Fears Conquered: CBT self-help guide for panic and agoraphobia. by The CBT Resource by Marie Chellingsworth

Fears conquered with Exposure and Habituation

Marie Chellingsworth Photography by Andy Poplar [Vinegar & Brown Paper] ®

© 2020 Marie Chellingsworth. The CBT Resource ®. 3rd Edition. Last updated May 2020. The right to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patent Act, 1998. All rights reserved. This work is provided under specific license for individual clinical use only by subscribed members of The CBT Resource Annual CPD & Resources plan in 2020/2021. It may be photocopied, printed, and distributed to patients only by the subscription holder for their individual clinical use only in the original binding. You cannot host this booklet electronically on any website, or pass it onto any other non-subscription holder for clincial use. This condition must be imposed at all times and this work cannot be sold for profit, used for training, edited, copied in full or part, repackaged or amended in any other way without the express permission of the author. The work cannot be circulated for use outside of the license boundaries. It is the responsibility of the service to ensure that staff who support this material are suitably qualified, have specific CPD training in this protocol and receive regular case management and clinical skills supervision. The main photographs used in this booklet are subject to copyright and the work of Andy Poplar[vinegar&brownpaper] and are used with kind permission (see the about the author section for more information about Andy’s work and his own experiences with anxiety and depression). It is the responsibility of the service to ensure that staff who support this material are suitably qualified, have specific CPD training in this protocol and receive regular case management and clinical skills supervision. We would like to thank the focus groups and practitioners who have provided feedback on the development of this workbook design. Your help has been invaluable. The readability score is 13.4 and the Flesch reading ease is 80, calculated independently with Readability Studio©. This information booklet has been designed to meet NHS information Standard Principles and conform to good practice guidelines for self-help and patient information. It is designed to be combined with support by a suitably qualified practitioner who has received specific CPD training in supporting this protocol. Disclaimer: This information is provided for information, not advice you should rely on. It is not a substitute for proper diagnosis, treatment or the provision of advice by an appropriate health professional or an alternative to specific advice. If you have questions about any medical matter or think you are experiencing any medical condition, you should consult your doctor or relevant professional healthcare provider without delay. Information provided is intended for information purposes only, upon recommendation of and alongside the support provided by a suitably qualified clinician. While every reasonable effort has been made to ensure the accuracy of the information, no guarantees, representations or warranties can be given that the information is accurate, free from error or omission, complete or up to date. The diagnosis and treatment of mental health conditions requires the attention of a qualified medical or mental health professional. If you are seeking diagnosis or treatment, you should consult a mental health professional in the first instance. We shall accept no liability for any act or omission occurring in reliance on the information or for any consequences of any such act or omission. By using this information, you are agreeing to the provisions of this disclaimer and copyright notice.

Contents 1-4

What is panic disorder and agoraphobia

5-6

How exposure and habituation helps

7-8

Meet Alison and Ferg

9-10

My own vicious cycle

11-12

My targets for treatment

Building motivation

The 4 essential conditions

16-17

Creating your hierarchy

Planning your first week of exposure and habituation

19-20

Alison’s example diary of week 1

My exposure diary

22-24

Reviewing week 1 and planning week 2

25-26

Reviewing week 2 and planning week 3

Carrying on with exposure and habituation

28-33

Relapse management

34-37

Spare diary and review sheets

Where to get more help

Your notes

About the author and Andy’s images

What is panic disorder and agoraphobia?

This workbook contains a CBT treatment called Exposure and Habituation. It is recommended for the treatment panic disorder and agoraphobia, due to its large evidence base.

What is panic disorder and agoraphobia? Panic disorder is widely experienced problem. It is an anxiety disorder that affects about 7 in every 1000 people in the UK. A panic attack is a rapid rise in anxiety, usually reaching a peak within ten minutes. It is experienced as a rush of physical sensations. These sensations are the result of the adrenalin response in the body and are not harmful. While the attacks are not dangerous, they are very frightening and unpleasant at the time. They can feel very concerning and people can think they are a sign of something more sinister or catastrophic happening. Anyone can experience a panic attack. Some people have a one off attack and then don’t experience any ongoing anxiety afterwards. Some people have panic attacks, but as just one part of a different anxiety disorder and not the main focus of their fear, such as in a specific phobia, social anxiety disorder, illness anxiety disorder or Post Traumatic Stress Disorder (PTSD). These disorders are treated differently to panic disorder, so an assessment of current symptoms is important first, to get a clear picture of what is happening. In panic disorder, the person has a first panic attack and then goes on to have multiple attacks on a regular basis. The panic attacks can be unexpected and seem like they come out of the blue. The physical symptoms of anxiety rise to a peak within minutes and are very frightening at the time. People with panic disorder understandably fear having more attacks and begin to avoid situations, places or activities that seem to bring them on. Some people also experience agoraphobia alongside their panic disorder. This is when someone feels panic in situations they are unable to escape from quickly or where getting help would be difficult. This includes crowded busy places, public spaces or wide open areas. This can be anywhere out of their home. This leads to high levels of avoidance and restrictions on how they can live their life.

