Panic Disorder & Agoraphobia

1. www.phobics-society.org.uk Links in this document are live if in presentation mode (click on the icon at the bottom left of your screen) Panic Disorder & Agoraphobia 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

2. “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.

3. Here are some questions we get asked frequently about panic disorder and agoraphobia

4. 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 • Nausea or churning stomach • Choking • Fear of dying • Fear of losing control or going crazy • 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.

5. 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.

6. 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.

7. 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 “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!

8. 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.

9. 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.

10. 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.

11. 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

12. 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 circle that we call panic.

13. 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 “I’m going to pass out” Frightened and petrified “I’m dying”

14. Are there support groups I could contact? Services offered by NPS 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:support@phobics-society.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.

15. 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

16. 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@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@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"

17. 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/ Triumph Over Phobia www.triumphoverphobia.com