“Antony and McCabe have presented evidence-basedtreatments for panic disorder from both psychological and pharmacological view points in a superbly clear and succinct manner. Undoubtedly, their overview will be a tremendous aid for individuals in need of treatmentguidance for panic disorder. Their review provides anexcellent resource for professionals as well.”

—Michelle G. Craske, Ph.D.,professor of psychology, Universityof California, Los Angeles

How to Overcome Panic Attacks, Calm Physical Symptoms

& Reclaim Your Life

MARTIN M. ANTONY, PH.D.RANDI E. McCABE, PH.D.

New Harbinger Publications, Inc.

10 Simple Solutions to Panic

This book is ded i cated to all of our patients and cli ents, whose cour age and per se ver ance have taught us most about over com -ing anx i ety.

—Mar tin M. Antony—Randi E. McCabe

Pub lisher’s Note

This pub li ca tion is de signed to pro vide ac cu rate and au thor i ta tive in for ma tion

in re gard to the sub ject mat ter cov ered. It is sold with the un der stand ing that

the pub lisher is not en gaged in ren der ing psy cho log i cal, fi nan cial, le gal, or other

pro fes sional ser vices. If ex pert as sis tance or coun sel ing is needed, the ser vices of

a com pe tent pro fes sional should be sought.

Dis trib uted in Can ada by Raincoast Books.

Copy right © 2004 by Mar tin An tony and Randi McCabe

New Har bin ger Pub li ca tions, Inc.5674 Shattuck Av e nueOak land, CA 94609

Cover de sign by Amy ShoupText de sign by Michele Wa ters-Kermes

ISBN 1-57224-325-2 Pa per back

All Rights Re served

Printed in the United States of America

New Har bin ger Pub li ca tions’ Web site ad dress: www.newharbinger.com

06 05 04

10 9 8 7 6 5 4 3 2 1

First print ing

Contents

Ac knowl edg ments v

In tro duc tion 1

1 Un der stand Your Panic and Fear 6

2 Make a Con tract and Set Re al is tic Goals 20

3 Track Your Panic Symp toms 32

4 Re place Anx ious Thinking with Re al is tic Thinking

42

5 Con front Places Where Your Panic At tacks Oc cur

61

6 Con front Your Phys i cal Symp toms 78

7 Stop Playing it Safe—Elim i nating Sub tle Avoid ance

92

8 Learn to Breathe Normally 98

9 Re duce Life Stress and Im prove Your Health

107

10Choose Med i ca tions that Work 117

Afterword 129

Rec om mended Read ings and Videos 133

Ref er ences 136

iv 10 Sim ple So lu tions to Panic

Acknowledgments

We would like to thank Sam Katerji for her assis tance inpre par ing this book. We are also grate ful to our edi -tors at New Har bin ger, Cath ar ine Sutker and Carole

Honeychurch, for their sup port and care ful atten tion to detail. Finally, a spe cial thanks to the many indi vid u als who arerespon si ble for orig i nally devel op ing and study ing the treat -ments described in this book, includ ing James Ballenger, David H. Barlow, Aaron T. Beck, David M. Clark, Michele G.Craske, Don ald F. Klein, Isaac Marks, S. Rachman, RonRapee, and many oth ers.

Introduction

About a third of peo ple report hav ing panic attacks fromtime to time (Norton, Dorward, and Cox 1986), andincreas ingly, panic attacks are becom ing rec og nized as a

com mon expe ri ence. Although the term “panic attack” was not offi cially used until the early 1980s (Amer i can Psy chi at ricAsso ci a tion 1980), it is now a famil iar phrase in our cul ture.The topic appears fre quently in the media, and a num ber ofceleb ri ties, includ ing Donny Osmond, Kim Basinger, and Wil -lard Scott, have spo ken openly about their strug gles withpanic. In fact, one of the “fre quently asked ques tions” listed on the Web site www.healthypet.com is “What can I do about my dog’s panic attacks?” That’s right—it seems that even dogsmay have panic attacks!