The good news is that the National Institute for Health and Care Excellence (NICE) recommends a Cognitive Behavioural Therapy (CBT) treatment for panic disorder and agoraphobia called exposure and habituation. It is the recommended treatment as it has a large evidence base to support its use. This workbook helps you to use exposure and habituation, with support from a trained practitioner.

What are the symptoms of panic disorder? In panic disorder, the person will have experienced one or more panic attacks, with at least one month of fear of having another attack and significant adaptations to behaviour to avoid having another. The physical symptoms of panic, which are brought on by the adrenalin,in response, can come on when the person is anxious, or when they are calm , as unexpected attacks. Four or more of the following symptoms should be experienced: • • • • • • • • • • • •

Palpitations, pounding heart, increased heart rate Sweating Trembling or shaking Shortness of breath Feelings of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady or light-headed Chills or heat sensations Numbness or tingling sensations (paresthesias) Feeling detached from what is going on around you (de-realization) Fear of losing control, going crazy or of dying

What is the adrenalin response? The physical changes of the adrenalin response are a normal reaction in the body to some kind of threat or danger. This is sometimes called the ‘fight or flight’ response. We share this response system with all other mammals, to keep us safe from harm. It is a helpful safety response that we all need when there is a threat or danger we need to © Marie Chellingsworth (2020). The CBT Resource.

respond to quickly. For example, when you go to pull out to change lanes on the motorway, but then see a car has just changed lanes and is racing up the lane you are about to cross into. It is this response that kicks in to help you to take action to swerve back into your lane and avoid a collision. The main function of the adrenalin response is to prepare the body to quickly move out of harms way or take an action to stay safe. It is to prepare the body for vigorous, quick action when there is an immediate threat or danger to respond to. In panic disorder, this process is being triggered when there isn’t an actual threat or danger to respond to. We do not have adrenalin in our bodies all the time. On response to a trigger, we only produce just enough to get our way out of the acute situation as quickly as possible. When the body perceives there is an immediate danger to respond to, like seeing the car in the lane on the motorway, it sends an alarm signal to the amygdala in the brain. in turn this communicates with the hypothalamus. The hypothalamus is like a command centre in the brain. It triggers the sympathetic nervous system, the arousal response, to release adrenalin. Adrenalin is released through the activation of nerves connected to the adrenal glands. These nerves trigger the secretion of the adrenalin into the bloodstream. As the adrenalin circulates through the bloodstream it brings on a number of automatic physical changes. This process happens very quickly. When adrenalin is released, breathing changes from the nose to through the mouth, to take in more air. Breathing becomes more rapid. These changes can make the mouth feel dry or like you cannot get your breath. Small airways in the lungs open wide to enable more oxygen to be taken in with each breath you take. The extra oxygen is sent to the brain to increase alertness and to the bloodstream to reach the arms and legs with oxygenated blood. The heart rate goes up to pump the oxygen rich blood around to the arms and legs to allow us to move quickly. The adrenalin response also ensures that heart rate does not go too high and is regulated (although it can feel like it is very high at the time). Blood vessels dilate or constrict to allow the oxygenated blood to reach the arms and legs more quickly and efficiently and to reduce the flow to areas where it is not as needed temporarily.

This can feel a little strange and may lead to pins and needle feelings, shaking or dizziness as the oxygen rich blood travels around the body. The senses also sharpen. Your field of vision may narrow to enable you to focus on the threat (fight) or widens to enable you to get to safety and escape (flight) depending on the situation. It is these physical changes that give the feelings of high anxiety and can also be misinterpreted as being harmful themselves. Once the threat is over, or when we use up the adrenalin secreted into the bloodstream (whichever comes first) the physical symptoms of the adrenalin response, along with the feelings of anxiety, come back down naturally. Why do some people develop panic disorder? In panic disorder, the physical sensations of the adrenalin response have been misinterpreted by the body as being a sign of imminent danger themselves. For example, the body may interpret the heart rate increasing as being a sign of being about to have a heart attack, the feelings of dizziness of being about to collapse or the dry mouth of a sign of being about to choke. The problem with this is, the alarm system then learns it should fear these symptoms and it goes off any time they occur, thinking there is a real danger or threat we need to respond to. A bit like an over-sensitive smoke alarm warning there is a ‘danger’ when there is no emergency to attend to. In other words, the body has learnt to trigger the adrenalin response for the physical symptoms of fear itself or situations that can bring these on. The body is treating these as a reason to trigger and sound the alarm. These triggers can be places you have had anxiety or panic before or situations that bring on the physical symptoms that mirror the adrenalin response symptoms like exercise, sex or even walking up stairs for example as these increase your heart rate. Understandably, you begin to avoid things that trigger you feeling this way as much as possible. You may also try to escape from these situations if you begin to have symptoms, or may do things to make them go more quickly. People often also have a range of things they begin to do to feel ‘safer’ in these situations. These are called safety seeking behaviours and are often done initially to help with the unpleasant physical symptoms you experience, such as carrying water for a dry mouth or distracting yourself in some way from your anxiety. © Marie Chellingsworth (2020). The CBT Resource.

How does exposure and habituation help?

