Panic disorder is a debilitating disorder marked by unexpected and recurring panic attacks – periods of intense anxiety and physical symptoms that resemble heart attacks. Panic disorder is already stressful, but it becomes even more stressful when it goes untreated because it puts you at risk for developing agoraphobia: the fear of being out of your home (or "safe" places).
This article will help you learn more about panic disorder both with and without agoraphobia, describe how panic disorder can result in agoraphobia, and recommend common courses of treatment for both.
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How It Starts – Panic Disorder
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Those with panic disorder experience intense periods of severe anxiety that do not always appear to have a clear cause. This anxiety leads to many physical symptoms including, but not limited to:
- Rapid heart rate
- Shortness of breath
- Chest pain
- Fear of dying
These symptoms often last for several minutes, peak, and then slowly start to fade away. For many, the experience resembles having a heart attack, except nothing is physically wrong with your heart.
Panic disorder is considered one of the most severe forms of anxiety. But what can make panic disorder even worse is that it may also lead to the development of a related problem, known as "agoraphobia."
What is Agoraphobia?
Agoraphobia has two different definitions. Some describe it as the fear of going outside or to unfamiliar places. Others describe it as the fear of being "unable to escape" to a place of comfort. They're both related to the same issue - feeling uncomfortable in unrecognized places - and they are both caused by panic attacks.
When psychologists and doctors diagnose panic disorder, they use one of two terms: Panic disorder with agoraphobia and panic disorder without agoraphobia. Those without agoraphobia have a slight advantage because they haven't yet developed habits that may make it more difficult to treat anxiety.
Agoraphobia is Called More Severe Panic Disorder
Some claim that those with agoraphobia have "severe" panic disorder, while those without agoraphobia have less severe panic disorder. This is fairly misleading though because many of those with panic experience profound panic attacks, but do not associate those attacks with safe or unsafe spaces.
A good way of testing the severity of your panic attacks is with my free 7-minute anxiety test. It is clear that those that have panic disorder without agoraphobia can still experience severe anxiety and panic - arguably as severe as those with agoraphobia. Thus, calling panic w/agoraphobia more "severe" is misleading.
However, panic disorder without agoraphobia may be slightly easier to treat. That's because the willingness and ability to be out and do things necessary to control your panic can be extremely advantageous. Both can be treated, but those without agoraphobia may have a slight upper hand.
How Panic Disorder Causes Agoraphobia
In some, but not all cases of agoraphobia, panic disorder is the primary cause. You can blame this, in large part, on a little part of your brain called the amygdala.
The amygdala stores memories of events based on the intensity of the emotional reaction to a given experience. If a particular place becomes associated with the intense physical and emotional responses associated with fear, the amygdala will regularly trigger fear when you are in that place again. This causes you to believe that the two are linked.
EXAMPLE: Let's say you heard a gunshot while sitting in a restaurant and it filled you with anxiety. The next time you are in that restaurant, you may be on edge or anxious EVEN IF you forgot about the gunshot. Your amygdala associates the restaurant with anxiety. Indeed, it is possible a restaurant with similar decor or one with the same chairs could trigger anxiousness because of this association.
The same is true for panic attacks. Panic attacks are extreme emotional and physical events. When you have a panic attack while out, your amygdala associates the location with these intense emotions. The next time you are there, it may trigger anxiety and panic again. You may start to notice the association and avoid that place, hoping it will decrease your future panic attacks.
Unfortunately, if you have a panic disorder, it means that you are just as likely to experience an attack in one place as in another. So while you may start to avoid one place because it seems to trigger panic attacks, you'll eventually have one somewhere else and feel like you have to avoid that too.
Over time, more and more places become “blacklisted.” The more places you find you have to avoid, the more you begin to fear going to unfamiliar places. This is agoraphobia—an inability to leave your place of residence or comfortable areas (such as work or the grocery store) without anxiety, and severe anxiety if you do go to unfamiliar places.
Other Ways Panic Attacks Lead to Agoraphobia
It should also be noted that avoidance behaviors in general also create more anxiety. The science on this is complex, but when you avoid places you reinforce the idea that those places are something to fear, which means that you experience even more fear there in the future.
EXAMPLE: Let's say there is a house that your friends say is haunted. You do not believe in ghosts and would happily go inside, but your friends stop you and tell you to avoid it. The more you avoid it, the more it tells your mind "maybe it is something I should fear." Over time, the idea of going inside the house may cause anxiety, even though initially you were not anxious and nothing changed since.
In the case of agoraphobia, you may become afraid to leave your home because of the way your anxiety was reinforced by avoiding places for fear of a panic attack.
Finally, panic attacks themselves are intense, embarrassing, debilitating events. They make people feel like they're going to die. Many people may start to develop signs of agoraphobia simply because they're afraid of being elsewhere when they suffer from them. They would prefer to be at home when they have these symptoms so that if they do suffer, they do so in private and with everything that makes them comfortable readily available.
