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Hi, once again: Here is Article Nine in the series from my book – “Freedom From Agoraphobia.” It gives the essential techniques from Behavior Therapy for overcoming panic attacks. These techniques have been proven over and over. They are quite powerful – if. If what? If you go to the trouble of doing them. It’s amazing to me how many people don’t and put themselves to much, much more trouble (not to mention suffering) instead.
The usual disclaimer of course applies: Since I am an M.D., I cannot express my point of view without being concerned about liability. So please note this disclaimer before reading further: Any medical information in this article is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional. (This is particularly true with regard to the technique called “Flooding.”)
As always, I hope you will enjoy and learn from reading this article.
Mark Eisenstadt, M.D.
Article Nine Even though the cause of your panic attacks may have been removed, you might well have developed the habit of panic symptoms in response to certain situations. For example, your Life Trap has been resolved but you still have panic attacks when going to the grocery store. What’s going on here? A habit. A habit is a physical response to a certain stimulus. Most people are aware of the famous example of Pavlov's dogs. Pavlov was a scientist who trained dogs to expect to eat after hearing a bell rung. He discovered that after a while, that he could cause the dogs to salivate just by ringing the bell. They had developed a habit.
Habits can be undone in just the way they were created. The habit of developing panic symptoms when going to the grocery store was created by repeatedly doing that - going to the grocery store and having panic symptoms. To undo this habit, you need to simply go to the grocery store and not have panic symptoms. Repeatedly. This is Behavioral Therapy. Systematic Desensitization Behavioral Therapists studied the process of forming and unforming habits. They came up with the most efficient ways to do this. One of the most important of these is called "Systematic Desensitization.” This is a $10 word with a simple meaning: When you go to the grocery store and get panic symptoms, you are said to be "sensitized" to going to the grocery store. When this being sensitized is undone, you are said to be "de-sensitized.” When you go about desensitizing yourself in a systematic way, you are doing "Systematic Desensitization.” But how can you desensitize yourself? And how can you be systematic about it? Going to the grocery store has many parts to it: 1. You write out a grocery list; 2. You put on your coat; 3. You head for the door; 4. You go out to the car; 5. You drive down the street towards the grocery store; 6. You pull into the grocery store parking lot; 7. You get out of the car and start walking towards the store; 8. You go in the door; 9. You take a shopping cart and begin to walk around looking for the items on your list; and so on. Any one of these steps can produce anxiety symptoms. In other words, you can be sensitized to writing out the grocery list, or to putting on your coat, or to heading for the door. To systematically desensitize yourself, you take each of these steps in turn and develop the habit of feeling calm instead of anxious in response to that step. How to do this? Take the step and then calm down. You can calm yourself by any of the methods taught in these articles such as Whole Body Relaxation, meditation or focusing. Let's say you have chosen Whole Body Relaxation as your method of calming down. To systematically desensitize yourself, you need to go through enough steps to begin to feel anxious. Stop at that point and do your Whole Body Relaxation. When you are calm once more, start at the beginning and go through the steps to the one that got you anxious. Again, stop and do your Whole Body Relaxation. Go back to the beginning and do it all again. And again. Until you are not only calm when you take that step but you are even bored. You can stop there for the day or you can go on. The next step is to start back at the beginning and go beyond that step until you again begin to get anxious. Do your Whole Body Relaxation and repeat the steps until you now can go all the way through this step feeling only bored. Repeat this process all the way into the grocery store and through the checkout line. Congratulations!! You have now systematically desensitized yourself. Here's an example of how this works: You have decided to systematically desensitize yourself to going to the grocery store. So you write out your shopping list, checking whether you are beginning to feel anxious. No? Okay, so you put on your coat. Anxious yet? No. So you walk to the door, get in the car and back out to the street. Anxious now? Yes. Okay. Drive back into the garage, walk back into the house, take off your coat and throw out your grocery list. Then practice Whole Body Relaxation until you are calm and comfortable. Next, do it all again: write out a new list, put on your coat, go out to the car and back out to the street. Anxious now? Yes, a bit. So it’s back into the house, Whole Body Relaxation and try it again. When you get out to the street the next time, let's suppose you are no longer anxious. What you do? Do you go on to the next step? No! Go back into the house and start all over again. The next time you get to the street, let's say you are still not anxious but are beginning to get bored with the process. Fine! Now it's time to move ahead. You start at the beginning, get out to the street, find that you are still not anxious so you drive to the grocery store. Anxious yet? No. Fine. Then drive into the parking lot, park and get out of the car. Still not anxious yet? Okay, then go into the store. Anxious now? You bet! So get back in the car, drive home, do Whole Body Relaxation and start over with a new shopping list. Let's say that when you get into the store the next time, you are still anxious. So you repeat the whole process. Until you can do it all and be only bored with going into the grocery store. But, you say, I still haven't done the shopping and I've spent hours slogging back and forth to the store. Fine! Doing the shopping wasn't the purpose! You are spending the afternoon