Self Help for Panic and Agoraphobia

Self Help for Panic and Agoraphobia

• Do you often experience uncomfortable physical symptoms such as a rapid heart beat, breathlessness, shaking, dizziness and sweating?
• Do you feel unable to go to places that you would like to, because you worry about experiencing these symptoms?
• Do you often feel as though you are about to faint or have a heart attack?
• Do you worry about being unable to cope in public places?
• Do you feel anxious if you are far away from home?
• Do you find it hard to be in crowds?
• Do you make sure you have company with you when you leave the house?
• Do you try to be aware of all the 'exit routes' when indoors?

If the answer to any of these questions is 'yes,' you may be experiencing symptoms of panic and agoraphobia and you may find this workbook helpful.

This workbook aims to help you to:

• Recognise whether you may be experiencing symptoms of panic and agoraphobia.
• Understand what panic and agoraphobia is, what can cause it and what stops us overcoming it.
• Find ways to overcome your panic and agoraphobia.

Do I have symptoms of panic and agoraphobia?

If you are troubled by panic and agoraphobia, it is likely that you will recognise some of the symptoms described below.

Please tick the boxes which regularly apply to you.

Feelings

Anxious / panicky

Frightened / vulnerable

On edge

Fear/dread

Physical Symptoms

Heart / mind races

Chest becomes tight

Sweat

Tremble / shake

Dizzy / light-headed

Breathless

Butterflies in your stomach

Tense body / muscular pain

Thoughts

I'm having a heart attack / panic attack

I'm going to faint / choke

I'm going crazy / mad

I must always be in complete control

People can see how anxious I am

I can't cope outside on my own

Behaviour Patterns

Avoid crowds / public places / open spaces

Avoid places that are hard to escape from

Sit near the isle / exit (e.g. at the cinema)

Drink alcohol to calm you down

Avoid being alone

Sit / lie down when you feel anxious

If you have ticked a number of these boxes you may be experiencing symptoms of panic and agoraphobia. However try not to be alarmed, as this is very common and there are things you can do to help. You may find some useful strategies in this workbook.

What is panic and agoraphobia?

Anxiety is something we all experience at times. Panic is basically the word used to describe high levels of anxiety. When people experience panic, many uncomfortable physical symptoms occur in their body. These can include: a rapid heat rate, sweating, a tight and painful chest, breathlessness and dizziness. As these physical feelings of panic are so intense, they can be very frightening. Because of their severity, people often worry that they are having a heart attack, going mad, or are about to faint.

As soon as people begin having thoughts like these, they become even more anxious and their physical symptoms of panic get worse. As they get worse, people become even more convinced that they are having a heart attack, going mad etc. Before long, a vicious cycle develops which continues in this way until someone experiences a full blown panic attack. A panic attack is basically when these symptoms reach their peak.

As panic attacks are so unpleasant, people naturally go out of their way to steer clear of them wherever possible. Situations that often trigger people's panic symptoms include:

• Crowds
• Public places (e.g. town centres)
• Open spaces (e.g. fields)
• Enclosed spaces (e.g. lifts)
• Places far away from home

As a result, they tend to avoid these situations whenever they can. When people avoid these situations, it is referred to as agoraphobia. Panic and agoraphobia is therefore when people avoid doing the things that they would like to do because they fear experiencing symptoms of panic. This, of course, can result in people's lifestyle becoming very restricted.

Although panic attacks often occur in the situations described above, they can also occur 'out of the blue', for example when at home or in bed. These panic attacks are sometimes even more frightening as people can become confused as to what is happening to them.

What causes panic and agoraphobia?

Evolutionary Reasons:

People may develop panic and agoraphobia because of evolutionary factors. To understand this, it may help to consider that most people with symptoms of panic and agoraphobia avoid very similar situations (e.g. crowds, being far away from home etc). Because of this, it is argued that evolution may have primed us to develop fears around these situations, because of the benefits this would have brought in the past. For example, being in situations where escape is difficult would have posed a threat to people back in primitive times as they could be cornered by predators. Similarly, open spaces would also leave people vulnerable to attack. By having an inbuilt tendency to fear these scenarios, people would be more likely to avoid them and keep safe. In other words, we may be predisposed to become anxious and panicky in certain situations to encourage us to avoid them. Of course by avoiding them, we would protect ourselves from the threat they brought in times gone by.

