Panic Disorder

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Panic Disorder Agoraphobia
www.phobics-society.org.uk
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• Information on Panic Disorder Agoraphobia
• Prepared by Professor Paul Salkovskis and the
  Panic Agoraphobia Team at the
• Centre for Anxiety Disorders and Trauma,
• Maudsley Hospital, London
• In response to The House of Agoraphobics
• On Channel 4, December 2006
• We are unable to answer individual queries, so
  have prepared this information to supplement that
  provided in our website.

www.nopanic.org.uk
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The house of agoraphobics

• Channel 4 recently screened this programme, which
  showed the intensive treatment (using Cognitive
  behavioural therapy) of three people suffering
  from panic disorder and agoraphobia. The
  treatment used was a modified version of
  cognitive behaviour therapy, which is the first
  line treatment for this problem according to the
  recommendations made by NICE in its anxiety
  guidelines.
• Treatment in this programme was carried out by
  therapists from the South London and Maudsley
  Foundation Trust (SLaM) Centre for Anxiety
  Disorders and Trauma. Although this unit provides
  a national service for Obsessive Compulsive
  Disorder, we can only offer treatment for Panic
  Disorder and Agoraphobia for patients living
  within the catchment area of SLaM living in the
  boroughs of Lambeth, Lewisham and Southwark. We
  are not able to accept private referrals or
  referrals for Panic and Agoraphobia from outside
  our catchment area.
• This presentation also offers some suggestions on
  obtaining help elsewhere.
• We are unable to answer individual queries, so
  have prepared this information to supplement that
  provided in our website.

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Here are some questions we get asked frequently
about panic disorder and agoraphobia
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What is panic disorder?

• A panic attack is a sudden episode of intense
  fear, accompanied by four or more symptoms from
  the following
• Palpitations or rapid heart rate,
• Breathlessness
• Feeling unsteady, dizzy, light-headed or faint
• Trembling or shaking
• Sweating
• Having a hot flush or chills
• Chest pain or discomfort
• Numbness or tingling sensations
• Feeling as if you or surroundings are unreal

• Different people have different combinations of
  symptoms, but the general pattern is usually the
  same
• A sudden increase in anxiety
• A range of unpleasant sensations in the body
• Fear that something terrible is going to happen
• Often people are afraid that they may collapse,
  lose consciousness, have a heart attack, lose
  control, go mad or even die.
• Panic attacks usually come on very suddenly and
  reach their peak within 10 minutes. The peak
  generally lasts for 5-10 minutes, but it can take
  much longer for all the anxiety to subside. In a
  panic, normal fear reactions are happening at the
  wrong time the body's "alarm system", which is
  designed to help you deal with emergencies, gets
  triggered off, exactly as if you were in real
  danger.

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What is panic disorder?How common is panic
disorder?

"Panic Disorder with Agoraphobia" is anxiety
about being in places or situations for fear of
having a panic attack or panicky feelings.
Situations may include being away from home,
queuing, travelling on public transport or using
lifts. Some people avoid these situations
completely. Others force themselves into feared
situations, but feel anxious and panicky
throughout. How common is panic
disorder? Between 1 and 4 people in 100 have
panic disorder at some stage in their life. It is
twice as common in women as in men. It usually
starts between the ages of 15 and 19 or between
25 and 30 years of age.
"Panic Disorder" means having repeated, frequent
panic attacks. People with panic disorder are
often very apprehensive about having more
attacks, and may change their behaviour or
lifestyle as a result of the attacks. "Limited
symptom panic attacks" are panic attacks with
less than four symptoms. For example, a sudden
episode of intense dizziness or nausea,
accompanied by fear that something terrible is
about to happen. Many people have a mixture of
full and limited symptom panic attacks.
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What is Agoraphobia?

• The word Agoraphobia is derived from fear of
  the Agora-the marketplace. People with
  agoraphobia typically fear being out in crowded
  places where it may be difficult to escape or
  find safety. The fear of being embarrassed also
  features, although this is also a feature of
  Social Phobia. Agoraphobics usually, but not
  always, fear crowded places some may also fear
  being alone, because they are concerned that they
  may panic when no-one is there to help them. Most
  people suffering from agoraphobia also feel
  anxious about or avoid public transport, because
  they feel it is difficult to escape. For some
  people their car can become an extension of
  home and allows them to travel greater
  distances. Most people with agoraphobia prefer to
  be accompanied if they go out, usually with
  someone they know well and trust. The avoidance
  typically interferes with the persons ability to
  work and socialise, often to the point of being
  housebound.
• Although agoraphobia commonly occurs in people
  suffering from Panic Disorder, there are many
  people who suffer from Agoraphobia alone. Some
  may have other problems which make them fear
  leaving their house, including Irritable Bowel
  Syndrome, Epilepsy and Osteoporosis.

