Panic Disorder and Agoraphobia: Causes and Clinical Approaches

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Panic Disorder and Agoraphobia: Causes and Clinical Approaches

Abnormal Psychology · Chapter 11: Anxiety-Based Disorders: Origins and Therapeutic ApproachesSection 11.2 · lesson 40 of 9716 min · free with a free account

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In this lesson

Why the condition is defined by what happens between the attacks.

  • Separate a panic attack from panic disorder
  • Explain agoraphobia and its current diagnostic status
  • Trace the cognitive model of panic through a cycle
  • Explain why safety behaviors block disconfirmation

Transcript

Everything said in the video, section by section (2,197 words). Read along, or search it.

Anxiety-Based Disorders: Origins and Therapeutic Approaches

Panic Disorder and Agoraphobia: Causes and Clinical Approaches

Someone has three episodes of sudden, terrifying fear over eight months, and changes nothing about their life. Someone else has one attack, and a year later no longer takes trains. Only the second one has panic disorder. That distinction is what this section is about. We begin with the attack itself, and why it is a feature rather than a diagnosis. Then the condition, which turns out to live in the gaps between the attacks. Then agoraphobia, which is not really about open spaces at all. After that, the cognitive model that organizes current treatment. And finally safety behaviors, which look like coping and are the reason the problem persists.

The Attack

A Feature, Not a Disorder

A panic attack is an abrupt surge of intense fear or discomfort. It reaches its peak within minutes, with physical and cognitive symptoms from a recognized list. Pounding heart, sweating, trembling, breathlessness, chest discomfort, nausea, dizziness. Also chills or heat sensations, numbness, a sense of unreality, and fear of losing control or dying. The abruptness and the rapid peak are what separate an attack from anxiety that builds gradually. Two distinctions matter immediately. An expected attack happens in a situation the person already fears. It has an obvious cue. An unexpected attack has no identifiable trigger at all. It can arrive from a calm state, or out of sleep. The unexpected kind does the work in panic disorder, and here is why. An attack with no apparent cause invites the person to search for an internal cause. So a panic attack is a feature, not a disorder. Attacks occur in depressive presentations, in the phobias of eleven point three, and in substance withdrawal. They also occur in people with no psychological condition at all, and many people have exactly one. One thing before we continue. This material is educational, and is not a basis for diagnosis. New or unexplained chest pain, breathlessness or fainting requires medical assessment, and must never be assumed to be panic.

The Condition

What Happens Between the Attacks

Panic disorder requires two things, and the second is where the condition actually lives. First, recurrent unexpected attacks. Second, a persistent consequence of them. That means sustained concern about further attacks, or about what they mean. Or a significant maladaptive change in behavior. Or both. The consequence must have lasted an extended period, rather than a few days. And the presentation must cause significant distress or impairment. Attacks fully accounted for by a substance or a medical condition are excluded. Now the clinically important part. The condition is not defined by how many attacks occur. It is defined by what has happened to the person between them. Anticipatory anxiety is apprehension about having another attack. It converts an intermittent event into a continuous state, and that shift has a name. The fear of fear. The object of apprehension moves from the outside world to the person's own body. So someone can have frequent attacks and not have the disorder, if nothing changes between them. And someone can have infrequent attacks and be severely impaired, because their life has reorganized around avoiding them.

Physiology

Every Alarming Sensation Is a By-Product

The bodily events of an attack are the sympathetic branch of the stress response. That was introduced in three point one, and is treated fully in chapter thirteen. Functionally, the system is preparing the body for vigorous action. Heart rate and force increase, to move blood to the large muscles. Breathing quickens, blood is redirected away from the skin and the digestive system. Sweating begins, to pre-cool the body. The pupils widen. Every sensation the person finds alarming is a by-product of that preparation. The pounding heart is cardiac output rising. The breathlessness is over-breathing, relative to what the body is actually consuming. That alters blood chemistry, and produces dizziness, tingling, and a sense of unreality. The chest tightness is intercostal muscle tension. The nausea is digestion having been shut down. Two things have to be held together here, and students usually drop one of them. First, the sensations are not themselves dangerous. The response evolved to be survivable, and it is self-limiting, because the system cannot sustain that output. Fainting during an attack is uncommon, because blood pressure rises rather than falls. Second, none of that licenses anyone to conclude that their own chest pain is panic.

