Panic attacks and agoraphobia

As many as 10% of people (around 25 million Americans) will at some time experience panic attacks, i.e. re-occurring, unpredictable, sudden, intense, almost unbearable spells of terror. Most of these people will have only a few, widely scattered episodes, but about 1% to 2% of us will have frequent attacks and/or such intense fear of panicking that it seriously disrupts our lives. This is called a panic disorder. In serious cases (four or more attacks per month), it is very disabling: associated 70% of the time with another psychiatric disorder, often depression, suicide (20% attempt it!), alcohol abuse, poor health, and great difficulties socially, maritally, and at work. The risk of suicide is especially high among women who drink and started panicking in their teens or early twenties. Yet, less than 25% seek treatment--and it is fairly treatable. Many victims avoid treatment, just the same as they do other scary situations. Other victims, fearing some serious physical disease, see an average of 10 doctors before the disorder is correctly diagnosed.

But because of the seriousness of a panic disorder (not just one or two attacks) and the suicide risks (even higher than depression), it is crucial that competent professional treatment be sought immediately. Unfortunately, many professionals give ineffective drugs and don't use the best therapy methods. Panic attack victims are given 50% of all angiograms, which are unnecessary and quite expensive. So seek a panic disorder specialist, if possible. The therapist should insure that there is no physical problem, possibly prescribe anti-depressive drugs (not minor tranquilizers), and provide psychotherapy involving relaxation, exposure to the frightening situation, and cognitive restructuring.

The causes of panic attacks are not known. Some psychiatrists think the body is simply malfunctioning--sending a false message that it is suffocating (being unable to breathe is terrifying); thus, these theorists see it as purely a physical problem (actually, the onset of panic disorders are often associated with major stressful life events). Other theorists believe panic sufferers were born shy, nervous children with over-demanding, suffocating parents. Later, as over-dependent, eager-to-please but resentful-of-authority young people, they frequently have an intense confrontation with an authority. Their anger leads to the first panic attack, according to this theory. More recently, three major theories about panic have evolved:

  • 1. Catastrophic thinking: heightened anxiety in a stressful situation may cause bodily sensations which lead the person to falsely conclude he/she is having a heart attack, going to faint, about to die, going to lose control, going crazy, etc. These thoughts lead to panic. So, the thoughts need to be corrected.

  • 2. Hyperventilation: anxiety causes some people to hyperventilate, which, in turn, leads perhaps to too much carbon dioxide, dizziness and panic. So, better breathing habits must be developed

  • 3. A conditioned panic: a scary experience (or hyperventilation) may cause certain feelings, such as rapid heart beat, sweating, shaking knees, etc., that are paired with the first panic attack. Thus, conditioning occurs and, subsequently, noticing a rapid heart beat and sweating while under stress may arouse a strong fear--a panic attack. So, in this case, the person may need, for example, to experience a rapidly pounding heart several times in a safe place in order to find out that nothing awful is going to happen.

An astonishing 10 million (about half of all people with Panic Disorder) Americans are afraid to leave home (agoraphobia), sometimes because they fear panicking and losing control away from home. About half the time agoraphobia is preceded by a panic attack. As a child, 42% of adults with agoraphobia experienced separation anxiety from a parent (home), suggesting a long history for this fear. Panic attacks are more likely to first occur during a stressful period involving a loss, like a divorce, a conflict or a death but, many occur without any obvious precipitating stresses. The mid-twenties are when many panic disorders start. Biological factors may also play a role in causing panics, it runs in families.

Further confusing the situation, several chemicals or conditions occasionally produce attacks in panic prone people: sodium lactate, caffeine, mitral valve prolapse, thyroid gland malfunctioning, and hyperventilation. Likewise, since anxiety produces or contributes to many physical disorders, and, conversely, many physical, biochemical, and hormonal problems produce anxiety or anxiety-like symptoms, it is always a good idea to have a good physical exam to diagnose or rule out physical-hormonal factors, including hypoglycemia and PMS. (But remember 50% of angiograms are given to panic disorder patients.)

Anti-depressive drugs "greatly improves" only about 30% of clients with panic attacks and/or with agoraphobia (but a placebo reportedly improves 25%). The drug treatment approach is simple and takes six months to one year. However, there are several possible problems: some of these drugs are highly addictive (especially if one has a tendency towards alcoholism) and may have side effects; drugs have high refusal-drop out rates (50%) and high relapse rates (from 35 to 85%); drugs do not solve underlying problems, if there are any.

For the 70% of panic disorders and agoraphobics who do not respond to drugs the treatment of choice involves cognitive therapy (reducing negative thinking, irrational ideas, false conclusions about dying, going crazy, etc.) combined with gradual exposure to stressful situations (with support, relaxation, useful skills, and more confidence). Misinterpretations of bodily sensations are challenged, e.g. a therapist helps you test your belief that feeling faint will actually lead to fainting. This kind of therapy is supposedly effective 75%-85% of the time (with tentative indications that the relapse rate is low). Some specialists dealing with panic disorders claim that "guided mastery" is more effective than simple "exposure" to the scary situation. This might be because more attention is given to developing helpful self-instructions and self-confidence in mastering the situation. For instance, in guided mastery, the helper (therapist or friend) of a person afraid of heights would observe the phobic's behavior and do such things as offer encouragement when approaching the top railing of a high building, ask the phobic to look in all directions and down, to let go of the railing, to approach the railing over and over, and to do so more rapidly, and so on. Cognitive-behavioral treatment may have fewer relapses than drug treatment but its placebo effect is probably at least as high (25%).

Extensive research is being done; better treatment is coming which will supplement the old "face your fear" homily. Actually, using two or three different treatment approaches, say cognitive therapy or breathing instructions, along with cue exposure, on the same person is proving to be most effective. Drugs are important in some, but by no means all, cases..