Panic Attacks and Emetophobia
Why You Panic When You Feel Nauseous
Part 3 - How trying to prevent nausea, sickness and panic attacks is actually causing your panic attacks
For someone with emetophobia, panic attacks can feel particularly frightening because the symptoms of anxiety and nausea can convince you that you are going to be sick.
This free CBT guide explains why this happens, what keeps the panic cycle going, and how to stop fear of the symptoms from controlling your life
Understanding safety behaviours for panic attacks
If you have read the previous sections and have completed your panic diary you should now have a good understanding of how panic attacks are caused by an interplay between your thoughts and physical sensations. However, there is another really important part of the puzzle which explains why you keep believing your misinterpretations despite them rarely or never coming true. This is due to actions called safety behaviours.
What are safety behaviours?
Safety behaviours are any action you may be tempted to use to prevent your anxious prediction from happening or to try and monitor, prevent or stop your panic attacks.
In response to real dangers, these actions can be highly effective at keeping you safe. However, when used excessively, inappropriately or to things that not really dangerous but only ‘feel dangerous’, these actions can backfire and lead to an anxiety disorder.
When these actions are used out of proportion to the real danger faced, these actions are called ‘safety-seeking behaviours’, often shortened to just ‘safety behaviours’. The reason they are called this is because they are actions done to provide a sense of safety from your fear. However, in reality they often provide little benefit in actually keeping you safe or are excessive for the real danger they are being used to prevent. Often safety behaviours feel very helpful at preventing your fears or reducing your anxiety. However, when I work with clients, the first thing I help them realise is that if they stop using their safety behaviours, then their emetophobia, panic and anxiety disorder goes away. This is because they are making your phobia worse and in reality making you feel less safe.
If you want more information of these, visit my self-help page.
While safety behaviours seem harmless or even helpful, these behaviours actually cause you to continue to have panic attacks. This is because they can convince you that the worst would have happened if you did nothing to prevent your fear.
Let’s demonstrate this using an analogy I like to call “barking at the postman”.
“Barking at the postman” - An analogy of why safety behaviours keep you afraid of sickness
We all know that most dogs bark at the postman. Lets imagine a dog who is scared of the postman. When the postman comes close to the house, the dog perceives a threat. The dog thinks that the postman is going to break in or is a danger in some way.
So the dog barks!
And the postman posts his letter and walks away.
The dog congratulates himself on getting rid of the threat. He learnt that barking keeps the postman away. Good boy!
However, we all know the postman would have walked away on his own. Each time the dog sees the postman he still sees him as a threat and barks. He thinks his barking is working.
Now imagine you could speak with dogs and you ask him to take a “risk” and not bark at the postman for the week.
The dog see’s the postman coming and does not bark. To his surprise the postman posts his letter and walks away… He thinks “maybe I got lucky, I am sure he will break in next time”.
The day next comes, and the next day after that. The dog doesn’t bark and the postman still hasn’t broken in. Soon the dog realises he was wrong and that the postman was not trying to break in.
“Key message:
When we use our safety behaviours we never get to see what would have happened if we did nothing. We are barking at the postman even when he was going to walk away anyway.
So, we need to test out our predictions of what will happen by facing our fear without trying to prevent it.
Safety behaviours only keep you trapped feeling anxious, even when nothing bad happens.
Want a complete CBT guide to panic disorder and agoraphobia?
My 70-page CBT guide takes you through the same principles used in therapy, including understanding panic, identifying catastrophic thoughts, reducing safety behaviours and gradually facing your fears. Also including tips on better sleep and relapse prevention.
Are panic attacks disrupting your life? This powerful, yet easy to follow eBook offers a proven roadmap to preventing panic attacks. Developed using my years of practice as a Cognitive Behavioural Therapist (CBT).
What’s Inside:
70 page PDF: A complete guide written by a BABCP qualified CBT therapist.
4 Transformative Strategies: Learn how to manage panic, reduce avoidance, improve sleep, and prevent relapse.
Step-by-Step Worksheets: Practical exercises to help you track progress and apply techniques in real life.
Goal and Recovery Focused: Set meaningful goals and measure your recovery with clarity.
Relapse Prevention Toolkit: Stay on track long-term with personalized strategies for lasting change.