Thinking Styles:

Some people may have a thinking style that lends itself to experiencing symptoms of panic and agoraphobia. More specifically, people who have a tendency to misinterpret symptoms of anxiety and panic as dangerous are more at risk. For example, thinking that anxiety symptoms are the beginning of a heart attack can cause anxiety to rise further until it reaches the point of a panic attack. Similarly, people who believe that they are going to have future panic attacks are actually more likely to do so. This is because they look out for signs that one is occurring and as a result, notice small symptoms of anxiety which they then misinterpret in the way described above.

Life Events :

People commonly experience their first panic attack during stressful periods in their life. For example experiencing pressure at work, relationship or financial problems, bereavement, or illness, all lead to higher anxiety levels. When people's anxiety levels are heightened, they are more likely to experience panic attacks.

Biological Reasons:

It has also been suggested that panic and agoraphobia may have familial ties. In other words, if someone in your immediate family has experienced panic attacks in the past, there is a slightly higher chance that you will do so as well.

In reality, it is possible that a combination of these factors play a role in the development of panic and agoraphobia. However, in some ways it is less important to know what causes it, and more important to know what stops us moving past it.

What keeps our panic and agoraphobia going?

Unhelpful thoughts:

People's unhelpful thoughts make it more difficult for them to overcome their panic and agoraphobia. For example, because people interpret symptoms of anxiety as dangerous (e.g. a sign of a heart attack or going crazy), they actually make themselves even more anxious. To illustrate, someone may notice a change in their breathing and think this is a sign that they are about to choke and die, as opposed to a normal physical symptom of anxiety. Another example could be believing that their increased heart rate is a sign they are about to have a heart attack. As soon as people think in these catastrophic terms, they make themselves even more anxious and their physical symptoms get stronger. Of course, as their physical symptoms grow stronger, so does their belief that they are going to choke or have a heart attack. This creates a vicious cycle that often leads to a full blown panic attack.

The unhelpful thoughts people have about being unable to cope in certain situations also keeps their panic and agoraphobia going. For instance, they may believe that because they had a panic attack whilst shopping once, they will have another one every time they shop in the future. This of course stops them from ever trying and they don't have the chance to prove otherwise.

Avoidance:

As we have learned, people tend to avoid or escape situations that they believe will trigger a panic attack (e.g. buses, restaurants, the countryside, the cinema etc). Although this is a very understandable way of coping, it is actually one of the main reasons that people find it hard to overcome their difficulties. This is because by avoiding these situations, people prevent themselves from having the opportunity to prove that they can cope in them better than they think. Furthermore, the longer someone has been afraid of a situation and avoided it, the more daunting it becomes and it is increasingly difficult to face. Not only this, but when people avoid one situation, they begin to doubt they will cope in similar situations and start avoiding more and more. Soon their fear generalises to the point that their lifestyle is extremely restricted.

Using Safety Behaviours:

Often, the only time that someone with symptoms of panic and agoraphobia feels capable of facing their feared situations, is when they use what is known as a 'safety behaviour.' An example of a safety behaviour would be: only going into town if you are with someone you trust (to come to your rescue if you panic), gripping tightly onto a shopping trolley (to reduce the chances of fainting), or lying or sitting down when you feel anxious (to avoid fainting). Basically, a safety behaviour is anything people do to try and make it easier for them to cope with their fears.

Although such safety behaviours help people cope with symptoms of panic and agoraphobia in the short term, they are actually unhelpful in the longer term. This is because, like avoidance, safety behaviours stop people from having the opportunity to prove to themselves that they can cope with their fears, without putting such precautions into place. Instead they may put their successes down to other factors (e.g. "I only coped because I had my friend with me" or "I would've fainted if it wasn't for my trolley") and their fears remain in place. Before long people become reliant on their safety behaviours and avoid going places when they are unable to use them.

