Pages 246-257 from the Management of Mental Disorders, published by World Health Organization, Sydney. Editions in Australia, Canada, China, Italy, New Zealand and the United Kingdom.

Management plan for panic disorder

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Management strategies will always vary from one individual to the next depending on the individual's particular problems. Generally, however, the management of panic disorder usually involves:

1. Ongoing assessment of the disorder.
2. Education about the nature of the disorder, tailored to each individual's needs. Some basic information about anxiety is provided in Section 4.1.1 and in the handouts in Section 4.14.2, 4.14.3 and 4.14.4, and this education includes:
   • · The nature of anxiety and the fight or flight response
   • · The nature of panic attacks
   • · The role of hyperventilation in anxiety
   • · Common fears held by people who panic
3. Instructing the individual not to avoid any situations or places, even though he or she may feel uncomfortable at times. Otherwise, avoidance may lead to the development of agoraphobia, and increased disability.
4. Providing training in strategies to control anxiety symptoms, and encouraging the individual to practice these techniques regularly:
   • Breathing control - the slow breathing exercise (Section 4.1.2)
   • · Relaxation training (Section 4.1.3)
5. Individuals are to be encouraged to avoid using sedative medication to control their anxiety. In some cases antidepressant medication can be useful in the control of severe panic attacks (see Chapter 2: Medication).
6. Referral or specialist consultation if panic attacks continue despite the above measures.

4.2.3 Dealing with fears held by people who panic - cognitive therapy
When panic attacks occur without any obvious explanation, people can misinterpret these symptoms as indicating a serious physical or mental problem. Hence, the symptoms themselves become threatening and can trigger the whole anxiety response again. Some common myths and misinterpretations that some people have about panic are discussed on the following page. It is what people think about an event that causes the anxiety not the event itself. People with panic disorder become sensitized to the possibility that symptoms of the flight or fight response will occur and that those symptoms may lead to losing control, going mad, having a heart attack, collapse or death. It is the panic outcome fears that are the principal concern. What if they happen is the question. Three of the commonest fears are discussed below but the role of the clinician is to encourage the person to recognize the symptoms as part of the flight or fight response or of hyperventilation and not presume that they are indicators of a serious outcome. There are two ways of doing this. One, derived from the cognitive therapy position is to keep disputing the certainty of the panic outcome:

"What evidence do you have that people with panic go mad?"

"`Well none really, but it feels as if I could"

"You have told me about the last twenty panic attacks, and that you have feared going mad, but here you are, sensible and rational. Now, does that add up?"

The second is derived from the literature on graded exposure and means that people learn by confronting their fears. People with panic should deliberately enter feared situations that evoke the symptoms, with the precise aim of exploring whether the panic outcome fears eventuate. Once they discover that they do not eventuate their panic outcome fears attenuate. Thus with cognitive therapy and with exposure to situations that evoke the symptoms they can gradually learn that the exaggerated symptoms of the flight or fight response do not have to be feared or avoided.

Fear of going `mad'
Many people fear that when they experience the physical sensations of anxiety or panic they are going mad. If individuals hold these fears it will be important to differentiate between anxiety symptoms and other mental disorders such as schizophrenia. By providing information about the symptoms and causes of other mental disorders, individuals can be reassured that they do not suffer from these other disorders. Furthermore, it can be reassuring for individuals to be told that the symptoms they are experiencing are not unique and are in fact shared by many other people.

Fear of losing control
Some people believe that they will `lose control' when they become very anxious. Presumably they mean that they will become totally paralysed and be unable to move, will collapse, or will not know what they are doing thus may run around wildly, hurting people or yelling out obscenities and embarrassing themselves. It is important to explain where this feeling may come from. Quite simply, during the anxiety response the entire body is ready for action and there is often an overwhelming desire to get away from any potential danger. It may be comforting to explain to the individual that there has never been a documented case of anybody doing anything `wild', `out of control', or against their wishes while experiencing a panic attack. It may also be helpful for the individual to ask himself or herself, "Have I done something wild or out of control at other times when I have had a panic attack?" Chances are that the individual behaved appropriately under the circumstances and will behave the same way if another panic attack occurs.

