Staring Down Panic: Your Guide to Effectively Confronting Anxiety With Exposure and Response Prevention

Ph.D.

Copyright © 2018 Brian D. Ott, Ph.D.

Cover and Image Design by

William Finnerty

All rights reserved. No part of this book may be reproduced, stored, or transmitted by any means—whether auditory, graphic, mechanical, or electronic—without written permission of the author, except in the case of brief excerpts used in critical articles and reviews. Unauthorized reproduction of any part of this work is illegal and is punishable by law.

The information, ideas, and suggestions in this book are not intended as a substitute for professional advice. Before following any suggestions contained in this book, you should consult your personal physician or mental health professional. Neither the author nor the publisher shall be liable or responsible for any loss or damage allegedly arising as a consequence of your use or application of any information or suggestions in this book.

ISBN: 978-1-4834-8659-8 (sc)

ISBN: 978-1-4834-8658-1 (e)

Library of Congress Control Number: 2018906734

Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.

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Rev. date: 7/13/2018

Reaction to Staring Down Panic

Staring Down Panic is extraordinary for its articulation of the rigorous science guiding clinical practice with persons experiencing anxiety and panic, and for its clarity, commitment, and gentle humor. Dr. Brian Ott certainly delivers on his promise to offer an easy read and a little fun as he masterfully conveys the compassionate engagement, wise pragmatism, and well-developed science underlying clinical excellence in the contemporary treatment of anxiety. Staring Down Panic is a must-read for those who experience impairing anxiety and panic, medical and behavioral health professionals who encounter them, and psychotherapists who aspire for excellence in the effective treatment of anxiety and panic.

Robert Kinscherff, Ph.D., J.D.

Senior Fellow in Law and Applied Neuroscience

    Center for Law, Brain and Behavior, Massachusetts General Hospital / Harvard Law School

Former Assistant Commissioner for Mental Health,

    Massachusetts Department of Mental Health

In Staring, Down Panic, Dr. Brian Ott has provided a book that is clinically astute, scientifically informed, and user-friendly. Essentially, this book is an invaluable resource for anyone who suffers from panic attacks or acute anxiety, just as much as it is a practical and directly applicable guide for mental health providers in their work with anxious and panic-disordered patients. In this book, individuals will find understanding of … and relief from … panic and anxiety. At the same time, providers will find interventions grounded in the latest findings from cognitive neuroscientific research. Through stories, personal and professional, you will delight in Dr. Ott’s blending of clinical expertise and heartfelt concern for his readers.

David Gleason, Psy.D.

Founder and Director, Developmental Empathy, LLC

Author of At What Cost?

Staring Down Panic is an easy-to-read, comprehensive book that uniquely integrates psychoeducation about the etiology of anxiety with the experiences of those who battle panic every day. This is accomplished through a clever and unconventional weave of refreshingly real clinical conversations and clearly stated clinical instruction. While there are many self-help manuals written to assist in the treatment of panic disorder, this book stands out in its orientation of providing both a framework for treatment interventions based on behavioral theory alongside a comprehensive review of associated research findings. Dr. Ott does a remarkable job of taking complicated research and clinical concepts and making these concepts relatable and relevant to those struggling with anxiety and panic. While this book is written specifically for panic disorder, its concepts and clinical applications can be used across a range of anxiety disorders. Get ready for a view of panic that toggles between the lecture hall seat and the therapy office easy chair.

Karen Jacob, Ph.D.

Director of Clinical Services, Gunderson Residence

McLean Hospital

Dr. Ott has produced a work that is at once human and scientific, entertaining yet practical. Bringing together the fields of anxiety treatment, cognitive neuroscience and human learning, he has provided us with a book that is true to decades of clinical research. But Starring Down Panic is also an invitation into the therapist’s office. Care is taken to provide not only the steps of Exposure and Response Prevention, but also the challenge of living with anxiety and confronting it effectively. His years of teaching are reflected in the many accessible examples, as well as his practical tips for application in the real world. The difficulty of dealing with anxiety is never underestimated. And, while his language is every day, information is not dumbed down. Each reader will come away from this book with a clear and sensible understanding of how anxiety develops and what is needed to address its impact on our lives. Dr. Ott reveals himself as a clinician and teacher who makes the complex simple without being simplistic and a compassionate clinician who appreciates the task at hand. Staring Down Panic is a must read for patients and clinicians alike.