Increased Self Focus :

Another factor that helps keep people's panic and agoraphobia going is their tendency to be hypervigilant. This means that they study their body for any sign of physical changes that may suggest a panic attack is on its way. Although they do this, hoping to be reassured that everything feels normal, this strategy actually makes things worse. This is because they tend to notice small physical changes that would have otherwise gone unnoticed (e.g. feeling hot). Once a small change has been noticed, people naturally 'keep their eye' on it. However, the more they focus on a change, the more anxious they become and a vicious cycle begins that can lead to a panic attack. Alternatively, if people notice a change due to hypervigilance, they tend to escape the situation that has triggered it. However, as we know, this strategy is unhelpful too.

It is likely that a combination of all these factors play a role in keeping our panic and agoraphobia going. See overleaf for an illustration of how these factors can interact and make it difficult for us to overcome our panic and agoraphobia.

How can I overcome my panic and agoraphobia?

Fortunately, there are a number of strategies that we can use to overcome our panic and agoraphobia. These include:

1. Understanding more about anxiety and panic.
2. Learning breathing strategies that help to keep panic at bay.
3. Learning how to challenge your unhelpful thoughts and see things in a more realistic light.
4. Removing the use of avoidance and safety behaviours and gradually confronting your fears.

When going through this booklet it can sometimes be more helpful to try out the ideas above one at a time, rather and trying to learn them all at once. However simply take things at your own pace.

Understanding anxiety and panic

Panic is simply a more extreme form of anxiety. We also know that due to the unpleasant and severe nature of panic, people often become frightened about the physical symptoms they experience. For example, they worry that their symptoms are early signs of a heart attack, chocking, fainting or going mad. As soon as people think in these catastrophic terms, they make themselves even more anxious and their physical symptoms get stronger. Of course, as their physical symptoms grow stronger, so does their belief that they are going to have a heart attack or choke etc. Soon a vicious cycle develops that often leads to a full blown panic attack.

From this information, it is clear to see that not fully recognising and understanding the physical symptoms of anxiety and panic is a major part of the problem. Therefore an important goal is to become more knowledgeable about anxiety and panic. By learning more about how anxiety and panic affects us, and why we experience it in the first place, we can begin to see that it is not harmful. This can help us to be less fearful of the uncomfortable symptoms we experience, meaning we won't misinterpret them as catastrophic. This prevents the vicious cycle of panic occurring and keeps our symptoms at a more manageable level.

When considering this, it is therefore important to remember that anxiety is a natural feeling that everyone experiences. Of course, some people experience anxiety more often than others. It is also true that the intensity of anxiety people experience varies at times (i.e. it can range from mild anxiety to a full blown panic attack). However, anxiety is not harmful; in-fact it is quite the opposite. As we will see next, we actually experience anxiety because of the benefits it has brought over the years.

If after reading this section you are still concerned that some your symptoms are not caused by anxiety, you should contact your GP to have this clarified before continuing with this guide.

Why do we experience anxiety?

The symptoms we experience when anxious are often referred to as the 'fight or flight' response. This comes from the idea that people primarily experience anxiety to help them either fight or run away from danger. For example, if someone was attacking you, two options open to you would be to either - fight them off (fight) or try to run away (flight). Our fight or flight response would kick in to help us at this point. For example:

• Our hearts would begin beating more quickly (supplying blood to our muscles).
• We would sweat (to cool us down).
• Our muscles would become tense (ready for action).
• We would take deeper breaths (to supply oxygen to our muscles).

In essence, all of these responses would aid our escape or improve our ability to stay and fight the attacker. When considered in this way, we can see how the symptoms of anxiety are helpful to us. Indeed, all of the physical symptoms we experience when anxious play a helpful role in protecting us in such circumstances.

The fight or flight response was likely even more vital to human survival back in the days of early man, when people had to hunt for their food and were under a greater threat from predators. Nowadays we do not face the same threats, but unfortunately, our bodies and minds have not caught up with these changes. As a result, we now experience anxiety in situations where it is not necessarily as helpful because we cannot fight or run away from them (e.g. financial problems, stress at work, busy places, open spaces, etc). However, the one thing that has stayed true is the fact that these symptoms are not dangerous; they are in many ways the right response but at the wrong time.

