The Basics about Panic Attacks - Introduction

Although the first panic attack may seem to appear "out of the blue," it typically comes during
an extended period of stress. This stress is not caused by a few days of tension, but extends over
several months. Life transitions, such as moving, job change, marriage, or the birth of a child,
often account for much of the psychological pressure.

For some individuals, learning to manage this stressful period or to reduce the pressures will
eliminate the panic episodes. For others, it is as though the stress of the life transition or problem
situation uncovered a psychological vulnerability. If the panic-prone individual accepts increased
responsibilities -- for instance, through a job promotion or through the birth of a first child -- he
may begin to doubt his ability to meet the new demands, the expectation of others, and the
increased energy required for these responsibilities. Instead of focusing on mastering the task, he
becomes more concerned with the possibility of failure. This attention to the threat of failure
continually undermines his confidence. Either gradually or quickly, he translates these fears into
panic.

Certain people experience symptoms in the middle of sleep. These are either caused by panic
disorder or are identified as "night terrors". Most nighttime (or nocturnal) panics take place
during non-REM sleep, which means they do not tend to come in response to dreams or
nightmares. They occur between a half-hour to three and a half hours after falling asleep and are
usually not as severe as daytime panics. These are distinct from night terrors, known as pavor-
nocturnus in children and incubus in adults. The similarities are that they produce sudden
awakening and autonomic arousal and tend to not be associated with nightmares. However, a
person who experiences a night terror tends to have amnesia for it and returns to sleep without
trouble. He also can become physically active during the terror -- tossing, turning, kicking,
sometimes screaming loudly or running out of the bedroom in the midst of an episode. Nocturnal
panic attacks, however, tend to cause insomnia. The person has a vivid memory of the panic. He
does not become physically aggressive during the panic attack, but remains physically aroused
after the occurrence.

WHAT IS AGORAPHOBIA?

Each person diagnosed with agoraphobia (meaning "fear of the marketplace") has a unique
combination of symptoms. But common to all agoraphobics is a marked fear or avoidance either
of being alone or of being in certain public places. It is a response strong enough to significantly
limit the individual's normal activities.

For the person who experiences panic attacks, the distinction between agoraphobia and panic
disorder is based on how many activities he avoids. In panic disorder, the person remains
relatively active, although he may avoid a few uncomfortable situations. If the panic-prone
person begins to significantly restrict his normal activities because of his fearful thoughts,
agoraphobia is the more appropriate diagnosis.

For some, agoraphobia develops from panic disorder. Repeated panic attacks produce
"anticipatory anxiety," a state of physical and emotional tension in anticipation of the next
attack. The person then begins to avoid any circumstances that seem associated with past panic
attacks, becoming more and more limited in his range of activities.

The fearful thoughts that plague the agoraphobic often revolve around loss of control. The
person may fear the development of uncomfortable physical symptoms familiar from past
experiences (such as dizziness or rapid heartbeat). He may then worry that these symptoms could
become even worse than they were in the past (fainting or heart attack), and/or that he will
become trapped or confined in some physical location or social situation (such as a restaurant or
party). In the first two situations, the person senses that his body is out of control. In the third, he
feels unable to readily control his surroundings.

The following list shows the types of surroundings that can provoke these fears.

FEAR OF THE SURROUNDINGS

 Public Places or Enclosed Spaces

 Confinement or Restriction of Movement

 Streets
 Barber's, hairdresser's, or dentist's chair
 Stores
 Lines in a store
 Restaurants
 Waiting for appointments
 Theaters
 Prolonged conversations in person or on the
 Churches phone
 Crowds

 Travel

 On trains, buses, planes, subways, cars

 Over bridges, through tunnels
 Being far away from home

 Remaining at Home Alone

 Open Spaces

 Traffic
 Parks
 Fields
 Wide streets

 Conflictual Situations

 Arguments, interpersonal conflicts, expression of anger

The agoraphobic may avoid one or many of these situations as a way to feel safe. The need to
avoid is so strong that some agoraphobics will quit their jobs, stop driving or taking public
transportation, stop shopping or eating in restaurants, or, in the worst cases, never venture outside
their home for years.

