Overcoming Panic

1. What is Panic Disorder?
   • Some anxiety is necessary for normal functioning but severe anxiety can be disabling.
   • Panic attacks are sudden episodes of acute anxiety. Along with physical symptoms (e.g. difficulty breathing) there are distressing thoughts (e.g. I’m going to faint).
   • Panic attacks can leave you feeling exhausted and confused. Some people seek medical help while others suffer in silence.
   • Panic disorder is when people suffer from repeated panic attacks or have had one or two severe attacks and fear another attack. In both cases the problem disrupts their life.
   • People with panic disorder often develop agoraphobia. They tend to avoid circumstances where in the event of a panic attack, escape is difficult – or they put up with the situation only with a lot of worry.
   • Some people may develop agoraphobia because they come to associate particular situations with panic.
   • Physical and/or psychological vulnerability together with stress can set off panic attacks.
   • Sufferers of panic attacks tend to lead constrained lifestyles and may become depressed. A sense of shame may exacerbate this and desperation may lead to overeating and alcohol and drug abuse to try to forget the problems.
   • One of the common symptoms of panic disorder is worrying excessively that there is a physical illness.

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2. The Causes and Treatment of Panic Disorder
• Panic disorder can run in families due to genetic inheritance and/or the experiences of family life. Distressful early life experiences can lead to vulnerability to panic disorder as well as many other emotional problems.
• Factors in later life include:
  1. Psychological factors – sufferers of panic attacks tend to have a negative thinking style.
  2. Social factors – People from all walks of life develop panic disorder but women are more vulnerable than men.
  3. Physical factors – In panic disorder the ‘fight or flight’ response to threat is set into action without an appropriate reason. Some people may have a lower ‘trigger’ threshold or their control mechanism to stop the fight or flight response may be less efficient.
• You should check with your doctor that a physical illness is not the cause of your panic disorder. A person may suffer from both a physical illness and panic disorder and need treatment for both but usually there is no physical illness causing the panic disorder.
• Hyperventilation is a trigger for panic symptoms as is misuse of alcohol, drugs and medications.
• Factors which may cause a vicious cycle to be set up that maintains panic disorder are:
  1. Psychological factors – life stresses and poor coping ability, fear of illness and further panic attacks, negative thinking.
  2. Social factors – pressures at work or at home, chronic stress, reducing leisure time for work, becoming socially isolated.
  3. Physical factors – hyperventilation, insufficient sleep, overexertion, poor general health, misuse of alcohol, drugs or other stimulants.
• Medications for the treatment of panic disorder are usually the minor tranquilizers (benzodiazepines) and the tricyclics under the direct supervision of a medical practitioner. The newer medications include selective serotonin reuptake inhibitors (SSRIs) and the reversible MAOIs or mono-amine oxidase inhibitors. Other medications include beta-blockers and Buspirone. In the short-term medications may be useful but in the long-term there may be side effects, dependence and they do not enable you to learn to control your problem.
• Various psychological treatments may be used to treat panic disorder in particular cognitive behaviour therapy. A combined treatment may be required in cases of severe anxiety where medication is needed to reduce the levels of anxiety so that psychological treatment can be applied.
• Over 80% of people find cognitive behavioural approaches produce noticeable and lasting improvement.

