Panic disorder and agoraphobia*

60 PANIC DISORDER AND AG0RAPHOBIA

Panic disorder

Key cognitions in panic disorder

The physical and mental catastrophes feared in panic disorder are numerous, and are usually experienced as imminent. Patients may fear fainting, falling, vomiting, having a stroke, going crazy, having a heart attack, becoming paralysed with fear, not being able to walk properly, suffocating, dying, or being suddenly incapacitated in some other way. There can also be some overlap with hypochondriasis, in which the feared catastrophe is seen as likely to occur at some time further in the future, when the current symptoms of hypothesized disease culminate in severe illness or death. Dizziness or blurred vision may be seen as an early symptom of a brain tumour, and this interpretation may cause an exacerbation of anxiety, and hence of worrying symptoms, leading to a panic attack.

Typical safety behaviours

Safety behaviours are behaviours the patient engages in to ensure that the feared catastrophe does not occur. These include avoidance of certain situations, and a host of other small behaviours designed to abort symptoms and catastrophes. These include holding on to things or people, deliberate changes in breathing pattern, distraction, etc. It has been demonstrated (Salkovskis 1991) that there are logical links between safety behaviours and catastrophic beliefs in panic disorder. Thus, a person who fears that they are about to have a heart attack or a stroke will slow down or stop, whilst someone who fears that they are about to be paralysed by fear will keep moving. People who fear impending insanity may use distraction to control their thoughts, and may also keep tight control over their behaviour.

Triggers for panic attacks

A huge variety of stimuli can trigger a panic attack. People with panic disorder will be acutely attuned to their bodies and prone to notice immediately any physiological changes, which they interpret as signs of impending catastrophe. These might include feeling hot, heart pounding or missing a beat, dizziness, visual disturbance, feeling wobbly, racing thoughts, de-realization, and many other sensations. The causes of these trigger symptoms can also be hugely varied and could include physical exertion, too much coffee, a hot day, a nightmare, or emotions like anger or excitement. The initial symptoms can be spotted so rapidly and the misinterpretation is often made and followed by anxiety symptoms so swiftly that it may seem to the patient that the attack has come out of the blue.

SPECIAL CONSIDERATIONS 61

Treatment of panic disorder

Treatment involves generating alternative, less catastrophic, credible explanations for the causes and consequences of the symptoms of which the patient is so fearful, and from which they try to protect themselves by avoiding triggers and carrying out safety behaviours. Detailed accounts of the structure of treatment are given in the references cited above.

Special considerations

The model suggests that people with panic disorder are very afraid of their symptoms and do not understand what is causing them. Therapy may involve asking the patient to do something in order to evoke the frightening symptoms and test their consequences. Understandably, patients will be reluctant to deliberately evoke symptoms which they assume may be lethal or otherwise catastrophic. There are various ways to handle this:

1If the patient is fairly well engaged, and has a measure of trust, it may be beneficial not to explain in advance that this manoeuvre may evoke the symptoms. This can be helpful in two respects: firstly, the patient is likely to be less reluctant, and secondly, the symptoms evoked are more likely to be unexpected and therefore frightening, and hence seen as more similar to those experienced during a panic attack. The patient may quickly become distressed, and it is important to spend ample time reflecting and debriefing, as described in the example below. Before conducting such an experiment the ground will usually be prepared by verbal discussion. This means that the therapist can then refer back to alternative, non-catastrophic theories about the causes and consequences of their symptoms, and help the patient reflect on which theory is best supported by their experience during the experiment.

2If it seems that the relationship may be damaged by not being open, explain the rationale. This may mean that the patient holds back, or finds the experience only mildly reminiscent of panic (because the patient knows what is causing the symptoms, and how to stop them). Again, these aspects will need to be addressed, using questions such as ‘So those experiences were similar to those in your panic attacks, but not exactly the same—what would the experience have been like if those symptoms had come on out of the blue?’

3It may help to do the experiment with the patient, so that both of you evoke symptoms that can be compared. The therapist can even start to evoke the symptoms some seconds before indicating to the patient that he should start, so that he can observe how the therapist reacts.