Listed below are the types of fearful thoughts associated with the dreaded situations. These are
irrational, unproductive, and anxiety-producing thoughts which last anywhere from a few
seconds to more than an hour. At the same time, they are the primary cause of agoraphobic
behavior. These thoughts serve to perpetuate the agoraphobic's belief: "If I avoid these situations,
I'll be safe."

FEARFUL THOUGHTS

 Fainting or collapsing in public

 Developing severe physical symptoms
 Losing control
 Becoming confused
 Being unable to cope
 Dying
 Causing a scene
 Having a heart attack or other physical illness
 Being unable to get home or to another "safe" place
 Being trapped or confined
 Becoming mentally ill
 Being unable to breathe

Some agoraphobics experience no symptoms of panic. Fearful thoughts continue to control

these individuals, but they have restricted their lifestyle, through avoidance, to such a degree that
they no longer become uncomfortable.

When agoraphobics retreat to protect themselves, they often have to sacrifice friendships,
family responsibilities, and/or career. Their loss of relationships, affections, and accomplishments
compounds the problem. It leads to low self-esteem, isolation, loneliness, and depression. In
addition, the agoraphobic may become dependent on alcohol or drugs in an unsuccessful attempt
to cope.

Professional Help

Panic disorder is the only psychological problem whose predominant feature is recurring panic
(or anxiety) attacks. The following is a brief summary of professional treatment of this
problem.

One of the most difficult problems for individuals with panic disorder is getting the right
diagnosis. Panic disorder is regarded as one of the great impostors of medicine because its
symptoms are similar to those found in a number of physical ailments (see Physical Causes of
Paniclike Symptoms), including heart attacks, some respiratory illnesses and thyroid diseases.
Once diagnosed and proper treatment begun, recovery may occur in a matter of months, but can
take longer depending on individual circumstances.

The most successful treatment regimens include a combination of behavior therapy and
cognitive therapy, sometimes with medication. Support groups may also be extremely useful,
because many individuals need the reassurance that they are not alone. A successful treatment
program must address all the individual's problems, including depression or substance abuse,
that might accompany the underlying emotional disorder.
Cognitive-behavior therapy attempts to alter the way a person thinks and acts in certain
circumstances. Specifically, the therapist helps the patient develop anxiety reduction skills and
new ways to express emotions. Relaxation techniques, such as controlled breathing, are a typical
feature. The patient also may be taught to re-examine the thoughts and feelings that trigger his
fears and maintain his anxiety. The patient often is gradually exposed to the feared situation, and
taught that he can cope.

There are a number of anti-anxiety and antidepressant medications that can be effective in
controlling panic disorder. The medication regimen may last just a few weeks, but in many cases
this therapy may be required for a year or longer. Medication should be accompanied by other
therapy, however, because the majority of patients treated only with drugs relapse once the
medication is discontinued.

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

 Physical disorders with paniclike symptoms

 <="" a="">Rapid or irregular heart rate
 Chest pain
 Difficulty breathing
 Dizziness and vertigo
 Multiple symptoms
 Side effects of medications

Physical disorders with paniclike symptoms

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

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

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

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

2. A minor physical problem produces a few symptoms. The individual then becomes
introspective and oversensitive to these physical sensations and uses them as a cue to become
anxious. His heightened awareness and unnecessary concern will produce an increase in
symptoms. If this continues, he can turn an insignificant physical problem into a major
psychological distress.
3. There is no physical basis for the symptoms. Some combination of the following will help:
education about the problem, reassurance, psychological treatment and medication treatment.

