The Five Steps of AWARE

By David Carbonell, Ph.D. is a Chicago psychologist who specializes in the treatment of fears and phobias. He maintains a popular self help web site at www.anxietycoach.com, where this material, and much more, appears. He is the author of Panic Attacks Workbook, The Worry Trick, and Fear of Flying Workbook.

 

 

The five steps to overcoming panic attacks are:

Acknowledge & Accept

Wait & Watch (and maybe, Work)

Actions (to make myself more comfortable)

Repeat

End

Let's take a look at what each step entails.

Acknowledge & Accept

All progress starts here. This is the most important single step to overcoming panic attacks.

Acknowledge

Here I acknowledge the present reality, that I'm afraid and starting to panic. I won't try to ignore it, or pretend it's not there. I won't struggle to distract myself, tell myself to "stop thinking about it!", or snap any rubber bands on my wrist.

I'm acknowledging simply that I am afraid, not that I am in danger. The thought that I am in danger is just another symptom of panic, not an important or useful thought.

Accept

Here I accept the fact that I'm afraid at this moment. I don't fight the feeling; ask God to take it away; blame myself, or anybody else. I accept, as best I can, that I'm afraid in the same way I would accept a headache. I don't like headaches, but I don't bang my head against the wall in an effort to get rid of them, because that makes them worse. Overcoming panic attacks begins with working with, not against, my panic and anxiety symptoms.

How Can I Accept a Panic Attack?

What makes a panic attack acceptable (not desirable, but acceptable) is that, while it feels awful and fills me with dread, it isn't dangerous. It won't kill me or make me crazy. Someone pointing a gun at me, that's not acceptable. I might get hurt or killed. If someone points a gun at me, I have to do whatever I can to change that: run, hide, fight, yell, bribe, or beg, because the consequence of being shot is so terrible that I must try to avoid it.

On the other hand - a policeman giving me a ticket, even if I don't deserve it, I can live with that, and can hopefully keep my temper in check so I don't make things worse for myself.

Accepting the symptoms, not resisting, is a powerful step to overcoming panic attacks.

What Can a Panic Attack Do to Me?

It makes me feel afraid, that's what a panic attack does. And, if I'm having a panic attack, I'm already there! I'm already experiencing the worst that will happen. I just need to ride it out. That's the surest path to overcoming panic attacks.

Why should I accept a panic attack? Because the more I resist panic, the worse it gets. The more I develop the habit of acceptance, the more progress I make toward my goal of overcoming panic attacks. 

That's Acknowledge & Accept. How does that compare to what you usually do during a panic attack?

Wait & Watch (and maybe, Work)

Wait

What I mean by "Wait" is this: don't just do something, stand there. It's similar to the suggestion "count to ten before you get mad".

One of the hallmarks of a panic attack is that it temporarily robs you of your ability to think, remember, and concentrate. This step will buy you a little time to regain those abilities before you take any action.

When you react before you have a chance to think straight, what do you do? If you're like most people, you probably flee, or struggle. You do things that actually make it worse. This is what people mean when they say things like "I know I'm doing it to myself" and the harder I try, the worse it gets.

Jumping into action too quickly is a big obstacle to overcoming panic attacks.

So, even though you have a powerful urge to leave, postpone that decision for a little bit. Don't tell yourself you CAN'T leave - keep that option open so you don't feel trapped - but put off the decision about whether or not to leave. Stay in the situation. You don't need to run away to get relief. Let relief come to you.

Watch

Use the occasion to observe how the panic works, and how you respond to it. The best way to do this is to fill out a panic diary. The diary is a questionnaire which helps you notice important aspects of a panic attack, so you can respond more effectively over time. Feel free to download and reproduce it for your own personal use. You can also download a set of instructions.

My patients often report that just filling out a diary helps them to calm down. How does this work? It's not that they're distracted from the subject of panic, because the diary questions are all about panic. It helps you get a little distance from your emotions. It works because, while you complete a diary, you're in the role of an observer, rather than feeling like a victim.

