What is panic disorder and agoraphobia

This workbook contains a CBT treatment called Exposure and Habituation. It is recommended for the treatment panic disorder and agoraphobia, due to its large evidence base. What is panic disorder and agoraphobia?

Panic disorder is widely experienced problem. It is an anxiety disorder that affects about 7 in every 1000 people in the UK. A panic attack is a rapid rise in anxiety, usually reaching a peak within ten minutes. It is experienced as a rush of physical sensations. These sensations are the result of the adrenalin response in the body and are not harmful. While the attacks are not dangerous, they are very frightening and unpleasant at the time. They can feel very concerning and people can think they are a sign of something more sinister or catastrophic happening. Anyone can experience a panic attack. Some people have a one off attack and then don’t experience any ongoing anxiety afterwards. Some people have panic attacks, but as just one part of a different anxiety disorder and not the main focus of their fear, such as in a specific phobia, social anxiety disorder, illness anxiety disorder or Post Traumatic Stress Disorder (PTSD). These disorders are treated differently to panic disorder, so an assessment of current symptoms is important first, to get a clear picture of what is happening. In panic disorder, the person has a first panic attack and then goes on to have multiple attacks on a regular basis. The panic attacks can be unexpected and seem like they come out of the blue. The physical symptoms of anxiety rise to a peak within minutes and are very frightening at the time. People with panic disorder understandably fear having more attacks and begin to avoid situations, places or activities that seem to bring them on. Some people also experience agoraphobia alongside their panic disorder. This is when someone feels panic in situations they are unable to escape from quickly or where getting help would be difficult. This includes crowded busy places, public spaces or wide open areas. This can be anywhere out of their home. This leads to high levels of avoidance and restrictions on how they can live their life.

The good news is that the National Institute for Health and Care Excellence (NICE) recommends a Cognitive Behavioural Therapy (CBT) treatment for panic disorder and agoraphobia called exposure and habituation. It is the recommended treatment as it has a large evidence base to support its use. This workbook helps you to use exposure and habituation, with support from a trained practitioner.

What are the symptoms of panic disorder?

In panic disorder, the person will have experienced one or more panic attacks, with at least one month of fear of having another attack and significant adaptations to behaviour to avoid having another. The physical symptoms of panic, which are brought on by the adrenalin,in response, can come on when the person is anxious, or when they are calm , as unexpected attacks. Four or more of the following symptoms should be experienced: • Palpitations, pounding heart, increased heart rate • Sweating • Trembling or shaking • Shortness of breath • Feelings of choking • Chest pain or discomfort • Nausea or abdominal distress • Feeling dizzy, unsteady or light-headed • Chills or heat sensations • Numbness or tingling sensations (paresthesias) • Feeling detached from what is going on around you (de-realization) • Fear of losing control, going crazy or of dying

What is the adrenalin response?

The physical changes of the adrenalin response are a normal reaction in the body to some kind of threat or danger. This is sometimes called the ‘fight or flight’ response. We share this response system with all other mammals, to keep us safe from harm. It is a helpful safety response that we all need when there is a threat or danger we need to

respond to quickly. For example, when you go to pull out to change lanes on the motorway, but then see a car has just changed lanes and is racing up the lane you are about to cross into. It is this response that kicks in to help you to take action to swerve back into your lane and avoid a collision. The main function of the adrenalin response is to prepare the body to quickly move out of harms way or take an action to stay safe. It is to prepare the body for vigorous, quick action when there is an immediate threat or danger to respond to. In panic disorder, this process is being triggered when there isn’t an actual threat or danger to respond to. We do not have adrenalin in our bodies all the time. On response to a trigger, we only produce just enough to get our way out of the acute situation as quickly as possible. When the body perceives there is an immediate danger to respond to, like seeing the car in the lane on the motorway, it sends an alarm signal to the amygdala in the brain. in turn this communicates with the hypothalamus. The hypothalamus is like a command centre in the brain. It triggers the sympathetic nervous system, the arousal response, to release adrenalin. Adrenalin is released through the activation of nerves connected to the adrenal glands. These nerves trigger the secretion of the adrenalin into the bloodstream. As the adrenalin circulates through the bloodstream it brings on a number of automatic physical changes. This process happens very quickly.

When adrenalin is released, breathing changes from the nose to through the mouth, to take in more air. Breathing becomes more rapid. These changes can make the mouth feel dry or like you cannot get your breath. Small airways in the lungs open wide to enable more oxygen to be taken in with each breath you take. The extra oxygen is sent to the brain to increase alertness and to the bloodstream to reach the arms and legs with oxygenated blood. The heart rate goes up to pump the oxygen rich blood around to the arms and legs to allow us to move quickly. The adrenalin response also ensures that heart rate does not go too high and is regulated (although it can feel like it is very high at the time). Blood vessels dilate or constrict to allow the oxygenated blood to reach the arms and legs more quickly and efficiently and to reduce the flow to areas where it is not as needed temporarily.

This can feel a little strange and may lead to pins and needle feelings, shaking or dizziness as the oxygen rich blood travels around the body. The senses also sharpen. Your field of vision may narrow to enable you to focus on the threat (fight) or widens to enable you to get to safety and escape (flight) depending on the situation. It is these physical changes that give the feelings of high anxiety and can also be misinterpreted as being harmful themselves. Once the threat is over, or when we use up the adrenalin secreted into the bloodstream (whichever comes first) the physical symptoms of the adrenalin response, along with the feelings of anxiety, come back down naturally.

Why do some people develop panic disorder?

In panic disorder, the physical sensations of the adrenalin response have been misinterpreted by the body as being a sign of imminent danger themselves. For example, the body may interpret the heart rate increasing as being a sign of being about to have a heart attack, the feelings of dizziness of being about to collapse or the dry mouth of a sign of being about to choke. The problem with this is, the alarm system then learns it should fear these symptoms and it goes off any time they occur, thinking there is a real danger or threat we need to respond to. A bit like an over-sensitive smoke alarm warning there is a ‘danger’ when there is no emergency to attend to. In other words, the body has learnt to trigger the adrenalin response for the physical symptoms of fear itself or situations that can bring these on. The body is treating these as a reason to trigger and sound the alarm. These triggers can be places you have had anxiety or panic before or situations that bring on the physical symptoms that mirror the adrenalin response symptoms like exercise, sex or even walking up stairs for example as these increase your heart rate. Understandably, you begin to avoid things that trigger you feeling this way as much as possible. You may also try to escape from these situations if you begin to have symptoms, or may do things to make them go more quickly. People often also have a range of things they begin to do to feel ‘safer’ in these situations. These are called safety seeking behaviours and are often done initially to help with the unpleasant physical symptoms you experience, such as carrying water for a dry mouth or distracting yourself in some way from your anxiety.