This week we focus on practice, practice, practice with TIPP skills–and learn a little about the mechanics of a panic attack.


Legend has it that TIPP skills were originally included in DBT because when clients call their therapist for coaching and they are in a panic attack, or well….ugly crying…its really hard to communicate. The first three TIP skills can all be used without alot of practice to immediately interrupt the overwhelming emotion and make it so that the client can actually be understood. (No judgement, we have all ugly cried at some point.)

There are four TIPP Skills: Tipping your body tempurature, Intense Exercise, Paced Breathing, and Paired Muscle Relaxation. All of the skills work with your nervous system to TIP you from your Sympathetic nervous system setting (the fight or flight response) into your Parasympathetic nervous system setting (Relaxation response.)

Most of us are familiar with the Fight/flight response and the relaxation response. In Fight flight, our bodies prepare to flee from danger or fight off attackers. In the relaxation response, we are chill–relaxed in mind and body.

There is a third setting to the nervous system though–this is the dissociative setting. When we sense danger, our fight flight response kicks in–because we need to get away! Or defend ourselves. But when the danger is so bad that its hopeless, like the zebra when the lion has tackled it. When there is no place to run or way to fight back, we dissociate, its a kind of leaving. Children often learn to dissociate because of the powerlessness of their situation when the adults around them are acting in scary ways. TIPP skills can be helpful for both the fight flight response and for a dissociative response.


Use cold water or cold packs on the face while holding your breath to trigger the Human Dive Reflex. (To learn more about this please visit my blog post at: https://dbtforlife.com/2020/12/14/explore-dbt-ice-and-anxiety-using-cold-water/

This video provides an excellent introduction to the TIPP skills and using cold water

It is so important to PRACTICE! Practicing will help you remember this when you need it.

Prep a ziplock bag with ice and water, or cold packs, or a bowl of ice water, then lean over and either place your face in the water, or the packs over your eyes, bridge of your nose, forehead and upper cheeks to make your body feel like you are diving into water. Then hold your breath. The video suggests 30 seconds because it can take up to 20 seconds for the effect to work. But I think this exercise is less stressful if you allow yourself to hold your breath as long as is comfortable and then repeat. Repeat at least three times.


I found this wonderful article on the http://www.deploymentpsych.org website. It is so informative that I literally read it aloud in group and we went over the chart of all the things that happen in your body and why they happen. Its so informative! Please do take a moment to read and digest. My hope is that when you start to feel a panic attack, you can be mindful of what the function of each aspect is. So you will feel less crazy… And without further ado–here is that deploymentpsych.org handout: https://deploymentpsych.org/system/files/member_resource/Handout_Panic_attacks_hyperventilation_1.3_0.pdf

What are Panic Attacks? Understanding the body’s “Fight or Flight” response to a threat.

We all have a built-in alarm system that turns on automatically to make sure we survive whatever danger triggers it. This alarm is a lot like a burglar alarm on a house; once it detects something that might be a threat, it automatically sets off several events. If someone were breaking into your house, you would want the alarm system to call the police immediately. You would also likely want to turn on lights and even sound an audible alarm to wake you and scare off the intruder. The brain’s alarm system sets off a series of events as well, commonly called the “fight or flight” response.

The fight or flight response is meant to put us in a state of high alert so that we can fight off an enemy or flee to escape with our lives. This alarm makes us faster and stronger and more focused than we would normally be. Our ancestors may not have survived if the human body was not hardwired with the fight or flight response. The reaction is automatic. It helps us survive, and we do not have to think about it; it just happens. But because it is automatic, we do not get to choose which things will set it off.

Sometimes, the fight or flight response can start firing if it thinks there is danger, even when there isn’t any real threat around. This is especially common in people who have been through a traumatic event. It’s important to know that if this happens, your body isn’t out of control, and you’re not going crazy. Your body is just reacting to a perceived threat. Your brain is getting your body ready to protect itself, even if there isn’t any actual danger. This can result in a panic attack.