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3. Identifying When You Are Anxious
   • It is important that you learn to differentiate between the symptoms of anxiety and those caused by physical illness.
   • When a diagnosis is made several symptoms that occur in a regular pattern are identified bearing in mind that these symptoms vary slightly for each individual.
   • Write down your general pattern of symptoms when you are depressed. Make a list of your major symptoms of panic and in future remember these are symptoms of anxiety and not physical illness.
   • Monitor your panic attacks to identify panic triggers. For a few weeks note in a diary the date, situation and the trigger. Rate your anxiety symptoms 0-10 (0 is the least possible symptoms and 10 is the worst possible symptoms). Rate your coping ability 0-10 (0 is worst level of coping and 10 is best level of coping). Also note how you would have preferred to cope with each situation.
   • Find out what circumstances cause anxiety for most people by discussing this with others.
   • Some triggers of anxiety that may exacerbate your symptoms in particular situations are:
     1. Inability to escape from a specific situation;
     2. Embarrassment that others are aware of your distress;
     3. Lack of possible help such as the company of a trusted friend;
     4. Catastrophic thoughts such as ‘I’m going insane’;
     5. Fear of losing control over your behaviour.
   • If you can think of other triggers, list them on a separate sheet of paper.
   • Make a list of situations in which you experience anxiety and identify the triggers that make your symptoms worse for each situation.
   • list situations you have been avoiding or activities you are unwilling to participate in and rate them 0-10 (0 is no anxiety and 10 is severe anxiety).

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4. Altering Your Lifestyle (1)
   • A stressful and unhealthy lifestyle can increase your susceptibility to panic attacks. The panic attacks make the initial problems more difficult to solve and a vicious cycle is set up.
   • You need to increase your resilience to daily stress.
   • There are two types of stress:
     1. Mental stress – symptoms include worry, fears and low self-esteem;
     2. Physical stress – symptoms include tiredness, headaches and stomach upsets.
   • Be aware that the mind and body are linked, so that you can improve your physical health to increase your resistance to stress.
   • Regular exercise can build your resilience to stress. It is a good way of reducing your tension, meeting people and can help you sleep better.
   • If you are just starting to exercise choose something you enjoy and do not overexert yourself – begin with gentle regular exercise and progress to more vigorous exercise when you feel ready. Try to have a routine and stick to it tolerating disruptions. Reward yourself for exercising.
   • Agoraphobia may restrict you to exercising at home till you are confident enough to go out or you might ask a friend to accompany you.
   • Make sure your diet is adequate and you have regular meals. Reduce your caffeine, nicotine and alcohol intake and avoid drugs unless prescribed by a doctor.
   • Eat enough fruit and vegetables and drink plenty of water. If you want to lose weight do this gradually.

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5. Altering Your Lifestyle (2)
   • Sleep Management
   • The length of sleep necessary varies from person to person.
   • Worrying will prevent you from sleeping.
   • You need less sleep as you get older.
   • Sleep is affected by mood, stress, food, alcohol, exercise and medicines.
   • In the long-term, sleeping tablets are not helpful and can be addictive.
   • You can manage your sleep problems by changing your behaviour rather than resorting to medication.
   • Keep a sleep diary for several nights to ascertain if you have a problem. Note the date and anything that might affect your ability to sleep e.g. your activity before retiring. If you have waking episodes, note your activity to restore sleep. Was it helpful? Next day note the number of hours of sleep you managed to get and rate how alert you feel 1-10 (1 is dull and sleepy and 10 is very alert). Rate your performance that day 1-10 (1 is poor performance and 10 is performed well). If you do have a problem the following suggestions might be helpful:
     1. Analyze your sleep diary to see if poor sleep is due to stress and is likely to get better as this eases; are there behaviours which result in poor sleep that you could change?; identify helpful and unhelpful ways of coping and avoid the latter.
     2. Introduce pleasant smells into your sleeping environment to help you relax e.g. potpourri or lavender oil.
     3. Try to relax an hour or two before you go to bed. Keep your daily stress low and seek counselling or the support of friends if you feel the need. Exercise during the day. Avoid caffeine, nicotine and alcohol and try a warm milk drink before bed. Make sure you are not hungry before retiring as this will keep you awake. · Ensure you have a quiet bedroom and a comfortable bed and have emptied your bladder before trying to sleep. Use your bed only for sleeping and set an alarm so you wake regularly each day. Avoid naps during the day.
     4. If you sleepwalk you are advised to discuss this with your doctor as it can be dangerous.
   • To cope with disturbing dreams you could try:
     1. Constructing a positive ending to your disturbing dream and mentally practicing this alternative ending several times before sleeping;
     2. Practicing beforehand what you might say if the dream occurs;
     3. Keep water and a towel by your bedside to wash your face with if you wake up sweating - this will help you re-orientate;
     4. Keep a notepad and pencil within reach so you can record your dreams but beware of reading too much into their interpretation.
   • Relaxed Breathing Method
   • You could try the following method of relaxed breathing to ease tension and promote sleep:
     1. Ensure you have some time to yourself and push your worries to one side;
     2. Sit or lie comfortably and close your eyes with your arms by your side;
     3. Concentrate on breathing naturally;
     4. Place your hands on your stomach and breathe in deeply and hold for a few seconds feeling your stomach rise. Breathe out and feel your stomach contract. Repeat and as you breathe out think of a relaxing image or sound. Continue doing this until you feel thoroughly relaxed;
     5. Count back from 10 then open your eyes and feel how relaxed you are now. Slowly get up and resume normal activities.