Essen tially, a panic attack is a rush of fear involv ingintense phys i cal sen sa tions, and for most peo ple, panic attacksare trig gered by par tic u lar feared sit u a tions. For exam ple, peo -ple who expe ri ence anx i ety over pre sen ta tions may have apanic attack when giv ing a speech. Like wise, peo ple who fearheights often expe ri ence panic attacks in high places. For the

most part, this book will not dis cuss panic attacks that are trig -gered by com monly feared objects and sit u a tions such as these. Instead, the empha sis of this book is on panic attacks thatoccur unex pect edly or “out of the blue” in a con di tion knownas panic dis or der.

Panic dis or der is an anx i ety dis or der in which indi vid u als expe ri ence panic attacks that are not asso ci ated with any obvi -ous trig ger or cause. The attacks can occur at any time or inany place, includ ing dur ing times of relax ation or when lyingin bed, fast asleep. Often they occur in pub lic places or in sit u -a tions from which escape is dif fi cult (e.g., a movie the ater orcrowded bus). Because panic is typ i cally accom pa nied byfright en ing symp toms such as rac ing heart, sweat ing, diz zi ness, and feel ings of unre al ity, the attacks may be mis taken as signsof a heart attack, stroke, faint ing, or an impend ing loss of con -trol (for instance, going crazy or not mak ing it to the bath -room in time). How ever, despite these fears, panic attacks aregen er ally not at all dan ger ous.

Is this Book for You?This book is likely to be use ful if you answer “yes” to most ofthe fol low ing ques tions:

! Do you expe ri ence intense peri ods of fear thatbegin quickly and that are accom pa nied by sev -eral uncom fort able phys i cal symp toms, such asrac ing heart, nau sea, breath less ness, and diz zi -ness?

! Do these peri ods of fear appear to occur out ofthe blue, even in sit u a tions where you don’texpect to feel anx ious or ner vous?

! Do you antic i pate the attacks, won der ing whenthe next one will strike?

2 10 Sim ple So lu tions to Panic

! Do you worry about the pos si ble con se quencesof the attacks? For exam ple, dur ing the attacksdo you worry that you might die, faint, go crazy,lose con trol, vomit, lose bowel con trol, have astroke, or embar rass your self?

! Do you fear or avoid sit u a tions where the attacks often occur? Are there other things that you doto pro tect your self from expe ri enc ing panic attacks?

! Do your panic attacks and the ten dency to avoidfeared sit u a tions inter fere with your life? Forexam ple, does the prob lem affect your work,hob bies, or rela tion ships?

! Are you ready to work on your panic attacks? Ifyou are too busy, or if there are other prob lemsthat are likely to get in the way (for exam ple,severe depres sion or sig nif i cant alco hol or druguse), this may not be the best time to beginwork ing on your panic.

Can a Self-Help Book Really Help?There are a num ber of rea sons to assume that a book such asthis one may be help ful. First, the strat e gies described in thisbook have been researched exten sively, and there are a lot ofstud ies show ing that these treat ments are effec tive whenadmin is tered by a trained ther a pist (Antony and Swinson2000). In addi tion, there is quite a bit of evi dence that thestrat e gies described in this book are effec tive for many peo pleeven when admin is tered in a self-help for mat (Gould andClum 1995; Hecker, Losee, Fritzler, and Fink 1996). Ofcourse, sim ply read ing this book will not make your panicattacks go away, any more than just read ing a book on phys i cal fit ness will help you to get in shape. To get the most out of it,

Introduction 3

you will need to prac tice the strat e gies described in the bookover and over again.

Researchers have shown that self-help treat ments oftenwork better when they are accom pa nied by occa sional vis its toa doc tor or ther a pist to dis cuss your prog ress (Febbraro, Clum, Roodman, and Wright 1999). If you find it dif fi cult to use thestrat e gies in this book on your own, you may want to con sidercom bin ing the treat ments described with occa sional vis its to apro fes sional ther a pist or to a fam ily doc tor who is expe ri enced with treat ing panic dis or der.

This book is designed for peo ple who are inter ested inknow ing the basics about how to over come prob lems withpanic, but who don’t nec es sar ily want to read a larger book on the topic. If you find, after read ing this book, that you want to learn more, there are a num ber of other excel lent books onover com ing panic. Some of our favor ites are listed in the rec -om mended read ings sec tion at the back of this book. You mayalso ben e fit from obtain ing addi tional treat ment via theInternet (one excel lent site can be found at: www.paniccen -ter.net), by join ing a sup port group in your com mu nity, or byseek ing help with a pro fes sional ther a pist.

