4 Agoraphobia

Agoraphobia
AgoraphobiaSymptoms
Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situational predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.
The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.
See also Panic disorder symptoms.
Panic Attack

Panic AttackSymptoms
A panic attack is a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:
§ palpitations, pounding heart, or accelerated heart rate
§ sweating
§ trembling or shaking
§ sensations of shortness of breath or smothering
§ feeling of choking
§ chest pain or discomfort
§ nausea or abdominal distress
§ feeling dizzy, unsteady, lightheaded, or faint
§ derealization (feelings of unreality) or depersonalization (being detached from oneself)
§ fear of losing control or going crazy
§ fear of dying
§ paresthesias (numbness or tingling sensations)
§ chills or hot flushes
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Panic Disorder
Panic DisorderSymptoms
People with panic disorder have feelings of terror that strike suddenly and repeatedly with no warning. They can't predict when an attack will occur, and many develop intense anxiety between episodes, worrying when and where the next one will strike. In between times there is a persistent, lingering worry that another attack could come any minute.
When a panic attack strikes, most likely your heart pounds and you may feel sweaty, weak, faint, or dizzy. Your hands may tingle or feel numb, and you might feel flushed or chilled. You may have chest pain or smothering sensations, a sense of unreality, or fear of impending doom or loss of control. You may genuinely believe you're having a heart attack or stroke, losing your mind, or on the verge of death. Attacks can occur any time, even during no dream sleep. While most attacks average a couple of minutes, occasionally they can go on for up to 10 minutes. In rare cases, they may last an hour or more.
Panic disorder strikes between 3 and 6 million Americans, and is twice as common in women as in men. It can appear at any age--in children or in the elderly--but most often it begins in young adults. Not everyone who experiences panic attacks will develop panic disorder-- for example; many people have one attack but never have another. For those who do have panic disorder, though, it's important to seek treatment. Untreated, the disorder can become very disabling.
Panic disorder is often accompanied by other conditions such as depression or alcoholism, and may spawn phobias, which can develop in places or situations where panic attacks have occurred. For example, if a panic attack strikes while you're riding an elevator, you may develop a fear of elevators and perhaps start avoiding them.
Some people's lives become greatly restricted -- they avoid normal, everyday activities such as grocery shopping, driving, or in some cases even leaving the house. Or, they may be able to confront a feared situation only if accompanied by a spouse or other trusted person. Basically, they avoid any situation they fear would make them feel helpless if a panic attack occurs. When people's lives become so restricted by the disorder, as happens in about one-third of all people with panic disorder, the condition is called agoraphobia. A tendency toward panic disorder and agoraphobia runs in families. Nevertheless, early treatment of panic disorder can often stop the progression to agoraphobia.
Specific Symptoms of this Disorder:The person experiences recurrent unexpected Panic Attacks and at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
§ persistent concern about having additional attacks
§ worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
§ a significant change in behavior related to the attacks
Presence or absence of Agoraphobia.
The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).
Panic disorder is often accompanied by other conditions such as depression or alcoholism, and may spawn phobias, which can develop in places or situations where panic attacks have occurred. For example, if a panic attack strikes while you're riding an elevator, you may develop a fear of elevators and perhaps start avoiding them.
Some people's lives become greatly restricted -- they avoid normal, everyday activities such as grocery shopping, driving, or in some cases even leaving the house. Or, they may be able to confront a feared situation only if accompanied by a spouse or other trusted person. Basically, they avoid any situation they fear would make them feel helpless if a panic attack occurs. When people's lives become so restricted by the disorder, as happens in about one-third of all people with panic disorder, the condition is called agoraphobia. A tendency toward panic disorder and agoraphobia runs in families. Nevertheless, early treatment of panic disorder can often stop the progression to agoraphobia.
Specific Symptoms of this Disorder:The person experiences recurrent unexpected Panic Attacks and at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
§ persistent concern about having additional attacks
§ worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
§ a significant change in behavior related to the attacks
Presence or absence of Agoraphobia.
The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).
Social Phobia
Social Phobia Symptoms
Social phobia is an intense fear of becoming humiliated in social situations, specifically of embarrassing yourself in front of other people. It often runs in families and may be accompanied by depression or alcoholism. Social phobia often begins around early adolescence or even younger."
If you suffer from social phobia, you tend to think that other people are very competent in public and that you are not. Small mistakes you make may seem to you much more exaggerated than they really are. Blushing itself may seem painfully embarrassing, and you feel as though all eyes are focused on you. You may be afraid of being with people other than those closest to you. Or your fear may be more specific, such as feeling anxious about giving a speech, talking to a boss or other authority figure, or dating. The most common social phobia is a fear of public speaking. Sometimes social phobia involves a general fear of social situations such as parties. More rarely it may involve a fear of using a public restroom, eating out, talking on the phone, or writing in the presence of other people, such as when signing a check.
Although this disorder is often thought of as shyness, the two are not the same. Shy people can be very uneasy around others, but they don't experience the extreme anxiety in anticipating a social situation, and they don't necessarily avoid circumstances that make them feel self-conscious. In contrast, people with social phobia aren't necessarily shy at all. They can be completely at ease with people most of the time, but particular situations, such as walking down an aisle in public or making a speech, can give them intense anxiety. Social phobia disrupts normal life, interfering with career or social relationships. For example, a worker can turn down a job promotion because he can't give public presentations. The dread of a social event can begin weeks in advance, and symptoms can be quite debilitating.
