Exposure Therapy for Anxiety and Phobias

When we’re anxious about something, it’s natural to want to avoid it. But avoidance is only a short term solution. Eventually we to need to face our fears. And the longer we’ve been putting something off due to anxiety, the more anxiety we’ll feel when we have to do it. Or we may be able to avoid something that’s causing us anxiety altogether this time. But then the next time we’re in a similar situation, it’s going to cause us even more anxiety.

In CBT, exposure therapy is an important B-for-behavioral technique to combat avoidance behaviors and reduce anxiety. Exposure therapy involves exposing ourselves to whatever is making us anxious, rather than avoiding it. And as we start to expose ourselves to the source of our anxiety—in other words, when we do things that cause us anxiety—we learn that these things aren’t as threatening or dangerous as we fear. Our predictions about the negative consequences that we expect are going to happen usually don’t occur or aren’t as bad as we feared. And even if we do experience uncomfortable emotions such as anxiety we’re able to tolerate it. And as a result the situations begin to provoke less anxiety.

Exposure Therapy for Anxiety

This transcription was auto-generated by YouTube and edited with ChatGPT

Exposure therapy is a type of behavior therapy that’s an important component in treating many types of anxiety as well as PTSD.

When we fear something or something causes us anxiety, our natural inclination is to want to avoid it. And avoidance can provide some short-term relief. As long as we can avoid whatever we’re afraid of, there’s nothing to feel anxious about. But in the long term, avoidance only increases our fear and anxiety because each time we avoid something that we’re anxious about, we’re reinforcing the idea that this thing is scary and dangerous. So we begin to fear it even more, and it causes us even more anxiety.

Avoiding things we’re anxious about deprives us of the opportunity to have new experiences and new learning that teach us that these things aren’t as threatening or dangerous as we fear. And that even if we do have some anxiety while we’re in these situations, it’s okay to have some anxiety. It’s uncomfortable, but anxiety itself isn’t dangerous, and we’ll get through it. We don’t need to avoid things just because we’re going to feel anxious while we’re in those situations.

Now the opposite of avoidance is exposure. Instead of avoiding the things that make us anxious, we expose ourselves to them. Put ourselves in those situations, and as we do this, they start to cause us less fear and anxiety.

There are a couple of ways of doing exposure therapy that we’re going to look at in this video. The traditional method involves what’s known as graded or graduated exposure. We make a list of about eight to ten situations related to what we fear or are anxious about, and then rank them into a fear hierarchy or ladder based on how much fear, anxiety, or distress they each cause us. Then we gradually expose ourselves to our fears by starting with a situation that causes us the least amount of anxiety and working our way up the list.

Now most of you watching this video aren’t going to set up experimental exposures to practice putting yourselves in situations that cause fear and anxiety. But these situations arise naturally in our lives, and we can still apply the things we’ll learn in this video, especially with regards to the second type of exposure therapy we’ll be talking about to everyday situations to help decrease the amount of fear and anxiety they cause us over time.

So each exposure exercise involves putting ourselves in one of the situations from our exposure list and then staying in that situation until our fear begins to subside and we experience some level of reduction in anxiety. And we repeat each exposure situation until it no longer causes us significant fear or anxiety, and then we move on to the next item in the list.

This is known as habituation-based exposure, and habituation is the process through which we experience a decrease in our fear or anxiety responses as a result of repeated exposure to a situation or stimulus. As we become less sensitive to it, we get used to it.

And there are three types of exposure. In Vivo, we simply put ourselves in real-life situations that cause us fear or anxiety. If we have a fear of dogs, we put ourselves in a situation where there is a dog.

Now, with imaginal exposure, we don’t actually put ourselves in a situation. We imagine the situation. This is common in treating PTSD. Imaginal exposure helps us process traumatic experiences in a safe and controlled environment, revisiting the traumatic event in our minds and imagining it in detail. This helps us gradually reduce the distress and anxiety associated with traumatic memories.

Interceptive exposure involves exposing ourselves to physical sensations in our bodies that cause us fear and anxiety. Usually, these are sensations that lead us to start panicking. So we might do some exercise that increases our heart rates and leaves us short of breath to help us learn the symptoms we have when we’re feeling anxious, like a racing heart or shortness of breath. This teaches us that these symptoms don’t necessarily mean we’re having a heart attack. Or we might spin around until we’re feeling dizzy to teach us that feelings of dizziness don’t mean that we’re having a stroke or about to pass out.

But if you’re not sure that your physical symptoms are the result of anxiety and are concerned there may be an underlying medical condition, then please consult a medical professional before trying interceptive exposure.

Recent research suggests that habituation isn’t the most effective or reliable way to reduce anxiety through exposure, and there’s been a shift towards what’s known as inhibitory learning-based exposure. Inhibitory learning involves new learning that takes place during the exposure that inhibits or suppresses our previously learned fear or anxiety response in that situation. Our goal isn’t to experience a reduction in anxiety during the exposure, although that may happen. Instead, there are two main things we want to accomplish: we want to violate our expectations about what we fear is going to happen, which leads to new inhibitory learning that inhibits or suppresses our previously learned fear and anxiety responses to these situations that stem from our beliefs that these situations are threatening or dangerous. And we want to learn that we can still do things even if they cause us some fear or anxiety.

We can apply this inhibitory learning-based approach to fear and anxiety-provoking situations that arise naturally in our lives to help learn new ways of thinking about these situations that lead to a reduction in our fear and anxiety responses. So keep that in mind as we look at the formal process of inhibitory learning-based exposure therapy.

So let’s look at how this works in practice using social anxiety as an example. First, we come up with a list of exposure exercises related to our social anxiety. With traditional exposure therapy, we would rank these situations based on how much distress they cause us and then start from the one that causes us the least amount of distress and then work our way up the list in order. But now it seems to be more effective if we go through the list in a quasi-random order.

We can still start with the situation that causes us the least amount of anxiety if that makes it easier for us to get started, or we can prioritize situations that seem most important or relevant to us. So, if we’ve been criticized at work for not speaking up enough at meetings, we might prioritize doing an exposure exercise related to this, even though it may cause us a great deal of anxiety compared to some of the other items on our list, like talking to a cashier, which may not seem like a particularly valuable situation for us to prioritize.

So now, let’s go through some examples of inhibitory learning based exposure for social anxiety, and you can download a copy of an exposure therapy worksheet that guides you through this process from the link in the description. Let’s say our anxiety prevents us from attending a lot of social events that we’d like to go to because we’re just too uncomfortable being around people we don’t know, and we decide that talking to someone we don’t know in a social setting would be a useful exposure exercise to prioritize, even though the thought of it causes us a lot of anxiety.

So first, we need to set a specific and measurable goal for the exposure, not just something like, “next time I’m at a social event, I’m going to try to talk to people I don’t know,” but something like, “at Mia’s party this weekend, I’m going to talk to two people I don’t know for at least five minutes each.” We want to make sure that the goal is something we expect is going to be challenging because we want to give ourselves a chance to violate our expectations about what’s going to happen as much as possible because that’s going to lead to the greatest amount of learning.

So, something like, “I’m going to say hi to someone I don’t know, and then if I’m feeling uncomfortable, I can excuse myself to go to the restroom,” isn’t going to be that productive. First, because we don’t expect that anything that bad is going to happen, so there’s not that much opportunity for inhibitory learning to take place. Second, we’re getting out of the situation as soon as we start to feel uncomfortable, so we’re depriving ourselves of the opportunity to learn that it’s okay to have some anxiety in these situations, that we can tolerate this anxiety, and it’s not something we need to avoid.

Then we predict what’s going to happen and write down our expectations and the feared outcome or outcomes we’re most worried about, and the feelings and emotions we’re worried that we won’t be able to tolerate. “I’m going to feel so anxious it’s going to be difficult for me to speak properly,” “My anxiety will be so bad I’ll start having a panic attack,” “I’m not going to have anything to talk about, and the other person is going to get so bored they’ll make an excuse to get away from me before the five minutes are up.” Then we rate on a scale from zero to a hundred how much we expect that these outcomes will actually happen.

Then we do the exposure, and afterwards, we compare our expectations of what we thought was going to happen with what actually happened. The first conversation went on for a couple of minutes, and then someone they knew joined us, and I felt a little awkward and didn’t have much to say after that, but they didn’t abandon me or seem to mind that I was still there. The second person I talked to turned out to have some friends in common with me, and so we talked about them for a while, and after some initial anxiety, I felt pretty comfortable once we started talking.