When you avoid, escape from situations or use safety seeking behaviours, your anxiety comes down quite quickly. In the short term this provides some relief from the unpleasant symptoms. So, you begin to avoid more and more things that trigger your symptoms, placing increasing restrictions on your life. The problem however, is that your body does not then get the opportunity to learn it does not need to set off the panic alarm for these triggers and that the symptoms come down naturally themselves. They actually confirm to your body is should fear these symptoms. It doesn’t stop the body triggering the response in the future. So, each time you face a trigger internally or externally, your anxiety level goes up right back up again to the high level like in the diagram below. It feels horrible each time, so you do thing try to bring it down again more quickly. Your body associates feeling safer to these behaviours, rather than learning that it does not need to produce these symptom in response to the triggers in the first place. So it keeps happening, keeping you in a vicious cycle of panic, avoidance and anxiety. Level of Anxiety (%)

In exposure and habituation, you gradually face things that make you feel anxious and that you avoid, in a way that feels manageable and is planned in advance. This breaks the vicious cycle of anxiety and panic as your body learns not to produce fear on response to the triggers anymore.

100 80 60 40 20 0

Time (mins)

How does exposure and habituation help? Exposure and habituation works by helping the body to over-learn it does not need to produce the adrenalin response for these triggers, that the physical symptoms of adrenalin are not harmful and do naturally come down by themselves. Habituation is a form of learning that takes place to decrease a response to a stimulus (trigger) through repeated and prolonged presentations to it. In other words, when your body is exposed to a fear producing trigger and you remain with the anxiety so it comes down naturally, learning takes place that your body does not need to produce the same level of adrenalin response to the trigger next time. You do this in a graded way that feels manageable and not overwhelming. You create a hierarchy, a list of things that you currently fear and avoid and rate them. Then, starting with things that are easier, but still give enough symptoms of anxiety for habituation to take place, you expose yourself to the trigger and remain with the physical symptoms of fear until they drops by half from the start of the exercise.

Level of Anxiety (%)

100 80 60 40 20 0

Time (mins)

The fear drops as your body begins to use up the adrenalin that it has produced. As it goes down, your body learns that it managed the situation and it wasn’t as much of a threat as it predicted. So next time, it will produce less fear as a result. Each time you repeat the exercise, the anxiety should be lower and not last as long. As you repeat this more times, it should get easier and easier until your body has learned that it does not need to produce high fear on response to that exercise, as in the diagram above. This is a process called habituation. Then, you can step up the hierarchy list and work on the next item.

Meet Alison: I first had a panic attack in a lecture at university. I had gone as an older student to study nursing and didn’t really know many people as I didn’t live in. I really thought I was going to die when I first had a panic attack. It was horrible. My heart was beating out my chest and I could not catch my breath. I ran outside and everything seemed to slow down around me. People were staring and someone called an ambulance. After that, the attacks became more regular. I started to avoid any busy, crowded place in case it happened again. I stopped socialising. I couldn’t go on the bus or train. I didn’t like driving on busy roads. Everything became hard, even getting past my front door. I woke up having one sometimes, which was terrifying. I had read about CBT online and wanted to try it to get my life back. I wanted to be able to finish my course and be able to travel to placements. I referred myself for an assessment. It was probably the hardest thing I have done, but so worth it.

Physical symptoms Heart racing Shaking Sweating Rapid breathing Dry mouth

Behaviours

Altered thoughts

Avoiding busy, crowded places Missing lectures Only going out at quiet times Ordering everything online Avoiding the cinema Only driving locally outside of rush hour

“What if I am having a heart attack?” “I am going to pass out” “If I go out without water I will have an attack” “I must keep myself safe”

Meet Ferg: I went to my GP for help. I didn’t feel able to go out anywhere without Joe, my partner. He had to take me to work and collect me each day around his own job, or I would have to work from home. Places like bars, restaurants and shops all became a no go. Even if we needed a pint of milk, I would wait for Joe to come home and get one. I would only do it when it was really quiet, as a last resort. It was all really hard on our relationship. I stopped playing 5-aside and going to the gym. I even avoided sex, as that could bring it on. Exposure and habituation wasn’t easy, it was the total opposite of what I wanted to do to be honest! But hiding away had just made life worse for us both. Facing my fears has given us both our lives back. I can sit in a cafe, go to restaurants, the cinema, do the shopping and have started commuting to work again. I feel like the old me again.

Physical symptoms Rapid heart beat Pins and needles Shaking Sweating Dizziness

Behaviours Avoiding the gym and exercise Avoiding going out alone Avoiding public transport Taking the lift rather than the stairs Avoiding sex

Altered thoughts “I can’t cope with another attack” “I don’t feel safe unless Joe is with me” “I am going to collapse” “All this anxiety is weakening my heart”

Ferg: “It helped me to write things down and see how much it was affecting Joe’s life as well as it was mine. It made me want to get this sorted for both of us. I set goals of what I wanted to do and where I wanted us to go when my anxiety was better. That made me realise how much I would gain from this. I knew it was worth facing my fears” 9

My own vicious cycle Write down the symptoms you are experiencing in each of the areas below. Think about where you are not able to go as a result of your symptoms, things you are no longer doing and also any things you have started doing to feel safer, even subtle things (safety seeking behaviours). Try to write thoughts as actual thoughts that go through your mind when you are having the physical symptoms you experience. Exposure and habituation will help you to break into the cycle to being about change. You can then set some targets and goals for treatment next for when these symptoms improve.