Fear of having a heart attack
Some of the symptoms of a panic attack are also experienced during a heart attack (e.g., chest pain). It is therefore understandable that a person who is having a panic attack may think he or she is having a heart attack. If chest pain is recurrent or long-lasting it is wise to have a thorough medical investigation to rule out the presence of heart disease. If heart disease is not present then it is unlikely that subsequent chest pain is caused by a heart attack. The information below may be helpful for distinguishing between symptoms of panic and symptoms of a heart attack.

Ischaemic heart disease is very rare in young women, the group most likely to experience panic disorder. Heart disease does NOT cause panic attacks and panic attacks do NOT cause heart disease.

Generally, if an individual who is prone to panic attacks experiences another similar attack, it is probably best for him or her to sit quietly and use the slow breathing exercise for about five to ten minutes. It may also be helpful for the individual to ask himself or herself, "Did I die or have a heart attack last time I experienced these symptoms?"

However, if pain is still present after ten minutes of slow breathing, the individual is advised to seek medical advice.

4.3 Agoraphobia

4.3.1 Description and diagnosis

Description
The main feature of agoraphobia is anxiety about being in a situation or place from which escape may be difficult, or in which help may not be easily available should a panic attack or panic-like symptoms occur. It is therefore usually a complication of panic disorder. This anxiety usually leads to avoidance of a variety of feared situations. Situations which are commonly avoided by individuals with agoraphobia include: being alone away from home; being home alone; crowded areas; travelling in buses, trains, cars, or planes; and being in an elevator or on a bridge.

Some individuals are able to face these situations but usually do so with reluctance and dread. Or sometimes the individual feels more comfortable about being in these situations if accompanied by someone else (even a child).

Agoraphobia usually develops after the individual has experienced a panic attack or panic-like symptoms. However, once this disorder has developed, panic symptoms may or may not continue to occur. For example, if the individual avoids feared situations, anxiety will be lower and panic symptoms may occur less frequently or not at all. However, the agoraphobic avoidance often persists despite the absence of panic attacks or panic-like symptoms because the fearful anticipation of panic usually remains.

Diagnosis
According to the World Health Organization's (WHO) International Classification of Diseases (ICD)-10th Edition, agoraphobia is diagnosed when:

• The anxiety occurs mainly (or only) in at least two of the following situations: crowds; public places; travelling away from home; and travelling alone.
• Avoidance of the feared situation is prominent.

ICD-10 and DSM-IV differ in the way they classify agoraphobia. ICD-10 uses the classifications of `agoraphobia with panic disorder' and `agoraphobia without panic disorder'. ICD-10 also allows for the classification of `panic disorder' alone (as per Section 4.2.1). By contrast, DSM-IV has the reverse classifications of `panic disorder with agoraphobia' and `panic disorder without agoraphobia'. DSM-IV also has the additional classification of `agoraphobia without panic disorder', which is reserved for cases in which the individual fears the occurrence of panic-like symptoms or limited symptom panic attacks (e.g., fear of becoming dizzy, or developing diarrhoea) and the criteria for panic disorder (with or without agoraphobia) have never been met. Clinicians are referred to ICD-10 or DSM-IV for further information about the classification and diagnostic criteria of agoraphobia.

Differential diagnosis
In severe cases of social phobia, individuals may also avoid leaving home or entering public places due to the fear of being scrutinised by others. In agoraphobia the individual fears having a panic attack.

Avoidance is not a result of delusions or obsessional thoughts. For example, individuals with a delusional disorder may avoid public places because they hold the delusional belief that people in the street are trying to harm them, or individuals with obsessive compulsive disorder may avoid public transport because they have the obsessional fear that contamination may occur.

Epidemiology
Agoraphobia with or without panic disorder affects close to 2% of the population in any year. It is more common in females than in males and its onset peaks during the mid to late 20s.

Course and prognosis
If untreated, agoraphobia can be a chronic disabling disorder. Avoidance can cause significant interference in an individual's work and social functioning. The majority of individuals with agoraphobia can be successfully treated with cognitive-behavioural programmes, some are relieved by medication (see Chapter 2: Medication).