And were we able to tolerate the distress? I felt anxious but not so anxious that it was hard to speak. I did feel pretty anxious a couple of times but never close to panicking.

And how was this outcome different from what we expected? I felt anxious but not as anxious as I thought I would, and my anxiety never made it difficult for me to get my words out. Once we started talking, the other person was really friendly and easier to talk to than I feared.

And what did we learn from this experience? Even when anxious, I’m able to carry on a conversation with someone I don’t know, and once we start talking, I start to feel more comfortable. I didn’t really need anything that interesting to talk about; we just talked about random stuff, and it was fine. So through this exposure, we’ve experienced quite a bit of discrepancy between the bad things we feared and expected were going to happen and what actually occurred. This learning will help inhibit our fear and anxiety responses in similar situations in the future. We can apply this process to situations that arise naturally in our lives: look at what we expected was going to happen in a situation we were having some fear or anxiety about and how that was different from what actually happened, and then ask ourselves what we can learn from this result that can help reduce our fear and anxiety in similar situations in the future.

And here’s an example from an article I’ll link to in the description that has examples and case studies of how to use exposure therapy to treat a wide range of issues, and also covers everything we talk about in this video in much more detail. I like this example because it demonstrates the type of exposure exercise that might not occur to us on our own to help test the hypothesis that the emotions we’d experience in certain types of situations would be intolerable and therefore need to be avoided at all costs. In this case, the emotion being embarrassment or humiliation in public. So the goal of the exposure is to ride the elevator at the local mall for 30 minutes, calling out the number of each floor in a loud voice.

What are we worried will happen? People will look at me angrily and ask, “What’s wrong with you?” I’ll feel so humiliated and embarrassed I’ll start crying and have to run out of the elevator.

And then we do the exposure, and afterwards we look at what actually happened. When I called out the floor numbers, some people looked over at me with a confused look on their face, but nobody seemed angry, and most people just kept their heads down and ignored me. I did feel really embarrassed and humiliated, but not to the point of crying, and I was able to stay in the elevator the whole time.

How is this different than what I’d expected? Well, people seem more confused than angry, and nobody said anything to me, and most people just ignored me altogether. And even though it was really humiliating to embarrass myself like that, and I did feel really uncomfortable, I was able to tolerate these feelings and stay in the elevator until the end of the exercise.

And what did I learn as a result of this exposure? Even if I do something really embarrassing in public and humiliate myself, it’s not the end of the world. And this exercise seems way more embarrassing and humiliating than anything that would actually happen in real life. So if I can get through this, I can get through whatever embarrassment or humiliation I may experience in the course of any sort of typical real-life situation.

So as a result of this exposure exercise, we’ve experienced new learning about the effects of feeling embarrassed or humiliated in public, which has taught us that these experiences are actually tolerable. So in the future, if we find ourselves in situations in which we fear we may be embarrassed or humiliated, or if we do in fact embarrass or humiliate ourselves, this new learning will help inhibit or suppress our previously learned fear or anxiety responses regarding these types of situations or these emotional responses.

Exposure is an important component in treating many types of anxiety, as well as PTSD, because it gives us the opportunity to learn that the bad things that we fear or expect or predict are going to happen in certain situations usually don’t actually happen or aren’t as bad as we’d worried they’d be, which helps inhibit and suppress our fear and anxiety responses in these situations. And we learn that we can still do things even if they cause us some fear or anxiety, and so we don’t need to avoid things, especially things that are important to us, just because they provoke fear or anxiety.

Here’s a great article that goes in to a lot more derail about inhibitory learning based exposure along with a number of case studies, and you can download the Exposure Therapy Worksheet in PDF or Word format. If you have any questions or comments, please leave them on the YouTube video page.

Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd ed.). The Guilford Press.

Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5–27. https://doi.org/10.1016/j.brat.2007.10.003

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. https://doi.org/10.1016/j.brat.2014.04.006

How To Make A Decision

Decisions can be hard to make. And while it’s understandable that we’d have trouble making important decisions that are going to have a big impact on our lives, sometimes even the smallest decisions can be agonizing. And when we’re feeling anxious or depressed, it can seem impossible to make any sort of decision.

In this video we examine:

  • Different types of decisions, from day-to-day decisions to potentially life-altering decisions
  • Why some decisions are so difficult to make
  • Different decision-making strategies
  • Why some decision-making processes tend to lead to better decisions than others

Now just because we don’t like the results of a decision doesn’t mean we made a bad decision, or that we’re not good at making decisions. And so we explore how it’s possible to make a good decision, yet not get the results we want.

And then we learn a decision-making strategy that involves:

  • Assessing the pros and cons of our various options
  • Listening to our guts and intuition
  • Making a decision that’s in line with our goals and values

How to Make a Decision

This transcription was auto-generated by YouTube. I’ve only added minimal editing, so I apologize for any errors, run-on sentences, etc.

How to make a decision. In this video we’re going to look at why some decisions are so hard and what we can do if we’re having trouble coming up with a decision. And we’re going to learn a decision-making process that can help us make decisions that we can be comfortable with and confident in.

Often it’s difficult to come to a decision because of the stakes involved: the higher the stakes the more careful we tend to be when making a decision. But even seemingly insignificant low stakes day-to-day decisions like what to wear or what to eat can sometimes seem overwhelming.

Sometimes decisions are hard because we feel like we don’t have enough information to make an informed decision other times we have too much information and just don’t know how to make sense of it all. Or there can be too many options to choose from. Or we can’t find any options that we’re happy with or that meet our criteria.

And sometimes when we’re struggling with a decision it’s not the actual decision that’s so challenging; our indecisiveness is a symptom of something else: like decision overload where we’re overwhelmed by the number of decisions we need to make and we just can’t deal with another one.

Or we’re afraid our decision is going to disappoint someone so we keep trying to put it off.

Or we avoid making a decision because we don’t know how to act on it.

Or don’t want to have to act on.

Or our difficulty making a decision could be related to anxiety about something connected with the decision for example we’re getting ready to travel and having trouble deciding what to pack being really anxious about it. But it’s not really the decision about what the pack that’s causing our anxiety we’re anxious about traveling and we don’t have much control over the aspects of traveling that are actually causing our anxiety so we redirect our anxiety onto our packing because that’s something we have control over. But unfortunately there is no perfect way to pack that’s going to make our travel anxiety disappear.

And making decisions can often be really hard if we’re depressed for many of the reasons above so do you recognize yourself in any of these.

Now let’s look at some of the ways we make decisions and see if any of these sound familiar a pros and cons list which could be an actual written list or it could just be a process we go through in our heads.

Or we go with our guts or intuition and choose whatever feels right.

Or we make decisions based on our values and goals.

Or we make impulsive or emotional decisions and choose whatever offers the most instant gratification or makes us feel better right away i can’t deal with all of this stress i quit.

Or we hate making decisions so much and just want to avoid them that we go with the first option that’s at all tolerable just to get the decision over and done with so we don’t have to think about it anymore whatever this is fine.

Or we can spend a long time agonizing over decisions continuing to mull things over and unable to come to a decision even though we’ve looked at it from every angle multiple times and already spent more time on the decision than is warranted based on the importance of the decision.

Or we make a decision and keep changing our minds second guessing ourselves and going back and forth between different choices.

Or make a decision and keep asking others for reassurance that we’ve made the right choice should i wear my navy suit are you sure that one’s okay.

Or maybe we ask someone else to decide for us can you please just tell me which one to wear.

So in most cases making a good decision is going to involve coming up with a list of options going through the pros and cons of each while listening to our guts and intuition and then making a decision based on our goals and values.

So let’s say we’ve been offered a new job and we’re trying to decide whether to take the new job or stay at our current jobs so first we take some time to think about all the various options we have and write them down and then we just go through these options and see which are worth further consideration. And let’s say we’ve narrowed it down to just two candidates worth considering.

And so now we make a pros and cons list for each. So we start with our first option and we come up with a list of pros of staying at the current job and cons of staying at the current job and then also pros of not saying at the current job, and cons of not staying at the current job.

And then we look at the second option and consider the pros of taking the new job and the cons of taking the new job, as well as the pros of not taking the new job and the cons of not taking the new job.