If you do seek pro fes sional help, we highly rec om mendthat you make sure the indi vid ual is expe ri enced in treat ingpanic dis or der, either with med i ca tions or with cog ni tive behav -ioral ther apy. As dis cussed through out this book, these are thetwo main treat ments that have been found to be effec tive forthis prob lem. A cou ple of good sources of infor ma tion on pro -fes sion als who treat this prob lem include the Anx i ety Dis or dersAsso ci a tion of Amer ica (www.adaa.org) and the Anx i ety Dis or -ders Asso ci a tion of Can ada (www.anxietycanada.ca).

Don’t be fooled by the size of this book. Though youmay be able to read it in one sit ting, your panic attacks willnot go away over night. The strat e gies described here are meant to be used almost daily over an extended period of time. It will also be impor tant to mon i tor your prog ress care fully. A jour nal or note book will be the one essen tial tool you’ll need to work

4 10 Sim ple So lu tions to Panic

through the all the exer cises in this book. Many of the tech -niques described here require you to take notes, to record your expe ri ences, and to mon i tor your use of var i ous treat mentstrat e gies. Exer cises requir ing the jour nal begin early on, soyou may want to have it handy before you start read ing chap -ter 1. With a bit of luck and lots of hard work, you shouldnotice a sig nif i cant decrease in anx i ety after using the strat e gies for a num ber of weeks or months.

For tu nately, panic dis or der is among the most treat ableof psy cho log i cal prob lems. The strat e gies described in thisbook have been researched exten sively and have con sis tentlybeen shown to be effec tive for com bat ing panic attacks andrelated anx i ety prob lems. If you put your mind to it, you canfeel better.

Introduction 5

UnderstandYour Panicand Fear

The pur pose of this intro duc tory chap ter is to set the stagefor over com ing your dif fi cul ties with panic. To start, it’simpor tant to under stand exactly what a panic attack is and

what is meant by other rel e vant terms, includ ing “anx i ety,”“panic dis or der,” and “ago ra pho bia.” In addi tion to pro vid ingthe def i ni tions of these terms, this chap ter will also pro videimpor tant back ground infor ma tion regard ing the nature of,causes, and proven treat ments for panic attacks and panicdis or der.

Defining Fear and AnxietyIn every day life, terms such as “fear,” “anx i ety,” “worry,” and“panic” are often used inter change ably. How ever, for the pur -pose of under stand ing the nature of these prob lems, we will

1

dis tin guish between these terms. We begin with def i ni tions offear and anx i ety.

Fear is a basic emo tion that is expe ri enced by all peo ple.It is a reac tion to an imme di ate dan ger (or at least an imme di -ate per ceived dan ger), and it is some times referred to as a“fight or flight” response. This is because when peo ple expe ri -ence fear, their phys i cal and men tal resources are focused onpro tect ing the self from the threat, either by flee ing from thesit u a tion or by defend ing themselves with an aggres siveresponse toward who ever or what ever is pro duc ing the threat.

When we feel fear, our bod ies become acti vated. Ourhearts race to ensure that oxy gen-rich blood is cir cu lated tothe areas of the body that need it. We breathe more heavily topro vide the extra oxy gen that’s required to facil i tate escape.We also sweat, which cools off the body so it can per formmore effec tively. In addi tion to the phys i cal changes that occur dur ing fear, there are also cog ni tive changes (the term “cog ni -tion” sim ply means “thought”). We tend to focus almost exclu -sively on the source of the threat, which makes it dif fi cult tothink about other things, includ ing what ever you hap pen to be doing at the time. Fear is also accom pa nied by a strong urge to do almost any thing to get rid of the feel ing, such as escapefrom the sit u a tion.

Anx i ety is related to the emo tion of fear, but there areimpor tant dif fer ences between anx i ety and fear. Anx i ety tendsto be more future-oriented. Whereas fear is a reac tion to animme di ate threat (like being attacked by a dog), anx i ety occurs when we antic i pate a future threat of some kind (like wor ry ing about an upcom ing exam). Compared to fear, anx i ety tends tobe more dif fuse, harder to describe, lon ger last ing, and slowerto come on. When we feel anx ious, we may expe ri ence someof the same phys i cal symp toms that occur dur ing fear (forinstance, nau sea, diz zi ness), but other com mon fea tures of anx -i ety include mus cle ten sion, sleep less ness, and worry aboutfuture events.