When thinking about anxiety in this way, we can begin to see that we should not fear it; instead we should see it as our body's healthy protection system. Remembering this can help you to be less fearful of the symptoms of anxiety. Instead of seeing the symptoms as dangerous (e.g. the early symptoms of a heart attack) you should think of them as a safe and natural response. By understanding this, you can stop the catastrophic misinterpretations that lead to panic attacks.

How does anxiety affect the body?

Anxiety can be particularly difficult to recognise because it affects our body in so many different ways. Over and above this, anxiety can affect everyone slightly differently. For example, some people regularly get headaches when anxious, whilst others may be more prone to becoming breathless or light headed. Below is a list of some of the different ways anxiety can affect us. Being more aware of these can help us to recognise that many of the physical changes we notice in our bodies are in fact anxiety symptoms. This can help stop us from misinterpreting bodily changes as something more serious.

Coping statements

When we are anxious or panicky, it is easy to forget what you have just learned (e.g. that it is not dangerous and cannot harm us). It can therefore be helpful to have 'coping statements' that you can refer to. These are basically statements that you can use to remind yourself about the facts of anxiety and panic, whenever you begin experiencing them. Reminding yourself about these facts can help to prevent cycles of panic occurring. These coping statements may particularly helpful when it comes to section 4 'Removing the use of avoidance and safety behaviours'.

Statements

• Anxiety is normal
• Panic is simply high levels of anxiety
• Everyone experiences anxiety and panic at times
• Anxiety and panic are not dangerous
• Anxiety is designed to protect us and is not harmful
• By remembering these symptoms are nothing more than anxiety, I can prevent a cycle of panic occurring
• I can tolerate the symptoms of anxiety and panic without them getting out of control
• Slowing my breathing down can help me to control my anxiety and panic
• My anxiety and panic will pass naturally given time it doesn't last forever
• I can continue without using escape, avoidance or safety behaviours
• I don't always have to feel in complete control
• I've never fainted, choked, gone mad, or had a heart attack before
• People can't tell how anxious I feel

Feel free to add in any other statements that may help you cope into the space provided below.

Learning how to control your breathing

People who experience panic attacks often have a tendency to 'over breath' when they are anxious. This basically means that they take deeper breaths than normal (which they are sometimes unaware of). This usually has the affect of making them feel short of breath and as though they are going to choke. As a result of these sensations, they take deeper breaths to try and correct this which actually just makes the sensations worse (this pattern is often referred to as hyperventilation). Before long a cycle of panic can develop.

Taking deeper breaths than usual also results in people ending up with the wrong amount of carbon dioxide in their bodies. This normally results in them feeling dizzy and disorientated. It can also cause chest pains to emerge. These sensations typically leave people feeling as though they are about to faint or have a heart attack which can also cause a cycle of panic to begin.

By learning 'controlled breathing' exercises, you can learn how to slow your breathing down to a better rate. This helps to fend off the uncomfortable physical feelings such as dizziness, light-headedness, chest pains, and shortness of breath. By doing so you can stop the cycle of panic and the feelings soon pass.

The following steps will take you through a 'controlled breathing' exercise. You can use this strategy whenever you feel anxious or panicky. In particular, you should use this strategy if you ever feel faint, light-headed or short of breath, as it should help these sensations to pass.

Step 1

Try to get into a slower and stable breathing rhythm. A good rhythm is to breathe in for three seconds, hold this breathe for two seconds, and then breathe out for three seconds. Make sure you don't take too big 'gulps' of air whilst doing so.

Step 2

It can be helpful to count to yourself as you do this (e.g. in two three hold for two out two three hold for two).

Step 3

As you breathe, try to make sure that your stomach expands as you take each breathe. This helps you to stop breathing from the chest which tends to result in short and shallow breaths that can add to the problem.

Step 4

Repeat this action for a few minutes. You should soon begin to feel the uncomfortable sensations pass.

'Controlled breathing' exercises can also be used as a more general relaxation strategy anytime you like. Many people find slowing their breathing down in this way to be very relaxing.

