Transcript Panic Disorder & Agoraphobia

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Panic Disorder &
Agoraphobia
Information on Panic Disorder & Agoraphobia
Prepared by Professor Paul Salkovskis and the Panic & Agoraphobia Team
the
Centre for Anxiety Disorders and Trauma,
Maudsley Hospital, London
In response to “The House of Agoraphobics”
On Channel 4, December 2006
at
We are unable to answer individual queries, so have prepared this
information to supplement that provided in our website.
“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
What is panic disorder?
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How common is panic disorder?
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What is agoraphobia?
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What happens during a panic attack
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Can panic disorder be treated?
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How do I get help?
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Practical advice
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I live with someone who suffers from panic disorder. How best can I help them?
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I suffer from agoraphobia and can’t get out to get help. What can I do?
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How panic works
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Are there support groups I could contact?
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Recommended reading
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Is anyone doing research on panic disorder
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Useful helpline numbers & websites
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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,
Different people have different combinations of
symptoms, but the general pattern is usually the same:
• Breathlessness
• A range of unpleasant sensations in the body
• Feeling unsteady, dizzy, light-headed or faint
• Fear that something terrible is going to happen
• Trembling or shaking
Often people are afraid that they may collapse, lose
consciousness, have a heart attack, lose control, go mad
or even die.
• Sweating
• Having a hot flush or chills
• Chest pain or discomfort
• Numbness or tingling sensations
• Feeling as if you or surroundings are unreal
• Nausea or churning stomach
• A sudden increase in anxiety
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.
• Choking
• Fear of dying
• Fear of losing control or going crazy
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What is panic disorder?
How common is panic disorder?
"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.
"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.
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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 person’s 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?
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 “I’m 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 didn’t get
the opportunity to discover that the thing they are afraid
of didn’t happen!
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”.
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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 isn’t 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: 0808 808 0545
www.nopanic.org.uk
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I suffer from agoraphobia and can’t 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
doesn’t 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
“I’m 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 I’m 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
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circle that we call panic.
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
Frightened and petrified
“I’m going to pass out”
“I’m dying”
Are there support groups I could
contact?
"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.
Services offered include 1:1 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: 0870 122 2325
Email:[email protected]
www.phobics-society.org.uk
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Recommended reading
Panic Disorder: The facts by Stanley Rachman and
Padmal de Silva (2nd Edition) published by Oxford
University Press 2004.
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 stepby-step self-help plan is included.
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 emailing [email protected]
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
[email protected]
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:0870 122 2325
 www.phobics-society.org.uk
No Panic
Tel:0808 808 0545
 www.nopanic.org.uk/
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