1.2. COMPETENCIA LITERARIA Y COMPETENCIA COMUNICATIVA
1.2.2. Modelos de competencia comunicativa
1.2.2.5. Modelo del Marco común europeo de referencia para las lenguas (Consejo de Europa, 2002)
This Manual is both a guide to treatment and a workbook for persons who suVer from panic disorder and agoraphobia. During treatment, it is a workbook in which individuals can record their own experience of their disorder, together with the additional advice for their particular case given by their clinician. After treatment has concluded, this Manual will serve as a self-help resource enabling those who have recovered, but who encounter further stressors or diYculties, to read the appropriate section and, by putting the content into action, stay well.
Contents
Section 1 86
1 The nature of anxiety, panic, and agoraphobia 86 1.1 How do panic disorder and agoraphobia develop? 88
1.1.1 Stress 88 1.1.2 Anxiety 88
1.1.3 Hyperventilation or overbreathing 89 1.1.4 Personality characteristics 89 1.2 The nature of panic 89
1.3 The development of situational fears 90 1.4 Subtle avoidances 92
1.5 Rationale of the program 93 1.6 Hindrances to recovery 94
1.7 The nature of anxiety: a true alarm 94 1.8 Anxiety: a false alarm 96
1.9 Why do I have false alarms? 97 1.10 The eVect of personality 97 1.11 Summary 98
1.12 Hyperventilation 98 1.13 Types of overbreathing 101
1.14 Common myths about anxiety symptoms 102 1.14.1 Going crazy 103
1.14.2 Losing control 103 1.14.3 Heart attacks 103 Section 2 104
2 Control of hyperventilation 104 2.1 Recognizing hyperventilation 104 2.2 Slow-breathing technique 105
2.2.1 Troubleshooting 106 2.3 Daily record of breathing rate 106 Section 3 107
3 Relaxation training 107
3.1 The importance of relaxation training 107 3.2 Recognizing tension 108
3.3 Relaxation training 110
3.3.1 Progressive muscle relaxation 110 3.3.2 Isometric relaxation 110
3.3.3 Further isometric exercises 112 3.3.4 DiYculties with relaxation 113 Sectn 4 114
4 Graded exposure 114
4.1 More about avoidance 114 4.2 Planning your program 115 4.3 Implementing your program 118 4.4 Practicing the steps 118
4.5 Facing fears in imagination 119 4.6 Achieving your own personal goals 119 Section 5 122
5 Thinking straight 122
5.1 Step 1: Identifying anxiety-provoking thoughts 124 5.1.1 Anxiety-provoking thoughts in panic disorder 124 5.1.2 Misinterpreting physical sensations 125
5.1.3 Situational fears and unhelpful thinking 125 5.1.4 Wishful thinking 127
5.1.5 More tips on detecting unhelpful thoughts 128 5.2 Step 2: Challenging anxiety-provoking thoughts 128 5.3 Step 3: Generating alternative thoughts 129 5.4 Troubleshooting 130
5.5 Summary 131
Section 6 131
6 Producing the panic sensations 131 6.1 Panic sensations exercises 132
6.2 Constructing a stepladder of panic sensation exercises 134 6.3 Practicing the panic sensation exercises 134
6.4 Scheduling the panic sensation exercises during the program 134 6.5 Troubleshooting 135
6.6 Plan for break 136 Section 7 138
7 Producing panic sensations in your daily life 138 Section 8 141
8 More about thinking straight 141 8.1 Coping statements 143 8.2 Summary 144 Section 9 144
9 Keeping your progress going 144
9.1 Coping with setbacks or diYculties in making progress 144 9.1.1 Managing anxiety and hyperventilation 144
9.1.2 Planning of goals and steps 144 9.2 Emotional problems during setbacks 145 9.3 Expect lapse occasionally 145
9.4 Conclusion 146 Section 10 146
10 Recommended resources 146 10.1 Books 146
10.2 Video 147
10.3 Internet resources 147
SE CTI ON 1
1 The nature of anxiety, panic, and agoraphobia
Since the time of the ancient Greeks there have been consistent reports of a disorder causing the most irrational fears in otherwise sane persons. It was not until the latter part of the nineteenth century that this came to be known as agoraphobia, which literally translated means ‘‘fear of the market place’’. More recently, it has come to be known more generally as a fear of public places or open spaces.