So now we look over our pros and cons list with the intention of selecting the option that scores highest. But often our pros and cons lists don’t point to a clear winner there are pros and cons to each option that are relatively equal and seem to balance each other out so what do we do now.

Well we can go back to our list of options and see if there’s another option we overlooked that didn’t make our original list. But assuming there’s nothing we left out and there is no better option that we’ve overlooked then what often happens is we keep going through the pros and cons hoping we’ve missed something and that if we keep thinking about it long enough eventually the right decision will become clear. But this usually just leads to us thinking in circles we’re changing our minds back and forth and back and forth again and in the end still never getting any closer to making a decision.

So then the next step is to try listening to our guts and intuition and see if they’re telling us anything. So what does this mean? Well sometimes we just get a feeling about something and so if our intuition is pointing us in a certain direction then we can factor that into our decisions. So maybe when we went for the interview we just had a bad feeling about the new place our intuition was telling us something was off so maybe that points us towards staying at our current jobs.

Or maybe our guts are telling us no matter how long we stay at our current jobs things just aren’t going to get any better and so that helps tip the scale towards accepting the new job.

And then before making the decision we want to consider our goals and values. So maybe our goal right now is to advance our careers as much as possible and one of our values is we’re not going to let fear rule our lives. So we single out the things on our pros and cons list related to these goals and values and maybe assign them a little more weight.

Or maybe one of our goals is wanting to work less and spend more time with our families and one of our values is we don’t want to decide things just based on money. And so we single out the pros and cons related to these and so considering our goals and values can bring some clarity to our pros and cons lists and can help us make a decision.

But let’s say we’ve done all this and we’re still no closer to being comfortable making a decision now what do we do? So at this point first we need to realize that we’ve been using a solid decision-making process and we’ve spent enough time on this decision that whatever we choose is going to be a reasonable decision and we’re making a good choice. But still how do we actually make that decision?

Well sometimes we can try on a decision for a while. So maybe we’re leaning towards taking the new job but still not ready to commit and so we decide to try acting as if we’ve taken the new job for a while and just see what that feels like. We visualize ourselves in our new jobs tell our friends we’re pretty sure we’re going to take the new job and just talk it through a bit with other people and just see how it feels living in that decision for a while and if it feels comfortable that can help us feel more comfortable committing to that decision.

And we can look back at our goals and values and maybe we decided you know i promised myself not to let anxiety rule my life. But there’s nothing so compelling about this new job that means I’m letting myself down if i don’t take it it’s okay to stay where i am for now while i try to find a better opportunity.

Or related to our goals and values we can ask ourselves if i choose this option will i be able to accept the results of my decision even if they’re not what i wanted? And maybe we think at least i know what my current job is like and if i stay here and things don’t get any better it’s not great but it’s tolerable and if i have to stay here for a while longer i know i can manage that but my new job could be a lot worse and i don’t know if I’d be able to deal with that. So I’m going to go with the option that has the least possible downside or the highest floor and I’m going to stay at my current job because worst case scenario i know I’ll still be okay working there for a while.

Or we could choose the option that has the highest ceiling or best possible outcome. I know what my current job is like and i know it’s never going to get much better than this but this new job could be so much better. And so we use that as the basis of our decision and if we still can’t decide we need to understand that if we’re unable to make a decision then by default we’re actually deciding that things are going to stay as they are the job is going to get offered to someone else before we decide whether or not to take it. So in the end one way or another a decision is going to be made.

And sometimes it seems more comfortable to allow that decision to be made for us as a result of our inaction because then if things don’t work out the way we wanted we don’t feel as responsible for the results since technically we didn’t choose that option. But the flip side to this is that then we can start to feel like we don’t have much control over our lives.

So what if we still can’t decide well when we get this stuck? Often one of the issues is that before we’re willing to commit to a decision we’re looking for some sort of certainty about what the results of the decision will be—which makes sense because it’s going to be the results of our decisions that ultimately impact our lives. But often decisions involve situations that are inherently uncertain. There’s just no way to know in advance if we’d like the new job any better than our current jobs and so the amount of certainty we’re seeking before we feel comfortable making a decision is never going to be possible.

And so here the issue isn’t with our decision making but with our difficulties accepting uncertainty. And managing the stress and anxiety and worry associated with that uncertainty and we’ll look at some ways to help us manage these challenges in a minute. But first let’s talk about uncertainty regarding the results of our decisions so in a moment I’m going to flip a coin and you need to decide whether you want to choose heads or tails and if you need a moment to think over your decision you can pause the video.

And here we go.

So did you make the right decision? Well if you chose tails you got the result that you wanted but does that mean if you decided to pick heads you made a bad choice? Well no because in this example either option was a perfectly reasonable choice because each outcome was equally likely and you had absolutely no reason to choose one option over the other. And so based on the information available there was no way to know to choose tails and so choosing tails wasn’t a better decision than choosing heads, it just led to a better result but you had absolutely no control over what that result was going to be when you made your decision.

And did you spend much time making your decision to choose heads or tails? Hopefully not because there was nothing to be gained by spending any time on that decision because unless you can see into the future there was no information available that would have been relevant to your decision one way or another.

Now not all of our decisions are coin flips but a lot of the time when we’re having trouble coming up with the decision it’s because the various alternatives are so close that they might as well be coin flips. And no matter how long we spend researching our decisions there’s usually going to be an element of chance influencing the results that we’re not going to be able to eliminate. So in most cases there’s no way to know what the right decision, if we’re judging based on results, is going to be.

So in order to come up with good decisions we need to focus on using a good decision-making process like the one we’ve been learning rather than trying to get certainty about what the results of our decisions will be, because to at least some extent the results of our decisions are going to be beyond our control and all we really have control over is the process we use to make our decisions.

And now instead of flipping a coin I’m going to roll a die and you have to decide whether you think I’m going to roll a 2 or below or 3 or above and you can pause the video if you need time to make your decision I’m going to roll the die in three two one.

So did you make the right decision? Well if you picked two or below you got a good result but you made the wrong decision. Because there’s six numbers on the die I’m gonna roll a three or above four out of six times. So two thirds of the time it’s going to be 3 or above. So in this case using a good decision making process—the laws of math and probability—the correct decision is clear. We should always pick 3 or above. But the thing is a third of the time I’m gonna roll a two or below and you’re gonna get a bad result even if you made the right decision.

So the point here is that we can make what’s clearly the right decision and it still leads to a bad result. And we can make what’s clearly the wrong decision yet have it lead to a favorable result. And so this is why we need to focus on the process of making the decision rather than worrying about having certainty about what the eventual results of our decisions are going to be, because it’s the process that we have control over, and there’s always going to be some uncertainty surrounding the results.

And one last thing about results is that in most cases even if we’re not happy with the result of the decision we made we’ll rarely know what the results would have been if we’d made the other decision. So if we take this job, for example, and we don’t like it, that doesn’t necessarily mean we got the worst result, because if we’d stayed in our current jobs maybe things would have ended up just as bad or even worse.

And so if we start second-guessing our decisions based on the results and telling ourselves things like i knew i should have gone with the other decision, if only I’d gone with that things would be so much better now, how could I’ve been so stupid, I’m ruining my life, we usually have no way of knowing if this is actually true or not and are just making ourselves feel bad for no reason.

Okay but we still haven’t decided whether or not to take the job. What do we do now? Well at this point it doesn’t really matter what we choose. We’re not going to find any more information that’s going to make our decision any clearer. So we just need to pick something.

And then once we’ve made our decision the final step is that if we’re still feeling anxious about the decision and finding the uncertainty difficult to tolerate we need to focus on managing our anxiety and accepting the uncertainty, rather than second guessing our decisions and going through the whole decision-making process over and over and over again hoping we’ll find a decision that eliminates all anxiety and all uncertainty because that’s never going to happen.

So how do we do this how do we manage our anxiety and learn to accept uncertainty? Well i have a number of videos with strategies that can help that I’ll link to in the description. And we can also use our less significant decisions when there’s not so much at stake to practice managing our anxiety around decisions and uncertainty.