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6. Altering Your Lifestyle (3)
• Stress Awareness Training
• You need to monitor your stress and become familiar with what sets it off and the feelings, thinking and actions associated with the anxiety. You can do this by keeping a diary. When you feel anxious note the date and time. What was the event? Rate your distress 1-10 (1 is no distress and 10 is extreme panic). What caused your anxiety? What was your response to cope with the problem? Re-rate your distress.
• After two weeks of monitoring your stress levels you should become aware of what triggers your distress, your bodily feelings and thoughts when distressed, how your distress levels vary with different situations, what you tend to do when distressed and what is the best way for you to cope with your distress.
• Make two lists – one of short-term only coping strategies and the other of long-term coping strategies. You can refer to these when you feel stressed. Try to incorporate more of the long-term strategies into your set of coping techniques and attempt to gradually abandon your short-term methods.
• Avoid turning to stimulants such as alcohol, caffeine and nicotine as coping methods. These have unpleasant effects in the long-term.
• Study your diary to determine what drives your cycles of distress. Is it bodily, psychological, behavioural or social?
• Controlling Your Breathing
• Hyperventilation – faster breathing occurs in response to exertion and stress. In the long-term this can be uncomfortable and cause unpleasant physical symptoms which trigger more anxiety and more hyperventilation. Another cycle of stress is set up and can result in a panic attack.
• You can rectify hyperventilation by learning to control your breathing.
• First practice lying down and later sitting or standing. Place one hand on your stomach and the other on your chest. Breathe in slowly through your nose until your lungs are full then exhale slowly through your nose. Breathing in and out counts as one breath – aim to take 8-12 breaths a minute.
• In order to be effective you need to practice this exercise repeatedly.
• Relaxation
• Make a list of relaxation activities you enjoy. How often do you do them? Ensure you have enough relaxation and recreation in your daily schedule.
• You need to develop relaxation into a skill you can use when you feel muscular tension due to stress.
• Try to develop a routine and practice your relaxation exercises. Start by lying down and later you can try sitting or standing. Control your breathing.
• Record your experiences noting the date and time. Rate your distress before the relaxation exercise, 1-10 (1 is tense and 10 is very relaxed). Which exercise did you use? Rate your distress afterwards. Make notes of the sort of day it was, your preoccupations etc.
• Below are three exercises – only move to the next one when you are fully relaxed after a routine.
  1. Progressive Muscular Relaxation (PMR) – Breathe slowly and regularly as you focus on different parts of the body: feet – tense your feet then relax and repeat; legs – straighten your legs then relax and repeat; abdomen – tense your abdomen then relax and repeat; back – arc your back then relax and repeat; shoulders/neck – bring your shoulders up and in and press your head back. Relax and repeat; arms – stretch out your arms and hands. Relax and repeat; face – tense your face and bite hard then relax and repeat; whole body – tense your whole body then relax and repeat.
     
