Panic attacks and agoraphobia
What is panic disorder and agoraphobia? Almost everyone feels anxious at times. But panic attacks are characterized by severe levels of anxiety, which you may misinterpret as an indication that you are having a heart attack, going insane, or losing total control. During a panic attack, you may feel short of breath, tingling sensations, ringing in your ears, a sense of impending doom, trembling, feeling like you are choking, chest pain, sweating, and heart pounding. You should see your physician in order to rule out medical causes such as hyperthyroidism, caffeine addiction, mitral valve prolapse, or other causes.

Many patients who have panic disorder also experience agoraphobia. Agoraphobics fear places or situations from which escape might be difficult or places where they might have a panic attack. For example, agoraphobic people avoid being out alone, supermarkets, trains, airplanes, bridges, heights, tunnels, open fields and elevators. Many panickers experience panic when they are asleep--possibly because the large decrease in pulse rate during sleep elicits a compensating increase in pulse rate, resulting in feeling jolted out of sleep.

Some agoraphobics experience anxious arousal in sunlight, some in dimming light. Heat is a major factor in panic disorder--there is a dramatic increase in panic and agoraphobia during the summer, primarily because heat increases pulse rate, dizziness, and dehydration and there are more opportunities to be outside where the individual feels more vulnerable. The individual fears that, in these situations, he or she will have a panic attack.

What is the cause of panic disorder and agoraphobia?
Many situations that agoraphobics fear and avoid may be situations that earlier in our evolution were truly dangerous. For example, being trapped in a tunnel could lead to suffocation or collapse; heights may be dangerous; in open fields, the individual is more susceptible to predators (like lions or wolves); public places may have brought our ancestors into contact with hostile strangers. Thus, we now view many of the fears of agoraphobia as reminiscent of these earlier instinctive and adaptive fears. However, these situations are not dangerous today.

The agoraphobic experiences either a desire to flee ("I need to get out of here") or a sensation of collapse (fainting). However, since escape may be blocked or collapse might be embarrassing, the agoraphobic interprets these physical sensations as "false alarms" that something terrible is happening. He or she focuses 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". We call these false alarms because they signal that something dangerous is imminent when there is no danger present.

As I indicated, many of the situations that activate panic and agoraphobia were of adaptive value earlier in our species. Research does demonstrate a genetic cause for agoraphobia. However, agoraphobia and panic are not entirely inherited. In any given year, 30% to 40% of the general population will have a panic attack. However, most of these people will not have a catastrophic interpretation of the panic. The panicker tends to have excessive self-focus on physical sensations and catastrophic interpretations of his or her sensations. For example, panickers focus on their heart rate and jump to conclusions about having heart attacks.

Initial panic attacks are activated by stressful situations--for example, leaving home, marital conflict, surgery, abortion, new responsibilities, or physical illness. Many people who have panic disorder also experience depression, partly as a consequence of their feeling out of control and unsure as to how to handle their problem.

How does agoraphobia develop?
The initial panic attack may lead to hypervigilance--that is, cautious worry that other panic attacks will occur. As a consequence, panickers learn to avoid situations that arouse anxiety. In fact, avoidance and escape become the major coping mechanisms used to handle anxiety. Many agoraphobics enlist a "safe person"--someone who accompanies them in case the panicker becomes anxious and needs to escape. The panicker suffers from anticipatory anxiety---"Will I have an anxiety attack on the subway?" or "Will I have an anxiety attack at the party?" Panickers fear driving because they fear that they might have a panic attack and lose control of the wheel.

Even though their avoidance may have led to few or no anxiety attacks in months, panickers often worry about the next attack. The world becomes smaller and smaller as a result of this avoidance. Because of this constriction in their lives, many panickers are also depressed. Some panickers become so anxious that they self-medicate with alcohol, valium or xanax.

How effective is cognitive-behavioral therapy for panic? Fortunately, there have been a number of studies examining the effects of cognitive therapy. These studies have been done at Oxford, University of Pennsylvania, State University of New York at Albany and at other universities and medical schools. Over a course of treatment of 20 to 25 sessions, the efficacy ranges from 85% to 90 %. Furthermore, once treatment is terminated, most patients who are tested one year later have maintained their improvement.

Medications for panic disorder
There are a number of medications that are useful in inhibiting the arousal or panic. These include a wide range of anti-depressants, such as tofranil, prozac, zoloft, MAO-inhibitors, xanax, as well as beta-blockers.

These medications help reduce the arousal, but once you terminate the medication your panic symptoms may return. Consequently, we recommend that even if you use medication for panic disorder that you also include cognitive-behavioral therapy.

What are some of the steps in the treatment package for panic disorder?
The treatment of panic is organized around several goals: first, educating the patient about the nature of agoraphobia, anxiety and panic; second, determining the range of situations that you avoid or fear; third, evaluating the nature of your symptoms, their severity, frequency and the situations that elicit your anxiety; and, fourth, evaluation for other problems that may co-exist with panic--for example, depression, other anxieties, substance abuse, overeating, loneliness, and marital problems.

Your therapist may include the following treatments: relaxation training, rebreathing training (especially if you hyperventilate), gradual exposure to situations that elicit panic, identification of your interpretation of your panic or arousal, stress reduction, training in general cognitive therapy principles ( challenging your negative beliefs, your concern about losing control, your fears of negative evaluation, and your demands for certainty), assertion training (when needed), and training in the ability to recognize and reduce your panic symptoms when they occur. In addition, other problems that you may have (such as depression) may also be addressed in the therapy.

What are some common misconceptions about panic?
Some people incorrectly believe that panic is a result of deep-seated psychological problems. Of course, anyone with or without panic may have deeper problems, but panic disorder and agoraphobia are not necessarily related to deeper psychological problems. You may become depressed, dependent and self-critical because you have panic disorder--- but panic, in itself, can be treated effectively without long-term therapy exploring your childhood experiences. Panickers often have unrealistic beliefs about anxiety---such as, "All anxiety is bad" and "I have to get rid of my anxiety immediately". Some panickers misinterpret their anxiety as a sign of a dangerous medical condition. Others believe that because they have had panic attacks and agoraphobia for many years---and because traditional therapy has not been helpful for these problems---that they can never improve. Cognitive-behavioral therapy, with or without medication, is often quite effective in the treatment of panic and agoraphobia.

What we expect of you as a patient
Cognitive-behavior therapy is not a passive experience for patients. You are expected to come to sessions weekly (sometimes more than once per week), fill out forms that evaluate your problems, and do self-help homework that you and your therapist plan and assign. As indicated, most patients who participate in this treatment experience improvement on panic and agoraphobia---some experience rapid improvement. Even if you experience rapid improvement, you should complete the full treatment package. Premature drop-out from treatment increases the likelihood that you will have relapses.

Some data on this page was derived and/or influenced by the writings of Robert L. Leahy B.A., M.S., Ph.D., Director of the American Institute for Cognitive Therapy