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

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

1. Find a physician whom you trust.

2. Explain your symptoms and your worries to him or her.

3. Let your physician conduct any evaluations or examinations necessary to determine the cause
of your symptoms.

4. If your primary physician recommends that another medical specialist evaluate your problem,
be certain to follow that advice. Make sure that your primary physician receives a report from the
specialist.

5. If a physical problem is diagnosed, follow your physician's treatment advice.

6. If your doctor finds no physical cause for your anxiety attacks, use the methods presented in
the Panic Attack Self-Help Program to take control of your symptoms. If your symptoms persist,
ask your physician or some other source for a referral to a licensed mental health professional
who specializes in these disorders.

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

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

Physiological Disorders with Paniclike Symptoms

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

Respiratory

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

Endocrine/hormonal

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

Neurological/muscular

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

Aural

 Benign positional vertigo

 Meniere's disease
 Labyrinthitis
 Otitis media
 Mastoiditis

Hematic

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

Drug related
 Alcohol use or withdrawal
 Side effects of many medications
 Illicit drug use
 Stimulant use
 Medication withdrawal

Miscellaneous

 Caffeinism
 Head injury

STEP 2: Understand Your Body's Emergency Response

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 blood decreases in arms and legs and pools in head and trunk

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

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

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

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

Possible Symptoms During Hyperventilation

 chest pain
 irregular heart rate
 blurred vision
 dizziness, lightheadedness
 numbness or tingling of mouth, hand,
 shortness of breath
feet
 "asthma"
 muscle pains or spasms
 choking sensations
 shaking
 lump in throat
 nausea
 difficulty swallowing
 fatigue, weakness

 heartburn
 confusion, inability to concentrate

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

1. Our body properly responds to the messages sent to it by the mind. If we label a
situation as dangerous, and then begin to approach that situation, the body will secrete
hormones that prepare us physically for crisis. Even if the situation appears relatively
safe, if the mind interprets it as unsafe, the body responds to that message.
2. If we become mentally involved with thoughts of a past event, the body may respond as
though that event were taking place now.
3. When we question whether we can handle a fearful situation, we tend to unconsciously
predict failure. Our body responds to our fearful thought by becoming tense and on guard.
4. If we visualize ourselves failing to cope with a future event, our body will tend to respond
as though we are currently in that event.
5. Within the panic cycle, the body is responding appropriately to unnecessarily alarming
messages sent by the mind.
6. By changing our images, our thoughts and our predictions about our ability to cope, we
can control our physical symptoms.
7. When we become anxious, our rate and pattern of breathing change. These changes can
produce hyperventilation that may cause many of the uncomfortable physical symptoms
during panic. By changing the way we breathe we can reduce all of those uncomfortable
symptoms.

Step 3: Change your Attitude!

Introduction: The basics of this attitude change

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

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

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

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

A vaccine consists of a dead or modified form of a disease-causing microbe. Once injected, it

stimulates the body's production of antibodies to the organism. If the microbe should then enter
the body, the antibodies help neutralize and remove the microbe from the body before it can
multiply and cause disease.

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

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

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

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

THE EIGHT ATTITUDES OF RECOVERY

THE EIGHT ATTITUDES OF RECOVERY

Expected Attitudes Healing Attitudes

"I can't let anyone know." "I am not ashamed."

"Panic is evil, bad, the enemy." "What can I learn as a student of panic?"

"I want to avoid the symptoms." "I want to face the symptoms to gain skills."

"I must relax right now." "It's OK to be anxious here."

"I must stay on guard." "I won't guard myself against anxiety."

"This is a test." "This is practice."

"I must be certain (that there is no risk)." "I can tolerate uncertainty."
"This had better work." "It's OK if it doesn't work."

Step 3: Change your Attitude!

Introduction: The basics of this attitude change

panic attacks, panic attack

The Don't Panic Self-Help Kit, Section A: Shift Your Attitude

Don't Panic, Chapter 9. Why the Body Reacts

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

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

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

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

A vaccine consists of a dead or modified form of a disease-causing microbe. Once injected, it

stimulates the body's production of antibodies to the organism. If the microbe should then enter
the body, the antibodies help neutralize and remove the microbe from the body before it can
multiply and cause disease.