Understand Your Panic and Fear 7

What Is a Panic Attack?As we men tioned in the intro duc tion, a panic attack is a rushof fear. It is an imme di ate response to a per ceived threat, andit is accom pa nied by intense phys i cal sen sa tions. Accord ing tothe offi cial def i ni tion (Amer i can Psy chi at ric Asso ci a tion 2000), a panic attack must include at least four of the fol low ing thir -teen symp toms:

1. Racing or pound ing heart

2. Sweating

3. Trem bling or shak ing

4. Short ness of breath

5. Feel ing of chok ing

6. Chest pain or dis com fort

7. Nau sea or abdom i nal dis tress

8. Feel ing dizzy, unsteady, or faint

9. Feel ing unreal or detached

10. Numb ness or tin gling sen sa tions

11. Chills or hot flushes

12. Fear of dying

13. Fear of going crazy or los ing con trol

In addi tion to these defin ing symp toms, it is not unusualfor peo ple to expe ri ence other uncom fort able feel ings, includ -ing blurred vision or a tight feel ing in the throat. Panic attackstend to increase in inten sity very quickly, often reach ing theirpeak within sec onds (though accord ing to the offi cial def i ni -tion, the peak can be reached within ten min utes or less). Theattacks typ i cally last any where from a few min utes to an houror so. Although some peo ple report “panic attacks” last ingmany hours or days, these are prob a bly not true attacks.Instead, such indi vid u als are likely expe ri enc ing mul ti ple panic

8 10 Sim ple So lu tions to Panic

attacks through out the day, with high lev els of anx i ety inbetween.

What is Panic Disorder?Panic dis or der is an anx i ety dis or der in which indi vid u alsexpe ri ence panic attacks out of the blue, with out any obvi oustrig ger or cause. In some cases, attacks are rel a tively infre quent (per haps once every few months), but they can also occur asfre quently as many times per day. In addi tion, peo ple withpanic dis or der are fright ened by their attacks. They worryabout when the next attack will occur, and they worry aboutthe pos si ble con se quences of the attacks (for exam ple, whether they will die, lose con trol, go crazy, vomit, have diar rhea, orfaint). They also change their behav ior in order to cope withthe attacks or to pre vent them from occur ring alto gether. Thedevel op ment of agoraphobic avoid ance (to be defined shortly)is the most com mon type of behav ioral change that occurs inpanic dis or der, though there may be other types of behav ioralchanges as well. Some exam ples include:

! Carrying med i ca tion, money, cel lu lar tele phone,pager, water, or other safety items

! Avoiding activ i ties (like exer cise or sex) that trig -ger panic-like symp toms of phys i cal arousal

! Insisting on being accom pa nied when leav ing the house

! Drinking alco hol to com bat feel ings of panic

! Avoiding caf feine, alco hol, or other sub stances

! Fre quently check ing your pulse or blood pres sure

! Dis tracting your self from the symp toms (forinstance, read ing a book on the sub way)

! Always need ing to know where your spouse orpart ner is

Understand Your Panic and Fear 9

! Sit ting near ex its when at the mov ies or at a res -tau rant

Before a diag no sis of panic dis or der can be given, it isimpor tant to rule out any med i cal con di tions or pos si ble sub -stance-related rea sons for the attacks. Exam ples of med i cal dis -or ders that can trig ger symp toms of anx i ety and panic includethy roid prob lems, bal ance dis or ders, sei zure dis or ders, and car -diac con di tions. Use of stim u lants (like cocaine, caf feine, dietpills, and cer tain other med i ca tions), with drawal from alco hol, and use of other drugs (like mar i juana) can also trig gerpanic-like feel ings. Before assum ing that your symp toms aredue to an anx i ety dis or der, it’s impor tant to have a full med i -cal workup to deter mine whether there is a phys i cal cause foryour prob lems. Once phys i cal causes are ruled out, you can bemuch more con fi dent when try ing the strat e gies described inthis book.