While fear of public places or open spaces does characterize the majority of
suVerers of agoraphobia, recent evidence suggests that these situational fears are not the primary fears in agoraphobia. It is the fear of panic or anxiety attacks, regardless of where they occur, that is the primary fear in panic disorder and agoraphobia.
Many people have attacks of panic. However, only a few people continue to have frequent or distressing attacks of panic that begin to interfere with their day-to-day functioning. When panic attacks are very frequent or when a person spends a considerable amount of time fearfully anticipating the next attack of panic, that individual may be said to suVer from panic disorder.
Some people with panic continue their daily lives despite the attacks of anxiety that strike them out of the blue. For other people with panic, the attacks of anxiety lead them to avoid situations for fear of panic. Typically, people who panic do so for one of three reasons. First, they may avoid situations because they see a link between the various situations and their panics. For example, panic attacks may occur regularly in shopping centers, so the person comes to avoid these places.
Second, people with panic can avoid situations where a panic may occur because of the physical or social eVects of panicking in that place. For instance, someone who fears urinating during a panic may avoid places where people easily may observe the consequences of such a loss of control. Finally, individuals may avoid situations where they perceive that they do not have the resources to manage a panic. For instance, a person may avoid driving if they fear that a panic may rob them of the capacity to drive safely.
The avoidance of situations for fear of panic typically includes crowded areas, open spaces, buses, trains, closed-in places, and being a long way from home or help. Remember, these fearful avoidances are secondary to the basic fear: the fear of panic. It is, therefore, more appropriate to describe agoraphobia as a fear of panic attacks that may lead a person to avoid any situation or activities that they think will provoke these attacks or prevent escape or hinder help arriving.
The distinction between primary and secondary fears is important. For individ-uals with panic disorder it will be necessary to learn to control the primary fear, the panic attacks. For individuals with panic disorder and agoraphobic avoidances, the fact that the fear of situations is secondary to the fear of anxiety means that to overcome the problems of agoraphobia it is necessary to learn to control the anxiety and panic attacks. Once this primary fear is controlled, an individual with agoraphobia can learn to overcome the situational fears. As individuals learn that they can control their anxiety and their panics, they can confront those situations that they have previously avoided, secured by the knowledge that they can prevent panic attacks.
This primary fear in agoraphobia is often described as a fear of fainting or collapsing, having a heart attack, going crazy, losing control of bowel or bladder,
or in any other way losing personal control. The secondary or situational fears are many and varied. These fears include any situation that an individual believes will provoke or is associated with high anxiety. The important point here is that one does not actually have to experience an anxiety attack in all of these situations, but need only believe that the situation might provoke an attack. In this sense it is not only the attacks of anxiety but the way in which an individual thinks about the attacks that determines which situational fears develop. In our experience, almost all people with a long-standing panic disorder come to avoid some situations for fear of panic. The extent of your avoidance will determine the amount of time and energy you will need to allocate to overcoming this problem.
Some disorders occasionally mistaken for agoraphobia include depression, schizophrenia, social phobia, and obsessive–compulsive disorder. However, a reasonable understanding of the nature of agoraphobia as previously described generally allows for easy classiWcation of these disorders as not constituting agoraphobia.
1.1 How do panic disorder and agoraphobia develop?
1.1.1 Stress
For many people, theWrst panic attack occurs during a period of increased stress.
Stress can be psychological or physical.
Psychological stress: such as arguments with parents or partner, death or illness in the family, problems with others outside the home,Wnancial problems, or work pressure.
Physical stress: resulting from personal illness, exhaustion from overworking, excessive use of alcohol or drugs, lack of sleep, low blood sugar as a result of dieting.
1.1.2 Anxiety
Both physical and psychological stress can produce an anxiety reaction. Becoming anxious is not the inevitable consequence of stress, but it is a common result.
Often these stresses and the associated anxiety can be quite subtle, but it is in these situations that a person is more vulnerable to a panic attack.
At some time or another everyone experiences stress and reacts by becoming anxious. However, not everyone who experiences anxiety develops panic attacks.