To master this technique, it would actually be helpful to practice it at times when you are not in an anxious or panicky state. This will help you master the technique for times when your symptoms are more troublesome.

Challenging unhelpful thoughts

The way that we think about things has an impact on our panic and agoraphobia. Many of these thoughts occur outside of our control, and can be negative or unhelpful. It is therefore important to remember that they are just thoughts, without any real basis, and are not necessarily facts. Even though we may believe a lot of our unhelpful thoughts when we are anxious or panicky, it is good to remember that they should be questioned as they are often based on wrong assumptions.

The following section will help you begin to recognise if you are thinking about things in an unhelpful or unrealistic way, and discuss how you can start to make changes to this. By doing so, you can learn to see things in a more realistic light which can help to reduce your panic and agoraphobia. You might have unhelpful thoughts about all kinds of things. Here are some examples:

Interpreting physical changes in the body as dangerous:

• These feelings are dangerous
• This will lead to a heart attack
• I'm going to faint / choke
• I'm going crazy

Underestimating your ability to cope in certain situations:

• It'll be too busy
• I won't be able to escape
• I'll have a panic attack
• I'll embarrass myself

Believing you must always be in complete control

• I should never be anxious
• Feeling anxious means I'm weak
• I should always feel 100% in control

It is clear to see how this kind of thinking might feed into people's panic and agoraphobia. Do you ever think in any of the ways outlined above? Fill in your examples below:

You might find it difficult to identify an unhelpful thought. Try thinking about a time when you felt panicky. Consider what was running through your mind at that time.

Patterns of unhelpful thinking

First you need to be able to recognise an unhelpful thought. Then you can challenge it. Being aware of the common patterns that unhelpful thoughts follow can help you to recognise when you have them. Here are some of the common patterns that our unhelpful thoughts follow:

Predicting the Future:

When we feel panicky it is common for us to spend a lot of time thinking about the future and predicting what could go wrong, rather than just letting things be. In the end most of our predictions don't happen and we have wasted time and energy being worried and upset about them. For example:

• Worrying that the supermarket will be very busy.
• Worrying you will choke and suffocate if you go into a lift.

Catastrophising:

People commonly 'catastrophise' when they feel panicky, which basically means that they often blow things out of proportion. For example:

• I'll get anxious, completely lose it and totally embarrass myself - when in all likelihood you have experienced anxiety in the past and coped well.
• The bus will get so busy that my exit will be blocked and I won't be able to get off.

Should Statements:

People often imagine how they would like things to be or how they 'should be' rather than accepting how things really are. For example:

• I should always be 100% comfortable in crowds.
• I should be able to travel on trains.

This critical style of thinking simply creates extra pressure and stress.

Over Generalising:

Based on one isolated incident you assume that all others will follow a similar pattern in the future. Basically, you find it hard to see a negative event as a one off which can leave you feeling hopeless. For example:

• Because you had a panic attack one time whilst shopping, you believe that you will panic in every shop you go into in the future.

What If Statements:

Have you ever wondered "what if" something bad happens? For example:

• What if I have a panic attack at the party?
• What if I faint on the train?

These thoughts result in us restricting our activities.

Black and White Thinking:

Often when feeling panicky, people see things as either black or white, there is no in between. For example:

• They believe any sign of anxiety is weak.
• They believe they never cope well when they go out.

This sets up expectations that can hold us back.

Ignoring the Positives:

Often people can ignore the positive aspects of life or situations, and instead focus on the negative elements. For example:

• They remember feeling panicky in the supermarket, but forget that they always cope well in the busy town centre.

These thoughts keep our confidence levels low and we attempt to do less.

Labelling:

Do you find that you attach negative 'labels' to yourself? For example:

• I'm weak.
• I'm always panicking.
• I'm incapable.

Labels like these tend to follow us around and hold us back.

Do any of your unhelpful thoughts follow some of these patterns? Jot down any examples you can think of into the box below:

We can learn techniques to challenge these unhelpful thoughts. This can help to reduce your panic and agoraphobia. The next part of this handout will discuss how we can go about challenging our unhelpful thoughts. You may come up with a more balanced thought that is accurate and based on evidence.