Physical symptoms

Behaviours

Altered thoughts

My targets for treatment Imagine into the future and that the symptoms in the cycle have improved and the vicious cycle of panic and anxiety has been reversed. How would your life be different from now? Answer the questions below and think how things would be different for you and what you would be doing that is difficult now:

Where would you be going?

(For example, I would be able to go on holiday. I would be able to socialise outside the home more with friends, I would be able to go to an evening class...).

What would you be doing?

(For example, I would be sleeping better, I would be spending more time with my friends and family instead of worrying, I would be able to travel more, I would be able to apply for the promotion I keep avoiding, I would be sleeping better....)

Who would you be with?

(For example, I would be spending more time with my flat mates or partner, or spending more time with my children at weekends....)

If these are targets you would like to work towards in treatment you can make goals for them below:

Goal 1: for example, see my friends every couple of weeks. Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so:

Goal 2: for example, not bring work home with me Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so:

Goal 3: for example, drop off to sleep more easily, without waking up worrying during the night

Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so:

Building motivation Thinking about the problem and beginning to work on the goals you have set. On a 0-100 scale rate: How much impact does the problem have on my life currently? 0 50 100 not at all affects everything

How important is it for me to reach my goals? 0 50 100 not at all totally important

How willing and able am I to set aside enough time to get better? 0 50 100 not at all totally willing

How much of a priority is getting better for me at the moment? 0 50 100 not at all complete priority Activity: Some people find it helpful to complete the following exercise. This is useful if you are struggling with your motivation because of how you are feeling. Write two short letters to yourself. In the first letter, you are writing to yourself now as if it is five years into the future and you haven’t set aside the time to get better or improve your panic disorder symptoms. What would life be like? What would you like to say to your current self, to get you to set some time aside now for feeling better? Next, in the second short letter to yourself. It’s five years in the future and you have made the changes to break the vicious cycle and feel better by using exposure and habituation. How pleased are you? What changes has it opened up in your life? What would you be doing? Where would you be going? Visualise your life improved as a result. Turn to the next page to get going towards that now. Every step is a step in the right direction. 13

Alison: “I found it hard to imagine leaving the house again, to get back to doing the things I couldn’t do with this. I missed going to the beach so much. I wanted to get a dog again and be able to walk him there. That really helped to motivate me. I wanted to get my degree and be able to work in the job I always dreamed about helping others. I certainly didn’t want to bring on my symptoms, but I also didn’t want to stay the same anymore, stuck spending my in my own living room. The pros of doing it, really did outweigh any cons.” © Marie Chellingsworth (2020). The CBT Resource.

The 4 essential conditions

Exposure and Habituation has 4 essential conditions to make it work effectively that you should check your plan against each time. Making sure your plan meets these conditions means you will be able to habituate and help your body to learn to switch off the alarm for things it doesn’t need to respond to.

Graded: The first condition is that is graded so there is enough

anxiety to habituate, but it is not overwhelming and feels manageable. 50-60% is a good starting exercise.

Prolonged: The second condition is that each time you do the

exercise you stay in the situation until your anxiety drops by 50% from the rating at the start of your exercise.

Repeated: The third condition is that you need to repeat each step of

the hierarchy until it no longer triggers a high level of fear. 4-5 exercises of exposure a week on average is needed to achieve this. Some weeks you will do a mix of steps if you habituate to one. This needs to be done over this short time frame so that the repeated exercises are close enough together for habituation to take place. You repeat each step of the hierarchy as an exercise until your anxiety drops to 40% or less before and at the start of the exercise. Then you know habituation to that step has taken place and you can move to the next exercise. Remember each step will produce an increased level of fear as you work up the hierarchy, even when you have habituated to the previous step, although it often gets easier than predicted.

Without distraction: The final condition is that you need to be

aware of any internal or external distractions, even subtle things that can distract you as you are doing the exercise. You must experience the anxiety without any safety behaviours or anything to bring your anxiety down artificially.

Creating your hierarchy

Use the hierarchy worksheet to help you to identify what you are avoiding and any triggers for your fear and panic. These triggers may be situations, places or physical sensations. Put the things that you find most anxiety provoking towards the top of the hierarchy and add things that would be less anxiety provoking that or more difficult than the easier things. Grade in increasing levels of fear up the hierarchy. You don’t grade things on your hierarchy by an amount of time you will expose yourself to them, grade them by how difficult they would be to do in terms of the fear they produce. In exposure and habituation, you need to stay in the situation until your anxiety drops by at least 50% from where it is at the start of the exercise and we do not know how long this will take. You could end up leaving the situation too soon, which would mean the treatment was not effective. You don't want to face your fear, feel the anxiety and not actually benefit from habituating to it! If you can’t imagine being able to drop a safety behaviour at the start of your treatment, for example, you currently only go out with your partner, you may wish to include this in the treatment initially. For example, you might go out to a place with your partner somewhere you would currently avoid, as an easier step of the hierarchy. The first important thing if you do this, is that it still needs to produce 50-60% anxiety doing that exercise to be suitable for treatment, if it is below this, it can still go on, it just won’t be where your treatment should start. The second important consideration is that it is important that the same exercise should then be graded on the hierarchy without that safety seeking behaviour e.g. going to the same place at that time, without your partner. This should be a higher step on the hierarchy to ensure the safety seeking behaviour is dropped during treatment. Once you have created your hierarchy, select the step that causes you some anxiety, but one you feel you could manage. It should still give you enough symptoms of anxiety to enable habituation to take place.. A useful suggestion is that it needs to give you at least 50-60% anxiety to use in an exposure exercise. You may have easier things on the hierarchy, but if it is under 40-50%, it does not provoke enough fear to use for treatment. You would still feel fearful, but not have enough physical symptoms for habituation to take place. © Marie Chellingsworth (2020). The CBT Resource.

