Panic attacks are frightening experiences. During a panic, you experience strong physical sensations that feel very serious and threatening at the time. This can leave you fearful of having further panic attacks. This chapter outlines how to understand and beat panic attacks at this time. Pregnancy is a time of lots of physical change and lots of focus on those changes, which can be difficult if you have become worried about physical sensations. It can be difficult managing panic attacks if you are caring for young children. We guide you through the cognitive understanding of panic attacks, that they are driven by understandable but incorrect interpretations of physical sensations. We will help you to apply this theory to your individual situation, to recognise which sensations are particularly frightening, and outline experiments to target behaviours such as avoidance, focus on sensations and other factors that keep the fear going.

This chapter provides an overview of what anxiety problems are, and why the perinatal period features all the key ingredients that can lead to problemmatic anxiety. Nurturing and caring for a baby is not easy for anyone and involves large emotional and physical demands, managing uncertainty and avoiding harm. All in the context of disturbed sleep and a major life change. The cognitive-behavioural model of anxiety states that it is not just the situation we find ourselves in, but the particular meaning we give to our experiences that drive and make sense of our emotions and other responses. In pregnancy and the postnatal period these meanings may be influenced by a complicated and sometimes traumatic journey to pregnancy and birth, beliefs about the importance of thoughts or physical sensations, and how we respond to the responsibility of being pregnant or in charge of a baby, as well as other personal and historical factors. There are many common factors across anxiety problems. In the rest of the book we explain how to apply this basic understanding to overcome particular forms of maternal anxiety.

Anxiety disorders make sense only in the evolutionary context of the origins and functions of normal anxiety. Anxiety is an adaptation that adjusts diverse aspects of individuals in ways that increase fitness in dangerous situations. Subtypes were partially differentiated by different dangers. Anxiety is not fully differentiated from other aversive emotions, especially low mood. Anxiety disorders result when regulation systems fail. Explaining them requires considering five possible reasons for vulnerability. However, much harmful anxiety arises from normal mechanisms. These insights are valuable in the clinic, and they suggest new research initiatives.

In this session, the patient is queried about issues of anger management, and is taught emotion regulation skills. This session presents the anger toolbox: a set of tools to use when angry.

The session introduces a Trauma-Recall Protocol, which consists of a set of “tools” (for example, emotion regulation techniques) to be used when unwanted trauma recall occurs, and that help the patient to tolerate exposure. During the teaching of the protocols, be sure that the patient does the stretching and other motions, and, if the patient does not, encourage the patient to do so. The therapist should maintain a playful demeanor. At times, to ensure that a sense of relaxation is being conveyed, the therapist should purposefully slow and deepen the voice. (This creates a sense of shift in the session.)

In this session, applied stretching is taught, and the patient is led once more through the whole body muscle relaxation (with contract-release and stretch-release relaxation) with visualization. As in almost all lessons, there is a section on mindfulness and stretching. As indicated in the last session, the therapist should be sure that the patient does the stretching and other motions, and, if the patient does not, the therapist should encourage the patient to do so, all the while with a playful mien, a playful demeanor. This models a positive way of interacting and it also creates new positive associations to the topics being discussed. At times, to promote relaxation, the therapist should purposefully slow and deepen the voice. This also creates a sense of shift in the session: a shift in voice and emotional register.

In this session, again somatic symptoms and associated trauma networks and catastrophic cognitions are explored and addressed (on our model of how somatic symptoms are generated, see the Multiplex Model of Trauma-Related Disorder). The session also reviews key information such as emotion protocols (e.g., anxiety and anger protocol) and the applied stretching protocol.

Applied muscle relaxation” is traditionally used to describe the relaxation of muscles by contracting a muscle, holding the contraction, and then releasing tension. This might also be called “contract-release muscle relaxation.” Another method of muscle relaxation, such as that used in yoga, involves stretching a muscle by forced elongation and then holding the forced elongation a certain time, then releasing it. This might also be called “elongation-release relaxation” or “stretch-release relaxation.” CA Multiplex CBT teaches both applied muscle relaxation (i.e., “contract-release” relaxation) and applied muscle stretching (i.e., “elongation-release” relaxation), but emphasizes elongation-release relaxation, that is, yoga-type stretching. Traumatized patients have multiple symptoms induced by muscle tension. Examples of sensations caused by muscle tension include joint soreness, muscle soreness, and headache. Additionally, as discussed in the Introduction, applied muscle stretching allows for the introduction of phrases and images that promote a positive self-image of flexibility and prime to being flexible. These are embodied metaphors.