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People with social phobia are aware that their feelings are irrational. Still, they experience a great deal of dread before facing the feared situation, and they may go out of their way to avoid it. Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout. Afterwards, the unpleasant feelings may linger, as they worry about how they may have been judged or what others may have thought or observed about them.
Specific Symptoms of this Disorder:
A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situational bound or situational predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
In individuals under age 18 years, the duration is at least 6 months.
The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder.
If a general medical condition or another mental disorder is present, the fear in the first criteria is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.
Specific Phobia
Specific Phobia Symptoms
Many people experience specific phobias, intense, irrational fears of certain things or situations--dogs, closed-in places, heights, escalators, tunnels, highway driving, water, flying, and injuries involving blood are a few of the more common ones. Phobias aren't just extreme fear; they are irrational fear. You may be able to ski the world's tallest mountains with ease but panic going above the 10th floor of an office building. Adults with phobias realize their fears are irrational, but often facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.
Specific phobias strike more than 1 in 10 people. No one knows just what causes them, though they seem to run in families and are a little more prevalent in women. Phobias usually first appear in adolescence or adulthood. They start suddenly and tend to be more persistent than childhood phobias; only about 20 percent of adult phobias vanish on their own. When children have specific phobias--for example, a fear of animals--those fears usually disappear over time, though they may continue into adulthood. No one knows why they hang on in some people and disappear in others.
Specific Symptoms of this Disorder:
Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.
The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
In individuals under age 18 years, the duration is at least 6 months.
The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder.
Treatment of Generalized Anxiety and Trauma
Most anxiety disorders are readily treatable with a combination of psychotherapy and medication. Learn the details of these treatments and other treatment options for generalized anxiety disorder, panic disorder, agoraphobia, social phobia, specific phobia, and post-traumatic stress disorder/acute stress disorder. Treatments for anxiety depend upon the specific disorder diagnosed by a trained mental health professional. Below you will find some general treatment guidelines for different Anxiety Disorders.
This document deals with the treatment of Generalized Anxiety and Trauma. Other available documents deal with the treatment of Panic-Related Anxiety (including Agoraphobia), and Phobias (fears).
Generalized Anxiety Disorder
Introduction
Since anxiety disorders can sometimes have a medical cause or component, it is important for individuals to have a thorough medical exam before immediately assuming that their anxiety symptoms are due to psychological causes. For instance, individuals who drink a lot of caffeine can present with many similar symptoms of anxiety, and even have panic attacks from caffeine intoxication. The following are all medical syndromes that can cause significant anxiety and physiological arousal: hypoglycemia, lack of sleep, allergies, mitral valve prolapse, hyperthyroidism, and premenstrual syndrome. A good medical examination is important to rule out the possibility that anxiety symptoms are being caused by biological or environmental problems.
Anxiety is often a component found within many other mental disorders as well. The most common mental disorder that presents with anxiety is depression. Clinicians generally regard such anxiety as a good sign, because it means that the individual hasn't simply accepted their depressed mood as they would a free meal; they are anxious because they are aware that being depressed does not fit with the image that person has of himself/herself. A thorough initial evaluation is rudimentary to ruling out other possible and more appropriate diagnoses.
Treatment for generalized anxiety disorder (also known as GAD) is varied and a number of approaches work equally well. Several of the approaches for GAD work well in reducing the underlying cognitive and physiological symptoms associated with the other anxiety disorders as well. Typically the most effective treatment to reduce anxiety will be an approach that incorporates cognitive-behavioral interventions. Depending upon the severity of the anxiety, both psychological and psychopharmacologic approaches may be needed. Medications, while usually helpful in treating the bodily symptoms of acute anxiety (e.g., panic attacks), are best used for this disorder as a short-term treatment only (a few months). Clinicians should be especially watchful of the individual becoming psychologically or physiologically addicted to certain anti-anxiety medications, such as the benzodiazepine, Xanax.
It is very important to note that medications should never be used solely to treat anxiety disorders because that will just act as a band-aid covering up the symptoms. Pure medical treatment of anxiety will likely guarantee a return of the symptoms once medication is stopped. Effective psychotherapeutic treatment interventions are designed to treat the underlying dynamics of the symptoms, which leads to long-term symptom reduction. Medication are most useful when anxiety is moderate to severe, and causing great discomfort or impairment to the client who needs relief immediately.
Psychotherapy
Psychotherapy for GAD should be oriented towards combating the individual's low-level, ever-present anxiety as well as helping the patient to develop healthier thinking patterns that will help combat the patient's tendency to worry excessively, thereby reducing anxiety. Because poor planning skills, high stress levels, and difficulty in relaxing often accompany this anxiety, the therapist can play an especially effective teaching role.
Relaxation skills can be taught either alone or with the use of biofeedback. Education about relaxation and simple relaxation exercises, such as deep breathing, are excellent places to begin therapy. Progressive muscle relaxation and more general imagery techniques can be used as therapy progresses. Teaching an individual how to relax, and the ability to do it in any place or situation is vital to reducing the low-level anxiety levels. Individuals who learn these skills, which can be taught in a brief-therapy framework, go on to lead productive, generally anxiety-free lives once therapy is complete. A common reason for failure to make any gains with relaxation skills is simply because the client does not practice them outside of the therapy session. From the onset of therapy, the individual who suffers from GAD should be encouraged to set a regular schedule in which to practice relaxation skills learned in session, at least twice a day for a minimum of 20 minutes (although more often and for longer periods of time is better). Lack of treatment progress can often be traced to a failure to follow through with homework assignments of practicing relaxation.