My Hierarchy List

Most difficult...

Stress / anxiety rating (0-100%)

More difficult...

Stress / anxiety rating (0-100%)

Easier...

Stress / anxiety rating (0-100%)

Planning your first week of exposure and habituation exercises Select a first exercise on the easier section of your hierarchy. It should be one that still meets the condition of graded, whilst giving enough physical symptoms of anxiety to habituate to. Aim for 50-60% anxiety as a starting point. You may have lower graded exercises, but these won’t provide enough symptoms to habituate. Write your chosen exposure exercise into the exposure diary and make a plan for when you will do it and be able to repeat it 4-5 times over the next week. Remember it can take somewhere between 20 minutes to 120 minutes to come down and each person metabolises the adrenalin back in at a slightly different rate. So leave enough time for the first exposure exercise. After that, if the conditions are met, each repeated exercise of that step should come down a little more quickly and not go as high. That gives you an indicator of how much time you will need to set aside for the first week. Once you have decided when you will be able to do your first exposure exercises, fill in the dates and times on your exposure diary. This is where you will detail what you did, how it went and your anxiety levels to check if you are habituating to it. You can then plot it out on the blank habituation graph. Your Practitioner supporting you will help you to review how it went and problem solve any difficulties in your next session. An example of Alison’s completed week 1 diary is provided for you to see what she did, her ratings and when she stepped up. When you begin to prepare to do your exposure exercise before going into the situation, just before the planned start time, fill in the ‘Before Exercise’ rating to indicate how much anxiety you are experiencing. Use the rating scale at the bottom of the diary to help you. Just as you start your exposure exercise in the situation, re-rate your anxiety again using the ‘Start of the Exercise’ rating column. This is the figure you will use to know when to stop the exposure exercise when this level has dropped by 50%. Once your anxiety has dropped by half, fill in the time you did the exercise over in the ‘Duration’ box on the worksheet. This helps you to plot your exposure on the habituation graph to see how your anxiety went and how long it took to drop for each exercise.

Alison: “I felt like I didn’t have much time around my course, so I was worried about doing this at first. Although I knew if I didn’t get this sorted then I might not be able to finish uni at all. I really just wanted to be able to get on with things like my friends and not feel this way anymore. My practitioner James helped me to make my plan and was really supportive. My first week wasn’t easy, but by the second rung on the hierarchy it wasn’t as bad as I had predicted it would be. I had good days and bad days, but looking back now, my only regret is not doing it sooner” 19

25 mins

70 mins

Saturday 14. 45

Sunday 09. 30

Mild distress/anxiety 25%

To walk to the local park when quiet

To walk to the next street alone at a quiet time of day

What exercise are you doing?

70%

30%

40%

80%

85%

*Start of exercise

Moderate distress/anxiety 50%

60%

30%

45%

55%

Before exercise

Comments

Panic 100%

Felt hard again to begin with but I was expecting this and it got better,

Feel ready to try the next exercise!!! eek

Not as bad this time :)

Still horrible but I did it!

Terrifying but I did it! It took a while to drop by half but I stuck with it

Severe distress/anxiety 75%

35%

15%

20%

35%

40%

End of exercise

Rating of distress/anxiety level

* Your anxiety rating should drop by half from the start of exercise rating during each exposure exercise. Step up the hierarchy when the step you have been doing no longer triggers more than 40% anxiety before and at the start of the exercise.

No distress/anxiety 0%

40 mins

75 mins

Monday 06. 30

`Wed 06. 00

85 mins

(complete at end)

Sunday 09. 30

Date & time

Duration

Alison’s completed week 1 diary

(complete at end)

Mild distress/anxiety 25%

Before exercise

End of exercise

Severe distress/anxiety 75%

Start of exercise

Rating of distress/anxiety level

Moderate distress/anxiety 50%

What exercise are you doing?

Panic 100%

Comments

No distress/anxiety 0%

Date & time

Duration

Exposure recording diary

Reviewing your first week Plotting out your exposure exercises Congratulations in doing your first week of exposure and habituation! You have taken a massive step forwards towards feeling better. On the blank exposure and habituation graph, you can plot out each of your exercises from the ratings that you took. This can be done with your Practitioner in your next session, or if you feel able, you can fill it in advance and discuss it at the next appointment. This gives a clear visual idea if you have habituated enough to the step on the hierarchy you started with and if you are ready to move up to the next step. Start on the zero and plot your before rating, your start of exercise rating and your end of rating and draw the line between them for the amount of time it took to drop by 50%. Then plot out each exposure exercise you repeated. See if it looks like the image at the start of this guide where habituation has taken place, with each repeated exercise getting a little easier and taking less time to get to a 50% reduction, until it no longer triggers a substantial amount of anxiety anymore. Then, use the review questions on the next page to guide you for next steps Even if you did not complete your exercises, or If you did anything that brought your anxiety down artificially, like used a safety behaviour or left the situation, still plot what you did do and still make a plan for your next appointment with your practitioner. You can review what happened with your supporting practitioner and make a plan to move forwards and they can always help and provide support to move forwards. 100

Level of Anxiety (%)

0 © Marie Chellingsworth (2020). The CBT Resource.

