Panic Disorder and Agoraphobia
- What are panic attacks?
- What is panic disorder?
- What is agoraphobia?
- Prevalence
- Cognitive Behaviour Therapy
- Medication
See also www.climateclinic.tv for a treatment package we are currently trialling. It contains elements of the cognitive behaviour therapy in an illustrated story line to show you just what to do to recover. And pictures can speak more loudly than words.
What are panic attacks?
Panic attacks are sudden periods of intense anxiety or fear, where four (or more) of the following symptoms develop abruptly and peak within 10 minutes:
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You will notice that the last two symptoms mentioned are different to all the others because they are fears rather than physical sensations. One of the most frightening things about a panic attack is that the person does not know what is happening to them or why. Because there doesn't seem to be any reason for these sudden and intense physical symptoms, most people interpret them to mean that they are about to lose control, have a heart attack, die, or go crazy. In other words, they take the symptoms as a sign that something dangerous and terrible is happening. As you will see in the treatment section, this interpretation is very important because it can inadvertently contribute to the cycle of panic.
What is Panic Disorder?
Panic Disorder occurs when the person has both recurrent panic attacks and either a fear of having another panic attack or a fear of losing control, having a heart attack, or "going crazy". If the person also avoids situations for fear of these attacks they may have Agoraphobia as well as Panic Disorder.
What is Agoraphobia?
Agoraphobia occurs when the person is anxious about being in places or situations where they might have a panic attack. Hence they either:
- avoid these situations, or
- only go places with a companion, or
- endure these situations despite severe anxiety
Most commonly agoraphobia involves a fear of going into places where it might be difficult or embarrassing to escape quickly if they have a panic attack and need to get away, or places where there would be no quick access to medical help. Click here for a list of situations typically avoided in agoraphobia. (link to list)
How common is Panic Disorder and Agoraphobia?
Recent surveys of the general population have found that about 2% of adults have had Panic Disorder or Agoraphobia in the last twelve months. That is approximately one out of every fifty adults. Panic Disorder occurs at the same rate in men and women, whereas Agoraphobia is twice as common in women than it is in men. Studies have also shown that as many as 40% of people have had spontaneous panic attack at some stage in their life, but have not gone on to develop Panic Disorder or Agoraphobia.
Treatments For Panic Disorder And Agoraphobia
Two kinds treatment have been proven to help people overcome Panic Disorder and Agoraphobia. One is Cognitive Behaviour Therapy (also called "CBT"), and the other is medication using either Tricyclic or Serotonin Reuptake Inhibitor Antidepressant drugs.
1. Cognitive Behaviour Therapy (CBT)
This type of therapy is conducted either in groups or in individual therapy sessions, usually with a Clinical Psychologist or a Psychiatrist. It involves:
Education about the physical symptoms of panic, the role of avoidance and the influence of thoughts and fears
- Changing thoughts and fears about the physical symptoms of panic
- Exposure to places where panic might occur
- Exposure to the physical sensations of panic
- Techniques to reduce over-breathing and anxiety symptoms
Education
What causes all those feelings you get during a panic attack?
A lot of different processes in the human body take place automatically, without us having to think about them at all, like breathing. When we exercise, the muscles in our body need more oxygen so we start to breathe more quickly, but we don't choose to do this, it just happens automatically.
Another automatic process in the human body is called the "fight or flight response". This is an in-built safety device which allows us to respond very quickly whenever we are threatened or in danger. Since most of the threats to our survival as human beings were once physical threats, this response is designed to help us move quickly to fight off a predator or escape from a dangerous situation. So when our fight or flight response goes off we release adrenaline which causes various changes throughout the body, such as increasing our heart rate and breathing rate, and tensing our muscles ready for action. We also start to sweat and have a strong urge to flee. These reactions would be useful if we had to run or fight, but in most situations nowadays it is not appropriate to run or fight. So all that extra oxygen you're breathing in and carbon dioxide you're breathing out can start to make you feel dizzy and light-headed, even nauseous. Your arms and legs may start to shake and you may get muscle cramps from being tense for too long. Do these symptoms sound familiar?
