Panic Disorder and Agoraphobia: A Strategic Approach

The World Health Organization defines panic disorder as a significant problem that affects up to 20 percent ​​of the world’s population, and women are twice as likely to be affected as men. While the experience of panic can seem mysterious and, at times, inexplicable when it happens, through our research, we have observed that panic disorder regularly evolves through progressive attempts at trying to control our own natural and spontaneous reactions to a perceived threat. This attempt at control usually seems to work for a period of time, up to and until the person experiences their first complete loss of control.

This overwhelming sense of panic and psychophysiological arousal that goes beyond the normal limit is perceived as a truly frightening and often akin to a life-threatening episode. It is normally the case that the fear of the experience of fear brings about the very panic the person is seeking to avoid, and the ongoing failed attempts at eradicating this cycle create a spiraling problem that becomes a vicious circle of behaviour and perception, which gets even more rigid with the increased repetition of the patient's unhelpful solutions.

A Problem Chasing Its Own Tail

The ongoing hypervigilance of the person toward themselves—their breathing, heartbeat, balance etc.—along with a strong desire to enforce control on any alteration in their physiology, precipitates the very fear the patient is seeking to control. When we reach this point, we can say that the "genie is out of the bottle," and the body’s natural arousal system is triggered. The greater the level of control one seeks to impose on one’s bodily reactions, the worse they become—leading to a panic disorder. The patient’s solution has now become their problem, and their problem is a result of their solution (see earlier post on mental traps). The person is now trapped, and any attempt to solve it through control is doomed to fail. This fear of panic and, later, the fear of it happening while out and alone, induce agoraphobia, or even claustrophobia with panic attacks.

Agoraphobia

In the case of agoraphobia, the patient usually seeks help and looks for anyone that might assist them by accompanying them in social situations or on any journey outside of the home. As referred to previously in this blog, all human behaviour is a form of communication, and every time a person seeks help and gets it, they trap themselves in what Watzlawick et al. (1967) called a double-bind. Each time someone accompanies them, "they confirm that they are safe because they have help, yet they also confirm they are incapable because they need the help," and, thus, their solution fuels their problem, and this drives their phobia to new extremes.

Some people with panic disorder have a clear and distinct location or situation that triggers fear, and others seem to live in constant fear of this ghost frightening them at any hand's turn, living their lives feeling like a soldier on a minefield perpetually anticipating a loss of control. Effective treatment allows us to act on these mechanisms and rapidly block the problem and resolve their disorder in 7 to 10 sessions.

Common Symptoms of Panic

• An overwhelming sense of dread or fear
• Chest pain or a sensation that your heart is beating irregularly
• Feeling that you might be dying or having a heart attack
• Sweating and hot flushes or chills and shivering
• A dry mouth, shortness of breath, or choking sensation
• Nausea, dizziness, and feeling faint
• Numbness, pins and needles, or a tingling sensation in your fingers
• A need to go to the toilet
• A churning stomach
• Ringing in your ears

Diagnosing Panic and Agoraphobia

Not everyone who has panic attacks has panic disorder. For a traditional diagnosis of panic disorder, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association, lists the following criteria:

• You must have frequent and unexpected panic attacks.
• At least one of your attacks has been followed by one month or more of ongoing worry about having another attack; continued fear of the consequences of an attack, such as losing control, having a heart attack, or "going crazy"; or significant changes in your behaviour, such as avoiding situations that you think may trigger a panic attack.
• Your panic attacks aren't caused by drugs or other substance use, a medical condition, or another mental health condition, such as social phobia or obsessive–compulsive disorder.

Panic is often misdiagnosed as generalized anxiety disorder (GAD), where, in reality, there is no experience of there being total loss of control, typical of panic with GAD. In GAD, the state of arousal is constant, but there is rarely, if ever, a tipping point into fear. Panic as we have defined it, is characterised by an extreme form of fear arousal, which begins to block people in their lives, or we might say it becomes "pathological," therefore requiring professional help. When the person becomes blocked by the problem—despite ongoing personal attempts to solve it—professional help becomes the most helpful solution. If we are to resolve this problem rapidly, then we use a strategic diagnosis, in which we focus our attention, not on describing the problem, but on intervening on how the problem functions or operates in the person's life and how we can intervene on the patient's attempts at a solution that are actually driving the problem.

Common Failed Attempts Used by Patients in Solving Panic

• They attempt to avoid fearful situations, which make them feel less able to face that monster that consumes their thinking and behaviour and increases their fear of those avoided situations and, thus, their self-confidence.
• A search for help and protection from fear, which at the same time provokes the feeling of safety, but then further fuels the perception of fear and felt sense of being incapable of managing their fears. By delegating our fears to others, we become wholly incapable of facing these situations alone and, thus, feed our sense of dependence and incapability.
• The ongoing and continual attempt to control one's own physiological reactions to fear, which paradoxically leads to a complete loss of control over our natural reactions.

Avoid Avoiding

To resolve this kind of difficulty, the clinician must act on the avoidant behaviour as we outlined. To do this, we must employ a series of suggestive interventions that are capable of redirecting the person's conscious attention during their feared situations leading to counteravoidance measures being adopted by the patient. Finally, through the use of refined, specific techniques (Gibson, 2021) we can interrupt their attempt to voluntarily suppress their spontaneous reactions with minimal effort, and we can then produce emotional detachment from the situation and create a newfound ability, on behalf of the patient, to manage their situations better.

In a later post, I will speak about the difference between a type of panic that is triggered by a fear of losing control and that which comes from a fear of dying, because the treatment is different (Clarke, 2018; Gibson, 2016, 2021; Nardone, and Portelli and Nardone, 2005).