Panic Disorder and Agoraphobia
It is normal to feel anxious at times. Panic attacks are when anxiety reaches severe levels, and can often be misinterpreted as an indication that something serious is wrong (e.g. that you are having a heart attack, going mad, losing control etc.). During a panic attack, you may feel shortness of breath, tingling sensations, trembling, feel light-headed, experience choking sensations, chest pains, have an upset stomach, sense impending doom, sweat profusely and be aware of your heart pounding.
Panic disorder is often called the “fear of fear,” because sufferers typically become afraid of the symptoms produced by fear and panic attacks, and interpret these symptoms as indicators that something is imminently wrong with them. There is in fact a healthy side to fear – it is adaptive, in that is has helped us humans to survive. Fear normally occurs when we are in true danger, and it serves as an alarm or a signal to our brains that we are in danger, so that we can protect ourselves against it. The symptoms of fear mentioned previously are designed to energise us for either running away to safety or fighting danger (this is called the “fight-or-flight response”). This is a natural response to actual danger. When you panic, your body thinks you are in danger, even though no real danger is actually present. Over time, you begin to fear the very symptoms of fear that are designed to protect you from true danger, because you don’t understand why you are experiencing these symptoms. You begin to assume that having a panic attack is dangerous—that it means there is something wrong with you. But as you begin to perceive panic attacks as dangerous, you keep triggering more fear or more panic attacks in the future, as a way of coping with what you believe is dangerous. The irony of panic disorder is that you begin to fear the very symptoms that are designed to protect you from danger.
Given that they believe that panic attacks are dangerous, individuals with panic disorder begin to worry about having future attacks. They can even begin to fear and avoid anything that mimics symptoms of panic and brings on similar sensations (heat, exercise, sunlight, pleasure or excitement, sexual arousal, anger, etc.). Individuals with panic disorder begin to focus on these internal sensations: “My heart is pounding—I’m going to have a heart attack,” or “I’m feeling weak and dizzy—I’m going to collapse.” It is even possible to experience panic when you are asleep.
Many patients who have panic disorder also experience “agoraphobia.” Individuals with agoraphobia fear places or situations from which escape might be difficult if they have a panic attack (e.g., “I may have an anxiety attack on the subway and faint in front of everyone”). They may avoid being out alone, being home alone, supermarkets, trains, airplanes, bridges, heights, tunnels, open fields, driving, elevators, and the like. These individuals fear that they will have a panic attack in these situations and, as a result, will avoid or escape them as their way of coping with anxiety. When these situations cannot be avoided, the individuals typically come up with various ways (or safety behaviours) to make themselves feel “safe” (e.g., carrying around a bottle of water). Some may insist on only going out if they have someone accompanying them.
Such avoidance and safety behaviours may well result in a dramatic reduction in panic attacks but this is creates more problems ultimately as the world becomes smaller and smaller as a result of their avoidance. Because of this constriction in their lives, many individuals with panic disorder and agoraphobia become depressed and chronically anxious, and many resort to self-medication using alcohol, prescription or even recreational drugs. In the long run these strategies only serve to strengthen these individuals’ beliefs that they are in danger and in need of protection. Therapy helps to “retrain” the brain to learn that feared situations are not dangerous, that panic attacks are harmless symptoms of fear, and that no safety behaviours are needed.
What Causes Panic Disorder and Agoraphobia?
While 30–40% of the general population will have a panic attack, most of these people will not have a catastrophic interpretation of their panic attack and develop panic disorder. Panic disorder and agoraphobia occur in individuals who appear to be vulnerable to them. Research suggests that they run in families and appear to result from a combination of genetics, temperament, biological factors, and psychological vulnerabilities. The problem may also be learned through early experiences. Early experiences linked to the development of panic disorder include those that teach individuals to perceive the world as a dangerous place, and specifically to perceive internal bodily sensations as harmful. Individuals with panic disorder tend to focus excessively on their physical sensations and to develop catastrophic interpretations of sensations. Initial panic attacks may also be activated in vulnerable individuals by stressful situations—for example, leaving home, relationship conflict, surgery, new responsibilities, or physical illness. Many people who have panic disorder and agoraphobia also experience depression, partly as a consequence of their feeling out of control and feeling unsure about how to handle their problem.
Treating Panic and Agoraphobia
While medication can provide symptom relief in the short term, but once you terminate the medication, your panic symptoms may return. Consequently, we recommend that even if you use medication, you should also include cognitive behavioural therapy (CBT). CBT has been scientifically demonstrated to be extremely effective in the treatment of panic disorder and agoraphobia. This type of therapy helps people correct their beliefs, misconceptions, and judgments about these disorders. Patients are helped to accept that they have an illness that can be treated by using psychotherapeutic strategies, and are helped to understand that it can be treated effectively without long-term therapy exploring childhood experiences.
CBT treatment of panic and agoraphobia
CBT for panic disorder and agoraphobia is organised around several goals:
1. helping you to understand the nature of anxiety, panic, and agoraphobia;
2. determining the range of situations that you avoid or fear;
3. evaluating the nature of your symptoms, their severity and frequency, and
4. the situations that elicit your panic
5. determining whether any other problems coexist with panic—for example, depression, other anxieties, substance abuse, overeating, loneliness, or relationship problems.
Your therapy may include some or all of the following treatment strategies:
- educating you about panic so that you learn not to fear it;
- breathing retraining;
- relaxation training;
- inducing panic (to show your brain that panic attacks are harmless and that you are not in danger);
- gradual exposure to s
ituations that elicit panic;
- identification and modification of your misinterpretations of your panic or arousal (e.g., “My heart is pounding, so I must be having a heart attack”), as well as the assumptions (e.g., “Physical sensations are dangerous”) and beliefs (e.g., “I am fragile and weak”) on which the misinterpretations may be based;
- coping with life stresses;
- assertion training (when needed);
- training in the ability to recognize and reduce your panic symptoms when they occur.
How to get the most from your CBT treatment?
CBT therapy is not a passive experience for patients. You are expected to come to sessions regularly, complete forms and questionnaires which help to explore and evaluate your problems, and do therapy assignments between sessions that you and your therapist plan and assign. Most patients who actively participate in this treatment experience improvement—and some experience rapid improvement. However even if you experience rapid improvement, however, you should complete the full treatment package. Premature dropout from treatment increases the likelihood that you will have relapses.
It is likely that you will need about 12 sessions. The first few sessions are used for evaluation and explanation of the treatment with the remaining sessions used to implement strategies. After acute treatment is over, follow-up sessions may be scheduled bi-weekly, monthly, and so on to maintain gains and prevent relapse. This treatment can be viewed as a way in which you can learn how to help yourself. That is why your commitment to engaging in therapy both within and between session is so important.