 60% of
a large group of patients were free of panic after eight weeks. The appropriate dose
of Klonopin is 1.5–4 mg per day.
Side effects of these medications include sleepiness, poor coordination, and
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memory problems. However, starting with low doses and gradually increasing over
time can reduce these side effects. The initial feeling of sleepiness usually subsides
as one adapts to the medication. It is important to realize that the side effects
decrease over time and are not dangerous.
The different benzodiazepines differ in how long they remain active in your body.
This is referred to as half-life (or, the amount of time it takes for one half of a dose
of medication to be eliminated from the body). With longer half-life, medication is
taken less frequently. Klonopin has a longer half-life (15–50 hours) than Xanax
(i2–15 hours). Therefore, Klonopin is taken less frequently than Xanax. With a
medication of shorter half-life, people often feel the effects of the medication
wearing off and notice increased anxiety when the levels of medication in the body
are low, such as when wake in the morning.
Benzodiazepines are believed to work by increasing the effect of a chemical in the

brain called gamma amino butyric acid (GABA). GABA is distributed throughout
the brain. It functions to inhibit the firing of nerve cells. Benzodiazepines help
GABA to “put the brakes on” those areas of the brain which cause anxiety. As you
can probably imagine, stopping benzo-diazepines will “let up on the brakes” and is
usually associated with an increase in anxiety. This is one reason why many (if not
most) people relapse when they stop benzodiazepines.
Withdrawal symptoms are felt when benzodiazepines are stopped. These include
anxiety, jitteriness, difficulty concentrating, irritability, sensitivity to light or sound,
muscle tension or aching, headaches, sleep disturbance, and stomach upset.
Sometimes these withdrawal symptoms lead people to become very concerned and
anxious, especially because the withdrawal symptoms are similar to symptoms of
panic and anxiety. People are sometimes so upset by the withdrawal symptoms that
they begin the medication again in order to get rid of the withdrawal symptoms.
Alternatively, they may relapse (i.e., suffer a recurrence of panic and anxiety).
Relapse is especially likely if the withdrawal symptoms are mistakenly viewed as
being harmful. Actually, most withdrawal symptoms are not harmful. Instead,
withdrawal symptoms reflect the body’s adjustments to the chemical changes. Also,
withdrawal symptoms go away with time. With this type of information and some
other behavioral strategies, the withdrawal process is generally much easier. Thus,
slow tapering off of benzodiazepines, combined with the types of strategies
described in this workbook, dramatically reduces withdrawal and relapse when
benzodiazepines are discontinued.
Beta-Blockers
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Many people take beta-blockers to reduce blood pressure or regulate heart rate.
These medications act on a specific receptor, the beta-receptor, which is involved in
regulating aspects of body functioning such as heart rate. Therefore, if one needs to
avoid physical tension for medical reasons, beta-blockers are often used. There are
many types of beta-blockers, but the most popular is propranolol (Inderal). Given
the information about the psychological factors involved in panic disorder,
especially the notion of anxiety focused on physical symptoms of fear, one would
think that any medication that decreases bodily symptoms such as fast heart rates
would eliminate panic attacks. But there is little if any evidence that Inderal is
useful in any way for panic attacks, although some people might feel a little bit
better. For that reason, doctors knowledgeable about the medication treatment of
anxiety almost never prescribe this as the main medication to treat anxiety and
panic. It is sometimes included as an adjunct or secondary medication.
Table 11.1. Medications Used to Treat Panic Disorder
Medications with indications approved by the Food and Drug Administration for
panic disorder are listed in Table 11.1, along with additional medications that,
although not specifically approved, are likely to be just as effective in certain
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instances for some people. As always, your physician should work with you in
making the final decisions on which medication is best for you.
SECTION 2 Stopping Your Medication
Now that you have finished this program, you should be ready to stop your
medication, if you wish to do so. If this is a particularly difficult problem for you,
an additional brief program for stopping medications with proven effectiveness is
available from the Treatments ThatWorkTM series available from Oxford University
Press called Stopping Anxiety Medication. Be very sure that you stop your
medication under the supervision of your physician; only your doctor can decide
how quickly it will be safe for you to taper off your medication to the point where
you can stop it altogether. This will be particularly true for medications like Xanax,
which are best tapered off very slowly. With what you have learned from this
program, you should have little trouble stopping your medication if you follow
these general guidelines.
1. Withdraw from your medication relatively slowly. Do not try to do it all at