4If all else fails, it is useful for the therapist alone to bring on the symptoms first, to demonstrate their normal, harmless (though unpleasant) quality.

BEHAVIOURAL EXPERIMENTS 63

significantly—she was unable to venture out unless accompanied by one of her children or her husband, and had become depressed. Her first husband and her mother both died of a heart attack. She was afraid that she would die in the same way, and scanned her body for physical symptoms to support this belief. She also believed that if she felt hot or dizzy during a panic attack she would faint.

Target cognition ‘When I get palpitations (i.e. my heart beats more quickly), this is a sign of heart disease, and indicates that I am going to have a heart attack.’

Alternative perspective An increase in heart rate may be the result of lots of benign things, such as an increase in exercise, anxiety, stress, or too much caffeine.

Experiment The patient was asked to run up and down stairs with the therapist for one minute.

Rationale (not explained in advance) An increase in heart rate is the body’s way of coping with the extra demands placed on it. In terms of stress or anxiety, it is the body’s natural response to an increase in adrenaline, preparing an organism for ‘fight or flight’.

Reflection Ellen’s heart rate increased and she was out of breath. The therapist described similar sensations. Ellen noted the similarity between these symptoms and those she experienced in a panic attack or when under stress, even though she was less frightened because she understood what was causing them. Ellen was then asked several questions:

What did she make of the fact that both she and the therapist experienced the same physical sensations?

What did she make of the fact that symptoms similar to those experienced during a panic attack could be brought on by exercise?

What did she make of the fact that she didn’t have a heart attack despite feeling this way?

What did she make of the fact that although she kept exercising she did not have a heart attack and her symptoms reached a plateau?

The therapist explained that this experiment was carried out to see whether there might be less frightening explanations for some of her symptoms. It was suggested that Ellen might like to ask a friend to do this experiment and see what happened. She was also asked to reflect on what effect this experiment had on her belief that an increase in heart rate always has a serious cause.

64 PANIC DISORDER AND AG0RAPHOBIA

Tip If the symptoms induced had not been seen as similar to those in panic, the therapist would have moved the session on. This format can be used in any experiment where the aim is to help the person discover the true causes of symptoms. Usually it is best to explain the rationale after the test rather than before, as this enhances the likelihood that the patient will be prepared to make the test, and increases the chance that the element of surprise will create a more similar experience to that observed in panic.

A set of similar experiments to discover benign causes for symptoms is laid out in Table 3.1.

Discovering the true consequences of symptoms when safety behaviours are not carried out

People with panic disorder feel they have good reasons for believing that catastrophe may strike, and are therefore motivated to protect themselves by engaging in safety behaviours. Then if no physical or mental catastrophe ensues they are likely to conclude that the precautions they took were necessary and effective, or that they had a lucky escape. The experiments described here are to investigate what happens if the symptoms once evoked are allowed to continue, without the use of safety behaviours. The rationale is explained in advance: as providing an opportunity for the patient to discover if it is worth putting so much effort into preventing a catastrophe that may not occur.

Experiment 3.2: to determine the consequences of feeling wobbly

Problem Sally was 36 years old and suffering from panic disorder with agoraphobia, depression, social anxiety, and an eating disorder. She had been unemployed for two years, following a row at work.

Target cognition ‘I feel wobbly when I panic. If I do not hang on to someone or something I will collapse or fall over.’

Alternative perspective ‘The wobbliness is just a feeling. I do not need to control it—I will not end up collapsing or falling down.’

Prediction ‘If I let go of my shopping trolley (or my husband’s arm) when I feel panicky I will fall or collapse.’

Experiment Sally usually went shopping with her husband. She stayed with the trolley and he went to get the food. In this experiment, Sally went into the supermarket where she often felt panicky. She pushed a trolley into the shop and left it in an aisle. She then walked along several aisles alone, which would

68 PANIC DISORDER AND AG0RAPHOBIA

Target cognition ‘If I feel light-headed I will faint. The longer I feel this way the greater the chance that I will collapse.’

