Panic Disorder: assessment, diagnosis and treatment via Zoom on 15th June 2021

Panic Disorder is an intensely distressing condition. If you haven’t experienced it for yourself you’ll have a hard time understanding just how frightening it can be. Panic attacks may occur a few times in a lifetime or many times a week. In my experience learning to assess for, and then treat, “panic attacks” is an absolutely critical skill for anyone working with anxiety and stress.

Panic Disorder is typically characterised by symptoms such as blurred vision, racing heart, inability to “catch your breath”, dizziness, a feeling of being unable to control oneself… this is rather different from the everyday use of the word “panic”, and generates a very real sense of danger.

The focus on avoiding danger and being safe can grow to a sense that one must not venture far from thw comfort zone and so there is often an association with agoraphobia. This can persist even after successful treatment of the panic disorder itself.

Prior to the cognitive-behavioural model that was developed, panic disorder was considered very difficult to treat. However it is one area of mental health where there has been great advancement and treatments have gone from “zero to hero” – with the latest treatment model enabling therapists to treat panic with a good degree of success. Notably treating panic disorder without agoraphobia is associated with very good outcome rates and is deemed one of the most successful treatments that has been developed.

However, people who have panic attacks but don’t have an anxiety disorder are at risk of developing mental health problems further down the line. Effective early intervention can therefore be very helpful and is surprisingly effective.

Panic attacks and panic disorder are surprisingly common. The 12 month prevalence for panic attacks is about 2.7% and the life time prevalence about 22%. Moreover in social phobia panic attacks or full blown panic disorder is present in 33% of cases or more.

What this course will do for you
The training covers a wide range of CBT topics from introductory through to advanced. The combination of lecture, case studies (video/audio analysis) and role play significantly develops skills and knowledge of CBT techniques and provides an effective and cost efficient investment in your professional development.

This training will provide a CPD Certificate (6 hours) signed by a senior BABCP accredited psychotherapist and lecturer as well as the principle of the college.

Addictive Behaviours on 29th June 2021 !

CBT for addictions used to rest on the assumption that clients are able to identify ways of thinking that lead them to engage in addictive behaviours. However, research into implicit cognitive processes and self-control suggests that some important determinants of addictive behaviour may not be consciously accessible. Lets explore together the research and treatment of addictions on June 29th – an online seminar via !

Winning the mental warfare with COVID-19 (CBT Self-Help for COVID-19 Anxiety)

Audio version

Recent reports indicate that the level of mental health symptoms amongst the general population are on the increase. A Young Minds study published in The Guardian on March 31st 2020 asked 2,111 under 25s with a history of mental health needs, how the pandemic had affected them. 83% said the pandemic had made their mental health worse.

More recent clinical experience also indicates that the overall numbers of mental health disorders, in particular anxiety and depression  are on a steady increase and will eventually cover many different segments of the population.

There is currently a justified, growing concern for the mental health of all frontline workers from NHS and the police forces across the country; but also for delivery drivers, various transport workers, engineers, cleaners and supermarket workers. No doubt, these truly are the heroes of the day.

On the other hand there seems to be less focus on other clinicians from the second tier of exposure who may not necessarily be on the frontline, directly tackling COVID-19 patients, for instance GPs, mental health nurses, psychotherapists, psychiatrists, physiotherapists in smaller hospitals or private clinics. Even less thought is given to the general population who cannot it seems, cope psychologically and emotionally in self-isolation.

The potential consequences of self-isolation

We know from various psychopathology,  biology and behaviour studies  that in spite of displaying incredible resilience in the face of various diseases, humans are not well equipped to deal with social isolation and ‘psychological  uncertainty’ for prolonged periods of time –  this would inevitably be a catalyst for a range of mental health pathologies including depressive and anxiety disorders. For those that are already suffering from a mental health problem, it could symptomatically be even worse, as the recent Young Minds study clearly outlined only a few days ago. Social isolation, catastrophical thinking, long episodes of negative rumination, lack of purpose, increased drinking and less physical exercise are risk factors for major depressive disorders and anxiety disorders.

Self-isolation therefore may be both a blessing and a curse, since it will clearly help us manage COVID-19 but at the same it might bring with it a series of challenges including, how to spend time at home in a way that improves our mood and does not increase feelings of fear, sadness, anger, isolation and lack of purpose.

There are several self-help tools originating in the family of Cognitive Behavioural Therapies that are likely to help. To offer some context, Cognitive Behavioural Therapy or CBT is an umbrella term for a range of evidence-based psychotherapies that successfully combine behaviourism with philosophy, learning theories, cognitive psychology and more recently neuroscience and neuroaffective research. Unlike other therapies, CBT is structured, symptoms focused, goal-oriented and aims to enhance self-efficacy by introducing a range of self-help technology. These techniques could  be very helpful in the current climate.