once. Once again, your physician will be able to give you the best advice on
how fast is best for you.
2. Set a target date for stopping your medication. Once again, this will have to be
planned with your physician, so make it a reasonable date in view of your own
tapering-off schedule. On the other hand, the date should not be too far away.
Generally, the quicker, the better—as long as it is within a schedule that is safe
for you, as determined by your physician.
3. Use the principles and coping skills that you have learned in this workbook as
you withdraw from the medication.
The reason that we have not addressed this topic until now is because it is
important for you to learn how to master your anxiety and panic before successfully
stopping medication. One reason for this is that you may begin to experience
anxiety and panic at more intense levels as you come off the medication. If you
were never on medication, you should have mastered panic and anxiety by now. If
you are on medication, the principles you have learned will need to be applied again
to deal with some increased anxiety and panic as you come off medication. Once
again, most people do not find this a problem and gradually reduce their
medication as they become more comfortable in dealing with their anxiety and
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panic.
If your anxiety and panic seem to be increasing as you decrease your medication
dose, it is most likely due to mild withdrawal symptoms. The symptoms simply
reflect your body readjusting to the chemical changes of having the medication
withdrawn. The withdrawal symptoms do not mean that you must go back on the
medication, nor do they mean that something is seriously wrong with you. Instead,
the withdrawal symptoms mean a period of adjustment, and they should last only a
week or two (in rare cases, a little longer), until the medication clears from your
system. In addition, you now have the skills to handle these symptoms. This is a
perfect opportunity to use your skills of breathing, relaxing, looking at the evidence,
and putting things back into perspective.
In this way, withdrawal from medication can be seen as the last item on your list of
activities described in chapter 10. That is, withdrawing from medication is another
way to produce physical feelings of which you are, or at least were, afraid.
Therefore, medication withdrawal can be added to your list of activities, and it can
be treated as an opportunity to practice breathing and looking at the evidence to
avoid jumping to conclusions and putting things back into perspective about the
withdrawal symptoms. Rather than becoming distressed at the physical feelings
that you experience as you withdraw from medications, follow the guidelines in
chapter 10 for learning to be less afraid of them.
After you withdraw from medications, it is very important that you face all of the
symptoms, activities, and situations that you faced while on the medication.
Homework
If you are on medication and wish to withdraw, then your assignment for this week
is to speak with your prescribing physician about the best way to do so.
Plan how you will deal with any of the withdrawal symptoms by using the various
skills that you have learned in this program.
Draw up a specific step-by-step plan for yourself.
Self-Assessment
Answer each of the following by circling true (T) or false (F). Answers can be
found in the appendix.
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1. It is essential that withdrawal from medication is conducted
gradually, under the supervision of your prescribing physician. T F
2. You are unlikely to feel any different when you withdraw from
your medication. T F
3. Use physical symptoms, anxiety, or panic that you experience

when withdrawing from medication as an opportunity to breathe
slowly from the abdomen, change mistaken beliefs, and face
your fear. T F
4. Experiencing physical symptoms or anxiety and panic when

withdrawing from medication is a sign of a loss of all your
treatment gains. T F
5. Experiencing physical symptoms or anxiety and panic when

withdrawing from medication is a sign that you will not be able
to get off the medication. T F
6. The great majority of patients who have completed this program

are able to get off their medications. T F
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Chapter 12 Accomplishments, Maintenance, and Relapse
Prevention
Goals
Evaluate your progress
Learn how to structure continued practice
Ways of maintaining progress
High-risk times and management of setbacks
Evaluate Your Progress
It is time to consider the kind of changes that you have made since you first began
this program. This can be done in several ways. Using your Progress Record,
compare the frequency of panic attacks from the beginning to this point, and
examine the course of change throughout the program. There may indeed be ups
and downs. Also, compare the severity of your daily anxiety from the beginning to
now. If the frequency of your panic attacks and/or the severity of your anxiety have
decreased, check YES next to the item labeled panic and anxiety in the list below.
If not, check NO.
Second, look at your thoughts. Have you made significant changes in the ways you
think about panic, anxiety, and the physical symptoms? In other words, are you
much less likely to jump to conclusions and to blow things out of proportion,
particularly when it comes to panic and the physical symptoms of panic? If so, then
check the YES box for the item labeled Negative Thoughts. If not, check NO.
Third, look at your initial fear ratings for your hierarchies of symptoms and
activities. Now, rate your current level of fear of the same symptoms and activities,
using the same 0–10-point scale (where 0 = no fear and 10 = extreme fear). Are you
able to handle physical symptoms produced by hyperventilation, spinning, holding
your breath, exercising, drinking coffee, or watching a horror movie with much less
fear than the first time you rated these various exercises? If there has been a
significant reduction in your fear of these items, check YES next to the item
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labeled Symptoms and Activities. If not, check NO.
Progress Evaluation
Evaluate your own progress since you began this program.
Panic and Anxiety
Significant reduction in frequency of panic, severity of panic,