Why It Works:
This guide doesn’t just explain panic, it helps you rewire your response to it. By understanding the biology behind anxiety and applying CBT therapy principles, you will learn to break the vicious cycle of fear and avoidance causing your panic attacks to occur in the first place. Whether you struggle with Panic Disorder, Agoraphobia, or anxiety-triggered insomnia, this book is a must have.
Paperback available on amazon:
How Safety Behaviours Maintain the Panic Attack Cycle
The main way safety behaviours keep panic attacks going is that they feed your catastrophic misinterpretation of these symptoms. This is because they block you learning. When using them it becomes difficult to disprove these misinterpretations. So each time you have the same physical feeling, your brain automatically makes the same interpretation and you end up using a safety behaviour again.
Lets add this to our panic cycle using a double sided blue arrow between out catastrophic interpretation and avoidance and safety behaviours. Our thoughts validate the need for these safety behaviours, and our safety behaviours validate the misinterpretation of these symptoms. So despite your fears rarely (or never) actually occurring, you remain afraid.
Safety behaviours can also directly cause a panic attack or create and escalate anxiety symptoms. For example, if you have a tight chest and have the interpretation that you can not breathe you might try to take more rapid breathes to get more oxygen in. This faster breathing often leads to an increase in the tightness in your pain and can cause pain, numbness and tingling. This causes your original symptoms to worsen an produces even more symptoms to misinterpret or validate your original anxious thought.
Regular use of a safety behaviour can start to become a crutch that you feel compelled to use. However, there are times we want to use a safety behaviour but can’t for some reason, this raises your anxiety further and causes more symptoms. In some cases our safety behaviours can heighten the threat in a situation. For example, if you call for an ambulance as a safety behaviour, then people around you might panic or buy into your misinterpretation, which convinces you more in it.
This can be seen on the diagram with the blue arrow on the right. Our behaviours can directly influence how we feel, and not always for the best. However, in some cases, these actions work and reduce our physical sensations. Which sounds like a good thing but in reality it often validates your interpretation or provides short term relief but heightens your fear of future panic attacks as you feel you got a ‘lucky escape’. So even though your fear never came true, the reduction in your action due to these behaviours convince you that these behaviours must have worked - The barking at the postman effect.
Examples of Safety Behaviours During Panic Attacks
Safety behaviours are any action you take to prevent your fear from happening or to monitor, prevent or avoid panic attacks. These actions are usually very unique to you and your personal experience but examples can include:
Preventing our misinterpretation: People often take actions to prevent their interpretation from occurring or acting as if it is true. For example, opening windows to prevent suffocation, calling for an ambulance for a heart attack, taking anti-sickness tablets for nausea, trying to breathe through the anxiety, or listening to calming music or podcasts to reduce anxiety.
Avoidance: We avoid situations we think are going to be unpleasant. But as we do so, we never learn that we can cope with them.
Control: Attempting to control a situation is another common safety behaviour. We can attempt to be close to exits, only go places we know, research a place before going, taking medication or substances to exert control over the outcome of the situation or our level of anxiety. This again backfires as you never learn we can cope in situations outside of our control and makes those situations outside of your control feel scarier (which may actually trigger the onset of a Panic Attack).
Distraction: Distraction can be a powerful safety behaviour. Distraction can be when we overly focus on an object, thought process (such as wishful thinking) or another task (such as listening to music). However, if we think this through logically, the fact that distraction works to reduce anxiety proves that nothing in the situation is dangerous. For example, distraction wouldn't stop a bad thing such as a heart attack from occurring. This safety behaviour stops us from learning this.
Reassurance: We can start to rely on others for safety. For example, only going to locations with certain people. Or asking others if everything is going to be okay, or if they think a panic attack will occur.
Objects: We can carry objects in an attempt to stop or reduce panic attacks. These objects can be anything, from lucky charms to carrying medication "just in case", or even carrying around a bottle of water.
Breathing techniques: Most people try to change their breathing to calm down. Usually these backfire by either causing your symptoms to worsen or teach you that you must do so to prevent or cope through a panic attack.
This isn’t a full list and almost anything can become a safety behaviour if used to try and prevent your anxious interpretation in the moment of panic. Have a look at your panic diary and reflect on the actions you take to cope with your panic attack. these actions most likely feel helpful and necessary but they might be the very things making the problem worse.
How to stop using safety behaviours when you have a panic attack?
