A panic attack can be defined as a short period of intense anxiety or tension. Usually, the attack comes on suddenly, intensifies quickly and then subsides after a few minutes. People who have a panic attack often do not understand what is happening to them. Some think they are having a heart attack, others think that they are passing out or losing control. People often feel a strong need to flee the situation which evoked the panic attack. Some of the physical sensations that can occur are heart palpitations, sweating, dizziness, feeling ‘weird’, hot flushes, shortness of breath, nausea, tremors, breathing faster or not being able to think clearly.

What exactly is a panic attack?

Anxiety and panic are physical responses to a situation that are experienced as nerve-wracking or dangerous, such as taking a driving test or giving a presentation. Your heart beats faster, you feel hot and you may feel your legs shaking. By doing this, your body is preparing to respond and take action. This physical reaction is harmless. Your blood pressure rises, your heart beats faster, and you begin to sweat, etc. This does not mean that you are going to have a heart attack or go crazy. Fainting or passing out is also practically impossible, because it requires your blood pressure to drop rather than rise.

Then why is it possible to experience a panic attack when there is no apparent danger? You can regard a panic attack as a type of ‘alarm’ response that usually only goes off in the presence of danger. In your case, however, that alarm may be too sensitive, and it can go off when there is no ‘real’ danger. The first attack may be so scary that you consciously or unconsciously start to focus your attention on what is going on in your body to see whether another panic attack will occur. You will start to react to any signal that could indicate a panic attack with a lot of anxiety. For example, if your heart skips a beat once, you may feel scared, while someone without anxiety wouldn’t even notice. A person who experiences panic attacks is more sensitive to their bodily sensations, and, in turn, their fearful interpretations and thoughts create a new anxious reaction, causing even more physical sensations. This results in a vicious cycle.

Vicious panic circle

A panic attack consists of three components:

• You will feel something during a panic attack (heart palpitations, dizziness, tremors)
• You will have alarming thoughts about the physical sensations (“oh, help, this is wrong, I’m going to pass out”, “I have to go home soon” or “I am going to lose control”)
• You will react in some way (quickly go home or sit down)

This circle can cause you to become so scared of having a panic attack that you run away from situations or end up completely avoiding them. Avoidance can provide some short-term relief because you will not experience another panic attack, but, in the long term, it will worsen your symptoms and the panic disorder will persist. You won’t experience that it is possible to endure your anxiety, and, by avoiding your anxiety, you will end up participating increasingly less in (social) activities.

Panic Treatment

With the help of Cognitive Behavioural Therapy (CBT), you will break this vicious cycle by intervening during every stage of the panic circle. Each component is therefore discussed during treatment. You learn to manage your fear. It is not possible to prevent an attack, but once you are less afraid of them, they become less common.

We start by teaching you how to get used to the physical feelings by consciously evoking them, which will prove to you that they cannot do you any harm. After a few sessions, we will investigate your thoughts – what you are thinking during a panic attack, for example, and what you are afraid of exactly. We are going to challenge these thoughts together and try to interpret them differently. Finally, the behavioural (reaction) component is discussed, during which we will tackle the avoidance. You will practice with situations that you find difficult or that you actively avoid, so that you learn to manage your fear instead of avoiding the situations.

The most important thing you will learn during the treatment is that what you are most scared of will not happen.

Source: Keijsers, G. P. J., Van Minnen, A., Verbraak, M., Hoogduin, C. A. L. & Emmelkamp, P., (2017). Protocollaire behandelingen voor volwassenen met psychische klachten.

Interoceptive exposure is a part of Cognitive Behavioural Therapy (CBT). The purpose of interoceptive exposure is to replicate the physical sensations of a panic attack, so that you can learn to tolerate them. This will provide you with new associations (such as “palpitations are harmless”), which will compete with the old associations (such as “palpitations are dangerous”) through practice. It is important to emphasize these new associations after each exercise by asking yourself “What did I learn from this exercise?”.

Interoceptive exposure: the foundation

There are a number of interoceptive exposure exercises you can try. When an exercise no longer evokes anxiety for a week, you can stop doing the exercise. Take note of the following each time you do an exercise:

• Write down how anxious you were during the exercise, from 0 (= not at all) to 10 (= very much).
• Write down to what extent these anxious feelings correspond to the anxiety you feel during a real panic attack, from 0 (= no resemblance) to 10 (= very strong resemblance).
• Write down what you would expect to happen if you had those same feelings during a real panic attack. For example, what do you expect to happen when your heart rate accelerates, similar to what happens if you do the ‘running on the spot’ exercise?
• Take note of whether your anxious expectation came true.
• Ask yourself “what did I learn from this exercise?”.