Yes No
or level of anxiety about panic.
Negative Thoughts
Significant reduction in jumping to conclusions and blowing

Yes No
things out of proportion.
Symptom and Activity Exercises
Significant reduction in “fear of symptom induction”

Yes No
exercises and activities.
Agoraphobia Situations
Significant reduction in fear and/or avoidance of situations

Yes No
associated with panic.
Fourth, look at your initial fear ratings for your Hierarchy of Agoraphobia
Situations. Now, rate your current level of fear of the same situations using the 0–
10-point scale (where 0 = no fear and 10 = extreme fear). Are you able to consider
driving, flying, being alone, being away from home, and so on with much less fear
than when you first rated these situations? If so, check YES next to the item
labeled Situations. If not, check NO.
If you have checked the YES box for at least three of the four items, you may
consider that you have done very well with this program. If, on the other hand, you
have checked NO to three or more items, there is still room for gains to be made.
What to Do Next
You may have a number of activities or situations to practice. Use the Practice Plan
on page 194 to list all of the things to be practiced over the next few weeks in terms
of:
186
Figure 12.1.
Example of Completed Practice Plan
breathing skills;
thinking skills;
facing agoraphobia situations;
facing symptoms.
At the end of each week, revise your Practice Plan according to your progress and
the next steps to take. This may continue for six months or more, or for as long as
you want.
Long-Term Goals
You may begin long-term planning for things that you were previously unable to do
because of panic and anxiety. Here are some examples of things for which you
might now plan. Perhaps you have always wanted to:
go back to school;
have children;
meet someone new;
187
Practice Plan
Things to Practice Description
Breathing Skills _________________________
_________________________
_________________________
_________________________
_________________________
Thinking Skills _________________________
_________________________
_________________________
_________________________
_________________________
Facing Agoraphobia _________________________