To stop panic attacks, we need to learn one very important thing:
That our catastrophic misinterpretation of these symptoms is incorrect.
Going back to the ‘barking at the postman’ idea, it is incredibly hard to learn this lesson when we are using our safety behaviours. They block us from learning we are safe. So, to get better we have to stop barking at the postman (stop using safety behaviours). Only then can we change our point of view.
The strongest and easiest way to achieve this is by using something called a ‘behavioural experiment’.
What Are Behavioural Experiments for Panic Attacks?
A behavioural experiment is just a way to test out if our thoughts are correct by changing how we act. Let’s use a silly example to show how this works. Imagine I was holding a battery in front of me and had a thought that ‘if I drop this battery, it will just float in mid-air’.
How could I test how true this thought is?
Drop the battery and see what happens. If the battery floats, I know my thought was true, but if it falls, I know that my thought was incorrect. That is a behavioural experiment. The reason they work so well is that they provide physical proof of how true our thoughts are. The battery either falls or doesn’t. Either way we learn something about the thought we are testing.
Another example of this goes back to the barking at the postman idea. If the dog purposely decides to not bark at the postman the next time he see’s him and nothing happens. He can learn if his thought about the postman trying to break in is true or false. During panic attacks, we need to prove if our behaviours are needed or not. If it is true that our thoughts are just a misinterpretation of these symptoms, then we are safe regardless of these behaviours. We just need to prove it.
If you have the courage to try using behavioural experiments, you will start to overcome your panic attacks.
How to create a CBT Behavioural Experiment for overcoming panic attacks
Behavioural experiments are quite simple to create, but they do require a little creativity. Before you can design an experiment, you first need to identify the safety behaviours you use when you feel anxious or panicky.
You have already started doing this through your Panic Diary. Look back over the behaviours you wrote for your “coping behaviours.” Many of these may actually be safety behaviours. You do these things you do to prevent a panic attack, keep yourself safe during one, or make the anxiety stop as quickly as possible. But they are only causing you to get more panic attacks in the long term.
If you struggled to find your behaviours. try to complete the following sentences:
To prevent a panic attack, I…
To prevent a panic attack, I avoid…
To try to make a panic attack stop, I…
When I am having a panic attack and believe X might happen, I…
Safety behaviours are not always obvious. They can include things you do, things you avoid, things you check, what you focus on, ways you distract yourself, ways you control your breathing, or ways you try to control or escape uncomfortable sensations.
Make a list of these behaviours now.
Creating a Behavioural Experiment
Now you have a list of your safety behaviours, the next step is to test them. Rather than assuming these behaviours are keeping you safe, we want to find out whether they are actually needed.
Next to each of your safety behaviours, write down what you think will happen if you don’t use that behaviour and why.
For example, ‘When I feel nausea, I take anti-nausea medication because if I didn’t then it would get worse and I will be sick” or “I need to sit down and control my breathing, otherwise I might have a heart attack.”.
This is important because we then have two statements to test.
1) What you fear this sensation means (your misinterpretation)
2) What you think will happen without your safety behaviour.
So, your experiment is testing both whether the feared outcome will happen and whether your safety behaviour is actually needed to prevent it.
Download the chart below or make your own on a piece of paper.
For each symptom writing down your:
1) Catastrophic thought or prediction (what you think the symptom means).
2) Write down your safety behaviour and why you think it is needed.
Once you have done this, we need to design some experiments to put these predictions to the test.
You will need to be creative here.
Your experiments might involve:
Facing something you normally avoid + whilst not using your safety behaviour.
Reducing or dropping that safety behaviour in general.
Doing both at the same time.
Waiting until you next panic and dropping your safety behaviour in the moment.
Experiments often work best when you face a situation where you might normally panic without relying on your usual safety behaviours.
For example, you might go somewhere you normally avoid because you fear having a panic attack and, while there, resist your usual attempts to control, prevent or escape the panic.
The aim is not to make yourself panic. The aim is to create an opportunity to discover what happens when you stop trying to protect yourself from your anxiety.
On your chart:
Design a way to put your safety behaviours to the test. If you can’t think of a way, ask a friend or use AI help you create your experiment.
Now to the courageous thing. Do your experiments.
Now comes the challenging part: giving it a go.