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What happens during a panic attack?
These understandable behaviours such as avoidance
or more subtle behaviours which occur during a
panic attack can become very prominent and indeed
sometimes become the problem itself! Thus, in
agoraphobia the avoidance can often become more
of a problem than the panic attacks. Notice
however, that it is not a matter of just pull
yourself together. Everyone who suffers from an
anxiety disorder tends to think this kind of
thing. The reality is that nobody wants to suffer
from an anxiety problem and if the sufferer knew
how to pull themselves together they would do so!
Very often what the person needs is guidance on
how best to set about pulling themselves
together.
In a panic attack people typically become
frightened of the sensations of anxiety itself!
For example, a person walking down the street may
notice that their heart is beating quickly and
pounding. This, or other physical sensations,
although harmless can trigger off ideas such as
Im having a heart attack. Not surprisingly,
that kind of thought increases anxiety which in
turn increases bodily sensations which seem to
confirm the idea that the person is having a
heart attack further increasing anxiety and so on
in a vicious circle. The vicious circle which
most people experience is shown in a very
simplified form in the next page. Notice that a
panic can be triggered by physical sensations but
also by feeling anxious or upset and by the
thoughts themselves. The type of things which
people typically fear in a panic vary from ideas
of losing control over your behaviour through to
more physical catastrophes such as having a heart
attack, a stroke or fainting. Once the panic
attacks begin, a number of things can keep them
going. Particularly important is the things that
people do the person who is in the supermarket
when they have their panic attack rushes out
thinking that they just got away with it. In
fact, by rushing out what really happened is that
they didnt get the opportunity to discover that
the thing they are afraid of didnt happen!
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Can panic disorder be treated?

Yes! Cognitive therapy has been shown to be a
very effective way of treating panic disorder and
agoraphobia relatively quickly. This therapy is
very practical and active it focuses on your
thoughts and the way you behave. You and your
therapist work together to find out what is
keeping the problem going, and how to overcome
it. You may already have started to make efforts
in this direction. Cognitive therapy will offer
you new techniques, and will strengthen your own
efforts. The team at our clinic have played a
leading role in developing and improving
cognitive therapy for panic and agoraphobia. We
have an ongoing therapy and research programme
which aims to increase the understanding and
treatment of this condition. Treatment for
Panic Disorder and Agoraphobia at our Centre is
available for people whose GP is covered by
Southwark, Lewisham or Lambeth Primary Care
Trusts.
We are currently offering cognitive therapy for
panic disorder, and for panic disorder with
agoraphobia to patients who live within the South
London and Maudsley NHS Trust area. Treatment
involves up to twelve sessions with a therapist,
over a period of three months. Sessions are about
one to one and a half hours long. You will be
asked to keep written records of your panic
attacks, and to carry out "homework" tasks
between sessions to speed up your progress. One
of the most important goals of therapy is to help
you to become your own therapist in order to cope
with and overcome panic permanently.
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How do I get help?

If you have panic disorder, or panic with
agoraphobia, the first step is to VISIT YOUR GP.
They will be able to refer you to a cognitive
behavioural therapist or a clinical psychologist.
They may also offer you medication. If you live
within the South London and Maudsley (SLAM)
catchment area, you can ask your GP to refer you
to us, at the Centre for Anxiety Disorders and
Trauma. (Please see the SLAM website to find out
which areas it covers). Your GP can refer you to
us directly and just needs to send a short
letter. Occasionally, he or she may refer you to
a community mental health team or to a
psychiatrist first, for an initial assessment,
and they may refer you on to us.
Once your referral letter is received, we will
contact you to offer you an appointment for
assessment. This will involve filling in some
detailed questionnaires and attending an
assessment interview. If the assessment shows
that our treatment is likely to be helpful to
you, you will be placed on our waiting list for
therapy. We are usually able to offer people
appointments for assessment within a few weeks of
receiving the referral, but you may have to wait
for several months before beginning therapy. We
are doing our best to reduce waiting times. You
can also contact the British Association for
Behavioural and Cognitive Psychotherapies who
hold a list of all accredited therapists in the
country. You can visit their website at BABCP and
click on the find a therapist link or call them
on 01254 875277.
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Practical advice