How to challenge unhelpful thoughts

Once you have recognised an unhelpful thought the next stage is to challenge it. To do this, you can ask yourself a serious of questions. See the example below:

Situation: You are due to meet your friend for tea in a restaurant.

How you feel: Panicky, afraid.

Unhelpful thought: I know I'll have a panic attack if I go into the restaurant!

Challenges to an unhelpful thought

Now you can challenge your unhelpful thoughts by asking these questions.

Is there any evidence that contradicts this thought?

• I was in a coffee shop a few weeks back and I didn't have a panic attack.
• I've been in this restaurant in the past and coped fine.

Can you identify any of the patterns of unhelpful thinking described earlier?

• I'm predicting the future, as I can't say for sure what will happen.
• I'm discounting positives as I've coped in similar situations in the past.

What would you say to a friend who had this thought in a similar situation?

• I'd say you've coped before so there is no reason you can't cope again.

What are the costs and benefits of thinking in this way?

• Costs:
• Its making me anxious before I even go in.
• Its making me want to avoid it and let down my friend.
• It makes it hard to focus on anything other than how I am feeling.
• Benefits: I can't think of any.

Is there a proactive solution to this unhelpful thought?

• I could read my coping statements before I go in.
• I could use breathing exercises to help me calm down.

Once you have asked yourself these questions, you should read through your answers. Try to come up with a more balanced or rational view. For example:

Although I may get anxious, it doesn't mean I'll have a panic attack. I've been in similar situations before and I've coped ok.

Try to apply these questions to the unhelpful thoughts that you notice. It can help to reduce your panic and agoraphobia. You can use this technique to test your thoughts are realistic and balanced.

Removing the use of avoidance and safety behaviours

One of the main reasons that people find it difficult to overcome their panic and agoraphobia is because they avoid situations that they worry about panicking in. Furthermore, whenever they do confront these situations, they tend to use safety behaviours. Safety behaviours are any actions that people use to try and minimise the anxiety they experience in such situations (e.g. only travelling on buses that are very quiet; going shopping late at night when it is quiet; sitting down if they feel light-headed; only going to public places if they have a friend with them).

Although it is easy to see why people use avoidance and safety behaviours to cope with their panic and agoraphobia, in the longer term these strategies only make things worse. This is because, the longer we avoid a situation we fear, the more frightening it becomes. Perhaps even more importantly, avoidance and 'safety behaviours' prevent us from having the opportunity to prove that we can cope in these situations and that they are not as frightening as previously thought. Because of this, one of the best ways to overcome panic and agoraphobia is to gradually confront these situations without using safety behaviours.

Of course confronting these situations can be daunting, especially given that your anxiety levels rise when you do so. You may also have experienced a panic attack in similar situations in the past. However, your new knowledge of anxiety and panic should help you to keep your anxiety at a manageable level. Remember, if you don't misinterpret these symptoms as catastrophic (e.g. the early signs of a heart attack, losing control etc) you can fend off panic attacks.

If you can do this, research shows that when we are anxious (e.g. on a bus; in a supermarket etc), our anxiety eventually peaks and drops if we remain in that situation for long enough. It is almost as though our bodies and minds become 'used to' the situation and our anxiety begins to fall. This may take around 30 minutes, but often happens more quickly. More importantly, if we subsequently confront the same situation again, the amount of anxiety we experience will be less and less on each occasion. Not only this, but it will pass more quickly each time too, until the point that the situation causes us little or no anxiety.

For instance, do you remember ever being nervous before starting a new job or college course? In these situations, it is normal to feel very anxious before you arrive. However once you arrive, often you gradually begin to feel more comfortable and relaxed as the day progresses. Not only this, as each day passes in your new surroundings, you usually begin to feel less and less nervous.

The same is true when you confront a situation that makes you anxious. Although your anxiety may be high beforehand and initially rise when you confront it, this will soon begin to drop if you remain in the situation for long enough. Following this, each time you confront the same situation, the levels of anxiety you experience will get less and less, just as it would as each day passed in a new job. Soon you should be able to confront such situations and feel minimal (if any) fear at all.