 CBT strategies for social isolation

A number of evidence-based strategies are recommended by CBT therapists. It might be best to organise those in 3 categories: mind, body and regulation of emotions; or in CBT terms, cognitive interventions, behavioural interventions and regulation of affect (or emotional regulation).

Mind or Cognitive Interventions

When it comes to the ‘mind’ everyone is different but individuals’ reactions to threats are very similar.  The current ‘threat’ is obviously that of being infected with a dangerous virus which leads to fear, intense preoccupation, hypervigilance and a range of other symptoms associated with an anxiety disorder and stress.

A good place to start is by understanding and truly accepting that ‘fear’ is an essential emotion, much like sadness, anger or joy; all these emotions are very well embedded and encoded in our genes, in our neurological circuits. Such complex connections essentially enabled our species to survive over tens of thousands of years. And as such, this is not an emotion we would want to get rid of. For example, if we would not experience a higher degree of fear in relation to COVID-19 we would be too laid back and less inclined to protect ourselves and other members of our community. 

Nonetheless, there is a very fine line between the emotion of fear and an anxiety disorder, best explained perhaps by some of the cognitive psychology research which stipulates that people tend to get anxious when they overestimate the probability and possibility of the threat and underestimate their coping skills or other (external) rescue factors, resources and so on, they might have at their disposal (when or if faced with the predicted threat).

Following up from that, a very useful self-help strategy evolves from this formula which focuses on ‘de-catastrophising‘ the impact of the threat. In this case obviously, it translates into decatastrophising the threat that COVID-19 would pose to our health and our community in the long run.

Decatastrophising COVID-19

The process of decatastrophising might feel a little slow involving several daily practices, it is best to be patient and thorough.

Mindfulness & acceptance of your distressed thinking

To begin with, we could attempt a very simple mindfulness and acceptance technique.  My advice for everyone at home is to practice regularly and gradually learn to increase their awareness of unhelpful ‘trains of negative and catastrophical thoughts’ in order to learn to distance themselves from them.

Just allow your thoughts to come and go as they please and do not engage with the content, with the message these thoughts are trying to deliver…  just accept them…

You will soon learn to view your thoughts exactly for what they are – just normal mental activities – you do not have to believe every thought that pops into your mind AND feel the need to immediately act on it… learn to indentify Gaps of Silence in-between these ‘trains of thoughts’…  gaps where you feel safe and not urged to do anything… it might be helpful to imagine [whilst engaging your slow abdominal breathing] that there is always a gap in-between these long, sometimes connected trains.. Aim for the Gap.. Aim for the Silence. 

Mindfulness-based techniques can feel difficult when you try them for the first time, be patient with yourself, allow for mistakes, you do not have to get it perfect. It is a bit like going to the gym for your first time, your muscles will hurt, however you will get stronger if you persist.

Facts Finding, Installing Hope and Positive Self-Talk

A completely different way of dealing with catastrophic or negative thoughts, would be to practice generating a much more optimistic and hopeful ‘Self-Talk’ or ‘Self-to-Self dialogue’ between your ‘Anxious-Self’ and ‘Strong-Self’.

This optimistic and positive dialogue could be extended to someone in your household or to your social media community and consists of research and careful examination of all the evidence surrounding the threat (i.e. CORONA-19), keeping a focus mostly on positive facts:

Fact number 1: in regards to the level of threat, the virus is indeed dangerous but the majority of people will recover and most will build immunity against it.

Fact number 2: NHS, universities and research labs across the world are working tirelessly to develop testing tools and treatments which would more than likely build our immunity against COVID-19.

Fact number 3: there are a lot of specific examples of successful treatments, perhaps people that we know (i.e. Matt Hancock, Health Secretary) and have now recovered and are well. It may be important to write down these specific cases in bullet points and describe in detail a situation that impressed you and gave you hope.

Fact number 4: in regards to available resources and coping skills, much can be said about external resources which are literally improving every day (i.e. the new Nightingale Hospital in East London). But in regards to coping, ask yourself the following questions:

– Given all the above facts and the real threat this virus poses to me, how could I cope and what resources are currently at my disposal?

– What else lingers from my recent findings… perhaps more optimism… more coping strategies… or more hopeful facts…?

– In light of all my research and recent evidence, how true are all these statements?