When we are startled or perceive something that could be potentially threatening (even if it is not), chemicals are released into the blood stream to give us a “jump start” and prepare us for quick action. For example, if you are in the woods and see a large bear running towards you, the alarm would kick in. Chemicals released in your body would direct your heart to beat faster in order to get more blood to your muscles, the muscles controlling your lungs to breathe faster to increase your oxygen, and your skin to increase sweating. When this process starts, your entire body is affected. The table above outlines some of the physical changes that your body goes through when this reaction is triggered. Each of these changes has some function that helps you survive in dangerous situations.

All of these physical responses are intended to keep us alive in the face of a threat and are supposed to be happening if your mind is registering a threat. Because these responses are important to our survival, they occur quickly and without thought.

If you have a panic attack, and you are not in a situation where you are running for your life, having these reactions can make you feel like you are losing control of your mind and body. This reaction is sometimes made even worse if you begin to hyperventilate.


When an individual experiences extreme anxiety, they very often breathe more rapidly as a result of the fight or flight reaction. This allows them to have plenty of oxygen in their bloodstream to take quick physical action (fight or escape). When a panic attack happens, however, we are not always in a position to escape or fight. This is especially true if you are standing still. For example, if you are at work or sitting in traffic when you experience a panic attack, you may breathe more rapidly but not use or “burn off” the extra oxygen that you are taking in. Ironically, this rapid breathing can lead to people feeling like they are not getting enough air. This feeling is called hyperventilation

When we hyperventilate, our brains are being fooled by a curious physiological effect: the brain tells us we do not have enough oxygen, even though we have plenty. Our bodies naturally maintain a balance between the amount of oxygen and carbon dioxide (CO2) in the bloodstream. But when a person hyperventilates, they quickly exhale (breath out) a lot of carbon dioxide, shifting the balance.

I think this chart is fantastic! With any luck, when you start sweating you can laugh to yourself about the helpfulness of being “slippery”.
This little video isn’t very exciting, but any of the postures he teaches can easily be done for intense exercise in a bathroom stall–so no one has to know you are doing it!!!

INTENSE EXERCISE (to calm your body when it is revved up by emotion)

Both Intense Exercise and Paced breathing are meant to reduce your oxygen levels in your blood. Your blood needs lots of oxygen for aerobic activity–all that fighting and running. But when you just sit still and are panic breathing (or ugly crying) you tend to take in too much oxygen. Sitting still and breathing like that will make you feel kinda crazy.

Intense exercise discharges that oxygen. If you can, take a run, or swim or just go for a brisk walk. Jumping jacks will do in a pitch.

PACED BREATHING (to pace your breath by slowing it down)

My preference for paced breathing involves a soft belly, breathing into that belly, breathing in through the nose to the count of 2 and out through the mouth to the count of 4 (like you are blowing out a candle.)

This is the paced breathing exercise we used last week as well.

PAIRED MUSCLE RELAXATION (to calm down by pairing muscle relaxation with breathing out)

This one definitely takes practice. Its a wonderful thing to practice when you are going to bed. As a way of preparing for sleep. The idea is that you are pairing the relaxing of your muscles with a cue word, so that over time, when you think the cue word, your body will relax. The suggestion is to use the word “Relax” but one group member who has been using this practice suggested saying “I am safe” instead. She finds the word “Relax” off-putting so we experimented with this substitution and it seemed quite positive and effective.

This is the version of Paired Muscle Relaxation that we used in Group. I substituted “I am safe” as the cue word, instead of “Relax”.


Practice your TIPP skills. I am including several videos of different lengths of Guided Paired muscle relaxation for you to try out.

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Diana is a licensed professional counselor based in Nashville. She has been teaching DBT skills for the last ten years after writing her master's thesis about making DBT skills training interesting and engaging. She loves using story telling to help illustrate how skills can be used.

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