If you think this sounds like the symptoms of a panic attack, you're right! A panic attack happens when your fight or flight response goes off and you breathe more than you need. These feelings cannot hurt you. They occur because your body is trying to protect itself from danger.
But what sets off my fight or flight response?
The fight or flight response occurs whenever we judge a situation to be dangerous. In Panic Disorder or Agoraphobia this can be triggered simply by saying to yourself "what if I lose control and have a panic attack?" or by remembering that you had a panic attack in the same place once before. This happens because the thought of a panic attack is itself very scary, usually because the person believes that they might not survive the next panic attack - that they might go crazy or have a heart attack and die. If this were true you would be in great danger, and so your body activates the fight or flight response.
So how can I stop my fight or flight response from going off?
By changing your thoughts and learning not to be afraid of the physical symptoms of a panic attack.
Changing Thoughts
After many panic attacks, most people realize they are unlikely to die or lose control because they have survived so many attacks in the past. But this knowledge may be forgotten during a panic attack because the feelings are so intense that they fear this time may be different.
During a panic attack most people are focussing on the physical feelings they have in their bodies, like their pounding heart, or their dizziness, or their shaking hands, and they are interpreting these symptoms to mean that something dangerous and awful is happening to them. Unfortunately this only makes matters worse, because when you tell yourself you are in danger you activate the fight or flight response, you release more adrenaline, and the physical symptoms of panic get worse.
Step 1. Identifying anxious thoughts
Hence the first step is to learn to identify what you are saying to yourself leading up to and during a panic attack. Collect a sample of these thoughts and write them down. This may take some practice because at first it may seem like you are just feeling things and not thinking anything at all. But human beings always think about and interpret what happens to them. If you cannot identify what you are thinking try asking yourself what you believe is happening to you, and notice whether you are judging what is happening as being awful or dangerous.
Step 2. Challenging your anxious thoughts
Once you have identified what you say to yourself leading up to and during a panic attack, the next step is to start talking back. Look at the list of anxious thoughts you have written down.
Did you think what was happening to you was dangerous?
e.g. were you thinking things like "oh no, I'm having a heart attack", "I'm going to lose control", "if I don't get help I'll die" or "I'm going crazy"?
Did you think what was happening to you was unbearable?
e.g. were you thinking things like "I can't cope", "this is awful", "I can't stand these feelings"?
Although these thoughts might reflect how you are feeling at the time, they do not reflect all the facts. Anxious thoughts tend to exaggerate both the danger and the awfulness of the situation, and make you believe that you won't survive or cope. All of the physical symptoms of a panic attack have a harmless physical cause. They occur because at some level you are thinking something scary and your fight or flight response has released adrenaline. This response is not dangerous, which is why you have survived so many panic attacks in the past. You may be afraid that the next time will be different but it will not. The worst thing that can happen is that you will have a panic attack. The feelings may be unpleasant but they cannot hurt you. Panic attacks do not cause heart attacks, death or madness, nor do they cause people to lose control of their voluntary behaviour, so you won't run or scream unless you choose to. Think about it... how many times have you felt like these things were "about to" happen, but they never did?
Now, imagine you had a friend who suffered from panic attacks and you had read about panic and discovered it was unpleasant, even scary, but not dangerous. What would you say to your friend next time you were with him or her and she started to panic? Do you think it would help to say "you're going to die", "what if you go crazy?" "I don't think you can cope with those feelings"? Of course not! You would probably just make them feel worse!
You need to say something that will reassure and comfort them and help them to settle down. And it's just the same when you're the one panicking - thinking the worst makes panicky feelings worse. Reminding yourself that you are not in danger and that you can cope with a panic attack helps you to turn off your fight or flight response and stop releasing adrenaline. An example of how to talk back to anxious thoughts is given below.