Reducing stress and increasing overall coping skills may also be beneficial in helping the client. Many people who have GAD also lead very active (some would say, "hectic") lives. Helping the individual find a better balance in their lives between self-enrichment, family, significant other, and work may be important. People who have GAD have lived with their anxiety for such a long time they may not recognize a life without constant worrying and activity. Helping the individual realize that life doesn't have to be boring just because one isn't always worrying or doing things may also help.
Individual therapy is usually the recommended treatment modality. It is very beneficial for the therapist to take a cognitive approach to treatment. A cognitive therapeutic approach will help the person learn to identify unrealistic beliefs that cause them anxiety and then challenge the validity of their beliefs. As the therapy progresses, the patient is taught how to replace the old anxiety producing beliefs with more realistic or adaptive ways of thinking so that his/her anxiety and worrying are reduced. The therapeutic environment should also be a supportive and accepting one so that the patient feels safe to explore his/her unrealistic belief systems. In addition, examining stressors in the client's life and helping the individual find better ways of handling these stressors is likely to be beneficial. Modeling techniques of appropriate social behaviors within the therapy session may help as well.
Hypnotherapy is also an appropriate treatment modality for those individuals who are highly suggestible. Hypnotherapy can be used as an effective relaxation technique to battle anxiety.
Medications
Medication should be prescribed if the anxiety symptoms are serious and interfering with normal daily functioning. Psychotherapy and relaxation techniques can't be worked on effectively if the individual is overwhelmed by anxiety or cannot concentrate.
The most commonly prescribed anti-anxiety agent for this disorder has historically been benzodiazepines. Some of the most commonly prescribed benzodiazepines are Alprazolam (Xanax), Lorazepam (Ativan), and Clonazepam (Klonopin). Individuals on these medications should always be advised about the medications' side effects, especially their sedative properties and impairment on performance throughout the day. These medications can also be quite addictive or habit-forming so it is important that someone who is taking these be closely monitored by a psychiatrist. These medications should not be prescribed to someone who has a substance abuse problem or addictive tendencies.
Another effective anti-anxiety medication called Buspar (Buspirone) has been found to alleviate anxiety symptoms with very few side effects. Another added benefit of Buspar is that it is not addictive or habit-forming like the benzodiazepines, which makes it a highly appropriate drug of choice for GAD. In addition, some antidepressant medications can also be helpful in relieving symptoms of anxiety.
Self-Help
The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Many support groups exist within communities throughout the world, which are devoted to helping individuals with this disorder share their common experiences and feelings of anxiety. Individuals should first be able to tolerate and effectively handle a social group interaction. Pushing an individual into a group setting, whether it is self-help or a regular group therapy experience, is counterproductive and may lead to a worsening of symptoms.
The mind/body integrative approach called Mindfulness may be very helpful for those suffering from GAD and is a self help intervention that can be sought out on one's own. Mindfulness combines stress management skills with Eastern Practices, such as meditation and yoga. Mindfulness is usually taught by an instructor during a 6-8 week course. The underlying principle of Mindfulness emphasizes keeping one's mind focused on the present and approaching stress in a way that allows for better coping abilities. Because of its emphasis on staying focused on the here-and-now it may be highly effective for those suffering from GAD who are always worrying about possible future stressors.
Obsessive-Compulsive Disorder
Please view the treatment section of our Obsessive-Compulsive Disorder Center
Post-Traumatic Stress Disorder/Acute Stress Disorder
Introduction
Post-traumatic stress disorder (PTSD) occurs after a person has experienced a terrifying event in which he/she perceives that their life or the physical integrity of themselves or others is in danger and their response to that event involves a significant degree of horror, fear, and/or helplessness. Most often, PTSD is associated with the psychological effects of military combat, especially veterans of the Vietnam and Gulf Wars. Today, we know that other victims of traumatic events experience PTSD, including those exposed to earthquakes and other natural disasters, rapes, muggings, car accidents, and poorly performed invasive medical procedures. The greatest numbers of victims struggling with PTSD today are women and men who been raped. Due to the high number of female rape victims in the United States, women experience PTSD twice as often as men do.
It is estimated that around 7.8 percent of people in the United States will experience PTSD at some point throughout their lives. Because of the psychological and physiological symptoms characterized by PTSD including nightmares, recurrent images of the traumatic experience, physiological reactivity, sleep disturbances, difficulty concentrating, increased irritability, hypervigilance, and exaggerated startle response, it negatively impacts those suffering from PTSD on a daily basis. These symptoms begin to impair an individual's ability to perform effectively at work or in relationships. In an effort to try and cope with their symptoms, those suffering from PTSD can often turn to substance abuse, gambling, or develop an eating disorder in an attempt to numb themselves from their emotional pain.
Fortunately, researchers have developed effective treatments and therapies for those suffering from PTSD. Similar treatment interventions are utilized for both PTSD and Acute Stress Disorder in which the symptoms from a trauma last only between 2 days to 4 weeks. The treatment interventions for both stress disorders focus on the over-riding symptoms of re-experiencing the event through nightmares and/or flashbacks, avoidance of anything that reminds the person of the traumatic event, emotional numbing, increased physiological arousal, and hypervigilance of their environment in an effort to protect themselves from any threatening future incidents.
