attacks before.
This series of exercises is designed to help you quickly gain control of panic symptoms and attacks; to remain in control; and if needed, to help you overcome the residual fears some people have after they gain control of their hyperventilation and panic.
Phase One: GAINING CONTROL
GOAL: Learning deep, relaxed diaphragmatic breathing.
You do this by:
- Learning to switch from upper-chest to diaphragmatic breathing
- Practice slower, deeper breathing.
- Increasing your breath volume by practicing with a volumetric exerciser.
- Cut back on tranquilizing medications as soon as you see progress.
- Practice neutralizing anxiety-producing thoughts.
Once you have gained control, staying in control becomes the focus. This takes some further awareness and practice.
Phase Two: STAYING IN CONTROL
GOAL: Make relaxed, diaphragmatic breathing a part of everyday life.
You do this by:
- Using Reminders during the day to breathe using the diaphragm.
- Continuing diaphragmatic breathing under stress conditions.
- Reconnecting breathing with talking and moving.
- Learning to relax using diaphragmatic breathing, relaxation tape and hand warming.
- Learning to detect early warning signs
As you go through the exercises you will note that there is an overlap between Phase One and Phase Two exercises. Many Phase One exercises are used for the entire eight weeks of practice. Using the volumetric exerciser for more than six weeks, for instance, helps you achieve complete recovery from panic attacks.
Using the Daily Logsheets
As you get into the training you will see that more than one thing is being taught and learned at one time. The logsheets help you keep doing one exercise long enough, drop those exercises that have accomplished their purpose, and start a new phase. By keeping a written record, you can go back through the daily logsheets and see your progress. This is self-validating and provides you with an added measure of confidence.
You will notice that when something is added to the exercises, a + symbol is used to call your attention to the new material.
You have been given daily logsheets for eight Weeks and instructions of how to proceed from the Ninth Week onward. Each Week begins with goals and special instructions for that Week. Many weekly sections are preceded by additional information about the exercises you will be doing that Week. The reading and exercises appear in the order you will be using them. If you want to clarify something, you can go back and reread the information.
You may find that the pace of treatment is too fast. There is no harm, and definite
benefits, in repeating one or more of the Days or Weeks as you go along. How long you continue practicing the various exercises is up to you, but keep in mind that you don't have to achieve perfect mastery before moving on. Some of the exercises may not seem necessary to you. Try them first, then decide whether or not to continue using them. Don't give up if they are too hard; persistence pays off. Only stop if the exercises become too easy!
If you suffer from Panic Disorder without Agoraphobia, you may need only eight to ten
weeks of practice. Some people respond very quickly to this treatment. For people who have suffered for many years and have, through necessity, developed many compensatory strategies to try and avoid panic attacks, eight to ten weeks is a minimum course for learning skills. These skills will provide a good start on the road of recovery.
USING THE GRAPHS IN THE DAILY LOGSHEETS
The graph at the top of each logsheet is where you record the intensity of your symptoms, and this is where you can go back to see your progress. It is important that you fill in the graph at least once a day, as this helps you identify when your symptoms are most intense and any suspected causes of your symptoms. The grids for your charting are labeled by time of day (X axis) and severity of symptoms (Y axis). The severity scale is None (no symptoms), Mild, Moderate, Severe, and Panic Fear. Record the intensity of any type of panic or hyperventilation symptom as Mild, Moderate, or Severe. Symptoms can include trembling, dizziness, chest pains, or abdominal upset. Use "Panic Fear" when you experienced an attack during which you felt like you were being suffocated and could not breathe for a period of time.
This is an idea of how the graph might look after you have marked it to record your
symptoms.
| SYMPTOMS | 4am | 6am | 8am | 10a | 12N | 2pm | 4pm | 6pm | 8pm | 10p | 12M | 2am |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PanicFear | ||||||||||||
| Severe | X | |||||||||||
| Moderate | X | X | ||||||||||
| Mild | X | X | X | X | X | X | ||||||
| None | X | X | X |
By marking X's in the squares, you can keep a day-to-day record of your improvement.
Also, if the graphs indicate that your symptoms are habitually more severe at certain
times of the day, these are the times to watch your breathing, reduce stress, or make sure your blood sugar doesn't get too low. You may also want to consider changing the time you take a medication.
RECORD ANXIETY MEDICATIONS
The record of medications is another way you can see progress. As your symptoms are
alleviated you will feel less need for medication, take it less often, and probably stop it altogether.
If you are taking one of the benzodiazepine medications (Xanax, Valium, Atavan, and
Klonopin are the most commonly used) or buspirone (BuSpar), it is important that you
get your doctor's help in tapering off and withdrawing as soon as you are able. Starting to cut back during the first week of breathing practice is not too soon, but you may have to take more time to develop confidence in your ability to control the attacks by yourself. Do not stop taking these medications abruptly, as this can lead to extreme anxiety and provoke intense panic attacks or seizures. These medications get in the way of learning and remembering, to a much greater degree than is generally appreciated. Treatment failure for panic disorder is associated with continued use of these types of drugs. This is true even if you are taking benzodiazepine medications on only an "as needed" basis.
