When a panic attack strikes, there’s an overwhelming feeling of terror that you could die or completely lose control. Your body reacts with a host of stress symptoms that may include a racing heart, shortness of breath, a flushed feeling, weakness, dizziness, and feeling faint, as well as feelings of detachment, spaciness, and unreality. For many people struggling with panic disorder, the feelings of unreality and depersonalization are the most frightening of all because they interpret them as harbingers of insanity.
Panics often come unpredictably, and as a result, panic-prone individuals are burdened with anticipatory dread. They try to avoid any situation where they feel at all vulnerable to panic. This explains why untreated panic disorder often evolves into agoraphobia – the fear of leaving the confines of your safe place.
Fortunately, in recent years there have been important breakthroughs in the treatment of panic disorder by several research teams (Barlow & Craske 1989; Clark 1989). The result is a clinical program that includes four main components:
- Education about the nature of panic – what causes it and how it can be controlled.
- Breath control training – a simple technique to simultaneously relax your diaphragm and slow down your breath rate.
- Cognitive restructuring to help you reinterpret frightening physical symptoms while learning to control catastrophic thinking.
- Interoceptive desensitization – a technique that exposes you to your most feared physical sensations in a safe, controlled way, while teaching you how to cope.
A variation of the intervention program described was found by Barlow and Craske to free 87 percent of panic disorder subjects from symptoms of panic. This response was maintained at a two-year follow-up. Many other researchers have reported 80 to 90 percent effectiveness with similar protocols.
Hackmanm and his associates (1992) showed that panic disorder treatments can be effective with minimal clinical contact – his subjects used self-help manuals during a four week program.
Time for Mastery
Some people can use this program to master panic symptoms in as little as six to eight weeks. However, if the child is now struggling with significant problems of avoidance or agoraphobia, they will need additional intervention steps to expose the child to situations where they fear having a panic attack
Step 1: Understanding Panic
Panic differs from most forms of anxiety in that the primary focus is not external dangers and events. Panic disorder centers on events going on inside the person’s body – physical sensations that scare them and make them afraid of losing control.
If a person is prone to panic, they may become hyperalert to physical symptoms that they associate with anxiety. They are vigilant for the first sign of a racing heart, shortness of breath, and feelings of detachment and unreality. They monitor the body for sensations of weakness, dizziness, flushing, or light-headedness This vigilance has one purpose – to brace yourself for a rush of panic. By watching and worrying about bodily sensations, you are trying to somehow to prepare for that awful moment when the panic swells, screaming that you are going to die or go insane.
The Panic Sequence
Ironically, it is this vigilance and fear of the body’s symptoms that actually causes panic attacks. Panic starts with an event that can be internal or external. External events include upcoming stresses and challenges, or situations where the person experienced panic before. Internal events are the physical symptoms that the person has begun to recognize as the precursors of panic.
The event triggers worry. Worry thoughts anticipate danger. Worry thoughts interpret external stressors and key bodily sensations as signals to get ready for catastrophe. This step in the panic sequence can be lightning fast. The worry thoughts often appear in a shorthand that’s so compressed, the child may not notice it. But while this step may be all but invisible, it sets the panic cycle into motion.
The next step is an intensification of physiological symptoms called the fight-or-flight response. The body starts to get ready to confront danger. Heart rate increases to provide blood to the large muscles needed to run or do battle. As blood pools in the legs, they often feel weak and shaky – despite the fact that the extra blood makes them stronger than ever. The rate of breathing increases to provide more oxygen for sudden, strenuous movement. But a common, harmless side effect is the feeling that the person can’t get enough air, accompanied by pain or tightness in the chest.
The blood supply to the brain decreases, producing feelings of dizziness, confusion, and unreality. The blood flow also diminishes to skin, fingers, and toes to reduce bleeding if injured. This makes the extremities cold while, simultaneously, the person may feel flushed.
The fight or flight response triggers sweating, so the skin will be slippery and hard for a predator to grasp. It also slows digestion, often triggering cramping, nausea, and so on.
While fight-or-flight symptoms are harmless, they are quite noticeable and even at times dramatic. That’s how we get to the next step in the panic sequence; catastrophic thoughts about your fight or flight sensations.