The human race is fighting back in a variety of ways!”  (0-100%)

“We are not giving up!”   (0-100%)

We have seen much worse! We refuse to fall victims!”  (0-100%)  

* Rate the level of your belief in those statements from 0-100% and if the scoring is below ‘50%’ ask yourself, what could you do in order to improve the rating? How about backing these statements up with some more research and even more examples of resilience and recovery or other recent achievements and posting those on social media or write it in your personal journal (as opposed to focusing mostly on negative and sad stories).

Positive Data Logs

Another useful cognitive-behavioural intervention, would be compiling a Positive Data Log (PDL) on social media or indeed in your personal journal (or both, if you prefer it).

It is important to use these questions as guidance for your new PDL, though one could get very creative and add to it, there are no limits put on your exploration.

What am I learning from this experience about myself, about significant others (i.e. family & friends) and about the world around me?  

In how many positive ways has my life changed as a result of this situation?

I could of course think of a few things including, having more time with my wife and child, the desire to help the most vulnerable in the community, writing this article, being less focused on material things and more focused on the health needs of the family, on the needs of community in general, a renewed focus on hobbies long forgotten, on my true values, religion or spirituality or indeed the positive impact the virus has on pollution and nature.

All such mental strength or resilience building exercises could be viewed as ‘personal training’ for the mind; is it not curious that we find it absolutely normal and natural to go to a gym, invest time and money in strengthening our bodies and yet when it comes to our minds we hesitate… Why don’t we start right now infusing and enriching our minds with a positive attitude, more optimism and hope… What would that feel like?

The one thing that most people in social-isolation would have right now is time, this makes us a lot wealthier than we were this time last year.

Time can be used to catch up on your hobbies or unfinished projects, it provides space for creative and positive thinking, an opportunity to reconnect and talk to your partners or old friends (… I probably spoke more with my wife this last week then the whole of 2019 – we had a lot of catching up to do…)

Time provides us with an opportunity to repaint the spare bedroom, make bad music, practice our weird dance moves or read more. So what if you have not read a book in years – right now might be a good time to start by choosing the one you missed as kid.

All of the above strategies are very effective mind techniques or cognitive interventions against negative and catastrophical thinking and in favour of installing hope and a more optimistic outlook on life. Such positive mental focus and creative thinking would eventually lead to a variety of self-discoveries, interesting experiments and more valued actions.

….. For example only a few days ago I discovered for the first time how much I enjoy gardening with my family. It is something I would have never considered Pre-COVID19I might decide now, to show off by posting online this gardener-version of myself; I may briefly describe my newly found talent and in doing so, perhaps I will inspire another friend….

Behavioural interventions

I already mentioned earlier how my own positive data log and research lead to the discovery that I like gardening and enjoy longer talks with my family. Of course, not acting on these self-discoveries would have not provided me with the evidence that I actually enjoy new activities and therefore I could incorporate them in my daily or weekly routine. 

It is therefore important that we put into practice all new valued actions through routine and structure. In CBT we propose a self-management tool called Behavioural Activation this intervention is based on a simple idea – we feel much better when we engage with activities that we Enjoy, Feel a Sense of Achievement or Feel Connected with Others.

Enjoyment, Achievement and Connection!

Research into treating depression indicates that a day that includes a good balance of those three types of activities leads to significant improvements in our mood. Getting stuck in a vicious cycle of not doing things would make us feel unsatisfied, low in mood, less productive and less likely to want to do anything in the future.

Another important Behavioural Activation principle (briefly mentioned earlier) includes having clear routines and a daily structure. It might be tempting, even enjoyable in the short-term to have a flexible daily schedule however, once again the evidence clearly suggests that having a clear sleep routine, specific mealtimes and a strict exercise routine is much more helpful. Of course, there is no harm in having some unstructured or ‘down’ time during the day however, a general lack of achievable goals and structure may lead to helplessness and hopelessness (which could predispose an individual to more symptoms of depression).

SMART Planning at this stage becomes very important. For those that are not familiar with the concept, having SMART goals refers to goals which are Specific, Measurable, Achievable, Realistic and Timed – SMART ! If your goals do not meet the criteria, they need further tweaking or even changing.

For example, the goal ‘I want to be happy’– is not specific enough and cannot be measured whereas… ‘I would like to spend 20 minutes every day doing yoga with my partner’ is clearly a SMART goal, more likely to lead to feelings of joy and relaxation.  

When planning your day or even your week ahead, we must remember to carefully examine what we actually planned for. Look out for a combination of activities that include enjoyment, achievement and connection. If you are missing one element in the day try to build that in, later in the week – it is important that you do not abandon your plans and you do not procrastinate if it seems at times too challenging.