And as we become more comfortable making these smaller decisions and managing the anxiety and uncertainty around them they start to cause us less anxiety. And we’re building skills that transfer over into our bigger more important decisions where we’re feeling even more anxiety and more discomfort with the uncertainty about the results of these decisions. But this anxiety and uncertainty is somewhat more manageable now as a result of the practice and experience we’ve gained through our smaller decisions.

So some decisions are always going to be difficult but as long as we have a good decision-making process in place, and understand that there’s almost always going to be at least some uncertainty surrounding the results of our decisions, and have some practice from our smaller decisions managing the anxiety around decisions ,then we’ve prepared ourselves to be able to make any types of decisions that might arise, even though we may still experience some anxiety making the decisions and accepting the uncertainty surrounding the coming videos when they come out

This decision-making process doesn’t guarantee that we’ll always be happy with the results of our decisions. Sometimes the results are beyond our control. But this decision-making process is an effective way to make decisions that we can be comfortable with, and confident in, knowing we’ve done everything possible in order to make the best decision with the information available.

If you have any questions or comments, please leave them on the YouTube video page.

CBT for Anxiety and Cognitive Restructuring

Cognitive restructuring is one of the main components of cognitive behavioral therapy (CBT) for anxiety. The previous post provided a brief overview of cognitive restructuring in CBT. Now we’re going to look at how to use cognitive restructuring to manage anxiety.

We’ll examine some common types of negative thoughts and worries associated with anxiety. And then learn how to modify these thoughts with cognitive restructuring in ways that reduce our anxiety and make us less anxious.

CBT for Anxiety and Cognitive Restructuring

Cognitive restructuring is important in CBT because it helps us change how we’re thinking. And in CBT, changing our thoughts is one of the main ways we change how we feel. If we’re able to modify our worries and anxious thoughts in order to:

  • more accurately estimate a situation’s level of threat and danger
  • consider outcomes other than the worst case scenario
  • feel more confident in our abilities to cope with negative outcomes

then we’ll start to reduce our anxiety.

The questions in the Cognitive Restructuring for Anxiety Worksheet [download PDF] or [download Word] can help with cognitive restructuring of worries and anxious thoughts.

Next we’ll learn how to complete a worry record. The worry record is a thought record that’s been modified to focus on worries, and guides us through the process of cognitive restructuring for anxiety. If you have any questions or comments, please leave them on the YouTube video page.

All or Nothing Thinking and Anxiety

All or nothing thinking is a type of cognitive distortion in which we see things in black or white terms, with no shades of grey in between. Things are either all good, or all bad. We’re perfect or we’re a failure. If we don’t accomplish all that we’ve set out to do, we’ve done nothing. If someone doesn’t do everything we ask of them, then it’s like they’ve done nothing.

All or nothing thinking leads to stress and anxiety, because we put so much pressure on ourselves to achieve or accomplish all, rather than be left with nothing. And all or nothing thinking can damage our self esteem and lead to depression. If we’re often feeling like we’ve done or achieved nothing, it hurts our self worth and can leave us feeling depressed.

All or Nothing Thinking

This transcription was auto-generated by YouTube. I’ve only added minimal editing, so I apologize for any errors, run-on sentences, etc.

If you find yourself feeling stressed or anxious a lot of the time, or are struggling with low self-esteem or depression, one of the reasons could be all or nothing thinking. In this video we’re going to learn all about all or nothing thinking: what it is, why it can be such a problem, and what we can do to reduce our all or nothing thinking so that it doesn’t have such a negative impact on our lives.

All or nothing thinking is a type of cognitive distortion. Cognitive distortions are exaggerated and negatively biased patterns of thinking that distort reality and lead us to perceive or evaluate situations and experiences inaccurately. I have a video that describes a number of different types of cognitive distortions that I’ll link to in the description. But i wanted to make a video just about all or nothing thinking because it’s one of the most common cognitive distortions and it can negatively affect us in a lot of different ways.

So when we engage in all or nothing thinking, we see things as black or white with no shades of gray in between. Things are either all good or all bad. If we don’t do something perfectly, we failed. If we don’t accomplish everything we’ve set out to do, we’ve done nothing. Someone makes a mistake or disappoints us and they’ve let us down completely. All or nothing thinking arises in all sorts of contexts so let’s look at some examples.

All or nothing thinking often involves how well we do at something. Either we completely succeed—we ace the test, we come in first place, we get a promotion at work—or we’ve completely failed. We get a b plus when the class average is a c, but because we didn’t get an a plus, as far as we’re concerned we might as well have gotten an f. Or we come in second place with a personal best, but because we didn’t come in first who cares that means nothing. We get a raise, but someone else gets the promotion we wanted, so our careers are going nowhere and we’re terrible at our jobs.

All or nothing thinking can also involve how much we accomplish. If we don’t complete everything we’ve set out to do today, then we’ve achieved nothing. We had 10 things on our to-do list but since we only knocked off eight, what a waste of a day, we got nothing done. Or we were going to clean the kitchen tonight, but after we did the dishes and put them away and wiped the counters and cleaned the sink, we were too tired and had to be up early the next day. So we went to bed before we got around to sweeping and mopping the floor, so we’re just so lazy. Or we cleaned the whole kitchen but it’s not spotless so we might as well not bothered cleaning it at all.

And all or nothing thinking doesn’t allow for any understanding or compassion or mistakes. We get impatient with our children and we’re terrible parents, even if it’s just one lapse over a stressful day in which we handled everything else really well. And we can apply our all or nothing thinking to other people. Someone does us a favor but they forget one thing and so it’s like they’ve done nothing. Someone makes one small mistake on a project at work and they’re completely useless.

So what’s the impact of all or nothing thinking? Well when we apply all or nothing thinking to ourselves, we put so much pressure on ourselves to hit that all level, that we can push ourselves too hard, which can leave us feeling really stressed out or give us a lot of anxiety. And when we don’t accomplish or achieve all, we come away feeling like we’re left with nothing, which can damage our self-worth and self-esteem and can leave us feeling depressed. And when we apply our all or nothing thinking to other people, it can damage personal and professional relationships.

And all or nothing thinking can lead to procrastination, because we know it’s going to be so much work to try to hit that all, all of the time, that we can’t even bring ourselves to get started.

And all or nothing thinking can make it harder for us to achieve our goals, because we give up halfway through when we realize all is no longer a possibility. And so since we’re ending up with nothing, we might as well save ourselves the effort and just give up now. I wasn’t going to drink on weeknights anymore, but i had a glass of wine with dinner so i’ve ruined today and i might as well just finish the rest of the bottle.

So what can we do about our all or nothing, black and white thinking? Well the simple answer is to learn to recognize some shades of gray in between, and to see things along a spectrum rather than on a binary scale. So how do we get ourselves to do this?

Sometimes a helpful first step can be to find a good enough compromise in between all or nothing. We can strive to get ten things done, but seven is going to be good enough. We don’t have to do the next three if we don’t feel like it. We can aspire to achieve the equivalent of an a or a plus on whatever we’re working on, but once we reach a b or b plus level that’s good enough, and we don’t need to worry about getting that extra bit of improvement if it’s going to take too much effort, be too stressful, and cause us a lot of anxiety trying to get there. And it also makes it less likely that we fail in ways that damage our self-esteem and can lead to depression.

But that’s only half the story, because it’s still not really seeing shades of gray. It’s just a single shade of gray in between black or white, which means that if we don’t hit that compromise not quite all but good enough level, we still can end up feeling like it’s nothing.

But achieving c level work instead of b or a plus, getting five of our ten things done instead of seven or ten, is still not nothing. Sometimes that’s all we’re able to do. Sometimes we could do more but the costs in terms of stress or anxiety are too high. And sometimes we could do more, but we choose not to because there are other things going on in our lives that also need our time or attention, or that we just want to do instead. And that’s okay.

So in order to recognize the shades of gray in between black and white, and to be able to accept results and outcomes across a whole spectrum of possibilities, instead of focusing on what we didn’t do, what we didn’t accomplish, what we didn’t achieve, we need to learn to reframe things in terms of what we did do, what we did accomplish, what we did achieve, even if it’s not everything or all we set out to accomplish or achieve. And as long as we can name just one thing, then we’re no longer at nothing. And maybe we didn’t do as well or as much as we’d hoped or wanted or expected, but at least we did something. We barely got started on our to-do lists, but at least we replied to that one email we’ve been putting off for days.