Exercise 1

The aim of this exercise is to stand up for 90 seconds while breathing fast and shallow (hyperventilate). It is an exercise, not a test. Indicate what you feel.

Exercise 2

Shake your head from side to side, gently shaking ‘no’ without forcing your neck. Do this for 30 seconds.

Exercise 3

While seated, keep your head between your knees for 30 seconds and then stand up quickly.

Exercise 4

Run on the spot for 90 seconds.

Exercise 5

Hold your breath for 30 seconds or longer.

Exercise 6

While standing, keep your body in a push-up position against a wall, with bent arms at shoulder height. Maintain this position for 60 seconds. If you have a lot of strength in your upper body and the wall exercise is too easy for you, you can push your body up from the floor and hold the plank position.

Exercise 7

Spin around on an office chair (with your eyes open) for 60 seconds. If there is no chair available, you can also do the exercise by spinning around while standing up.

Exercise 8

Stand up facing a white wall with your face about 6 inches (15 centimetre) away from the wall. Stare at one specific spot on the wall for 90 seconds.

Exercise 9

Breathe through a straw (with your nose closed) for 90 seconds.

The exercises that you find induce physical sensations that resemble a real panic attack or that evoke anxiety will become homework assignments. This means that you will practise these exercises at two or three set times every day. Exercise 1 (hyperventilating) is always a good exercise to do, regardless of your anxiety level.

Source: Keijsers, G. P. J., Van Minnen, A., Verbraak, M., Hoogduin, C. A. L. & Emmelkamp, P., (2017). Protocollaire behandelingen voor volwassenen met psychische klachten.

You can create an anxiety hierarchy to gain insight into which situations you consider to be anxiety-inducing, and how anxious you get thanks to them. After establishing a hierarchy, you can perform exercises to learn how to manage the different situations. You can start with the least fearful situations, but you can also mix them up. Recent research has shown that performing them in a scrambled order delivers the best results.

Example of an anxiety hierarchy

Below, you can find an example of a completed anxiety hierarchy:

10 – Seeing a picture of a bus

20 – Seeing a video of a stationary bus

30 – Seeing a video of a moving bus

40 – Seeing a bus shelter on the street

50 – Seeing a stationary bus on the street

60 – Seeing a moving bus on the street

70 – Walking next to a bus

80 – A moving bus passing me

90 – Boarding a bus

100 – Sitting on a moving bus

Source: Keijsers, G. P. J., Van Minnen, A., Verbraak, M., Hoogduin, C. A. L. & Emmelkamp, P., (2011). Protocollaire behandelingen

Everyone is likely familiar with it: anxious and tense feelings in social situations – when you have to talk in front of a group, for example. You may experience sweating, trembling or stomach ache. You might find it difficult to focus on a conversation, because you feel uncomfortable. These feelings of anxiety are quite normal. However, if you suffer from anxious feelings such as these on a daily basis and, as such, avoid social situations, you may suffer from a social anxiety disorder.

People with social anxiety tend to feel judged in social situations and/or feel that they aren’t doing anything right. You can be afraid of being critically judged or even rejected. You may feel insecure at work, afraid of having a conversation, or afraid of being found strange.

Causes

Usually, your own thoughts play a major role in the anxiety.

For example, if you think that everyone is going to think you’re stupid, understandably, you will start to feel anxious. These nasty and anxious thoughts can cause:

• Anxiety symptoms, such as blushing, shaking hands, sweating and/or a dry mouth. Negative thoughts will direct attention to your own anxious behaviour, leading you to pay more attention to the physical anxiety symptoms.
• Confirmation of the anxious thoughts; you will constantly seek confirmation for these negative thoughts about yourself. You seek – and often find – evidence for your own negative perspective of how others view you.
• Safety behaviour; these negative thoughts cause you to behave differently. Safety behaviour is a trick to make you feel more comfortable – think of avoiding eye contact, preparing conversations, breaking off contact quickly, or drinking alcohol. If you rely on safety behaviour often, it can become your permanent remedy for any nerve-wracking situation.

An example of such a filled-in situation looks like this:

Therapy

 During treatment, you will look at which behaviour and thoughts are fuelling your anxiety. The treatment that applied for this is Cognitive Behavioural Therapy (CBT). You will practice entering anxiety-inducing social situations, such as having a chat with a stranger. Then you will check whether your negative expectations come true. You will also practice not using safety behaviour. You will learn that your anxious expectations often don’t come true and that when you experience social awkwardness, the impact is only small.

