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Advance praise for Mastery of Your Anxiety and

Panic: Brief Six-Session Version for Primary
Care and Related Settings

“This brief six session treatment of panic disorder has been shown to be effective in primary care
settings when administered by behavioral health specialists. As most patients with panic attacks first
contact their primary care providers, use of this evidence-​based manual can avoid years of struggling to
get an accurate diagnosis and the most effective evidence-​based treatment. This brief version is likely to
be used in other settings where a longer treatment may not be feasible. I enthusiastically recommend
this manual for every primary care facility and other settings where a brief treatment is warranted.”
—​Ricks Warren, PhD, ABPP, Clinical Professor, Department
of Psychiatry, University of Michigan Medical School
“This suite of therapist manuals and patient workbooks, focusing on cutting edge CBT treat-
ment for panic disorder, remains a classic in the field. The authors are internationally renowned
for their expertise in this area and have updated the text with new research, an enhanced em-
phasis on inhibitory learning to inform the process and conduct of exposure exercises, and new
and improved case material. Starting with the previous version, the program pays more attention
to variability in how fast or slow a client is able move through the treatment, improving the pa-
tient—​treatment ‘match’. The end result facilitates implementation for the user and is in a way
like having a personal supervision experience with the authors.”
—​Peter Roy-​Byrne, MD, Professor Emeritus of Psychiatry, University
of Washington School of Medicine
“The Mastery of Your Anxiety and Panic volumes—​the therapist guide and the workbooks for
clients—​are indisputably the finest evidence-​based books for helping people overcome panic dis-
order. The workbooks for clients, including one suitable for primary care settings, are engaging,
informative, and devoid of jargon, rendering them ideal for anyone struggling with panic attacks.”
—​Richard J. McNally, PhD, Professor of Psychology and
Director of Clinical Training, Harvard University
ii

TREATMENTS T H AT W O R K

Editor-​in-​Chief

David H. Barlow, PhD

Scientific Advisory Board

Anne Marie Albano, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Jack M. Gorman, MD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

iii

T R E AT M E N T S T H AT W O R K

Mastery of Your Anxiety

and Panic
Brief Six-​Session Version for Primary Care
and Related Settings

Second Edition

WO RKB O O K

MICHELLE G. CRASKE
D AV I D H . B A R L O W
LAUREN S. WOODARD

1
iv

1
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the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2022
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Craske, Michelle G., 1959- author. | Barlow, David H., author. | Woodard, Lauren S., author.
Title: Mastery of your anxiety and panic : Brief six-session version for primary care and
related settings / Michelle G. Craske, David H. Barlow, Lauren S. Woodard.
Description: Second edition. | New York, NY : Oxford University Press, [2022] |
Series: Treatments that work | Includes bibliographical references and index. |
Identifiers: LCCN 2021043374 (print) | LCCN 2021043375 (ebook) |
ISBN 9780197608678 (paperback) | ISBN 9780197608692 (epub) | ISBN 9780197608708
Subjects: LCSH: Panic disorders—Treatment. | Anxiety disorders—Treatment. | Self-help techniques.
Classification: LCC RC535 .C734 2022 (print) | LCC RC535 (ebook) | DDC 616.85/223—dc23/eng/20211109
LC record available at https://lccn.loc.gov/2021043374
LC ebook record available at https://lccn.loc.gov/2021043375
DOI: 10.1093/​med-​psych/​9780197608678.001.0001
9 8 7 6 5 4 3 2 1
Printed by LSC Communications, United States of America
v

About T R E AT M E N T S T H AT W O R K

One of the most difficult problems confronting patients with various

disorders and diseases is finding the best help available. Everyone is aware
of friends or family members who have sought treatment from a seemingly
reputable practitioner, only to find out later from another doctor that
the original diagnosis was wrong or that the treatments recommended
were inappropriate or perhaps even harmful. Most patients or family
members address this problem by reading everything they can about the
patient’s symptoms, seeking out information on the Internet, or aggres-
sively “asking around” to tap knowledge from friends and acquaintances.
Governments and healthcare policymakers are also aware that people in
need do not always get the best treatments—​something they refer to as
“variability in healthcare practices.”

Now healthcare systems around the world are attempting to correct this
variability by introducing “evidence-​based practice.” This simply means
that it is in everyone’s interest that patients get the most up-​to-​date and
effective care for a particular problem. Healthcare policymakers have
also recognized that it is very useful to give consumers of healthcare as
much information as possible, so that they can make intelligent decisions
in a collaborative effort to improve health and mental health. This se-
ries, Treatments ThatWork™, is designed to accomplish just that. Only
the latest and most effective interventions for particular problems are
described, using user-​friendly language. To be included in this series, each
treatment program must pass the highest standards of evidence available,
as determined by a scientific advisory board. Thus, when individuals suf-
fering from these problems or their family members seek out an expert
clinician who is familiar with these interventions and decides that they
are appropriate, the patients will have confidence that they are receiving
the best care available. Of course, only your healthcare professional can
decide on the right mix of treatments for you.

There has been recognition in recent years that panic attacks are prevalent
and that individuals suffering from panic disorder with varying levels of
agoraphobia constitute 5% to 8% of the population of the United States,
with comparable figures now available from other countries around the

v
vi

world. This means that one out of approximately every 12 people suffers
from this devastating disorder at some point during their life.

Panic disorder patients use primary care services at three times the rate of
other patients, thus creating a need for this workbook that is designed spe-
cifically for patients in primary care, rehabilitation, or settings other than
traditional mental health clinics. The program outlined in this workbook,
now in its second edition, is more acceptable for primary care patients
or patients in related settings since it can be delivered in six visits with a
behavioral health specialist. Although the six-​session structure does not
permit extensive practice with some of the exercises involving exposure to
feared situations, it presents an introduction to the skills and principles
that can be practiced by the clients on their own, as has been proven in
evaluations of this workbook.
We are all striving toward a goal of preventing the occurrence of panic dis-
order and associated anxiety. But for the time being, governments around
the world and their health services have stipulated cognitive behavioral
treatments such as this one as the first-​line approach in relieving the con-
siderable suffering associated with panic disorder.
David H. Barlow, Editor-​in-​Chief
Treatments ThatWork™
Boston, Massachusetts

vi
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Contents

Chapter 1: The Nature of Panic Disorder and Agoraphobia 1

Chapter 2: Learning Breathing Skills and Understanding Your Negative

Thinking 51

Chapter 3: Learning More Breathing and Thinking Skills 71

Chapter 4: Learning to Face Your Fear 85

Chapter 5: Facing Fear Out There 97

Chapter 6: Planning for the Future 119

About the Authors 127

vii
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1

The Nature of Panic Disorder

CHAPTER 1
and Agoraphobia

GOALS

■ Understand the nature of panic attacks, panic disorder, and

agoraphobia.
■ Learn about factors that cause panic disorder.
■ Learn about which medications work and why.
■ Understand that panic is not harmful.
■ Begin to record panic and anxiety.

Do You Have Panic Disorder or Agoraphobia?

If you answer “yes” to the questions below, then you may be suffering
from panic disorder and agoraphobia, since these conditions often occur
together.

■ Do you experience sudden rushes of fear that make you think that
you are sick, dying, or losing your mind?
■ When these panicky feelings happen, does it feel as if your heart is
going to burst out of your chest or as if you cannot get enough air?
■ Or maybe you feel dizzy, faint, trembly, nauseous, chilled, sweaty, or
disconnected from reality?
■ Do the feelings sometimes come from “out of the blue,” when you
least expect them?
■ Do they last for several minutes at a time?
■ Are you worried about when these feelings will happen again?

1
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■ Do these feelings interfere with your normal daily routine or prevent

you from doing things that you would normally do?

The rushes of fear are called panic attacks. Usually, panic attacks are
accompanied by general anxiety about the possibility of another attack.
Together, the panic attacks and general anxiety are called panic disorder.
Agoraphobia refers to anxiety about, or avoidance of, situations where
panic attacks or other physical symptoms are expected to occur. Here
are some examples of how panic disorder and agoraphobia can affect
people’s lives.

Case Studies

Mateo

Mateo was a 31-​year-​old sales manager who suffered from attacks of dizziness,
blurred vision, and heart palpitations. The first panic attack occurred at work,
in the presence of his coworkers, and began with feelings of weakness, nausea,
and dizziness. Mateo asked a colleague to call a doctor because he was afraid
that he was having a heart attack since his father had recently died of one. In
addition to this personal loss, Mateo was dealing with a lot of stress at work.
Several months before the first panic attack, there were times when Mateo had
been nervous and his hands had become shaky while writing, but apart from
that, he had never experienced anything like this before. After a thorough
physical examination, his doctor told Mateo that there was nothing physically
wrong with him. The doctor identified stress and anxiety as the underlying
cause of these physical symptoms. Despite Mateo’s physical health, the panics
continued, mostly at work, and in situations with no easy exit, such as during
shopping excursions at a crowded mall. Sometimes they were unexpected or
out of the blue, particularly the ones that woke him out of deep sleep. Mateo
felt tense and anxious most of the time because he worried about having an-
other panic attack. Once he experienced his third panic attack, Mateo began
to avoid being alone whenever possible. He also avoided places and situations,
such as being in stores, shopping malls, crowds, theaters, and waiting in lines,
where he feared being trapped and embarrassed if he panicked. Wherever he
went, Mateo carried a Bible, as well as chewing gum and cigarettes, because
glancing at the Bible, chewing gum, or smoking cigarettes made him feel more
comfortable and better able to cope with the possibility of another panic at-
tack. In addition, Mateo took medication with him wherever he went to help
deal with his panic attacks.

2
3

Lisa

Lisa was a 24-​year-​old woman who had repeated attacks of dizziness, breath-
lessness, chest pain, blurred vision, a lump in her throat, and feelings of unre-
ality. She was afraid that these feelings meant that something was wrong with
her brain, such as a tumor, or that she was losing control of her mind. The
problem began when Lisa was 19 years old. While at a party, Lisa smoked
some marijuana, and within a short period of time she began to feel very dizzy
and disconnected from reality. Never having had these feelings before, Lisa
thought that she was going insane or that the drug had damaged her brain.
She asked a friend to take her to the emergency room. The physicians did some
tests and reassured Lisa that her symptoms were due to anxiety. Lisa never
touched marijuana or other recreational drugs after that, fearing they would
lead to more feelings of panic. In fact, she became nervous about any chemical
substances, even ones prescribed by her doctor for allergies and sinus infections.
The frequency and intensity of Lisa’s panic attacks waxed and waned over the
years. At one point, she had no attacks for three months. However, she con-
tinued to worry about having another panic attack almost all of the time,
regardless of whether she had consumed chemical substances. She felt uneasy
in situations where it would be difficult to get help if another panic attack
occurred, such as being in unfamiliar places or when she was alone, but she
did not actually avoid many places. Lisa coped with her panic by getting as
involved as she could in activities in order to keep her mind off the potential
of having another panic attack.

Mei

Mei was a 41-​year-​old, married woman who was unemployed because of her
panic attacks. Mei had quit her job as a paralegal several years before because
it had become increasingly difficult for her to leave her house. Mei’s panic
attacks involved strong chest pains and feelings of pressure on her chest, numb-
ness in her left arm, shortness of breath, and heart palpitations. Each time she
panicked, Mei was terrified that she was dying of a heart attack. In addition,
Mei frequently woke up out of deep sleep with feelings of panic, particularly
pressure on her chest, shortness of breath, and sweating. Mei lived with her
extended family, who were of Chinese descent and believed that the nighttime
events represented demons descending on her. Her grandmother convinced
Mei that she would die if she did not wake up in time. Consequently, Mei be-
came very afraid to go to sleep. She would spend many hours pacing the floors
when everyone else was asleep. Instead, she napped throughout the day, when
other people were around. Her life had become very restricted to the house,

3
4

with occasional outings to stores and doctors as long as a family member or

friend accompanied her. Mei had seen many doctors and cardiologists, and
she had undergone several cardiovascular stress tests and had worn a portable
heart monitor to measure her heart over extended periods of time. Nothing
abnormal was detected, yet Mei remained convinced that she would have a
heart attack or that she would die in her sleep.

Diagnosis and Definition of Panic Disorder

The mental health classification system used in the United States and
many other countries, referred to as the Diagnostic and Statistical Manual
for Mental Disorders, fifth edition, identifies the problems addressed in
this workbook as panic disorder and agoraphobia. The key features of
panic disorder are:

1. one or more episodes of abrupt, intense fear or discomfort (i.e., a

panic attack); and
2. persistent anxiety or worry about the recurrence of panic attacks,
their consequences, or life changes as a result of the attacks.

Panic attacks refer to an abrupt rush of intense fear or discomfort that

reaches a peak within minutes accompanied by a number of physical and
cognitive (related to mental processes) symptoms, which are listed below.
Occasional panic attacks are common, and not everyone who experiences
occasional panic attacks develops panic disorder. We discuss details about
the frequency of panic attacks and panic disorder in the general popula-
tion later in this chapter.

Symptoms of panic attack are listed in Box 1.1.

Panic attacks are not unique to panic disorder; they may occur as a part of
many different anxiety disorders, as well as other psychological disorders,
and may even occur in some medical conditions (e.g., respiratory and
cardiac). In panic disorder, the panic attacks become the major source of
concern and worry, whereas within the context of other anxiety problems,
panic attacks usually are not what the person is most worried about.

Panic attacks can be triggered by specific situations, stressors, or anx-

ious thoughts. According to the technical definition of panic disorder,
individuals must report experiencing recurrent (i.e., at least two, although

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Box 1.1. Panic Attack Symptoms

■ Shortness of breath or smothering sensations

■ Heart palpitations or a racing or pounding heart
■ Chest pain or discomfort
■ Trembling or shaking
■ Feelings of choking
■ Sweating
■ Feeling dizzy, unsteady, lightheaded, or faint
■ Hot or cold flashes
■ Nausea or abdominal distress
■ Feelings of unreality or detachment
■ Numbness or tingling
■ Fears of dying
■ Fears of going insane or losing control

typically there is a longstanding pattern of recurrence), unexpected panic

attacks. In other words, these attacks seem to occur out of the blue, in the
absence of any obvious trigger or cue. A good example of an unexpected
panic attack is an attack that occurs when relaxing or when deeply asleep.

For some people, panic attacks continue to occur unexpectedly, and for
other people, the panic attacks become tied to specific situations. These
predictable panic attacks usually occur in situations in which the indi-
vidual has previously had a panic attack and thus anticipates having an-
other. In fact, some people become quite good at predicting their panic
attacks and may experience few unexpected panic attacks.

Individuals with panic disorder often avoid, feel hesitant about, or feel
nervous in situations where they expect panic attacks or other physical
symptoms (such as strong feelings of nausea) to occur. Typically, these
situations are ones where you may not be able to escape or find help.
A common example is a crowded shopping mall, where it might be hard
to find the exit and difficult to get through all the people if you have to
leave suddenly because of a panic attack. Avoiding situations because of
fear when no real danger exists is called a phobia. Avoiding situations
from which escape might be difficult or where help may be unavail-
able in the event of a panic attack or other physical symptoms is called
agoraphobia.

5
6

More specifically, agoraphobia is characterized by intense fear or anx-

iety about going into certain places or situations in which you might
have panic-​like or other embarrassing symptoms (e.g., needing to run
to the restroom, vomiting, fainting), especially in contexts where es-
cape might be difficult or help unavailable. Although the term literally
means “fear of the marketplace,” agoraphobia can span a wide range
of situations, including (1) using public transportation (e.g., buses,
trains, airplanes), (2) being in open spaces (e.g., standing in an open
field), (3) being in enclosed spaces (e.g., elevators, movie theaters),
(4) standing in line or being in crowded areas, and (5) being outside
of the home alone. A full list of typical agoraphobia situations can be
found in Box 1.2.

While panic disorder and agoraphobia are separate disorders, they often
occur together. In most cases, agoraphobia develops after the onset of
panic attacks. There are some people, however, who experience panic
attacks without developing agoraphobia. Conversely, some individuals de-
velop agoraphobia without experiencing panic attacks. For some people,
physical symptoms are the primary cause of agoraphobic thoughts and
behaviors. Someone who experiences abdominal distress may experience
nervousness when going places where bathrooms are not easily acces-
sible. Abdominal distress may be part of irritable bowel syndrome, which
involves a chronic disturbance in bowel habits and includes nausea, sto-
mach cramping, constipation, or diarrhea. These types of symptoms are
often intensified by stress, such as the stress of the situations listed in
Box 1.2. Individuals may avoid these situations because of other bodily
symptoms that are not on the list of panic attack symptoms. A list of these
symptoms is included in Box 1.3.

In general, agoraphobia comes from being anxious about uncomfort-

able physical symptoms in certain situations. These situations are ones in
which it seems difficult to cope with the uncomfortable feelings because
of the feelings of being trapped or of there being no way of getting help.

It is possible to be anxious about and avoid these types of situations for

reasons unrelated to uncomfortable physical symptoms. For example,
many people refuse to fly because of concerns about crashing or being
hijacked. Or, difficulty driving can be based on concerns about being hit
by other drivers. Similarly, avoidance of being alone or of leaving one’s
safety zone can be related to concerns of being attacked or mugged or fear
of other external dangers. This workbook is not written with these kinds

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7

Box 1.2. Typical Agoraphobia Situations

■ Driving
■ Traveling by subway, bus, or taxi
■ Flying
■ Waiting in lines
■ Crowds
■ Stores
■ Restaurants
■ Theaters
■ Long distances from home
■ Unfamiliar areas
■ Hairdressing salon or barbershop
■ Long walks
■ Wide, open spaces
■ Closed-​in spaces (e.g., basements)
■ Boats
■ Being at home alone
■ Auditoriums
■ Elevators
■ Escalators

of fears in mind. Instead, this workbook is for fear and avoidance beha-
vior due to uncomfortable physical symptoms and panic attacks.

Medical Problems

Certain medical problems can cause panic attacks, and controlling these
medical problems eliminates panic attacks. These medical problems in-
clude hyperthyroidism (overactive thyroid gland) and pheochromocy-
toma (a tumor on the adrenal gland, which is very rare). Other medical
problems include extreme use of amphetamines or caffeine (10 or more
cups of coffee per day). However, these medical problems are different
from panic disorder. In panic disorder, the panic attacks are not caused by
medical problems.

There are other medical problems that cause panic-​like symptoms, but
controlling these medical problems does not eliminate panic attacks.

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8

Box 1.3. Other Physical Symptoms That Might Lead to Agoraphobia

■ Headaches
■ Tunnel vision or sensitivity to light
■ Muscle spasms
■ Urinary retention problems
■ Weakness
■ Fatigue
■ Diarrhea
■ Sensations of falling

These include hypoglycemia (low blood sugar), mitral valve prolapse

(flutter of the heart), asthma, allergies, and gastrointestinal problems
(such as irritable bowel syndrome). It is possible to have one of these
medical problems as well as panic disorder. For example, low blood-​sugar
levels may cause weakness and shakiness and thus lead to panic, but cor-
rection of blood-​sugar levels through diet does not necessarily stop all
panic attacks. In other words, these types of medical problems may be
a complicating factor that exists alongside panic disorder, and removing
these medical problems does not always remove panic disorder, which
would require a different treatment such as described in this workbook.

If you have not had medical tests in the past year, it may be wise to un-
dergo a full medical examination to check for possible physical causes of
panic-​like symptoms and to identify other physical conditions that might
contribute to panic and anxiety. These factors can then be taken into ac-
count during the treatment program.

How Common Are Panic Disorder and Agoraphobia?

Panic attacks and agoraphobia are very common. The most recent large-​
scale surveys of the adult population of the United States show that from
5% to 9% of individuals experience panic disorder and/​or agoraphobia
at some time in their lives. This means that somewhere between 16.5 and
30 million people in the United States alone suffer from panic disorder
and/​or agoraphobia, and roughly one out of every 12 people suffer from
panic disorder and/​or agoraphobia at some time in their lives.

8
9

In addition, many people have occasional panic attacks that do not de-
velop into panic disorder. For example, over 30% of the population has
had a panic attack during the past year, usually in response to a stressful
situation such as an examination or a car accident. Moreover, a significant
number of people experience occasional panic attacks from out of the blue
or for no real reason—​around 12% by the best estimate in the last year.

Panic attacks and agoraphobia occur in all kinds of people, across all so-
cial and educational levels, professions, and types of persons. They are
also present across different races and cultures, although panics may be
described and understood differently according to specific cultural beliefs.

Unhelpful Ways of Coping with Panic Attacks

We already mentioned a common way of coping with panic

attacks: avoiding situations where they might occur (i.e., agoraphobia).
Although avoidance of situations decreases anxiety in the short term, in
the long term it contributes to anxiety. The same is true for several other
ways of coping with panic attacks, including distractions, superstitious
objects and safety signals, and alcohol.

Avoidance

In addition to avoidance of situations from which escape is difficult or help

is not easily available (i.e., agoraphobia), avoidance extends to avoiding
activities and other commonplace occurrences. For example, consider the
following behaviors:

■ Do you avoid drinking coffee?

■ Do you avoid taking medication of any kind, even if prescribed by
your doctor?
■ Do you avoid exercising or other physical exertion?
■ Do you avoid becoming very angry?
■ Do you avoid having sexual relations?
■ Do you avoid watching horror movies, medical documentaries, or
sad movies?
■ Do you avoid being outside in very hot or very cold conditions?
■ Do you avoid being away or out of touch from medical help?
■ Do you avoid being rushed?

9
01

Usually, these activities are avoided because they produce symptoms that
are similar to panic attack symptoms. Again, while avoidance helps relieve
anxiety and panic in the short term, it contributes to anxiety in the long
term by reinforcing the idea that these are activities to be avoided.

Distraction

Many people attempt to “get through” anxious situations by distracting

themselves. There is no limit to the methods used for distraction, and we
have seen many creative ones. For example, consider the following poten-
tial responses to becoming anxious or panicky:

■ Do you play loud music?

■ Do you carry around something to read?
■ Do you use apps on your phone to distract yourself?
■ Do you pinch yourself?
■ Do you snap an elastic band on your wrist?
■ Do you place cold, wet towels on your face?
■ Do you tell somebody who is with you to talk about
something—​anything?
■ Do you keep yourself as busy as possible?
■ Do you keep the television on as you go to sleep?
■ Do you imagine yourself somewhere else?
■ Do you play counting games?

Chances are that these types of distractions have helped you get through
a panic attack in the past and may well help you in the future. However,
distractions can become a crutch. For example, if you forget your reading
material or your elastic band, you may have to go home to get it or else
risk having no means to prevent a panic attack. Also, in the long run, these
strategies are not very helpful. Distraction is like placing tape around a
broken table leg without fixing the break; it may work temporarily but
does not address the underlying problem or provide a long-​term solution.
We will discuss this further in ­chapter 4.

Superstitious Objects and Safety Signals

Superstitious objects or people are specific items or persons that make you
feel safe. (They are also called safety signals or safety aids.) Examples in-
clude other people, food, or empty or full medication bottles. If these
objects or people were not around, you would probably feel more anx-
ious. The reality is that these superstitious objects do not actually “save”

10
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you because there is really nothing to be saved from. Other superstitious

objects are listed in Box 1.4. As with distractions, these objects become a
crutch and can contribute to anxiety in the long run.

Alcohol

Perhaps you use a far more dangerous coping strategy—​alcohol. We

now know that many men (more so than women) drink to get through
situations where they might have a panic attack. In fact, from one third
to one half of people with alcohol problems began the long road to al-
cohol addiction by “self-​medicating” anxiety or panic. Using alcohol to
cope with your panics and anxiety is extremely dangerous. This is because
while alcohol works for a little while, you are likely to become dependent
on the alcohol and require more and more of it. As you drink more and
more, alcohol becomes less and less effective at reducing anxiety. Instead,
anxiety and depression tend to increase. If you drink to control your anx-
iety, make every effort to stop as soon as possible, and ask your doctor or
mental health professional for help.

How Does This Program Help You Cope with Panic and Agoraphobia?

Instead of relying on avoidance, distractions, superstitious objects, al-

cohol, or other unhelpful methods, this program is designed to educate
you and to teach constructive ways of coping. This program focuses on
ways of coping with panic, anxiety about panic, and avoidance of panic.
The kind of treatment that is described in this program is called cognitive
behavioral therapy (CBT). CBT differs from traditional psychotherapies
in several important ways:
■ Unlike traditional psychotherapies, CBT teaches skills to manage
anxiety and panic. Specifically, you will be taught ways of slowing
your breathing, ways of changing the way you think, and ways of
facing the things that make you anxious so that they no longer
bother you. For each set of skills, we begin with educational
information and then outline exercises for you to practice. Then, we
build on the previous practice by developing new skills. Finally, the
skills are used to cope with panic and anxiety.
■ Unlike traditional psychotherapies, you will be given homework
assignments. Thus, CBT is much like attending class and continuing
to learn on your own by further study between classes. In many

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Box 1.4. Superstitious Objects and Safety Signals

■ Food or drink
■ Smelling salts
■ Paper bags
■ Religious symbols
■ Flashlights
■ Money
■ Cameras
■ Bags or purses
■ Reading material
■ Cigarettes
■ Pets
■ Cellphones

ways, it is the self-​study aspect of this program that is the most

essential to your success.
■ Unlike traditional psychotherapies, we do not emphasize your
childhood memories and experiences (unless they are directly related
to your panic attacks, as might occur if witnessing someone die of
a heart attack when you were a child led you to fear that you will
also die of a heart attack). Instead, CBT emphasizes the interruption
of the factors that currently contribute to your panic disorder and
agoraphobia. As you will see, it is this method that has proven to be
highly effective.

Is This Program Right for You?

The following list will help you to determine whether you can benefit
from the Mastering Your Anxiety and Panic (MAP) program.

Consider if you have experienced any of the following:

■ Episodes of abrupt and extreme discomfort or fear (i.e., panic)

■ At least some panic attacks that include physical symptoms and
fears, such as:
■ Shortness of breath or feelings of being smothered
■ Heart palpitations or racing or pounding heart
■ Chest pain or discomfort

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■ Trembling or shaking
■ Feelings of choking
■ Sweating
■ Feeling dizzy, unsteady, lightheaded, or faint
■ Chills or hot flushes
■ Nausea or abdominal distress
■ Feelings of unreality or detachment
■ Numbness or tingling
■ Fears of dying
■ Fears of going insane or losing control
■ At least two panic attacks that were unexpected or came from out of
the blue
■ Persistent anxiety or worry about panic attacks, their consequences,
or life changes as a result of the attacks
■ Avoidance of different situations (such as driving, being alone,
crowded areas, unfamiliar areas) or activities (such as exercise) in
which you expect to panic
■ Panic attacks that are not the direct result of physical conditions or
diseases

As already mentioned, panic attacks can be a part of all types of anxiety

problems, such as social phobia, obsessive-​compulsive disorder (OCD),
generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD),
and specific phobias. Panic attacks may also occur in mood disorders,
such as depression. The distinguishing feature of panic disorder is that the
panic attacks themselves become the main source of anxiety and concern.
If you experience panic attacks but are not anxious about having panic
attacks, and instead you are worried about other things, then consult with
your mental health professional to learn if a different treatment is more
appropriate. This program will be a good fit for you if your main concern
is the panic attacks themselves and, of course, if the panic attacks are not
the direct result of physical conditions or diseases.

The Components of Anxiety and Panic

Let’s begin with some information to help you understand panic attacks.

There are three major components of panic and anxiety: physical

symptoms, thoughts, and behaviors. The physical aspect includes the
symptoms of rapid heartbeat, difficulty breathing, nervous stomach,

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diarrhea, sweating, shaking, headaches, stomachaches, a lump in the

throat, frequent urination, fatigue, restlessness, visual disturbances, a
sense of pressure in the head, and many more. The physical symptoms
can be acute, lasting a short period of time (as in panic attacks), or can be
prolonged, lasting hours or days (as in general anxiety). Also, the acute
physical symptoms can shift from one panic attack to the next. On one
occasion, you may notice strong symptoms of shortness of breath, while
on another occasion you may instead notice a racing and pounding heart.

Thoughts refer to beliefs: things that we say to ourselves, or images we

experience. Images of impending doom, or an unshakable sense that
something terrible is about to happen, are examples of thoughts. More
specifically, we refer to these upsetting beliefs as negative thoughts. Most
often, thoughts during panic attacks are about immediate physical
catastrophes (such as fainting, dying, having a heart attack, or having a
brain tumor), social catastrophes (such as being the target of ridicule or
jeering), or mental catastrophes (such as going insane or losing control).
In contrast to these immediate concerns, thoughts stemming from anx-
iety are about bad things that could happen in the future, such as job loss
or the worst panic attack ever.

Behaviors are the things we do, such as pacing up and down, fidgeting,
or escaping from or avoiding places where we expect anxiety and panic
to occur. An example of escaping is to leave a shopping mall as soon as
feelings of anxiety or panic develop. An example of avoiding is to not
enter a shopping mall at all because of concerns about panicking once
you are inside. Other behaviors include looking for exits or ways out of
situations, relying on objects that make you feel better (these are the su-
perstitious objects listed in Box 1.4), or seeking help (such as at medical
centers).
Physical symptoms, thoughts, and behaviors often differ depending on
whether you are experiencing anxiety or panic. As mentioned above,
thoughts during anxiety usually have to do with the future (e.g., “My boss
could give me a negative evaluation at the end of the year” or “It would
be horrible if I panicked at the party tomorrow”), whereas thoughts
during panic attacks are usually about the immediate situation (e.g., “I
am going to faint right now” or “I must be crazy”). Anxious behaviors
include avoiding situations or being extra cautious (such as mapping out
directions fully in advance), whereas behaviors during panic have more
to do with escaping or finding help. Finally, physical symptoms during

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anxiety are typically long lasting and involve muscle tension, restlessness,
and fatigue; in contrast, panic attack symptoms are more abrupt and tend
to decrease more quickly than the physical symptoms of anxiety.

The Panic Cycle

Physical symptoms, thoughts, and behaviors contribute to each other

in what is called a negative cycle. In other words, they combine to gen-
erate a snowball effect wherein each of the three components becomes
increasingly pronounced. For example, negative thoughts can directly in-
crease physical symptoms. If we tell ourselves that something dangerous
is about to occur (e.g., “I am about to have a heart attack”), then physical
tension will increase because our bodies pump out more adrenalin and
operate at faster rates whenever we face (or perceive) danger. In turn,
a physical symptom, such as a racing heart, may lead to more negative
thoughts. This is particularly likely if you believe that normal symptoms
of tension are dangerous (e.g., “The fact that my heart rate has not slowed
down must surely mean that something is terribly wrong”). Behaviors of
fidgeting, pacing, and escaping a situation can increase levels of physical
tension as well because of the physical effort they involve.

Consider a more specific example. While experiencing a racing heart,

you have the thought that a racing heart is a sign of heart disease. This
thought is frightening and produces more racing of the heart. In turn, the
increased racing leads to stronger beliefs that something is terribly wrong
with your heart. It may also lead to attempts to get medical help. Such
negative thoughts and behaviors may yet again prolong the racing of the
heart. Another example is if you experience shortness of breath and con-
sequently think you are going to suffocate. That thought will cause more
physical tension and more shortness of breath. It may lead to attempts
to breathe more deeply, which in turn may contribute to shortness of
breath (for reasons described later), seemingly confirming the idea that
you are suffocating. As these examples illustrate, negative thoughts lead
to fear, and fear leads to more physical symptoms and escape behaviors
that snowball into more negative thoughts, and so on. The end result is
intense fear or panic, as is shown in Figure 1.1. This is called a panic cycle.

In contrast to the examples above, experiencing a racing heart and then

thinking that this physical symptom is harmless and no reason for con-
cern will interrupt this panic cycle, with the end result that panic does

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Physical
Negative thoughts
symptoms of
of heart attack
racing heart

Escape from
situation to find
medical help

Figure 1.1.
The panic cycle

not occur. This is shown in Figure 1.2. Similarly, realizing that shortness
of breath is not a sign of impending suffocation will offset the chances of
a panic attack.

The Agoraphobia Cycle

If you are anxious about physical symptoms, it is likely that you are espe-
cially watchful for those symptoms as you enter a situation from which

Physical symptoms Thoughts that “It is

of racing heart harmless”

Continue with usual

activities

Symptoms of racing
heart go away

Figure 1.2.
Interruption to panic cycle

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Anxiety about facing a

“trapped/unsafe” situation

Increased attention to physical

symptoms on entering the situation

Mistaken belief that the physical

symptoms are harmful or
unmanageable

Tension and attention intensify

symptoms that, in turn, intensify fear

Attempted or actual escape from the

situation

Increased anxiety and avoidance of

the situation in the future

Figure 1.3.
The agoraphobia cycle

escape is not easy or in which help is not available. For example, you
might be particularly attentive to dizziness as you drive on an unfamiliar
road. If you become afraid of the symptom in that situation, it is under-
standable that you might feel panicky or attempt to exit the situation.
However, after escaping the situation, you will likely feel even more anx-
iety the next time you attempt to enter it, or you will be less likely to enter
the situation at all moving forward. That is, the fear has been reinforced
because you did not learn that it was safe to continue in the situation,
despite the physical symptoms you experience. Instead you reinforced the
idea that the situation is one you cannot cope with and thus needs to be
avoided. This sequence of events is shown in Figure 1.3.

Interrupting Panic and Agoraphobia Cycles

This program teaches you ways of interrupting the panic and agoraphobia
cycles. It consists of strategies to help you think differently about and

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behave differently toward physical symptoms. It teaches you how to no

longer be panicked by your experience of physical symptoms and to no
longer avoid physical symptoms or the situations in which they are ex-
pected to occur.

Throughout this program you will be taught two coping skills. The
first strategy is breathing skills. Breathing skills are designed to regulate
breathing and interrupt the panic and agoraphobia cycles by providing
a tool for you to continue whatever activity you are engaging in and
face your fear rather than avoid it. The second coping skill is directed
at your negative thoughts. Once you are able to discover exactly what
negative thoughts you have, you will learn to treat them as speculations
rather than facts. You will learn to be skeptical of these thoughts and
will develop alternative ways of thinking, more based on evidence than
conjecture.

You will use these two coping skills to deal with the situations that you
have been avoiding because of anticipation of panic attacks (i.e., agora-
phobia). You will learn to be less afraid of these situations and will realize
that they are almost always harmless. In addition, you will use the coping
skills to deal directly with physical symptoms that make you anxious,
such as shortness of breath, dizziness, or palpitations. You will learn to be
less afraid of those symptoms and will realize that they too are generally
harmless. You will also learn how to deal directly with physical symptoms
when they occur in agoraphobia situations. You must practice everything
you learn in this treatment over and over again until it becomes part of
your natural method of responding.

What Causes Panic, Anxiety, and Agoraphobia?

The question of what causes panic, anxiety, and agoraphobia is very diffi-
cult, and we do not know all of the answers just yet, but it is important to
say several things here about the causes of panic and anxiety.

Biological Factors

First, the research does not suggest that panic attacks are due to a biolog-
ical disease. Of course, there are the relatively rare examples mentioned
earlier in this chapter, where a medical condition does cause symptoms
that resemble a panic attack, such as hyperthyroidism or a tumor on the

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adrenal gland. However, common panic attacks do not seem to be due to

biological dysfunction.

Many people ask whether panic attacks are due to a chemical imbalance.
Neurochemicals are substances in the central nervous system, including
the brain, that are involved in sending nerve impulses. Neurochemicals
that may influence panic and anxiety include noradrenalin and serotonin.
While these types of substances may be present in greater amounts in
the midst of anxiety and panic, there is no evidence to suggest that a
neurochemical imbalance is the original or main cause of panic and anx-
iety. Some recent evidence using brain scan procedures called positron
emission tomography (PET) and functional magnetic resonance imaging
(fMRI) has shown that certain parts of the brain seem to be particularly
active in anxious patients. However, it is not at all clear whether this acti-
vation is the effect or cause of anxiety.

On the other hand, certain biological factors that may be inherited or

passed on through genes may lead some people to be more likely to
panic. Many believe that what is inherited are overly sensitive parts of
the nervous system, which lead to a tendency to experience all negative
emotions, including anger, sadness, guilt, and shame, as well as anxiety
and panic more frequently than individuals who do not experience panic.
However, inheriting vulnerabilities to experience negative emotions does
not guarantee that you will experience panic attacks or panic disorder. In
other words, panic is not inherited in the same way that, say, eye color
is inherited. If you inherit the genetic structure for blue eyes, then you
will have blue eyes. You do not, however, inherit panic disorder in this
way. People probably inherit a tendency (or a vulnerability) to panic dis-
order—​something (like a personality trait or temperament, such as neu-
roticism) that increases the chances of developing panic disorder but does
not guarantee it. Furthermore, even with a vulnerability to panic, it is
possible to think and act in ways that prevent panic attacks from recur-
ring (which is exactly what we teach in this program).

Biological factors (whatever they may be) probably help explain why panic
disorder tends to run in families. In other words, if one family member
has panic disorder, then another person in the same family is more likely
to have panic disorder than are others in the general population. That
is, whereas 5% to 9% of the U.S. population has panic disorder and/​or
agoraphobia, 15% to 20% of first-​degree relatives (parents, siblings, chil-
dren) of someone with panic disorder themselves develop panic disorder.

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Psychological Factors

Psychological factors are important also. People who experience panic

attacks tend to have certain beliefs that lead them to be especially afraid
of physical symptoms such as a racing heart, shortness of breath, dizzi-
ness, and so on. The beliefs are that physical symptoms are harmful, either
mentally, physically, or socially. Examples of such beliefs include thoughts
that a racing heart could signal heart disease, that lightheadedness could
mean you are about to pass out, that a growling stomach could mean you
will lose control of your bowels, that strong emotions mean you are out
of control, or that a sense of unreality means that you are losing control
of your mind or going insane.

The sources of these beliefs are not fully known, but personal experiences
with health and illness may be one important contributor. For example,
parents who are overprotective about their child’s physical health may
contribute to a general overconcern about physical well-​being in the child
that gradually develops into beliefs that physical symptoms are harmful.
Or, the sudden and unexpected loss of close family members to medical
problems, such as heart attacks or stroke, may increase the likelihood
that individuals believe that their own physical symptoms are harmful.
Another example is to observe a family member suffer through a pro-
longed, serious illness such as chronic obstructive pulmonary disease,
which may tend to make one very sensitive to respiratory symptoms or
distress.

However, beliefs are not the sole cause of panic attacks. As with the bi-
ological factors described previously, beliefs that physical symptoms are
harmful probably increase the likelihood of panic attacks and panic dis-
order but do not guarantee them. Furthermore, this type of psychological
vulnerability can be offset by learning to think and act in different ways.

Most likely, the vulnerability to panic is based on a complex interaction

between psychological and biological factors. What we do know is that
a panic attack is a surge of fear that by itself is a normal bodily response.
What makes it abnormal is that it occurs at the wrong time; that is, when
there is no real reason to be afraid. Again, the response itself is normal and
natural, and it would be the same kind of reaction you would have if you
were to face a real danger (such as being attacked by a person with a gun).
In addition, it is normal and natural to become anxious about having an-
other panic attack and to avoid places where you think that panic attacks
are likely to occur, if you believe that panic attacks are harmful to you.

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What About Stress?

For most people, their first panic attack happened when they were under
a lot of stress. In addition to negative stressful events, such as job loss,
stress can be the result of positive events as well, such as moving to a new
home, having a baby, or getting married. This may explain why panic
attacks are more likely to begin when we are in our 20s, since that is when
we tend to take on new responsibilities, such as leaving home and starting
new careers and relationships.

During stressful periods, everyone is more tense, and even little things
become harder to manage. Stress can increase overall levels of physical
tension and can lower our confidence in our ability to cope with life.
Additionally, having to deal with many negative life stresses can cause us
to think of the world as a threatening or dangerous place. For all these
reasons, a situation that may normally be very manageable becomes
much more stressful when it occurs in the context of other ongoing
stress. Think of a woman who has recently lost her job and whose mar-
riage is breaking up. Within that background of stress, it may be much
more difficult for her to deal with traffic delays than if there were no
background stress. So, as a result, stress increases the chances of panic
attacks. However, stress alone is not an adequate explanation. Some
people do not panic even though they are under a lot of stress. Instead,
they have other reactions to stress, such as headaches, high blood pres-
sure, or ulcers. It seems that stressful events increase the likelihood of
panic attacks in people who are vulnerable or susceptible to panic. These
vulnerabilities include the biological and psychological factors already
described.

Furthermore, stress is rarely the reason why panic attacks persist. For ex-
ample, although panic attacks may have begun during a time of a lot
of marital problems, they are likely to continue even after the marital
problems have been resolved. This is because panic attacks and anxiety
tend to take on a negative, self-​maintaining cycle of their own.

Medications

Many people with anxiety and panic attacks have had their doctors pre-
scribe medications. If this is true for you, you may take this medication
regularly or perhaps only when you feel you need it. Many people go

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through this program without ever starting medication; others would

just as soon not take the medication but are doing so on the advice of
their physicians. For some, the anxiety and panic are so severe that they
feel they cannot handle even one more day with them and need relief
as soon as possible. Others may not feel that they have the time to de-
vote to mastering the information in this workbook right now. For these
individuals, medication is an appealing option; even the medication that
takes the longest to act would begin to take effect in approximately three
weeks. Some of the shorter-​acting medications can work within a day
or two. Of course, some people seek medication simply because they
strongly believe it is the best treatment for their anxiety.

In any case, almost 60% of the people who come to our clinic for psy-
chological treatment are taking some kind of medication for their anxiety.
Some have been taking it for quite some time. For others, their physician
has given them a prescription to get them through a few weeks and has
told them to come to our clinic as soon as possible.

At this point, the evidence seems clear that some types of medications, if
prescribed at the right dosage, can be effective for at least the short-​term
relief of anxiety or panic for some people. Many of these medications,
however, are not effective in the long term unless you continue to take
them. Even then, they may lose some of their effectiveness unless you
learn some new, more helpful methods of coping with anxiety and panic
while you are on the medication. Nevertheless, there are some people
who begin a course of medication therapy and stop several months later
without any need to go through a program such as this. Whether the
particular stress they were under has resolved, whether there were some
changes in their sensitivity, or whether they developed a different attitude
toward their anxiety and panic, medication for this short time was all they
needed.

For all of these reasons, it seems useful to review the ways in which
medications work and the different types of medications prescribed for
anxiety and panic.

How Do Medications Work?

Medications are believed to decrease vulnerability to experiencing panic

and anxiety. Medications seem to make it harder for the body to have a
full fear (panic) reaction. In addition, medications reduce general anxiety
and, therefore, reduce the severity of daily worry about panic attacks.

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Because the symptoms of general anxiety are reduced, there are fewer
symptoms to become afraid of in a “fear of fear” cycle.

Medications decrease panic and anxiety by changing the proportions

of neurotransmitters (i.e., chemicals) in certain parts of your brain and
nervous system. This process of adjustment in the brain chemistry often
takes several weeks, which is why many medications do not work imme-
diately (although some do). During this adjustment, the brain rebalances
itself. Therefore, medication is not giving your brain something extra that
it lacks, nor is it taking away something that the brain has too much of.
Rather, it is helping your brain rebalance and work more efficiently doing
the job it has to do.

Imagine that the brain has a “stress thermostat” that keeps it in balance,
like a thermostat adjusts to keep a room the same temperature when it
becomes too hot or too cold. Panic and anxiety may occur when the
“set point” that determines the ideal level of neurotransmitters (i.e., tem-
perature) gets moved too high or too low. For example, stress can move
the set point. So can certain substances, such as caffeine. The process of
rebalancing moves the set point back to the middle so that the brain can
work more like it has before. After some time, medication may no longer
be needed, provided that you can develop better ways of coping with
stress so that future stressful events do not move the thermostat set point
out of balance again.

Different Types of Medications

Antidepressants

There are several classes of antidepressants that control anxiety and panic
attacks. Antidepressants called specific serotonin reuptake inhibitors
(SSRIs) include medications such as fluoxetine (Prozac), sertraline (Zoloft),
fluvoxamine (Luvox), and paroxetine (Paxil). Related antidepressants
called serotonin–​ norepinephrine reuptake inhibitors (SNRIs) include
venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs are considered
the first-​line drug treatment for anxiety and panic, though SNRIs (partic-
ularly Effexor) are also frequently prescribed for this purpose. In general,
these two classes of medications are less toxic and cause fewer side effects
than older medications such as tricyclic antidepressants (TCAs) and mon-
oamine oxidase inhibitors (MAOIs; described next). Nevertheless, some
people still experience stomach upset and other gastrointestinal symptoms,
headaches, and other side effects—​particularly sexual dysfunction—​with

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these medications. In addition, there may be some initial worsening of

anxiety, although this can be decreased by starting with lower doses (such
as 5 mg/​day of Prozac). The most effective doses for controlling panic and
anxiety for drugs most often prescribed are 20 to 40 mg/​day of Prozac, 75
to 150 mg/​day of Luvox, 20 to 40 mg/​day of Paxil, and 100 to 200 mg/​
day of Zoloft (see Table 1.1 on page 25).

TCAs include imipramine (Tofranil), clomipramine (Anafranil),

desipramine (Norpramin), nortriptyline (Pamelor), and amitriptyline
(Elavil). Tofranil was formerly the most commonly used antidepressant
for anxiety and panic but has been largely supplanted by SSRIs, as noted
above. These medications are generally helpful for panic and anxiety when
administered in the range of 150 to 300 mg of Tofranil or its equivalent.
There may be some worsening of anxiety initially. However, the initial
worsening is only small when beginning with small doses (such as 10 mg
of Tofranil). These doses are gradually increased to effective levels. Also,
the initial worsening goes away after the first week or so of treatment.
Other side effects include dry mouth, constipation, blurred vision, weight
gain, and lightheadedness. However, these side effects are generally harm-
less and go away after a few weeks. It usually takes several weeks before the
medications control anxiety and panic, so getting through the first few
weeks is critical. It is difficult because the first few weeks are when the side
effects are the strongest but the medication is not yet having a positive
effect on reducing panic and anxiety. After that, the side effects decrease,
and so do panic and anxiety.

Another type of antidepressant medication is the MAOIs. While effec-

tive, these medications can have significant side effects. For this reason,
they have largely been replaced by SSRIs and SNRIs. In fact, MAOIs are
often prescribed only after individuals have failed to respond to these
other forms of medication. The best-​known MAOI for anxiety and panic
is phenelzine (Nardil). Others include tranylcypromine (Parnate) and
isocarboxazid (Marplan). MAOIs can cause side effects such as lighthead-
edness, weight gain, muscle twitching, sexual dysfunction, and sleep dis-
turbance. As with other medications, treatment usually begins with low
doses, such as 15 to 30 mg per day of Nardil, and is gradually increased
to effective levels, such as 60 to 90 mg per day of Nardil. MAOIs are
seldom used for panic disorder these days because there are severe dietary
restrictions for those taking this type of medication. For example, you
cannot eat cheese, chocolate, or other foods containing tyramine, and you

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Table 1.1. Medications Used to Treat Panic Disorder

Medication Brand Name Initial Dose Dosage Range

FDA-​Approved Drugs for Panic Disorder

SSRIs

Fluoxetine Prozac 10 mg/​day 10–​60 mg/​day

Paroxetine Paxil 10 mg/​day 10–​60 mg/​day

Sertraline Zoloft 25 mg/​day 50–​200 mg/​day

SNRIs Effexor 37.5 mg/​day 75–​300 mg/​day

Venlafaxine
Benzodiazepines

Alprazolam Xanax 0.25–​0.5 mg/​day 0.25–​4 mg/​day

(3 times per day) (3 times per day)

Clonazepam Klonopin 0.25 mg/​day 1–​3 mg/​day

Not Approved by FDA at This Time for Panic Disorder

SSRIs

Escitalopram Lexapro 10 mg/​day 10–​60 mg/​day

Citalopram Celexa 10 mg/​day 20–​60 mg/​day

Fluvoxamine Luvox 25 mg/​day 25–​300 mg/​day

Benzodiazepines

Diazepam Valium 4 mg/​day 4–​40 mg/​day

Lorazepam Ativan 1.5–​2 mg/​day 4–​8 mg/​day

TCAs

Imipramine Tofranil 75 mg/​day 50–​200 mg/​day

Clomipramine Anafranil 25 mg/​day 25–​250 mg/​day

Desipramine Norpramin 25–​50 mg/​day 100–​200 mg/​day
Nortriptyline Pamelor 25 mg/​day 100–​200 mg/​day

25
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cannot drink red wine or beer. If you do, you risk dangerous symptoms,
including high blood pressure.

The antidepressant medications seem to be about equally effective for

panic attacks, anxiety, and agoraphobia. One thorny problem with an-
tidepressant medications is the side effects during the first few weeks. In
addition, the side effects are sometimes similar to symptoms of panic and
anxiety. For that reason, many people do not want to continue taking the
antidepressant or at least do not want to increase the dosage to the levels
that are needed to reduce panic and anxiety (this is called the therapeutic
dosage). And yet, research has shown that it is important to take enough of
this medication to get the full benefits. Therefore, it is best to stick it out
through the first few weeks until reaching the therapeutic dosage while,
of course, checking with your prescribing physician from time to time.
It is much easier to stop taking antidepressants than benzodiazepines
(described below). In other words, there are usually fewer withdrawal
symptoms when antidepressants are ended than when benzodiazepines
are ended. Therefore, the relapse rates are much lower for antidepressants
(around 40% to 50%) than for benzodiazepines after finishing treatment.

Benzodiazepines

Medications commonly prescribed for anxiety and panic in the past, but
less frequently now, are the minor tranquilizers. Two of the most common
are diazepam (Valium) and chlordiazepoxide (Librium). Typically, these
medications are prescribed for short-​term relief of anxiety. They are gener-
ally believed to be unhelpful for panic attacks unless they are prescribed in
very high dosages. For example, you might need 30 mg or more of Valium
per day to make a dent in your panic attacks. At this dosage, chances
are that you would feel very sedated (i.e., sleepy). For this reason, minor
tranquilizers are not usually prescribed for panic attacks by psychiatrists
and physicians knowledgeable in the medication treatment of panic. Also,
over time, you may need increasingly larger dosages of the medication to
obtain the same effects. This is called tolerance. Unless you work carefully
with your physician, there is a danger that with long-​term usage, you may
become psychologically and physically dependent on these medications
(i.e., suffer addiction) that had been intended only for short-​term treat-
ment of anxiety.

High-​potency medications have stronger effects per dose than lower-​po-

tency medications. High-​potency benzodiazepines alleviate panic attacks

26
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without causing such side effects as extreme sleepiness, which are seen
with higher doses of lower-​potency benzodiazepines (e.g., Valium). These
high-​potency medications work very quickly; their effects are usually no-
ticeable within 20 minutes of ingestion, and they are still the most fre-
quently prescribed medications for panic and anxiety. The best-​known
high-​potency benzodiazepines are alprazolam (Xanax) and clonazepam
(Klonopin). To give you an idea of how strong Xanax is, 1 mg of Xanax
equals approximately 10 mg of Valium. The therapeutic dose of Xanax
for panic attacks varies from person to person and also with the nature of
the panic attacks. Usually, 1 to 4 mg per day would be the best dosage for
panic attacks, but a dosage of more than 4 mg per day is sometimes re-
quired for severe agoraphobia avoidance. With these doses, 60% of a large
group of patients were free of panic after eight weeks. The appropriate
dose of Klonopin is 1.5 to 4 mg per day.

Side effects of these medications include sleepiness, poor coordination,

and memory problems. However, starting with low doses and gradu-
ally increasing them over time can reduce these side effects. The initial
feeling of sleepiness usually subsides as one adapts to the medication. It
is important to realize that the side effects decrease over time and are not
dangerous.

The different benzodiazepines differ in how long they remain active in

your body. This is referred to as half-​life (the amount of time it takes
for half of a dose of the medication to be eliminated from the body).
Medications with a longer half-​life are taken less frequently. Klonopin
has a longer half-​life (15 to 50 hours) than Xanax (5 to 27 hours).
Therefore, Klonopin is taken less frequently than Xanax. With a med-
ication that has a shorter half-​life, people often feel the effects of the
medication wearing off and notice increased anxiety when the levels
of medication in the body are low, such as when they wake up in the
morning.

Benzodiazepines are believed to work by increasing the effect of a chem-

ical in the brain called gamma amino butyric acid (GABA). GABA is dis-
tributed throughout the brain. It functions to inhibit the firing of nerve
cells. Benzodiazepines help GABA to “put the brakes on” those areas
of the brain that cause anxiety. As you can probably imagine, stopping
benzodiazepines will “let up on the brakes” and is usually associated with
an increase in anxiety. This is one reason why many (if not most) people
relapse when they stop taking benzodiazepines.

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28

Withdrawal symptoms are felt when benzodiazepines are stopped. These

include anxiety, jitteriness, difficulty concentrating, irritability, sensitivity
to light or sound, muscle tension or aching, headaches, sleep disturbance,
and stomach upset. Sometimes these withdrawal symptoms lead people
to become very concerned and anxious, especially because the with-
drawal symptoms are similar to symptoms of panic and anxiety. In fact,
sometimes these reactions are more severe than the most severe panic
attacks ever experienced. People are sometimes so upset by the withdrawal
symptoms that they begin the medication again in order to get rid of the
withdrawal symptoms. Alternatively, they may relapse (i.e., suffer a recur-
rence of panic and anxiety).

Relapse is especially likely if the withdrawal symptoms are mistakenly

viewed as being harmful. Actually, most withdrawal symptoms are not
harmful. Instead, withdrawal symptoms reflect the body’s adjustments
to the chemical changes. Also, withdrawal symptoms go away with time.
With this type of information and some other behavioral strategies,
the withdrawal process is generally much easier. Thus, slow tapering
off of benzodiazepines, combined with the types of strategies described
in this workbook, dramatically reduces withdrawal and relapse when
benzodiazepines are discontinued.

Beta-​B lockers

Many people take beta-​blockers to reduce their blood pressure or regulate

their heart rate. These medications act on a specific receptor, the beta-​re-
ceptor, which is involved in regulating aspects of body functioning such
as heart rate. Therefore, if one needs to avoid increased arousal for med-
ical reasons, beta-​blockers are often used. There are many types of beta-​
blockers, and one of the most popular is metoprolol succinate (Toprol
XL). Given the information about the psychological factors involved
in panic disorder, especially the notion of anxiety focused on physical
symptoms of fear, one would think that any medication that decreases
bodily symptoms such as fast heart rates would eliminate panic attacks.
But there is little if any evidence that beta-​blockers are useful in any way
for panic attacks, although some people might feel a little bit better after
taking the medication. For that reason, doctors knowledgeable about the
medication treatment of anxiety almost never prescribe this as the main
medication to treat anxiety and panic. It is sometimes included as an ad-
junct or secondary medication.

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29

Medications with indications approved by the U.S. Food and Drug

Administration (FDA) for panic disorder are listed in Table 1.1, along
with additional medications that, although not specifically approved, are
likely to be just as effective in certain instances for some people. As al-
ways, your physician should work with you in making the final decisions
on which medication is best for you.

Typical Mistaken Beliefs About Medications

Because the side effects and withdrawal symptoms from medications are
similar to the symptoms of panic and anxiety, they too are sometimes
mistakenly believed to be harmful. There are a number of general myths
and mistaken beliefs about medications. In the following, we discuss
some of these.

Myth 1: Side Effects Are Harmful

Some people believe that the side effects of medications indicate that the
drug is causing damage to their bodies, or that they have a physical di-
sease. Actually, side effects show that the body is adjusting to the presence
of the drug and are almost always harmless. Most often, these side effects
go away with time. Sometimes the side effects resemble the symptoms of
panic and anxiety. However, this does not mean that anxiety and panic
are actually worsening. It indicates that the body is adjusting to the chem-
ical changes introduced by the medication. To help you stick it out, re-
member the following:

1. Side effects are not an indication of something wrong or harmful hap-

pening to your body. That is, the side effects do not generally indicate
that physical damage is occurring to your body. Nor do they indicate
a physical disease. In fact, side effects indicate that medications are
having their intended chemical effects.
2. Side effects are not an indication that your anxiety is increasing.
Instead, side effects indicate that your body is going through a period
of adjustment to the medication, and sometimes, the side effects of
this adjustment are symptoms that are similar to panic and anxiety—​
but they are not actual panic and anxiety.
3. Side effects usually go away after a few weeks.
4. Strategies described in this treatment will help you to be less afraid of
the side effects and achieve therapeutic dosages of medication.

29
0
3

Myth 2: You Will Never Be Able to Tolerate Medications

A second mistaken belief about medication is that it is impossible ever

to tolerate medications. Some people believe that they will never lose
their initial discomfort about taking medications. Actually, people usu-
ally adapt to taking medications given a long enough period of time. For
example, even though some people with diabetes initially think they will
never be comfortable pricking their fingers to check their blood-​sugar
levels, let alone giving themselves regular insulin injections, these actions
eventually become second nature to them. The same is generally true with
medications for anxiety.

Myth 3: Medications Are Permanently Addictive

Sometimes people mistakenly believe that they will become addicted to

medications, unable to withdraw from them successfully, and will thus
be stuck taking medications for the rest of their lives. A similar belief
is that withdrawal will cause serious medical problems. There is no ev-
idence that antidepressants are addictive. While it is true that some
benzodiazepines have addictive properties for certain people who require
an increasing amount of the drug in order to achieve a therapeutic effect
(i.e., tolerance), recent research shows that most patients do not steadily
increase their dosage of benzodiazepines over the years. This suggests
that when used properly to treat anxiety, these medications are not as
addictive as once thought. In addition, as already stated, cognitive be-
havioral strategies as taught in this workbook, combined with a slow
tapering off of medications, results in well over 75% of people having
no problem withdrawing. Finally, while it is true that sudden or “cold
turkey” withdrawal may cause seizures and some more serious medical
problems, slow tapering off of medications is not harmful. The with-
drawal symptoms simply reflect the fact that the body is readjusting to
chemical changes. Think of medications as having the same effect as the
reins on a horse: When the reins are let out (when the medication treat-
ment is ended), horses generally run a bit faster at first, but then eventu-
ally slow down again to a normal pace.

Myth 4: Medications Increase Anxiety and Panic

A fourth mistaken belief is that medications will lead to more anxiety

and panic. As discussed before, it is sometimes the case that medications
(particularly the TCAs and SSRIs) initially worsen anxiety symptoms, but

30
31

this usually passes within a week or so. Medications may worsen anxiety
if one mistakenly believes that the medication is causing loss of control,
or is medically damaging. However, in such a case, it is the beliefs that are
causing the anxiety, not the medication itself.

Myth 5: Medications Become a Crutch

Some people believe that medications become a crutch and prevent self-​
management of life problems. It is true that certain medications can
become a crutch, particularly the fast-​acting medications such as the
high-​potency benzodiazepines. It is easier to take a pill than learn to cope
with problematic situations. However, when medications are combined
with cognitive behavioral approaches, it is possible to learn new ways
of behaving and thinking in order to cope better with stress and to self-​
manage even after medication is withdrawn.

Myth 6: Medications Impair Functioning

Finally, some people believe that medications will impair their concen-
tration and ability to function to such a degree that they won’t be able to
work, drive, or take care of their children or other responsibilities. With
correct monitoring of dosage levels, this degree of impairment is very rare.
Only with very high doses of the low-​potency benzodiazepines does this
kind of impairment occur.

Misconceptions about medications often coincide with misconceptions

about the nature of panic itself. Just as it is important to challenge myths
about medications, so too is it necessary to be informed about the func-
tion of panic. The following section provides information on panic, which
will help you correct misconceptions you may have about panic or panic
disorder.

Panic Is Not Harmful

Scientifically, immediate or short-​term fear (i.e., a panic attack) is named

the flight-​or-​fight response. The effects of this response are aimed toward
fleeing from danger or, if that fails, fighting to survive. Thus, the number-​
one purpose of panic is to protect us from danger. When our ancestors
lived in caves, it was vital that when faced with danger, an automatic re-
sponse would take over, causing them to take immediate action (attack or

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32

run). Even in today’s hectic world, this can be necessary. Just imagine if
you were crossing a street when suddenly a car sped toward you blasting
its horn. If you experienced absolutely no fear, you would be killed. What
actually happens is that your flight-​or-​fight response takes over, and you
run out of the way. The purpose of panic is to protect us, not to harm
us. It is our survival mechanism, and it involves the following physical
changes in our bodies.

Nervous and Chemical Effects

When danger is detected, the brain sends messages to a section of our

nerves called the autonomic nervous system. The autonomic nervous system
has two subsections, or branches, called the sympathetic nervous system and
the parasympathetic nervous system. These two branches of the nervous
system are directly involved in controlling the body’s energy levels and
its preparation for action. The sympathetic nervous system is the flight-​
or-​fight system, which releases energy and gets the body ready for action
(fighting or fleeing). The parasympathetic nervous system is the restoring
system, which returns the body to a normal state. Activation of the sym-
pathetic nervous system is believed to cause most panic attack symptoms.

The sympathetic nervous system tends to be an all-​or-​none system: When

it is activated, all of its parts respond. This may explain why most panic
attacks involve many physical symptoms and not just one or two. In ad-
dition, the sympathetic nervous system responds immediately, as soon as
danger is close at hand (e.g., think of the rush that you experience when
you think another car on the freeway is about to hit you). That is why
the physical symptoms of panic attacks can occur almost instantaneously,
within seconds.

The sympathetic nervous system releases two chemicals, adrenalin and

noradrenalin, from the adrenal glands on the kidneys. These chemicals
are used as messengers by the sympathetic nervous system to continue
activity so that once activity begins, it often continues and increases for
some time. However, the sympathetic nervous system activity is stopped
in two ways. First, the chemical messengers adrenalin and noradrenalin
are eventually destroyed by other chemicals in the body. Second, the par-
asympathetic nervous system (which generally has opposing effects to the
sympathetic nervous system) becomes activated and restores a normal
state. Eventually, the body will “have enough” of the flight-​ or-​
fight

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3

response, and the parasympathetic nervous system will restore normality.

In other words, panic can neither continue forever nor spiral to ever-​
increasing and damaging levels. The parasympathetic nervous system
stops the sympathetic nervous system from getting “carried away.”

Adrenalin and noradrenalin take some time to be fully destroyed. Even

after your sympathetic nervous system has stopped responding, you are
likely to feel keyed up or on edge for some time because the chemicals
are still floating around in your system. This is perfectly natural and
harmless. In fact, there is a purpose to this—​in the wild, danger often
has a habit of returning. So, it is useful for us to remain in a keyed-​up
state so that we can quickly reactivate the flight-​fight response if danger
returns.
Each physical effect of the flight-​or-​fight system is intended to prepare us
to fight or flee—​that is, to protect us. The flight-​or-​fight system affects
our hearts, blood flow, breathing, sweating, pupils, muscles, and digestive
system, as well as other parts of our bodies.

Cardiovascular Effects

Activity in the sympathetic nervous system increases heart rate and the
strength of the heartbeat. This is vital to preparation for action (to fight
or flee) because it speeds up the blood flow, improving delivery of oxygen
to the tissues and removal of waste products from the tissues. The muscle
tissues need oxygen as a source of energy for fighting or fleeing. This is
why a racing or pounding heart is typically experienced during periods of
high anxiety or panic.

Also, there is a change in the blood flow. Basically, blood is taken away
from the places where it is not needed (by a tightening of the blood
vessels) and is directed toward the places where it is needed more (by an
expansion of the blood vessels). For example, blood is taken away from
the skin, fingers, and toes. This is useful because, thinking back to our
ancestral cave days, the extremities are the most likely place to be attacked
and injured. Having less blood flow there means that we are less likely to
bleed to death. As a result, the skin looks pale and feels cold, especially
around the hands and feet. Instead, the blood goes to the large muscles,
such as the thighs, heart, and biceps, which need the oxygen for fighting
or fleeing.

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34

Together, these physical changes cause the heart to race or pound and the
skin to feel pale and cold, especially around the toes and fingers, some-
times causing feelings of weakness in the hands and feet. You might feel
cold even though it is a warm day. These are normal physical feelings
under conditions of being afraid or anxious. It is a sign that the body is
preparing to take action.

Sometimes people report feeling hot instead of cold. Hot feelings are more
likely to occur during the abrupt rush of panic, as soon as the sympathetic
nervous system is activated and before the blood flow is redirected. The
cold chills that go along with the redirection of the blood flow are more
likely to occur with slow-​building or longer-​lasting anxiety.

Respiration (Breathing) Effects

Another effect is for breathing to become faster and deeper, because the
body needs more oxygen to be able to fight or flee. Sometimes, breathing
can become unbalanced and cause harmless but unpleasant symptoms
such as breathlessness, choking or smothering feelings, and pain or tight-
ness in the chest. Also, the blood supply to the head may be decreased.
While this is only a small amount and is not at all dangerous, it produces
unpleasant (but harmless) symptoms, including dizziness, blurred vision,
confusion, feelings of unreality (or, feeling as if you are in a dream state),
and hot flushes. These physical symptoms might be uncomfortable but
are not at all harmful and are not a sign that something is seriously wrong
with you.

Sweat-​Gland Effects

The flight-​or-​fight response increases sweating. Sweating cools the body

to prevent it from overheating and allows you to continue fighting or
fleeing from danger without collapsing from heat. In addition, excessive
sweating makes the skin slippery, so that it is more difficult for a predator
to grasp. Perspiration is a common symptom of anxiety and panic.

Other Physical Effects

The pupils (the center of our eyes) widen to let in more light. This helps
us to scan the environment for whatever is dangerous. Remember, panic
and anxiety are reactions to the perception of threat, and if a threat or

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danger is expected to occur, then it makes sense for us to be on guard and

look for it by increasing our field of vision. At the same time, the change
in the pupils may cause symptoms such as blurred vision, spots in front
of our eyes, or sensitivity to bright lights.

Another physical effect is a decrease in salivation, resulting in a dry mouth.

In fact, the activity of the whole digestive system is decreased, so that the
energy needed for food digestion can be redirected to the muscles that
are needed to fight or flee. This often causes nausea, heavy feelings in the
stomach, and sometimes diarrhea as material that could “weigh us down”
while attempting to fight or flee is evacuated from the body.

Also, many of the muscle groups tense up in preparation for flight or

fight, and this results in feelings of tension. This tension can sometimes
cause aches and pains, as well as trembling and shaking. Another inter-
esting effect is the release of natural analgesics (i.e., painkillers) from the
brain, so that we are less likely to feel pain when we are afraid. The pur-
pose of this release is to enable you to continue fighting or fleeing from
danger even if you have been injured. Connected with this is the release of
coagulants and lymphocytes into the blood, which helps to seal wounds
and repair tissue damage. In addition, there is a contraction of the spleen,
so that more red blood cells are released to carry more oxygen around the
blood, and there is a release of stored sugar from the liver, so that the mus-
cles have more sugar available as a source of energy.

Finally, because the flight-​or-​fight response produces a general activation

of the whole body, which takes a lot of energy, people generally feel tired,
drained, and “washed out” afterward.

In summary, the physical changes that underlie the physical symptoms

of panic and anxiety are protective in that they are designed to help us
escape from or fight off danger. The symptoms are real, but they are not
harmful. Interestingly, physical symptoms are sometimes felt in the ab-
sence of actual physical changes. For example, sometimes people feel as
if their heart is racing when, in fact, it is beating at a normal pace. Or,
sometimes people feel hot, even though their skin temperature has not
changed. This occurs because an intense and anxious focus on physical
feelings can create the perception of a physical disturbance even when
none really exists. However, intense panic attacks are almost always based
on real physical changes. These are summarized in Table 1.2.

35
36

Table 1.2. Physiology of Fear

Physical Change Purpose Symptom

Increased heart rate and Speed up delivery of oxygen Racing or pounding heart
strength of heartbeat and removal of carbon dioxide

Redirection of blood flow away Provide the big muscles with Pale and cold, especially in hands and feet
from skin, toes, and fingers and energy for flight-​or-​fight
toward the big muscles response, lose less blood if
attacked

Increased rate and depth of
breathing
Provide more oxygen for
muscles as energy for flight-​
or-​fight response
Fast breathing; also, dizziness,
lightheadedness, shortness of breath,
feelings of hot or cold, sweating, chest
discomfort, visual changes, if the increased
oxygen is not used

Increased activity in sweat Cool body to prevent Sweating

glands exhaustion from overheating

Dilation of pupils (eyes) Increase visual field to scan for Eyes more sensitive to light
danger

Less energy to digestive system Direct all energy toward Dry mouth, nausea, stomachache, cramps,
flight-​or-​fight response diarrhea

Increased muscle readiness Preparation for flight-​or-​fight Muscle tension, muscle cramps, trembling,
response shaking

Release of natural painkillers Dulls pain sensitivity to allow Less sensitive to pain
(opioids) continued fighting or fleeing if
injured

If There Is Nothing to Be Afraid of, Why Panic?

It is understandable to have the flight-​or-​fight response if we are attacked,

trapped in an elevator, or experiencing any other major stress. But why
does the flight-​or-​fight response occur where there is nothing to be fright-
ened of, when there is no obvious danger? Remember, a panic attack is
basically the normal bodily response to the emotion of fear. What makes
it abnormal is that it can occur at the wrong time, when there is no real
danger.

It appears that people with panic attacks are frightened of the physical
symptoms of fear. Panic attacks represent anxiety about fear. A panic at-
tack follows a typical sequence:

36
Another random document with
no related content on Scribd:
run in while you get the boat ready and tell Sister Betty that we are
going.”
“Don’t go, Letty,” Betty advised. “Suppose you should encounter the
British.”
“We’ll not, I am sure; they are away off down the bay, and we’ll not
go far.”
“Well, I wish you wouldn’t go at all. James ought to have more sense
than to take you.”
“He had to, because I told him I’d go alone if he didn’t.”
“Sauce-box! you’d do no such thing.”
“Wouldn’t I?”
“Lettice, you wouldn’t. Don’t you ever dare to do such a thing.
Remember Hampton.”
Lettice looked suddenly grave. “I reckon I’d better not go alone,” she
said, as she turned away.
“It is such a lovely afternoon for a sail,” she remarked, as she settled
herself in the boat. “You don’t expect to shoot any game, do you,
Jamie? What’s the gun for?”
“For defence, if need be, and this pistol, too.” He laid it down by the
side of the gun.
Lutie put both hands to her ears. “Law, Mars Jeems, yuh ain’t gwine
in de way o’ dem Britishers, is yuh?” she asked in terror.
“I’m not going to get in their way if I can help it, but they may get in
ours. I think, after all, Lettice, you and Lutie had best go back.”
“Not I!” Lettice returned. “I’m here, and here I’ll stay, Britisher or no
Britisher. I don’t mean to have you go alone; besides, Aunt Martha is
not well, and I ought to go over as soon as I can, she might need
me.”
“Rhoda said they might need me, not you.”
“How self-satisfied some one is all of a sudden! I say they may need
me. Now, push off; there’s no use parleying. I’ll jump in and swim
there if you don’t hurry.”
“I believe you are capable of it,” Jamie returned.
“Of course I am. I am sure the packet would not be running if there
were any danger, and you told me, yourself, that none of the enemy
had been seen around here.”
“I know I did; I would bear you back to the house by force if I thought
there would be any danger for you. At all events, we’ll trust to luck,
and get over to the landing as quickly as possible.”
“We’ve plenty of time, haven’t we?”
“Yes.”
“Then do let us stop at Betty’s cove. Mrs. Cooke promised me a
plant, and I’ve long wanted a chance to get it.”
James consented, and before long they were turning into a little
creek which lay back of Mr. Cooke’s property. The boat, however,
hardly touched her moorings before a shout was heard, and two men
started up from behind some bushes, crying: “Halt there! We’ve got
you, have we, you foul deserter!”
James, who had scarce set foot on shore, turned and dealt the man
about to grab him a heavy blow; but before he could regain his
footing upon the boat, the second man gave a shout, and a couple of
others came running from a small boathouse near by. The first
seized James and dragged him off, despite his manful resistance.
For a moment Lettice was nearly paralyzed with fright, then she
recovered her wits, and, grabbing the gun, she pointed it at James’s
assailant. The gun was heavy, and her hands trembled with the
weight of it. Suppose she should shoot wildly and kill her brother.
With a swift, silent prayer that James might be spared, she took aim,
fired, and dropped the gun. “Hand me the pistol,” she cried to Lutie.
“Run, Jamie, now’s your chance!” she shouted, for one of the men
holding James, being wounded in the shoulder by the shot Lettice
had fired, had dropped his prisoner’s arm; and James, with a
wrench, tore himself from the remaining hold upon him.
 “Come on,” she yelled.
He had too often shared in the athletic sports common upon holidays
not to be a good runner, and he was but an instant in reaching the
edge of the water; dashing in, he swam around to the other side of
the vessel, which was slowly drifting farther and farther out, Lettice
meanwhile standing resolutely pointing her pistol at his pursuers.
“Lutie,” she cried, without turning her head, “pick up that axe, and if
any one dares to touch this boat, brain him. You hear me?”
Lutie, though quaking with fear, gained courage from the attitude of
her young mistress and picked up the axe. “Come on,” she yelled.
“Come on, yuh po’ white trash, yuh! Jes’ lemme ketch one o’ yuh
techin’ mah young mistis, an’ I’ll lay dis axe ’bout yo neck lak yuh
was a chicken fo’ brilin’. Yuh ole good-fo’-nothin’ tu’key buzza’ds,
yuh!” She stood with axe raised, and the two defenders of the little
vessel did present such a formidable aspect that the men fell back.
Only one or two were prepared to fire. They had been disturbed in
the taking of an afternoon nap, and had previously divested
themselves of all superfluous accoutrements. Therefore, though one
or two bullets whizzed across the bows of the vessel as she
retreated, not one touched the occupants.
Slowly, farther and farther out the little craft floated, and finally
James, who had scrambled aboard, was setting sail for the opposite
shore, and told Lettice they were beyond danger. “I feel like a
cowardly wretch,” he said, “to run from the foe at the very moment
you needed me for defence. What would have happened to us all,
but for my brave little sister?”
And then Lettice sank down and began to cry hysterically, thus
demanding Lutie’s administrations; and for some time the maid
found herself fully occupied in soothing her young mistis. “Law, Miss
Letty, yuh is safe,” she repeated. “Huccome yuh cry when ’taint
nobody daid?”
“I want to go home, I want to go home! Jamie, take me home!”
Lettice wailed.
“I will, sis. We are getting there as fast as we can. Don’t you see we
have turned about and are going back?”
“And you won’t go to meet the packet? Say you won’t.”
“Never mind about that now. If I do go, it will be on horseback, and I
will go around by the road; so you needn’t worry about that.”
“I don’t want you to go,” Lettice persisted. “I don’t want you out of my
sight.”
James laughed. “You’re funny, sis. I can’t help laughing at you. A
minute ago you were so fierce and valiant, and now you’re weeping
and going on like a baby.”
“But you’re all wet,” sobbed Lettice.
“Suppose I am? That’s nothing; and on a hot afternoon, too. I have
often been as wet as this when I’ve been out ducking, and when it
was a good bit colder. Come, sit up here and help me. We shall have
to tack across, for the wind has died down.”
“You are sure you are not hurt at all?” said Lettice, drying her eyes.
“No, not a bit. I look rather the worse for wear, that is all.”
“It was so awful to see them dragging you off,” and Lettice burst into
tears again.
“They didn’t drag me very far, did they? Thanks to my little soldier girl
of a sister. There, honey, don’t cry any more; we’re nearly home.”
And he hugged and petted her till, by the time they reached their
own landing, she had somewhat calmed down. But as James led her
up the steps to her sister Betty, she lapsed again into a woful state,
and it required the combined efforts of Mammy, Dorcas, Lutie, and
Betty to quiet her; for one minute she would burst into wild laughter
as she looked at Lutie, and would say, “She looked so funny
standing there threatening to chop off their heads like chickens,” and
then she would fall to weeping because it was so awful to see them
dragging off her brother. At last, under the combined effects of red
lavender, salts, and finally a mint-julep, she fell asleep. “I don’t trust
you off this place again without me,” said Betty, bending over the
exhausted little figure and kissing the white forehead around which
damp curls clustered. And with Mammy to fan her on one side, and
Lutie on the other, she was left in the quiet of her own room.
James hurried off his wet clothes, donned another suit, and springing
upon his horse, galloped across country to the landing, arriving just
in time to see the packet come in, and to welcome his aunt and
Rhoda. A flush mounted to his face when he saw in attendance Mr.
Robert Clinton. “I don’t see what they needed me for,” he muttered.
“Mr. Clinton surprised us by arriving from Philadelphia last night,”
Rhoda told him. “My father was not willing that I should come down
here, he sent word.”
“But you came. Why?”
“Because it is my duty to remain with my aunt, and I cannot let my
personal convenience stand in the way of duty,” replied Rhoda, a
little primly.
“And Mr. Clinton came because it was his duty, or because you did,
which?” said James, in a vexed tone.
“My father would have it so. When he learned that I intended to
remain with Aunt Martha, he said that he should prefer that we have
the protection of either Mr. Clinton or himself, and since his affairs
did not permit of his presence here just now, he sent Mr. Clinton.”
“I see.” James looked at her fixedly, and she looked down, blushing
faintly.
“Where is Lettice?” she asked, to turn the subject. James told her of
their late experience.
Rhoda shivered. “Is it as bad as that?” she asked.
“Yes, and may be worse. I wish you had not come down.”
Rhoda bit her lip. “Aunt Martha insisted,” she murmured.
“Unwisely, I think. I should advise that you return at once.”
Rhoda shook her head. “I will stay as long as Aunt Martha does. She
will need me.”
“But you will persuade her that there is danger?”
“I will try.”
But Aunt Martha, once she took a decision, was not to be moved,
and she refused utterly to return to the city, saying that her
husband’s interests demanded her presence on the plantation, and
she felt it her duty to remain at all hazards. “The place will go to rack
and ruin while he is away, if I don’t look out for it,” she declared, “and
I cannot neglect my husband’s affairs when he is away. I am willing
to take the risks, for I think my presence may be a saving means for
us all, in case of a visit from those bands of foragers.”
And therefore Lettice heard with mixed feelings that her uncle’s
home was likely to hold for some time, not only her aunt and Rhoda,
but Robert Clinton.
 CHAPTER IX.
Love and Politics.
The presence of the enemy in the neighborhood convinced every
one of the necessity of taking every precaution to protect themselves
and their property. At first alarm many persons had hidden their plate
and other valuables, and many had sent their families farther inland.
But beyond the discomforts occasioned by raids, when houses were
sacked and often burned to the ground, and when slaves were
enticed away, the people of Maryland did not suffer as much as did
those of lower Virginia. Where there was no marked resistance, and
where there was no reason to suppose the heads of families were in
the American army, allowance was made for property taken, and pay
given. Therefore Aunt Martha had reason on her side when she said,
“I shall simply let them take what they want and shall expect pay for
it.”
“That is not what we will do,” Lettice said. “We are not going to
pretend that we are friends, but of course it is different with you, Aunt
Martha.” Lettice had recovered from her fright and was really
enjoying life. If James lost no opportunity in visiting Sylvia’s Ramble,
neither did Robert Clinton fail to make a daily appearance at
Hopkins’s Point, till Lettice came to look for his coming as part of her
day’s pleasure. He was truly a very attractive young man, every one
conceded.
“I haven’t a word against him,” said Lettice’s brother William, “except
for his politics. You’ll not go over to the enemy, will you, sis?” he said,
pinching her cheek.
“Never!” returned Lettice, steadily. Nevertheless, the telltale blush
upon her cheek was not caused by the pink sunbonnet she wore.
The little maid of seventeen found it hard to remember her politics
when she was listening to the beguiling words of the young New
Yorker, who by this time had declared himself her devoted suitor.
“Why do you deny me, sweet Lettice?” he said. “Must I leave you
altogether? Am I so hateful to you?” This was but the night before,
when the two were coming home from a frolic at Becky Lowe’s.
“There is Rhoda, you know,” Lettice had answered in a low tone.
“Rhoda, yes; but—” he looked down as he gathered Lettice’s hand in
his—“but you see, I don’t love Rhoda, nor does she love me.”
“How do you know?” Lettice asked, wondering if it were right to allow
her hand to lie so long in his clasp.
“I know that Rhoda feels toward me as I do toward her. We are
excellent friends. I admire and respect her greatly, and to no one
would I be more ready to give my confidence, for she is discretion
itself; but I know full well who it is that has captured my heart, and
besides, did you see your brother James and Rhoda as we passed
them just now? I do not think they were thinking of either of us.”
“No, I did not notice them, I wasn’t looking; besides, Rhoda doesn’t
love James’s politics any more than I do yours.”
“Politics? What have sweet lasses like you to do with politics? Let
the men settle the affairs of the nation, and let the maidens rule in
the court of love, where they are more at home.”
Then Lettice sighed and did not draw her hand away. The witching
moonlight, the summer night, the low pleading tones of her lover—all
these cast a glamour over her, and so swayed her that it seemed
that the present alone was the only thing to consider, and Robert
walked across the fields to Sylvia’s Ramble, feeling that his wooing
would soon come to a happy ending.
And yet, the next morning Lettice said never would she go over to
the enemy. “I told Brother William I never would. I have promised
him,” she said to herself, as she ran swiftly along the path to the old
graveyard. Lutie started up from where she was sitting before one of
the cabins in the quarter, but Lettice waved her back. “I don’t want
you, Lutie,” she said. “You can go back.”
“Whar yuh gwine, Miss Letty?”
“Never mind where I am going. I don’t need you, and I don’t want
you to follow me. Stay where you are.”
“Miss Letty gwine whar she gwine. She got no use fo’ nobody dis
mawnin’,” Lutie remarked to the old woman before whose cabin she
sat.
Lettice made a detour and came around by the rear of the old
graveyard. The thicket was closer here, and hid her from the view of
any one passing. She threw herself down in the long grass, hiding
her face in her arm. “I said that, and I am afraid I am growing to love
him,” she murmured. “I have made one promise to my brother, and
how can I make another to him?” She lay still a long time, and once
in a while a tear trickled down her cheek.
Presently she sat up. A sudden thought had struck her. Suppose she
could win her lover over to her side of thinking. That would be a
triumph indeed! Why shouldn’t she? Did he love her, he certainly
would not give her up; yet as she pondered upon the subject, she felt
that she was by no means certain of the success of her effort, and
her face grew grave again.
From over the hedge came a voice, calling softly, “Lettice! Sweet
Lettice, where have you hidden yourself?”
She sprang to her feet and stood where she could be seen. Robert
pressed aside the detaining vines and came up to her. “Lettice,
sweetheart, I could not stay away. Do you forgive me for coming so
early? Was it a dream? a beautiful dream which I had last night, or
did I see a light in your dear eyes? I love you so, sweet Lettice, that I
could not sleep last night for thinking of you.” He gently pushed back
the sunbonnet she had drawn over her face. “Sweetheart, you have
been weeping,” he said in a troubled tone. “Your sweet eyes are wet.
What is wrong?”
Lettice gave a little sob, and for one moment yielded to the clasp of
his arm, burying her hot face on his breast. She felt a sudden joy to
be thus near him, to hear him speak, but only for an instant she
allowed herself to remain thus, and then she sprang away, and stood
a little beyond him. “Tell me,” she said, “do you love me enough to
join the cause of my father and my brothers?”
He looked at her gloomily, and then, leaning on the tall headstone
which her movement had placed between them, he said slowly: “Do
you make that an issue between us? You love me less than you love
the platform upon which rests the opinion of certain members of your
family?”
She looked troubled in her turn. There was a long pause. An utter
stillness prevailed. Once in a while a bird darted from the faintly
rustling leaves. The distant sound of water plashing against the side
of the bay shores, or the murmur of voices from the fields struck their
ears. Lettice noted these things unconsciously, and with them the
faint odors of the growing greenness about her, and the shapes of
the shadows on the grass. She drew a long breath. “You do not love
me, if you are willing to lose me because I love my country.”
“It is my country, too. There is not a difference in our love for our
native land, but in our belief in what is good for her. I believe that the
war is unrighteous and will be the country’s ruin. I am hostile to
nothing except the war. I am for peace at any cost. You pin your faith
on your father’s beliefs, that is all; and it cannot, it shall not, separate
us.” He made a step toward her, but she drew back.
“No, no,” she cried. “While my father is fighting on the Canada
border, so far away, perhaps at this moment lying wounded, or
dead,” she whispered, “can I promise myself to one who is willing to
encourage his foes to work his destruction? No, I cannot, I cannot!”
The young man turned aside and leaned heavily against a gnarled
old tree which overshadowed them, and again there was silence.
When Robert spoke, it was very quietly. “That I would encourage a
foe of yours is a thought too terrible to contemplate; that I could ever
do aught to bring you one moment’s pang seems to me impossible.
The war cannot last. I do not give you up, I but wait till the war is
over, and then—Lettice!” He held out his hands yearningly, but she
did not move. “Promise me, dearest, promise me, that when the
question is settled, that you will no longer deny me my place, and
meantime keep me in your heart.”
“Provided you do us no wrong, provided you do nothing to bring
trouble upon us, after the war—I will—consider it.”
“Even that ray of hope is much. I make this concession, and you,
dearest, can never know what it costs: I promise to take no active
part in the measures against the carrying on of the war. I have been
an earnest partisan, I acknowledge; yet I will henceforth be a neutral.
God forgive me, if I am wrong; if to win your favor is more to me than
the approval of my countrymen. Can you not give me a proof of a
like measure of love?”
“If when the war is over, you come to me with hands unstained, and
with a conscience clean of having done no injury to our side, I think I
may, perhaps, be ready to promise you—what you ask.” She hung
her head, and the last words were in a whisper.
“And you will seal the bond, beloved, you will?” He advanced and
would have kissed her, but she retreated, crying:—
“No, no, the war is not over yet.” She spoke gayly, however, and held
out her hand, which he pressed to his lips. But just then Lutie’s voice
broke in upon them.
“Miss Letty, Miss Betty say huccome yuh fo’git yuh-alls is gwine to yo
Aunt Marthy’s to dinner? She say yuh bleedged ter come an’ git
dressed e’ssen dey leave yuh ’thout nothin’ but cold pone.” Lutie’s
giggle followed the message, and Lettice, with Robert at her side,
took her way to the house.
“Law, Letty,” cried Betty, meeting her in the hall, “you certainly are
feather-brained these days. Here I am all ready, and you are
mooning about, nobody knows where. It is high time we were off.
This is to be a state dinner, remember, and Aunt Martha will never
forgive us if we are late.”
“I didn’t know what time it was,” said Lettice, as she ran upstairs.
Aunt Martha’s state dinners were rather dreary affairs. Solemn
dinings to which dignified heads of families were invited. In this
instance it was in honor of an elderly bride that the invitations were
sent out. One of Mr. Hopkins’s cousins had taken to himself a
second wife, and Lettice did not anticipate any great joviality; yet her
hopes were high, for she had gained a great point, she considered.
Robert would be true to his promise, she knew he would; and if the
war would but end, then he would make his request of her father in
proper form, and her father would not refuse. She was entirely
unworldly in her thought of it all, and hardly gave a passing
consideration to the fact that her lover was a wealthy man, and
considered an excellent match; all that troubled her was his politics.
She stopped so often, and was so preoccupied in the making of her
toilet, that Lutie finally exclaimed:—
“Yuh sholy mus’ be in lub, Miss Letty. Yuh ain’t gwine put on bofe
dem scarfs, is yuh?”
Then Lettice laughed and told Lutie she was a saucy minx, that if
she didn’t behave she should be sent out with the field hands. And
Lutie, who knew just what that threat amounted to, having frequently
heard it before, giggled and further remarked that: “Mars Clinton a
mighty fine gemman,” and when Miss Letty went to New York to live,
Lutie hoped she wasn’t “gwine be lef’ behin’,” for which speech she
received a rap of Lettice’s knuckles, and then mistress and maid
descended the stairs, the latter as proud of her young lady, in her
best summer attire, as the young lady was of herself.
It may have been that Lettice was not willing to risk sitting by Betty’s
side under the ardent gaze of her lover on the opposite seat of the
carriage, and with Betty to watch every glance of his eye, for at the
last moment she declared that she wanted Jamie to drive her over,
and would wait for him, and wouldn’t the others please go on without
her.
“You are a contrary little piece,” said Betty, out of patience. “Here you
have kept us waiting all this time, and now you won’t go with us. Why
didn’t you say so in the first place?”
“I didn’t think of it,” returned Lettice, calmly. “You flustered me so by
telling me it was late, that I forgot about Jamie.” And seeing she was
bound to have her own way, Betty and Mr. Clinton drove off without
her.
The company had all assembled when the last guests from
Hopkins’s Point reached Sylvia’s Ramble, and Lettice wished she
had come earlier when she saw that Mr. Clinton was at the gate to
meet her, and that with him in attendance she would be obliged to
pass under the scrutiny of a dozen mature cousins, each of whom
felt it a prerogative to make as many personal remarks as he or she
desired; so that the girl was glad to escape with Rhoda, who, though
critical, was not so aggressively candid as one’s relatives are likely
to be.
The guests, although knowing that Mrs. Tom Hopkins was a Boston
woman, supposed her frankly siding with her husband, and therefore
they did not scruple to discuss at the dinner-table politics from their
point of view. News of the Remonstrance Act of Massachusetts had
just been received, and those favoring the war policy were hot
against the Bay State, and did not hesitate to voice their feelings.
“With our brave Lawrence not cold in his grave,” said Mr. Jacob
Seth, “the Massachusetts people adopt a resolution that it is not
becoming a moral and religious people to express any approbation
of military or naval exploits not immediately connected with the
defence of their sea-coast and their soil.”
“And it was in Boston harbor that the fight between the Chesapeake
and the Shannon took place,” said another guest.
Rhoda bit her lip and glanced quickly at James, who regarded her
with an amused look, while Lettice’s eyes sought Robert. His face
was flushed, and he was looking steadfastly into his plate.
“Massachusetts believes the war to be caused by ambition and
desire for conquest,” put in Aunt Martha, stiffly.
“I beg your pardon, Cousin Martha,” said Mr. Seth, “we forget that
you are not a Marylander. Cousin Tom has taken such a decided
stand, that we do not realize that perhaps you may be less
enthusiastic. The women of our land whose husbands have gone to
the war could scarcely be expected to approve it.”
“It is not a cheerful subject, anyhow,” the bride remarked.
“And I am sure the occasion warrants a livelier one,” returned Mr.
Seth, gallantly. And they fell to chaffing each other, and in the end,
Lettice declared a more pleasant dinner she had never enjoyed at
Aunt Martha’s.
“I am surprised that Robert did not immediately take up the cudgels;
he is not wont to be so circumspect,” said Rhoda, musingly, as she
and Lettice were walking in the garden.
“Isn’t he?” returned Lettice. “Perhaps we are converting him to our
way of thinking.”
“That would scarcely be possible,” Rhoda replied. “He is pledged to
support his cause, and is too ardent an adherent to give in easily. My
father says he is a strong aid to him, and he depends much upon
him in various important matters, although Robert is so much the
younger.”
“I suppose that is true,” said Lettice, thoughtfully. “I do not wonder,
then, that he is anxious that you should be fond of each other. How
about it, Rhoda?” she asked teasingly.
Rhoda showed no special emotion except by the nervous closing of
her hand. “When the war is over,” she replied, “these vexing, political
problems will not interfere with our decisions in other directions, as
now they must do.”
“That is very true, Rhoda,” Lettice answered softly. “Let us suppose
the war over, and each of us free to act as she would? Is there then
no reason why you should not favor Mr. Clinton? What says your
heart?”
Rhoda looked her squarely in the eyes. “I admire Robert. I have
known him since I was a little child. He is entirely worthy any
woman’s regard.” Then suddenly. “And you? What does your heart
say?”
Lettice looked confused; then she replied, laughing, “I’ll tell you when
the war is over.”
Rhoda regarded her gravely. “Robert Clinton will never desert his
party,” she said; “and I think he will spare no means to forward the
interests of those whose opinions he endorses.”
“Perhaps,” Lettice returned lightly; “but men are not infallible. The
best of them are mistaken sometimes, and he may yet change.
Rhoda, would or could any one in the world make you differ from
your father in politics?”
Red grew Rhoda’s cheeks. “I don’t know,” she returned faintly.
 CHAPTER X.
Suspicions.
So far, with the exception of the raid into the upper Chesapeake, the
eastern shore of Maryland had not suffered greatly from the enemy’s
depredations, but during the spring and summer of 1813, St. Mary’s
County, on the western shore, was seldom safe from marauders,
who plundered and burned and destroyed till the people were
reduced to extreme poverty. The men compelled to perform constant
military duty received no help from the government, and in
consequence of the deplorable condition of affairs, many took their
families and emigrated to the far West. During the summer over one
thousand volunteers and recruits were sent from Maryland to the
Canada border, sadly as their help was needed at home.
Many of the people of the Eastern shore, with the enemy terrorizing
them, likewise abandoned their homes; for Kent Island, a point lying
directly opposite the city of Annapolis, was taken possession of by
the enemy early in August, and when three thousand British troops
landed, it was to find but a small remnant of the population left. From
this point foraging expeditions were constantly sent out, keeping the
inhabitants of the neighboring shores in a constant state of
uneasiness. On August 8, three ships of the line, five frigates, three
brigs, two schooners, and some smaller vessels, advanced toward
Baltimore, but the prompt appearance of those who were determined
to defend the city, and the visible preparations which had been
made, were sufficient to ward off any attack, and the enemy moved
off and threatened Annapolis which lay across the bay from their
station on Kent Island. Here likewise there was no lack of
preparation, and the British finally withdrew.
All this set astir those in the neighborhood of Lettice’s home. Many
fled, and those who had not already buried their valuables, or had
not placed them in some safe hiding, made haste to do so. Lettice
and Betty had long since seen to it that the family treasures were
safely hidden; but since no one knew where the next attack might be
made, they declared that as far as their personal safety went, they
might as well be in one place as another.
It was on the morning of August 7, that William came hurriedly in,
saying: “The British are making for our shores! I must hurry off, Betty.
Don’t look so terrified, my love. I trust we shall not suffer from the
attack, but the militia are ordered out, and James and I must go.
Here, Lettice, take these papers and put them in safe hiding
somewhere; they are valuable. I ought to see to it myself, but I shall
not have time. If anything happens, get over to Uncle Tom’s as
quickly as possible. I fancy Aunt Martha can hold her own, and there
is strength in numbers.” And kissing his weeping wife and trembling
sister, he mounted his horse and was off, accompanied by James,
who made his adieux with a last whisper to Lettice, “If I fall, Lettice,
give this little packet to Rhoda.”
Lettice nodded, too full of distress to speak, and the two women,
holding each other closely, watched the young men as they galloped
out of sight. “Oh, Lettice, Lettice,” Betty sobbed, “suppose we never
see them again!”
“Don’t!” cried Lettice, sharply. “Betty, don’t say such things. Let us
busy ourselves about something, or we shall not be fit to face trouble
when it comes. I must hide these papers at once.” She concealed
them under her apron, and stole through the orchard to the
graveyard, where, dropping on her knees, she hastily dug a hole
close by the leaning footstone of Theophilus Hopkins’s grave, and in
the cavity she placed the box of papers. From time to time she
glanced apprehensively around to be sure that no one observed her,
and she was startled in the very act of covering up the place of
hiding, by hearing some one say: “I knew I should find you here. Are
you honoring your ancestor by planting fresh flowers upon his
grave? It is rather late in the season, isn’t it?”
Lettice, looking greatly confused, stammered: “I—yes—no, I was not.
It is rather late for some flowers, to be sure, but some can be planted
at almost any time, you know.” As she recovered herself, she spoke
with more assurance. “How long have you been watching me, Mr.
Clinton?” she asked.
“Only a few moments. I saw you digging away for dear life, but I
didn’t disturb you, for I liked to watch your little white hands.” He tried
to take them in his, but Lettice drew them away.
“They are all covered with earth and stuff,” she said. “You came very
early.”
“Yes, I came from your aunt with a message. We have heard that the
British are moving in this direction, and Mrs. Hopkins thinks you will
all be safer under her roof. I suppose your brothers are off at first
alarm.”
“Yes, they have gone; but I am not sure what Betty will consent to
do. The negroes, to be sure, are scattering off toward the woods,
and our being here will scarcely keep them together. The older and
more faithful ones will stay anyhow, and we could take Lutie, and
Mammy, and Speery with us. Jubal has been stirring them all up with
his fearsome tales, and I shouldn’t be surprised if he coaxed off a lot
of the field hands. I never did trust Jubal,” she said meditatively.
“Then I will escort you over, if your sister consents.”
Lettice agreed, and they started for the house. “Do you know if it is
simply a foraging party of British on the way here, or is it really a
large force?” Lettice asked.
“I believe it is quite a large force; at least I was told so by some one
who brought the news. A company of scouts under Captain Massey
made the discovery that the British were advancing, and there has
been a skirmish. Major Nicholson and his troops are at Queenstown,
which I believe is expected to be the point of attack.”
“Has it come to that? Then we may look for anything. I am sure
Brother William would want to have us go to Uncle Tom’s.”
They found Betty quite willing to follow Mr. Clinton’s advice;
therefore, taking the baby and three of the servants, they hastened
over to Sylvia’s Ramble, to find Mrs. Hopkins somewhat nervous, but