Psychotherapy
There are three main psychotherapy treatments at present that have proven to be most effective in treating post-traumatic stress disorder and acute stress disorder. These include stress inoculation training (SIT), prolonged exposure (PE), and cognitive processing therapy (CPT). A first step within the initial sessions, though, no matter which treatment intervention is utilized, is to create a safe, nurturing, and supportive environment for the patient in which there are no implications that the patient is to blame for the event (s) that took place.
Stress inoculation training teaches the victim a variety of coping skills in order to achieve mastery over his/her fears. The average length of therapy is twelve sessions and it combines techniques that focus on the three main areas of functioning affected by PTSD including behavioral, cognitive, and physical abilities. To help the patient learn how to cope better behaviorally, covert modeling and role-playing techniques are taught. Covert modeling consists of imagining facing a feared situation and then imagining successfully handling the situation so that it does not seem so scary or leave a person feeling victimized. By imagining these scenarios, it prepares a person for how to successfully handle similar scenarios that evoke fear or anxiety in real life. The second behavioral technique of role-playing involves the therapist and client acting out successful ways of coping in anxiety-producing scenes that the client is confronted with throughout his/her day that are associated with the traumatic event. Role-playing can also be done in a group therapy setting as well.
The client's cognitive beliefs that are negatively affected by a traumatic event are also addressed through the techniques of thought stopping and guided self-dialogue. Thought stopping helps teach the client how to stop the ruminative thoughts he/she has about the traumatic event. During a session, the patient is asked to talk about the ruminative thoughts in which the therapist shouts, "STOP" and breaks the patient's cognitive ruminating. The client is then taught to say, "Stop", or whatever cue is preferred, to himself/herself and ultimately the client says it covertly rather than out loud. Guided dialogue is when a patient is asked to talk about the traumatic event and the therapist points out cognitive distortions along the way. The therapist then helps the client replace the distorted cognition with a more realistic cognitive belief. For example, the patient might say, "I guess I am to blame for being raped because I did not scream or fight back." The therapist would help the patient in the moment develop a realistic belief to replace the old belief such as, "I am not to blame for being raped because I did everything I could to try and keep myself safe during an act of violence done to me against my will."
To help the client gain mastery over his/her increased physiological arousal and anxiety, the client is taught muscle relaxation and deep breathing exercises. Clients are taught to employ these relaxation techniques when they are role-playing or imagining anxiety-producing scenes so that if the scenario is feeling too intense they can handle it. Also, they can utilize relaxation techniques when confronted with anxiety producing incidents in real life to help them gain mastery over the incident and be able to handle it successfully.
The second treatment intervention that has been found to be effective with PTSD is called prolonged exposure. This technique involves having the patient imagine the traumatic event while describing it aloud to the therapist. As sessions progress, the patient provides greater and greater amounts of detail as compared to earlier sessions. Before each session is over, the therapist helps reduce the patient's anxiety levels so that the patient does not leave the session feeling emotionally vulnerable. Because the patient is exposed to the event by talking about it repeatedly, this helps the patient learn to process the memory in a different way so that it no longer seems as emotionally painful.
The third technique called cognitive processing therapy combines exposure with cognitive re-structuring. It is a twelve session structured approach that challenges the cognitions the patient has that were disrupted due to the trauma. Memories of the event are elicited by having the patient write about the traumatic event in detail including thoughts, feelings and sensory stimuli they may have experienced. The patient is instructed to read the accounts that they wrote several times to themselves and then to read them aloud to the therapist during the first few sessions. As the client reads his/her account of the event, the therapist helps the client with several therapeutic processes. First, the therapist helps the client label his/her feelings. Second, the therapist points out to the client places where he/she got "stuck", meaning where a conflict occurred for the patient between prior cognitive beliefs and new information from the traumatic event. The themes of these client conflicts usually involve beliefs about themselves and the world, such as safety, intimacy, competence, and self-esteem. And lastly, the therapist helps the client modify his/her cognitions around these stuck points.
While these three interventions are generally the treatments of choice for PTSD, there is another technique called Eye Movement Desensitization and Reprocessing (EMDR) that has also been used with some success in treating PTSD patients.
EMDR is a supplemental technique to be used within a comprehensive treatment plan; it is not in itself a panacea. The technique focuses on helping the patient to more readily access painful memories around incidents that were traumatic or threatening to one's self-esteem. According to the founder of this technique, Francine Shapiro, Ph.D., memories and their emotional and sensory associations seemed to be more easily accessible when a person's eyes moved back and forth while following the motion of another person's finger. Dr. Shapiro found that when the patient would talk about the memory with their eyes moving back and forth, that Dr. Shapiro could suggest to the patient alternative successful ways to handle the traumatic event, which then became incorporated into the patient's memory processing system. Thus, by replacing the patient's negative associations to the event with associations that do not feel so emotionally upsetting and painful, the traumatic event did not hold the same emotional power it once did. EMDR has been studied primarily with Vietnam Veterans, and while not conclusive, the research has shown this to be an effective technique for some people struggling with PTSD.