Situations
_________________________
_________________________
_________________________
_________________________
Facing Symptoms _________________________
188
_________________________
_________________________
_________________________
Figure 12.2.
Example of Completed Long-Term Goals Form
travel;
take up new hobbies;
change jobs;
buy a new car.
Whatever the case, consider your long-term goals and the steps needed to reach
those goals. These can be revised every month.
How to Maintain Progress
There are several ways to maintain the progress that you have made so far. First, if
189
you feel doubtful about entering certain situations or doubt that you can perform
certain activities because of your fear or anxiety, that is a sign for you to go ahead
and face those situations or activities.
Use your breathing skills.
Long-Term Goals
Long-Term Goal Steps to Achieve Long-Term Goal
__________________ __________________
__________________ __________________
__________________ __________________
__________________ __________________
__________________ __________________
__________________ __________________
__________________ __________________
__________________ __________________
__________________ __________________
__________________ __________________
__________________ __________________
Use your thinking strategies to help you cope with whatever it is that you are
anxious about.
Remember, avoidance is one of the biggest causes of growing anxiety.
190
Second, record your mood. That is, at least once a month, consider how you have
been doing in terms of your general level of anxiety and, if appropriate, your
number of panic attacks. It is easier to take corrective action at an early stage rather
than waiting until you are in the midst of intense panic and anxiety. Record your
mood at least once a month by simply asking yourself how anxious you have felt
over the last week, or how much have you been worrying about things, or whether
you have had any panic attacks. It helps to tie this recording to a regular event that
will remind you. Examples include monthly payment of bills or monthly meetings.
Each month, record your mood just before or after such events.
Third, every now and then, review the educational information in chapters 3 and 4.
Newly learned material needs to be reviewed for it to become a solid part of your
way of thinking.
Your High-Risk Times
The most high-risk times for panic or anxiety to increase are stressful periods in
your life. These periods can be any times in which you are under a lot of stress;
whether that means job loss, the breakup of a relationship, the birth of a child, or a
serious illness. Stress affects our nervous systems in ways that make us generally
more tense and, therefore, causes us to have more physical symptoms and to be
more likely to think negatively.
For these reasons, it is helpful to anticipate the kinds of stressful events ahead of
time and to prepare for them in a matter-of-fact way.
First, think of ways in which to manage your own anxiety. Be aware of your
habits of jumping to conclusions, or blowing things out of proportion, or
avoiding things.
Second, think of concrete steps for managing the stress, such as how to deal
with an angry boss or an overdue bill.
Setbacks
A panic attack or resurgence of anxiety does not mean that you are getting worse or
that you have lost all of the progress that you have gained. Consider it like being on
a road trip and having one of the tires on your car go flat. Yes, you need to fix the
tire, but that does not mean you must go back to the beginning of your road trip.
Fix the damage and continue on with your journey.
191
With panic and anxiety, fixing the damage means to think about what triggered the
panic or anxiety, where you were jumping to conclusions or blowing things out of
proportion, and how can you think more calmly and realistically. Then, continue to
move forward by facing the things that made you anxious.
The most important thing to do when you have a flare-up of anxious symptoms is
to repeat everything you have already done: breathing skills, thinking skills, facing
agoraphobia situations, and facing symptoms.
Just because panic and anxiety have reoccurred does not mean that the treatment
will not work again. It is like the old saying: if you fall off the horse, you need to
dust yourself off and get back up.
For complete accounts of recent research on the nature and causes of panic and
anxiety, you may wish to read David H. Barlow, Anxiety and its disorders: The nature
and treatment of anxiety and panic, second edition (2002), and Michelle G. Craske,
Anxiety disorders: Psychological approaches to theory and treatment (1999).
192
Appendix Answers to Self-Assessment Quizzes
Chapter 1
1. T 4. F
2. T 5. F
3. F 6. F
Chapter 2
1. T 4. T
2. F 5. T
3. F
Chapter 3
1. T 5. T
2. F 6. F
3. F 7. F
4. F
Chapter 4
1. F 4. T
2. F 5. F
3. T 6. T
Chapter 5
1. F 3. F
2. T 4. F
Chapter 6
Section 1
1. T 4. F
193
2. F 5. F
3. F 6. T
Section 2
1. F 3. F
2. F 4. T
Section 3
1. F 3. T
2. F
Chapter 7
Section 2
1. F 4. T
2. T 5. F
3. F 6. T
Section 3
1. F 4. F
2. F 5. T
3. T
Section 4
1. F 3. T
2. F 4. F
Chapter 8
1. F 4. F
2. F 5. T
3. F 6. T
Chapter 9
1. F 4. F
2. T 5. F
3. T
Chapter 10
194
Section 1
1. T 4. F
2. F 5. F
3. T
Section 2
1. F 3. T
2. F
Section 3
1. F 3. F
2. F 4. F
5. T
Section 4
1. T 3. F
2. T 4. F
Chapter 11
1. T 4. F
2. F 5. F
3. T 6.T
195
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202
About the Authors
David H. Barlow received his PhD from the University of Vermont in 1969 and
has published over 500 articles and chapters and almost 50 books and clinical
workbooks, mostly in the areas of emotional disorders and clinical research
methodology. The books and workbooks have been translated into over 20
languages, including Arabic, Mandarin, and Russian.
He was formerly Professor of Psychiatry at the University of Mississippi Medical

Center and Professor of Psychiatry and Psychology at Brown University and
founded clinical psychology internships in both settings. He was also Distinguished
Professor in the Department of Psychology at the University at Albany, State
University of New York. Currently, he is Professor of Psychology, Research
Professor of Psychiatry, and Director of the Center for Anxiety and Related
Disorders at Boston University.
Barlow is the recipient of the 2000 American Psychological Association (APA)

Distinguished Scientific Award for the Applications of Psychology. He is also the
recipient of the First Annual Science Dissemination Award from the Society for a
Science of Clinical Psychology of the APA and recipient of the 2000 Distinguished
Scientific Contribution Award from the Society of Clinical Psychology of the
APA. He also received an award in appreciation of outstanding achievements from
the General Hospital of the Chinese People’s Liberation Army, Beijing, China,
with an appointment as Honorary Visiting Professor of Clinical Psychology.
During the 1997–1998 academic year, he was Fritz Redlich Fellow at the Center
for Advanced Study in Behavioral Sciences in Palo Alto, California.
Other awards include Career Contribution Awards from the Massachusetts,