And even those times when it feels like we didn’t do anything, we probably did do at least something. We finished some tasks for work, and even if we didn’t do a really good job, at least we got it done. Or at least we got part of it done. And sometimes these things may not seem like a lot, and they’re certainly not all, but they’re still not nothing.

And even if we spend all day lying on the couch watching tv or, in front of our computers watching YouTube videos, well maybe what we accomplished is that we gave ourselves a bit of a needed break. We took some time to look after ourselves, to reduce the stress and anxiety in our lives, and made it easier on ourselves to get back to doing more things tomorrow.

And even if we do achieve or accomplish so little that it might as well be nothing, that doesn’t make us bad people. When this happens there are reasons it’s happening. Maybe we’re just too tired, don’t have the energy, or are feeling too discouraged or depressed to be able to bring ourselves to do much of anything. And so in these cases we need to try to extend ourselves some compassion and understanding, rather than beating up on ourselves and feeling bad. Because when we don’t achieve or accomplish whatever we set out to achieve or accomplish, being too hard on ourselves serves no purpose. It’s just not helpful.

We often feel like we need to be hard on ourselves in order to push ourselves to do more and to reach our potentials. And while this attitude may be able to provide some motivation in the short term, in the end it catches up with us, because it increases our stress and anxiety, which eventually can become too much for us to manage, and it’s discouraging it can damage our self-worth and self-esteem and can leave us feeling depressed all of which make it more difficult for us to do things in the future. So if we don’t achieve or accomplish all that we set out to do, or even most of it, it’s much better to be understanding with ourselves, and learn to practice some self-compassion and self-acceptance.

And if we need to do better next time, being kind to ourselves now is not going to prevent this. It’s not going to get in the way. But if we adopt an attitude of, I’m such a failure, i can’t do anything right, i got absolutely nothing done, well that can get in the way because it’s so discouraging and demoralizing it can affect our motivation, damage our self-confidence and self-worth and self-esteem, which can negatively impact the quantity and quality of work we’re able to do.

Now we can still acknowledge if we didn’t try our best, if we could have done more, or could have done better, without being too self-critical and putting ourselves down. And maybe we do have to do better next time, but beating up on ourselves isn’t going to help us do that. And then instead of being self-critical and beating up on ourselves, we can reflect on anything we did accomplish—anything we did achieve, anything that went well—and try to find ways to do more of that in the future. And then look at what didn’t go so well and figure out what we need to do differently next time so that things go better.

And everything we’ve just talked about regarding ourselves applies to our interactions with other people as well. Holding others to strict all or nothing standards can damage personal and professional relationships, and doesn’t really encourage people to change their behaviors, and instead tends to lead to conflicts or just leaves them feeling discouraged or resentful.

So if we’re able to shift our mindsets away from all or nothing thinking, and recognize that accomplishments and achievements occur across a broad spectrum rather than just on a binary scale, we’ll be able to do more and perform better, while reducing the amount of stress and anxiety in our lives, and making it less likely that we become depressed, while improving both our personal and professional relationships.

If you have any questions or comments, please leave them on the YouTube video page.

Walking and Breathing Exercise for Panic Attacks and Anxiety

When we’re anxious or starting to have a panic attack it can be hard to sit still and breathe. Here’s a breathing exercise that helps slow our breathing down while incorporating walking in with our breaths. We begin walking at a slow-ish but comfortable pace, and then tie our breathing in with our footsteps. So we breathe in for three or four steps (or maybe more, or maybe just two steps, depending on how quickly we’re walking), and then breathe out for the same number of steps.

This breathing exercise can be very relaxing, and help ensure we’re not breathing too quickly. And paying attention to our footsteps reconnects us with the present moment, and helps get us out of our heads, which reduces anxiety. Paying attention to our footsteps can also shift our focus away from any distressing physical sensations that are feeding in to our panic. And it helps disengage the catastrophic thoughts we’re having about these sensations that can bring on a panic attack.

Guided Walking and Breathing Meditation Instructions

Extended Guided Walking and Breathing Meditation

If you have any questions or comments, please leave them on the YouTube video page.

Best Ways to Cope with Panic and Stop A Panic Attack

Man Having a Panic Attack

Having a panic attack can be one of the most terrifying things in the world. In this post we’ll learn how cognitive behavioral therapy (CBT) helps us respond to panic, and calm panic before it can escalate into a full-blown panic attack. Or, if we’re already in the middle of panic attack, how we can deescalate panic.

Panic attacks are so scary because we’re reacting to our anxiety as if it were a life-threatening situation. This engages our sympathetic nervous systems, setting off the fight or flight response. And this leads to a number of intense and distressing physiological symptoms associated with panic attacks such as:

  • Chest pain or discomfort
  • Elevated heart rate and/or racing or pounding heart
  • Heart palpitations or our hearts skipping a beat
  • Breathing faster or hyperventilating
  • Feeling like we’re choking or suffocating
  • Dizziness, light-headedness or feeling weak in the knees
  • Nausea and other stomach symptoms
  • Feeling detached, or like we’re floating away or watching ourselves from outside our bodies
  • And many more …

And these physiological symptoms increase our anxiety, leading to catastrophic thoughts that are common during a panic attack, such as:

  • I’m having a heart attack
  • I can’t breathe
  • I’m going to suffocate
  • I’m having a stroke
  • I’m about to pass out
  • I’m losing control
  • I’m going crazy
  • I’m going to be sick
  • I’m going to embarrass myself
  • And so on …

In order to prevent or deescalate a panic attack, we need to come up with more accurate and less catastrophic thoughts about what’s going on in our bodies. And we need to reverse the effects of the sympathetic nervous system and the fight or flight response that’s driving our panic attack, by engaging our parasympathetic nervous systems.

In the video below, we’ll learn how to do all of this and more to manage a panic attack with techniques from CBT, which is the most effective way to treat panic attacks:

The Best Way to Stop Panic Attacks

This transcription was auto-generated by YouTube. I’ve only added minimal editing, so I apologize for any errors, run-on sentences, etc.

In this video we’re going to learn how panic attacks get started, what happens during a panic attack, and how we can calm and de-escalate a panic attack once it does start to happen.

Panic attacks arise when we feel so anxious that our sympathetic nervous systems kick in and set off our fight-or-flight responses. And this brings on a wave of intense physiological reactions: we get a rush of adrenaline; our heart rates and breathing speed up; our pupils dilate and our muscles become tense; we start to produce more sweat; and so on. And these are all great ways for our bodies to react when we’re in a life-threatening situation. But during a panic attack our bodies misinterpret our anxiety as a life-threatening situation and react accordingly, setting off this fight-or-flight response as if our lives were in danger.

And if we were in a life-threatening situation our bodies would use this physiological response to help us fight off or flee from whatever the danger is. But when these physiological reactions arise in response to our anxiety, there’s nothing for us to do with them, there’s no outlet for them, because there is no life-threatening situation to fight off or escape. So we’re left with all of these intense physical symptoms and they don’t make any sense. We don’t understand why this is happening.

And so we start having catastrophic thoughts about what’s going on, and misinterpreting this physiological response as symptoms of some sort of health or medical crisis. And these thoughts cause more anxiety, that intensifies our physiological reactions, leading us to have more catastrophic thoughts, and so on, setting off a vicious cycle that can lead us into a full-blown panic attack. So let’s look at how this happens in more detail.

Sometimes our anxiety builds throughout the day and we might have moments of panic here and there that don’t escalate into a panic attack, but then at some point all of this anxiety becomes too much and it does set off a panic attack. Other times it can be an extremely anxious thought or distressing body sensation that sets off a panic attack. Or we may not even know what sets it off and it just seems to happen out of nowhere.

But regardless of the source when we have a panic attack something at some point signals to our sympathetic nervous systems that we’re in danger, which sets off the fight-or-flight response, initiating all of those physiological reactions we mentioned earlier, which again, are great to have if we’re in an actual life-threatening situation.

But if the threats are something like: we’re standing up in front of a group of people about to give a presentation; or we’re in an airplane or on a bus or in a mall or at the dentists and start feeling trapped or claustrophobic; or we’re sitting down about to write an exam; or we’re in a social situation where we’re really uncomfortable because we don’t know anyone; in these sorts of circumstances this intense physiological fight or flight response serves no purpose and can often set off a panic attack.