Medications
There are no medications to treat the entire syndrome of PTSD. Instead, when specific symptoms or associated disorders, such as anxiety and/or depression, become significant enough to warrant medication, then specific medications are prescribed. Anxiety symptoms, such as insomnia, difficulty concentrating, nervousness, and panic attacks tend to be the ones most commonly experienced by those with PTSD. The SSRI antidepressant medications, such as Paxil and Zoloft are commonly prescribed for anxiety. The anti-anxiety medication, Buspar, can be quite helpful to those suffering from anxiety symptoms and has very few serious side effects. The benzodiazepines, such as Klonopin and Xanax, are used cautiously for PTSD, because of their highly addictive nature.
For associated depression, the SSRI antidepressant medications, again, are the treatment of choice. For those who do not have a positive response to these medications, there are the MAOI (monoamine oxidase inhibitor) antidepressant medications, which require maintaining a strict diet of foods that do not include the pressor amine, Tyramine, such as cheese, alcohol, or yeast products. If these foods are eaten while a person is taking an MAOI they run the risk of having a hypertensive crisis, which can lead to a stroke or heart attack. Because of the dietary restrictions with MAOIs, they are not commonly prescribed.
Self-Help
For those suffering from PTSD, there are several self-help activities to help get through painful times. Incorporating stress management techniques such as daily exercise, eating right, and getting adequate rest is a good place to start to take care of oneself. These types of lifestyle practices help a person have the energy to deal with the extra demands of PTSD symptoms or at least to reduce some of the anxiety symptoms.
Another powerful self-help technique that is important for a PTSD sufferer is to empower oneself. There are many ways to feel empowered. Self-empowerment activities might include joining a support group; re-claiming a sense of self in the world through involvement with nature, whether it be hiking, sitting by a serene body of water, or working with animals; taking a self-defense class; reading books; learning assertiveness skills, keeping a diary; or joining a house of worship.
A very important aspect of self-help for those with PTSD is to reach out to others and develop a strong social support network if one is not already in place. Having a support network helps to combat the alienation from others that often accompanies PTSD. Many withdraw from other people as part of the avoidance and emotional numbing that can occur with PTSD. Also, since PTSD can be very draining on a person's energy levels, it can be quite helpful to have a support system in which a person can reach out and ask others for help in order to relieve some of the stresses of daily life. By asking others for help, it allows the PTSD sufferer to be able to put more energy into his/her emotional healing process.
Treatment of Panic-Related Anxiety Disorders
Most anxiety disorders are readily treatable with a combination of psychotherapy and medication. Learn the details of these treatments and other treatment options for generalized anxiety disorder, panic disorder, agoraphobia, social phobia, specific phobia, and post-traumatic stress disorder/acute stress disorder. Treatments for anxiety depend upon the specific disorder diagnosed by a trained mental health professional. Below you will find some general treatment guidelines for different Anxiety Disorders.
This document deals with the treatment of Panic and Agoraphobia. Other available documents deal with the treatment of Phobias, Trauma and Generalized Anxiety
Panic Disorder
Introduction
Panic attacks and panic disorder can be very disabling conditions for the people who suffer from them. Although panic attacks are not harmful or dangerous to the body, they often feel so frightening to those that experience them that sometimes the attacks can lead to avoidance of any activity or environment that have been associated with feelings of panic in the past. This can, in turn, lead to the more severe and disabling disorder of agoraphobia.
Panic attacks typically begin in young adulthood, but can occur at any time during an adult's life. A panic episode usually begins abruptly, without warning, and peaks in about 10 minutes. It can last anywhere from a few minutes to a half hour or longer. Panic attacks are characterized by a rapid heartbeat, sweating, trembling, and shortness of breath. Other symptoms can include chills, hot flashes, nausea, cramps, pain or tightness in the chest, derealization or depersonalization, a feeling that there is a lump in the throat, trouble swallowing and dizziness. Women are more likely than men to have panic attacks. Research has demonstrated that the body's natural fight-or-flight response to danger is involved in having a panic attack. For example, if a grizzly bear came after you, your body would react instinctively. Your heart and breathing would speed up as your body readied itself for a life-threatening situation. A panic attack is really the body's flight-or-fight response system getting triggered without the presence of an actual external threat.
Panic disorder develops in individuals who have a genetic predisposition for having a sensitive central nervous system. When such an individual is exposed to a highly threatening external stressor, it causes a panic attack. The most common stressors that facilitate a first time panic attack usually includes: 1) experiencing a traumatic event, such as a rape or other assault, an earthquake, or the death of a loved one, 2) an extended period of chronic stress that depletes a person due to life demands, such as pressures at work, family, friends, academic pressures, health concerns, etc., 3) a medical procedure that causes the person to pay more attention than usual to his/her physical self, and 4) an adverse reaction to an illicit drug, usually marijuana, or to a prescription medication.
The initial panic attack sensitizes the central nervous system to symptoms of slight physiological arousal experienced from typical daily anxiety. Because the nervous system has become sensitized, the person begins to have anxiety/panic symptoms without the presence of any external threat. When the person starts to experience these symptoms such as dizziness or chest pain from the anxiety, the person interprets it as meaning that there has to be something internally wrong with them since there is no external threat causing the person to feel anxious.
