Panic and Agoraphobia
A panic attack can be a terrifying experience marked by intense physiological sensations and fear that can often come out of the blue or is out of proportion with the situation at hand. The nature of the fear may differ based on the physical sensations that are involved. For instance, if it was primarily chest pain and a racing heart, one might fear a heart attack; or if it was mostly shortness of breath and a tight throat, one might fear not being able to breathe or choking; if dizziness and feeling lightheaded were most prominant, one might fear fainting; or in the case of unreality or depersonalization, one might fear going crazy; or more generally, one may fear the embarrassment of having these sensations in public.
In reality, what is happening is simply a misfiring of the sympathetic branch of the autonomic nervous system. This is the part of the nervous system that is responsible for the fight-flight-or freeze response that evolved to get us out of trouble in case of an emergency, like if a bear was chasing us. Once activated, heart rate increases, breathing becomes quick and shallow, blood flows more into the large muscles, etc. This reaction is adaptive and not at all dangerous.
It is scary in the case of panic because there is no bear, i.e., no identifiable threat. As a result, our brain looks for an internal cause: Is there something wrong with my heart? Will I stop breathing or what if I just can’t catch my breath? etc.
The experience of a panic attack is so aversive that we then start to monitor bodily functions to detect anything that would be a cue to the start of a panic attack so that we can prevent one from happening. This “hypervigilance” to bodily functions maintains our nervous system on high alert, which then is bound to cause more panic attacks.
We may also start to avoid places or situations where we could have a panic attack and it is difficult to leave, at which point agoraphobia sets in. Common examples are being in a crowd or standing in line, being stuck in traffic, on a bridge, or in an elevator, or even simply being in a work meeting. One may also fear traveling far from home or from a hospital.
Treatment
If you suffer from a panic disorder with or without agoraphobia, you are not alone. Up to one in 28 people will suffer from a panic disorder at some point in their life. The good news is that CBT is highly effective for panic (with or without agoraphobia), and, in fact, it is the most recommended treatment.
If you believe you suffer from panic and want help, please CONTACT US.
If you have a panic disorder, chances are you have already consulted your medical doctor, but if not, it can be a good idea to do so for a general check-up to rule out any medical contribution to some of the symptoms, like hyperthyroidism, for instance.
Changing thoughts: For a panic attack to occur, two elements are necessary: physical sensations and a catastrophic interpretation of these sensations.
The real issue is not the physical sensations. If you experienced these sensations before you ever had your first panic attack, while at the gym or after running frantically after the bus, you would not give them a second thought and they would dissipate. The real issue is that these physical sensations are occurring unexpectedly or inappropriately (at least at first) and therefore are interpreted as a sign that something is terribly wrong and that there is a real and imminent danger, whether it is going crazy, having a cardiovascular event, or even dying; or at a minimum, that this may be embarrassing if it happens at work or in public.
Part of the treatment is providing and discussing information about panic (its causes and why it is not dangerous) and correcting faulty beliefs. However, even when one knows that panic attacks are not dangerous, the physical sensations have previously been associated with fear, such that they may still elicit a fear reaction despite this knowledge. This is where our behavioural strategies come in.
Changing behaviors: In panic, the physical sensations of panic are associated with fear. With a technique called “interoceptive exposure”, we can break this association. It consists of slowly eliciting a feared physical sensation until one is comfortable with it and gradually increasing the intensity. It can be best understood with this more concrete analogy:
Let’s say you are afraid of cats. What we would do is place a cat in a corner of the room and have you start in the other corner. We would take one step towards the cat together and stay there until you feel comfortable being one step closer to the cat. Once this is done, we would take another step and then another step…until you are with the cat and unafraid. This is called “systematic desensitization”; you become desensitized to the cat.
With panic, the cat is the physical sensations. The moment your heart starts beating a bit faster or skips a beat, you become afraid. You then try to make it go away by trying to distract yourself, leaving the situation, seeking reassurance, etc., which is the equivalent of running away from the cat. You run to the cat and then run away; desensitization cannot occur. By contrast, what we do together is bring up a mild sensation and stay with it until you are comfortable with it. We then increase the intensity a bit and stay with it, until a point is reached where you can have the physical sensations that you experience during a panic attack and feel fine, i.e., be desensitized to them.
If agoraphobia is present, we would also use systematic desensitization to expose you gradually to feared places or situations. For instance, if fear of the metro is an issue, we may first go to the metro and stay on the platform until you are comfortable there. We may then take the metro only for one station, and then gradually increase the number of stations, until you are comfortable staying on the metro for many stations on your own.
It is important to know that exposure is highly effective and is done at your pace. We would never ask you to do anything that poses a clear danger, that you do not see the necessity or usefulness of, or that you are not up to doing. CBT is collaborative in nature, and we always do the exercises with you first and then together decide on next steps. Let us help you conquer your panic disorder.
Optional additional treatment strategies
Relaxation and proper breathing: Reducing one’s overall level of anxiety reduces the likelihood of a panic attack.
Mindfulness and Acceptance: Learning to be in the here and now, and to suspend judgment (i.e., instead of labeling experiences as “good” or “bad”, accepting them the way they are).