Panic attacks can bring a wave of terrifying thoughts and sensations. Among them, derealization preoccupations—thoughts like “I think I’m going crazy” or “What if I lose control and do something reckless?”—are particularly distressing. In this article, we’ll explore how to effectively address these fears using exposure therapy, reality testing, and eliminating safety behaviors to help you regain confidence and control.

Understanding Derealization Preoccupations

Derealization preoccupations refer to catastrophic thoughts that occur during states of panic, such as:

• “I think I’m going crazy.”

• “I’m going to lose control and do something stupid.”

• “What if I get locked up in a psychiatric hospital?”

These fears are a response to the overwhelming physical sensations of panic. The good news is that the process for overcoming them is the same as addressing other panic-related concerns—it just requires a different reality testing approach.

Step 1: Exposure Therapy – The Key to Recovery

To reduce the power of these preoccupations, you must gradually expose yourself to the sensations and thoughts that trigger them. This process helps retrain your brain to recognize that these fears do not signal real danger.

How to Trigger Exposure

One way to create controlled exposure is through hyperventilation—taking rapid, deep breaths to mimic the physical sensations of panic. Try five quick breaths in a row and observe what happens. For many, this will begin to jump-start the panic cycle in a controlled setting, allowing you to work through the fear.

If hyperventilation does not trigger panic for you, we need to identify your specific situational triggers. For example, if your panic attacks occur when crossing the street or being far from home, exposure should involve gradually engaging in these situations while practicing reality testing and eliminating safety behaviors.

Step 2: Identifying Safety Behaviors and Removing Them

Safety behaviors are actions people take to try to prevent panic but which actually reinforce the fear. Common safety behaviors include:

• Sipping water frequently, believing it prevents fainting

• Repeating reassuring phrases like “I’m okay” to calm down

• Distracting yourself with your phone or music

• Avoiding eye contact with people around you to feel less "noticed"

These behaviors prevent your brain from truly learning that panic is not dangerous. The goal is to gradually eliminate safety behaviors while exposing yourself to feared situations. For example, if you always carry a water bottle to prevent fainting, try reducing the amount of water you bring until you no longer rely on it.

Step 3: Reality Testing – Challenging Your Fears

Reality testing involves actively testing your catastrophic thoughts to prove to yourself that they are not true. Here’s how to reality test common panic preoccupations:

Fear: “I’m going crazy.”

• Ask yourself: What exactly do I mean by ‘going crazy’?

• Test it: Try to recall your name, where you are, or a recent memory. If you can answer, you are still grounded in reality.

• Ask yourself: Can I still plan for the future? If you can think about tomorrow’s plans, you’re still mentally present.

Fear: “I will lose control and do something dangerous.”

• Test your control: Move your hands, press your feet on the ground, or grip an object. If you can consciously do these things, you are in control.

• Try doing something structured, like tying your shoelaces or writing a sentence. If you can follow a simple sequence, you are not losing control.

Fear: “What if I get locked up in a psychiatric hospital?”

• Reality check: Am I actually doing anything that would warrant hospitalization? Simply feeling anxiety or panic is not a sign of psychosis or danger.

• Ask someone you trust: If you’re concerned about making sense, check in with a friend or therapist. They can confirm that you are speaking and behaving normally. However, be mindful that this reassurance can become a safety behavior itself, meaning it may need to be gradually phased out later in the exposure process.

Step 4: Gradual Exposure and Confidence Building

Once you’ve identified your triggers, safety behaviors, and catastrophic fears, the next step is to gradually increase your exposure intensity while eliminating crutches.

Breaking Exposure into Manageable Steps

1. Start with the smallest possible trigger (e.g., five hyperventilation breaths).

2. Observe and reality test your reactions.

3. Remove one safety behavior at a time.

4. Ask yourself: Am I ready to take the next step? If yes, increase exposure intensity slightly. If not, repeat the previous step until it feels manageable.

5. Repeat the process until you can handle even the most intense situations without panic.

Remember: Reality testing is an action, not just a mental exercise. It involves actively proving to yourself that your fears will not come true by systematically testing them in real-life situations.

Final Thoughts

Derealization preoccupations and panic-related fears can feel overwhelming, but they can be overcome with the right approach. By gradually exposing yourself to feared sensations, eliminating safety behaviors, and actively testing your fears, you can retrain your brain to stop associating these experiences with real danger.

If you want more structured guidance on overcoming panic, sign up for my FREE Panic Survival Guide Newsletter here: https://www.ajbcounseling.com/free-panic-survival-guide. Or, if you’d like one-on-one support, book a free consultation here: https://www.ajbcounseling.com/panic-home.