Remember our new knowledge about anxiety and panic should help us to stay in the situations we fear for long enough to allow this to happen. This is because it can help us to prevent cycles of panic occurring like they did in the past.

Having said this, confronting these situations can still be a daunting thought. The 5 steps described next can make this more manageable.

Step 1: Generating ideas for your exposure hierarchy

As confronting the situations that make you feel panicky can be a daunting thought, it can be helpful to do so in a gradual way. Creating an exposure hierarchy can help you to do this. An exposure hierarchy is basically a list of all the situations surrounding your panic and agoraphobia that cause you varying degrees of anxiety (see the example below). The idea is that you confront the easiest (or least anxiety provoking) item on your hierarchy to begin with and work your way through to more difficult items as your confidence grows.

Use box 1 on page 25 to list items for your hierarchy. Don't worry about ranking the order of your items at this stage. To help you get ideas for your hierarchy, it may help to consider all the situations that:

• Make you anxious
• You avoid
• You fear panicking in
• You only confront if you are using a 'safety behaviour' (e.g. gripping tightly onto a trolley in the supermarket to stop you fainting)
• You escape from (e.g. dash round the supermarket as quickly as possible)

Note: It is important to try and ensure that the items on your list cause you varying degrees of anxiety (e.g. is going to some shops more frightening than going to others). This will allow you to work on overcoming your fear towards 'easier' items on your hierarchy to begin with.

Step 2: Ranking the items on your hierarchy

Once you have a list of items for your hierarchy, the next stage involves trying to rank them in order of least anxiety provoking to most anxiety provoking. To help, try to predict how anxious you believe each item would make you feel on a scale from 0 to 100, where 100 is the most anxious you have ever felt and 0 is the most relaxed you have ever felt (use box 2 on page 25). Once you have completed this, simply rearrange the items on your list from least anxiety provoking to most anxiety provoking (use box 3 on page 25). For example:

Step 3: Confronting the first item on your hierarchy

Once you have finalised your hierarchy, the next step is to confront the first item on it as soon as possible (this is often referred to as an exposure task). This should be the item that you predict will cause you the least amount of anxiety from your list. During exposure tasks it is important to:

• Remember that although your anxiety will initially rise during an exposure task, it will fall if you remain in the situation for long enough.
• Stay in the situation until your anxiety reduces by at least half. For example, if your anxiety rises to 50 during an exposure task, you should remain in the situation until it reduces to 25 or (preferably) less. The amount of time this takes will probably vary from task to task. It may take anything up to 30 - 45 minutes, but commonly happens more quickly.
• Remember panic is simply strong symptoms of anxiety.
• Remind yourself that anxiety is a natural and healthy reaction that everyone experiences. Although it can feel unpleasant, it is not dangerous and will gradually pass if you remain in the situation (you can use your coping statements to remind you about the other facts of anxiety and panic).
• Try not to 'look out' or be hypervigilant for any physical symptoms that you may experience.
• Remember to use your breathing exercises if you begin to feel faint or dizzy.
• Avoid using any safety behaviours as they simply slow down your progress (e.g. don't grip trolleys to stop you fainting, don't sit near the exit on buses etc). If it is too hard to remove them all at once, try to gradually reduce them over time.

It may also be helpful to try and challenge any unhelpful thoughts you have about confronting these situations before you do so (see section 3).

Step 4: Repeating the exposure exercise

Once you have completed your exposure task once, the next step is to do so again, over and over, as often as possible, until you have overcome your anxiety towards that item. You should find that each time you confront the item on your hierarchy, it will become slightly easier. As a rule of thumb, try to ensure that you engage in your exposure task everyday if you can. Remember that the more often you expose yourself to an item on your hierarchy, the quicker you will overcome your fear towards it.

Step 5: Moving onto the next item on your hierarchy

Once you have overcome your fear towards the first item on your hierarchy, you should follow the same steps with the next item on your hierarchy. Continue through your hierarchy in this manner until you have reached the top and you are less troubled by panic and agoraphobia.