desensitizing yourself to going shopping. If getting the shopping done was the point, you could have sent someone to the store for you. Right? Although it may be tedious, what you are doing is earning yourself the freedom to go where you want. Not just for this time but for all the time. Let's suppose that you have spent the afternoon at this and only gotten through the steps to get inside the grocery store. And now it's time for dinner. No problem. Your gains will remain. You have taught yourself to be able to comfortably enter the grocery store. You won't lose this. You can continue the process tomorrow. Perhaps it'll take one or two tries to get back to today's level of comfort, but not more. Then you can continue with the rest of your steps. A study of Systematic Desensitization was done on people who had Obsessive-Compulsive Disorder. These people had a compulsion to do certain things such as repeatedly wash their hands. They washed whenever they shook hands with someone, touched another person, or touched a doorknob. They felt that they had to wash in order to avoid illness from getting other people’s germs on them. In other words, these people essentially had a phobia of germs. (They felt just as embarrassed about this as you do about not being able to stay in a grocery store so no snickers please.) Anyhow, they were given a Systematic Desensitization plan consisting of gradually exposing themselves to stimuli that made them anxious. Each time they became anxious, they would use a method such as Whole Body Relaxation to calm down before going on. So, for example, they would go to the library, open the door, handle books that others had touched and give the librarian their card to check out a book. At whatever point they became anxious, they would use their relaxation techniques and then repeat the exercise from the beginning – without washing their hands! The Systematic Desensitization was as effective as usual. People became more and more free to expose themselves to germs without becoming anxious and having to wash. No surprise - this result had already been proven. What the researchers wanted to study was whether the timing of the exposure made a difference. They found (and this is the point for your practice) that it did not matter what the timing was – only the total time of exposure to the anxiety-provoking stimulus. Thus, a person would get just as far by practicing Systematic Desensitization for 4 hours every other day for 2 weeks (28 total hours) as they would by doing 28 hours on 3 consecutive days or even by spreading them over two months. It is entirely up to you, therefore, how quickly you want to do the work of Systematic Desensitization and how quickly you want to reap the rewards. The more time you spend, the more you gain. Simple as that. Putting Systematic Desensitization To Use You can work your way through
all of your habits by using Systematic Desensitization. First, create
your "Phobic Hierarchy.” This is just a fancy term for a
list of those things you have trouble doing. It is a hierarchy because
you put it in order from easiest to hardest. Starting at the easier
end, you can work your way through the list until you are free to do
everything on it comfortably. This actually takes less time than you
may think because you will be able to skip some items. For instance,
you may find that once you have developed comfort going two miles from
the house, you are also comfortable going 10 miles. A patient in New York determined to become free to use the Subways. Whenever she got on it to go to work, she would panic. So, she bought herself a bag full of subway tokens. And one Sunday, she got busy. She got on the subway at the stop near her home. She went one stop away, became anxious and came back to the home stop. She relaxed herself and then got back on and went to the next stop again. And again until she was bored with it. Then she went two stops. And back. And two stops. And back again until she was bored with this. Next, she felt she could go four stops. She found there was still no discomfort so she went back to her starting point, got on again and went eight stops. At this point, she was beginning to feel anxious. So she went back to the start, calmed down and began again. She conquered the subways and ultimately tried her dream of crossing the country by train. Yep, a month later, she sent back a postcard from the West Coast. And she wrote her revelation of the first night: "I realized that wherever I was was home! From then on, it was easy!" Imaginal Systematic Desensitization Question: What if exposing yourself to even the first step of a stimulus causes you so much anxiety that you cannot get yourself to do it? Answer: Use Imaginal Systematic Desensitization. This technique is the same as regular Systematic Desensitization except that you do the exposure in your imagination. In this technique, you sit down in a quiet and comfortable place that is free from interruptions. You may want to close your eyes. Then imagine taking that first step in doing whatever you have chosen to work on. Make your imagining as realistic as possible. Add in the sights you would see, the sounds you would hear, what you would be physically feeling (temperature, wind on your face, etc.) and any smells or tastes. Imagine whom you would be with, what you would be wearing and what you would be doing (walking, sitting, carrying something). To make it more realistic, you can ask yourself: “How do I know this isn’t actually happening?” Whatever your answer, imagine that it is not that way. So, for example, if your answer is: “Because I can feel myself sitting in this chair”, then imagine how it would be if you could not feel yourself sitting in the chair. Then, how do you know it isn’t really happening? Suppose your next answer is: “Because I know that I can open my eyes and see the room I am sitting in.” In that case, imagine that you couldn’t open your eyes and see the room – it isn’t there. Then how do you know it isn’t really happening? And so on. This process helps you identify those factors that tell you that you are really not in the situation so that you can change what you are imagining to make it more realistic for yourself. Once you have your imagined situation as realistic as you can make it, begin going through the experience of