Two Readings

The Sensation Is Identical; Only the Reading Differs

Now put the sensations and their two possible readings side by side. A racing heart is sympathetic activation raising cardiac output. The catastrophic reading is, I am having a heart attack. The accurate reading is a normal, self-limiting cardiac response to alarm. Which does not remove the need to medically assess any new cardiac symptom. Breathlessness is breathing rising above what the body is consuming. The catastrophic reading is, I am going to suffocate. In fact oxygen is abundant. The sensation is one of too much breathing, not too little. Dizziness and tingling come from altered blood chemistry produced by over-breathing. The catastrophic reading is fainting. But fainting is uncommon, because blood pressure rises. Detachment from oneself is altered processing under high arousal, and it resolves as arousal falls. Look at what changes across those rows. The sensation is identical. Only the reading differs. That is the whole rationale for treatment. Nothing about the body needs to change for the attack not to escalate.

Agoraphobia

Organized Around Escape and Help

Agoraphobia is marked fear about situations from which escape might be difficult. Or in which help might be unavailable, if panic-like or incapacitating symptoms occurred. The name gets misread as fear of open spaces. That is not the organizing theme. The theme is escape and help, which is why a crowded shop can be harder than an empty field. The situations cluster into recognizable groups. Public transport. Open spaces such as parking lots or bridges. Enclosed spaces such as shops and movie theaters. Standing in line or being in a crowd. And being outside the home alone. The diagnosis requires fear across several of those clusters. That is what separates it from a specific phobia of one of them. In the current classification, agoraphobia is a diagnosis in its own right. It was previously a subtype or specifier of panic disorder. The change reflects evidence that it occurs in people who have never had full panic attacks. One more thing deserves separate mention. The safety person. A companion whose presence makes a situation manageable helps enormously in the short term. And obstructs in the longer term, because every successful outing is credited to them. The person accumulates experience of coping, and none of it counts.

The Model

Catastrophic Misinterpretation

The account that organizes current treatment was set out by David Clark, in nineteen eighty-six. Its central claim is that attacks result from catastrophic misinterpretation of benign bodily sensations. An ordinary or stress-related sensation is read as evidence of immediate catastrophe. A racing heart is read as a heart attack beginning. Dizziness as an imminent collapse. Unreality as losing one's mind. The misinterpretation is what closes the loop. Follow it round. Interpreting a sensation as dangerous produces apprehension. Apprehension activates the sympathetic response. That response intensifies the very sensation being interpreted. And the intensified sensation confirms the interpretation. The cycle escalates within seconds, not minutes. That is why an attack peaks so quickly, and why it feels unlike ordinary anxiety. Now notice where this model says the loop can be opened. The sensation cannot be prevented, and the physiology cannot be argued with. But the interpretation is a belief. And beliefs can be tested.

Body Sensitivity

Why Attacks Appear to Come From Nowhere

Interoception is the perception of internal bodily states. Two processes make a person more and more likely to detect the sensations they fear. The first is interoceptive conditioning, following the classical conditioning principles of five point one. A low-level bodily sensation becomes a conditioned cue for alarm. So a slight increase in heart rate, far below the level of an attack, now triggers apprehension. The second is attention. A person monitoring their body detects more of what is there. Ordinary fluctuations that everyone has are constantly available to be noticed. The result is someone who detects more sensations, and responds to smaller ones. Which is exactly why attacks can appear to come from nowhere. One condition-specific biological proposal is worth describing. Donald Klein's suffocation false alarm hypothesis was published in nineteen ninety-three. It proposed that panic involves the misfiring of a system that monitors for suffocation. An alarm is triggered with no actual respiratory threat present. It is supported by two findings, and limited by three qualifications. People with the condition are more likely to have attacks when inhaling air with raised carbon dioxide. And respiratory symptoms are prominent in the presentation. But not everyone responds that way, and respiratory symptoms are not universal. The finding is also compatible with the cognitive account, so treat it as partial support.

Safety Behaviors

The Single Most Important Maintaining Factor

A safety behavior is an action taken to prevent a feared catastrophe. Or simply to make a situation tolerable. Sitting down, holding onto something, carrying water or medication, staying near an exit. Checking one's pulse, breathing in a particular way, having a companion present. They feel entirely sensible. They are the single most important maintaining factor in this condition. The mechanism is blocked disconfirmation, and it is worth going slowly here. The person believes that without the safety behavior, catastrophe would follow. Every time they perform it and survive, the experience confirms that belief rather than testing it. The outcome gets attributed to the behavior. So a person may have had hundreds of attacks, all of them survived. And hold the belief that they are dangerous exactly as strongly as ever. Because on their own account, they survived because of what they did. This is why simply entering feared situations is not sufficient treatment. Dropping the safety behaviors is the active ingredient. They are easy to miss, because they look like coping and go unreported unless asked about. So ask what the person does to get through the situation, not only whether they avoid it.