You inoculate yourself by taking in some of the causative agent in order to experiment with it or
to become immune to it. Therefore, inoculations are paradoxical treatments: they take you close
to what you want to avoid. That's how you can use this section. Stop doing the activities that
seem instinctual in the face of panic. Instead, go directly toward panic, drop your guard and let it
touch you. Clearly you will be "experimenting" when you apply these inoculating attitudes. I
predict that you also will become immune, which means "not affected by or responsive to" panic.
How valuable can your attitude be? I know some people who have applied no techniques -- they
didn't control their breathing, they didn't learn relaxation skills, they didn't plan strategies for
coping with symptoms -- and they still brought their panic under control in a matter of weeks.
They did that by focusing strictly on the eight attitudes presented in this section.

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

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

THE EIGHT ATTITUDES OF RECOVERY

Expected Attitudes Healing Attitudes
"I can't let anyone know." "I am not ashamed."
"Panic is evil, bad, the enemy." "What can I learn as a student of panic?"
"I want to avoid the symptoms." "I want to face the symptoms to gain skills."
"I must relax right now." "It's OK to be anxious here."
"I must stay on guard." "I won't guard myself against anxiety."
"This is a test." "This is practice."
"I must be certain (that there is no risk)." "I can tolerate uncertainty."
"This had better work." "It's OK if it doesn't work."

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

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

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

STEP 4: Practice Your Breathing Skills

panic attacks, panic attack

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

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

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

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

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

The Calming Response (Parasympathetic Response)

oxygen consumption decreases

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

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

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

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

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

It's very simple and it goes like this:

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

Natural Breathing

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

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

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

Here's how it goes:

Calming Breath

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

Practice this Calming Breath at least ten times a day for several weeks. Use it during times of
transition, between projects or whenever you want to let go of tension and begin to experience a
sense of calmness. This will help you become familiar and comfortable with the process. And use
it any time you begin to feel anxiety or panic building. When you need a tool to help you calm
down during panic, you will be more familiar and comfortable with the process.
The third technique is called Calming Counts. It has two benefits over Calming Breath. First, it
takes longer to complete: about 90 seconds instead of 30 seconds. You will be spending that time
concentrating on a specific task instead of paying so much attention to your worried thoughts. If
you can let time pass without such intense focus on your fearful thoughts, you will have a better
chance at controlling those thoughts. Second, Calming Counts, like Natural Breathing and the
Calming Breath, help access the Calming Response. That means you will be giving yourself 90
seconds to cool your body out and quiet your thoughts. Then, after that time has passed, you will
less anxious than you were.

Here's how this skill works:

Calming Counts

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

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

Check out all physical symptoms

STEP 2
Understand your body's emergency response

STEP 3
Change your attitude!

STEP 4
Practice your breathing skills

STEP 5
Practice formal relaxation skills

STEP 6
Use paradox

STEP 7
Approach your goals through small steps

STEP 8
Handle your worries
STEP 5: Practice Formal Relaxation Skills
panic attacks, panic attack

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

Cue-Controlled Deep Muscle Relaxation

Generalized Relaxation and Imagery
Meditation
Which method is best for you?