Assessment
The methods of assessment for panic disorder will also be useful and the Fear Questionnaire, which has been designed specifically for phobic individuals, will also be useful (see below and Section 4.14.8). The Fear Questionnaire, developed by Marks & Mathews in 1979, is designed to monitor change in phobic individuals. This pencil and paper questionnaire is initially administered prior to commencing treatment so as to obtain a baseline against which improvement can be measured. In addition, this questionnaire will allow for the identification of the stimuli that cause avoidance, as well as problems caused by the avoidance, thus guiding the management plan.

At the completion of the treatment programme, the individual fills out this questionnaire once again. A lower post-treatment score on any of the categories indicates improvement. If the individual's score is the same or higher following treatment and he or she is still distressed by the phobic symptoms, it would be wise to refer the individual to someone who has expertise in treating phobias. A copy of the Fear Questionnaire and scoring instructions are provided in Section 4.14.8.

4.3.2 Management plan for agoraphobia
Management strategies will always vary from one individual to the next depending on the individual's particular problems. Generally, however, the management of agoraphobia usually involves:

1. Ongoing assessment of the disorder
2. Education about anxiety (see Section 4.14.2)
   • The nature of anxiety
   • Management of the fight-or-flight response
   • The role of hyperventilation in anxiety
   • Common fears held by people who panic
   Handouts on panic attacks and hyperventilation if present (Section 4.14.3 & 4.14.4) Education about phobic avoidance (see following page)
3. Providing training in strategies to control anxiety symptoms, and encouraging the individual to practise these techniques regularly.
   • Breathing control - the slow breathing exercise (Section 4.1.2)
   • Relaxation training (Section 4.1.3)
4. Graded exposure to feared situations (Section 4.3.4).
5. Individuals are to be encouraged to avoid using sedative medication to control anxiety. In some cases antidepressant medication can be useful in the control of severe panic attacks. (See Chapter 2: Medication for a discussion of drug treatments).
6. Referral or specialist consultation if panic symptoms or avoidance persist despite the above measures.

4.3.3 Education about phobic avoidance
It is important that individuals who have a phobic disorder are provided with information about how phobias can develop and how they may be overcome.

Why do phobias develop?
When anxiety occurs for the first time in a certain situation, most people believe that, should they find themselves in that same situation again, they would be more than likely to become anxious. Anxiety is unpleasant and individuals with anxiety disorders soon learn to anticipate anxiety-provoking situations before these situations occur. By anticipating these situations it is also possible for individuals to learn to avoid these situations in order to avoid the anticipated anxiety. Sometimes, however, it is not always possible to anticipate anxiety-provoking situations. Therefore, if individuals find themselves in such situations, they may leave the situation quickly or distract themselves.

Both behaviours (i.e., leaving and avoiding) can make the fear worse. By leaving a situation when they have experienced anxiety, or by avoiding a situation in which anxiety is anticipated, the individual experiences a feeling of relief and a drop in anxiety. These positive feelings are gratifying, hence, the avoidance behaviour is strengthened or reinforced.

If anxiety can be prevented or reduced by avoiding or leaving fearful situations, why are individuals discouraged from doing so? One reason is because once avoidance behaviour begins, it becomes harder and harder to face the feared situation. The avoidance can then become disabling (e.g., in the case of agoraphobia, some individuals may not be able to leave the house). Additionally, it is not always possible to avoid feared situations and the distress can be severe when an individual is forced to face feared situations. A second reason is because once an individual begins to avoid feared situations, he or she often begins to tolerate lower and lower amounts of anxiety. Hence, he or she begins to avoid more situations as these new situations are also labelled as being anxiety-provoking.

It should be emphasised that in most cases the feared situations are not actually the cause of the original anxiety. The anxiety is mistakenly attributed to the situations which are thereafter avoided in an attempt to avoid a recurrence of the anxiety.