40 Time (mins)

70 22

Reviewing week 1 and planning your second week If you did the exercises without any distractions and meeting the conditions 4-5 times, but you are still producing above 40% anxiety rating before or at the start, it may be that you need a few more repetitions to habituate to that particular step in week 2.Some steps take longer than others to habituate to. This was your first go with the exercises, so it may take a bit longer in some cases for habituation to take place depending on how anxious the exercise made you feel. Sometimes an exercise on the hierarchy produces more (or less) anxiety than initially predicted. You can always adjust your hierarchy and move things around based on how each step goes. You may also wish to add more exercise steps on their hierarchy or re-grade things based on your first weeks experience. Sometimes, not habituating to a step, and getting a more angular pattern on the graph rather than a gentle curve down in anxiety rating could be a sign that something happened to bring your anxiety down artificially, like a safety behaviour, as these can be very subtle sometimes. Usually this can be spotted on your graph as the curve does not come down as gradually and is more pointed. Reflect if anything may have done this if this applies to you. This could be anything internally or externally to distract you. If you have, don’t worry, sometimes this happens. You can still make a plan for next week by repeating the step you started until habituation takes place with the conditions met. If your first exercise step on the hierarchy it is no longer producing 40% anxiety before or at the start of an exercise, that is a good sign you are ready to step up the hierarchy to the next thing you want to habituate to. Well done! Each new step you move to will provoke a higher level of anxiety again, but just like before, through repeating it will come down and you will habituate. People often find as they work up the hierarchy a few steps, it also gets easier than they were expecting too. If something stopped you from doing one or all of the exposure exercises, reflect on what got in the way. Was it something external, like someone you needed to help you not being able to help after all, someone popping in unexpectedly, or a childcare issue for example. Or, was it something internal, such as your fear or any off putting thoughts? If you make a note of what happened you can discuss this at your session. Sometimes, because the hierarchy is a prediction of how anxious something will make you, when you get started, it may provoke a higher level of anxiety than feels manageable. This can happen and we know this can be unpleasant. Please still speak to your practitioner who can help you to adjust the hierarchy and make a new plan based on what you have learned as a result. Based on your own first weeks experience, make a new plan for next week, ensuring you meet all the 4 conditions, by checking the plan is graded, repeated enough and flexible for step up if needed, that you have the time to meet the prolonged condition and will carry it out without any internal or external distractions.

(complete at end)

Mild distress/anxiety 25%

Before exercise

End of exercise

Severe distress/anxiety 75%

Start of exercise

Rating of distress/anxiety level

Moderate distress/anxiety 50%

What exercise are you doing?

Panic 100%

Comments

No distress/anxiety 0%

Date & time

Duration

Exposure recording diary

Reviewing your second week and planning week 3 As you did last week, on the graph below, start on the zero and plot your before rating, your start of exercise rating and your end of rating and draw the line between them for the amount of time it took to drop by 50%. Then plot out each exposure exercise you repeated. If you did more than one step on the hierarchy, use another blank graph for it using the spare pages at the back. Can you see the habituation curve forming? Do you need to do a few more repetitions of this step before moving to the next one, or are you ready? If you are ready, make a plan for your exposure and habituation for next week ensuring it meets the conditions. If you notice the anxiety came down more quickly than would be expected, what do you think caused this? was it something you recognise you did, or something more subtle, like an internal safety seeking behaviour? Make a plan for next week to repeat the step until habituation takes place if so. If it provoked too much anxiety, go back to your hierarchy and consider grading of the steps and if any alterations need to me made. Plan out your next week of exposure exercises, using the conditions to guide you. 100

Level of Anxiety (%)

Time (mins) 25

Mild distress/anxiety 25%

Before exercise

End of exercise

Severe distress/anxiety 75%

Start of exercise

Rating of distress/anxiety level

Moderate distress/anxiety 50%

What exercise are you doing?

Panic 100%

Comments

No distress/anxiety 0%

Date & time

(complete at end)

Duration

Exposure recording diary

Carrying on with exposure and habituation Carry on with your exposure and habituation exercises each week until you feel you are no longer struggling with your symptoms, are no longer avoiding situations or triggers and you have met your targets and goals

There is no set answer of how long you should be carrying on with exposure and habituation. Both Alison and Ferg both differed in how long they carried on working up their hierarchy and the time it took them to meet their goals. We would usually see an improvement within 6-8 weeks, but this varies and you may want to continue working on your hierarchy and symptoms further or may need some more support. Further blank graphs and diaries are provided at the back. Look at whether your symptoms are improving. Go back to the vicious cycle you completed at the start • Have they improved since you started? • How are your physical symptoms and your avoidance, escape and safety seeking behaviours now? • What changes have you noticed? • Are you able to go to the places that were difficult at the start? • Are you able to do the things you wanted to be able to do? • Are you still having any symptoms out of the blue? How far have you moved towards your goals? • Have you met any of these? • If not, are you close to meeting any? • Are there any which need more work? If so, what are you going to do and when are you going to do it? When you feel you are ready, you can move on to the Moving Forwards section.