STEP 6: Use Paradox

panic attacks, panic attack

Don't Panic, Chapter 17. Paradox in Action

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

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

The balance of power

Giving up the struggle
Inviting the symptoms
STEP 7: Approach Your Goals Through Small Steps
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The Don't Panic Self-Help Kit, Section P: Handle Your Physical Symptoms
The Don't Panic Self-Help Kit, Section "Start Here": How to Design Your Own Program
Don't Panic, Chapter 18. Experience: The Greatest Teacher

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

Here are the topics we will cover. Begin at the first one - "Set your long-term goals" - and
progress through the fourth one - "How to practice your skills".
Set your long-term goals
Set your short-term goals
Create short-term tasks
How to practice your skills

STEP 8: Handle Your Worries

panic attacks, panic attack

The Don't Panic Self-Help Kit, Section W: Handle Your Worries

Don't Panic, Chapter 14. Your Mind's Observer
Don't Panic, Chapter 15. Finding Your Observer
Don't Panic, Chapter 16. Taking a New Stance: The Supportive Observer

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

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

Handling worries as "signals"

Handling worries as "noise"

Change #1
"I can't let anyone know." to "I am not ashamed."
It's hard to let others know of our problems. First, we can feel embarrassed to admit that we
don't have our lives together as well as (we fantasize) they have theirs. Then, if our problems are
lasting awhile, we don't want others to get fed up with our complaints. Or, we might explain
what's bothering us only to have others say, "I don't get it. I don't know what you mean." Or,
worse yet, "What's the big deal?" In addition, people can start giving us advice on how to fix it
and expect us to take action soon. Speaking to someone about a problem doesn't mean that we
are feeling courageous enough to try to fix it. These possible reactions can be good reasons to
keep our problems to ourselves.

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

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

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

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

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

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

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

 I can't tell anyone.

 I can't bother other people with my problems.
 I have to take care of others.
 I can't let people see me this way.
 People won't think I'm OK if they know I'm anxious.
 I must hide my anxiety, hold it all in, not let anyone know my feelings, fight it.
This attitude section focuses on the influences of our beliefs on our daily lives. These include the
belief that we are worthy of success and happiness and the belief that we have a variety of
positive choices available to us in our lives. These are attitudes that help us solve problems. They
are convictions that affirm us.

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

Accepting Who I Am

 I'm OK just the way I am.

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

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

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

Supporting What I Do

 It's OK to say no to others.

 It's good for me to take time for myself.
 It's OK to think about what I need.
 The more I get what I need, the more I'll have to give others.
 I don't have to take care of everyone else.
 I don't have to be perfect to be loved.
 I can make mistakes and still be OK.
 Everything is practice; I don't have to test myself.
 I am not ashamed.

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

Explore what obstacles stand in the way of these affirmations for you. Sometimes discussing
these issues with a close friend or a self-help group will help. Other times the causes of these
blocks are not so clear or easily removed. If you feel stuck, consider turning to a mental health
professional for insight and guidance.
Once you address those issues that block your willingness to support yourself, then pay attention
to these affirmations. Find ways to accept these kinds of statements, then let your actions reflect
these beliefs. (You may have to begin by acting as though you believe them -- even when you
don't -- before you discover how well they will serve you.) In addition to the support of friends
and a mental health professional, look for courses in your community on assertiveness training.
Such course teach you how to turn your positive beliefs into actions.

Change #2
"Panic is evil, bad, the enemy" to "What can I learn as a
student of panic?"
Who wouldn't be angry and rejecting toward something that produces such chaos in your life?
Seeing panic as the enemy is a natural response. I assume that up to now that you have had plenty
of practice viewing panic as the villain. Now try something new -- consider panic your teacher.

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

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

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

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

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

Welcoming Panic

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

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

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

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

I am not saying that panic always comes into people's lives because they are
missing some basic learning (although sometimes it does). Taking the
stance of a student who truly wants to learn is a way to stop taking a
resistant stance toward panic. The focus of our attention right now is how
to get better. Choose to become a student of panic because it is the attitude
that best moves you toward health. If you are paying attention to how you
can learn from panic, then you will stop fighting against panic. As you
reduce your fear and defensiveness, you influence the entire dChange #3
"I want to avoid the symptoms." to "I want to face the symptoms to gain
skills."

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

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

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

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

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

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

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

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

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

Change #4
"I must relax right now." to "It's OK to be anxious here."