Alternative perspective ‘Feeling dizzy when anxious is not a sign that I will faint or collapse, even if it persists for a long time. This sensation is caused by breathing more quickly and/or deeply than usual, which is part of the ‘fight or flight’ reflex when someone is scared.’

Experiment Patient and therapist stood up and breathed deeply, (exactly as Brian would in a panic attack) for five minutes. The therapist ensured that the patient did not use safety behaviours.

Reflection After 30 seconds, Brian felt light-headed, had blurred vision, and was starting to feel panicky. He was willing to continue over-breathing to find out what would happen. By the end of five minutes his fingers were tingling and he believed that he might faint. However, his symptoms had begun to plateau after about 30 seconds. He commented on the similarity between these symptoms and those he experienced in a panic attack. The therapist then disclosed how she felt—she also felt dizzy and light-headed, her vision was blurred, and she felt as if she was swaying to and fro.

Brian realized that he did not come to any harm, and that beyond a certain point symptoms did not get any worse despite being unpleasant. He noted that by not holding onto the chair or wall he allowed himself to find out that he still would not fall down. He realized that he did not need to worry about the symptoms of panic; that he was not going to cross a threshold and collapse—it just didn’t get any worse beyond a certain point.

Tip Some therapists are nervous about this experiment, having heard (for example) of people who did collapse after over-breathing at school in an attempt to avoid games lessons or assembly. This is achieved by the Val Salvia manoeuvre, in which deliberate over-breathing is followed by abrupt cessation of breathing and intense pressure in the diaphragm. This is difficult to achieve even with effort, and is different from the increased respiration associated with panic.

This format can be used in any experiment where the aim is to help the person discover the true consequences of symptoms. As before, it is usually best to explain the rationale after the test rather than in preparation for the experiment. Any symptoms the patient fears can be exaggerated in this way. In every case it is helpful for the therapist to model the experiment before the patient tries it. Also, patients sometimes enjoy persuading a friend or relative to test their predictions.

A set of similar experiments is laid out in the Table 3.3.

70 PANIC DISORDER AND AG0RAPHOBIA

Testing if certain safety behaviours may make symptoms worse

Some things that patients do to try and feel better unfortunately make the symptoms worse. The patient can be encouraged to repeatedly carry out the safety behaviour and observe the results.

Experiment 3.4: to test the effects of exaggerating a safety behaviour (tensing legs)

Problem June had become very anxious about her health, and had lots of panic attacks.

Target cognition When June had a panic attack, she would often feel as though her legs would give way. She tensed her legs as hard as she could, in order to prevent herself from collapsing.

Alternative perspective The other possibility was that focusing on her legs and tensing them as she walked made them feel much worse.

Prediction operationalized June and the therapist both agreed to walk around the shopping centre, first tensing their legs as much as possible, and then focusing away from their legs and letting them relax.

Experiment June and the therapist tried this out.

Reflection June realized that by tensing her legs she was making it harder to walk normally. She and the therapist felt much better when they did not tense up and when they focused away from their legs. June realized that she was inadvertently creating the strange sensations she was trying to control.

Table 3.4. shows some more safety behaviours, their imagined benefits, and likely effects.

Agoraphobia

Key cognitions

It is interesting to speculate why some people with panic disorders are more avoidant than others, and why they avoid particular types of situation (Clum and Knowles 1991). In particular, it is curious that public places are avoided, since help might be more readily available then when alone. It has

72 PANIC DISORDER AND AG0RAPHOBIA

been suggested (Hackmann 1998) that the anxiety equation may throw light on this puzzle. Beck et al. (1985) point out that anxiety is a product not only of the perceived probability of a feared event, but also of the perceived cost, and the perceived lack of coping and rescue factors. A recent study of the images of agoraphobics (Day et al., in preparation) suggests that the imagined interpersonal cost of a physical or mental catastrophe is typically inflated, and is combined with doubts about the ability to cope or the likelihood of being rescued.