     After the routine if you still feel tense then repeat it then when you are relaxed think of something calming to relax your mind. Get up slowly and gently.
     
     You should practice PMR twice a day until you feel relaxed after the exercise.
  2. Shortened PMR – You can miss out the tensing and go straight to relaxing the different muscles. When you have achieved this you can progress to using the routine at other times and places.
  3. Simple Relaxation Routine – Identify a word, object or scene you find calming. Sit comfortably and close your eyes. Be aware of your breathing as you inhale through your nose. As you exhale, think about your calming mental image. Continue this until you feel relaxed. You should practice this exercise frequently.
• When you have learned to relax using the three exercises you can start to use the skills throughout the day. Use something to remind you regularly to relax. Apply your relaxation skills whenever you need to use them in response to physical tension.

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7. Altering Your Lifestyle (4)
   • Managing Your Time
   • Good time management requires being aware of:
     1. Your needs and strengths – list these opposite each other.
     2. Your standard procedure – find out how you use your time at present by keeping a record of how you spend your time. From the record you will be able to work out the best way of working. Try to get a balance of work tasks and include breaks.
     3. Your priorities – identify and rank in order of priority the different areas of your life. Consider the time you allocate to each and what is realistic and necessary. Perhaps others are making demands of you that you need to be more assertive about?
     4. Setting reasonable goals – keep in mind the important areas of your life when pursuing goals. Clearly define your goals so you know when you have achieved them. Some goals will need to be broken down into more manageable steps.
   • Once you know the above you can draw up a new more efficient schedule. Use an organizer and list long-term (within six months), medium-term (within a month) and short-term (within a week) goals. Set aside time each day to organize. Try to do a ‘To do’ list of prioritized tasks every day. Plan flexibly and review every month.
   • Delegating – giving over responsibility with authority, to others for appropriate tasks, is part of good time management.

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8. Coping Techniques For Panic Attacks
   • Hyperventilation – faster breathing occurs in response to exertion and stress. In the long-term this can be uncomfortable and cause unpleasant physical symptoms which trigger more anxiety and more hyperventilation. Another cycle of stress is set up and can result in a panic attack.
   • You can rectify hyperventilation by learning to control your breathing.
   • First practice lying down and later sitting or standing. Place one hand on your stomach and the other on your chest. Breathe in slowly through your nose until your lungs are full then exhale slowly through your nose. Breathing in and out counts as one breath – aim to take 8-12 breaths a minute.
   • In order to be effective you need to practice this exercise repeatedly. Use this exercise when you notice early symptoms of panic to prevent a full-blown panic attack.
   • Another technique when you feel panicky is to place a small paper bag over your mouth and nose without any gaps so air cannot escape and breathe into it slowly and regularly until your panic subsides. Alternatively you could try cupping your hands around your mouth and nose and breathing slowly.
   • Focusing on your symptoms worsens a panic attack – the following distraction techniques may be helpful:
     1. Wear a rubber band around your wrist and when you start to feel panicky, stretch it out and let it snap back onto the inside of your wrist. The pain caused by the band can distract you from the symptoms of panic and give you time to use some other technique if this alone is not enough.
     2. You could try counting objects in your environment or multiplying numbers in your mind to distract yourself from the symptoms of panic.
     3. On the early signs of panic try visualizing a pleasant or enjoyable scene in as much detail as possible. You will find it easier if you use the same scene everytime.
     4. Try intellectualizing the symptoms of panic by being objective about them – when anxious you could note your symptoms and fears rating their severity.
     5. Everyday activities such as watching television can also be distracting.
   • List the distraction techniques rating them 1-10 for effectiveness. This will clarify which techniques to use in future.
   • Write down on a card all the techniques that help you to control your panic attacks and keep it close at hand for when you feel panicky.
   • Try to remain where you are for a while after your panic attack subsides so that you do not start avoiding the situation in future.
   • Reward or praise yourself for coping with the panic attack. The occasional panic attack is to be expected and should be seen as only a minor setback and used to consolidate your skills.