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

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

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

Your accepting inner voice may go something like this: "It is really no surprise I am anxious right
now. This is my first flight since I got scared during the trip to Orlando. I don't like to feel
trapped and out of control. This is harder than driving because I can pull off the highway when I
need to. I can't get off this plane whenever I want. So I'm going to practice all the skills I've
brought on board with me. If I'm still anxious, that's OK. I can handle those feelings, and as I do,
I won't be so worried on the next flight."
So, shop in that mall, give that speech, go to that dinner, or climb that ladder . . . and use all your
many skills to help you stay cooled out. Just add to those skills the important attitude of "It's OK
to be anxious here."

Change #5
"I must stay on guard." to "I won't guard myself against anxiety."

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

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

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

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

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

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

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

There is a second choice for your attention when you stop focusing on what terrible things might
happen in the future. Pay loving, caring attention to yourself in this moment. By asking, "What
do I need right now to handle these feelings?," you will contribute to your self-control far more
than by asking, "What will I do if that (terrible thing) happens next?" Start supporting yourself
based on what you need at this moment, instead of becoming anxious about what will happen
thirty seconds from now. The upcoming Steps will suggest what actions to take. Apply those
skills with the attitude of, "I don't need to stay on guard against panic." Change #6
"This is a test." to "This is practice."

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

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

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

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

When you test yourself during every activity, you inhibit your learning. If you say to yourself,
"That action I took yesterday proves that I'm never going to make it," you essentially have said,
"Don't bother learning from yesterday; it's too late for you." Of course, the truth of the matter is
that making mistakes and studying them are among our best learning tools.
Since everyone who takes on a challenge has setbacks, you can assume you will too. When you
hear your self-critical or hopeless comments rise up, let them go. They will only distract you
from learning.

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

As you approach events, concentrate on what you can do to improve your outcome. Experiencing
some worry and anxiety about the outcome is understandable. Just don't let it consume your
creative thinking. There are two important focal points for your attention when you leave a scene
without meeting your goal. The first is, "What can I learn from my experience in that situation
that I can apply next time?" The second is, "How can I take care of myself now that I am leaving
this difficult situation?" Practice the skill of supporting yourself in the face of a disappointment.
If your goal is improving your performance next time, how do you want to treat yourself after
your difficulty this time? Stop being critical of yourself and begin developing a supportive voice
within you. Change #7
"I must be certain (that there is no risk.)" to "I can tolerate uncertainty."

Most problems with anxiety relate to a fear of uncertainty.

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

"Can I know for certain that I won't have any symptoms?"

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

If we look at a different anxiety problem -- obsessive-compulsive disorder -- we find the same

kinds of questions:

"Can I know for certain that this object is clean?"

"Can I know for certain that I won't get contaminated if I touch the ground?"
"Can I know for certain that my family will be safe?"
"Can I know for certain that I didn't run someone over?"
"Can I know for certain that I unplugged that iron?"
"Can I know for certain that I won't kill my child?"
If it is true that some people's brains cause them to feel a strong yet inappropriate need for
certainty, then confronting that problem involves disrupting those demanding thoughts. It
involves confronting them consistently and directly everyday to produce the change we want.
This is where your new attitude comes in. You must find ways to accept risk and tolerate
uncertainty.

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

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

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

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

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

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

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

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

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

For fear of heart attacks: "I accept the possibility that this time could actually be a heart attack.
I'm going to respond to it as though it is a panic attack. I accept the risk that I might be wrong."
For fear of dying on a plane: "I accept the possibility that this plane could crash. I'm going to
think and feel and act as though this plane is 100% safe. I accept the risk that I might be wrong."

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

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

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

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

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

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

Reading about the next attitude shift will give you a better understanding of the value in
accepting uncertainty. Change #8
"This had better work." to "It's OK if it doesn't work."

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

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

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

But she kept having trouble.

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

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

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

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

What's wrong with that?, you say.

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

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

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

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

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

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

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