These catastrophic thoughts signal the body, through the release of adrenaline, to intensify preparations for danger. All the fight or flight symptoms start cranking up. The heart rate and respiration increase, the person may start to hyperventilate, legs feel shakier and weaker, and you find yourself even dizzier, hotter, and more depersonalized.
Observing these symptoms, the catastrophic thinking becomes more dire. The cycle gathers momentum: Catastrophic thoughts trigger adrenaline and more fight or-flight symptoms, which generate more catastrophic thought, spiraling upward until you pass the panic threshold.
This cycle, once triggered. does not have to continue. The key is changing how the person interprets and reacts to normal stress symptoms. When your child can recognize the hot flush, the dizziness, and the spacy, depersonalized feelings as harmless symptoms of fight or flight, s/he will have taken a crucial step toward controlling panic.
How long panic and the subsequent anxiety last is something you control. Maintaining thoughts can keep the fight or flight reaction going for hours.
What The Symptoms Mean
The Symptom Explanation Chart [CBT#08-001] provides medical explanations for the symptoms of panic. Make a copy of this for the child and have him/her put an asterisk by the symptoms that are the most disturbing. On a file card that you can have the child carry, write the medical explanation for each symptom that is marked.
This whole process of education is designed to use rationale thought to identify physical symptoms and to provide alternative thoughts with which to change the feelings and control the ultimate behavior. It is almost irrelevant what the alternative thought is as long as it is believed by the child and provides an explanation for the physical symptoms. Thus it is not required that the child develop a medical knowledge of each and every symptom – rather that the child understand that each and every symptom is explainable and accepts [believes] that these symptoms are normal.
Step 2: Breath Control Training
This exercise, which has been adapted from Nick Masi’s audiocassette, Breath of Life (1993), is designed specifically for individuals with panic disorder. When most people feel panic, they have a tendency to gasp, take in a breath, and hold onto it. Then they take short, shallow breaths that fail to empty their lungs. This creates a sensation of fullness and a feeling that you can’t get enough air. The feeling that they’re not getting enough air is an illusion, a simple consequence of not emptying the lungs. Even though they are, in fact, getting plenty of air, the breath comes faster and faster. Eventually, they may cross the threshold into hyperventilation, which will likely trigger a panic attack. Here are the five simple steps of breath control training that you can teach the child:
- Exhale first. At the first sign of nervousness or panic, at the first worry thought about a physical symptom, completely empty your lungs. It’s important that you exhale first so that you feel like there’s plenty of room to take a full, deep breath.
- Inhale and exhale through your nose. Inhaling through your nose will automatically slow down your breathing and prevent hyperventilation.
- Breathe deeply into your abdomen. Put one hand on your stomach, the other on your chest. Breathe so that the hand on your stomach moves, while the one on your chest is nearly still. By directing the breath deep into your abdomen you stretch your diaphragm and relax tight muscles that make it seem hard to breathe.
- Count while you breathe. Exhale first, and then breathe in through your nose, counting, “One . . . two . . . three.” Pause a second, then breathe out through your mouth, counting, “One . . . two . . . three . . . four.” The counting protects you from rapid, panic breathing. Make certain that your exhalation is always one beat longer than your inhalation. This will ensure that you empty your lungs between breaths.
- Slow your breathing by one beat. Breathe in and count, “One . . . two . . . three . . . four”; pause and breathe out, counting, “One . . . two . . . three . . . four . . . five.” As always, you breathe out one beat longer than you breathe in.
Breath control training is an extraordinarily effective way to slow your breathing and prevent the hyperventilation so often associated with panic. If the child can slow his/her breathing at the first sign of anxiety, s/he can very often protect him/herself from the worst of the fight-or-flight symptoms.
The key is practice. The first efforts at breath control training should occur only in safe and relaxing environments. Don’t try at the beginning to use this technique when the child is panicked, or even anxious. Get the child comfortable and competent at slowing breaths where s/he won’t be disturbed. After several weeks of daily practice the technique will become “overlearned.” When s/he can easily initiate deep breaths while counting, the child should begin using breath control in situations where s/he is mildly nervous. Then have the child try breath control as s/he approaches situations where s/he is worried about panic or when s/he first notice disturbing physical symptoms.
Still don’t try breath control training during a full-blown panic yet. Wait until the child has mastered interoceptive desensitization. That will give the child the practice they need so that you can slow breathing even during the most disturbing anxiety symptoms.