Engaging in anxiety and letting go of safety behaviour can be very difficult and scary. This could result in you wanting to postpone exercises or avoid situations. Together with your professional, you will look at the pros and cons of your behaviour. This will give you more insight into your behaviour, which, in turn, can then help you learn to deal with it.

Sources:

Keijsers, G. P. J., Van Minnen, A., Verbraak, M., Hoogduin, C. A. L. & Emmelkamp, P., (2017). Protocollaire behandelingen voor volwassenen met psychische klachten.

People with obsessive-compulsive disorder (also called compulsive disorder) experience a lot of anxiety due to recurring obsessive thoughts. To reduce this anxiety, they act on it by showing compulsive or avoidance behaviour. With a compulsive disorder, there is a vicious circle of obsessive thoughts, compulsive behaviour, avoidance behaviour and fear.

Intrusions and obsessive thoughts

Intrusions are thoughts that suddenly come to mind. People without compulsive disorder also experience intrusions. Almost everyone experiences intrusions sometimes, such as when they are waiting for the train and suddenly experience the thought “If I step off the platform now, I will jump in front of the train”. Most people don’t dwell on these kinds of thoughts and carry on with their lives. For people with a compulsive disorder, these thoughts lead to a lot of anxiety. When the intrusions keep imposing themselves on you, we call them compulsive thoughts. These kinds of thoughts continually imposing on you can lead to you worrying about the thoughts being real and experiencing feelings of guilt and shame.

Some people try to suppress the thoughts. Unfortunately, this has the opposite effect. Instead of disappearing, the thoughts come up more often.

Compulsive thoughts can arise spontaneously, but can also be triggered by, for example, reading a news article about someone who has jumped in front of the train.

If-then expectations

It is not always clear to people struggling with compulsive disorder whether the compulsive thoughts are real. This leads to anxiety and expectations about the compulsions. We call these if-then expectations.

Looking at the example of the person who has obsessive thoughts about jumping in front of a train, this thought can lead to the following if-then expectation: “If I am at the station, I will jump in front of the train”. This is an incorrect expectation, but it can feel very real and, therefore, can cause a lot of tension.

Compulsive behaviour

The compulsive thought and if-then expectation lead to a lot of anxiety. Because of this, the person will want to suppress this obsessive thought. Instead of taking the train, he prefers to take the bus. By doing this, he avoids going to the station and, in turn, this prevents the compulsive thoughts. An alternative reaction is that they do take the train but ensure that they are far away from the track. We call this a compulsion.

People perform compulsions to suppress the fear that arises due to a compulsive thought or an if-then expectation. But by performing this type of behaviour, you actually reinforce the idea that the expectation is just and that the obsessive idea is true. If you do this often enough, you will strengthen the credibility of the expectation and the obsessive thoughts will become increasingly anxiety-inducing. People with a compulsive disorder are generally stuck in this vicious circle.

Exposure

Treatment for obsessive-compulsive disorder focuses on breaking this vicious circle. The first step is to investigate which compulsions and what if-then expectations are involved. Subsequently, treatment focuses on testing these expectations with experiments.

For every if-then expectation, you will come up with exercises that can be used to test whether the expectation is correct with the help of your practitioner. We call this type of treatment ‘exposure’. You will, with the guidance of a therapist, expose yourself to the things you fear.

An example of exposure: if you are often afraid that you have not locked the front door and, therefore, your house will be broken into, a good experiment would be to not double-check the lock of the door before leaving. Then you will find out what this will result in. Did you forget to turn the lock on the door? And was your house broken into? If you perform this experiment often enough, the credibility of the if-then expectation will decrease. As a result, the obsessive thoughts will evoke less anxiety.

Good to know

This form of treatment will generate a lot of anxiety in the beginning. This can be tough, but thankfully, anxiety decreases over time. It is the most effective treatment for compulsive disorders.

Why does anxiety exist?

In general, anxiety is experienced as a negative feeling. It’s an annoying feeling and, sometimes, it seems to get in your way more than it helps you. We often forget that it is very normal to feel anxious. Anxiety helps us to recognize and avoid danger and perform tasks in a better way. It makes you vigilant. Therefore, instead of rejecting our anxiety, we should accept that we can sometimes feel anxious. Everyone feels anxious sometimes.

The purpose of anxiety

Anxiety’s function is to prevent a bad outcome. For example, it ensures that you pay extra attention when you see a swerving driver. It keeps you on your toes. This is also why new things or unpredictable situations can cause more anxiety. We do not know what to expect and, because of this, we sometimes assume the worst.