Give your Behavioural Activation diary an interesting name like Katie’s journal, Journal of my Achievements, Mr Big’s Diary, etc., own it and design it, in any way you want to.

You could create your own list/s for the day or a timetable for the week. You could use digital diaries with reminders, smart mobile phones or tablets, you could use Alexa or Google Home or simply use post-it notes which you could move around if need be.

Avoidance and Safety-Seeking

When you are analysing your catastrophical thoughts or even when you are compiling your PDL’s you might, from time to time, notice a tendecy to avoid situations that are likely (in your perception) to cause you harm through contamination. Such ‘safety-seeking behaviours’ can be excessive and would maintain anxiety or the feeling of being under threat. For instance, wearing a face masks in a shop is a necessary measure, whereas wearing a mask in your own home where you live alone or in your garden or even in your car may be an exagerrated behaviour that maintains a sense of threat. Carefully examine your tendancy to avoid and safety-seek and ask a trusted friend or a trusted family member for their opinion if it helps – it may be important to modify such behaviours.

Refocusing on Personal Values & Interests

One other behavioural self-help tool is Refocusing on Personal Values, Hobbies & Interests. You can ask yourself:

Is the way I am spending my time in line with my own personal values and interests?

At this stage, it might be a useful to study your PDL and compile a list of all your values and interests. If you are someone that likes to help others, it is important to make sure that some of your time is dedicated to activities that do that… you might consider donating or even volunteering for a day or two every week.

If learning new things is important for you, make sure that there is time for that. You could make time for creative activities for relaxation or lots of other things that could be done from a distance, like writing, painting, or sending letters to loved ones.

Emotional checking-in

Another important technique is creating a routine of ‘Emotional Checking-ins’ (or emotional sharing) on a weekly basis. This is like calling a regular team meeting at work with all your colleagues for the regular feedback and follow-ups, only in this case the focus on the agenda is our emotional state and what we do.

Take a little bit of time for yourself when you are with your family or your housemates at the end of the week on each Friday evening, to review how things have gone for you during the week and work out if there are things you want to improve for the following week.

Try to answer these questions:

Did any activities noticeably affect your mood in a positive way?

What are you grateful for?

Who do you want to acknowledge this week?

Was there a day when you felt not so great?

What was going on then and what could you do in order to improve next week?

Checking-in with ourselves and each other about how we feel and what we have done, can improve the mood and quality of the communication between different members of the household. As a weekly exercise this could lead to many insights, though some families prefer to do it daily – for example, every dinner time or before bedtime.

Remember – this is a checking-in exercise it is not a forum for resolving outstanding problems, everyone gets a turn for a 3 to 5 minutes to talk about themselves, and everybody else listens, acknowledges and thanks the speaker.

Assuming that you plan to have these feedback sessions on every Friday evening, it may be important not forget to plan something special,  more relaxing and even more fun for the weekend, at the end of the each session, something to look forward to. This might involve a family movie or 60 minutes of ‘disco night’ whatever works for you, your family or your housemates.

Let’s also remember that for now, we are allowed to use the outdoors for 30 minutes of training or walks, we can use our gardens but also our balconies.

Emotional Regulation

When we are dealing with any kind of mental health problems we cannot ignore how the body reacts to all external negative feedback and internal catastrophical thinking. Our system is very complex, it relies on the body to communicate to our mind that something is up or something is going on and vice-versa. 

We know in other words, that stress and anxiety have an immediate impact on our physiological state and mood through a variety of, what could be perceived as, unpleasant symptoms.

Anxiety and stress in particular are characterised by symptoms of hyperarousal such as heart palpitations, sweats, laboured breathing, chronic muscular tensions and so on. Such symptoms maintain the illusion of severe anxiety and over time could even trigger a fear of actual symptoms of anxiety.

Therefore it becomes vital for us to learn to down regulate when we are in a state of hyperarousal to a normal state, so that our physiological system does not weaken the immunity further and in the long term it does not develop stress related chronic illnesses (such as chronic pains for example or a worse).  

Research shows that regular physical training, attention training exercises, abdominal breathing and progressive muscle relaxation can help with the process of down regulation.

8-Emotional Regulation Exercises for Mind, Body and Soul

  1. The 3 – 4 – 5 Breathing Method

Breathe in up to 3 (counting in your mind)… hold your breath up to 4 (counting in your mind).. and finally, very-very slowly breathe out, counting in your mind to 5 or more…  This breathing pattern is very important! It is preferred that you breathe in through your nose opening your diaphragm widely and relaxing your abdomen and slowly breathe out through your mouth. 