Step 3: Cognitive Reformation
Human beings are constantly trying to make sense of their experience. They try to label events and predict what those events will mean for the future. When you are anxious and on guard to the possibility of a panic, you tend to make two crucial errors of thinking. The first is overestimation – exaggerating the odds that a negative event is likely to occur. The second is catastrophizing – assuming events will be far more painful and unmanageable than you can endure.
Overestimation and catastrophizing are likely contributors to the anxiety. But there’s a way to overcome these patterns of thinking while diminishing anxiety in the process. It involves exploring hard evidence about the fears, as well as identifying alternative coping strategies. The key is a special kind of thought record called the Probability Form [CBT#08-003]. Make copies of the form and use it to have the child respond to catastrophic or maintaining thoughts whenever they occur.
Probability Form use. In the first column have the child write down the event that’s triggering anxiety. Remember, it can be external (they are meeting friends at a theater) or internal (they are feeling dizzy and spacy). Now, under Automatic Thoughts, write the interpretations and beliefs about the event. Have the child try to include his/her worst and most catastrophic thoughts.
As the child focuses on the automatic thoughts, s/he needs to rate (1) the percent of probability that what s/he fears will come true and (2) the intensity of the anxiety. A probability rating of 100 percent means there’s no possibility the catastrophe won’t happen. Anxiety is rated on a 0-100 scale, where 100 is the worst anxiety you’ve ever experienced.
These ratings of probability and anxiety are very important because the child will be able to watch them change. After the child fills in the Evidence and Coping Alternatives columns, s/he may see significant reductions in scores.
It’s time now to examine the automatic thoughts. Under Evidence, have the child write down any facts or experiences that either support or contradict the automatic thoughts. S/he should ask him/herself these key questions:
- Out of all the times you’ve done or felt this in the past, how many times did the catastrophe occur?
- What has usually happened during similar circumstances in the past?
- Is there anything in your past that leads you to expect a better outcome than you fear?
- What are the objective (medical) facts? It’s important to list here the relevant medical realities. You may need to remind the child of these facts.
- How long is this experience likely to last? Can you cope with it for that period? NOTE: if the child has experienced a panic attack at all s/her has coped with it before.
After the child has listed all the evidence s/he can think of, have him/her move on to Coping Alternatives. This is an action plan if the worst case should happen – how the child would cope with the crisis. Even though it’s uncomfortable, it helps to face what is most feared. Nearly every outcome, no matter how difficult, can be gotten through if there is a plan to cope. The child should include:
- Any relaxation or breathing skills that might be helpful.
- Any resources they have for coping (friends, family, financial resources, problem solving skills).
- Successful coping, strategies used in the past.
- Strategies others might use in this situation.
Be sure that the child takes time with the coping column. Brainstorm until you’ve developed at least three believable coping alternatives. If an alternative doesn’t seem realistic to the child, leave it out. But if s/he believes that there’s a chance it might work, include it and evaluate the outcome later.
The last step in completing the Probability Form is to re-rate percent probability and anxiety. Most people discover that the probability of catastrophe seems lower after weighing the evidence and developing a coping plan. They also report reduction in anxiety intensity.
Practicing with Probabilities
The child should use the Probability Form whenever s/he feels anxious. Have him/her try to fill in the columns as soon after the event as possible. Even events that are only physical sensations require a Probability Form. That’s because catastrophic interpretation of bodily sensations is the prime cause for panic. If the child uses the form consistently over the course of three to four weeks, s/he will find new confidence in the ability to handle fear.
Step 4: Interoceptive Desensitization
Interoceptive desensitization is among the most effective and challenging components of the intervention program for panic disorder. What you’re about to do is re-create, in a safe way, bodily sensations similar to those that the child associates with panic. The child can learn to experience these sensations as something uncomfortable, but not frightening. Dizziness, rapid heart beat, even feelings of unreality can become no more than annoying effects of fight or flight. And when these feelings are no longer associated with panic, the child will find him/herself less vigilant toward and less focused on the sensations inside the body.
Desensitizing to frightening bodily sensations is accomplished in three stages. In Stage 1 the child will briefly expose him/herself to ten specific sensations and then rate his/her reactions. Most of the following exposure exercises were developed and tested by Michelle Craske and David Barlow (1993). They induce feelings similar to those many people report prior to or during a panic.