What Is Agoraphobia?Most peo ple with panic dis or der develop some degree of ago -ra pho bia. The term ago ra pho bia is often mis un der stood. Some peo ple mis tak enly believe that it’s a fear of open spaces. Oth -ers assume that this prob lem is a fear of leav ing the home.Although a small per cent age of peo ple with ago ra pho bia mayfear open spaces, a fear of open spaces is actu ally quite uncom -mon among peo ple who suf fer from this con di tion. Fur ther -more, only the most severe forms of ago ra pho bia areasso ci ated with an inabil ity to leave one’s house.

Ago ra pho bia is a fear of sit u a tions in which escape mightbe dif fi cult or in which help might not be avail able in the event of expe ri enc ing a panic attack or panic-like symp toms (the lit -eral trans la tion of ago ra pho bia is “a fear of the mar ket place”). The types of sit u a tions that peo ple with ago ra pho bia avoidinclude:

10 10 Sim ple So lu tions to Panic

! Crowded places: Super mar kets, the aters, malls,sports events

! Enclosed places, and places from which escape isdif fi cult: Tun nels, small rooms, ele va tors, air planes, sub ways, buses, get ting a hair cut, long lines

! Driving: Espe cially on high ways and bridges, inbad traf fic, and over long dis tances. Being a pas -sen ger in a car may also be dif fi cult.

! Being away from home: Some indi vid u als have asafe dis tance around their home and find it dif fi -cult to travel beyond that dis tance. In rare cases,leav ing the home may be com pletely impos si ble.

! Be ing alone: Es pe cially in the sit u a tions listedabove

For some peo ple, ago ra pho bia is very mild (for exam ple,just a fear of pan ick ing on over seas flights), or there may be no agoraphobic avoid ance at all. For oth ers, ago ra pho bia can bevery severe, pre vent ing the indi vid ual from doing just aboutany thing out side the home. For most peo ple who suf fer frompanic dis or der, the level of agoraphobic avoid ance is some -where in between these two extremes.

Facts about Panic Disorder andAgoraphobiaIn this sec tion, we pro vide a few facts about panic dis or derthat may be of inter est. Full reviews on these top ics are avail -able else where (for exam ple, Antony and Swinson 2000; Tay -lor 2000). Panic dis or der is a rel a tively com mon con di tion,affect ing about 3.5 per cent of the gen eral pop u la tion at sometime in their lives (Kessler et al. 1994). If you do the math,that’s more than ten mil lion Amer i cans. About two thirds ofpeo ple with panic dis or der are women. In addi tion, women

Understand Your Panic and Fear 11

with panic dis or der are more likely than men with panic dis or -der to have more fre quent panic attacks, more severe ago ra -pho bia, and a more intense fear of panic symp toms (Turgeon,Marchand, and Dupuis 1998).

Panic dis or der tends to begin in early adult hood (dur ing aper son’s 20s), though it can also begin in child hood or late inlife. The onset of panic dis or der is usu ally some what sud den,often begin ning with a bad panic attack. Also, the onset oftenfol lows a period of stress in a per son’s life, includ ing eventssuch as grad u a tion, divorce, a new mar riage, a new baby, a newjob, unem ploy ment, death of a loved one, or ill ness in the fam -ily (for a review, see Antony and Swinson 2000).

With out treat ment, panic dis or der tends to be a chronicprob lem. For exam ple, one study found that 92 per cent ofindi vid u als with panic dis or der were still expe ri enc ing panicattacks a year after their ini tial assess ment (Ehlers 1995). Thegood news is that panic dis or der is a very treat able con di -tion—a point we will return to later in this chap ter.

Panic dis or der affects a wide range of life domainsinclud ing work, rec re ation, and social func tion ing. In fact, astudy from our clinic (Antony, Roth, Swinson, Huta, andDevins 1998) found lev els of impair ment in func tion ing among peo ple with panic dis or der to be sim i lar to impair ment lev elsof peo ple with seri ous med i cal con di tions, such as kid ney dis -ease and mul ti ple scle ro sis. If you suf fer from panic dis or der,this find ing may not be all that sur pris ing to you. Panic dis or -der is also costly in terms of its impact on the health-care sys -tem and on soci ety in gen eral. For exam ple, Siegel, Jones, andWil son (1990) found that peo ple with panic dis or der visit phy -si cians seven times more often than peo ple with out panic dis -or der, and they miss twice as many work days.