How can people overcome their phobias?
If avoiding specific situations or objects eventually makes these things harder and harder to face, what would happen if individuals confronted their fears? If the fear is reinforced by leaving the situation, what would happen if the individual stayed put? Actually, if feared situations were confronted for long enough, the fear would eventually pass and the fear experienced in that situation would be less the next time around.

Sometimes individuals with phobic disorders will have developed very strong fears of specific situations. For example, agoraphobics fear being away from home alone, social phobics fear performing tasks in front of others, and people with more specific phobias may fear heights, spiders, confined spaces, and so on.

Individuals with anxiety who have developed phobic avoidance as part of their disorder should be encouraged to gradually confront the things that they fear. One good way to break the avoidance is to start with confronting easy situations and slowly build up enough confidence to face the harder things. This technique is called graded exposure. In doing this it is critical that they remain in the feared situation until there is a decrease in anxiety. The other important strategy for overcoming fears is to control the level of anxiety by using breathing and relaxation exercises. Regular frequent exposure will convince sufferers that they can limit their initial anxiety and confidently expect the anxiety to decrease over time.

In difficult or persistent cases, referral to a specialist who has training in the behavioural principles of graded exposure (e.g., a clinical psychologist) is recommended.

4.3.4 Graded exposure
If the phobic avoidance is mild the following principles may be applied:

Principles Of Graded Exposure

1. Provide training for the slow breathing exercise (Section 4.1.2) and relaxation (Section 4.1.3). These exercises can be used prior to commencing each step of the graded exposure hierarchy to ensure that the individual is calm and relatively relaxed at the beginning of each graded exposure session. Slow breathing can be practised while in the feared situation, and targeted muscle relaxation can also be used if the individual notices tension in particular muscles (e.g., stomach muscles).
2. Help the individual Identify any exaggerated fears that occur in the avoided situations (e.g., "I will faint with fear") and decide what is more likely to happen (e.g., "I am anxious but I am unlikely to faint").
3. Remind the individual that just as anxiety initially rises when confronting at situation, it also falls within a few minutes. Only by remaining in the situation will they learn there is nothing to fear.
4. Plan a series of steps to build confidence in feared situations:
   • Identify a first small step towards overcoming the feared situation
   • Practise this step until it no longer causes anxiety
   • Move on to a more difficult step and repeat the practice
   • Continue this process until the person can manage the feared situation
5. Do not use alcohol or drugs to cope with feared situations.
6. If fears continue after the above methods have been tried, seek consultation from someone who has specialised training in the behavioural principles of graded exposure.

Problems encountered
Consider the following questions if problems are encountered during graded exposure therapy.

Is the individual trying to progress too quickly or too slowly?
Tasks that are too easy are not rewarding and tasks that are too difficult are scary and possibly demoralising. The secret to success is regular and gradual progress.

Do new steps need to be practised more frequently and for longer periods of time before moving on to more difficult steps?
It is important that the individual masters the present step before moving on to a more difficult step. Some steps are more difficult than others hence the individual may need to progress more slowly at times. Moving on without sufficient practice can lead to loss of confidence and motivation if the individual experiences a setback at the next step.

Is the increase in difficulty between steps too great?
If so, intermediate steps may need to be added so that the increase in difficulty is more manageable.

Is the individual continuing to identify exaggerated fears and replace these fears with more realistic thoughts about more likely outcomes?
Encourage individuals to ask themselves questions such as:

"What evidence is there that [a particular event or response] is going to happen?"

"Realistically, what is the worst thing that can happen? What if .... does happen? Will it really be so bad? What is more likely to happen?"

Remember that setbacks DO occur
If a setback occurs it may be helpful for the individual to return to a previous step at which he or she feels more comfortable. It will also be helpful to encourage the individual to view the setback in a positive light:

e.g., "I'm disappointed that I didn't do very well on this step but I have made a lot of progress so far. Setbacks are inevitable and I can learn from them. There's no hurry so I'll just take my time and start again. I'll get there bit by bit."

