The problem
Standard panic is a rapid escalation of anxiety caused by
the symptoms of anxiety being things that the client is anxious about.
Standard protocols are to understand this, then to challenge
a person’s catastrophic misinterpretations that they will die, faint, be sick,
shake uncontrollably, be incontinent, or be embarrassed.
With anxiety it would seem that all those outcomes apart
from death can be caused by panic.
It seems that anxiety escalates in the following way. There is something perceived as dangerous,
and attention narrows onto that. Then
the fight\flight\freeze mechanisms go into action. The client then becomes
anxious about those, which creates the escalating mechanisms. The client to look
after themselves wants to avoid the situation that they associate with anxiety,
i.e. the busy room, but if they can’t find it then that provides another source
of anxiety.
So panic is a combination of
1.
Initial anxiety felt as intolerable
2.
Catastrophic misinterpretation of anxiety symptoms
3.
Locating the cause of anxiety as outside the person,
i.e. in the busy room
4.
Increasing anxiety if their ways to manage anxiety
aren’t there (escape, safe person etc.)
Anxiety seems to be maintained then by a set of thoughts
1.
I can’t manage anxiety or I can only manage anxiety
with something\someone
a.
There will be physical or socially unbearable
consequences
2.
Anxiety is caused by external factors
a.
E.g. The busy room
3.
Predicting\associating anxiety with a range of
situations\scenarios
4.
Anxiety is more important than anything else
Anxiety seems maintained by behaviours
1.
Paying sole attention to the symptoms of anxiety, the
perceived causes of anxiety
2.
Avoidance of anxiety provoking situations, which both
keeps the beliefs alive, and also doesn’t allow the client to learn how to
manage their anxiety.
3.
Reducing doing valued behaviours which makes anxiety
more important than anything else
4.
Hyper ventilating, to cause light headedness
The Treatment
It’s difficult to give a cure all treatment plans, as people
have different difficulties with panic, but what follows are some things that
may be generally helpful.
Understanding
First of all clients need to make sense of what’s happening to
themselves, both generally and specifically
General understanding
Psychoeducation of anxiety symptoms and understanding the
fight\flight\freeze mechanisms.
Specific understanding
What are the sources of the initial anxiety?
The thought of a busy supermarket maybe?
What increases this once anxiety has started?
The thought that I can’t cope and will be embarrassed due to
my symptoms
Paying attention to the anxiety.
Hyper ventilating
What maintains the anxiety?
Avoidance which neither challenges my beliefs, nor allows me
to learn.
Values
A values perspective here changes the approach from trying
to create a life without suffering to creating a life worth suffering for.
This can be done both by a general understanding, what is
important to people generally that they will do even though they may feel
anxious, what have you done even though you have felt anxious, and then
specifically now, what is so important to you that are you willing to tolerate
some anxiety to enable you to do ?
Exposure
Produce a hierarchy that accords with their values, the
thing(s) they want to be able to do. The first two items on the hierarchy could
be imaginal exposure and ACTs emotional acceptance, then a panic induction.
During these initial exposures, then some engagement with
the experience could be useful, just to notice the experience of anxiety and to
describe without judging. This can also be supported by a mindful practice.
During exposure the client will now doubt feel anxiety, so
they may want to try some of the following coping responses.
1.
If hyperventilating
slow breathing down and try to make the out breath longer than the in breath
2.
Move attention to what is important, what you are
trying to do
3.
Describe what’s happening, e.g. I’m feeling anxious
because of x, my heart is racing as its preparing me to run
4.
If scary thoughts come, OMG I’m going to panic, mindfully
notice the thought and return attention to what you are trying to do, e.g.
shop, or if there’s nothing very much happening to your breath
5.
You might want to remind yourself of what’s important
to you about what you are doing
6.
Offering self some soothing, or encouraging thoughts,
e.g. I can do this, this anxiety will pass.
After exposure
1.
It can be helpful to write down after the exposure what
was learnt: how much can I tolerate anxiety? What creates anxiety? What makes
it increase? What beliefs about anxiety should I alter?