Find ings from our clinic (Antony and Swinson 2000)con firm those from a num ber of other cen ters show ing thatpanic dis or der often occurs along with other prob lems. Forexam ple, we found that almost one out of five indi vid u alsseek ing treat ment for panic dis or der at our center also suf fered

12 10 Sim ple So lu tions to Panic

from depres sion. Almost a quar ter had sig nif i cant prob lemswith anx i ety in social sit u a tions, and many indi vid u als hadother types of anx i ety dis or ders, includ ing pho bias, gen er al ized anx i ety dis or der, and obses sive com pul sive dis or der. For tu -nately, the pres ence of another anx i ety dis or der or depres sionoften does n’t have an impact on the out come of treat ment forpanic dis or der. In fact, tar get ing the panic dis or der can lead to improve ments in the other prob lems as well (Brown, Antony,and Barlow 1995).

Understand Your Panic and Fear 13

Exercise: Understanding YourProblems with Panic

In the pre vi ous sec tion we reviewed some ofthe typ i cal pat terns often seen in peo ple with panic dis or der. How does your own expe ri -ence match what has been found in theresearch? In your jour nal, record yourresponses to the ques tions below. Thinkabout how your own expe ri ences com pareto the “aver age” per son who par tic i pates inresearch stud ies on panic dis or der.

! How old were you when you expe ri -enced your first panic attack?

! Were you expe ri enc ing any life stressdur ing the year before your panic attacks began? If so, what types of stresses?

! What areas of your life are mostaffected by your panic attacks (work/school, social func tion ing, lei sure)?

! In addi tion to your panic attacks, doyou expe ri ence other prob lems withanx i ety, depres sion, exces sive alco holor drug use, or other dif fi cul ties?

Causes of Panic Disorder andAgoraphobiaThe causes of panic dis or der are com plex, and there is no sin -gle fac tor that is respon si ble for the prob lem in all cases. Fur -ther more, it’s impos si ble to deter mine the spe cific cause of thedis or der for any sin gle indi vid ual. The best we can do, basedon the cur rent state of the research, is dis cuss the types of fac -tors that are believed to play a role in the devel op ment ofpanic dis or der, based on stud ies of large groups of indi vid u alswho suf fer from the prob lem. Whether the results of thesestud ies are rel e vant to your own case is impos si ble to know.So, if you read some where that panic dis or der is caused by achem i cal imbal ance in the brain, bad genes, or bad parenting,don’t believe every thing you read. These fac tors may play arole for some indi vid u als, but they are only part of the story.

Per haps the best way to think about the cause of yourown prob lems with panic is to under stand that in all like li hood the prob lem has come about through a com plex inter ac tionbetween psy cho log i cal fac tors (your learn ing his tory, beliefs,etc.), bio log i cal fac tors (genetic vul ner a bil i ties), and envi ron -men tal fac tors (like stress). Although it is not nec es sary tocom pletely under stand what causes panic dis or der to be able to over come it, rec og niz ing the ways in which var i ous fac torsinflu ence the course of the prob lem can be enlight en ing.

BIOLOGICAL FACTORSOver the past twenty years, much evi dence has been

accu mu lated to sup port the view that our biol ogy influ enceswhether we develop prob lems with panic attacks and panicdis or der, as well as the course that these prob lems can takeover time. First, there are numer ous stud ies show ing that panic dis or der is influ enced by genetic fac tors. For exam ple, rel a tives of peo ple with panic dis or der are three times as likely to

14 10 Sim ple So lu tions to Panic

develop the prob lem than are rel a tives of peo ple with out panic dis or der (Mannuzza, Chap man, Klein, and Fyer 1994, 1995).Fur ther more, research ers have found that genet ics is at leastpar tially respon si ble for the trans mis sion of panic dis or derfrom gen er a tion to gen er a tion, though envi ron men tal fac tors(like learn ing) also play a role (Kendler et al. 1992, 1993).

In addi tion, there is con sid er able evi dence that cer tainneurotransmitters in the brain play a role in panic dis or der.Neu ro trans mit ters are chem i cals that trans mit infor ma tionfrom one nerve cell to another. The ones that seem to be mostinvolved in panic dis or der are noreprinephrine, sero to nin, andcholecystokinin (for a review, see Antony and Swinson 2000).For exam ple, sub stances that increase lev els of norepinephrinein the brain can trig ger panic attacks. In addi tion, the med i ca -tions that are most effec tive for treat ing panic dis or der (seechap ter 10 for a review) work by affect ing either sero to nin ornorepinephrine activ ity.