The best way to use the diary is to fill it out during the attack, rather than after. If you're in a situation where writing is impractical, perhaps while driving a car, you can: use a digital recorder; have your support person read the questions to you and record your answers; or pull over for a few minutes to write.

What About "Work"?

If you're in a relatively passive situation during the panic attack - a passenger in a vehicle, getting your hair cut, or waiting in a waiting room - "Wait & Watch" is all you need. If you're in a more active role - driving a car or giving a presentation - then you also need to attend to the "Work" of conducting that activity. Do "Wait & Watch", but also remain engaged in your task.

That's "Wait & Watch (and maybe, Work)". How does that compare to what you usually do during a panic attack?

Actions (to make myself more comfortable)

At this point, you've already gone through the two most important steps to overcoming panic attacks.

These steps, and all the steps necessary to overcome panic disorder and phobia, are covered in much more detail in my Panic Attacks Workbook.

What's Your Job During an Attack?

It's not your job to bring the panic attack to an end; that will happen no matter what you do.

Your job now is to see if you can make yourself a little more comfortable, while you wait for the attack to end.

Here are a few techniques that my patients have found particularly useful in overcoming panic attacks.

Belly Breathing

Regardless of what else you do, do belly breathing. It's also known as diaphragmatic breathing, but I think "belly breathing" is more descriptive. Many people think they know how to do deep breathing, but don't do it correctly, so they don't get good results. A good belly breathing technique is a very powerful tool in the work of overcoming panic attacks!

How to Talk to Yourself

Talk to yourself (silently!) about what is happening, and what you need to do. One question my patients find very helpful is this: is it Danger or Discomfort? Some of the other responses my patients like include the following:

1. Fine, let's have an attack! It's a good chance to practice my coping techniques.
2. Answer your "what if...?" fears by saying "So what? I'll get afraid, then calm down again."
3. It's okay to be afraid.

Get Involved in the Present

People don't panic in the present. People panic when they imagine something bad happening to them in the future or in the past. This is why your panic attacks are almost always accompanied by some "what if...?" thought.  The reason you say "what if...?" is because what you fear is not actually happening!

Get back into the activity you were engaged in prior to the attack, and become involved with the people and objects around you. If you're in a store, resume shopping, reading labels, comparing prices, asking questions, etc. It will move you closer to your goal of overcoming panic attacks when you bring your focus and energy back to the present environment. By this I mean, work with what is around you.

Work with Your Body

Identify, and relax, the parts of your body that get most tense during a panic attack. This typically involves first tensing, and then relaxing, the muscles of your jaw, neck, shoulders, back and legs. Do not allow yourself to stand rigid, muscles tensed, and holding your breath. That just makes you feel worse! If you feel like you "can't move a muscle", start with just one finger!

That's "Actions (to make myself more comfortable)". How does that compare with what you usually do during a panic attack?

Repeat

This step is here because you might start feeling better, then feel another wave of panic. Your first reaction might then be to think "Oh No, it didn't work!". The Repeat step is here to remind you that it's OK if that happens. Just take it from the top again. It's not unusual or dangerous. You may go through several cycles, and you just need to repeat the AWARE steps again, as often as you need.

How does that compare with what you usually do?

End

This is here to remind you that your panic attack will end; that all panic attacks end; that they end regardless of how you respond; that it's not your job to make the attack end; and that your only job is to make yourself as comfortable as possible while waiting for the attack to end.

Have these statements been true for you? Don't take my word for it. Review your own history of panic attacks and see.

And maybe the next time you panic, when you notice yourself thinking, once again, "Will this ever end?", you'll find yourself answering, "YES!"

Overcoming Panic Attacks

Want a copy of my Panic Attacks Workbook? It'll take you through the steps, from A to Z, of how to handle panic attacks in ways that lead them to fade away, as well as how to overcome the phobias and avoidance that usually accompany panic. It's pretty affordable, and you'll find it here.