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9. Altering Negative Thinking Styles
   • Unhelpful thinking styles can make you susceptible to panic attacks.
   • First you need to identify your negative thoughts e.g. ‘The pain in my chest means I am having a heart attack and will die’. Certain situations tend to be interpreted negatively.
   • Negative thinking styles include:
     1. catastrophizing (predicting the very worst);
     2. jumping to negative conclusions (interpreting things without evidence);
     3. emotional reasoning (an over-reliance on feelings to guide judgments);
     4. ‘I must (these thoughts involve feelings of being compelled to do something);
     5. disregarding and disbelieving the positives;
     6. disregarding and disbelieving others;
     7. increasing the strength of negatives by dwelling on them;
     8. all-or-nothing thinking (black-and-white thinking);
     9. over generalizing (you notice something that is true and make generalizations about it);
     10. mind reading (thinking you know someone’s thoughts when you do not); predicting the future;
     11. labeling (calling yourself names);
     12. wishful thinking;
     13. taking the blame when you are not at fault;
     14. being personally affected by things;
     15. having unrealistic expectations;
     16. overestimating failure and underestimating success.
   • Next you need to challenge your negative thoughts by finding more positive alternatives.
   • Consider the evidence for the negative thought, other possibilities and ask others how they interpret the situation.
   • Write down the day/date, situation and related negative thought. Rate your anxiety level 0-10 (0 is no anxiety and 10 is extreme anxiety). Note challenging thought and consider an alternative – a positive/appropriate thought.
   • Change negative thoughts to positive thoughts next time you come across a problematic situation. Think about and list the sorts of helpful thoughts you could say to yourself.
   • What advice would you give a friend in your situation? How would someone positive interpret the situation? Check your thoughts with a friend and look at your problem from different angles.
   • Try writing single positive thoughts on small cards to read when you feel you are reverting to negative thinking styles. Use your cards regularly until the positive thoughts become ‘second nature’.

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10. Managing Physical Sensations
    • Physical symptoms can trigger panic attacks and panic results in focusing on physical sensations – a vicious cycle is established.
    • list the physical sensations that you link to symptoms of panic.
    • Write down the activities or situations you avoid for fear of becoming too aroused and experiencing physical sensations that remind you of panic e.g. you may avoid strenuous exercise or arguments.
    • Two methods to become less fearful of physical sensations that remind you of panic are:
      1. Desensitization – consider your list of physical sensations associated with panic and think of ways of producing these sensations e.g. rapid heart rate – physical activity, or dizziness – spinning with open eyes. Allow yourself to repeatedly experience the physical sensations while controlling your anxiety. As you do this and suffer no negative effects, your anxiety will dissipate. Excluding sensations produced by vigorous exercise, controlled breathing and shortened PMR can be used to control your anxiety levels. Implement a gradual step-by-step approach e.g. increase your daily walking pace gradually until you experience some physical sensations then deal with these sensations.
      2. Dealing with Catastrophic Thoughts – Write down your physical sensation and related negative thought e.g. rapid heart rate – ‘I am having a heart attack’. Note your challenging thought by questioning the evidence, looking for other possibilities and asking others for their interpretation of the situation. Try changing your negative thoughts to more positive, helpful thoughts.
    • Write down on small cards the techniques to use when you fear physical sensations, and keep these close at hand.
    • Practice both these techniques regularly to effectively challenge feared physical sensations.