- Shaking the head from side to side
- Lowering the head between the legs, then lifting it
- Running in place (Check with the doctor first)
- Running in place with a heavy jacket
- Holding the breath
- Tensing the major muscles – particularly in the abdomen
- Spinning while sitting in a swivel chair (not to be done standing up)
- Very rapid breathing
- Breathing through a single, narrow straw
- Staring at self in a mirror
As you review this list, you can probably already tell that some of these sensations will be quite uncomfortable for the child. But it is precisely the feelings that s/he most fears that must be desensitized in order to recover from panic disorder. If exposing themselves to these interoceptive (physically arousing) experiences feels too frightening to do alone, they should only do them when a support person is to be present throughout the exercise. Later the child can discontinue support as s/he gets more comfortable with the sensations.
When the child exposes him/herself to each of the ten sensations, s/he will need to keep records to identify which ones create the most anxiety and have the greatest similarity to the panic feelings. The child should fill in the Interoceptive Assessment Chart [CBT#08-004] as s/he sequentially exposes him/herself to each interoceptive experience.
When rating anxiety intensity, the scale ranges from 0 to 100, where 100 is the worst anxiety ever felt. The column where you rate each exercise’s similarity to panic sensations is very important. The range is from 0 percent similarity to 100 percent – absolutely identical feelings.
Stage 2 of interoceptive desensitization involves making a hierarchy of frightening sensations from the Assessment Chart. Have the child put a check by each exercise that was rated 40 percent or above in similarity to actual panic sensations. Now, on the Interoceptive Hierarchy/Anxiety Intensity Chart [CBT#08-005] have the child rank the checked exercises from the least to the greatest anxiety-intensity rating. Fill in the anxiety rating from the first exposure under Trial 1.
Once the child has developed a hierarchy, it’s time to begin Stage 3 – the actual desensitization process. Start with the item lowest in anxiety on the hierarchy chart. It is probably helpful for the child to have a support person present during initial exposure. Here’s the actual desensitization sequence:
- The child should begin the exercise and note the point where s/he first experiences uncomfortable sensations. Have the child stick with the exercise at least thirty seconds after the onset of uncomfortable sensations – the longer the better.
- As soon as s/he stops the exercise, s/he should rate the degree of anxiety [with 100% being maximum] in the box for each exposure trial (on the Interoceptive Hierarchy Chart).
- Immediately following each exercise, the child should begin controlled breathing.
- Following each exercise, remind the child [and later s/he should remind him/herself] of the medical realities relevant to the bodily sensations s/he is experiencing. For example, if s/he feels light-headed or dizzy after rapid breathing, remind him/her that this is a temporary and harmless sensation caused by reduced oxygen to the brain. Or, if s/he has a rapid heart rate after running in place, you could remind him/her that a healthy heart can beat 200 times a minute for weeks without damage, and it’s certainly built to handle this little bit of exercise.
- Continue trials of desensitization with each exercise until the anxiety rating is no more than 25%.
Interoceptive Desensitization in Natural Settings
When the child has worked through the hierarchy to the point where each exercise triggers an anxiety-intensity rating of no more than 25, you can begin to have them experience desensitization in real-life settings. With clinical clearance, you can begin exposure to activities and experiences that were avoided because of feared panic. Have the child make a list of these activities and arrange them on a Hierarchy/Anxiety-Intensity chart [Form # ]. Rank them from least anxiety-evoking to most.
1. If the child has difficulty counting during breath control exercises, you can make a tape to help them learn the proper pacing.
To make a twelve-breaths-per-minute tape:
a) Say the word “in” for two seconds.
b) Say the word “out” for two seconds.
c) Pause one second.
d) Continue repeating “in” for two seconds and “out” for two seconds, followed by a one-second pause.
e) The tape should last about five minutes.
To make an eight-breaths-per-minute tape, do everything the same except say “in” and “out” for three seconds each.
2. If the child has difficulty desensitizing and lowering anxiety during interoceptive exposure, it may be because s/he has catastrophic thoughts that haven’t been addressed. As s/he begins an exposure exercise, have him/her monitor the thoughts about the bodily sensations that come up. What are they telling themselves? What terrible thing do they fear might happen? What is the worst possible outcome?
Once you’ve identified one or more catastrophic beliefs, have the child complete a Probability Form on those thoughts. Then, from the Evidence and Coping Alternatives columns, choose some realistic responses that they can use during exposure.