So at this point what’s driving our panic is a vicious cycle between what’s going on in our bodies—the physiological fight-or-flight response—and our thoughts about what’s going on in our bodies, and what all of these symptoms and sensations mean. So first let’s look at some of the most common physical and physiological symptoms associated with panic attacks.

A lot of these symptoms occur in our chests or hearts: like a feeling of tightness or tension in our chests; or an increased heart rate or a racing heart; or heart palpitations; or the feeling that our hearts are skipping a beat.

Symptoms related to our breathing are also common. We start breathing faster or even hyperventilating, and we can feel a tightness or lump or choking feeling in our throats, and it can start to seem like we can’t breathe or are suffocating.

Stomach symptoms are also common. We might feel nauseous or get cramps or have butterflies in our stomachs. Or get a sinking feeling in the pit of our stomachs. Or we might start to feel dizzy and like we’re going to pass out.

And we can start to feel warm or start to sweat or get sweaty palms. Or our hands may become cold or clammy or start to shake and our hands or feet might start to tingle or feel numb.

And then there are symptoms like feeling detached or like we’re in a dream or floating away or watching ourselves from outside our bodies.

There are any number of physical symptoms we can experience during a panic attack, and if yours didn’t get mentioned, the way we deal with all of them is similar enough that hopefully you’ll be able to find something that applies to your situation as well.

And then the other element involved in setting off a panic attack are the thoughts we have in response to these physiological symptoms and sensations in our bodies. So for example if we’re having a lot of symptoms in our hearts or chests we might think: I’m having a heart attack; I’m going to die.

For symptoms related to our breathing: i can’t breathe; I’m going to suffocate; I’m going to start choking.

For symptoms related to dizziness or feeling weak in the knees: I’m going to pass out; or I’m having a stroke.

And for symptoms related to our stomachs: I’m going to be sick; I’m going to throw up; or I’m going to have diarrhoea.

For symptoms like feeling detached or outside of our bodies we might think: I’m going crazy; or I’m losing control.

And then there are a number of common thoughts that can kick in regardless of the specific symptoms we’re experiencing: I’m so scared; i can’t stand this; this is never going to end; i don’t understand what’s happening to me. Or there’s something really wrong with me; something terrible is going to happen; I’m losing control; I’m going to need to run out of here; or I’m not going to be able to get out of here and I’m going to make a scene; I’m going to embarrass myself; what are people going to think of me?

And all of these types of thoughts increase our anxiety. And as a result our physiological and physical symptoms become more intense, leading to even more catastrophic thoughts, initiating a vicious cycle between our physiological and physical symptoms. And these catastrophic thoughts we have related to these symptoms that can lead us to start to panic.

So if we want to avoid this vicious cycle escalating into a full-blown panic attack, as soon as we start having these catastrophic thoughts about our physiological symptoms, we need to come up with alternative and more accurate explanations for what’s going on in our bodies that can help us reverse this cycle, making it less likely that we have a panic attack. So let’s look at some specific examples.

Probably the most common type of panic attack occurs when we experience something like a racing or pounding heart, maybe with some palpitations or some tightness in our chests, and we think we’re having a heart attack. And so we start panicking because we think we’re about to die. And it’s not uncommon for people to call an ambulance during a panic attack because they think they’re having a heart attack.

And if you ever do think you’re having a heart attack you should call for help. But if you’re watching this video it’s very unlikely that you’re going to have a heart attack anytime soon, because you’re probably under 55, an age at which heart attacks are very uncommon. But again if you do think you’re having a heart attack you should call your emergency services number. And if you’re worried about your heart’s health in general please consult your doctor.

And so this is a tricky thing for me to talk about because i don’t want to discourage anyone who thinks they’re having a heart attack from calling for help. But assuming we know there’s nothing wrong with our hearts and we’ve had panic attacks before, and we know what they feel like, and we know that this is just a panic attack, when we start getting these symptoms in our hearts and chests we need to remind ourselves that all of these symptoms are associated with anxiety and especially with the fight or flight response that gets activated when we start to panic. It doesn’t mean we’re having a heart attack. It doesn’t mean we’re going to die.

And by replacing a thought like, oh my god i think I’m about to die, with something like: I’m having extremely intense and uncomfortable feelings in my chest and heart because I’m panicking and my sympathetic nervous system has initiated the fight-or-flight response, we start to reverse the vicious cycle between our physical symptoms and our catastrophic thoughts about these symptoms that’s driving our panic.

And so we start to feel less panic. And as a result the intensity of our physiological symptoms begins to decrease. And because the physiological symptoms are no longer as strong, our thoughts about these symptoms continue to become less catastrophic and more calming, which further reduces our levels of panic.

And these physiological responses like a racing heart aren’t dangerous. They’re not going to cause a heart attack and they’re not going to damage our hearts. They’re just going to feel really uncomfortable, but then they’ll pass without causing any lasting harm.

And everything I’ve said about panicking or having a heart attack applies to panicking we’re having a stroke or any other sort of life-threatening medical crisis. All of our symptoms can be explained by anxiety and panic and the fight-or-flight response. And so if we’re in a heightened state of anxiety and start having these symptoms, it’s very probably just a panic attack. But if you think you’re actually in the middle of a life-threatening medical crisis then you should seek medical attention.

Now let’s look at symptoms related to our breathing. If we feel like we’re choking or can’t breathe or starting to suffocate, we need to reassure ourselves that this is nothing dangerous. It’s been set off by the fight-or-flight response, and it’s not physically possible for us to suffocate ourselves—when we need oxygen our bodies will reflexively breathe—so there’s no way we can suffocate during a panic attack.

But we can start to hyperventilate during a panic attack, which can lead to low levels of carbon dioxide in our blood, which can cause many of the symptoms we can have during a panic attack. So again if we start to hyperventilate we need to replace any catastrophic thoughts like, i can’t breathe, I’m going to suffocate, with reassuring thoughts that these are all normal symptoms of a panic attack and they’re nothing dangerous. And this can help calm our panic.

And then the second thing we can do about symptoms related to our breathing is to slow down our breathing, often we’re told if we’re feeling anxious we should take some deep breaths. But if we’re having a panic attack and we try taking deep breaths we often do this without slowing down our breathing as well. And then we start panting, taking lots of quick deep breaths, which can lead to hyperventilating. So we want to make sure that we’re taking slower rather than deeper breaths.

And there are all sorts of breathing techniques we can use to slow down our breathing so if you already have one that works for you there’s nothing special or magic about my technique. I just find it’s the easiest one for people to be able to do on the spot without any practice in the midst of a panic attack.

So i think the most effective way to slow down our breathing during a panic attack is to breathe into our nostrils for a count of two; pause for a count of two; and then breathe out of our mouths for a count of four through pursed or puckered lips, which slightly restricts the airflow naturally slowing down our exhale.

And then as our breathing slows down we can increase the length of the count breathing in for a count of three; holding our breath for a count of three; and then breathing out for a count of six, and so on. And i have a couple of videos that present this as a guided breathing exercise that you can try out if you are panicking and are finding it difficult to slow down your breathing.

So when we slow down our breathing like this not only does our breathing become easier and more comfortable, we engage our parasympathetic nervous systems. The autonomic nervous system is responsible for regulating our body’s unconscious actions. It includes the sympathetic nervous system, which is responsible for the fight-or-flight response; and the parasympathetic nervous system, which is the opposite of the sympathetic nervous system. And instead of a fight-or-flight response the parasympathetic nervous system is responsible for the rest and digest response, which helps our bodies recover and get things back to normal after a stressful situation.

And so slowing down our breathing helps not just with our breathing related symptoms, but since it engages our parasympathetic nervous systems, it reverses the effects of our sympathetic nervous systems and all of the physiological reactions brought on by the fight-or-flight response, so slowing down our breathing is a great way to help reduce panic.

This brings us to feelings of dizziness and fears that we’re going to pass out. A panic attack can’t cause us to pass out unless we have one of two phobias—a fear of blood or a fear of needles—in which case if we see some blood or get injected with a needle we might pass out. But otherwise we can’t pass out during a panic attack, because the fight-or-flight response elevates our blood pressure. And we pass out when there’s a sudden drop in our blood pressure. So having a panic attack is the opposite of being about to pass out. So the dizziness we feel is a result of anxiety and it’s not going to cause us to pass out or fall over.