Choose whether you want to record each time you take a medication or simply record
your daily intake. In the case of benzodiazepine medications, it is not recommended that you space out your medications, as your body has grown accustomed to having the drug at certain times. Rather, you should taper off by cutting back on the amount you take each time (generally three or four times per day).
The following table shows an example of how you might want to take as long as 8 weeks
to taper off of alprazolam (Xanax) as you do the exercises. This helps prevent rebound anxiety and withdrawal symptoms. Tell your doctor that this is how you want to go about it.
| First Dose (AM) | Second Dose (AM) | Third Dose (PM) | Fourth Dose (Bedtime) | |
|---|---|---|---|---|
| 1st Week | Usual dose | 1/2 usual dose | Usual dose | Usual dose |
| 2nd Week | Usual dose | 1/2 usual dose | Usual dose | 1/2 usual dose |
| 3rd Week | Usual dose | 1/2 usual dose | 1/2 usual dose | 1/2 usual dose |
| 4th Week | 1/2 usual dose | 1/2 usual dose | 1/2 usual dose | 1/2 usual dose |
| 5th Week | 1/2 usual dose | 1/4 usual dose | 1/2 usual dose | 1/4 usual dose |
| 6th Week | 1/4 usual dose | 1/4 usual dose | 1/4 usual dose | 1/4 usual dose |
| 7th Week | 1/4 usual dose | None | 1/4 usual dose | None |
| From now on | None | None | None | None |
Following the Exercise Directions
The program includes three types of exercises. First, there are those that you will do every Day throughout the 8-week training period. Next, there are "fall back" exercises that you will use if you experience symptoms of hyperventilation. Finally, there are those that you will do while you are in a particular phase of your training. The training logsheets are designed to remind you of all three types of exercises.
Meanwhile, you need to be aware of some general directions before you actually begin.
Practice when you are feeling at your best.
Especially in the beginning, your best may not be very good, but that's O.K. The point is that in the beginning this is practice for gaining control soon. Don't try to control panic attack symptoms right from the beginning; at first you are learning to catch the ball, not play baseball.
Stop practicing if you experience hyperventilation symptoms.
If you start to have symptoms during any exercise, stop doing the exercise. Use the "fall back" exercises to regain immediate control so that your symptoms don't escalate and get out of control. Get your mind off your breathing and come back to it later in the day.
This is so important! If you are phobic about other things and you allow symptoms to
build during breathing exercises, you'll soon be phobic about the exercises and not want to do them. That would be one more failure, and you and I want these exercises to be a success.
Build your strength gradually.
It's better to work with the exercises for just a few minutes when you begin and then increase your duration later as you develop more tolerance. When working with your breathing, always stay within the comfort zone. The comfort zone will expand as you practice. Just like with an exercise program, it may be a week or two before you notice improvement. Consider the first week or two an investment; don't give up the program without making an honest effort.
Give yourself some room to make mistakes.
In your trying, you may try too hard or may fail to follow the directions as given. You might provoke some symptoms or slow down your progress. Most people make some mistakes when they begin these exercises, because they are learning something that seems strange and unfamiliar.
Eat an adequate breakfast and a snack before you go to bed.
Many people who suffer from panic disorder seem to be prone to low blood sugar or tolerate it less well. This is stressful to the body and can cause hyperventilation. An adequate breakfast with protein, and a snack at bedtime that includes complex carbohydrates and protein will help level out your blood sugar between meals.
You do not have to do the exercises perfectly in order to feel that you can control hyperventilation symptoms or panic attacks. All you have to accomplish to get control is mostly breathe diaphragmatically and slowly when you are thinking about it. It's a downhill battle from there! |
Plan for First Week
- Make an appointment with your doctor to discuss any antipanic, antianxiety, and
antidepressant medications you are taking. Make a plan with your doctor to withdraw
from the antipanic and antianxiety medications. - Each morning before getting out of bed, practice three slow, diaphragmatic breaths. Continue to be aware of your breathing and breathe slowly as you get out of bed.
- Use the daily logsheets, which will help you to switch from upper chest to
diaphragmatic breathing.
GENERAL INSTRUCTIONS
- Always wear loose clothing during the exercises
- Starting to learn diaphragmatic breathing the first week is easier if you are lying down. Lie on the floor (or bed if it's firm). If you use the floor, use a carpeted surface or get a pad. A bed sheet over the carpet is a good idea.