 

Episode 5 anxiety

https://www.adaa.org/about-adaa/press-room/facts-statistics Did You Know?

• Anxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older, or 18% of the population. (Source: National Institute of Mental Health)
• Anxiety disorders are highly treatable, yet only about one-third of those suffering receive treatment.
• Anxiety disorders cost the U.S. more than $42 billion a year, almost one-third of the country's $148 billion total mental health bill, according to "The Economic Burden of Anxiety Disorders," a study commissioned by ADAA (The Journal of Clinical Psychiatry, 60(7), July 1999).
  • More than $22.84 billion of those costs are associated with the repeated use of health care services; people with anxiety disorders seek relief for symptoms that mimic physical illnesses.
• People with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders.
• Anxiety disorders develop from a complex set of risk factors, including genetics, brain chemistry, personality, and life events.

Anxiety and Depression

It's not uncommon for someone with an anxiety disorder to also suffer from depression or vice versa. Nearly one-half of those diagnosed with depression are also diagnosed with an anxiety disorder.

Facts

Generalized Anxiety Disorder (GAD) GAD affects 6.8 million adults, or 3.1% of the U.S. population. Women are twice as likely to be affected as men.

Panic Disorder 6 million, 2.7% Women are twice as likely to be affected as men. Very high comorbidity rate with major depression. Social Anxiety Disorder 15 million, 6.8% Equally common among men and women, typically beginning around age 13. According to a 2007 ADAA survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 or more years before seeking help. Specific Phobias 19 million, 8.7% Women are twice as likely to be affected as men. Typically begins in childhood; the median age of onset is 7.

Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are closely related to anxiety disorders, which some may experience at the same time, along with depression.

Obsessive-Compulsive Disorder (OCD) 2.2 million, 1.0% Equally common among men and women. The median age of onset is 19, with 25 percent of cases occurring by age 14. One-third of affected adults first experienced symptoms in childhood.

Posttraumatic Stress Disorder (PTSD) 7.7 million, 3.5% Women are more likely to be affected than men. Rape is the most likely trigger of PTSD: 65% of men and 45.9% of women who are raped will develop the disorder. Childhood sexual abuse is a strong predictor of lifetime likelihood for developing PTSD.

Major Depressive Disorder The leading cause of disability in the U.S. for ages 15 to 44.3 Affects more than 15 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year. While major depressive disorder can develop at any age, the median age at onset is 32.5 More prevalent in women than in men.

Persistent depressive disorder, or PDD,(formerly called dysthymia) is a form of depression that usually continues for at least two years. Affects approximately 1.5 percent of the U.S. population age 18 and older in a given year. (about 3.3 million American adults). The median age of onset is 31.1

Related Illnesses  Many people with an anxiety disorder also have a co-occurring disorder or physical illness, which can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders.

 

resting facts about stress and anxiety:

1. Stress has been called “the silent killer” and can lead to heart disease, high blood pressure, chest pain, and an irregular heartbeat.
2. While it is a myth that stress can turn hair gray, it can cause hair loss. In fact, hair loss can begin up to three months after a stressful event.
3. In recent studies, the top most stressful jobs are a surgeon, commercial airline pilot, photojournalist, advertising account executive, and real estate agent. The least stressful jobs were actuary, dietitian, astronomer, systems analyst, and software engineer.
4. The top three stressful cities in America are Chicago, Illinois; Los Angeles, California; and New York, New York.
5. Stress alters the neurochemical makeup of the body, which can affect the maturation and release of the human egg. It can also cause the fallopian tubes and uterus to spasm, which can affect implantation. In men, it can affect sperm count and motility and can cause erectile dysfunction. In fact, it may account for 30% of all infertility problems.
6. Stress can make acne worse. Researchers say stress-related inflammation rather than a rise is sebum (the oily substance in skin) is to blame.
7. Laughing lowers stress hormones (like cortisol, epinephrine, and adrenaline) and strengthens the immune system by releasing health-enhancing hormones.
8. The stress hormone cortisol not only causes abdominal fat to accumulate, but it also enlarges individual fat cells, leading to what researchers call “diseased” fat.
9. Stress is linked to the six leading causes of death: heart disease, cancer, lung ailments, accidents, liver cirrhosis, and suicide.
10. The stress of caring for a disabled spouse increases the risk of stroke substantially.
11. Chronic stress can impair the developmental growth in children by lowering the production of growth hormone from the pituitary gland.
12. A CNN poll reveals that the number one reason for stress in most countries is money. The countries most stressed about money are Malaysia, China, Singapore, and the United States. The countries least stressed about money are Russia, France, and Italy.
13. The term “stress” derives from the Latin stringere (to draw tight).
14. Stress causes capillaries to close, which restricts bleeding if a flesh wound should occur.
15. Pupils dilate (mydriasis) during stress much the same way they dilate in response to attraction: to gather more visual information about a situation.
16. Chronic stress floods the brain with powerful hormones that are meant for short-term emergency situations. Chronic exposure can damage, shrink, and kill brain cells.
17. Studies find that women with moderate levels of stress were at lower risk for suicide than those women who had very high or very low levels of stress.
18. Scientists suggest that stress is part of the evolutionary drive because it has enabled humans to survive. Specifically, it temporarily increases awareness and improves physical performance.
19. Stress makes the blood “stickier,” in preparation for an injury. Such a reaction, however, also increases the probability of developing a blood clot.
20. Research has shown that dark chocolate reduces stress hormones such as cortisol and other fight-flight hormones. Additionally, cocoa is rich in antioxidants called flavonoids.
21. Chronic stress increases cytokines, which produce inflammation. Exposure to constant inflammation can damage arteries and other organs.
22. Stress can alter blood sugar levels, which can cause mood swings, fatigue, hyperglycemia, and metabolic syndrome, a major risk factor for heart attack and diabetes.
23. Chronic stress worsens irritable bowel syndrome (IBS), a condition that irritates the large intestine and causes constipation, cramping, and bloating.
24. Peptic ulcers are caused by the H.pylori bacteria or the use of NSAIDS—not stress. However, stress can exacerbate ulcers and keep them from healing.
25. Chronic stress decreases the body’s immune system’s response to infection and can affect a person’s response to immunizations.
26. Stress can increase the ability of chemicals to pass the blood-brain barrier, which shields neurons from some poisons, viruses, toxins, and other fluctuations in normal blood chemistry.
27. Acoustic stress (caused by loud noises) can trigger an episode of Long QT Syndrome (LQTS), a disorder of the heart’s electrical system. LGTS is estimated to cause as many as 3,000 deaths in the U.S. each year.
28. Young people from military families who have a deployed parent report higher levels of stress and emotional problems than other adolescents and teens.
29. Stress increases the risk of pre-term labor and intrauterine infection. Additionally, chronic levels of stress place a fetus at greater risk for developing stress-related disorders and affect the fetus’s temperament and neurobehavioral development.
30. Post-traumatic stress physically changes children’s brains; specifically, stress shrinks the hippocampus, a part of the brain that stores and retrieves memories.
31. Chinese stress balls (Baoding balls) were created during the Ming dynasty (1368-1644) in Baoding, China. Originally made of iron, the balls are thought to relieve stress because they touch pressure or acupuncture points on the hand.
32. Stress can result in more headaches as a result of the body rerouting blood flow to other parts of the body.
33. The hyper-arousal of the body’s stress response system can lead to chronic insomnia.
34. An early record of post-traumatic stress syndrome dates from the eighth century B.C. in Homer’s Iliad when Achilles suffers severe battle stress in the Trojan War. Achilles complains of feeling emotionally “numb” or “dead” and expresses suicidal thoughts and rage.
35. In Shakespeare’s Henry IV, Lady Percy’s description of her battle-worn husband, Harry Hotspur, is surprisingly similar to the symptoms of actual post-traumatic syndrome, such as feeling estranged from others, difficulty sleeping, exhibiting an exaggerated startle, dysphoria, and strong anxiety.
36. When cells shrink due to exposure to stress hormones, they disconnect from each other, which contributes to depression.
37. Men are more likely than women to develop certain stress-related disorders, including hypertension, aggressive behavior, and abuse of alcohol and drugs.
38. Chronic low-level noise and low-frequency noise below the threshold of human hearing provoke stress hormones that can interfere with learning and can also elevate blood pressure, degrade the immune system, and increase aggression.
39. Stress creates hormonal changes in the human body that can decrease libido and sex response. However, the BBC reports that penetrative sex (as opposed to other types of sex, such as masturbation) decreased stress hormones while those who had no sex had the highest blood pressure.
40. Extreme or sudden emotional trauma can lead to “broken heart syndrome” (BHS), or stress cardiomyopathy (severe heart muscle weakness). This condition occurs rapidly and usually in women. In Japan, BHS is called “octopus trap cardiomyopathy” because the left ventricle balloons out in a peculiar shape.
41. Stress can kill.