In this session, diaphragmatic breathing is taught to illustrate that normal breathing relieves anxiety, and hyperventilation is used to show that abnormal breathing can induce symptoms but that those symptoms are not dangerous. The patient is educated about breathing and educated about trauma associations to and catastrophic cognitions about symptoms caused by hyperventilation and chest breathing, such as chest tightness, dizziness, and cold extremities. The patient is made to hyperventilate to educate about breathing-induced symptoms, to create positive reassociations to dizziness and other sensations, to address trauma associations to the symptoms, to reduce fear of the hyperventilation-induced symptoms, and to act as interoceptive exposure that creates new nonthreating associations to the symptoms.

In this session, the patient is queried about worry episodes and resulting distress. Among ethnic minority and refugee patients, worry is common, and often triggers somatic symptoms, for example, dizziness and headache; triggers psychological symptoms (e.g., poor attention and concentration); and triggers panic. We have found worry to be a key psychopathological process in many minority and refugee populations. This session addresses worry in many ways, such as eliciting causes, symptoms, catastrophic cognitions, and trauma associations. Many treatments are used, such as modifying catastrophic cognitions and teaching mindfulness, including introducing a new form of mindfulness (tea/coffee mindfulness exercise). As a form of switching attentional focus, to treat worry, we introduce two forms of behavioral activation: encouraging exercise (for example, wall push-ups), and prescribing pleasurable activities.

Interoceptive exposure is introduced, focusing on dizziness sensations that are induced by head rolling. We use head rolling to educate about dizziness, to modify catastrophic cognitions about dizziness, to create positive reassociations to dizziness, to address trauma associations to dizziness (and other induced symptoms), and to act as interoceptive exposure that creates new nonthreatening associations to dizziness (and other induced symptoms). Interoceptive exposure also acts as behavioral activation and as a way to create an attitude of playfulness, a sort of flexibility. In the session there is also further training in emotion regulation (emotion flexibility) by practicing certain emotions.

In this session, somatic symptoms and associated trauma networks and catastrophic cognitions are explored and addressed (on our model of how somatic symptoms are generated, see the Multiplex Model of Trauma-Related Disorder). The session also reviews key information, such as emotion protocols (e.g., anxiety and anger protocol) and the applied stretching protocol.

In this session, metaphors for teaching about trauma-related symptomatology are presented to educate about PTSD and to help emotional processing: the “inner child watching DVDs” analogy and “two-television sets” analogy. Catastrophic cognitions about anxiety symptoms are addressed: the patient is taught about the physiology of fear. This Western model then is contrasted with the cultural group’s interpretation of anxiety-type somatic symptoms as indicated by dire events. Emotional distancing is taught.

This chapter is a theoretical introduction to the treatment. This includes introduction to the model that guides treatment (the multiplex model), aspects of efficacy, and a review of studies supporting the approach.

In this session, sleep-related phenomena are addressed. Trauma victims often experience sleep-related phenomena including poor sleep, nightmares, sleep paralysis, and nocturnal panic.

In this session, the patient is taught several emotion regulation techniques; diaphragmatic breathing for relaxation, emotion distancing, and the use of adaptive emotional states. Two forms of behavioral activation are taught: encouraging exercise and doing wall push-ups, and prescribing pleasurable activities. (Of note, throughout the treatment we have the patient do behavioral activation. We consider such actions as stretching and interoceptive exposure to be a form of behavioral activation in that they allow the patient to enter a new zone of experience and involve activity.)

In this session, cultural syndromes (e.g., the syndrome “thinking a lot”) are used as a means to explore catastrophic cognitions and trauma associations, and emotional protocols and other key treatment aspects are reviewed. The session ends by encouraging the patient to do a transitional ritual in that culture.

The goal of this session is to briefly describe the goals of the treatment, and to begin to educate the patient about trauma and its psychological effects. Culturally appropriate analogies promote the acceptance and recall of the core teaching principles. In this first session, the main metaphor utilized is that of the “inner child” who remembers everything and is easily frightened. This is used as a way to teach about trauma-recall triggers.

In this session, meditation and applied stretching are introduced. The therapist should be sure that the patient does the stretching and other motions, and, if the patient does not, should encourage the patient to do so with a playful mien. The therapist should maintain a playful demeanor whenever possible. At times, to ensure that a sense of relaxation is being conveyed, the therapist should purposefully slow and deepen the voice. This also creates a sense of shift in the session and so promotes flexibility.