Anxious thoughts |
Helpful thoughts |
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| I can't cope | I don't like panic attacks but I've coped with plenty of these before so I'll cope again today. | |
| These feelings are unbearable | The feelings are unpleasant but they can't hurt me. These feelings will pass in a few minutes so I'll just try to stay calm and wait for it to pass. | |
| I'm going to die | This is a panic attack and I've survived lots of them so I'll survive this one too. | |
| I'm losing my mind | These feelings mean that I'm anxious and my fight or flight response has been set off. They don't mean I'm losing my mind. Anxiety doesn't cause madness so I'll get through this just like before. |
Notice that the helpful thoughts are realistic but not overly positive. These thoughts tend to be more effective when you know they are true because you have experience to back them up.
Challenging anxious thoughts is a very important part of learning how to manage your anxiety, so if you need more help than this text seek advice from a CBT professional who is familiar with this technique.
Exposure to places where panic might occur
When people are afraid of something they usually try to avoid it as much as possible. This makes sense when the thing you fear is truly dangerous, but if there is no danger then avoidance only makes your fears worse. This is because although you may feel better when you leave or avoid a situation that makes you anxious, leaving strengthens the idea that if you'd stayed something awful might have happened, so you'll be more afraid to go back next time. Avoiding situations in case of panic stops you from learning that you will cope and survive even if you have a panic attack. So to get better you have to start confronting your fears.
Graded Exposure
Graded exposure is a way of gradually confronting any situation where you are afraid of having a panic attack. The first step is to write down places you would like to go and things you would like to do if you weren't afraid of having a panic attack. Some examples are listed below.
| Exposure Goals |
| To catch a train by myself into the city and return in rush hour |
| To shop alone in the local supermarket and buy the weekly groceries |
| To go to the cinema with friends on a busy Saturday night |
| To go away for a weekend in the countryside |
Now imagine you decided that you wanted to get fit but you haven't done any exercise for years. Let's say you set yourself the goal of running in the local 10km fun run in three months time. On the first day of training would you set out to run 10km? Of course not! The most sensible way to reach your goal would be to start with a brisk walk or a short jog, then gradually increase the distance you run every week until you reach your goal. It's the same process that works best when confronting your fears. Once you have written down your goals break them into smaller steps so you can work up to them gradually.
For example, if you decided trains because you couldn't escape to safety if a panic occurred and your goal was to catch a train by yourself into the city and return, you could break it down into 10 steps as follows:
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Travel one stop and return on the train with a friend
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Travel one stop on the train by yourself at a quiet time, and have someone meet you at the other end
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Travel one stop and return by yourself at a quiet time
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Travel two stops and return by yourself at a quiet time
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Travel two stops and return by yourself at a busy time
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Travel five stops and return by yourself at a quiet time
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Travel five stops and return by yourself at a busy time
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Travel to the city by yourself and have a friend meet you there
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Travel to the city and return by yourself at a quiet time
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Travel to the city and return by yourself in rush hour
The first step should be something that you think you could do even though you would be anxious. Each step is repeated until you can do it with confidence. The first time is usually the hardest so it is important to keep confronting a step until your anxiety subsides. If a step is too easy then go to the next one. If a step is too hard then try to think of something which is easier than that step but harder than what you've already done. It is best to keep a diary so you have a record of what you have done and what was easy and what was difficult.
When breaking your goals into steps think about the following things:
- How far you go away from home
- How long you stay there
- Whether you go alone or with a friend
- Whether it is a quiet or busy time of day
- How many things you do while you are there
Grading exposure exercises can take practice and skill, so if you're not sure how to go about it seek advice from a CBT professional who is familiar with this technique.
Exposure to the feelings of panic
Because panic attacks can be so frightening, many people who suffer from panic attacks start to notice little changes in their body which most people don't notice. For instance, you might notice your heart beating faster as you climb the stairs, or that you feel a little dizzy when you stand up too quickly. Even though these changes are harmless, you may avoid these activities just in case they trigger off a panic attack. This avoidance makes your fear worse because it encourages the idea that bodily changes are dangerous, and stops you from learning to overcome your fear of panic sensations.
