Panic Disorder and Agoraphobia

Panic disorder and agoraphobia often occur together. In brief, panic disorder may be understood as a learned fearfulness of certain bodily sensations involved with panic attacks (see list of physical symptoms below), whilst agoraphobia is the behavioural response to the anticipation of these sensations. 

Panic attacks tend to occur suddenly and involve intense feelings of fear and dread which seem to arise 'out of the blue'. Typically sufferers fear loss of control, and have strong urges to escape situations perceived as threatening.

In agoraphobia, there will be an increasing tendency to avoid situations in future from which escape may be difficult. Common agoraphobic situations include going into a supermarket, travelling by bus or car, entering a crowded room, and being alone. Agoraphobia is a Greek word, meaning 'fear of the market place'.

The average age of onset for panic and agoraphobia is between 23 and 29 years. Around 72% can identify a significant stressor prior to their first attack, such as negative drug experiences, physical illness or death in the family. 

The first panic attack is often traumatic, and a high number of individuals seek emergency medical treatment due to their belief that their symptoms signify some serious physical illness and even impending death. Fear ridden beliefs such as 'my heart is racing, I could be having a heart attack' are common. A phobic attack may be triggered by an external event, and then the fear of the resulting physical symptoms in turn heighten the sufferer's anxieties so that a vicious cycle is established.

Psychological Symptoms

  • fear of losing control or going crazy
  • fear of dying
  • feelings of unreality or being detached from oneself
  • urge to escape from panic inducing situations
  • fear of fear itself

Physical Symptoms

  • palpitations
  • sweating
  • trembling or shaking
  • sensations of shortness of breath
  • feeling of choking
  • chest pain or discomfort
  • nausea or abdominal distress
  • feeling dizzy or faint
  • numbness or tingling sensations
  • chills or hot flushes

Diagnosis

If you are referred to a Psychologist or Psychiatrist, it is likely that you will be assessed via an in-depth interview, and a questionnaire such as the Anxiety Disorders Interview Schedule. The frequency, intensity and duration of panic attacks will be assessed, and triggers identified. The practitioner will ask you about physical symptoms, thoughts and behaviours surrounding your experience of panic. If panic attacks are recurrent, and there is a strong fear of having future panic attacks, it is likely that a positive diagnosis will be made. However, a medical evaluation may be carried out to rule out medical conditions; such as thyroid problems, hypoglycaemia, and caffeine or amphetamine intoxication (which produce similar physical symptoms) before a diagnosis of panic disorder and agoraphobia is given.

Medical Treatment

In some cases of panic disorder, benzodiazepines or tricyclic anti-depressants may be prescribed. However, there is a risk of dependency with tranquilisers in particular, and on withdrawal of the medication, symptoms tend to recur. Furthermore, while lessening physical symptoms, medication may interfere with cognitive-behavioural treatments (CBT), making them less effective. The soothing effects of anti-anxiety drugs tend to lower the motivation to learn behavioural techniques, and any successes are likely to be attributed to the medication rather than to the client's own efforts which may be counter-productive in the long term.

Psychological Treatment

There are a number of psychological therapies and techniques that are employed to help individuals combat panic disorder and agoraphobia. These include those listed below.

Cognitive Restructuring

Cognitive behavioural treatments for panic and agoraphobia are highly effective, and between 80% and 100% of clients undergoing such treatments are likely to be panic free by the end of therapy. Cognitive strategies are taught, whereby the client learns that their bodily sensations, whilst unpleasant, are normal and harmless. The client will be helped to identify unhelpful thoughts and beliefs, and to challenge these. Self monitoring is important too, and the client may be encouraged to keep a mood diary to raise levels of self-awareness, to gain objectivity, and to chart their progress.

Breathing Techniques

50% - 60% of sufferers describe symptoms of hyperventilation, and breathing retraining has been shown to be particularly helpful in such cases. Fear induces respiratory changes which add to distress. Breathing retraining and progressive relaxation have been found to reduce the frequency and intensity of attacks, by helping the client to regain a sense of control. The client is taught progressive muscle relaxation, and this skill is then practiced while undergoing certain anxiety provoking tasks (tailored to the individual) until the fear diminishes.

Exposure Therapy

Exposure therapy is specifically used to address fear and the avoidance of situations which provoke it. The client is encouraged to repeatedly approach objects or situations that have been triggering panic, such as getting onto a bus, or entering a busy shopping centre. Usually this will start with exposure to mildly threatening situations, building gradually to the situations found most threatening. With the aid of breathing techniques and cognitive strategies (mentioned above), a sense of mastery and control can be achieved, resulting in a relief from anxiety related symptoms.

Lived Experience

“At my worst, I was suffering with such extreme anxiety that I wouldn't leave the house except in the middle of the night; so terrified was I there may be someone else walking about who would make eye contact with me, or worse still, talk to me.

There were occasions when I had to venture out and be exposed to my fears...collecting benefit money from the Post Office. I would get all my food and other essentials, including PlayStation games of course, all in one mammoth but very swift shopping trip. I'd then struggle home with loads of bags whilst looking ultra-paranoid and dripping in sweat. Was anyone looking at me? Quite probably, I did kind of attract attention!

Things can and do get better though, you must remember this. They may get bad again, the road to recovery is not a smooth, straight highway with no traffic - it is a windy road, full of obstacles you have to tackle in tricky conditions.

It's a challenge, a test you face everyday just doing the simplest of things. The fact you persevere, in the most difficult and arduous of circumstances, day-in-day-out, means you are in truth a strong person and are well on your way to being a winner. You can beat it.”