• Here are some important facts about panic
  attacks
• No matter how bad it feels, panic attacks
  cannot actually harm you or make you go mad.
• Panic attacks do not last forever. They always
  pass after a while.
• How you think will affect how bad the panic is
  and how long it lasts.
• If you run away from a panic attack, you are
  making life harder for yourself in the longer
  term and your life will become more and more
  restricted.
• During a panic, remind yourself that you are not
  going to die, go mad or lose control. Try and
  just let the panic attack wash over you, without
  fighting it - just wait for it to subside by
  itself.

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I live with someone who suffers from panic
disorder. How best can I help them?

Everyone when stressed benefits from support. A
calm, reassuring presence whilst helping the
person to confront their fears is the best
approach if this is possible. However, when
someone is full of panic this can be difficult
and you should never force the person to do
things against their will. Once you have
identified the person has a problem, encourage
them to seek appropriate help. The anxiety
charities (see below) can provide useful advice
and support, sometimes through bulletin boards
and telephone helplines. The anxiety charities
offer self-help programmes either through
telephone, support groups or assisted by
booklets. Supporting the person and engaging in
these kind of programmes can be a very good way
of starting. Suffering from panic and agoraphobia
often goes with high levels of stress and
depression. People can feel hopeless and think
that they are never going to get better. Our
experience tells us that there is no such thing
as a hopeless case. It may be that the things
you have received before have not helped but
there is always going to be an alternative and
the person needs to keep trying until they find
their way through to something that will help
them.
If you are not able to find help and support then
encouraging the person to do a little bit every
day and then increasing the amount as time goes
on is an extremely useful strategy. However, if
every single occasion is accompanied by a panic
attack then it would be more appropriate to seek
professional help, not because it is harmful but
just because there is no point in keeping on when
something isnt working. Recognise that these
kind of problems can impact on yourself.
Supporting someone suffering from an anxiety
problem or other psychological difficulty can be
a great strain and it is helpful to have support
yourself. Sometimes professionals will offer such
support and the anxiety charities also can help
with this. National Phobics Society Tel 0870
122 2325 www.phobics-society.org.uk No Panic
Tel [phone] www.nopanic.org.uk
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I suffer from agoraphobia and cant go out to get
help. What can I do?
It is in the nature of agoraphobia that people
sometimes find it nearly impossible to get to a
clinic or sometimes even to their family doctor.
Some psychological treatment services offer
outreach which means that they will come to see
you in your own home. Your local service may also
be able to offer you contact details of support
groups who might be able to help you by
accompanying you to your GP or to the clinic. Of
course, if you have a relative or friend who is
able to take you that would probably be the best
alternative. We would suggest that whichever
service you might be likely to see, you write to
them explaining your difficulties in getting to
the service and asking whether they might be able
to make some special provision initially. If all
else fails, some of the self-help materials
specified in these pages may also be helpful in
terms of getting you to get started, perhaps to
the point where you can get to your GP. National
Phobics Society are currently offering
telephone-based help and this may also be an
alternative in the early stages of trying to
overcome your problem. An example of how panic
attacks work You will see a diagram on the next
page which helps you understand the kinds of ways
that panic attacks can evolve. Susan has panic
attacks whenever she goes into places where there
are a number of people that she doesnt know,
such as supermarkets or shopping centres. She had
a panic attack just thinking about going to her
local supermarket.
The panic started with her thinking about a
particular supermarket where she had previously
had several panic attacks. That thought triggered
feelings of being short of breath which, as it
started to build up, made her think Im going to
pass out. Not surprisingly she became
frightened at this idea and the fear increased
the physical symptoms she was experiencing so the
shortness of breath became worse and she started
to experience palpitations, chest pain, she felt
shaky and hot which reinforced the idea she was
going to pass out. Again, the strength of this
idea strengthened her fear and, as her chest
pains and palpitations became worse, a new
thought came to her mind which was perhaps Im
going to die and the anxiety will kill me. This
was even more frightening than the previous
thought and she became so frightened she
described it as feeling petrified. That very
intense fear and panic made the symptoms worse
and round it went in a vicious circle that became
a downward spiral making it impossible for her to
leave the house. The details of panic vary from
person to person but the basic vicious circle is
always pretty much the same which is physical
symptoms seeming to indicate that some terrible
thing is going to happen (having a heart attack,
fainting, losing control, going mad and so on).
Those very scary thoughts increase the fear which
in turn increases the physical sensation
reinforcing the belief and so on in the vicious
circle that we call panic.