4.3.5 Agoraphobia case study

Mrs Georgina Williamson (not her real name), a 33 year old female, presented to a community mental health centre having read a magazine article describing hypochondriasis. For the past ten years she has received many medical investigations because of her belief that her palpitations may be associated with a heart attack. Her psychiatric history reveals the following information:

Psychiatric history

Presenting problem
At least three times a month Mrs Williamson notices palpitations and becomes frightened that these palpitations signal a heart attack. She seeks reassuring medical advice. She is unable to leave home alone without her mobile phone and cannot go to busy places such as shopping centres or cinemas for fear of panic.

History of present illness
Ten years ago, while attending a post-natal exercise class following the birth of her only child, she noticed a dramatic increase in her heart rate. Afraid she was going to die of a heart attack, she noted a series of other symptoms. Her breathing became difficult, there was tingling in her hands, her muscles (most noticeably in her left side) became stiff, she was sweating, trembling, and she reported intense stabbing pains in the chest. She left her baby at the class and ran for help. An ECG was administered but no abnormality was detected. From this time on, a pattern began of experiencing palpitations and seeking medical advice.

Since the first "heart attack" Mrs Williamson has had great difficulty going places on her own where medical help could not be quickly obtained. She can travel alone, provided she takes her new mobile telephone with her, for she perceives that this telephone will enable her to contact emergency services. Even so she avoids crowded shopping centres and cinemas in case her escape is blocked. Without her telephone she is not prepared to leave home alone.

Personal and family history
As an only child, Mrs Williamson describes her parents as being "worriers" but they have had no contact with psychiatric services. Born and raised in a large city she left school to attend secretarial college. After working for six years she fell pregnant, married, and remained at home thereafter. She presently works part-time for her solicitor husband.

Previous psychiatric and medical history
Initially Mrs Williamson was treated with a variety of beta blockers for an "irritable heart". Her local medical practitioner has prescribed diazepam for the past 8 years. The diazepam (present dose is 30 mg per day) appears to make no difference to the frequency of her "heart attacks". She drinks three cups of weak coffee per day and consumes one glass of red wine per day since reading in a magazine that red wine decreases the risk of heart attacks. She has had no other psychiatric or medical illnesses.

Premorbid personality
She describes herself as having always been a "quiet, nervous type" with labile moods. She says her self-confidence "waxes and wanes" but is "usually on the low side". She did not report having any particular ambitions but would like to go on an overseas holiday at some stage. She says her relationship with her husband is a bit strained, partly because of her "heart attacks" and partly because of his lack of spare time.

Mental State Examination
Mrs Williamson was smartly dressed, well groomed, and her speech was soft and polite. Her mood was normal and she did not display thought disorder, abnormal perceptions, or delusional ideas. Her cognitive functioning was normal and her level of insight was good.

Management
You ask Mrs Williamson the questions relating to her panic attack record and ascertain that she does experience frequent (about twice weekly) panic attacks. You also ask her to fill out the Fear Questionnaire (Section 4.14.8). She has a score of 36 on the agoraphobia items, and scores low for the other phobias (10 and 9). Scores for items 18 to 22 total 28. The final question scores an 8.

From the information you have obtained you decide that Mrs Williamson has agoraphobia with panic disorder. The following management plan is devised (the number of sessions will vary for each person):

1. Mrs Williamson will receive education about the key features of anxiety. She will also be given the hyperventilation questionnaire and taught the slow breathing technique. She will take home the handouts in Section 4.14.2, 4.14.3, 4.14.4 and 4.14.5.
2. Each new session will begin with a discussion of any problems or questions that may have arisen since the last visit. Mrs Williamson will be taught about relaxation techniques and provided with a copy of the handout in Section 4.14.7. Using the items Mrs Williamson endorsed on the Fear Questionnaire, the topic of graded exposure can be broached. A graded exposure programme will be devised and will be implemented over the next few weeks. Further sessions are organised over the following three weeks to reinforce progress with hyperventilation control, relaxation, and graded exposure techniques. Any problems or difficulties that are encountered will be sorted out during these sessions.
3. Follow-up will be organised for one-month and six months post treatment, although Mrs Williamson will be encouraged to make extra appointments if required. The Fear Questionnaire will be administered on both follow-up occasions.

Outcome
There were no problems with breathing control or relaxation, however, Mrs Williamson had difficulty embarking on the graded exposure tasks without her mobile phone. It was suggested that she will never learn to control her disorder if she continues to rely on her phone. She was reminded that the aim is to take many small steps so that each situation is manageable.

By organising the tasks in order of increasing difficulty it was possible to commence with a very mildly challenging task. By accomplishing the easier tasks Mrs Williamson gained confidence and was able to move to slightly harder tasks each time. On a few occasions Mrs Williamson experienced panic symptoms which she had difficulty handling. However, she was able to control the level of panic to some extent with hyperventilation control. Once the panic was over she was not as scared as she used to be since, with her greater knowledge of the disorder, she reminded herself that she was not having a heart attack and was not going to die. She was able to continue with the programme until she succeeded with the most difficult task on her list.

At one month follow-up she reported that she was still experiencing anxiety but that the anxiety was just uncomfortable. Her score on the agoraphobia component of the Fear Questionnaire was 15, items 18 to 23 scored 17, and the final item scored a 3. At six months her scores were 8, 6, and 2 respectively. Although she was not totally `free' of the disorder at the end of treatment, she was remarkably improved and had learned to control the disorder and live normally.

.14.4 Hyperventilation
When you become anxious you set off an emergency or alarm reaction which leads to an increase in the speed and depth of breathing. This overbreathing, also called `hyperventilation', that may lead to the following symptoms:

• Light-headedness or faintness
• Dizziness
• Confusion
• Breathlessness, choking or smothering
• A feeling of unreality
• Blurred vision
• An increase in heart rate
• Tingling sensations or numbness in the hands, arms or feet
• Cold, clammy hands
• Stiffness of the muscles
• Irregular heartbeats

The good news is that, using a slow breathing method described in a separate handout, you can reduce the unpleasant symptoms of hyperventilation. Better still, next time you begin to hyperventilate, you can use the slow breathing method to stop the hyperventilation before it becomes too unpleasant.

4.14.5 Slow breathing exercise
When you get anxious your rate of breathing increases. This overbreathing is often referred to as `hyperventilation'. When you overbreathe you breathe out too much carbon dioxide which leads to a decrease in the level of carbon dioxide in the blood. The decreased level of carbon dioxide causes or worsens a number of symptoms such as breathlessness or light-headedness. You may experience these symptoms if you have panic attacks.

To get rid of these symptoms, the level of carbon dioxide in the blood must be steadied. One way of achieving increased levels of carbon dioxide is to breathe into a paper bag. A large proportion of the air you breathe out is carbon dioxide, therefore, by re-breathing your old air you are taking higher amounts of carbon dioxide into your lungs.

Although breathing into a paper bag is simple and effective, it may not always be convenient or socially appropriate to pull out your paper bag in public! Additionally, although breathing into a paper bag is effective during a panic attack, this method cannot prevent hyperventilation in the future. An alternative method which is less obvious to other people and more effective in the long run is the slow breathing exercise. This method will help you to control your hyperventilation. Also, by learning slow and regular breathing habits you will help to prevent future episodes of hyperventilation and other symptoms of panic.

The following exercise is to be practised four times every day for at least five minutes each time, AND at the first signs of panic or anxiety. Combining slow breathing with relaxation is particularly helpful.

Slow Breathing Exercise
(To be practised regularly and at the first signs of anxiety or panic).

1. Hold your breath and count to 5 (do not take a deep breath).
2. When you get to 5, breathe out and say the word relax to yourself in a calm, soothing manner.
3. Breathe in and out slowly through your nose in a six second cycle. Breathe in for three seconds and out for three seconds. This will produce a breathing rate of 10 breaths per minute. Say the word relax to yourself every time you breathe out.
4. At the end of each minute (after 10 breaths) hold your breath again for 5 seconds and then continue breathing using the six second cycle.
5. Continue breathing in this way until all the symptoms of overbreathing have gone.

It is important for you to practise this exercise so that it becomes easy to use any time you feel anxious. It is helpful to time it using the second hand of your watch or nearby clock.

Edited by Gavin Andrews MD, UNSW, 2007
©2007 CRUfAD