Finally, there is evi dence that cer tain areas of the brainare par tic u larly active among peo ple with panic dis or der, espe -cially dur ing panic attacks. One such area is the para hippo -campal region, located on the right side of the brain. Studieslook ing at blood flow in the brain have found increased activ -ity in this area among peo ple expe ri enc ing fear or panic. How -ever, it’s dif fi cult to form any def i nite con clu sions about therole of the brain in panic dis or der because stud ies often findcon flict ing results (see Antony and Swinson 2000).

PSYCHOLOGICAL FACTORSPer haps the most influ en tial psy cho log i cal the ory to

explain the pro cess of panic was devel oped by the Brit ish psy -chol o gist David M. Clark (1986, 1988). Accord ing to Clark,peo ple have unex pected panic attacks because they cat a stroph i -cally mis in ter pret the mean ing of phys i cal sen sa tions that, inreal ity, are per fectly safe. Just as believ ing that dogs are

Understand Your Panic and Fear 15

dan ger ous can lead to panic and fear in the pres ence of dogs,believ ing that phys i cal symp toms such as rac ing heart, diz zi -ness, and breath less ness are dan ger ous can lead to panic andfear when ever these symp toms are expe ri enced. And of course, we all expe ri ence these symp toms from time to time for rea -sons that are not at all dan ger ous. If you are afraid of thesesymp toms, or if you inter pret them as a sign of dan ger, itmakes sense that you would react with panic when they occur.

There is lots of research sup port ing this view of panicdis or der. As reviewed by Antony and Swinson (2000), peo plewith panic dis or der tend to pay atten tion to panic-relatedinfor ma tion, are very aware of panic-related symp toms, andare very fear ful of these symp toms when they occur.Compared to peo ple with out panic dis or der, indi vid u als withpanic dis or der are more likely to inter pret ambig u ous phys i calsymp toms as a sign of imme di ate dan ger, and they tend tobelieve these inter pre ta tions more strongly (Clark et al. 1997;Harvey, Rich ards, Dziadosz, and Swindell 1993). The types ofphys i cal symp toms that peo ple expe ri ence dur ing their panicattacks are closely linked to the types of thoughts that theyhave (Marks et al. 1991). For exam ple, sen sa tions such as rac -ing heart, short ness of breath, and numb ness and tin gling areoften inter preted as a sign of impend ing phys i cal disas ter (likea heart attack) by peo ple with panic dis or der. In con trast, feel -ings of deper son al iza tion are more likely to be inter preted as asign of some sort of psy cho log i cal disas ter (like los ing con trolor going crazy).

Of course, in real ity, these are all per fectly nor mal symp -toms that peo ple expe ri ence when they are fright ened, andoften they are not a sign of any catas tro phe what so ever. Asyou will see in the next sec tion, teach ing peo ple to changetheir anx ious beliefs about panic and the phys i cal sen sa tionsthey expe ri ence is a pow er ful way to pre vent panic attacks inthe future.

16 10 Sim ple So lu tions to Panic

Effective Treatments for Panic DisorderJust as both bio log i cal and psy cho log i cal fac tors con trib ute tothe devel op ment and main te nance of panic dis or der over time, both bio log i cal and psy cho log i cal treat ments have been shownto be effec tive for treat ing this con di tion. The out come ofthese treat ments depends on the indi vid ual. A small per cent age of peo ple get no ben e fit from treat ment, and some get onlypar tial ben e fit. For most peo ple, how ever, treat ment leads tosig nif i cant gains, and up to half of indi vid u als are almost com -pletely free of panic symp toms by the end of treat ment. Inaddi tion, cer tain herbal rem e dies and life style changes (likeget ting reg u lar exer cise) may help. Each of these approaches isdis cussed in detail through this book, so we will pro vide only a brief over view here.

With respect to bio log i cal treat ments, the most com monlyused approaches include anti-anxiety med i ca tions (like alpra -zolam, clonazepam) and cer tain anti de pres sants, includ ing theselec tive sero to nin reuptake inhib i tors (for instance, fluox etine,paroxetine) and tricyclic anti de pres sants (like imipra mine). Notethat although these drugs are called anti de pres sants, they areeffec tive for reduc ing anx i ety and panic attacks regard less ofwhether an indi vid ual expe ri ences depres sion.