Let’s look at symptoms related to our stomachs. Yes anxiety can cause us to get sick. We can throw up or have diarrhoea. But these aren’t life-threatening. They’re unpleasant and potentially embarrassing. But if we’re able to reassure ourselves that these feelings in our stomachs are the result of anxiety and the fight-or-flight response, which does affect digestion. And even if we’re not hyperventilating, slowing down our breathing still helps us engage our parasympathetic nervous systems, and the rest and digest response, which helps calm our anxiety, and our stomachs will start to feel better.

And we can’t go crazy or lose control during a panic attack. Symptoms that feel really weird or can be really scary like feeling detached or in a dreamlike state, or floating away, or watching ourselves from outside our bodies can make us feel like we’re going crazy, but we can’t go crazy (whatever that means) during a panic attack. Again these are just physiological symptoms brought on by our anxiety. And they’ll pass as the panic passes.

We can also try a grounding exercise called 54321 to help us reconnect with reality and we name: five things we can see; four things we can touch; three things we can hear; two things that we can smell; and one thing we can taste. And i have a video that helps guide you through this process if you want to try it out.

And for any other types of physiological or physical symptoms the strategy is the same. We replace our catastrophic thoughts about these symptoms with more accurate thoughts and explanations. And when we’re able to change our thinking then our anxiety and panic and the related physical symptoms we’re experiencing will begin to subside.

And then for the remaining thoughts we talked about earlier, we just need to come up with alternative and more accurate ways of assessing the situation that aren’t so catastrophic and therefore will reduce our anxiety.

For thoughts like, I’m so scared, i can’t stand this, this is never going to end, i don’t understand what’s happening, there must be something really wrong, with me something terrible is going to happen; instead we need to find a perspective more along the lines of, yes this is really scary and uncomfortable, but i know it’s a panic attack and it’s going to end, and the worst case scenario is that I’m going to feel really scared and uncomfortable for maybe 20 to 30 minutes. But then it’s going to pass and everything’s going to return to normal and I’m going to be fine. Or any similar perspective that helps calm our anxiety a little bit and makes it less likely that things continue to escalate.

For thoughts like, what if i can’t get out of here, what if i can’t escape, I’m going to end up making a scene; we need to remind ourselves that this is a panic attack. It feels really scary and uncomfortable but it’s not dangerous. These feelings are all because of anxiety, and slowing down our breathing can help us engage our parasympathetic nervous systems and the rest and digest response, which will help ease our feelings of panic. And doing a grounding exercise can also help, as well as replacing any of our catastrophic thoughts with more accurate and calmer ways of thinking about the situation we’re in. And even if we do have a panic attack, using these techniques can help reduce the severity and duration of the panic attack which is sometimes the best that we can do.

And for thoughts like, I’m losing control, I’m going to embarrass myself, what are people going to think of me; we need to tell ourselves we don’t lose control during a panic attack. It can feel like we’re losing control because of all the intense things going on in our bodies. But that doesn’t translate into acting out of control. And it’s unlikely that we embarrass ourselves during a panic attack, because most of the time nobody even notices. But even if people do notice, the fear “what will people think of me?” Is generally unfounded, because most people will have empathy and sympathy. So we may feel embarrassed, and that’s a natural reaction, but having a panic attack is not something the people around us will think we have any reason to feel embarrassed about.

But sometimes none of these things work and our panic escalates and we find ourselves in the middle of a full-blown panic attack. And so if this happens the best thing we can do is to just accept that we’re having a panic attack. Not because we don’t mind having a panic attack, but because at this stage there’s nothing we can do to prevent it from happening, because it’s already here.

And because trying to fight the panic attack is a battle we can’t win. And is only going to increase the fight-or-flight response, prolonging the panic attack and making it more intense. But the paradox is, if we’re able to just accept that we’re having a panic attack, and we just allow the panic attack to happen, it loses some of its power. Because since we’re accepting it rather than fighting it or trying to escape, there’s no need for the fight-or-flight response anymore—there’s nothing to fight and there’s nothing we’re trying to flee from—and so our physiological symptoms brought on by the fight-or-flight response begin to subside. And as a result our panic stops escalating and can begin to subside as well.

The Panic Attack Worksheet will help you plan how to respond to your physiological symptoms and catastrophic thoughts when you start to panic, in order to prevent or deescalate a panic attack. You can download the Panic Attack Worksheet in PDF or Word format. If you have any questions or comments, please leave them on the YouTube video page.

Mindfulness, Anxiety and Acceptance

Since acceptance can be such a difficult notion to grasp, in this post and the next, I’ve included videos that describe the nature of acceptance, and how and why we accept things even when they’re unpleasant.

Mindfulness and Acceptance

If you have any questions or comments, please leave them on the YouTube video page.

Anxiety, Cognitive Restructuring and Reframing Our Thoughts

In CBT we modify our automatic negative thoughts and cognitive distortions with a technique called cognitive restructuring. Cognitive restructuring involves changing our thoughts to make them more accurate and reflect reality better. And when we do this, we reduce our levels of anxiety.

Cognitive restructuring allows us to modify and reframe our anxious thoughts and worries to arrive at a more balanced perspective. It’s not a form of positive thinking. We’re not trying to change our negative thoughts into thoughts that are overly optimistic. We’re just coming up with ways of looking at things that are more accurate and realistic.

Cognitive Restructuring and Reframing Thoughts in CBT

If you have any questions or comments, please leave them on the YouTube video page.

Cognitive Distortions and Anxiety

When our worries persist and we can’t problem solve them or let them go, the next step is to use cognitive restructuring. But before we get to cognitive restructuring, let’s look at cognitive distortions.

Cognitive distortions are our negatively biased and exaggerated thought patterns that distort reality. When we engage in cognitive distortions, we perceive and evaluate our experiences, and the situations we find ourselves in, inaccurately. Our automatic negative thoughts are often full of cognitive distortions.

The following video explains a number of types of cognitive distortions. Any of these cognitive distortions can leave us feeling anxious, but the cognitive distortions most associated with anxiety are Jumping to Conclusions (Mind Reading and Fortune Telling), Magnification, Catastrophizing, Emotional Reasoning, “Should” Statements, and Personalization.

Cognitive Distortions in CBT

This transcription was auto-generated by YouTube. I’ve only added minimal editing, so I apologize for any errors, run-on sentences, etc.

Cognitive distortions are exaggerated and negatively biased thought patterns that lead us to perceive reality inaccurately. They’re a way our minds have of convincing ourselves to believe things that aren’t really true. They show up all the time in our automatic negative thoughts, and they’re significant because our thoughts have such a big influence over how we feel and how we act. And when we treat these cognitive distortions as if they were facts, we end up feeling and acting based on faulty assumptions, usually in ways that contribute to things like depression, anxiety, low self-esteem, anger, and countless other issues.

As we learn to identify cognitive disorders in our thought patterns, we become better at recognizing when and how our minds are leading us astray, which helps us see the ways in which our thoughts aren’t accurate; and makes it easier to reframe our thoughts and think about things in ways that are less likely to have a negative impact on our mood or mental health, and can help us start feeling better. So now let’s look at some of the most common types of cognitive distortions.

When we engage in all or nothing thinking we see things as black or white with no shades of gray in between. Something or someone is either all good or all bad. If we don’t do everything right we’re a complete failure. One bad thing happens and our whole day is ruined. Someone makes a mistake or disappoints us and they’re irredeemable.

All or nothing thinking is a hallmark of perfectionism. It leads to unrealistic standards for ourselves and others, which can negatively affect our motivation and set ourselves up for failure and disappointment. If you find yourself engaging in all or nothing thinking, try to start recognizing and acknowledging to yourself that things are rarely simply black or white, and start looking for the shades of grey in between.

Overgeneralization is when we see a single negative event as a never-ending pattern of failure or defeat. You’re making dinner and you burn something and you think, i always ruin everything, i never do anything right. You’re in a rush to get somewhere and hit a red light and think, nothing ever goes my way.

Overgeneralizations are often stated in terms of always, never or nothing. If you find yourself overgeneralizing, look for exceptions, and try replacing words like always never or nothing with words like sometimes or some things. And this can help you see that one negative event doesn’t define everything, and helps make your thinking less negatively biased and more accurately reflect reality.