2. The Breathing Square (also known as the Breathing Box)

The Breathing Square is similar, though in this case you also visualize drawing a square with your minds-eye while synchroning your breathing patters with the drawing of an imaginal square. You could also use your hand (or finger) to ‘air draw’ the square…   

Breathe in as you start drawing a lateral of the imagined square (starting with the right low corner), hold your breath on another lateral and exhale slowly through your mouth on the other two laterals, thus closing the square…

3. Progressive Muscle Relaxation

4. Body Scanning

Williams & Penman

5. Mindfulness training: Exploring Difficulties

Williams & Penman

6. Mindfulness training: The 3 minute Breathing Space

Williams & Penman

7. Body Appreciation

Body Appreciation’ might sound a little unusual for a mindfulness training exercise but experience shows that we can easily forget how to love, care and appreciate our bodies…

Have a long bath instead of a shower in the evening… use scents and your favourite bath cream… take your time to notice the pleasant smells… to feel the warmth of the water touching your body… imagine right now how this feels… give yourself permission to relax.. dont look back at your day.. dont look ahead at the rest of your night.. just allow your sense to come alive and feel… notice how the cream feels on your body as you gently apply it… do not rush this will only take a few more minutes.. minutes that you will soon learn to enjoy and appreciate..

8. Physical Strengthening

Physical Strengthening exercises are not any more difficult if you’re stuck indoors, but the motivation is usually low since training is naturally associated with going to a gym or a even park. Seek inspiration from tens of YouTube personal trainers, yoga teachers and other online classes. At the moment we still have the option to go out for 30 minutes of training but be realistic regarding your ability and plan a set of exercises which are tailored to your body and current ability. A walk with the dog is excellent exercise for some people whereas for others, complex martial arts or yoga exercises might be more appropriate.  

The basic principles of Emotional Regulation:

It is important to learn NOT to be afraid of our emotions, try to understand their role and allow them to alert you without immediately feeling the need to ACT – unless you are indeed in an imminent danger.

Learn to use your abdominal breathing and creative imagination to down regulate and calm yourself down… there is a lot of help, a lot of websites, apps and YouTube channels that provide excellent training in Mindfulness, Progressive Muscle Relaxation or Hypno-CBT.


  1. Write down a daily routine (your BA Diary should help with that) for Monday to Friday and a separate one for Saturday & Sunday – more relaxing and fun activities at the weekend and more time for hobbies and interests. Just like an ordinary week. Mon to Fri could be allocated to working from home but do not be tempted to work for more that 7 hours a day plus your regular breaks. Learn to switch off from work – working from home it’s not as straight forward as it sounds, it can be a mental health trap !
  2. Review your week every Friday (see Emotional Check-ins chapter) and make changes for the following week if necessary.
  3. Make sure your weekly plans include a combination of activities, the key words are: Achievement, Enjoyment with Connection.
  4. Check with your PDL, or personal journal and make sure that your values and interests are covered and leave some room for new ones that you will soon discover.
  5. Exercise – daily and schedule it in your diary, reserve 30 mins for physical training – outdoors (if safe and possible) and 30 mins more indoors if you can cope (i.e. jogging plus aerobic routines).
  6. Mindfulness – daily ! Aim to gradually increase your times over the following few weeks from 10 – 15 – 30 to 45 minutes of regular minfulness practice; no limits on this, as much as you can cope with – be patient you will not get it at first !
  7. If you are tired Sleep ! Do not fight it by trying to stay awake. Also train yourself to have power naps during the day or use a Mindfulness exercise to unwind.
  8. Nutrition and hydration: be sensible.. the temptation is to snack more and drink more alcohol, stay focused on healthy options, creative cooking (including smoothies) could be one of your new Values! Eat Well But Sensibly and Reduce the Alchool Intake ! Drink 1-2L of Water Every Day !
  9. Read and Write as much as possible… Start with the CBT exercises proposed above. Also do not forget to check out all the interesting links I have attached here for you, just click on the highlighted sections.

After all of that, do you still feel you are on a ‘holiday lockdown’?

A Free Podcast and more Free Links will be added to this article over the next few days, please feel free to come back and ‘check-in’ from time to time.

Whatever type of exercise or self-help tool you feel is appropriate for you and those you live with, it remains vital that you include this in your daily structure, you enjoy it, you feel a sense of achievement and even a sense of being connected with others while doing it.

As a final note, I would like to share a surprising poem of hope with you by O’Meara, C.