The only form of psy cho log i cal treat ment that has con sis -tently been shown in con trolled stud ies to be effec tive fortreat ing panic dis or der is cog ni tive behav ioral ther apy or CBT. Treat ment usu ally lasts ten to fif teen weeks, and includes acom bi na tion of strat e gies from the fol low ing list:

EDUCATION. The infor ma tion about the nature of panicattacks and panic dis or der that makes up this com po nent oftreat ment is sim i lar to the infor ma tion you are learn ing in thischap ter.

Understand Your Panic and Fear 17

COGNITIVE RESTRUCTURING. This strat egy involves teach ingpeo ple to become more aware of their anx ious beliefs and toexam ine the evi dence regard ing those beliefs. The goal of cog -ni tive restruc tur ing is to shift anx ious pat terns of think ing tomore bal anced, real is tic think ing based on a thor ough con sid -er ation of all the evi dence (instead of focus ing only on the evi -dence that sup ports your anx ious thoughts). You’ll learn howto do cog ni tive restruc tur ing in chap ter 4.

EXPOSURE TO FEARED SITUATIONS. One of the most pow er -ful ways to over come fear is by con front ing the feared sit u a -tion head on. Expo sure to feared agoraphobic sit u a tions (likedriv ing, being in crowds, or being alone) is a very effec tive way to over come a fear of being in these sit u a tions. You’ll learnabout sit u a tional expo sure in chap ter 5.

EXPOSURE TO FEARED SENSATIONS. Because peo ple withpanic dis or der are fear ful of expe ri enc ing panic sen sa tions such as diz zi ness and breath less ness, treat ment often includesrepeated expo sure to feared sen sa tions (for exam ple, spin ningin a chair to get dizzy) until they no lon ger arouse fear. Thistype of expo sure is called interoceptive expo sure or symp tomexpo sure, and you’ll learn how to use it in chap ter 6.

BREATHING RETRAINING. As you will learn in chap ter 8,breath ing too quickly for the body’s needs (also called hyper -ven ti la tion) can trig ger symp toms of panic. Learning to slowdown your breath ing using a tech nique called “breath ingretrain ing” may help to pre vent symp toms that are wors enedby hyper ventilating dur ing panic attacks.

You may be won der ing, what works better, CBT, med i ca -tion, or a com bi na tion of these approaches. In most stud iescom par ing these three options, all three work about equallywell in the short term, on aver age. In other words, over thecourse of treat ment (usu ally a few months), the same per cent -age of peo ple tend to respond to CBT, med i ca tion, or com -bined treat ment (for a review, see Antony and Swinson 2000).

18 10 Sim ple So lu tions to Panic

How ever, that does n’t mean that these approaches are equallylikely to work for you or for any other spe cific indi vid ual.Some peo ple who don’t respond to CBT still do well withmed i ca tion (Hoffart et al. 1993), and some peo ple who don’trespond to med i ca tion still ben e fit from CBT (Pol lack et al.1994). Fur ther more, some peo ple seem to respond best to thecom bi na tion of these approaches. Unfor tu nately, there is noproven way to pre dict who is going to respond best to oneapproach ver sus another except trial and error.

Even though med i ca tion, CBT, and com bined treat mentswork equally well in the short term, the more impor tant ques -tion is what works best in the long term. There are at least two large stud ies (Barlow, Gorman, Shear, and Woods 2000;Marks et al. 1993) show ing that in the long term, CBT isprob a bly a better option for most peo ple. The prob lem withmed i ca tion is a higher rate of relapse upon try ing to dis con -tinue the treat ment. A larger per cent age of peo ple who takemed i ca tion relapse dur ing the years fol low ing treat ment than is the case with CBT, for which treat ment gains tend to be main -tained over time. Also, for peo ple who receive both med i ca tion and CBT, one pre dic tor of long-term out come is their beliefsregard ing why they improved. In a study on com bined behav -ior ther apy and med i ca tion, BaÕo�lu et al. (1994) found thatthose who believed it was the med i ca tion that led to theirimprove ment were more likely to worsen dur ing the sixmonths fol low ing the end of treat ment than were those whobelieved it was the behav ior ther apy (and thus their ownefforts) that led to their gains.

Understand Your Panic and Fear 19