Differential

What Must Be Considered First

Panic disorder is diagnosed after physical causes have been considered. Never by assuming that alarming sensations must be anxiety. Cardiac conditions share chest discomfort, palpitations, breathlessness, sweating and fear. What distinguishes them is symptoms on exertion rather than at rest, and pain that radiates. Also symptoms that do not settle as arousal falls. Medical assessment is not optional here. And it does not become optional after a psychological diagnosis has been made. Respiratory conditions share breathlessness, chest tightness, and the sense of smothering. Look for wheeze, and for symptoms tied to exertion, allergens or infection. Endocrine conditions share palpitations, tremor, sweating and apprehension. There the symptoms are persistent rather than episodic, and may come with weight change. Thyroid conditions in particular can closely mimic this presentation. Vestibular conditions share dizziness, unsteadiness, unreality, and fear of collapse. There the dizziness precedes the alarm, rather than following it. Substance-induced panic can be indistinguishable in the moment. What settles it is the timing relative to use or withdrawal, with stimulants and caffeine among the associations. And finally, panic occurring within another anxiety condition. If every attack has a situational cue, the diagnosis lies elsewhere in this chapter.

Treatment

Derived Directly From the Model

Treatment follows directly from the cognitive model, and is described here at the level of principle. None of it is a procedure to attempt alone. Psychoeducation establishes what the sensations are and why they occur. That is what makes an alternative interpretation available in the first place. Cognitive work then targets the misinterpretation directly. It examines the evidence for the catastrophic belief, and for the alternative account. Interoceptive exposure is a clinician-delivered procedure. Sensations resembling those of panic are deliberately brought about, in a controlled setting. The person experiences them without the feared catastrophe occurring. So the conditioned association between sensation and alarm can weaken. The rationale is that the feared stimulus here is internal. Exposure therefore has to be to the sensations themselves, not only to places. Attempting to induce panic sensations without clinical guidance is unsafe. It can worsen the condition, and it is inappropriate where a physical cause has not been excluded. Situational exposure addresses agoraphobic avoidance, following the principles of five point four. And dropping safety behaviors runs through all of it. Exposure with the safety behaviors intact lets the person credit the outcome to them.

What To Carry

Durable Claims From This Section

Gather this into claims worth keeping. A panic attack is a feature, not a disorder. It occurs across conditions, and in people with none. Panic disorder is defined by the persistent consequence, not by the number of attacks. The sensations are by-products of preparation for action, and are not themselves dangerous. That never licenses attributing your own physical symptom to anxiety. Agoraphobia is organized around escape and help, and is now a diagnosis in its own right. The interpretation is the point at which the panic cycle can be opened. Safety behaviors block disconfirmation, which is why exposure alone is not enough. Medication is described by class only, with several antidepressant classes having evidence. Another class is sometimes used short-term, and can itself function as a safety behavior. Panic disorder responds well to treatment, and is among the more treatable conditions here. Two honest qualifications. Long-established agoraphobic avoidance takes longer to reverse than the attacks. And relapse risk is higher where safety behaviors were retained, because the belief was never tested.

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FAQ

Questions students ask us

About Panic Disorder and Agoraphobia: Causes and Clinical Approaches

What is the difference between a panic attack and panic disorder?
A panic attack is an abrupt surge of intense fear that peaks within minutes, while panic disorder requires recurrent unexpected attacks plus lasting consequences. Those consequences are persistent worry about further attacks or what they mean, or a significant change in behavior such as avoidance. Panic attacks also occur in other conditions and in people with no disorder at all. Panic disorder is defined by what happens between attacks, not by how many occur.
What is agoraphobia?
Agoraphobia is marked fear of situations where escape might be difficult or help unavailable if panic-like or incapacitating symptoms occurred. Despite the name, it is not mainly fear of open spaces; a crowded shop can be harder than an empty field. Feared situations include public transport, open or enclosed spaces, lines and crowds, and being outside home alone. In DSM-5 it became a separate diagnosis rather than a subtype of panic disorder.
What is the cognitive model of panic disorder?
The cognitive model, set out by David Clark in 1986, proposes that panic attacks result from catastrophic misinterpretation of harmless bodily sensations. A racing heart is read as a heart attack or dizziness as imminent collapse, the alarm triggers more arousal, and the stronger sensations seem to confirm the danger, so the cycle escalates within seconds. The interpretation is the point where treatment can break the loop, because a belief can be tested.
What role do safety behaviors play in panic disorder?
Safety behaviors, such as sitting down, carrying water, checking one's pulse, or bringing a companion, are considered the single most important maintaining factor in panic disorder. Each time the person survives an attack, they credit the behavior rather than learning that the sensations were not dangerous. Someone can survive hundreds of attacks and still believe they are dangerous. That is why entering feared situations is not enough unless safety behaviors are also dropped.

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