Bruce A. Levine, Ph.D. ABPP

Clinical Psychologist, The David Geffen School of Medicine at UCLA

Professor Emeritus of Psychology, State University of New York

Emeritus Member of the Editorial Board, Journal of Behavior Therapy & Experimental Psychiatry

Clinical Psychologist, Hoarders TV Series, A&E Network

The effectiveness of Exposure and Response Prevention has been documented in countless professional articles and is recommended as a best practice for many of the anxiety disorders. In Staring Down Panic, Dr. Ott translated this wealth of scientific data into a practical clinical resource for both patients and professionals. This engaging book is the work of a clinician and teacher. The behavioral and biological complexities of anxiety are captured and addressed in lessons that are true to the experience of those who suffer from it. Those lessons are structured in a manner that eases the task of applying these insights into our daily lives. This is a book you will read and gladly consult as you tackle your panic and anxiety.

Kim Leonte, Ph.D.,

Executive Director, Clearview Horizons

Foreword

Finding a therapist can be a confounding and intimidating process, especially if you are in distress. What qualities should you look for? Who will best help you, and how? What questions should you ask? How vulnerable should you make yourself? How protected?

When Brian Ott became my therapist, nearly twenty years ago now, I was in such bad shape I could hardly formulate these questions. Not long out of college, beset by high anxiety, perpetually on the cusp of a crying fit or a panic attack or both, I was desperate for help. That I should happen to find Brian at that moment I consider one of the great pieces of luck of my life. And luck it undoubtedly was: I picked Brian’s name off a list provided by my insurance company. (His office was not far from my own, and he seemed to have good credentials.) Over the following months I discovered what thirty-five years’ worth of Brian’s patients and graduate students know well, and what readers of this wonderful book are shortly to discover: a clinician of extraordinary wisdom, warmth, intelligence, respectfulness, and patience. In that Charlestown, Massachusetts, office I met each week with a clinician who would neither talk down to me nor allow me to marinate in self-pity, who knew when to challenge me and when to back off, when to educate me and when to crack wise (he really is funny), when to listen and when to speak. In short, I found the ideal therapist.

And now, at long last, readers across the country can find him too, in the pages of this book. The fruit of the author’s long experience treating anxiety disorders, and informed by the best contemporary science, Staring Down Panic is indispensable and true. It looks squarely at the frightening difficulties faced by people suffering from panic attacks, calmly lays out the physiology and psychology of the problem, and clearly articulates the best therapeutic solution.

It is an encouraging and optimistic work, not least of all because it refuses to encourage beyond the point of good sense. This is a guide to panic, thank goodness, that refuses to pander. (Beware of therapists who promise you the moon.) Instead what it does is educate, in an inimitable tone that, like Brian’s own, is at once comforting, witty, and bracing.

Reading Staring Down Panic I felt as though I was sitting across from Brian once again, looking at his bright, sly smile, being guided expertly through the storm. What a pleasure to know that that experience can now be shared widely.

Daniel Smith

NY Times Bestselling Author of Monkey Mind

Some Thanks

Two years ago, after conducting a workshop on Exposure and Response Prevention at a conference in Washington, D.C., a participant approached me and asked where she could buy the book. I told her there was no book. She instructed me to write one. And so it began.

I am grateful to so many for their help along the way. Some kept me focused with the repeated question: done yet? Others never blinked when I asked them, yet another time, to review some pesky wording. As I am sure is always the case in a project of this sort, I regret not keep a log of the many who gave of their precious time and expertise. There are more who helped than I can remember and may acknowledge here. But, that said, I do wish to offer some particular thanks.

David Gleason, Psy.D. The best thing about being a teacher is that your students so often become your mentors. Thanks for tossing out those two simple sentences. I wrote a book. You should write one too.

Lionel Joseph, Ph.D., Psy.D. You were the only one I trusted to tell me what the first draft was about. You nailed it.

Alex Young, Psy.D. It’s not everyone who will throw themselves into an eight-hour marathon squint to keep a project on schedule. Alex, that one-day turnaround and enthusiastic thumbs-up was the boost I needed.

Kim Leonte, Ph.D. A book of this kind requires two types of editors: one on style and one on content. Kim, thanks for your expert (Exposure and Response Prevention) eye.

David Jarsky, M.A. Giving me the correct form of the adrenaline curve did more than you will know.

The William James Crowdsource Proofreading Cooperative. For volunteerism above and beyond the call of graduate school duty, my thanks to: Alexandra Adair, Jason Allan, Nathalie Alexis, Kyra Berube, Joseph Boscarino, Brittany Burkins, Zachary Cohen, Philippe Begougne De Juniac, Erica Deshpande, Jessica Finnegan, Marie Galliotte, Dov Gold, Dana Goldberg, Rachel Hendrickson, Beverly Ibeh, Michelle Jolson, Mackenzie Jordan, Maegan Kenney, Jordan Lee, Luisa de Mello Barreto, Stephanie Messina, Peter Moulton, Evan Moran Queenan, Nicole Muratore, Julie Nason, Carol Rannie, Leah Reece, Roni Rubins, Olivia Skalski, Jacob Slater, Sarah Somogie, Christine Smith, Veronica Steller, Stephani Synn, Grace Waite, and James Walker.

Edward Pace-Schott, Ph.D. You brought me validation from the MGH Neuroscience Labs that my napkin scribbled diagrams of conditioned responses and extinction held water. Thanks for your kind instruction.

Karen Jacob, Ph.D., Robert Kinscherff, Ph.D., J.D. & Bruce Levine, Ph.D. Thanks for the encouragement, spoken and written.

Ilana Cooper, Psy.D., Molly Giorgio, Psy.D., & Kristen Ross, Psy.D. The cover concept brainstorm for this book began over salads and pasta. I owe you three another dinner.

Amanda Baker, Ph.D. Even while your little one was figuring out how to sleep, you found time to give the book a read and approval – Talk about above and beyond the professional call. Thanks for journeying from the Anxiety Disorders Lab to the wilds of Charlestown to share your knowledge and experience.

Carolina Abuelo, M.D. Your view from the primary doc’s office was invaluable. Now on to tackling the Upstairs Downstairs split.

Peter Marcus, Psy.D. & Rachel O’Connor, L.I.C.S.W. You dodging Boston traffic and the elements to get those photos right. Talk about truly risking life and limb.

Emily Lodish, Psy.D. You yielded your editors scalpel with skill, care and kindness

Gary Rose, Ph.D. Who else could provide me with an N2O–Adrenaline–Hollywood link. Next round of oysters are on me.

Anne Waters, Psy.D. Bless you for finding the jokes funny.

Cynthia Rettig. I think I’ve figured out the hyphen thing. Or is it hyphen-thing?

Nan Cee. You had the quickest turn around and the coolest questions.

Jane Mankoski. Thanks for your insights into sub-titles.

Constance Madre. There was never a week you didn’t check in.

Bill Finnerty. Before the Beatles had broken up, you were cracking me up with cartoons in the senior lounge. Thank you, Bill, not only for your artist’s eye and hand, or for transforming those many images, or providing that crash course in leading and kerning, or even turning my cover idea literally on its ear, but for winding back the clock. It was Neap running next to me across the finish line.

To my family, in order of appearance, Lorraine, Caroline, Nadine and Ken, how about a group hug for the early reads, edits, marketing plans and unwavering encouragement all along the way.

Finally, toughest critics and finest contributors have always been my patients, students, and workshop attendees. It was their questions and curiosities that shaped and guided my understanding of anxiety and what helps.

Brian Ott

June 2018

Introduction

A story ran on a local Boston news station last holiday season about a 35-year-old man named Bob. It began with an amazed and amused reporter detailing Bob’s 10-year history of avoiding places where he might encounter crowds. He had avoided office parties, the local supermarket, and even family birthdays. Crowds made him anxious. Large crowds made him panic.

A behavioral therapist was introduced. His credentials were not provided, but he was enthusiastic and clear that what Bob needed was to face his fears. Bob passed through the main entrance of a holiday mall, therapist at his side. As they walked, Bob asked what was going to happen. It was clear that little preparation had been provided and he was in the dark as to what was to come. Several shots captured Bob walking briskly through the mall, his hands held in fists, his breathing labored, eyes either locked straight ahead or closed as he was guided past festive store windows and stressed shoppers. At one point, he asked the therapist, Am I going to be alright? The therapist assured him that nothing bad could possibly happen and that they would only be in the mall for a minute or so. Bob was advised to breathe and stay calm.

Finally, Bob pushed through the exit doors. He continued to walk at a brisk pace away from the mall. The reporter jogged next to him and asked about the experience. Bob’s breathing was shallow and rapid and there was a noticeable trembling in his voice. He frequently touched his throat and chest. Bob had trouble finding words to express his journey through the mall. The behavioral therapist explained that this was to be expected with exposure therapy and that he would be much less anxious next time and that he was well on his way to never having a panic attack again. He patted Bob on the back. Bob kept walking. The reporter closed the story with a smile saying so maybe this will be a truly happy holiday for Bob now that he has used exposure therapy to overcome his fears.

Let’s cut to the chase. The best outcome of this semi-sprint through the mall is that Bob will be right back where he started. More than likely, this brief and unfocused effort may have INCREASED his odds of experiencing panic attacks in crowded situations. This was NOT Exposure and Response Prevention as defined by current professional standards. But it’s easy to be fooled.

The Harm of Rumors and Good Intentions

In your search for something that will work for panic attacks, you may have come across information on the web, or from a friend, or from a behavioral therapist about Exposure and Response Prevention. While you are headed in the right direction by gathering up as much information as you can, much of what you have read or have been told may, unfortunately, be misleading or just plain wrong. One of my patients summed it up well: There’s a lot of well-intentioned crap out there about anxiety.

Exposure and Response Prevention is not torture. The object is not to produce levels of anxiety so strong that you feel compelled to run for your life. Put simply, Exposure and Response Prevention, as the name implies, has two parts. The exposure part refers to a carefully planned approach to experiencing the triggers for your panic attacks, the places where these triggers may be found, and the anxiety you feel. These triggers can be place, events, sensations inside your body and even your own thoughts. The second involves preventing ourselves from doing the things that logically should be helpful, but are not. The first part is hard because no matter how much you plan and prepare, experiencing the things about which we panic sets off a natural human reaction. Our brains wisely tell us to run away from things that seem dangerous. The second part is hard because the ways we have learned to deal with panic, including running away from triggers and towards safety or help, may seem like the only things holding us together.

I urge my patients to consider Exposure and Response Prevention as they would a game my childhood friends and I would play on the see-saw at the local playground (some folks call it a teeter totter). Rather than playing the usual game of two people moving themselves up and down by sitting on opposite ends and kicking off the ground, we would see how long one of us could remain standing at the middle of the board keeping each end suspended in the air. It was a contest of balance. Exposure and Response Prevention requires a balance.

To effectively reduce anxiety, you must be exposed to panic triggers and feel the anxiety that follows. Prolonged exposure is what brings the anxiety down in the long run. The level of anxiety you feel in response to the trigger is one end of the see-saw.

ERP See-Saw

The other end is the likelihood that you will run away from the trigger. Running away or avoiding the trigger is the response that needs to be prevented in Exposure and Response Prevention. Scientists refer to this as neutralizing.

During exposure sessions, it is vital that we don’t run away or call off the session before the benefit can be achieved. It is remaining long enough in the presence of scary triggers that results in long term reductions in anxiety. And here’s where the balance comes in.

If the trigger is too weak and creates only small amounts of anxiety, it will be easier to stay put. But it is unlikely that there will be much benefit as research has shown us that we need to experience our anxiety in the short term to reduce it in the long term.

On the other hand, as anyone’s anxiety gets higher, the odds of a person sticking around go down. Exposing yourself to the worst situation possible is almost a guarantee that you will feel overwhelmed and run away before the benefits of the exposure can be achieved. Later in this book, you will learn that this running away takes many forms. Many of my patients remain physically in a situation, but distract themselves from the experience of being there. This can have the same negative effect as running away: the anxiety stays the same.

The take home message here is that exposure sessions are necessarily uncomfortable, but they can’t be so uncomfortable that we reach the tipping point on the see-saw and run away. Neither can the experience be so low that we swing in the other direction and don’t experience enough anxiety to get the benefit of the exposure session. We are looking for a sweet spot in Exposure and Response prevention that allows you to experience enough anxiety to do good, but not so much that you find it unbearable and run away.

ERP Sweet Spot

We are constantly seeking to keep the exposure side as high enough to do the trick while making sure the avoidance side doesn’t dip so far down. Achieving this balance comes from using a systematic method that teaches you:

- why your brain and body react the way they do

- why the reaction is happening when it does

- how to identify the triggers for these reactions and transform them into a ladder to climb

- how to expose yourself to the steps of the ladder at your own pace

- how to focus on these triggers and for how long, and,

- how to use exposure sessions to keep anxiety and panic from interfering with your life

Most importantly, Exposure and Response Prevention is based on over a century of laboratory and clinical research. However, many patients who find their way to my office are unaware of these facts and labor under the false impressions created by news reports and web sites that generally equate Exposure and Response Prevention to visiting a dentist who performs root canals without Novocain.

But there is another problem which can rob people of their chance to feel less anxious. Patients have told me stories of actions taken by licensed professionals who refer to their approaches as Exposure and Response Prevention that are ineffective at best, counterproductive at worst. Patients describe being encouraged to take part in activities that bear no resemblance to the research-based technique I know. (For now, I will spare you the details. There will be examples later.)

I do not think that these misguided behavioral therapists are by nature cruel. I’ve never met one who stays up late at night plotting to torment his patients. These unfortunate encounters seem most often to arise from a misunderstanding of the theories supporting Exposure and Response Prevention and an unfamiliarity with the steps required for the technique to be effective. Behavioral therapists often fail to appreciate that anxiety is not an emotion that always follows rational rules. There is also a tendency to interpret the word exposure as meaning all-or-nothing rather than step-by-step. Many also neglect staying current with discoveries in the field, especially in the area of brain science. The British statistician George Box once wrote: All models are wrong, but some are useful. He was referring to the fact that all models oversimplify real world events and that new discoveries change the way we understand the world around us (and inside us). Periodically, we need to revise how we think about things based on new information. While some of the research leading to modern approaches to anxiety treatment can be traced to work done over 100 years ago, research on the brain and the ways we develop anxiety and panic reactions completed in the last 20 years has brought about significant changes to the steps and procedures