    Everyday health, com 1 / 8   Arm Yourself With Information

When you're having a panic attack or anxiety attack, the symptoms — chest pain, flushing skin, a racing heart, and difficulty breathing — can make you feel like you're going to faint, lose your mind, or die. But the reality is, you won’t. The key to surviving is to learn about anxiety attacks and practice the skills you need to get through them.

“These techniques take some getting used to,” said Chicago anxiety therapist Dave Carbonell, PhD, but learning how to cope with anxiety attacks is important so that fear of having another won't keep you at home or limit your activities. A study in Alternative Therapies in Health and Medicine in 2013 found that multiple approaches to managing anxiety, including strategies like breathing and journaling, can help. 

Here's how to stop an anxiety attack and recover. 

 

“People have this powerful idea to make the attack stop,” Carbonell said, but you can’t make it stop through force of will. However, if you look back at your history, you'll see that every attack does indeed stop, even if it feels awful for a while.

Your best first step is to simply notice your symptoms and accept that you're having an attack. This can be challenging if it's one of your first attacks, but after that you'll know more about what to expect.

 

BREATH feeling short of breath is a hallmark symptom of an anxiety attack. But you can make the feeling worse by taking short, shallow breaths. Try belly breathing instead.

Carbonell compared the type of breathing you’ll need to the breathing of infants, whose bellies rise and fall with each inhale and exhale. When an attack starts, exhale deeply, loosen your shoulders, and focus on some longer, deeper inhales and exhales that let your belly rise and fall. Place one hand on your belly if you need to feel this happening.

JUST RELAX s easy to say "just relax," right? But once you start to observe your body during a panic attack, you might find that certain parts of your body clench up during an attack. Make a deliberate effort to tighten and then relax those parts of your body.

Or, if those parts feel like they won’t obey during an attack, pick a body part that will respond, such as your toes or your shoulders. The more you can breathe deeply and relax, the easier it will be to cope.

TALK TO YOURSELF When you give yourself permission to have the attack, say it out loud. Remind yourself that the attack will end, and it won’t kill you or cause you to faint.

Carbonell said that understanding the physiology of fainting and reminding yourself of it is important. People faint when their blood pressure drops. A panic attack can make you feel like you’re going to faint, but you won’t because your blood pressure doesn't drop during an attack. Remind yourself out loud of truths like these to counter your fears.

/ 8   Return to the Present

Although your gut response might be leave the stressful situation immediately, don’t. “Let your anxiety level come down,” advised Carmin. Then you can decide if you want to leave or if there's a way to get back to whatever you were doing when the attack started. Staying in the moment will help you overcome anxiety, but it’s hard to do this at first.

“It’s one of the things I respect the most about people I work with, that they are taking the leap of faith, and willing to do the things that terrify them," Carmin said. "That takes a lot of courage.”