And the people stayed home. And read books, and listened, and rested, and exercised, and made art, and played games, and learned new ways of being, and were still. And listened more deeply. Some meditated, some prayed, some danced. Some met their shadows. And the people began to think differently.

And the people healed. And, in the absence of people living in ignorant, dangerous, mindless, and heartless ways, the earth began to heal.

And when the danger passed, and the people joined together again, they grieved their losses, and made new choices, and dreamed new images, and created new ways to live and heal the earth fully, as they had been healed.

Stay Healthy and Hopeful!

by  Daniel Mirea (4.04.2020)

*Acknowledgement to Mark Williams & Danny Penman for some of the mindfulness materials used fairly and for non-profit purposes. Their complete training programme can be purchased via the link provided, currently there are free offers on on Amazon Prime through the Audible app.

*Training in Evidence-based Hypnosis ( Hypno-CBT ), Relaxation and Stress Management offered on-line during the lockdown here.

Beat Anxiety with Attention Training (NA-CBT)

One of the problems with anxiety and psychopathology in general is lack of psychological flexibility which translates without exception into poor attention training skills. When self-critical, self-blame thoughts, worry or shameful thoughts enter our awareness, our attention is literally hijacked by these thoughts and we start engaging with them.

For example, in the case of clinical perfectionism, when we are requested to produce an important business report we tend to worry about the language, typos, the format and so on, even after it has been completed. After we submit our work we might continue to worry about it or about the perceived negative feedback we could receive as a result of poor quality work. Of course, these are all false projections into the future or even catastrophical predictions (e.g. this is the end of me, I will lose my job this time 100%).

When these negative thoughts (predictions and so on) enter our mind our attention is 100% directed towards the content of such thoughts, which triggers our sense of threat. This means that our brain (and body) starts to believe that we are under threat and it responds by further triggering the Autonomic Nervous System (the sympathetic response), which manifests through a range of physiological symptoms of anxiety (heart racing, sweating, etc.). And thus, the ‘perceived threats’ start to ‘feel’ real. Over time and with lots of practice such negative thoughts begin to govern our existence and become more and more believable. In other words we become very good at getting anxious.


Selective and narrowed attention, directed towards the content of the thought (e.g. false predictions about the future) is clearly one of the principle precipitating (or triggering) factors and also an important perpetuating (or maintaining) factor in anxiety disorders.

So what can we do about it? Some of the methods involve learning to re-orient the attention towards something else, more positive or more constructive. But at times this exercise alone, would often fail. We have more recently discovered that, re-orienting the attention towards the breath and breathing, enables a shift towards the ANS parasympathetic response (the rest mode) which cancels symptoms of anxiety generated by the ANS sympathetic response (the threat mode) by encouraging a calm and relaxed state. When the action of breathing is coupled with a visualised self-instruction, the process is significantly faster and longer lasting.

For example, right this moment, direct your attention towards your breath, feel the air coming in and out for a few seconds, slow your breath down (shorter inhalations and longer exhalations) then.. with each outbreath, merge more and more into your favourite relaxation place (could be your garden, a yoga class, or your favourite holiday spot). Try it once again, right now…

ANS system

Awareness is key! Every time a negative thought enters your mind, you could train yourself to be aware by simply noticing without judgement that, this is happening. At this stage, you can start training your ‘attention muscles‘. Notice your thoughts, accept them as just thoughts and zoom out, bring your attention back to the present task (to whatever it is that you were doing a moment earlier) and then take your attention back to the thought – is it now just as captivating as it was earlier or did it move on? Accept if the thoughts are still there.. but also accept if they are not… just be an observer of your own mind… Be proud of your newly discovered ability and don’t attempt to master this. Allow for mistakes, just notice that sometimes you cannot get it right… remind yourself you are still in training. You are a student of your mind… indeed of your life… just allow this natural movement to happen.

Awareness (or self-awareness rather) is attention training !

Attention training is a major component in NeuroAffective-CBT and mindfulness based therapies which places this type of therapy under the third wave umbrella (see previous article on Third-Wave CBT). By paying attention to what happens right now (in the present moment), and doing it with an accepting attitude (towards whatever you notice), you become a safe and confident observer of your internal world and experience… your breath, body sensations, thoughts, feelings, sensory experiences, etc. Awareness and attention training involves practising how to notice when your attention is wandering away from the present, and then skilfully redirecting your attention back to the ‘here and now’. This is not an attempt to suppress, neutralise or control your thoughts in any way. But instead allowing these thoughts to be present and active, to do what they are meant to be doing. At the same time, develop efficacy and confidence by choosing to shift your attention back on to something purposeful.