Without the existence of an external threat to explain away the anxiety symptoms, the person becomes frightened about the anxiety symptoms themselves, thinking they are physical signs that something catastrophic is about to happen to them, such as having a heart attack or that they will go crazy. Their fear around the panic symptoms themselves then builds into a full-blown panic attack. Since panic attacks feel terrifying for most people, the fear then mostly becomes about the possibility of having another panic attack. Because of the intense fear around having another panic attack, the person has more panic attacks, and a vicious cycle evolves developing into panic disorder. Fortunately, with highly effective cognitive behavioral treatment interventions, panic disorder is a very treatable problem.
Treatment emphasizing a three-pronged approach is most effective in helping people overcome this disorder: education and information about panic disorder, cognitive-behavioral psychotherapy, and medication depending upon the severity and frequency of the panic attacks.
Psychotherapy
Education is usually the first factor in psychotherapy treatment of this disorder. Oftentimes, just receiving information about the fight-or flight response system and how that produces panic attacks in some people, helps to reduce anxiety symptoms right away. This is because for so many panic sufferers it often feels like such a mystery as to why they have such uncomfortable physical symptoms, especially if medical causes have been ruled out. So, receiving this type of information helps to greatly reduce their fears that the attacks themselves might somehow be dangerous or catastrophic, as well as clearing up much of the mystery around their symptoms.
The patient is instructed about the details of the body's "fight-or-flight" response and the associated physiological sensations. Learning to recognize and identify such sensations is usually an important initial step toward treatment of panic disorder. Treatment for panic disorder can be done in individual psychotherapy or group psychotherapy depending upon the individual's preferences and needs. The length of treatment is usually between 12-15 sessions. An emphasis on education, support, and the teaching of more effective coping strategies are usually the primary foci of therapy. Family therapy is usually unnecessary and inappropriate.
After the educational piece, therapy then teaches the patient relaxation and imagery techniques, especially deep breathing and progressive muscle relaxation. These are effective tools to be used during a panic attack to decrease immediate physiological distress and the accompanying emotional fears. The deep breathing especially is key since many of the uncomfortable physical symptoms the person experiences with panic, such as difficulty breathing and dizziness, are due to mild hyperventilation. Teaching a person how to breathe correctly greatly reduces panic symptoms and attacks.
Discussion of the client's irrational fears (usually of dying, passing out, becoming embarrassed) during an attack is essential in the context of a supportive therapeutic relationship. A cognitive or rational-emotive approach in this area is best. The therapist helps the patient identify maladaptive cognitive patterns such as overgeneralizing or catastrophizing that fuel the panic attacks. For example, if the patient's thought each time he/she feels mild chest pain is, "Oh boy, here it comes…I just know I am going to have a heart attack now" then the therapist helps the patient realize how he/she is misinterpreting these bodily signals and helps the patient develop an appropriate response to normal bodily sensations, such as "This is just a normal minor pain in my chest that is not going to hurt me and will go away soon." The therapist then helps the patient to replace irrational or maladaptive beliefs with more adaptive and realistic beliefs, which greatly helps to reduce the likelihood of having a panic attack.
The treatment for panic disorder also includes effective specific panic control techniques. These techniques include having the patient learn how to produce panic sensations on their own and then learn how to control them. This process takes away the scariness about some of the physical sensations people get with panic disorders
A crucial feature of treatment for panic disorder is having the patient engage in self-monitoring of their panic attacks and moods, as well as completing homework assignments, which involve practicing the various relaxation and panic control techniques on their own. Both the self-monitoring and the practice assignments are crucial for the patient to reduce the likelihood of having panic attacks. Self-monitoring of panic attacks and moods helps the patient to see correlations about when the attacks happen and what may trigger them. Completing the practice assignments is the only way that the patient will benefit from the techniques to reduce panic and anxiety and learn long-term coping skills to manage future panic and anxiety symptoms.
In addition, a behavioral approach emphasizing graduated exposure to panic-inducing situations is most-often associated with related anxiety disorders, such as agoraphobia or social phobia. It may or may not be appropriate as a treatment approach, depending upon if the client has become agoraphobic and/or is engaging in avoidance of places and situations due to the panic attacks.
Group therapy can often be used just as effectively to teach relaxation and related panic control skills. Psycho educational groups in this area are often beneficial because they allow other people with panic disorder the opportunity to realize that they are not alone with what they are experiencing, which also helps to alleviate some of the fear about panic attacks. Biofeedback, a specific technique that allows the client to receive either audio or visual feedback about their body's physiological responses while learning relaxation skills, is also an appropriate psychotherapeutic intervention.
All relaxation skills and assignments taught in the therapy sessions must be reinforced by daily exercises on the patient's part. This cannot be emphasized enough. If the client is unable or unwilling to complete daily homework assignments in practicing specific relaxation or monitoring skills, then therapy emphasizing such skill sets will likely be unsuccessful or less successful. This pro-active approach to change (and the expectations of the therapist that the client will agree to this approach) needs to be clearly explained at the onset of therapy. Discussing these expectations clearly up-front makes the success of such techniques much greater.
Medications
A lot of people who suffer from panic disorder can successfully be treated without resorting to the use of any medication. It is important to note that it is rarely appropriate to provide medication treatment alone without the use of psychotherapy to help educate and change the patient's behaviors related to their association of certain physiological sensations with fear. However, when medication is needed, the most commonly prescribed class of drugs for panic disorders are the SSRI antidepressant medications, such as Zoloft and Paxil, the tricyclic antidepressant medications, such as Imipramine, and the benzodiazepines (such as clonazepam and alprazolam). These medications can provide much relief from panic attacks and help the person get back to their normal level of functioning.