Agoraphobics are more likely to fear fainting than less avoidant panic patients (Salkovskis, personal communication). This is because they have distorted beliefs about how they imagine others would react (e.g. being totally ignored, attracting a huge embarrassing crowd, being taken to hospital and certified insane). In addition, more avoidant clients may fear that they would not be able to cope on their own if they felt ill, or that they could be separated from loved ones who would not come to rescue them. This is in line with the literature, which suggests that people with agoraphobia are more likely to exhibit features of avoidant or dependent personality, and to suffer from separation anxiety and a perceived lack of self-sufficiency than patients who suffer from panic disorder without agoraphobia. (For a detailed review and fuller discussion see Hackmann 1998.)

In the panic literature more emphasis has been placed on reducing the probability that certain symptoms mean that a physical or mental catastrophe will occur, than on investigating and treating distorted beliefs about coping and rescue factors. It appears that more avoidant clients have catastrophic ideas about how people would react if they vomited, fainted, collapsed, fell, wobbled, lost control, or looked weird. Predictions could include ridicule, being ignored, a crowd gathering, or being forced to go to hospital.

Typical safety behaviours

The most obvious safety behaviour in agoraphobia is clearly avoidance of places from which escape might be embarrassing or help unavailable in the event of a panic attack or panic-like symptoms. In addition, the patient may insist on the presence of a trusted companion, a mobile phone, or to carry a note of their name and address, or refuse to go to unfamiliar places or to travel far from home or from hospitals. They may be unfamiliar with travel, transport arrangements, or the use of maps. They may have had little experience of asking strangers for help or of asserting themselves when appropriate, all of which contributes to their anxieties about coping and rescue.

BEHAVIOURAL EXPERIMENTS 73

Behavioural experiments

Experiments to discover how others would react in the event of a physical or mental catastrophe

Experiments 3.5 and 3.6: to test how others would react to loss of bladder control

Experiment 3.7: to test the reactions of others to fainting

Experiments to see how well the patient could cope in these circumstances

Experiment 3.8: to test ability to cope with being lost

Experiments to determine the extent of rescue factors

Experiment 3.9: to test the existence of rescue factors in unfamiliar surroundings

Additional experiments in each category are presented in Tables 3.5 and 3.6.

Determining the reactions of others

In the classic experiment, the therapist accompanies the patient to a public place, then pretends to be going through the feared catastrophe whilst the patient studies passers-by for their reactions. It can be helpful to have two therapists present, so that one can support the patient whilst the other acts out the catastrophe. Therapists are understandably rather reluctant to test such beliefs, but practice helps them test their own predictions, as well as those of the patient. The results are most valuable and encouraging for the patient.

Experiments 3.5 and 3.6: to test the reaction of others to loss of bladder control

Problem Christine was a 50-year-old woman with a 32-year history of agoraphobia with panic and recurring severe depression. Her life had become very restricted by a wide range of difficulties. At a day-to-day level, her pronounced fear that she would lose control of herself and her bodily functions in public was perhaps most disabling, as it prevented her from engaging in many activities which might be beneficial to her self-esteem and mood. Christine had already undertaken a series of behavioural experiments to test the probability of the feared loss of control, and her belief about the likelihood of wetting herself during a panic attack had reduced to 40%. However, the perceived cost had remained unchanged and absolute (belief 100%).

Target cognition ‘If I faint I will be ridiculed—people will laugh and point at me.’

Testing the prediction Two therapists went with Susan to the High Street of her local town. One therapist watched with Susan, whilst the other pretended to have fainted and continued to lie on the floor.

Result One or two people approached the ‘patient’ to see if she needed help. No one laughed or pointed at her.

Reflection ‘People behaved respectfully towards the therapist, but they might jeer or laugh at me.’

Follow-on experiment The experiment was repeated with Susan doing the ‘fainting’ in a local shop. The results were the same: people were helpful, rather than mocking.