The question arises why some people develop panics while others don’t. Unfortu-nately, there is no single answer to this question as yet. There are, however, various possible explanations. First, there is some evidence that people who develop panic disorder and agoraphobia have been subjected to greater than normal amounts of stress just prior to their Wrst attack, thus making them more vulnerable than
others. Second, it may be the case that people who develop panic attacks are more vulnerable than others to stress and to worry about panic attacks.
1.1.3 Hyperventilation or overbreathing
To hyperventilate means to overbreathe, either by breathing too quickly or too deeply. The actual abnormal breathing often goes unnoticed by the suVerer;
however, the eVects of hyperventilation do not. The symptoms include dizziness, light-headedness, tingling sensations in hands or feet, weakness in the legs, palpitations, tightness and pains in the chest, and rising panic. These symptoms are the result of reduced carbon dioxide in the blood as a result of overbreathing.
Control of these symptoms will be discussed in Section 2.
1.1.4 Personality characteristics
Another possible reason why panic disorder and agoraphobia aZicts some and not others is that people have diVerent natures. Most suVerers of panic disorder and agoraphobia have a tendency to worry. They are often overly concerned with many aspects of their lives, especially their health. When things go wrong, or do not turn out as expected, some of us consider that it is a more drastic or serious problem than is actually the case. Control of these worrying and self-defeating thoughts, which often contribute to anxiety, will be discussed in detail later in the Manual.
For the present, we shall turn our attention to the attack of panic.
1.2 The nature of panic
A panic attack is a sudden spell or attack when you feel frightened, anxious or terriWed in a situation when most people would not feel afraid. During one of these attacks you may have noticed some of the following sensations:
∑ Shortness of breath
∑ Pounding heart
∑ Dizzy or light headed
∑ Tingling Wngers or feet
∑ Tightness or pain in the chest
∑ A choking or smothering feeling
∑ Feeling faint
∑ Sweating
∑ Trembling or shaking
∑ Hot or cold Xushes
∑ Things around you feel unreal
∑ Dry mouth
∑ Nausea or butterXies
∑ ‘‘Jelly legs’’
∑ Blurred vision
∑ Muscle tension
∑ Feeling you can’t get your thoughts together or speak
∑ Fear you might die, lose control or act in a crazy way
When the panic becomes severe, most people try to get out of the particular situation in the hope that the panic will stop, or else they get help so that should they collapse, have a heart attack, or go crazy, there will be somebody with them who will look after them. Occasionally, some people want to go somewhere alone so that they do not embarrass themselves in some way.
TheWrst few times that someone experiences a panic attack are usually very frightening because this is a new experience that is strange and abnormal. How-ever, after many such experiences most people know deep down that they’re unlikely to lose control, collapse, die, or go crazy. At least, they haven’t up till now.
However, many fear that the next time may be diVerent, that the next panic may be the worst. Some people manage to resign themselves to the experience of panic, even though they never like the experience.
Panics rarely come truly out of the blue. Even theWrst attack usually occurs at a time when the individual is under emotional pressure, or unwell (e.g., recovering from theXu), or when they are tired and exhausted and beginning to feel at the end of their tether. A person’sWrst panic attack is very uncommon when someone is truly safe, genuinely relaxed, and free from stress.
1.3 The development of situational fears
Most people rapidly learn to predict the situations in which the panic is likely to occur. It is not that the situation is so dangerous; it is just that they can identify it as an awkward place to have a panic. Planes, trains, buses, elevators, or escalators are often seen as awkward places to panic, since you have to wait until they stop in order to get oV. Having to wait in a line in a bank or a shop is often diYcult for the same reason. Being truly alone, as in being at home with no neighbors to call, or driving on a lonely road, or being in a lonely place like a beach or aWeld can have the same eVect: who would come to your aid if you panicked? Driving on your own and being caught in a traYc jam has all these problems: being alone, help can’t get to you, but you can’t really leave the car should you panic. Of course, for some, the fear of making a fool of yourself outweighs the need for help, and so you’d do anything to be alone.
When an event occurs in our lives, we seek an explanation for that event. Also, when a panic attack is experienced, an individual will seek an explanation for it. At the time of the attack, 90% of people with agoraphobia will have no true explanation of why the attack occurred. Stress, anxiety, and hyperventilation,
which have in fact caused the attack, are not seen as the reasons by the suVerer.