Choosing whether to try a benzodiazepine or an anti-depressant is a decision to be made with a psychiatrist and will depend on the severity of the symptoms as well as simply which one works best for each individual person. Benzodiazepines work quickly and can be taken just prior to a situation that might evoke a panic attack. However, benzodiazepines can produce strong physical and psychological dependence on the medication. They can also produce unpleasant side effects such as significant drowsiness that can impair the ability to function effectively throughout the day.
Antidepressant medications for anxiety include the SSRI medications, such as Zoloft and Paxil. These medications are taken on a continuous basis. While they usually have few side effects, they can produce headaches, nervousness, stomach upset, and changes in appetite, sleep, and libido. The other antidepressant medications prescribed for panic include the tricyclic, Imiprimane. This type of medication can produce anticholinergic effects such as dry mouth, dizziness, blurred vision, low blood pressure, and they can also affect cardiovascular functioning. The MAOI antidepressant medications can also be effective in treating panic, such as Nardil. The MAOI medications, though, require eating a strict diet that does not include foods high in the amine presser, Tyramine, such as cheese, beer, wine, fave beans, concentrated yeast extracts, and many more. Eating these foods while taking an MAOI can cause a severe hypertensive crisis, leading to stroke, heart attack, or even death. Because of the restrictions on one's diet, MAOIs are not commonly prescribed.
Self-Help
The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Many support groups exist within communities throughout the world that are devoted to helping individuals with this disorder share their commons experiences and feelings. Patients can be encouraged to try out new coping skills and relaxation skills with people they meet within support groups. They can be an important part of expanding the individual's skill set and develop new, healthier social relationships.
For those suffering from panic disorder, it is wise to engage in healthy lifestyle activities such as exercising, eating right, and getting enough rest. Engaging in these activities can be a great start to helping to reduce panic symptoms. This is because exercise, especially cardiovascular exercise, has been found to strengthen the communication center in the brain that affects the fight-or-flight response system to stress. Exercise also greatly relaxes the whole body, and improves mood.
Eating right by eating at regular intervals throughout the day is also very important in reducing panic and/or anxiety feelings. This is because if we go for long periods throughout the day where we do not get in enough calories, such as longer than 5-6 hours without something to eat, our blood sugar levels begin to fall. Some people are much more sensitive to the effects of low blood sugar, especially those who are prone to having panic attacks. When blood sugar levels fall, it can produce feelings of anxiety severe enough to cause a panic attack. Therefore, it is important to prevent the possibility of inducing a panic attack from low blood sugar by eating regularly throughout the day.
It is also important to get enough sleep, such as 7-9 hours a day. Research has demonstrated that a lack of sleep can produce physiologic arousal, especially in those with sensitive bodies. Again, this physiologic arousal can produce symptoms of anxiety and panic, such as feelings of unreality or depersonalization, nausea, and rapid heart rate, which can make it more likely someone will have a panic attack. Therefore, by getting enough rest a person can greatly diminish his/her chances of having a panic attack.
Agoraphobia
Introduction
People suffering with agoraphobia experience intense anxiety or panic attacks about being in situations or places in which help might be unavailable if they needed it or in which escape from the situation might be difficult if they needed to get home. However, being all alone at home can also be a dreaded situation because of the fear that that no one would be around to help if something were to happen to him/her. Another fear of agoraphobics is of being in situations or places in which they might do something embarrassing in public such as vomit, faint, not speak clearly, or have a bowel movement because of their anxiety levels. Because their fears limit their ability to go wherever they want to and move about feely in the world, they often feel that they are living within their own mental prison.
The most common situations and/or places that tend to be associated with agoraphobia include shopping malls, standing in line, driving, taking public transportation, restaurants, theaters, being a long way from home, staying at home alone, wide streets, going under tunnels or over bridges, supermarkets, crowds, planes, elevators, and escalators. Agoraphobia exists on a continuum of severity from mild in which a person white knuckles or endures through situations that raise anxiety levels, to severe in which another person refuses to leave the house at all or who will only leave the house with a trusted companion. People generally develop agoraphobia between the ages of 23 to 29, however most do not seek out help until around the age of 34.
Agoraphobia usually develops out of the behavioral response to a panic attack. More women than men are likely to develop agoraphobia as a response to a panic attack. Usually what happens is that if a person experiences a panic attack then he/she associates that particular location of where the panic attack happened with fear or possible threat. However, as the cycle of panic takes over, the person begins to generalize his/her response to feeling afraid in any place that panic symptoms may occur and the person would not be able to receive help or escape from the situation. As the person feels more and more vulnerable wondering what must be wrong that they are experiencing panic symptoms, the person also starts to feel more of a need to be dependent on others and feels that he/she can not handle the demands of being out in public places on his/her own.
While the majority of people with agoraphobia also have panic disorder (link to symptom page for panic disorder), that is not the case with all agoraphobics. There are some people who only have agoraphobia and have never had a panic attack, but that is a rare situation. Therefore, while panic disorder and agoraphobia are highly interrelated, they are separate disorders. For those who only have agoraphobia, they experience acute anxiety symptoms in particular places, which leads to avoidance and/or endurance of being in those places. For those with agoraphobia and panic disorder, it is vital to receive treatments for both that specifically target panic disorder (link to treatment page for panic disorder) as well as agoraphobia since they involve somewhat different treatment interventions.