Remember that as you progress through each stage of your hierarchy your confidence will grow. This should mean that items which are higher on your hierarchy - that seemed very daunting at first - will be less frightening when you actually come to face them because of your previous achievements.

Trouble shooting:

• If you attempt an exposure task and it does not go as well as you had hoped - try not to worry as this can happen from time to time. Try again as soon as you can.
• If the exposure task still seems too hard, see if you build in an extra step or two before it on your hierarchy. This will allow your confidence to grow further before facing it. For example:

• If you find that your anxiety is not reducing during an exposure task - ask yourself:
• Are you using a 'safety behaviour' which is preventing you from fully confronting your fear?

Final Word

We hope that you found some of the ideas in this booklet useful. You can continue to use the techniques you found helpful long into the future and they should continue to benefit you. If some of the ideas are not particularly helpful at first, it is perhaps worth sticking with them for a few weeks to give them a chance to work. If however you feel your situation remains largely unchanged or if you did not find this booklet useful, you should speak to your GP who can tell you about the other options available which you could find helpful.

Further Information and Resources

For further information and self-help resources go to Moodjuice online:

http://www.moodjuice.scot.nhs.uk

Moodjuice is a website designed to offer information and advice to those experiencing troublesome thoughts, feelings and behaviours. In the site you can explore various aspects of your life that may be causing you distress and obtain information that will allow you to help yourself. This includes details of organisations, services and other resources that can offer support. This self help guide comes from a series that you can access and print from Moodjuice. Other titles available include:

• Depression
• Anxiety
• Stress
• Panic
• Sleep Problems
• Bereavement
• Anger Problems
• Social Anxiety
• Phobias
• Traumatic Stress
• Obsessions and Compulsions
• Chronic Pain

Some Useful Organisations

The following organisations or services may be able to offer support, information and advice.

Samaritans

Samaritans provides confidential emotional support, 24 hours a day for people who are experiencing feelings of distress or despair, including those which may lead to suicide. You don't have to be suicidal to call us. We are here for you if you're worried about something, feel upset or confused, or you just want to talk to someone.

Phone:

116123

Web Site:

http://www.samaritans.org

Anxiety UK

National charity established in 1970 to provide support and services to those suffering from all anxiety disorders, obsessive compulsive disorder, generalised anxiety disorder, panic attacks, social phobia, simple phobia, phobia and tranquiliser issues.

Phone:

08444 775 774

Web Site:

http://www.anxietyuk.org.uk/

Breathing Space

Breathing Space is a free, confidential phone line you can call when you're feeling down. You might be worried about something - money, work, relationships, exams - or maybe you're just feeling fed up and can't put your finger on why.

Phone:

0800 83 85 87

Web Site:

http://www.breathingspacescotland.co.uk

Living Life to the Full

Living Life to the Full is an online life skills course made up of several different modules designed to help develop key skills and tackle some of the problems we all face from time to time.

Web Site:

http://www.llttf.com/

Further Reading

The following books may be able to offer support, information and advice.

Coping Successfully with Panic Attacks

Panic attacks happen when the bodys emergency button is being pressed continuously. Breathlessness, chest pains, sweating, shaking, dizziness and fainting are all among the symptoms, and the experience can be terrifying. Fluctuating blood-sugar levels, anxiety and exhausted nerves affecting muscle tension and breathing can all cause panic attacks. This book explains how to stop pressing the panic button. Shirley Trickett shows how to understand your inner self, and overcome panic attacks with a balanced approach to meet your physical and emotional needs.

Author: S Trickett

Published: 2009

Panic Attacks: What They are, Why They Happen and What You Can Do About Them

This book explains what panic attacks are, the theories behind what causes them and what to do when you have one. This book is consistently straightforward, informative and reassuring.

Author: Christine Ingham

Published: 2000

Panic Disorder: The Facts

Panic disorder is a remarkably common psychological condition, characterized by sudden attacks of intense fear and panic. Approximately 3% of the population will experience some aspects of panic disorder during their lifetime. Incredibly distressing, it can have an adverse effect on most aspects of the person

Author: S Rachman & P De Silva

Published:

2009

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