Try to follow the experiment you planned, even if anxiety or panic occurs. Remember that the point of this is to gather evidence. You cannot find out whether your prediction is true if you continue doing the things you believe are preventing it from happening. Remember the dog barking at the postman. It is highly unlikely your fears are to come true. But you need to see it for yourself to really start to believe it.
After each experiment, reflect on what you learnt from being courageous. Look back at what actually happened and compare it with what you predicted would happen.
We are interested in two important questions:
Was your original catastrophic prediction about your sensation correct?
Did this symptom mean what you thought it did despite not trying to prevent it?What happened without your safety behaviour?
If your feared outcome did not happen even though you reduced or stopped the behaviour, what does this tell you about whether that behaviour was actually keeping you safe?
For example, if you believed “I will be sick unless I chew gum,” but allowed your nausea to be there without chewing gum and you were not sick, you can learn something important about your original thought.
Perhaps the nausea was a symptom of anxiety and panic rather than a sign of being sick, and perhaps chewing gum was never preventing sickness in the first place.
Each experiment gives you an opportunity to test your old explanation against the evidence and gradually develop a more helpful understanding of what is happening during panic. The aim is to shift you away from your old view of seeing these symptoms as dangerous, and helping you realise that they are all just symptoms of the fight or flight response.
Going back to the bottom of the panic cycle. The thing driving the cycle on is the interpretation of anxiety symptoms as scary or dangerous. Once you truly realise your misinterpretation is incorrect and that these symptoms are just normal anxiety and not a threat, your anxiety stops escalating to panic. This is not to stop you ever feeling anxious, but to stop you being afraid of feeling anxious.
Keep repeating experiments until you have learnt:
1) Your symptoms are unpleasant but not dangerous.
2) Your safety behaviours are not needed.
The only way to learn this is to start going to the places you fear and putting these behaviours to the test.
What if I panic during the experiment?
You might have a panic attack during your experiment. That does not mean the experiment has gone wrong.
The experiment is not testing whether you can prevent yourself from feeling anxious or having a panic attack. If your goal becomes “I need to do this without panicking,” you can easily end up trying to control the panic again and use your safety behaviours more.
Instead, the experiment is about testing out what you believe the panic means and whether you need your safety behaviours to protect you from what you fear will happen.
For example, imagine your prediction is:
“My nausea means I am going to be sick”
During the experiment, you notice feeling nauseous and you have a panic attack. This might feel like things are going wrong, but this is actually an opportunity to test your prediction. Allow the nausea and don’t do anything to prevent being sick. That way you can learn if nausea when anxious leads to being sick or not.
In fact, having a panic attack can sometimes make an experiment more useful. You get to experience the sensations you fear, drop the behaviours you believed were keeping you safe, and discover what happens.
The success of an experiment is not measured by how calm you felt. It is measured by what you learned.
When you truly learn these symptoms are just anxiety symptoms and not your worst fear coming true, then your panic attacks start to reduce or completely stop in the long term.
Want a complete CBT guide to panic disorder and agoraphobia?
My 70-page CBT guide takes you through the same principles used in therapy, including understanding panic, identifying catastrophic thoughts, reducing safety behaviours and gradually facing your fears. Also including tips on better sleep and relapse prevention.
Are panic attacks disrupting your life? This powerful, yet easy to follow eBook offers a proven roadmap to preventing panic attacks. Developed using my years of practice as a Cognitive Behavioural Therapist (CBT).
What’s Inside:
70 page PDF: A complete guide written by a BABCP qualified CBT therapist.
4 Transformative Strategies: Learn how to manage panic, reduce avoidance, improve sleep, and prevent relapse.
Step-by-Step Worksheets: Practical exercises to help you track progress and apply techniques in real life.
Goal and Recovery Focused: Set meaningful goals and measure your recovery with clarity.
Relapse Prevention Toolkit: Stay on track long-term with personalized strategies for lasting change.
Why It Works:
This guide doesn’t just explain panic, it helps you rewire your response to it. By understanding the biology behind anxiety and applying CBT therapy principles, you will learn to break the vicious cycle of fear and avoidance causing your panic attacks to occur in the first place. Whether you struggle with Panic Disorder, Agoraphobia, or anxiety-triggered insomnia, this book is a must have.
Paperback available on amazon:
Your free CBT Panic Recovery Programme
A step by step guide to understanding panic attacks, breaking the cycle and reducing avoidance.