Psychotherapy
The most effective psychotherapeutic treatment approach to date for agoraphobia is called situational exposure. This is a cognitive-behavioral technique that involves having the patient create a hierarchy of places and situations that are least to most anxiety producing. The patient is then accompanied by the therapist and confronts in vivo the place or situation that seems the least scary and builds up to the most scary.
If the patient begins to feel anxious or a panic attack coming on, the therapist helps the patient utilize relaxation skills such as deep breathing to reduce the anxiety or panic. As the patient is able to handle exposure to a feared situation or place without having anxiety or panic, the patient moves on to the next place or situation on his/her hierarchy list. Studies have found that longer and more continuous sessions in which the patient is exposed to the feared place or situation seem to be somewhat more effective than shorter more interrupted sessions.
Supplemental to the sessions with the therapist, the patient is expected to try and engage in exposure to feared places and situations with a trusted companion in- between therapy sessions. This way the patient can continue to practice exposure throughout the week as well as start to associate their ability to have success experiences on their own and with a variety of people. Cognitive therapy is also used to help challenge the patient's irrational cognitive beliefs that feed the anxiety or the panic about being in specific places or situations. The therapist helps the patient replace these irrational beliefs with more realistic and adaptive belief systems to help reduce the fear and anxiety.
When compared with medications for treating agoraphobia, situational exposure is the treatment of choice for agoraphobia since it helps the patients confront the actual fears, a process which leads to long-term change. Medications can help alleviate anxiety or panic symptoms while someone is presently taking them, however they do not help a patient learn how to control the symptoms themselves or how to work through the fears that cause the symptoms.
In fact, often when a person is just placed on medications for the treatment of agoraphobia or panic disorder, the person's symptoms seem better while taking the medications. However, as soon as the person stops taking the medications the symptoms come back with as much intensity. Also, therapists have found that sometimes when a patient is on medications for anxiety symptoms while undergoing psychotherapeutic treatments, that the medications can sometimes undermine the patient's progress in therapy because the affect of the medication can blind the patient to really knowing how well he/she is doing in therapy. Therefore, it is strongly recommended that a person engage in psychotherapy utilizing situational exposure to treat agoraphobia and that medication be used only as an adjunct to therapy if someone's symptoms are more severe.
Medications
If a person suffering from agoraphobia has moderate to severe symptoms in which the anxiety or panic is so intense that the person needs more immediate relief, than the following psychotropic medications are prescribed. There are a variety of medications that can be used as an adjunct to treat agoraphobia. Two medications that are widely prescribed for agoraphobia are Alprazolam (Xanax) and Imipramine (Tofranil).
Alprazolam is an anti-anxiety agent in the benzodiazepine family. Benzodiazepines are short acting medications that are good for relieving anxiety that is stimulated by specific stressors. A dose is usually taken approximately 45 minutes before exposure to the stressor. Or, if a person is experiencing more chronic anxiety, daily doses taken at specific times can ward off anxiety in which there are multiple stressors that are unpredictable. The problem with benzodiazepines is that they are highly addictive often producing physiological and psychological dependence on them to relieve symptoms and feel good. Because of these characteristics of benzodiazepines they should only be prescribed to people who do not have a history of prior addictions and they need to be prescribed with caution to anyone who may use them.
Imipramine is a tricyclic antidepressant medication that has been shown to have some success with treating agoraphobia because it seems to reduce avoidance symptoms. However, like most tricyclic antidepressant medications there are often a variety of side effects. These kinds of medications often produce what are called anticholinergic side effects, which include poor memory and confusion, dry mouth, low blood pressure, constipation, dry eyes, and nasal congestion. These symptoms often go away after a few weeks, but some can remain. Tricyclic medications can also affect cardiovascular functioning, so they are contraindicated for those with heart difficulties.
The SSRI (Selective Serotonin Re-Uptake Inhibitor) antidepressant medications, such as Paxil and Zoloft, can also be used to treat agoraphobia because they act on reducing anxiety symptoms. These antidepressants tend to be best tolerated by people because they have far fewer side effects than the tricyclics. The most common side effects of SSRIs include headache, nervousness, nausea, diarrhea, change in sleep and/or appetite, and decrease in libido.
Self-Help
It is important whenever a person is having symptoms typical of anxiety or panic that they receive a medical examination to rule out the possibility that the symptoms are being caused by a medical problem. Once it has been determined whether the symptoms are from anxiety or due to a medical problem it is easier to treat the symptoms correctly, which is all a part of taking care of oneself.
Other self help strategies include bolstering your degree of social support by reaching out to others who may be experiencing similar symptoms of agoraphobia who can really understand what you are experiencing. There are many support groups available now for agoraphobia and if you are housebound there are online support groups or ways to communicate with others who have agoraphobia.
Self help activities should include empowering other aspects of self to fight the sense of vulnerability and powerlessness experienced by most agoraphobics. These activities could include exercising and eating right to feel stronger inside and out, getting enough rest, and reading about agoraphobia and building a strong knowledge base to help further understanding of the causes and treatments for agoraphobia since knowledge is power. Try and make a pact with yourself that this is time to focus on strengthening yourself emotionally and psychologically so it is okay to say no to the demands of others. Also, devise a plan of treatment strategies you will be willing to try out by a specific date so that you know you are working towards getting better and that this period of lack of freedoms, loneliness, and dependence is meant to only be temporary.