Therapy for Agoraphobia Panic Disorder
If you think you might have panic disorder or panic disorder that has caused or is causing agoraphobia, you may want to look into therapy, as these types of disorders can be hard to control without help. Cognitive behavioral therapy, or CBT, is the type of therapy shown to be most effective in treating anxiety disorders such as these.
Cognitive behavioral therapy usually involves a combination of exposure therapy, cognitive restructuring, and relaxation techniques.
Exposure therapy entails exposing a client to the object of their fear in a safe and controlled manner. If agoraphobia has developed, this will likely involve exposure to specific types of environments or specific locations. Over time, exposure therapy teaches the brain that there is actually nothing to fear and that the fear response is unnecessary.
Think of exposure therapy like "facing your fear." While the idea that you need to face your fear isn't always true, it is when you are showing avoidance behaviors. If you learn to be outside and learn to associate yourself with it, you'll eventually fear it less, which will reduce the likelihood of a panic attack and future agoraphobia.
Cognitive restructuring can help a person confront their fears in a safe and healthy way, and to lower their level of anxiety and tendencies towards panic in general. It entails learning about the beliefs and thought patterns that contribute to and often escalate feelings of panic, and replacing them with more useful beliefs and patterns that will help keep the person in a more positive frame of mind.
Cognitive restructuring can be done at home by yourself, but unfortunately, it helps to have someone challenge your thought patterns.
Relaxation techniques teach clients how to trigger relaxation in their bodies and minds when they find themselves in situations that usually cause panic, or feeling as though a panic attack is imminent. These often involve visualization exercises, positive self-talk, and creating positive associations that can be easily accessed (by a touch on the hand, for example, or by saying a particular word).
How to Help Yourself -- DIY Treatments
Part of overcoming agoraphobia with panic attacks is cultivating a more relaxed attitude in general. This often involves altering lifestyle choices that most people don’t think much about but that may be negatively affecting the severity of your disorders.
- Quit Smoking/Drinking - Smoking and drinking are thought to increase the likelihood of both agoraphobia and panic attacks. Their physical effects, including symptoms of withdrawal, shortness of breath, and heart and lung problems, can make fear responses more taxing physically and even endanger your life.
- Cut Out Caffeine - Caffeine raises blood pressure and increases alertness. If your brain has learned to be hyperaware in certain environments due to agoraphobia with panic disorder, heightened awareness will only lead to more stimuli for your brain to latch on to and panic about, increasing the number of objects and places you need to avoid. Caffeine itself doesn't cause anxiety – that's a myth. But it can contribute to issues that make it harder to control panic.
- Exercise Regularly - Regular exercise increases serotonin levels in the body. Regularly increasing your endorphins, the chemical associated with mood regulation and relaxation, will encourage your brain to create more serotonin receptors, making you happier and more relaxed in general. Find a way to run, especially, even if you have to do it on a treadmill, as running tends to have the best effect on mental health.
- Exposure - Finally, the truth is that if you can get yourself to spend more time out in new places and learn to be okay with the idea you may have a panic attack (often easier said than done, of course) the likelihood of future fear will decrease.
Taking care of yourself often involves taking the initiative to ask others for their help. However, making healthy lifestyle choices can be a big help in overcoming the disorders that are disrupting your life, and if you combine that with smart decisions for both your anxiety and panic disorder you may even be able to control it within your own home.
Panic Disorder Without Agoraphobia
Most people living with panic attacks do not have agoraphobia. But panic disorder without agoraphobia is still very difficult, and in many cases as severe as those living with agoraphobia. It's not entirely clear why some people develop agoraphobia while others do not, but with or without agoraphobia it is still important to treat your anxiety. Treatment options include:
Therapy is, by far, the most effective treatment available. It's 100% natural, and it's been researched thoroughly. This is especially true of cognitive behavioral therapy, which is believed to be the most effective type of therapy available.
Of course, even CBT is not for everyone. It's extremely expensive and time-consuming, and you need to find a therapist that you trust. No therapeutic option is a guarantee either, and therapy can never be done in the comfort of your own home. This is not a knock on therapy - it is still arguably the best choice - it's just not one that everyone can use.
The demonization of medications is not entirely fair. There are many very effective medicines for anxiety, and while almost all of them have some upsetting side effects, often those side effects are worth the risk. Benzodiazepines and antidepressants are the most common medications for panic attacks.
The problem with these medications isn't the side effects or the fact that they're unnatural. The problem is that they don't actually address the panic attacks, and someday you'll need to still learn how to control them:
- Benzodiazepines and other anxiety medications can grow ineffective over time.
- Panic attacks can be caused by fearing panic attacks, which is inevitable if you ever quit the medication.
- Time spent on medicine is time not spent learning new coping tools, which may cause setbacks in the future.