- The volume of breath to be taken in for an exercise is either seventy percent
[70%] or one hundred percent [100%] of maximum. In the beginning you will have to estimate how much this is. If you experience symptoms, reduce the volume of the inhale and exhale more slowly. - Unless you have a nasal obstruction, keep your mouth closed and breathe through your nose. If you have a nasal obstruction, breathe through pursed lips.
CAUTIONS
Be aware of the most common hyperventilation symptoms (especially dizziness). If you experience the symptoms, use the pursed-lips breathing technique explained below to increase the carbon dioxide level in your bloodstream.
Re-breathe air from a paper bag (instructions appear below) only if overwhelmed. Don't become dependent on this technique.
When beginning to use the diaphragm for breathing again, some people experience a fluttering or shaky sensation in their abdomen. If you experience this symptom, use the pursed-lips breathing technique.
Pursed-Lips Breathing Technique
Many people will experience hyperventilation symptoms when checking their breathing or beginning breathing exercises. If this happens to you, discontinue the exercise you are doing. Breathe in slowly and hold it for as long as 20 seconds if you can. Then breathe out slowly by pursing your lips, as if gently blowing out a candle. After only two or three breaths, you should no longer feel dizzy. Then, exercise a little by walking around as you maintain awareness of slow breathing. Come back later and complete the breathing check or exercise.
Instructions for Re-breathing Air from a Paper Bag
If at any time your symptoms escalate and you begin to feel out of control, breathe into a medium-sized paper bag and re-breathe the same air for a few minutes. This will help you replace the carbon dioxide your system has lost from over-breathing. This is a common "fix," but does not help you gain control of your breathing over the long run. Whenever you can, use pursed-lips breathing or the slow exhalation count, which do help you learn to gain control.
Instructions for Slow Exhalation Count beginning on Day Five
Step One
Make yourself comfortable in a recliner or on a couch, where you can lay back but still have your head and upper body raised up a little. Use the sweep second hand of a watch or other timer that shows you the time in seconds to help you gain control of your breathing.
Watching the second hand, gradually slow your breathing to 3 seconds for each inhale and 3 seconds for each exhale. Breathe with your diaphragm as you have been practicing. At this point in the exercise you may be inhaling only 30% of your maximum capacity.
Be sure to exhale completely by squeezing in the muscles of your abdomen at the end of the exhale. As you relax, extend the length of time for each inhale and each exhale to 4 seconds, then to 5 seconds. As you extend the time of each inhale and exhale you will need to take in more air with each breath. Keep at it until you notice that you have more control over your breathing.
Step Two:
Once you feel more in control and relaxed, you can progress to practicing deeper breathing by taking in the deepest possible diaphragmatic breath, pausing for a few seconds at the top of the breath, and then breathing out slowly and counting the seconds in a whisper until you have squeezed out all the air you can. So it's:
- BREATHE IN SLOW DEEP DIAPHRAGMATIC BREATH [70% to 100%].
- P A U S E;
- BREATHE OUT (Counting) ONE, TWO, THREE, FOUR, FIVE, SIX, SEVEN; etc.
Give yourself a rest of a few normal breaths before you try it again. Then, when you are ready, take another deep, relaxed, diaphragmatic breath and count out to a higher number if possible. You will find that the more relaxed you are, the deeper the inhale and the higher the exhale count.
The idea is to gradually increase the time you take to exhale without getting too much or too little air. This means always staying in your comfort zone. As you work with the timer and the slow exhalation count, you should start feeling a lot more relaxed. These are good exercises to do in the evening before you go to bed, as they help you become relaxed and able to sleep well once you are under the covers.
Medications
Working with your doctor is important, because your need for many types of medications will change as you practice diaphragmatic breathing and your overall breathing becomes more functional. If you are diabetic and take insulin, and if your doctor has approved slow breathing exercises, your need for insulin may change; you may need less than you did before. As you overcome panic attacks, your need for antidepressant medications may also change, or you may no longer require them. Only a medical doctor or psychiatrist in consultation with you is qualified to determine your needs.
As mentioned before, many antianxiety and antipanic medications are known or suspected to cause treatment failures. If you have taken some of these drugs for many months or years, the prospect of withdrawing can be uncomfortable. Taking this type of medication on an "as needed" basis is not recommended. Be willing to put up with some discomfort and to use the breathing exercises you will be learning to control anxious feelings. You should not stop any drug on your own; in some cases doing so can even be dangerous.
Verbal Reward
Give yourself an automatic verbal reward every time you do an exercise. This is important even if you do not feel totally successful. Positive thoughts relax your mind and body and lower anxiety. Even doing an exercise in such a way that you induce some symptoms is a positive learning experience. Such self-talk as "Wow, I did it!" or "That's O.K., I know I'm just learning" sets you up to continue your improvement the next time you practice.
-- Bert A., M.Div., Ph.D.
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