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11. Eye Movement Technique (EMT)
    • When you move your eyes rapidly back and forth while vividly imagining a stressful event, negative thoughts can be interrupted and you will gain relief from associated distress.
    • EMT can help you control anxiety that is caused by recent or past events.
      1. Focus on a stressful thought.
      2. Rate your level of distress (0-10) while focusing on the stressful thought (0 is complete relaxation and 10 is extreme distress). For EMT to be most effective you need a stress level rating of 5 or 6 (a moderate level of stress). If your initial rating is higher than 6, try reducing your stress level to 5 or 6 by using relaxation techniques. If your initial rating is less than 5, try focusing on the stressful event until you reach a stress level of 5 or 6.
      3. Once you have reached a stress level of 5 or 6 keep your head still and move your eyes back and forth twenty to twenty-five times between two corners of a room, between your hands placed on each knee or between two sides of a table. You should be able to stop focusing on the stressful event. If you are in a public place you can do EMT moving your eyes from side to side when your eyes are closed - it will look as if you are in deep thought or resting.
      4. As soon as you have finished rapid eye movement re-rate your distress. EMT significantly diminishes or blocks your ability to focus a thought or image. You should find you get a rating of 4 or less and additional sessions will reduce your level of distress further.
      5. Repeat steps 1-4 whenever the stressful thought recurs. EMT becomes more effective with repeated exposure. At first you may need to do EMT every ten minutes but soon you will get relief for longer.
    • Eventually you should be able to use EMT to gain relief in the moment you have a distressful thought.

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12. Imago Graded Exposure
    1. Make a hierarchy of stressful events and start with the easiest event. Make a list of coping thoughts which reduce your anxiety for that event.
    2. Relax - if necessary use Controlled Breathing and Relaxation Techniques.
    3. Imagine you are in the stressful situation - see, hear, taste, touch and smell the situation. Think about your anxiety provoking thoughts and feel your tension mounting.
    4. Once you are anxious, start relaxing and using coping thoughts while imagining the anxiety-provoking scene for about one minute.
    5. Rate your anxiety 0-10 (0 is no anxiety and 10 is extremely anxious). If your anxiety is 1 or 0 proceed to step 6 then move to the next situation in your hierarchy. If your anxiety is 2 or more, relax (step 6) and then repeat steps 3 and 4.
    6. Relax deeply before moving on to the next scene.
    7. Continue imagining and coping with the scenes until you can cope with the most difficult scene in your hierarchy.
    8. Practice daily - your first session may be 15-20 minutes but later you may want to extend this to 30 minutes.

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13. Dealing With Problem Behaviour – Avoidance: Graded Exposure
    • To overcome your fear you need to face it at your own pace. Identify and write down an accurate description of your fear. Deal with one fear at a time.
    • Graded exposure will show you that your fears are not really alarming and build your confidence. You are trying to learn to master your anxiety rather than avoiding it. There are three stages:
      1. Setting targets – Your descriptions of fears such as objects and situations that cause avoidance and anxiety needs to be arranged in order of difficulty with the easiest first. These are your targets.
      2. Grading tasks – Choose a target and plan a series of steps which become progressively difficult so that you can build on your successes. Each step should be altered in one aspect at a time to increase the difficulty and allow you to build your confidence. E.g. If your target is to shop at the supermarket, alone – you could start by shopping for one item at the local shop with the correct money then with a credit card then buy several items with a credit card. Next you could try graded steps at a local store followed by a mini-market and finally at a supermarket.
      3. Practicing – Repeat each step until your anxiety is no longer there, then proceed to the next task and reward yourself for your achievements.
    • Keep a diary to remind you of your progress. Note the date and task and give a rating for your anxiety 1-10 (1 is no distress and 10 is most distress). Write down any other related details.

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14. Dealing with Problem Behaviour – Avoidance: Problem-Solving
    • Sometimes there is no time to follow a graded approach – the problem-solving approach can be useful in these cases. You learn to focus your thinking and find solutions to your problem instead of panicking. There are six steps in problem-solving:
      1. Define the Problem – Be specific and try to break the problem into more manageable tasks. Do one task at a time. Choose your task and specify your goal.
      2. list Solutions – Try to write down as many ideas, to solve your problem, as you can.
      3. Evaluate the Pros and Cons of Each Solution – Consider your solutions and reject the unsuitable ones. list the remaining solutions in order of usefulness.
      4. Selecting a Solution and Planning Action - Choose your first solution and decide how you will put it into action. Rehearse your task and make sure you have a back-up plan in case your task does not go as planned.
      5. Do it - Attempt your solution.
      6. Review the Result of the Solution – If your solution is successful try to understand why it was so. If your solution is unsuccessful try to comprehend why it did not work. Praise yourself for having tried and choose your next solution from your list.