By practicing exercises that give you the same physical feelings as a panic attack, you can collect evidence that these feelings are not dangerous. You will probably never like these feelings, but the idea is to prove to yourself that they are harmless and to get used to them so they are not as frightening next time you have a panic attack. Remember, noticing harmless physical changes will only set off a panic attack if you think or believe that they are dangerous. So these exercises are also a good opportunity to practice the helpful thinking strategy described above
- Breathe as deeply and as quickly as you can for one minute.
- Shake your head from side to side for 30 seconds.
- Run up and down on the spot as fast as you can for one minute.
- Hold your breath for 30 seconds.
- Stand up and turn around in circles as quickly as you can for 30 seconds to make yourself dizzy.
- Breathe through a thin straw for one minute while holding your nose.
None of these exercises are fun. For a person afraid of panic they can be scary and confronting so do them systematically and carefully. If you need help seek advice from a CBT professional who is familiar with these techniques.
Techniques To Reduce Over-Breathing & Anxiety Symptom
Some people say that during a panic attack they feel like they are suffocating or that they can't get enough air. This is because your body needs a certain amount of carbon dioxide in order to use the oxygen you're breathing in. When you breathe too quickly there is not enough carbon dioxide to use all the oxygen you're taking in, and so it feels like you can't get enough air. But in order to stop this process you need to SLOW your breathing. This is why some doctors might have told you to hold your breath or breathe into a paper bag, because doing so will increase the amount of carbon dioxide so you can start using the oxygen you're breathing in. Breathing too much too quickly causes a lot of the symptoms of a panic attack, such as dizziness, lightheadedness, chest tightness and pain, tingling fingers and feet, hot and cold flushes, etc. To prove the link between breathing and panic symptoms try breathing as deeply and quickly as you can for one minute.
Slow breathing
The following slow breathing technique will stop you from over-breathing during a panic attack. This technique is also useful if you don't over-breathe during panic attacks because it helps you to settle down, stop releasing adrenaline and turn off the "fight or flight response".
- hold your breath for 6 seconds (time it)
- breathe in and out every 6 seconds (10 breaths a minute)
- say relax under your breath as you breathe out
- after a minute hold your breath again for 6 seconds
- breathe in and out every six seconds
- say relax under your breath as you breathe out
- stop when your anxiety drops.
To begin, you will need to practice when already relaxed. Then you can gradually practice in anxious situations. Like learning any new skill, slow breathing takes time and regular practice. You should practice this at least 4 times a day.
2. Medication
Antidepressants and Benzodiazepines are the medications most commonly prescribed for the treatment of Panic and Agoraphobia. These medications should only be taken under supervision of your doctor, who can tell you about the correct doses and common side effects.
A. Antidepressants
Although originally developed for the treatment of depression, a number of the antidepressant medications have been shown to be effective for the treatment of anxiety, even in people who do not suffer from depression. There is antidepressant medication that have been proven to benefit people with Panic Disorder or Agoraphobia. Some examples are listed below:
B. Benzodiazepines
Although benzodiazepines can also be of benefit to people with Panic Disorder and Agoraphobia, these medications have a number of problems that the anti-depressants don't have. The main problem is that you can become dependent on these medications, and after a while you may need larger doses to get the same effect. Stopping these medications can cause withdrawal symptoms and anxiety and should be done gradually under supervision of your doctor. Some examples of these medications are diazepam, lorazepam, andinazolam, clonazepam and alprazolam.
Choosing treatments that work: CBT or medication?
The majority of people show a positive response to CBT or medication, so choosing the best treatment for you may depend on other factors such as the financial and emotional costs of treatment, the side effects, and the availability of treatments in your local area. Most medications have some side effects although these vary depending on which medication you take, and from person to person.
What are my chances of getting better?
For every three people treated with CBT, one will be completely free of panic attacks following treatment (the other two may still be improved, but not completely panic-free). For every six people treated with medication, one will be panic free for as long as they remain on medication (the other 5 may be improved, but not completely panic free). Hence, you have a greater chance of mastering your panic attacks with CBT than with medication. With CBT the improvement continues after treatment is over, simply because you have learnt new ways of coping.
Edited by Gavin Andrews MD, UNSW, 2007
©2007 CRUfAD
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