For specialist courses in attention training follow the link below – the training is open to all !

Is ‘perfectionism’ a deal maker or a deal breaker ?

Most people would consider having high standards a good thing but at times this is just part of the plot or in other words, part of a complex trap called ‘perfectionism‘. Striving for excellence might indicate that you have a solid work ethic, strength and ambition. But if and when achieving success (in any domain) is consistently associated with one’s value, self-worth and esteem, we risk falling into the trap of perfectionism.

High standards could indeed propel one towards the peak level of their potential. This is very common with professional athletes or musicians for example, who train long and hard to reach excellence in their respective sport or art. Clinical perfectionism could however develop when the individual believes that his/ her worth, value and appreciation by others, uniquely depends on achieving success all of the time and never failing a task. In parallel with that, standards are set so high that they often cannot be met, or are met with a great deal of difficulty. Perfectionists tend to believe that anything short of perfection cannot and should not be tolerated, and that even minor mistakes or imperfections will lead to one conclusion only: that they are not worthy or good enough individuals.

Generally speaking, we might believe that it is important to try to do the best that we can in one or more areas of life. However, most people also believe that making mistakes from time to time is reasonable and inevitable. Making a mistake does not mean they have failed entirely and this will ‘define’ them and ‘follow’ them forever. Perfectionism positions itself within this spectrum. Adults and even adolescents* with perfectionism tend to believe that they should never make mistakes and that making a mistake means they are a failure across the board, they are unworthy individuals, consistently disappointing others. Thinking like this makes perfectionists hypervigilant because of the prospect of making mistakes and as such, perfectionists experience constant states of hyperarousal, shame and defeat.

When exploring an individual’s early years it is easy to understand the origins of such attitudes to self and others. Perfectionism is encouraged in many families. Sometimes parents consciously or unconsciously set very high and very rigid standards. It can actually be very easy for any parent to fall in this trap given how much more competitive the world is. Demanding parents however would require top marks in school, medals in sports and flawless ballet recitals. Mistakes could be harshly punished. The punishment does not need to be physical; it is mostly emotional, it is severe and abusive. This may include neglect, public humiliation, downgrading accomplishments, name calling, yelling, shaming, the silent treatment, and/or indeed sometimes even physical aggression. The principle message conveyed to the child via words or behaviours is very clear: ‘failure is not acceptable and it will not be tolerated’. It is natural for children to have a strong need to impress adults and main caregivers in particular. This ‘need’ is a natural surviving instrument and therefore parents’ unhealthy expectations and demands are viewed as the norm which gives rise to fear of failure and perfectionist attitudes (within children). Reinforcing behaviours and assumptions about how to navigate through a competitive world would soon follow. Those will become embedded and programmed in one’s bio-psycho-social system and neuroaffective systems and as such, adolescents could struggle with symptoms of depression and low self-esteem and/or anxiety for years before treatment is sought and the correct diagnosis is identified.

This is in fact, exactly what makes perfectionism difficult to identify and treat. It has roots in an emotionally abusive and demanding environment and it crosses borders into the depression and trauma spectrum, chronic low self-esteem, OCD, eating disorders, even some personality disorders. Unfortunately a range of mental health pathologies rely on psychological rigidity and unrealistic self-imposed standards.

For the typical perfectionist adolescent or adult, trying to be perfect is a daily effort and it does not stop when leaving the school or the office. Martina is a well regarded and respected nurse manager who would consistently take additional responsibilities when on duty. She does not like to delegate, because ‘no one can deal with certain tasks as well as she does’. She is the ideal employee and therefore managers reward her by assigning more and more complex cases. This would lead to stress and burn out almost on a daily basis. When she gets tired, she would make mistakes which would not be tolerated since it confirms her worst fears that she is a failure, she is an embarrassment to her patients and colleagues.

Problems do not stop here. When she leaves work and arrives home, her equally high and rigid standards would continue to be applied and diligently enforced. With very clear daily instructions and (hour by hour) rules in place her expectations from her husband and their children to deliver everything on time and at a high standard (e.g. washing up, homework, etc.) are relentless and exhausting for all involved. This would lead to frequent arguments and further feelings of worthlessness, shame, embarrassment and failure.

If investigated carefully, subtle differences between the two case scenarios (i.e. the work situation vs. the home situation) may be observed. Although all behavioural responses and associated assumptions (i.e. beliefs)  have a perpetuating role (or a role of maintenance which is, to reinforce the not good enough, failure or shame schemas), such elaborated cognitive strategies may be better understood as justifications or facilitating beliefs about why having high standards is important to the individual.