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How panic works.
The panic vicious circle spiralling out of
control
Thinking about going where you previously had a
panic attack
Short of breath Chest pain, etc
Im going to pass out
Frightened and petrified
Im dying
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Are there support groups I could contact?
Services offered by NPS include 11 cognitive
behavioural therapy sessions, telephone helpline,
specialist phone-in services (including
agoraphobia phone-in services), quarterly
magazine Anxious Times', email support, online
services etc. Zion Community Resource Centre,
339 Stretford Road, Hulme, Manchester M15
4ZY Tel [phone] Emailsupport_at_phobics-soc
iety.org.uk www.phobics-society.org.uk Triumph
Over Phobia www.triumphoverphobia.com
No Panic is a voluntary charity, designed to help
people with panic disorder and other related
anxiety problems. It provides support to
sufferers and their families and or carers, and
uses cognitive behaviour therapy as a basis for
recovery. No Panic has a confidential help-line
(free phone 10am to 10pm, every day) staffed by
trained volunteers. It also offers pop-in
centres, telephone recovery groups, support for
people trying to give up tranquillisers, a
telephone based one-to-one mentoring scheme. 93
Brands Farm Way Telford Shropshire TF3 2JQ Tel
0808 808 0545 www.nopanic.org.uk National
Phobics Society NPS is the leading anxiety
disorders charity in the UK and offers a wide
range of support and services to people affected
by anxiety.

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Recommended reading

Overcoming Anxiety by Helen Kennerly (Robinson).
A guide explaining how to overcome problem fears
and anxieties of all kinds - from panic attacks
and phobias to executive "burn out" - in order to
regain confidence and self control. A
step-by-step self-help plan is included.
Panic Disorder The facts by Stanley Rachman and
Padmal de Silva (2nd Edition) published by Oxford
University Press 2004. Understanding Panic by
David Westbrook Khadija Rouf. A short but
practical self-help booklet for people with panic
attacks, based on a cognitive model. Available
through The Oxford Cognitive Therapy Centre,
Psychology Dept. Warneford Hospital Oxford OX3
7JX www.octc.co.uk
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Is anyone doing research on panic disorder?
Several projects are running at the moment
including research on previous treatments people
have received, the way in which people suffering
from panic have been referred (or not been
referred) for specialist treatment, and projects
on beliefs and behaviours in panic and other
anxiety problems. For further information
please contact Sandra Ewing by e-mailing
s.ewing_at_iop.kcl.ac.uk Do you suffer from panic
attacks or obsessional thoughts / compulsive
rituals? Are you a mum? Being a parent can be
difficult at the best of times, but coping with
this and obsessions or panic attacks can be a
huge stress. At the same time, it is clear that
lots of mums manage it well, whilst at the same
time having difficulties with specific issues.
We need to know more about how mums cope as well
as what things are difficult. This will help us
find better ways to help mums who are dealing
with the combined stresses of parenting and
anxiety problems. We are looking for mums with
children of between 7 and 14. The research is
about general parenting issues and is
confidential. It involves questionnaires and a
short interview with you and your child. (Nothing
about your anxiety problems would be communicated
to your child.) We can come to you or reimburse
travel expenses if you visit the clinic. Please
help if you can. The research is being conducted
by Professor Paul Salkovskis and Fiona
Challacombe. To find out more, call 0208 375
1852 or email f.challacombe_at_iop.kcl.ac.uk

For details of other studies please visit our
website http.psychology.iop.kcl.ac.uk/cadat Then
click on "research involving anxiety sufferers"
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If you would like to speak to someone about panic
disorder..
National Phobics Society ?Tel[phone] ?
www.phobics-society.org.uk
No Panic ?Tel[phone] ? www.nopanic.org.uk/
Triumph Over Phobia ? www.triumphoverphobia.com