“Alison: Remember it takes time for you to reverse the cycle. It took me a few weeks for me to start to feel better and I felt a bit worse initially as I was ringing on my anxiety I normally avoided. Do not rush your exposure exercises and stick to the conditions. You want to make sure your symptoms have improved fully and you have met your goals.” 27

Moving forwards

It will take time to break the vicious cycle of fear, but these evidence based techniques will help you to do just that.

Once you have worked up the hierarchy and your anxiety level feels more manageable, it is time to think about next steps. Going back to the targets and goals you set at the start of this programme is a great way to do that. It may be you still want to work towards some of these, or you may feel you have now achieved these, which is great. This next section helps you to think about keeping your CBT skills fresh for the future and what to do if you feel anxious again. Everyday mood changes and anxiety It is normal for our mood to change day to day. Often more than once a day, depending on what happens to us! We all have times when we feel anxious for a few hours or even a few days at a time. Some situations it is entirely appropriate to feel fear in response to. We also have worries, a level of worry and fear in our lives is normal! and keeps us safe. Remember the adrenalin response is there for our safety. We need it to kick in when it should do. What do you do when you have a day like this? Try not to let any anxiety affect what you do. That’s when that vicious cycle can take hold again. It is part of everyday life to feel this way from time to time. You may even have a panic attack again in the future, remember anyone can have a panic attack. The key thing is to not let it affect what you do as a result. Be kind to yourself. Don’t put yourself under too much pressure that your mood has always got to be positive and you won’t feel anxious – you will have days where you feel down or where your anxiety is there. This is OK, we all do!

The important thing is to remember it is just a normal part of life. Try not to let it form a cycle again and affect what you do and how you feel about how far you have come. What is a lapse? Sometimes, you can lapse back into old ways for a few days. For example, you may avoid things or fall into using old safety behaviours. A lapse does not mean that you have relapsed. Spotting it means you can act to break the cycle before it takes hold. Recognise a lapse for what it is. Try not to worry that it is a sign that you have gone back to square one. It isn’t! If you spot this happening, it’s a sign to put your skills into action again. What is a relapse? A relapse is when you start to feel the way you did before over a longer period of time. Your physical symptoms of fear may return for several days in a row and be out of proportion to the situation. If this should happen, you have the CBT skills to put back into action again. That should mean that the problem doesn’t get as bad or last as long. Completing this guide can help you to spot early warning signs before that vicious cycle has a chance to take hold again. You can also refer yourself again for more support, should you need it.

“Ferg: I kept working up the hierarchy even after my support sessions had finished, just to prove to myself I could manage the things at the top I hadn’t got to yet. I am so pleased I did. I have done nicer things than exposure and habituation, but I have never done anything that has helped me so much! 29

My early warning signs Make a note of the things that you noticed first with your panic disorder and any agoraphobia. How did it affect you physically? What where you doing or not doing because of this? How did it affect your thoughts? Think about any safety behaviours you may have used that could be an early sign if you start using them again. Sometimes others around us noticed these things before we do. Ask those close to you what they noticed first. These are things to look out for as early warning signs in the future. Remember though, that you may have some of these symptoms as part of a normal mood pattern. If they are affecting how you are feeling and what you are doing more days than not, it is time to act.

Both Ferg and Alison suggest reflecting on how you feel now your panic and agoraphobia has improved. This is useful in staying well. Write can yourself a letter about how far you have come, how you are feeling and how you made that happen. Then, pop it into an envelope and address it to yourself. Or ask a trusted friend to post it to you then. Put a reminder on your calendar or on your phone. This can remind you to open it and enjoy reading it again in 3, 6 and 9 months from today’s date. Once opened, reflect on how you are feeling. Also reflect on the impact that making the changes you have put into place has had on your life since. Then re-seal it and put it somewhere safe you will remember for next time! You should take out your letter and read this again if you notice any early warning signs. This will motivate you to put your CBT skills back into action. This will help prevent your early warning signs from getting worse. Remember, you have helped yourself before. You can do it again if you need to!

“Alison: I found it useful to write a letter to myself. It enabled me to see how our life had improved and how far I had come. I knew I would be able to put my skills back into practice if I experienced any early warning signs.” 31

My monthly mood check Keeping check on my mood How has my anxiety and panic been this month?

Have I had any of my early warning signs?

YES

For how many days?

Reflect on the progress you have made since your last review and take a moment to think about what you would like to do in the next month to keep moving forwards

Am I avoiding things because of how I am feeling, having negative thoughts that are affecting what I am doing, or have I been doing things to feel better that only work in the short term?

YES

If yes: Do I need to put my CBT skills back into action? If so what am I going to do and when am I going to do it? Use the questions from the first aid kit to keep your exposure and habituation skills fresh

Use the first aid kit questions to keep your skills fresh

Think of your exposure and habituation skills as a first aid kit for your mood. They are always there if you need them. You just need to remember how to use them and to keep your skills fresh.

