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Approaching environmental cues of panic attacks






One of the best skills for dealing with the avoidance found among people with panic attacks is acting opposite to the emotion (Linehan 1993b). As we discussed in chapter 4, this skill is all about helping you change emotions that may be getting in the way of your life by responding to them differently. Although fear can be a very useful emotion, providing you with important information about threats in the environment, the experience of fear in the anxiety disorders can get a bit offtrack and start to malfunction. There are few better examples of this than panic attacks.

As mentioned, panic attacks are considered a misfiring of your body’s alarm system, or a false alarm. Therefore, one of the best ways to manage the fear associated with panic attacks is to approach what you fear head-on. If the situations or objects that bring about panic attacks were truly dangerous, then avoiding them would be quite helpful. The problem is that these situations and objects are not actually dangerous, and avoiding them will only make the panic worse. The best way to deal with the fear and avoidance of these cues is to approach them.

Now, we know this probably sounds incredibly counterintuitive (and really scary). Yet approaching these cues and situations provides you with the chance to learn that they are not inherently dangerous and may not always lead to a panic attack. And, if they do lead to a panic attack, it gives you the chance to learn that panic attacks themselves, although very distressing and uncomfortable, will not lead to some catastrophic outcome. Basically, you learn that you can make it through a panic attack and be okay, and you have the chance to practice other skills to help you get through the panic attack more quickly and easily.

So, how does acting opposite to fear work? Well, as we said, the basic idea is to approach what you are afraid of, over and over again. Approach any of the places, people, experiences, sensations, or activities you are afraid of, and keep approaching them until you are no longer captive to your fear. If you do this, we can guarantee that your fear of these activities and situations will decrease.

So, the first step is to identify the cues of your panic attacks that you try to avoid. Let’s start first with expected or cued panic attacks. If you have any panic attacks in response to specific cues in your environment (such as certain objects or situations), or when confronted with something in the environment that you fear, use the following exercise to help you figure out how to apply the acting opposite to fear skill to these cues.

First, take some time to figure out what situations, events, or objects tend to cue your expected panic attacks.

· If you have social phobia or an intense fear of being evaluated negatively by others, cues for your panic attacks may be social in nature and may involve situations in which you think you could be judged or evaluated, such as speaking in public, eating in front of others, or being around large groups of people.

· If you have specific phobia, then the cues for your panic attacks may be specific to whatever you are afraid of, such as enclosed spaces, spiders or snakes, airplanes, or elevators.

· If you have PTSD, then the cues for your expected panic attacks may be those that remind you of your traumatic event, such as smells or sights associated with your trauma.

Take some time now to identify the environmental cues that often trigger a panic attack for you, and then write them down in the first column of exercise 8.2.

Then, for each of those situations, see if you can come up with a plan for approaching these situations or objects rather than avoiding them. Try to focus on small steps you can take to begin to approach each one, or things you can do to increase your contact with these cues. Remember, as scary as they may feel, these situations and objects are generally not actually dangerous. So, figure out a plan for beginning to approach them.

For example, if you have come to avoid crowded places because they trigger panic attacks, steps you could take to act opposite to your fear could be to go to a coffee shop at eight or nine in the morning (when it is a bit more crowded), to the mall with a friend, or to a movie theater just before the next set of movies is about to start. The goal is to keep figuring out ways to be in crowds so that you can learn that these situations are not dangerous. As another example, if you fear spiders, you could begin by going to the bookstore and looking through a book on spiders, going online and looking at pictures of spiders, renting a film that features spiders, or going to a toy store and finding a toy spider—­anything to begin to approach this cue as much as possible. Now that you have the hang of it, see if you can identify three to five steps you can take to begin to approach the cues you just identified. Write these steps down in the second column.

Exercise 8.2 Identify and Manage Cues of Expected Panic Attacks

Write down all of the situations or objects in your environment that trigger expected panic attacks. Write down up to five steps you can take to begin to approach this situation or object. Focus on small, doable actions.
  1. 2. 3. 4. 5.
  1. 2. 3. 4. 5.
    1. 2. 3. 4. 5.
  1. 2. 3. 4. 5.
  1. 2. 3. 4. 5.

Now that you have identified a plan for approaching these cues, the final step is to do it. Get started on your plan now. Remember that the more you approach these situations and objects, the less you will fear them and the less control they will have over your life. So, get going and start approaching what you fear!

We started this exercise by focusing on expected or cued panic attacks, because people often find that it’s easier to identify the situations and objects outside of themselves that are a source of fear. If particular situations or objects in the environment sometimes lead to panic attacks, folks are generally aware of what these situations or objects are. They tend to be difficult to forget! For those of you who struggle with unexpected or uncued panic attacks, however, have no fear. Acting opposite to your emotion can also help with your panic attacks; it just requires a slightly different approach.


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