"When I have a panic attack, I feel like I'm dying. Now I'm scared to drive on the freeway. What if I have a panic attack when I'm driving?"

What are panic attacks?
A panic attack is a discrete period of intense fear or discomfort, in which symptoms develop abruptly, reach a peak within ten minutes, and involve four or more of the following symptoms:

• palpitations, pounding heart, accelerated heart rate
• sweating
• trembling or shaking
• shortness of breath or smothering sensations
• feelings of choking
• chest pain or discomfort
• nausea or abdominal distress
• feeling dizzy, unsteady, lightheaded, or faint
• derealization (feelings of unreality)
• depersonalization (feeling detached from one's self)
• numbness or tingling sensations in the extremities
• chills or hot flushes
• fear of losing control or going crazy
• fear of dying

An episode that involves fewer than four of these symptoms is called a "limited-symptom attack" and may also cause intense fear or discomfort.

What is panic disorder with agoraphobia?
Panic disorder is characterized by recurrent, unexpected panic attacks that seem to "come out of the blue" and are followed by at least 1 month of any of the following problems:

• persistent concern about having another attack
• worry about the implication or consequences of an attack (fear of going crazy or having a heart attack)
• significant behavioral changes because of the attack

People who have Panic Disorder often have Agoraphobia. Agoraphobia is anxiety about being in places or situations where escape might be difficult or embarrassing or where help may not be available in the event of a panic attack or panic symptoms. Typical situations that people with agoraphobia avoid include:

• driving (especially freeways, bridges, and tunnels)
• public transportation (subways, trains, and airplanes)
• crowds
• waiting in line
• restaurants, stores, theaters
• being alone
• being far from home

Cognitive-behavioral Model of Panic Disorder with Agoraphobia
Panic attacks occur when the body's natural fight-or-flight response is triggered out of context, that is, in the absence of a life-threatening situation. The cognitive-behavioral model of panic disorder with agoraphobia proposes that the symptoms of the disorder occur when people view the bodily sensations of the fight-or-flight response (sensations like increased heart rate, sweating, and lightheadedness) as dangerous, and then become frightened of the sensations and avoid places in which they fear experiencing them.

Cognitive behavior Therapy for Panic Disorder with Agoraphobia
Cognitive-behavior therapy for panic disorder with agoraphobia has several key elements:

• Education: Learn about the symptoms of panic attacks, their causes, and the factors that maintain them.
• Monitoring: Learn about the physiological, cognitive, and behavioral components of your panic symptoms and avoidance cycles.
• Cognitive strategies: Identify fear thoughts about panic sensations, challenge them, and develop more adaptive ways to think.
• Behavioral strategies: You and your therapist will devise a plan to gradually and systematically expose you to the sensations and situations you fear. To truly learn that the physical sensations of panic are not dangerous, it is important to test your beliefs. To do this, you and your therapist will practice exercises in which you purposely bring on the feared sensations (for example, by hyperventilating or spinning). To truly learn that you are not in danger and that you can cope in situations that you fear or avoid, you and your therapist will practice approaching feared situations (starting with easy ones and working up to harder ones) and staying in them until your anxiety decreases and your fears are disconfirmed. With repeated practice, your anxiety about sensations will decrease or disappear, and your belief in your ability to cope will increase.
• Breathing retraining: Learn to breathe using your diaphragm (abdomen) and slow your breathing rate if over breathing/hyperventilating is a problem for you.