The symptoms associated with anxiety can feel quite unpleasant: sweating, a bad feeling in your stomach or an increased heart rate. Why do you experience these symptoms? This is due to the release of adrenaline. This physical response is very helpful. Especially in our prehistoric past, during which we had to react quickly if we saw a dangerous animal, this reaction literally was of vital importance. If there is a threat, your brain sends a signal to your body to get into action. Your focus becomes sharper, your digestive system becomes less active, your blood is pumped faster, and your muscles tighten. In short, you must be able to exert all your energy immediately when disaster strikes!

Anxiety provides security

We all react to anxiety differently. The easiest way is to flee when you are anxious about a certain situation. You will then feel safe for the time being. However, fleeing reinforces the idea that you only feel safe when the threat is gone. Therefore, it is useful to remember that the feelings of anxiety you experience ensure that you can achieve a good and safe result.

The most difficult way is to explore how dangerous the threat actually is. You will learn this step by step. You can compare it to a toddler who is at a swimming pool with a parent for the first time. The water will be something new and exciting at first. After all, the child does not yet know what will happen. Fortunately, the child will not dive straight into the water to explore how safe this potential threat actually is. It will paddle first. It may startle at first, but, after getting used to it, the anxiety will decrease. Step by step, it will dare to go further and further into the water.

You may also have examples of comparable situations from the past. For example, entering an unfamiliar classroom, your first swimming lesson or being visited by unfamiliar people. Can you still remember how you experienced the anxiety then?

So, it’s okay to feel anxious. We should be careful in new situations. It ensures that we do not blindly dive into every possible danger head first and provides protection from dangerous situations.

When you suffer from anxiety- or mood-related problems, you often encounter negative thoughts about an event, or you have negative expectations about an event up front. To test these expectations, you can start a behavioural experiment for yourself. You will evaluate whether your expectation becomes reality. An example of such an expectation is this: “When I want to say something in a meeting, nobody listens to me” or “My boss gets angry when I ask for a day off”. 

A behavioural experiment often follows a completed Thought record, in which you’ve examined your thoughts about a situation and formulated an alternative helpful thought. A logical next step is to collect ‘evidence’ for the alternative thought in daily life by conducting a behavioural experiment.

Negative scenario

First you will do research on what is the worst thing that can happen, this is called the negative scenario or the disaster scenario. Example: “When I try to say something in a meeting, I will be interrupted and there will be no interest in the topic I am introducing. I feel very stupid then.” The behavioural experiment helps you to research and evaluate this thought.

The experiment

Together with your therapist you will think of an experiment and you are going to write this down in detail.
You can answer the following questions:

1. What is the unhelpful thought or expectation? How credible is this expectation in percentages?
2. What is the helpful thought or expectation? How credible is this expectation in percentages?
3. Describe the experiment that you are going to perform. What are you going to do? In Which situation? How are you going to behave yourself in this situation?
4. Pretend that the unhelpful expectation becomes reality, how is the experiment going to perform? What happens, how do you react, what is the outcome?
5. Pretend that the helpful expectation becomes reality, how is the experiment going to perform? What happens, how do you react, what is the outcome?

After you have performed the experiment, answer the following questions: 

1. How did the experiment play out? Which expectation did become reality?
2. What is, now that the experiment is performed, the credibility of your unhelpful expectation on a scale from 0-100%?
3. What is, now that the experiment is performed, the credibility of your helpful expectation on a scale from 0-100%?
4. What did you learn from the experiment?

You have completed your behavioural experiment! It helps to practise experiments more often.
Usually it takes repetition and practice before the credibility of the unhelpful and helpful thoughts changes.

In the NiceDay app the Behaviour experiment exercise is available.

Source

Keijsers, G. P. J., Van Minnen, A., Verbraak, M., Hoogduin, C. A. L. & Emmelkamp, P., (2017). Protocollaire behandelingen voor volwassenen met psychische klachten.

https://pratenendoen.nl/behandeling/cognitieve-therapie/484-2/gedragsexperimenten/ 

Would you like to know more about an online treatment with NiceDay? Or what to expect in preparation for your treatment? In this 3 minute video, we will explain everything you need to know.

You can offer an EMDR treatment within the NiceDay environment.  The EMDR functionality offers several different auditive cues that can be selected during treatment. Secondly, the professional can adjust the speed at which the cue is played. 

In this article you can listen to the different auditive cues.

• Audio 1:
  • The slowest pace:
  • The fastest pace:

• Audio 2:
  • The slowest pace:
  • The fastest pace:

• Audio 3:
  • The slowest pace:
  • The fastest pace: