The Panic Cycle

The Panic Cycle: The cognitive model of panic.

Panic attacks consist of an escalating feeling of terror and dread that is associated with a range of physical sensations. They are usually brief, in most case lasting for between 10 and 20 minutes. In some cases individuals report much longer panic attacks. The physical sensations are those that have already been outlined in the material on the “defensive cascade” or “fight or flight” response. Panic attacks can be associated with threatening situations such as public speaking, when confronted by some specific fear such as a spider or worrying about the future. In fact, the author writing this has experienced two panic attacks, one while he was sky-diving and the second when he was called into the hospital urgently as his wife was giving birth.


They can also occur “out of the blue” without a clear trigger or nocturnally (waking from sleep and having a panic attack). This can be very puzzling for the individual experiencing the panic attack and it can contribute to the belief that the panic attack represents a serious and potentially life-threatening physical problem. Unfortunately, as you will discover as you read on, these types of beliefs tend to maintain panic attacks unnecessarily. An explanation for panic attacks is therefore necessary. Further, the evidence-based treatment that is recommended for the treatment of recurrent panic attacks flows from the explanatory model.

Panic disorder is an anxiety disorder that affects approximately 1 to 2 % of adult Australians each year. The technical criteria contained within the Diagnostic and Statistical Manual (DSM- IV) requires “unexpected, recurrent panic attacks, followed in at least one instance by at least a month of a significant and related behavior change, a persistent concern of more attacks, or a worry about the attack's consequences.” (ref). The condition is often associated with a related condition called agoraphobia, which is an ongoing fear and avoidance of situations (public transport, tunnels, lifts, bridges, open spaces, shopping centres etc) that the individual believes may lead to panic attacks. It can be debilitating and in severe cases can leave people housebound.

The figure below describes a number of stages that individual’s move through as they are developing a panic attack and is based on David Clark’s cognitive model, originally published in 1986. The first component of the model “Pre-attentive vigilance to body sensations”, in large part explains why panic can often occur “out of the blue”. There is substantial evidence that individuals who experience panic attacks (and anxiety in general) demonstrate an unconscious bias for threatening information. What this means is that, without being aware of it, our senses are processing the environment for danger. There is also evidence that in panic disorder specifically individuals demonstrate a hyper-vigilance to body sensations. This is pronounced in those with a history of panic attacks (Schmidt, Lerew and Trakowski, 1997). So what appears to be happening is that our brain is processing the world for danger without our conscious awareness. If someone has experienced a panic attack previously, their brain is most likely keeping a close eye on bodily sensations. As you’d be aware if you’ve ever had your blood pressure or heart rate monitored continuously for a period, our physical system is constantly moving. It may be that a minor, benign change in our arousal is then detected by our sensitive monitoring system. Hence “a false alarm” occurs.

The second component of the model refers to a “focussing” process. Once our brain has unconsciously detected a possible perturbation in our body sensations, it comes to our conscious attention and we focus on it. The process of focussing on anything tends to increase our arousal, further escalating our physiological response.

The third stage refers (perhaps a bit dramatically) to Increasingly desperate attempts to control symptoms. The subjective experience of a panic attack is aversive. Although not technically harmful, panic attacks are unpleasant. As a result of this individual’s understandably begin to do their best to get control of the process. Unfortunately, the techniques that people most often use tend to either lead to further escalation, or act to maintain the problems in the longer term. So, for example, most people have seen panic attacks characterised in popular culture and note that breathing into a bag is recommended. Further, it can sometimes feel as though you are out of breath when having a panic attack, so people commonly take rapid breaths typically from their chest (as opposed to diaphragmatically) and this inadvertently leads to hyperventilation, further increasing the fight or flight response. The other behaviours that people engage in that tend to maintain panic attacks in the longer term will be addressed later.

Finally, and importantly, panic appears to be driven and maintained by a tendency to misinterpret the symptom “catastrophically”. People worry that the symptoms they are experiencing represent a cardiovascular event such as heart attack or stroke, they worry they may be going crazy or that they are losing control of themselves and the consequences will be terrible. This understandably increases the very symptoms that are feared and resisted and often culminates in a panic attack.

These experiences can cause great functional impairments in individuals. The experience of panic can impair performance during complex tasks such as speeches. But perhaps the greater problem occurs when people avoid situations in which they fear they may panic. For example, people may start avoiding lifts because they worry that will panic and this context offers no possibility of escape or risks humiliation. This may then generalise to tunnels and planes and before you know it the person’s world has become very small. This is referred to as Agoraphobia.

Another complication in panic disorder are safety behaviours. They are a set of behaviours that someone with panic attacks engages in in order to feel safe. For example, some people will carry benzodiazepines such as Valium. They may never take them, but have them there “just in case”. They may then be more susceptible to panic attacks if they accidentally forget to take their pills. Other examples include carrying water, having high frequency appointments with their GP or keeping a trusted individual close-by. These behaviours make someone more brittle and tend to maintain panic.

Psychological Treatments

There are various treatment models for managing panic disorder, however, most treatments will consist of the following components;

Psychoeducation- The client will be provided with education about panic disorder.

Panic surfing- They will then be taught a method for managing panic more effectively when it arises. One such method is called “panic surfing” and was developed by Andrew Baillie and Ron Rapee (1998). This approach encourages clients to “go with” the experience of panic rather than resisting it.

Exposure- In-vivo- The client will then build a list of those situations that are being avoided and they will progressively return to them for extended periods of time. This acts to desensitise the individual and is a very effective, if distressing, treatment.

Interoceptive- The client will be intentionally exposed to symptoms that mimic panic attacks, such as hyperventilation or spinning on a chair. Again, the idea is to desensitise the person by encouraging them to face the thing they fear, the fight or flight response.

Cognitive Therapy- The catastrophic misinterpretations of the symptoms of panic will be assessed and challenged in light of evidence.

panic image

Fight or Flight – Peter Walker

The Defensive Cascade (Focus, Freeze, Flight, Fight and Flop)

The defensive cascade, commonly referred to as the “fight or flight response”, is a coordinated set of behaviours, supported by physiological changes, that promotes survival in the face of some form of threat. As threat escalates, the nature of the defense response changes in a predictable way and this is supported by our physiology. This will be described below. The response is normal and adaptive; in fact, we would be at great risk without it. The defensive cascade is prominent when experiencing distress, such as when we’re anxious or angry.

Consider the following, somewhat far-fetched, scenario. On the drive in to the appointment you have with your psychologist you hear on the radio that a dangerous black bear has been sighted roaming the streets close to the practice. At this point you would most likely to move into the “focus” stage of the defensive cascade. Your body will start becoming physiologically aroused. Your heart rate would increase (tachycardia), blood pressure would rise (hypertension), your pupils would dilate and your senses would scan the environment for threat, in this case, bear related threat. This increased attention, concentration and focus on threat increases our survival as we are better able to avoid the threat.

Let’s say you make it to your appointment without incident, however the bear is in the same geographical location and decides to climb the stairs of the psychology practice in which you’re situated, out of curiosity. It is likely that the close proximity you are maintaining in relation to the bear would lead you to enter the next phase of the defensive cascade, freezing. To support this behaviour, physiological arousal (heart rate increases, blood pressure elevation, increased respiration etc) would continue to increase and additionally the body would increase in tension and maintain a rigid posture. This response increases our chances of survival as it reduces the chance that the bear will detect us.

If, despite maintaining a freezing posture, the bear continues its advance toward you, attempts would be made to run or flee. This is the flight phase of the response. It is important that your body is prioritising functions that assist your escape. Energy will be diverted away from lower priority functions such as digestion (hence the dry mouth, nausea, occasional vomiting and voiding of bowels) and directed to our muscles to maximize our speed. We may also demonstrate a fear potentiated startle response, ie a more pronounced tendency to startle due to arousal, which allows us to leap into action and as they say “hit the ground running”.

Perhaps we are cornered and unable to successfully escape from the bear. With the escalating threat, we may enter the fight component of the defensive cascade. Here, attempts are made to confront the threat physically. An interesting physiological development is particularly useful here. The brain modulates our experience of pain in a variety of ways such that our pain

f or f image
sensitivity reduces. Most of us have experienced this phenomena when playing sport. In the excitement of the game we notice little physical pain and only after the game has finished and we have calmed down do we notice the cuts and scratches we have sustained. A reduction in the intensity of pain helps to lessen the distraction that would be associated with injury and in turn increases the chance we survive.

When escape appears impossible and an individual’s demise seems certain, the final stage of the defensive cascade can occur. This stage can be referred to as “flop” and consists of fainting (threat induced syncope) and quiescence. It is important to note that this is a very rare and only occurs in situation where death is imminent and appears unavoidable. A commonly cited example is described in the 19th Century Scottish explorer David Livingstone’s diaries, when he was attacked by a lion in Mabotsa in present day South Africa.

“I saw the lion in the act of springing upon me. He caught me by the shoulder and we both came to the ground together. Growling horribly he shook me as a terrier dog does a rat. The shock produced a stupor similar to that which seems to be felt by a mouse after the first gripe of the cat. It caused a sort of dreaminess in which there was no sense of pain nor feeling of terror though I was quite conscious of all that was happening. It was like what patients partially under the influence of chloroform describe: they see the operation but do not feel the knife. This placidity is probably produced in all animals killed by the carnivora and if so is a merciful provision of Creator for lessening the pain of death.
David Livingstone (1857). Missionary Travels (pp. 11-12). London: EW Cole.
Post threat recovery- Once we consider we have become safe our body rapidly enters a recovery state. This state is characterised by exhaustion, a strong desire to withdraw, remain still and often sleep. Our sensitivity to pain returns and this ensures that any wounds are protected and attended to, aiding the healing process. Cardiovascular function (heart rate and blood pressure) and respiration normalise. It has been suggested that this behavioural response is what accounts for the extreme exhaustion that occurs after people have been in a stressful or threatening state for a period. They appear to “run on adrenalin” and then experience profound fatigue. Interestingly, modern models of psychological therapy for post traumatic reactions encourage those who suffer trauma to “go with” this behaviour. They are encouraged to “lay low”, surround themselves with the support they need, sleep as much as they require and create surroundings that feel safe. It is only later that exposure based treatments are suggested, and then only if the individual is displaying signs that their adjustment has been compromised.
These are the normal, hardwired behaviours that humans have evolved to manage threat. They are not pathological themselves, but can become so when our experience of them is interrupted in various ways. Read the blog post about panic disorder for an example of when the response becomes a problem.


What is CBT?

What is CBT?

Cognitive Behavioural Therapy or CBT is a tradition of psychotherapies that became most prominent and influential from the 1980’s to the early 2000’s. It is an active treatment in which the client develops skills to better manage distress and thoughts and behaviours associated with this distress.


Behaviour Therapy

CBT arose in opposition to Sigmund Freud’s psycho-analytic therapy that had been popular in the early 20th Century. Academic clinical psychologists had concerns about the lack of scientific rigour that they observed with psycho-analysis. The content for psycho-analysists seemed subjective and difficult to control. Therapists encouraged clients to free-associate, analysed dreams and made developmentally informed interpretations, all of which was difficult to verify and measure. The Behaviourist school of clinical psychology arose in direct opposition to the psycho-analysis. They chose to focus on things that they could reliably measure, such as how close an arachnophobe could get to a spider or how many times someone with Obsessive Compulsive Disorder has to check that the front door was locked before they could leave. The treatments that emerged from the behaviourism persist today and include behavioural activation for depression, exposure therapy for various phobia’s and contingency management strategies for children. The tradition, technically referred to as Behaviour Therapy (BT) until the 1980’s, had a reputation for being scientifically valid, brief and both clinically and cost-effective.

Cognitive Therapy

In the 1960’s and 70’s academic psychologists developed cognitive models of human behaviour and emotions. These models were Influenced by advances in computer science and focus on human’s ability to interpret, appraise and process information. In the early stages of the CBT tradition, the content of someone’s thoughts would have been too subjective for measurement and intervention, however, as is often the case, the intensity of the polemic against psychoanalysis had cooled, allowing cognitive therapy to establish itself. Cognitive therapy was based on the Cognitive Model. This model of human distress suggests that our emotions are causally linked to interpretations we make of situations we find ourselves in. For instance, one person may step inside a lift and believe that they will faint or go crazy, humiliate themselves, be forced to leave their job and then conclude they are a failure. This will almost certainly lead to anxiety and low mood. Another person may step inside the same lift and think to themselves that lifts go up and down hundreds of times each day and that there is a phone in case of emergency. This latter individual is likely to experience little distress. The cognitive model uses appraisals like these just described to explain distress. The therapy associated with the cognitive model teaches clients to identify their appraisals when they feel low, anxious or angry and challenge them in order to see the situation they are in more proportionally.

Mindfulness: The Third Wave of CBT

In the last 20 years ago, CBT has entered its third major revision. This has involved the addition of mindfulness. Mindfulness is a philosophical system with roots in eastern philosophy and is more than 3000 years old. Its clinical application emphasises cultivating present centred attention, developing a non-judgemental stance and equanimity, being non-reactive and letting go of our resistance and struggle against distress. Various innovative clinicians have adapted traditional CBT to include mindfulness. Examples include Dialectical Behaviour Therapy (DBT), Acceptance and Commitment Therapy (ACT), Mindfulness Based Cognitive Therapy (MBCT) and many more.


CBT is the most studied of all of the psychotherapies to date and has the most substantial evidence base. It has been used to treat people across the age range and has been applied successfully across an enormous range of psychological, relationship and health problems. It was initially developed to help people suffering from depressive and anxiety disorders, however over time it has been used to treat almost any problem that has a psychological component. It has demonstrated effectiveness with mood, anxiety (panic disorder, obsessive compulsive disorder, worry, social phobia) and anger problems and is considered a first line treatment for these problems. In more recent years, CBT has been used to treat major mental illness (delusions, hallucinations), drug and alcohol dependence, insomnia and relationships. Interestingly, CBT has been demonstrated to be effective in reducing disability and improving functioning with chronic health problems such as chronic pain, diabetes and chronic fatigue syndrome.

What does CBT consist of?

If you attend a psychologist and they implement a CBT treatment program this will most likely involve some behavioural component, cognitive therapy and mindfulness meditation. Most often the psychologist will take a few sessions to conduct a thorough assessment. They will then provide the client with a model or formulation of the problem that has been presented alongside a treatment plan outlining the cognitive, behavioural and mindfulness strategies that will be worked through.


In order for the client to understand the condition that they are presenting with the psychologist provides the client with “psycho-education”, an unfortunate term that refers to information about the psychological models of psychological disorders. For example, someone with social phobia would learn about the physiological (Eg tachycardia), cognitive (Eg “I’ll humiliate myself”) , attentional (Eg focus on what I’m doing with my hands rather than the topic I am presenting on) and behavioural (Eg avoidance of social situations) components of social anxiety.

Behavioural Strategies

Examples of behavioural strategies include; behavioural activation, exposure, pacing for those with pain or fatigue, contingency management and stimulus control for drug and alcohol problems.

Cognitive Therapy

Cognitive therapy involves monitoring your thoughts when distressed on specific monitoring forms. The client will then usually be taught to categorise their thoughts according to the cognitive bias in which they fit. Cognitive biases are stereotypical ways that humans distort information that relates to their emotions. For example, the Black and White thinking bias involves in people creating extreme, either-or categories in their beliefs. Someone is a success or a failure, they are gorgeous or hideous, they are good or bad, smart or stupid.

Finally, and most importantly, the beliefs and appraisals the client reports are challenged. The client learns to consider evidence for and against their belief, designs experiments to test out assumptions and generates alternative perspectives from their habitual interpretations. This often allows leads clients to identify less strongly with their thoughts and the intensity of their distress reduces.

Mindfulness Interventions

When we teach mindfulness in this practice we usually start formally, using the meditation techniques that many would have encountered in their local yoga class or meditation drop-in class. People are encouraged to bring their awareness to their breath. When they inevitably drift off they are encouraged to notice where they have drifted to and with a gentleness, bring their awareness back, again and again. We then move on to incorporate more complex exercises, such as the “body scan” or mindfulness of thought. The ultimate goal is to equip the client with the ability to bring on a mindful mental state and get into the habit of doing this regularly. The psychological benefits of this are varied. It reduces rumination, promotes acceptance of difficulty (emotional distress, physical pain etc), reduces reactivity, reduces resistance and avoidance and allows for greater appreciation of positive, joyful experiences that occurs in someone’s experience.

CBT is a short-term treatment, commonly lasting between 6 and 20 sessions. It can appear simple, however it can be complex in its implementation. It is an active and directive treatment, requiring collaboration between the client and clinician. It requires that the client complete tasks outside of the therapy session and the client ideally develops the skills to treat and maintain their own therapy, effectively becoming their own psychologist.

Fear and the Defense Cascade: Clinical Implications and Management – Peter Walker

Kasia Kozlowska, MBBS, FRANZCP, PhD, Peter Walker, BSc Psych, MPsychol, Loyola McLean, MBBS, FRANZCP, PhD, and Pascal Carrive, PhD

Evolution has endowed all humans with a continuum of innate, hard-wired, automatically activated defense behaviors, termed the defense cascade. Arousal is the first step in activating the defense cascade; flight or fight is an active defense response for dealing with threat; freezing is a flight-or-fight response put on hold; tonic immobility and collapsed immobility are responses of last resort to inescapable threat, when active defense responses have failed; and quiescent immobility is a state of quiescence that promotes rest and healing. Each of these defense reactions has a distinctive neural pattern mediated by a common neural pathway: activation and inhibition of particular functional components in the amygdala, hypothalamus, periaqueductal gray, and sympathetic and vagal nuclei. Unlike animals, which generally are able to restore their standard mode of functioning once the danger is past, humans often are not, and they may find themselves locked into the same, recurring pattern of response tied in with the original danger or trauma. Understanding the signature patterns of these innate responses—the particular components that combine to yield the given pattern of defense—is important for developing treatment interventions. Effective interventions aim to activate or deactivate one or more components of the signature neural pattern, thereby producing a shift in the neural pattern and, with it, in mind-body state. The process of shifting the neural pattern is the necessary first step in unlocking the patient’s trauma response, in breaking the cycle of suffering, and in helping the patient to adapt to, and overcome, past trauma.

Read the full paper here

Read the article from the Washington Post referencing this paper

Normalisation of Symptoms of Schizophrenia: Hearing Voices by Dr Oren Griffiths

Schizophrenia is a troubling and often debilitating disorder. People who have this disorder can experience a wide range of distressing symptoms. These include: hearing voices say offensive personal messages, disruption of normal thought and language, perceptual changes (colours and sounds seem more intense than normal, or seeing illusory sights or feeling illusory sensations), losing the ability to visually express emotion, losing the ability to initiate action, and holding very strong convictions that are not supported in fact (e.g. that I am Jesus, or that I am being stalked by my neighbour). The combination of these symptoms can be very distressing and thus cause people to act in unusual ways. For example, if someone with schizophrenia enters into a dialogue with a voice they are hearing, it may appear as if they are speaking to themselves.

For a long time, it was thought that these symptoms represented a complete break from normal experience; that some brain system was “broken” in people with schizophrenia and therefore that non-pharmaceutical interventions were simply a "waste of time". This view has been recently challenged on a number of fronts. For example, talk therapies focused on changing how people think and interact with their worlds have successfully reduced distress associated with these symptoms and even reduced the symptoms themselves. Even more interestingly, research has shown that one of the symptoms thought to be a defining feature of schizophrenia, hearing voices, are experienced by surprisingly large numbers of otherwise healthy people.

Beavan et al (2011) recently reviewed numerous surveys of thousands of people from all around the world, and found that hearing voices is not particularly unusual. Overall, about 20% of the people questioned had experienced at least one instance of hearing a voice when no one spoke to them. However, depending on the particular group sampled the estimate varied widely between 1% to 84%. Note that these refer to non-psychiatric samples. For example, some surveys were given to all the nurses in a particular hospital, others were given to all the people who attended a GP clinic (but did not have a mental health diagnosis). These were ordinary people going about their lives, and many of them hear voices from time to time. More than this, for many people without schizophrenia, the experience of hearing a voice talk to them is not unusual; these people regularly hear voices talking to them. The current estimates are that 2-4% of people regularly hear voices, which equates to up to one million Australians, far more than are diagnosed with schizophrenia.

In fact, for most people it is quite normal to hear voices during times of stress. There is evidence that many people hear voices after an extended period without sleep or immediately following the loss of a loved one.
Fatigue. A recent study at the University of Bonn (Petrovsky et al, 2014) showed that after only a single night of sleep deprivation, 24 otherwise healthy adults began to present with mild symptoms that are associated with schizophrenia, including auditory hallucinations. Chronic insomnia (greater than 100 hours without sleep) has been argued to produce more dramatic symptoms in otherwise healthy people.
Grief. In a large study of elderly German widows and widowers, recently bereaved people often reported hearing their lost partner speaking to them for some time after the death. About 30% of recently widowed elderly people report hearing their partner’s voice speak to them in the month following their death, and for 6% this experience continued after the first month.

For most people, as stress reduces, so too does the frequency of hearing voices. This research is promising for people who have schizophrenia for two reasons. First, it shows that many people who hear voices are not troubled by them; just because you hear a voice does not automatically consign you to a life of heavy medication and lengthy hospital admissions. Second, the observation that people hear voices at times of acute stress but not when the stress subsides, suggests that efforts to reduce emotional distress may reduce how often voices are heard, or how affecting this experience is. This is a primary goal of psychological therapy for schizophrenia.

Petrovsky, N., Ettinger, U., et al (2014) Sleep deprivation disrupts prepulse inhibition and induces psychosis-like symptoms in healthy adults. The Journal of Neuroscience, 34, 9134-9140.
Beavan, V., Read, J. & Cartwright & Cartwright, C. (2011) The prevalence of voice-hearers in the general population: A literature review. Journal of Mental Health, 20, 281-292. “Essential facts”

Social Anxiety Explained by Dr Nisha Sethi

Have you ever felt butterflies in your stomach before giving a speech or going to an interview? Or, have you ever found yourself looking for an excuse to get out of meeting new people or confronting others about something they are doing that you do not like? Or, are you uncomfortable when you have to make a phone call or when you have to talk to friends in a group setting? If you have answered ‘yes’ to any of these questions, you may have social anxiety.

So, what is social anxiety?

Social anxiety is basically a fear of social and/or performance situations that is driven by concern that others will judge us negatively. For some people, the anxiety is only present in specific situations (e.g., just when making speeches), and for others, the anxiety is present in several situations (e.g., when making speeches, being interviewed, being assertive, making phone calls, etc.). Also, the intensity of the anxiety can vary from person to person and from situation to situation. As you might have guessed, social anxiety is actually pretty common. I myself am anxious in certain social and/or performance situations!

What drives social anxiety?

There are a few different factors that may contribute to a person’s social anxiety. Some of these factors include:

How we think about the situation: if you worry that others are going to make negative judgements about you (e.g., “They will think I’m stupid.”) and/or that it will be difficult to cope with the consequences of those judgements, then you are more likely to experience at least some social anxiety. For example, the person who thinks “I won’t know the right thing to say and people will laugh at me!” during their speech is more likely to feel anxious. Also, the person who has high standards for how they are to act/perform in front of others (e.g., “I must not stumble over my words.”) is more likely to feel anxious.
How much we try to avoid the situation: when it comes to situations that frighten us, it is only natural that we would want avoid them as much as possible. Unfortunately though, avoidance is part of what maintains social anxiety because we deny ourselves the opportunity to confront our fears and disconfirm our negative beliefs about the situation. For example, the person who avoids being assertive will not be able to learn that they can be assertive and that the consequences of being assertive are not as bad as previously envisioned. Instead, they learn that they can temporarily reduce their anxiety by not being assertive, making them no more comfortable with being assertive in future if they ever need or want to be.

What do psychological treatments for social anxiety involve?

There is a great deal of evidence that supports the use of Cognitive Behaviour Therapy (CBT) in effectively treating social anxiety. Examples of what is typically included in such a treatment are information on social anxiety from a psychological perspective, learning how to think more realistically about the consequences of being in different social situations, and building your confidence in social situations by facing your fears in a very gradual, structured way. My personal experience in treating clients who have social anxiety is that they typically respond well to CBT and they often find themselves engaging in all sorts of social activities without too much discomfort by the end of it!

How do I know if my social anxiety is bad enough to do something about?

First up, it is a good idea to talk to your GP and/or clinical psychologist who can help you figure out if some kind of treatment would be useful for you. Other things to consider are:
• how much you believe that the anxiety is starting to “control” what you do and do not do
• how intense the anxiety becomes for you; and
• how important it is to you that you are better able to manage your anxiety so you can do the things that you find meaningful.


Clark, D. M. (2001). A cognitive perspective on social phobia. In Crozier, W. R. & Alden, L. E. (Eds.), International Handbook of Social Anxiety: Concepts, Research and Interventions Relating to the Self and Shyness. Chichester: John Wiley & Sons Ltd.
Turk, C.L., Heimberg, R. G., & Hope, D. A. (2001). Social anxiety disorder. In Barlow, D. H. (Ed.), Clinical Handbook of Psychological Disorders (3rd ed.). New York: The Guilford Press.

The Perils of Perfection – Peter Walker


Striving for excellence, beating our personal best, getting to our ideal weight, giving it our all, never giving up! These widely used statements conjure images of elite athletes, heads of industry, professional musicians, prestigious scientists. These figures are held up as a model to follow in order to thrive, achieve fulfilment and reach our potential. And what in the world could be wrong with that? For some people, nothing at all. But for a substantial number of us, striving for perfection contains the kernel of chronic dissatisfaction, worthlessness, depression and anxiety.

Perfectionism is the tendency to have high and unrelenting standards. These  can be solely directed at the self or can generalised to others. Perfectionism can apply to one area of our lives (Eg weight, academic performance, social performance) or affect a broad range of pursuits. It has long been recognised that this personal style can make one more vulnerable to anxiety, depression and eating disorders. It commonly affects high achievers in our society and often goes unnoticed.

What causes and maintains perfectionism?

It is likely that a range of factors contribute to the development of perfectionism, including someone’s intrinsic sensitivity and early environments where approval and love was conditional on achievement of certain standards

Once operating, perfectionism is maintained by a fear of failure and exhausting striving for success. Perfectionistic individuals evaluate themselves in terms of a set of rules or standards. These rules tend to be dichotomous, the individual either meets them or does not. The content of their thinking reflects this” all-or nothing” approach, seeing the world in terms of “should’s”,” musts” and “oughts”.

A strong value is placed on self-control. This will often take the form of limiting pleasure or “indulgence” not directly related to the pursuit of a goal. If goals are attained they are then often altered due the perception that the task was not difficult enough, leading to a certain relentlessness.

Thinking biases reinforce this behaviour. Perfectionistic individuals will focus on any evidence of failure and overgeneralise this. This results in the quite striking contrast between some individuals’ objective success and their belief in always being on the edge of ruin.

What can you do about it?  

The first step in reducing the impact of excessive perfectionism in your life is accepting that it is present and that it is worth working against. Treatments then focus on adapting one’s self-assessment from being excessively narrow (“I am worthwhile if I lose 5kgs”) to include a broader range of criteria (“I am a husband, son, athlete, performer, friend, painter”). Experiments can be set that test out someone’s belief that catastrophe will ensue if they produce work that is below their standards. I also like to encourage my clients to practice being “half-arsed” when they see an opportunity. This might mean sending an email that has not been edited and may contain spelling mistakes, present a talk with minimal practice or exercise without measuring the effort or outcome. Most of my clients find this anxiety provoking and aversive, but it improves their overall flexibility and often affords them the opportunity to relax.


Frost, R.O., Marten, P., Lahart, C. & Rosenblate, R.(1990). The Dimensions of Perfectionism. Cognitive Therapy and Research, 14, 449-468.

Riley,C., Lee, M., Cooper,Z., Fairburn, C.G., Shafran, R.(2007). A randomised controlled trial of cognitive-behaviour therapy for clinical perfectionism: A preliminary study. Behaviour Research and Therapy, 45, 2221-2231.

Shafran, R., Zafra, C. & Fairburn, C.G (2002). Clinical Perfectionism: a cognitive-behavioural analysis. Behaviour Research and Therapy, 40, 773-791.



CBT for Psychosis – Peter Walker

Psychosis, the experience of hallucinations (hearing voices, seeing things others don't) and delusions (holding beliefs that those in your community consider false) can be a terrifying and isolating experience. For many years psychological interventions were thought to be at best ineffective and at worst reinforcing of psychotic symptoms, so it was unusual for individual's distressed by these experiences to seek psychological support. This has changed dramatically

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Anti-depressant withdrawal – Peter Walker

Here is an article I wrote for Cleo magazine on the difficulties that can be experienced when people withdraw from anti-depressants rapidly. It is critical that people seek the advice of their GP or Psychiatrist when they are considering embarking on this process. Unfortunately, I see far too many people who withdraw rapidly and end up experiencing distressing side-effects (Eg head-aches, nausea and disconcerting symptoms such as "brain zaps") and a sudden decompensation into depressed mood. This can lead people to assume that their depression was laying hidden just under the surface and that their apparent improvement in coping was all a facade made possible by the anti-depressant. It is quite possible, however, that the depressive episode that occurs directly after the sudden cessation of medication that had been administered chronically for a long period, is in fact a withdrawal syndrome. This is why medical practitioners recommend a very gradual reduction in the dose of anti-depressant medication.

The Elusive “Good Night’s Sleep” – Peter Walker

Difficulty initiating and maintaining sleep often prompts people to seek the assistance of a psychologist. It is common for clients to attend my practice lamenting the loss of precious hours of sleep. They relate long hours spent staring at the ceiling, tossing and turning, physically and mentally exhausted, yet wide awake. As someone who has, at times, struggled with insomnia, I empathise powerfully with those unfortunate individuals’ who push through until the pre-dawn hours in which our feathered friends’ stir and acknowledge the dawning of a new day. In this instance, birdsong that would otherwise be associated with peace and serenity, provokes murderous rage.

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