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Panic disorder~15 min

Facing a fear of breathlessness: step ideas

Step ideas to choose from with your therapist for facing a fear of breathlessness, from noticing your breathing to everyday activity, stuffy places and agreed exercises. Based on Clark (1986) and Craske et al. (2014): a list of graded practice ideas for fear of breathlessness, with safety behaviours to drop and steps to carry to the exposure hierarchy.

Written by Tarun Vermani, Trainee Clinical Psychologist Updated

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This sheet gives you ideas for facing a fear of feeling short of breath, one small step at a time. Read through the ideas and tick any you could try, including ones that feel hard right now. Ticking an idea does not mean you have to do it. You will not do any of these steps on your own or before you have agreed them with your therapist. Together you will choose the steps that fit what you fear and add them to your graded exposure hierarchy. That is where you rank them and plan when and how to practise. Write the ones you choose in the last section. Therapist note: Use after the shared formulation and the rationale for exposure. This sheet is a menu only: the ticked items feed the graded exposure hierarchy, and any deliberate exercises are logged on the interoceptive exposure record. If the client has asthma, COPD or another lung or heart condition, agree the plan with their GP or the relevant specialist team (respiratory or cardiac) before any exertion or breathing exercise (see contraindications).

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How facing the fear helps

When you fear feeling short of breath, it makes sense to avoid things that bring the feeling on, or to keep checking your breathing. But avoiding and checking stop you finding out what really happens when you feel out of breath, and how well you cope.

Each step on this sheet is a chance to test what you fear, for example that you will run out of air, faint or lose control. Before a step, you and your therapist write down what you expect to happen. Afterwards, you write down what did happen. Your anxiety does not have to go down before you start or before you stop: what matters is finding out.

Practise each step more than once, and vary it: a different time, place or length.

Only practise steps you have agreed with your therapist, and leave out anything that would put your health or safety at real risk.

Only try exercises you have agreed with your therapist. Check with your GP first if you have a heart or breathing condition or epilepsy, or are pregnant. Stop if you feel unwell in a way that is different from your usual panic feelings.

Noticing and picturing breathlessness

These ideas start with paying attention to breathing instead of pushing the feeling away. What feels hard is different for everyone, so tick the ones that fit you.

Noticing ideas I could try

Everyday activity that leaves you out of breath

Everyday activity makes everyone a little out of breath. These ideas let you meet the feeling in daily life. They run roughly from easier to harder, but what is hard differs from person to person.

If you haven't had these feelings checked by a doctor, or they change or feel different from usual, see your GP. If you think something is medically wrong right now, get urgent help.

Activity ideas I could try

Warm, stuffy or crowded places

Many people who fear breathlessness avoid places where the air feels close or there is no quick way out. Tick any you avoid; what is hard differs from person to person.

Places and situations I could try

Short exercises agreed with your therapist

These bring on breathlessness on purpose, for a short time you agree in advance. Your therapist will usually try them with you in a session first, and can share a sheet for recording each one.

Exercises I could try with my therapist

Safety behaviours to drop

Safety behaviours are things you do to feel safer, like checking your breathing or resting at the first sign of breathlessness. They can stop you finding out what really happens, so dropping them is part of each test. Tick the ones you use.

Choose which safety behaviours to drop with your therapist. Keep precautions that protect your real health or safety. Do not stop or change any prescribed medication on your own; talk to your prescriber first.

If a nurse, doctor or physiotherapist taught you a breathing technique, pacing or a fan for a lung condition, keep using it.

Safety behaviours I use

Steps to add to my ladder

With your therapist, write down the steps you would like to try and what you fear will happen in each. Then rate how anxious you expect to feel, from 0 (no anxiety) to 100 (the most anxious you can imagine).

You and your therapist will add these steps to your graded exposure hierarchy, where you rank them and plan your practice.

#Step I could tryWhat I fear will happenExpected anxiety (0 to 100)Actions
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When to use ‘Facing a fear of breathlessness: step ideas’

‘Facing a fear of breathlessness: step ideas’ is an interactive cognitive behavioural therapy (CBT) worksheet, most often used in CBT for panic.

It is designed to be used within therapy rather than as a standalone self-help tool: a therapist introduces it, works through it collaboratively, and helps make sense of what it surfaces. You can preview the full worksheet above, then assign it digitally for clients to complete between sessions on any device or download it as a print-ready PDF.

How it works

Most people work through it in around 15 minutes. It moves through six short steps:

  1. How facing the fear helps: When you fear feeling short of breath, it makes sense to avoid things that bring the feeling on, or to keep checking your breathing. But…
  2. Noticing and picturing breathlessness: These ideas start with paying attention to breathing instead of pushing the feeling away. What feels hard is different for everyone, so…
  3. Everyday activity that leaves you out of breath: Everyday activity makes everyone a little out of breath. These ideas let you meet the feeling in daily life. They run roughly from easier…
  4. Warm, stuffy or crowded places: Many people who fear breathlessness avoid places where the air feels close or there is no quick way out. Tick any you avoid; what is hard…
  5. Short exercises agreed with your therapist: These bring on breathlessness on purpose, for a short time you agree in advance. Your therapist will usually try them with you in a session…
  6. Safety behaviours to drop: Safety behaviours are things you do to feel safer, like checking your breathing or resting at the first sign of breathlessness. They can…

Completed on the Formulate platform, your client's answers are saved automatically and shared straight back to you, so you can review them before the next session rather than waiting for a paper copy to come back.

The CBT approach behind it

In common with other CBT methods, ‘Facing a fear of breathlessness: step ideas’ works by gradually and safely facing avoided situations so anxiety can subside (exposure). The aim is not positive thinking but a clearer, shared understanding of what keeps a difficulty going and practical, testable ways to change it.

Because it is a CBT tool it stays focused on the here-and-now links between thoughts, feelings, the body and behaviour, and it works best as one part of a wider course of therapy rather than as advice or a diagnosis.

Evidence & sources

This worksheet is grounded in established cognitive behavioural therapy theory and practice. Key sources include:

  • Craske, M.G., Treanor, M., Conway, C.C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23. doi:10.1016/j.brat.2014.04.006
  • Clark, D.M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470. doi:10.1016/0005-7967(86)90011-2
  • Antony, M.M., Ledley, D.R., Liss, A., & Swinson, R.P. (2006). Responses to symptom induction exercises in panic disorder. Behaviour Research and Therapy, 44(1), 85-98. doi:10.1016/j.brat.2004.12.005
  • Livermore, N., Sharpe, L., & McKenzie, D. (2010). Panic attacks and panic disorder in chronic obstructive pulmonary disease: A cognitive behavioral perspective. Respiratory Medicine, 104(9), 1246-1253. doi:10.1016/j.rmed.2010.04.011

For use alongside professional support

Formulate provides educational CBT resources for use with a qualified therapist. They are not a substitute for professional assessment, diagnosis, or crisis care.

If you need urgent help now:

  • Emergency services: 999 — if you or someone else is in immediate danger
  • NHS 111 (NHS 24 in Scotland): 111 — choose the mental health option for urgent help, in England, Scotland and Wales (in Wales, press 2)
  • Lifeline: 0808 808 8000 — for urgent help in Northern Ireland, free, day or night
  • Samaritans: 116 123 — free, day or night, 365 days a year
  • Shout: 85258 — text SHOUT, free, day or night
  • SANEline: 0300 304 7000 — 4pm–10pm, every day

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