doing whatever you have chosen for desensitization. Just as in regular desensitization, as soon as you become anxious, stop going through the experience, come back to the room you are in and practice some form of relaxation. After you have relaxed, go through the experience in your imagination again. Repeat going to the point at which you became anxious and then relaxing until you are bored with going through that part of the experience. Then, just as in regular desensitization, go on further through the experience until you again become anxious. Again, desensitize yourself to this part of the experience. Continue on in this way until you can go through the entire experience with no anxiety. You have now imaginally desensitized yourself to the experience. This imaginal desensitization will carry over to actually going through the experience in the real world. The more realistic you have made your imagined experience, the more comfortable you will be with the real experience. Sometimes, people make their imaginal desensitization so realistic that they completely desensitize themselves to the real-world situation. They then find that they can go all the way through the real experience with no anxiety. This technique is especially useful for desensitizing to situations that are not available for practice such as airplane travel. An example in my practice occurred with a mechanic who had become phobic of reaching into automobile engines. This had come about when he had the experience one time of reaching way in and, in order to get at an inaccessible part, turning his hand in such a way that it became stuck. He could not get it out and no one was around to help. (Talk about a trap!) However he twisted, turned his hand, gently pulled, pushed or anything else he could think of to do, it would not come out. So he panicked. And in his panic, he just yanked his hand out, severely tearing it on various parts of the motor just to get it out no matter what. After this, he could no longer get himself to reach into an engine. I took him through imaginal desensitization. He mentally approached a car, opened the hood, looked at the motor, touched something on the surface of it and became anxious. After he calmed down, we repeated this several times. When he was comfortable touching the surface, he mentally reached further and further into the motor – again stopping and doing relaxation whenever he became anxious. Ultimately, we got to the point of his hand getting stuck. After several tries (with stops to calm down), he could remain with his hand stuck in the engine without much anxiety. He then realized that it was his fear of not being able to get his hand out that had caused him to panic and rip his hand. It came home to him that if he had remained calm, as he now was, there had to be a way out since there had been a way in. It just took not panicking and slowly trying things over and over until he found it. Mentally, he tried many ways of getting his hand out. We included imagining his getting frustrated and worried in the process. Finally, without any attempt on his part to make it happen, he found himself discovering the way his hand had gotten in the motor and it coming loose again. After this, he was able to mentally go through the whole experience in comfort. It must have been quite a vivid experience for him because it completely carried over to real life. He was able to go right back to working on automobile engines without needing any further desensitization. Also, the entire exercise took him about two hours. This was certainly a small price to pay for getting his vocation back. Exposure or Flooding (Note: Do not try this technique unless you have checked with your doctor and been advised that it will not be harmful to you.) No, this isn’t about going around in a storm with nothing under your raincoat. It’s about facing what you fear. And it’s probably the single most powerful technique for overcoming panic attacks there is. A very wise man once said that a fear not faced becomes the center of your life. If you are an agoraphobic, you don’t need that explained. So, you have to face (expose yourself to) what you fear. You can do this gradually as in Systematic Desensitization. Or, you can do it all at once. This is “flooding.” You simply flood yourself with what you fear. Nope, you won’t go crazy or explode into little bits. And unless you are in a precarious heart condition already, you won’t have a heart attack. Believe it or not, what happens is that after a while, your heart slows down, your breathing becomes regular and your whole body normalizes. Fact. The human organism seems to be built in such a way that it cannot sustain fear of a particular stimulus indefinitely. In fact, it cannot sustain it very long at all! That is why I am very skeptical when someone tells me she has panic attacks that go on for days. We just cannot keep up such a level of physical and mental arousal for that long. Even people who think they have panic attacks for hours usually do not. When they keep an Anxiety Diary, rating how much anxiety they experience with frequent ratings, they usually find out that their anxiety fluctuated during those hours. They (rarely) may have worked and reworked themselves into a series of panic attacks. But a single panic attack almost never keeps going like that. Check it out for yourself. People have long realized that exposure to fears reduces those fears. And avoidance increases them. That’s the reason for the old saying that you should get right back on the horse that threw you. And it’s also why you should quickly return to any new place where you have had a panic attack. Do not let that place be added to your avoidance pattern. That’s how avoidance patterns grow. If you are really gutsy or determined to kick your habits right now, you can do it. Use flooding. Just go into that supermarket and stay there until you are no longer panicking. Period. That’s it. And it works. And will keep on working. Tough? You bet. Effective? You bet, again. Next month, we will examine what can be learned from Cognitive Therapy – a form of treatment that has taken the U.S. by storm. Until then, I send you best wishes for peace and progress,
Mark Eisenstadt, M.D You can find article ten Here
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