What do I remember are the key points of the exposure and habituation approach that I learnt? What are the 4 conditions and how do you know you have met them?

Take a few moments to read through your intervention booklet again. Even if you are feeling well, this is a great way to make sure you know what you need to do if you need the skill again in the future. Do I feel confident enough to be able to use the techniques again if I needed to?

Put this page somewhere you will remember it and mark a review day on your calender once a month

Mild distress/anxiety 25%

Before exercise

End of exercise

Severe distress/anxiety 75%

Start of exercise

Rating of distress/anxiety level

Moderate distress/anxiety 50%

What exercise are you doing?

Panic 100%

Comments

No distress/anxiety 0%

Date & time

(complete at end)

Duration

Exposure recording diary

Reviewing your exposure and habituation

100

Level of Anxiety (%)

Time (mins)

Reviewing your exposure and habituation

100

Level of Anxiety (%)

Time (mins)

Mild distress/anxiety 25%

Before exercise

End of exercise

Severe distress/anxiety 75%

Start of exercise

Rating of distress/anxiety level

Moderate distress/anxiety 50%

What exercise are you doing?

Panic 100%

Comments

No distress/anxiety 0%

Date & time

(complete at end)

Duration

Exposure recording diary

Where to get more help Emergency help If you, or someone you are worried about, need support in an emergency situation, do not put off getting help. The following can be used in an emergency: • • • •

Emergencies: 999 An Emergency appointment with your GP Fast medical advice in a non-life threatening situation: 111 Samaritans: 116 123 (24-hour service)

Remember, do not be afraid to get help. Feeling this way doesn’t last forever and there are things that can be done to help! Below are some useful web links with good quality information for anxiety and depression and what treatments are recommended if you want to learn more:

Useful websites on Panic Disorder • The NHS: https://www.nhs.uk/conditions/panic-disorder/ • The National Institute for Health & Care Excellence depression information: https://www. nice.org.uk/guidance/cg113/ • The Royal College of Psychiatrists: https://www.rcpsych.ac.uk/mental-health/problemsdisorders/anxiety-panic and phobias • MIND The mental health charity: https://www.mind.org.uk • The Mental Health Foundation: https://www.mentalhealth.org.uk/a-to-z/d/anxiety Other useful helplines: • National Domestic Violence Helpline: 0808 200 0247 • Forced Marriages Unit: 0207 008151 • Support for Lesbian, Gay, Bisexual & Transgender (LGBT) Victims- Broken Rainbow: 0300 999 5428 or 0845 260 4460 • Support for Male Victims. Respect: 0808 801 0327 • Help for the Perpetrator. Respect: 0808 802 4040 • Childline: 0800 1111 • Debt helpline: 0808 808 4000 • Family lives (formerly Parentline): 0808 800 2222 • Citizen Advice Bureau: 0344 411 1444

Your notes

Marie Chellingsworth The CBT Resource ® Marie is a renowned consultant, academic and author in CBT. She is the Founder of The CBT Resource and Subject Matter Expert for a number of CBT and digital mental health services. Her work via The CBT Resource aims to help more people with anxiety and depression to be able to access evidence based treatments. She has over twenty years experience, publishing a wide range of CBT self help packages and national training for practitioners supporting people with these difficulties. She has worked with UK national bodies to maintain standards for CBT based approaches and was Consultant to the Australian Improving Access to Psychological Therapies programme. Prior to developing The CBT Resource, she was the Executive Director of Evidence Based Programmes at UEA, Senior Lecturer and Course Director at the University of Nottingham. Her passion for CBT and mental health first came after hearing a song called Howard Hughes (a B side of a band called Ride in 1992!). Outside of work she loves music, renovating her home and also spending time on local beaches and in the countryside with her Irish Setters. www.thecbtresource.co.uk

Andy Poplar [Vinegar & Brown Paper]® The photographs of etched glass throughout this programme are the work of Andy Poplar from [vinegar & brown paper]® ideas etched in glass. Special thanks and credit goes to him for enabling us to use these images. An award winning advertising creative, he set out to mend his head with [Vinegar & Brown paper] after his own experience with anxiety and depression. At the heart of Andy’s work are his reflections upon his own experiences that led to his career change into etching glass. As [vinegar & brown paper], Andy has spent the last 8 years taking vintage or iconic items of glassware and bringing them to life with the tools of typography, wit, word-play and a slightly askew way of looking at the world. You can now find pieces of [vinegar & brown paper] on bookshelves everywhere, from York to New York (and a much happier man too). You can find more of Andy’s work on his website and his Facebook and Instagram pages on the links below. Website: www.vinegarandbrownpaper.co.uk Instagram: instagram.com/mendyourhead Facebook: facebook.com/mendyourhead

Fears Conquered: CBT self-help guide for panic and agoraphobia.

Articles inside

About the author and Andy’s images

Relapse management

Where to get more help

The 4 essential conditions

Carrying on with exposure and habituation

My targets for treatment

My own vicious cycle

Planning your first week of exposure and habituation

Building motivation

What is panic disorder and agoraphobia

Meet Alison and Ferg