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15. Dealing With Interpersonal Relationships
    • Interpersonal relationships may have caused the panic attacks or may be preventing you from recovering – in any event interpersonal relationships will be affected by panic attacks.
    • You need to understand your personal relationships and be able to deal with them effectively.
    • Draw interpersonal maps – one for before you developed panic attacks and the other for afterwards:
      1. How your interpersonal relationships are at present;
      2. How your interpersonal relationships might be now if you did not suffer from your emotional problem;
      3. How your interpersonal relationships will be in 10 years if you continue to suffer from your emotional problem;
      4. How you would ideally like your interpersonal relationships to be.
    • These will summarize all your relationships and allow you to recognize any changes you may desire.
    • list all your important relationships and put yourself in the middle of the map in a circle.
    • Place each person’s name in a circle on the map, around you in the middle – the closer the relationship to you, the closer the circle to you.
    • Join these circle’s to you in the middle with an arrow outward if it is you mainly giving; an arrow inward if you are mainly receiving; a two-way arrow if giving and receiving is balanced; a question mark if you are unsure.
    • You could also draw maps for how you would ideally like your interpersonal relationships to be; how your interpersonal relationships might be now without panic attacks; how your interpersonal relationships will be in 10 years if you still have panic attacks.
    • Examine these maps noting any differences and set yourself goals to make any desired changes to your relationships.
    • For each relationship ask yourself:
      • who initiates and terminates contact;
      • are you happy with how often you see this person? ;
      • who decides what to do or what to talk about? ;
      • is there a balance between giving and receiving? ;
      • do you want to alter the relationship in any way?
    • Consider questions such as:
      • who could I confide in and get advice from? ;
      • who would be there for me if I fell ill? ;
      • who would lend me money at very short notice?
    • Next time you have contact with each person, examine the relationship – participate and observe. Were your predictions correct? – If not, what was different?
    • When you have a complete picture of your relationships, think about how you maintain them and in what way you want to change your relationships.
    • Two important reasons for making changes are:
      1. A balanced and supportive social network is necessary for your well-being;
      2. By altering your relationships but avoiding being controlling, you may increase your sense of control.
    • Start by making small changes and monitoring progress. You could also try discussing what you have learned about the relationship with the individual.

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16. Removing The Obstacles To Intimacy
    • Record and examine closely the things that prevent you from achieving intimacy with someone. Note your thoughts and reactions when you distance yourself from a friend or end a relationship and make an analysis e.g. are you overgeneralising?
    • Social inadequacy can be an obstacle to intimacy. Apply your assertiveness skills to your social and work life and observe how socially skilled people handle situations in particular difficult ones. Rehearse your social behaviours so that you are comfortable with them.
    • Try to grasp your anxious thoughts, examine them closely and if required, challenge them. What are your anxious thoughts? Is your outlook biased – are there misjudgments? Consider the evidence to support and discount your thoughts.
    • See ‘Overcoming Social Phobia’ in the Forward Counselling Advice Service.
    • It is possible to become over-intimate and make ourselves vulnerable to exploitation. Trust can be given in a series of stages and you can fluctuate as to how much you trust someone.
    • Communication is necessary for all relationships. Record the feelings which threaten your relationship (e.g. jealousy) and grasp the automatic thoughts. Analyze them and find alternative ways of dealing with the situation.

