Panic attacks / panic / anxiety attacks / hyperventilation / agoraphobia - product and technique usage training notes
Panic / anxiety attacks can be difficult to treat, but this need not be the case if a careful approach is utilised. In the first session very little should be attempted other than to teach some form of simple regular-breathing based relaxation technique combined with the installation of a safe place. Do not treat unless there is a doctors diagnosis.
If you assume that hyperventilation is a strong part of the process you will be correct in that assumption for the vast majority of cases. Either way, teaching some form of regular calming technique will be advantageous and will tend to accelerate the treatment process. Initially avoid using any form of progressive relaxation based approach or any approach that encourages muscular relaxation or an internal locus of focus. (Doing so may trigger a panic / anxiety attack).
Also as part of the first session re-educate the patient and directly confront limiting beliefs such as 'I may die as a result of having a panic attack' (no-one ever has died [FYI: directly] from a panic attack). Also explain the role of avoidance and also how we can amplify and become intolerant of certain internal bodily sensations.
After the first session consider the following:
Systematic Desensitisation via EMDR Pro
In advance of using EMDR construct a desensitisation SUDS scale and collect images that relate to each category for later use. The library supplied with EMDR Pro on the installation CD may contain some of the images required, other images may need to be downloaded from the web. Initially do not use images.
In the first instance keep movements slow and simple - no images, no audio, track in one plane only and keep the speed slow. Aim initially to reduce immediatly present levels of anxiety that might interfere with the session by combining EMDR with a focus on regular breathing. Consider interspersing blocks of EMDR with some form of breathing based relaxation technique. Allow the breathing to normalise at regular intervals and be on the alert for an escalation into over-breathing or hyperventilation. If the breathing rate increases slow it down or ask the patient to breath abdominally and inaudibly. (If you can clearly hear their breathing it is probably too fast and should be slowed-down).
Gradually begin the process of presenting anxiety provoking images stating with a neutral image at level 1. When changing images ask your patient to close their eyes and do some form of relaxation technique. Use some form of relaxing audio in the background, but don't enable Panning Tracking (bilateral audio) until later in the process because bilateral panning too early can be disturbing in its own right. As an alternative consider a silly beep with the volume initially set at a low level. Relaxing background audio helps to collapse negative anchors.
If the SUDS do not reduce with a specific image or category of images then drop down to the previous category. Never leave the process on a negative at the end of a session - again - drop down to the previous category.
If blockages appear see the section within the EMDR training notes dealing with blockages. Blockages can also be overcome by integrating other techniques into the process. If blocking continues then examine the patients motivation and consider the role of secondary gain.
Blocking / Limiting Beliefs
Limiting beliefs are an implicit part of panic disorder and may include a lack of belief in self, external locus of control, beliefs that panic is fatal or physical, and / or an over valuation of external judgement. These should be gradually targeted via direct re-education, management of self-talk, positive visualisation and EMDR belief processing.
Systematic desensitisation alternatives - Vivo / Flooder
If EMDR is contraindicated then consider using Vivo or Flooder. Flooder should be used gently to present specific narrow categories of images. Flooder can also be used carefully at the end of an EMDR based process to ensure that a specific category of stimuli has been fully dealt with. The speed of image presentation should be very slow at least initially.
Stress and anxiety management
See notes relating to Stress and anxiety management. Avoid using any relaxation technique that pushes the locus of focus inside the body. A breathing based technique is ideal.
Hypnotherapy CDs should be non-relaxation based eg a focus on hand approach with suggestions to reduce anxiety is advantageous. Consider asking the patient to play a low frequency audio file as background music when doing self-relaxation exercises.
When doing relaxation techniques the patient should be asked to include positive visualisations of themselves undoing avoidance and enjoying the benefits of doing so.
EMDR Home / Lite
It is advantageous as part of an ongoing management process for the patient to use EMDR on a regular basis to help process day-to-day stressors. This helps to maintain a lower level of stress overall, which in turn helps the patient undo avoidance gradually.
Dealing with phobic responses
There are many similarities between panic attack disorder and phobic disorders (negative projection, anticipatory anxiety, avoidance, ...) hence many of the approaches used to treat phobias are also applicable to panic disorder / panic attacks. (See notes dealing with phobia treatment). No matter what technique you employ never do too much too soon.
Tasking is especially important and should include relaxation techniques and gradual approaches to undoing avoidance. A contract for action may be required.
© Bill Frost 2006-2011