- Medications can cause personality changes and fatigue that may mean that you're still living a lower quality of life.
If your doctor says that you need to take a medication for anxiety to treat your panic disorder, then you may want to take the medicine. But you should note that it's crucial that you combine any medication with a long-term, non-medicinal treatment, otherwise the medication may do more harm than good in the end.
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Herbal medicines may be "natural" but they have the same problems as traditional medicines. There may be some side effects (although these tend to be weaker than pharmaceutical medications), the effects tend to be less strong, and if you stop taking the herbs it's possible that the panic attacks will come back. Still, they represent an interesting and potentially effective solution for those that prefer to avoid modern medications. The most popular include:
Kava appears to have the most research support. Talk to your doctor before trying any herbal medications for anxiety, as they may interact with any other medicines you may be taking. Never double up.
Exposure therapy - which can be done in the comfort of your own home - is another tool that some people use as a treatment for panic disorder without agoraphobia. Exposure is when you take the triggers that cause your anxiety and perform them on purpose until you eventually stop fearing the triggers. Some examples include:
- Forced Hyperventilation Since most of the symptoms of panic disorder are the result of hyperventilation, hyperventilating on purpose is a possible tool to get used to the feeling. It's not pleasant by any means and can actually trigger a panic attack, but if you try hyperventilating on purpose you can get used to the symptoms and if you find yourself hyperventilating it should cause less anxiety.
- Dizziness Dizziness and lightheadedness are also panic attack triggers. Spinning in a circle can get you more used to dizziness. If you do it often enough, it may cause no fear, and possibly limit or even prevent any panic attack from becoming triggered by the experience.
- Forced Thoughts It's not that common for recurring thoughts to create panic attacks, with the exception of a fear of panic attacks themselves (or health conditions because of health anxiety). But if you seem to have thoughts that cause you distress that ultimately trigger attacks, you can try thinking those thoughts on purpose until they no longer bother you.
These are examples of ways to get used to your anxiety triggers, and if you can get used to your triggers you can potentially reduce the frequency and severity of your panic attacks.
A sad statistic about panic disorder is that only 24% of those suffering are receiving what's known as "minimally effective treatment." That's because only 60% of those with panic attacks even seek treatment, and of those most try alternative therapies that have been proven ineffective.
Many people seek out alternative therapies as a way to reduce panic disorder. In some cases, these therapies can be very helpful. In other cases, they can be harmful or do nothing.
Alternative therapies can be fairly risky because many are the result of the placebo effect. The placebo effect is far more powerful than many realize, and is often used as a tool of marketing. Find enough people that tell you a product works, and it vastly increases the probability the product works.
Alternative panic disorder treatments are problematic. On the one hand, if it cures your panic attacks, then who cares if it is a placebo? What harm is there to a fake treatment if it works? But on the other hand:
- Placebo treatments generally do not work for very long, and in some cases, the time you spend on an alternative treatment is time not spent on a panic disorder treatment that actually works.
- Those that try one alternative treatment are more likely to try other alternative treatments, which means that they may be delaying their treatment for such an extensive period of time that treating panic attacks in the future becomes more difficult.
- Those that are cured of their panic because of placebo are more prone to telling others about its success. That spreads the idea that the treatment works, which can cause setbacks for other people that don't receive the placebo benefits.
- Many panic treatments claim to be essentially miracle cures that work right away. Depending on some type of instantly effective treatment and not making the necessarily life changes to keep panic attacks away can be harmful for your long term mental health.
- Some of these treatments may be genuinely dangerous, like depending on an herb that hasn't been tested or using it in large quantities with other herbs.
This is not to say you should avoid alternative treatments. Rather, view them as a skeptic, and remember that there are always traditional and effective approaches for anxiety reduction available.
Finding the Right Treatment for Your Panic Disorder w/o Agoraphobia
As mentioned, those that don't have agoraphobia have an extra advantage. They can look at attacking their panic attacks without the setbacks that come from agoraphobic problems.
But you still need to take a complete approach to reducing your panic disorder and you need to make sure that you're actively committed to your treatments and focused on your recovery. Panic disorder is treatable, and those that seek out the right treatment and focus on coping tools are more likely to find success in treating their anxiety in the long run.
I've helped thousands of those suffering from agoraphobia panic disorder control their symptoms with my free 7 minute anxiety test. Take the test now to learn more about how to control panic and agoraphobia.
Barlow, David H., et al. Behavioral treatment of panic disorder. Behavior Therapy 20.2 (1989): 261-282.
van Balkom, Anton JLM, et al. A meta-analysis of the treatment of panic disorder with or without agoraphobia: a comparison of psychopharmacological, cognitive-behavioral, and combination treatments. The Journal of nervous and mental disease 185.8 (1997): 510-516.
Author: Micah Abraham, BSc Psychology, last updated Apr 03, 2018.