The diagram further below explains the reinforcing mechanism. For example, at work it is all about keeping everyone happy (in order to be appreciated and valued) which involves (in the NA-CBT formulation) a series of Compensatory, Avoidant or Surrendering strategies (like not allowing ‘weaker’ workers to work on certain tasks). At home it is all about ensuring that her children are successful and parents are appreciated, respected and valued for their efforts. This is also backed up by a series of compensatory, avoidant or surrendering strategies (excessive organising and list making, not compromising on the timing, etc.).

The Pendulum-Effect Formulation

(NA-CBT by D Mirea)





The heart of the problem: “I am not ready yet, this is not good enough!”

Overcompensation reflects your inability to internally say to yourself: ‘this will actually do’ or ‘this is good enough as it is’. To stop constantly shifting the goalposts or to refrain from aiming higher and higher and at the same time believing that it is not just realistic but also very-very important – to reach such high standards.

The need to ‘control’ everything or ‘take control’ is yet another compensatory mechanism that facilitates perfectionism. Facilitating beliefs or justifications such as: ‘no one can do this as well as I can’ or ‘If I don’t do this, nobody else will..’ would inevitably lead to burn out, stress and eventually some type of failure – a sentiment that the perfectionist would like to avoid at all costs.

These attitudes or mindsets apply of course, to all areas of life whether personal, work or sports and therefore the language, behaviours and beliefs vary: having strong and rigid views or rules… being tough and correcting people or children when they make mistakescommenting when other people are not being appropriate and directing them to more appropriate behavioursarguing a point over and over again… not knowing when to stop, etc.


Procrastinating: “I can work on this later, when I am ready and when I am better prepared!”

Since your worth, your value and even personal image depends on constantly reaching a specific standard, the process of completing a project becomes very important (i.e. an essay that you wrote for school or a project you have to complete at work); therefore preparation and feeling ready or ‘right’ to get started on it can be very important. Procrastination and putting plans off is almost always the answer.

Other types of avoidance include indecisiveness or avoiding tasks the perfectionist fears is outside their sphere of competence in spite of all the evidence (i.e. an over qualified psychotherapist still afraid to open up a practice).


Not celebrating one’s success ! When achieving a goal  (even at the required standard) this soon becomes a ‘box ticking exercise’ rather than a celebration. And over time celebrations ( or celebrating achievements) would become completely absent from one’s life repertoire.

Giving up in shame or giving up too soon: “This is hopeless…”

This is not the same as avoidance, it is much more about giving up something already started and thus giving into the schema that suggests you are a failure and worthless. Surrendering could also involve ‘drinking to unwind’ – important to point out, this is not an effective relaxation exercise but part of the giving up process (a secondary problem such as binge drinking would develop in some cases); acting out of character, not being able to accept or assume a fault, frequent episodes of anger directed towards the self or (incapable) others, etc.

Most perfectionists feel exhausted after repeated and very long episodes of intensive worry and fears of failing and not reaching the (self-imposed) ‘required’ standard. Therefore at some point, one throws in the towel and retires into a depressive state, a state of shame and guilt. Examples would be quitting a project very recently started or even doing something very-very slowly, not to miss important details and then giving up.

Treating yourself with Neuroaffective-CBT (NA-CBT)

This method was developed by Daniel Mirea in response to a growing subclinical population of undiagnosed affective disorders that fall under the umbrella of shame and self-disgust. Since the treatment of such phenomenon crosses the boundaries of a clear diagnostic criteria, the therapeutic approach has to be both comprehensive and strategic. It is my view that self-help in general and especially self-help manuals can only go so far without the guidance and support of a kind, generous and well prepared CBT therapist.

NA-CBT relies on a clearly prescribed toolkit that aims to disrupt all mechanisms that predispose, perpetuate and precipitate the fears of failing, the shame and disappointment with the self, that are at the core of perfectionism.

There is a difference between the healthy and helpful pursuit of excellence and the unhealthy and unhelpful striving for perfection (though at times there is a very fine line). Experiencing negative consequences of setting such demanding standards, yet continuing to go for them despite the huge costs would point towards clinical perfectionism. An initial step is recognizing that there is a problem which needs to be addressed. Understanding the nature of the problem, the costs and benefits that perfectionism brings to one’s life and also understanding how one has firstly developed and then kept falling in the trap of perfectionism over years, is just the first part of the changing process.


* adolescents – the upper age limit is considered to be 24 according to neuroaffective case studies.

*** Training in Clinical Perfectionsim in West London on 20th May 2019. Details below