Mental filter refers to filtering out positives and dwelling on negatives. A mental filter is like one drop of ink that discolors a whole glass of clear water: that single drop of something negative colors everything. We pick one negative detail and dwell on it exclusively.

You get lots of positive feedback from your boss with one suggestion about how you could improve, and your takeaway is that you’re no good at your job, and you dwell on that one comment all day. You make a YouTube video that gets twenty positive comments and one person says how much they hate it, and you’re so discouraged you never want to make another video again. If you find yourself operating with a mental filter, learn to start asking yourself if there are any positives or even neutral things about the situation you’re overlooking, and then adjust your filter to let those aspects through as well.

Discounting the positive is similar to a mental filter, but instead of filtering out anything positive, we dismiss it and tell ourselves it doesn’t really count. We get a compliment or some praise and tell ourselves, well that doesn’t really count they’re just trying to be nice to me. Or we succeed at something, but it doesn’t really count because we tell ourselves anyone could do that, i just got lucky.

If you find yourself discounting the positive, take a moment to ask yourself, why doesn’t that count, what reasons do i have to just dismiss that? And most of the time we won’t be able to come up with a good answer. Which makes it harder to discount everything positive. And we can start giving ourselves at least a little credit when things go well. And there’s an exercise called three good things that i talk about in my video on depression that can help you stop discounting the positive, and you’ll find a time stamp link to that exercise in the description and pinned comment.

Jumping to conclusions involves interpreting things negatively without any facts to support our conclusions. When we mind read we make assumptions about what someone’s thinking based on their behavior without confirming with them what they’re actually thinking. If our partner is being quieter than usual we assume it’s because they’re upset with us. If we text a friend and they don’t reply fast enough we assume it’s because we’re not important to them or they don’t like us anymore.

We make these assumptions about what’s going through other people’s minds based on no conclusive evidence, it’s just our interpretation of their behavior, usually mixed in with projecting our own emotions into the situation. We’re feeling insecure about a relationship or friendship, and so we assume that their behavior confirms what we’re feeling and that they’re upset with us.

With fortune telling we predict the future, and that things are going to go badly, without any real evidence to back up the prediction. Again these predictions say more about how we’re feeling ourselves than they do about the actual reality of the situation. Fortune telling is a hallmark of the worrying that comes with anxiety or the hopelessness of depression.

If we find ourselves jumping to conclusions the best thing we can do is to simply ask ourselves, what are the facts of this situation what actual evidence do we have to support this conclusion? Is there any way to interpret the evidence to support alternate conclusions? Or is there any evidence we’re overlooking that suggests a different conclusion? And the goal isn’t to try to predict the right conclusion, but to recognize that there are lots of possible outcomes and we just don’t have enough information yet to know which one is going to come true. And so any conclusion we draw is going to involve jumping to conclusions.

With magnification and minimization we give greater weight to our perceived weaknesses and failures and to the strengths and success of others; and we give less weight to our own perceived strengths and success. It’s like looking through binoculars from each end. We look at our weaknesses and failures through the magnifying side of the binoculars, making them seem bigger and more significant than they actually are.

And then we reverse the binoculars when looking at our own positive attributes and successes, making them seem smaller and less significant than they actually are. And if you find yourself engaging in magnification or minimization, try imagining a friend or loved one in your shoes and see how you’d regard their qualities or results, and then see if you can’t be as generous to yourself in your assessment as you would be to someone else that you care about.

Catastrophizing is related to jumping to conclusions and magnification, and it’s typically what we do when we worry. We’re predicting the future and jumping to the worst possible conclusion no matter how unlikely it is. And we’re magnifying the consequences of this outcome and imagining it’ll be unbearable.

Catastrophizing often unfolds as a series of what-ifs: what if i made a mistake what if my boss finds out? What if i get fired what if i can’t find another job? What if i can’t pay my rent? And if you find yourself catastrophizing try asking yourself the following questions: you’ve already been asking yourself what’s the worst case scenario. So make sure to also ask yourself what’s the best case scenario? And then what’s the most likely scenario? And this helps you get a more balanced perspective and can help prevent you from automatically jumping to the worst possible conclusion.

And then ask yourself, if the worst case scenario did happen, how would i be able to cope with it? How have i coped with similar situations in the past? And this can help limit magnification of the consequences that so often goes along with catastrophization.

When we use emotional reasoning, we think the way we feel reflects reality. So we view ourselves and our situations based on how we feel, rather than on any external evidence. I feel this way therefore it must be true.

If we feel like an idiot that means we are idiots. If we feel anxious we know something bad is about to happen. If we feel depressed and hopeless we convince ourselves this means there is no hope. Or we feel angry so that means we must be being treated unfairly.

But the world doesn’t revolve around how we feel, and if we find ourselves engaging in emotional reasoning, we need to remind ourselves that just because we feel a certain way about something, doesn’t make it true and not to confuse feelings with facts.

The type of should statements we’re referring to here are the arbitrary rules we set for ourselves and others when we tell ourselves that things should be a certain way. I should make everyone happy. I shouldn’t make any mistakes. People should always be on time. When we use should statements we create unrealistic expectations for ourselves and others. When the should statements are directed towards ourselves we set ourselves up for guilt disappointment and frustration, and when we apply should statements to others we can feel let down disappointed or angry.

Often we try using should statements for motivation: i should go to the gym more often; i should stop eating junk food. But presenting these as shoulds can drain our motivation when we fail at something we think we should do, because we feel so bad about it. And should statements can make us rebel, because nobody likes to be told what they should and shouldn’t do, even if we’re the ones telling ourselves what we should do.

If you find yourself engaging in should statements, try rephrasing them with less judgmental terms like I’d like to, or I’ll do my best, or it would be nice if. That way we’re still acknowledging to ourselves what we’d like to do, or how we’d like other people to act, but we don’t have to feel guilty if we don’t, or as angry when people don’t behave the way we think they should.

Labeling is a form of all or nothing thinking and overgeneralization where we judge and label ourselves or someone else, usually in a very negative way, based on a single event or behavior, or attribute that doesn’t really define who we or they are. We knock our coffee off the table and it spills and we label ourselves an idiot. We try to make plans with friends and no one’s available and we label ourselves a loser. When someone has to reschedule a meeting and we label them a selfish jerk. Or they make a mistake at work and we label them useless.

When we use labels we don’t take context into account we don’t consider anything beyond what’s in front of us at this moment. We’re just reflexively assigning a negative label and using it to define the totality of ourselves or someone else. When we apply these labels to ourselves it hurts our confidence and self-esteem and can leave us feeling depressed. And when we apply them to other people it increases hostility and leaves little room for communication. The antidote to labeling is to recognize that one act isn’t defining: just because i made a mistake doesn’t make me an idiot; if someone disappoints us it doesn’t automatically make them a selfish jerk.

Personalization involves holding ourselves personally responsible for a situation that’s not entirely under our control. We take total responsibility for an external event that occurs and ignore any other important factors. As a consequence we end up completely blaming ourselves when something goes wrong, even when we may be only partially responsible, or not responsible at all for the results. Our kid gets sick and we blame ourselves for letting them sleep over at their friend’s house. We’re late for dinner because our partner isn’t ready on time, and we blame ourselves for not making sure they left work earlier.

Or instead of personalization, we can blame other people for things that aren’t totally their fault while overlooking our own contributions to the situation. If you’d reminded me about dinner tonight i would have been ready on time. If you weren’t always working all the time i never would have cheated on you. If you find yourself engaging in personalization and blame, take a moment to ask yourself if there are any other factors you’re overlooking that contributed to the outcome. And recognize that just because you have some responsibility for how something turned out, you’re almost never going to be in a position where you’re 100 to blame.

And if you have trouble accepting that it’s not entirely your fault, you can try using a responsibility pie, where you write down all of the factors that may have contributed to a situation, and then make a pie chart assigning a share of responsibility to each of these factors to help illustrate how you’re not fully responsible for the way things turned out.

And for some more tips on how to combat cognitive distortions check out my video on cognitive restructuring and reframing your thoughts and please like and subscribe and check out my other videos for more tips on how to manage negative thinking.

To see which cognitive distortions tend to arise in your patterns of thinking, you can complete this PDF worksheet from the Centre for Clinical Interventions (they refer to cognitive distortions as “Unhelpful Thinking Styles”). If you have any questions or comments, please leave them on the YouTube video page.