Tips Table 3.5. suggests ways to mimic other feared catastrophes, in order to test the reactions of others. Almost invariably the result is just what the patient would wish. They are not ignored if they would like help, and no one appears to take much notice if embarrassment is feared. Other people seem sensitive and helpful. Most do not appear to conclude that the patient is drunk, mad, seriously ill, abnormal, etc.

Seeing how the patient would cope if there was a catastrophe

Patients often have fears of getting lost, trapped, or separated, not getting home, not being able to explain their problems, or not being able to resist other people taking control in an unwelcome way. Some of these fears sound extreme and childlike, and indeed many of them have been around since childhood and have never been updated. Patients need support and encouragement to do experiments in public places to test their ability to cope if the worst happened.

OTHER RELATED CHAPTERS 77

Experiment 3.9: to test for the presence of rescue factors in unfamiliar situations

Problem Cheryl was in her forties, with a family. She suffered from panic disorder with agoraphobia, but also met criteria for avoidant personality disorder. As the panic attacks began to subside, Cheryl realized that she was still afraid of travelling to unfamiliar places.

Prediction ‘If I go to new places I will not be able to find my way around, or get back home.’

Experiment Cheryl arranged to travel to London by bus, to visit the London Eye.

Result Cheryl managed the trip without any problems. She discovered that everything was clearly marked and signposted, and that she could read the timetable. She also travelled by taxi to a London store, and found that her first ever taxi ride was also easy to cope with—the taxi driver understood her instructions and told her how much she owed him.

Reflection ‘I do not need to worry so much about new activities. There are always people around to help, and anyway it is usually made quite clear what one needs to do. However, I am going to have to keep practising, and slowly expand my horizons.’

Conclusion

Panic disorder can usually be treated with a range of experiments encompassing the causes and consequences of symptoms, including attention to any probability, cost, coping, and rescue factors about which the patient is concerned. With more avoidant patients nearly all experiments should be done out of the office, as cognitions are more likely to be accessible, and the full range of predictions can be tested. Behavioural experiments can be used to test negative automatic thoughts and assumptions, and even to weaken core beliefs. Some of the more entrenched beliefs may require more repetition of experiments, verbal discussion, and schema-focused techniques. However, even with very entrenched problems, behavioural experiments can be empowering and effective.

Other related chapters

Co-morbid depression may need treatment in its own right (see Chapter 10). Panic disorder and agoraphobia overlap significantly with health anxiety (see Chapter 4). Underlying issues may include problems with self-esteem (see Chapter 20), social anxiety (see Chapter 7), interpersonal difficulties (see

78 PANIC DISORDER AND AG0RAPHOBIA

Chapter 19), and avoidance of affect (see Chapter 17). Thus any of these chapters may be useful. The chapter on physical health problems (Chapter 15) may be of relevance to those with co-existing health problems.

Further reading

Salkovskis, P.M. and Hackmann, A. (1997). Agoraphobia. In: G. Davey (ed), Phobias: a handbook of theory, research and treatment. Wiley, Chichester.

Salkovskis, P.M., Clark, D.M. and Gelder, M.G. (1996). Cognition-behaviour links in the persistence of panic. Behaviour Research and Therapy, 34, 453–8.

Tales from the Front Line

An accidental experiment

Arriving at work in the usual post school-run rush, the therapist parked her car and charged upstairs to get ready for the first client of the day.

Half an hour later therapist and patient were considering evidence for and against the belief that the patient was the only person in the world who ever did stupid things, everyone else being mega effective and efficient. The patient would break off every now and then to question why they were wasting their time doing this when it was obviously true that she was indeed the most careless and stupid person ever to occupy a human body.

Just as the therapist began to despair, a loud crashing noise could be heard outside the window that had both therapist and patient out of their seats, peering down into the car park.

The therapist’s car had reversed at speed into the side of a brand new vehicle at the opposite side of the car park. In her rush, the therapist had left the hand brake off and her car had made good use of its freedom by rolling backwards down the slight incline, gathering momentum and achieving considerable speed before finally crashing into the other car.

Pausing for consideration, patient and therapist exchanged looks ‘You were saying?’

This page intentionally left blank