"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?

• discrete periods 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 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 (in the absence of a life-threatening situation). When people perceive the bodily sensations of the fight-or-flight response (sensations like increased heart rate, sweating, and lightheadedness) as dangerous, they 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 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;
• Physical control strategies: Learn breathing control exercises and relaxation training to manage anxiety;
• Cognitive strategies: Identify fear thoughts about panic sensations, challenge them, and develop more adaptive ways to think;
• Behavioral strategies: Expose yourself to the sensations and situations you are afraid of. 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, palpitations) and practice tolerating them without escaping them or panicking when you have them. 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 and panic symptoms will decrease or disappear, and your belief in your ability to cope will increase.

Additional resources

Web links:
The Anxiety Disorders Association of America
The Association for Behavioral and Cognitive Therapies
Freedom from Fear

Books:
For links to purchase these books and others, please go to Self-Help Books for Adults

Barlow, D.H., & Craske, M.G. (2000). Mastery of your anxiety and panic (3rd edition): client workbook for anxiety and panic. New York, NY: Oxford University Press, Inc. (Copyright by Graywind Publications Incorporated).

Bourne, E.J. (2005) The Anxiety and Phobia Workbook (4th edition). Oakland, CA: New Harbinger Publications.

Craske, M.G., & Barlow, D.H. (2000). Agoraphobia supplement to mastery of your anxiety and panic (3rd edition) New York: NY: Oxford University Press (Copyright by Graywind Publications).

Pollard, C.A. & Zuercher-White, E. (2003) The agoraphobia workbook: A comprehensive program to end your fear of symptom attacks. Oakland, CA: New Harbinger Publications.

Zuercher-White, E. (1999). Overcoming panic disorder and agoraphobia: A cognitive restructuring and exposure-based protocol for the treatment of panic and agoraphobia (client manual). Oakland, CA: New Harbinger Publications.

Zuercher-White, E. (1998). An end to panic: Breakthrough techniques for overcoming panic disorder. Oakland, CA: New Harbinger Publications.