This is because stress, anxiety, and overbreathing develop gradually, and the individual is often unaware of their presence.
The individual with agoraphobia mistakenly explains the panic attack in terms of the situation in which the panic was experienced. One way that this association is made is by the process of conditioning. Because the experience of the panic and the place in which it happened both occurred at the same time, the conditioning process leads to an association between the two events being made in memory.
Your memory of the attack is associated with your memory of the situation in which it occurred. It is this association that leads to the belief that the situation caused the attack. This belief leads to the development of the situational fears and the avoidance of certain situations.
As was mentioned previously, not all situations avoided by people with agora-phobia have necessarily been the site of previous panic attacks. These individuals need only think that a certain situation may provoke an attack to avoid it. This explains the often widespread fears and avoidances held by people with agorapho-bia. It also explains the speed with which these fears can develop. In fact, in 30% of people with agoraphobia, widespread avoidance develops within one week of the Wrst panic attack. The process by which these avoidance behaviors or fears spread is known as generalization.
It is important that you understand the concepts of conditioning and generaliz-ation because the successful treatment involves the breaking down of the associ-ations between the panic attacks and the avoided situassoci-ations that have been built up by these two processes.
Another reason why people with panic attacks develop avoidance of feared situations is because they see themselves as being unable to control a panic in that situation. Because the panic is out of control, the person begins to worry about the possible consequences of having a panic, the embarrassment or possible injury.
For example, you may worry that people will think less of you if you collapse in public, or you may worry that if you were to lose control of your actions you may injure yourself or loved ones. Whatever the reason, it appears sensible to avoid situations in which the consequences of having a panic (such as driving a car) are frightening.
Remember, the primary fear in agoraphobia is the fear of panic or anxiety attacks, not the fear of certain places or situations. The situational fears are secondary. Successful treatment involves,Wrst, learning to manage and control the anxiety and panic attacks and then, second, with that knowledge, learning to overcome the situational fears.
1.4 Subtle avoidances
We have already talked about avoidance of actual situations, but there are also other types of avoidance which, although more subtle, are nevertheless connected to panic attacks.
∑ Do you avoid medication of any kind even if your doctor prescribes it?
∑ Alternatively, do you avoid going out without medication?
∑ Do you avoid exercise?
∑ Do you avoid becoming very angry?
∑ Do you avoid sexual relations?
∑ Do you avoid very emotional movies such as horror movies or even very sad movies?
∑ Do you avoid being outside in very hot or very cold conditions?
∑ Do you hate being startled or frightened?
∑ Do you avoid being away from medical help?
∑ Do you keep an eye out for exit routes?
∑ Do you avoid standing and walking without structural support?
If so, these forms of avoidance may well be connected to panic attacks and will need to be overcome.
Distraction can act as another form of avoidance. Many people attempt to ‘‘get through’’ situations in which they are afraid of having panic attacks by distracting themselves. For example, if you feel yourself becoming anxious or panicky do you:
∑ Carry around something to read and then read it as intensely as you can?
∑ Open windows?
∑ Play loud music?
∑ Try to imagine yourself somewhere else?
∑ Tell somebody who is with you to talk to you about something – anything?
∑ Seek reassurance
∑ Play counting games?
If you have tried many of these tricks (or are still using them), then the chances are that they have helped you to get through a panic attack in the past and may well help you in the future. However, these tricks often become strong habits in themselves to the extent that many people come to depend on them. In the long run, these strategies, while not harmful, are not helpful, since they do not change the core element of panic attacks or your anxiety over the future occurrence of panic attacks.
In addition, if you are too busy distracting yourself, you will be unable to employ the techniques we will be teaching you to control worrying thoughts.
During a panic attack, the thoughts and statements that one tells oneself involve the sense of impending doom, that something terrible is about to happen, and involve a great deal of worrying about the present and future. There is an
anticipation of the worst and apprehension about what may be going to happen.
In addition, there are feelings that events could proceed uncontrollably or that one may not have control over one’s own reactions. We will be looking at how such thoughts can trigger, intensify, and prolong our anxiety reactions.
1.5 Rationale of the program
This program will teach you to alter your responses by learning to change the way you think and the way you react to certain events. In essence, you will be learning
This program will teach you to alter your responses by learning to change the way you think and the way you react to certain events. In essence, you will be learning