Understanding panic and agoraphobia
What is panic disorder?
Almost everyone feels anxious at some time in their lives; it is common to become anxious in situations such as a job interview, an examination or a public speaking engagement and mild anxiety of this type is so common it is not usually a cause for concern. For some people, however, anxiety symptoms are so severe and persistent that they can become disabling; people with such intense anxiety are often suffering from an anxiety disorder. In some cases, people can develop episodes of sudden and overwhelming anxiety, known as panic attacks, with physical symptoms so severe that the sufferer may feel they are having a heart attack or losing their mind. When a person experiences repeated panic attacks, or when the fear of panic attacks becomes an extreme preoccupation, they are suffering from panic disorder.
What is a panic attack?
A panic attack refers to a sudden and often unexpected burst of acute anxiety, usually accompanied by a number of physical symptoms and catastrophic thoughts. It usually lasts for between two and thirty minutes and when it does pass, the sufferer will feel weak and exhausted. Without effective treatment, panic attacks can escalate and occur several times a week, or even daily.
Common symptoms include:
- Difficulty breathing, or hyperventilation
- Palpitations or a pounding or rapid heartbeat
- Tightness, pressure or pain in the chest
- Shaking, trembling and weakness
- Feeling faint, dizzy or unsteady
- Sweaty palms and excessive perspiration
Accompanying these physical symptoms of panic, people commonly experience distressing thoughts, including feeling as if they are having a heart attack or stroke, fearing they are 'going insane' or that they might faint, collapse or embarrass themselves in public.
What is agoraphobia?
People who have had a panic attack in a particular situation may start to find that they avoid that place for fear of having another attack; for example, someone who has experienced an attack in a shopping centre may begin to avoid going shopping altogether. This kind of behaviour is known as agoraphobia. While agoraphobia is often associated with panic disorder, it may also develop on its own or as part of another disorder, such as depression.
Agoraphobics tends to avoid, or tolerate with considerable fear, situations in which escape might be difficult if they have a panic attack.
Common examples of such situations are:
- Driving a car in heavy traffic
- Travelling over bridges or through tunnels
- Taking public transport
- Visiting crowded shopping areas
- Going out to social occasions
- Being alone at home
What causes panic and agoraphobia?
A number of factors work together to cause panic attacks and panic disorder and the particular combination will vary from person to person, although these can be understood as a chain of factors of broadly three types that progressively build up to produce panic:
Some people are vulnerable to developing panic attacks and agoraphobia as a result of their constitution and life experiences. Risk factors in early life can include genetic inheritance, the nature of family relationships and childhood trauma. Temperamental factors, such as an ingrained tendency to worry, together with continuing stress over a period of time, can also make people predisposed to panic attacks.
Immediate stresses or triggers can bring on a sudden panic attack. A common 'trigger' is 'overbreathing' or hyperventilation - many panic attack sufferers experience shallow breathing during an attack, but some people may actually be hyperventilating chronically (two common signs are excessive sighing or yawning). Hyperventilation results in typical symptoms of panic, such as dizziness and weakness, which are then misinterpreted and trigger a full-blown panic attack. Another crucial trigger is the misuse of alcohol, drugs or other stimulants, as these can provoke the nervous system and exacerbate anxiety.
3) Perpetuating factors
There are a number of influences that keep the panic process going, often leading to a vicious cycle in which panic attacks are made worse or brought on more frequently. These can be divided into psychological, social and physical factors:
People prone to high levels of stress, fear of illness and catastrophic thinking often have lingering worries after a panic attack subsides that they are ill, insane or dying; constant apprehension re-triggers the nervous system into a state of emergency, a panic attack ensues, and the vicious cycle is set up.
Social crises that lead to a build-up of tension before the onset of panic disorder, such as pressure at work or home, may continue after the attacks begin, causing the sufferer continuing stress and creating a high risk of panic attacks reoccuring.
Bouts of illness such as the 'flu or viral infections, poor general health and the effects of drugs can all mimic anxiety and thus intensify panic symptoms.
Panic attacks can also be caused by other anxiety disorders, such as social phobia, obsessive-compulsive disorder or post-traumatic stress disorder.
Management and treatment
There have been impressive advances in the treatment of panic disorder since the early 1980's. Studies and clinical experience have shown that, with guided practice, most sufferers of panic disorder can make a good recovery. Medications such as minor tranquilisers and tricyclics (traditionally used to treat depression) are effective in reducing the symptoms of panic, but for those who are unable, or do not wish to, use medication there are also a range of effective non-drug approaches to treating the disorder. Cognitive behaviour therapy in particular has been used extensively and can make a major impact on panic and agoraphobia; indeed, over 80 per cent of panic sufferers report significant and lasting improvement from using this approach.
Cognitive behaviour therapies, or CBT, work by addressing the patterns of thinking that are associated with a person's problematic behaviour and symptoms, and offering strategies and techniques for breaking these negative thought processes. CBT offers the sufferer from panic disorder and agoraphobia the possibility of learning, by practice and repetition, new ways of dealing with difficult situations and the anxieties they may cause.
Treatment is usually conducted by a therapist, but many of the CBT mechanisms have also been adapted into the form of self-help manuals. These manuals help the sufferer to recognise and address the range of reactions, thoughts and feelings that they may be experiencing, and offer a systematic programme of treatment which the sufferer is advised to work through to overcome their difficulties. For a great many people, cognitive behavioural self-help manuals provide a lifeline to recovery and a better future.
Derrick Silove & Vijaya Manicavasagar
Professor Derrick Silove is a practising clinical psychiatrist and Director of the Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales.
Associate Professor Vijaya Manicavasagar is a senior clinical psychologist and is Director of Psychological Services at the University's Black Dog Institute.
Overcoming Panic, a classic self-help guide, now recommended as part of the NHS Books On Prescription scheme, can help you overcome panic attacks and associated agoraphobia step by step using techniques of Cognitive Behavioural Therapy (CBT).
See sample pages from the book
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Self-help course you can download now
The book has been developed into a course of modules that presents the self-help guide in a practical interactive format, the Overcoming Panic and Agoraphobia self-help course, using clinically proven CBT techniques.
See sample pages from the modules
Learn more about the Overcoming Panic and Agoraphobia self-help course
As an alternative, those suffering from panic attacks might find it useful to begin by reading An Introduction to Coping With Panic, written by Charles Young. Part of a small series of CBT booklets presented in an easy-to-read A4 format, it is often used by mental health therapists as part of a course of guided self-help treatment, and can make a very good first step to recovery.
The Overcoming series [is] central to any cognitive behavioural therapist's library.