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17. Assertiveness Training
    • The aim of assertive behaviour is to stand up for your legitimate rights and face others without putting yourself or them down.
    • Assertiveness training teaches you to increase the number and variety of situations in which you are assertive.
    • There are three types of interpersonal behaviour:
      1. Aggressive - you may be forceful in expressing your opinions, feelings and wants.
      2. Passive - your opinions, feelings and wants may be withheld completely or partly.
      3. Opinions, feelings and wants are stated with respect for the rights of others.
    • Make sure you are aware of your fundamental rights which include: asking for what you want; saying 'No' without guilt; not being perfect; being ignorant about something; being responsible for your actions; having your own perspective and emotions; being indecisive; choosing whether or not to deal with others' difficulties; expecting privacy, independence and success.
    • There are five steps to being assertive:
      1. What do you want? ;
      2. What is fair? ;
      3. Be clear in asking for it;
      4. Contemplate and be ready for the risks;
      5. Stay calm
    • Practice your arguments in advance and repeat yourself to get the message across. Be prepared to negotiate.
    • Think about situations in which you are not assertive and how you could change this and be assertive.
    • Write out a detailed description of problem scenes - note when and where the problem occurs; who is involved; what your difficulties are; how you handle it; your fear of what will happen if you are assertive; your goal.
    • To deal with a problem situation:
      1. Consider your rights and wants.
      2. Unless spontaneous action is required, arrange a mutually convenient time to discuss your problem with the other person.
      3. Define the problem as specifically as possible.
      4. Describe your feelings using 'I' messages, to give the other person an understanding of how important the issue is to you.
      5. Make your request in one or two simple but firm sentences.
      6. Give positive reinforcement to get what you want e.g. we'll be able to spend more time together. If this will be ineffective try negative reinforcement, describing the alternative way you will look after yourself if your wishes are not met.
    • You need to arrive at a workable compromise. Agree to review this after a specified length of time and if you are not both satisfied you can renegotiate.
    • Avoid being manipulated - techniques include:
      1. 'Broken Record' where you choose a concise assertive statement to say over and over to get your message across.
      2. Delay responding to a challenging statement until you are more prepared.
      3. Inviting criticism may reveal what is troubling the other person.
      4. When someone puts you down, acknowledge something you can agree with in their criticism and ignore the rest.
      5. You can change the focus, from discussing the topic to analyzing the interaction between the two of you.
    • In instances where you lack time you could use the short form assertiveness technique. Consider:
      1. Your thoughts - state the facts as: 'I think…'
      2. Your feelings - express as 'I' statements: 'I feel…'
      3. Your wants - specify behaviour change as: 'I want…'
    • You need to develop assertive body language. Practice the following basic rules in front of a mirror so that you learn how to apply them to problem situations:
      1. Maintain eye contact and an erect body posture.
      2. Speak clearly and firmly.
      3. Emphasize what you are saying with gestures and facial expressions.
    • Learn to listen assertively:
      1. Make sure you are both ready to listen.
      2. Listen giving the other person your full attention and ask them to clarify if necessary.
      3. Let the other person know you have heard what s/he has expressed to you.
    • Practice being more assertive in problem situations and consider how it makes you feel.
    • Role-playing is a good way to improve your assertiveness in a safe environment before trying it out in real life situations.

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18. Conclusion
    • Your recovery will fluctuate but if you practice the techniques your anxiety level will gradually reduce so that the symptoms disappear completely.
    • A relapse is a serious set back in contrast to the expected ‘ups’ and ‘downs’.
    • The recurrence of external stresses is among the combination of factors that results in relapse.
    • To prevent relapse consider if there are new stresses in your life, if you are trying to progress too quickly, whether you are keeping a healthy lifestyle, whether you have stopped or changed your medication dosage, and is your thinking reverting to negative thinking styles?
    • If panic attacks continue seek advice from your doctor – remember you can deal with temporary set backs by applying your techniques enthusiastically and can put yourself back on the road forward.

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