California, and Connecticut Psychological Associations; the 2004 C. Charles
Burlingame Award from the Institute of Living in Hartford, Connecticut; the First
Graduate Alumni Scholar Award from the Graduate College of the University of
Vermont; the Masters and Johnson Award from the Society for Sex Therapy and
Research; the G. Stanley Hall Lectureship, American Psychological Association; a
certificate of appreciation for contributions to women in clinical psychology from
203
Section IV of Division 12 of the APA, the Clinical Psychology of Women; and a
MERIT award from the National Institute of Mental Health (NIMH) for long-
term contributions to clinical research efforts. He is Past President of the Society of
Clinical Psychology of the APA and the Association for the Advancement of
Behavior Therapy, Past Editor of the journals Behavior Therapy, Journal of Applied
Behavior Analysis, and Clinical Psychology: Science & Practice, and currently Editor-
in-Chief of the Treatments That-WorkTM series for Oxford University Press.
He was Chair of the APA Task Force of Psychological Intervention Guidelines,

was a member of the DSM-IV Task Force of the APA, and was a co-chair of the
work group for revising the anxiety disorder categories. He is also a Diplomate in
Clinical Psychology of the American Board of Professional Psychology and
maintains a private practice.
Michelle G. Craske received her PhD from the University of British Columbia in
1985 and has published more than 200 articles and chapters in the area of anxiety
disorders. She has written books on the topics of the etiology and treatment of
anxiety disorders, gender differences in anxiety, and translation from the basic
science of fear learning to the clinical application of understanding and treating
phobias, in addition to several self-help books. In addition, she has been the
recipient of continuous NIMH funding since 1991 for research projects pertaining
to risk factors for anxiety disorders and depression among children and adolescents,
the cognitive and physiological aspects of anxiety and panic attacks, and the
development and dissemination of treatments for anxiety and related disorders. She
is Associate Editor for the Journal of Abnormal Psychology and Behaviour Research &
Therapy, and she is a Scientific Board Member for the Anxiety Disorders
Association of America. She was a member of the DSM-IV Anxiety Disorders
Work Group Subcommittee for revision of the diagnostic criteria surrounding
panic disorder and specific phobia. Craske has given invited keynote addresses at
many international conferences and frequently is invited to present training
workshops on the most recent advances in the cognitive behavioral treatment for
anxiety disorders. She is currently a Professor in the Department of Psychology and
Department of Psychiatry and Bio-behavioral Sciences at the University of
California, Los Angeles, and Director of the UCLA Anxiety Disorders Behavioral
Research Program.
204

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Mastery of Your Anxiety and Panic

David H. Barlow, PhD

Anne Marie Albano, PhD

Peter E. Nathan, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

David H. Barlow • Michelle G. Craske

Copyright © 2007 by Oxford University Press, Inc.

Published by Oxford University Press, Inc.

Oxford is a registered trademark of Oxford University Press

This particular program presents the latest version of a cognitive-behavioral treatment

David H. Barlow, Editor-in-Chief,

Chapter 1 The Nature of Panic Disorder and Agoraphobia

Chapter 3 Negative Cycles of Panic and Agoraphobia

Chapter 7 Thinking Skills

Chapter 10 Facing Physical Symptoms

Appendix Answers to Self-Assessment Quizzes

To understand the nature of panic attacks, panic disorder, and agoraphobia

To learn about factors that cause panic disorder

To learn about this program for overcoming panic and agoraphobia

To determine whether or not this program is right for you

Do You Have Panic Disorder or Agoraphobia?

Diagnosis and Definition of Panic Disorder and Agoraphobia

Panic attacks refer to an abrupt rush of intense fear or discomfort accompanied by a

Panic Attack Symptoms

Heart palpitations or a racing or pounding heart

Chest pain or discomfort

Feeling dizzy, unsteady, lightheaded, or faint

Hot or cold flashes

Nausea or abdominal distress

Feelings of unreality or detachment

Fears of going insane or losing control

Another feature of panic disorder is avoiding, hesitating about, or feeling very

Typical Agoraphobia Situations

Traveling by subway, bus, or taxi

Long distances from home

Hairdressing salon or barbershop

Wide, open spaces

Closed-in spaces (e.g., basements)

Being at home alone

Another example of agoraphobia without panic disorder is when abdominal distress

Agoraphobia without history of panic disorder also refers to avoidance of situations

Other Physical Symptoms That Might Lead to Agoraphobia

Tunnel vision or sensitivity to light

Urinary retention problems

How Common Are Panic Disorder and Agoraphobia?

Unhelpful Ways of Coping With Panic Attacks

We already mentioned a common way of coping with panic attacks: avoiding

In addition to avoidance of situations from which escape is difficult or help is not

Do you avoid medication of any kind, even if prescribed by your doctor?

Do you avoid exercise or physical exertion?

Do you avoid becoming very angry?

Do you avoid sexual relations?

Do you avoid watching horror movies, medical documentaries, or very sad

Do you avoid being outside in very hot or very cold conditions?

Do you avoid being away from medical help?

Do you avoid being rushed?

Many people attempt to “get through” anxious situations by distracting themselves.