Panic Disorder and Agoraphobia?

WHAT ARE PANIC DISORDER AND AGORAPHOBIA?

BASIC FACTS • SYMPTOMS • FAMILIES • TREATMENTS

RT P SE A Mental Illness Research, Education and Clinical Center E C I D F

I A C VA Desert Pacific Healthcare Network

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R E E Long Beach VA Healthcare System N T T N A E L C IL L LN A E IC S IN Education and Dissemination Unit 06/116A S R CL ESE N & ARCH, EDUCATIO 5901 E. 7th street | Long Beach, CA 90822 2 WHAT ARE PANIC DISORDER AND AGORAPHOBIA? - MIRECC - FALL 2016 cal factors, personality and psychological factors, and stressful life stressful and factors, psychological and personality factors, cal biologi- disorders, mood or anxiety other or disorder panic of tory his- family and genetic including disorder, panic of development Causes their lifetime. in point some at it experiencing people of disorder,5% about with panic of that to similar is agoraphobia of prevalence The distress. of degrees high with associated often are symptoms panic clinical sub- Nonetheless, disorder. panic of severity full the to progress never symptoms subclinical these but lifetime, their in point some one third of the population will experience panic-like symptoms at to quarter one approximately that estimated is It women. in mon com- as twice about is it and lifetimes, their in point some orderat Prevalence a diagnosis of agoraphobia also have a diagnosis of panic disorder. with people many Thus attack. panic a having of fear for avoided dure the situations with extreme anxiety. These situations are often en- they and/or person, another by accompanied be to need they anxiety.of possible, levels not high is avoidance their If of because viduals with agoraphobia often try to avoid these feared situations crowd.Indi- a in being or alone home their of out being as such as such situations, of types other of anxiety or fear extreme have also might agoraphobia of diagnosis a with people However, spaces.” things theyassociatewiththeattacks. or places, people, avoiding as such result, a as changes behavioral make to and attack panic another having about worry to disorder panic with individuals for common is It fromsleep. up them wake which attacks, panic nocturnal experience disorder panic with ple peo- cases, some In occurs. one after exhausted or anxious feel to continue sometimes people but minutes, within peak their reach numbness or tingling, and/or a fear of dying. Panic attacks usually breathing, difficulty rate, heart rapid as such symptoms with iety anx- intense of rush a sudden is response, flight” or “fight or tack, recurrentby andsometimes unexpected panicattacks. A panicat- disorders that oftenoccur together. Panic disorder is characterized some point in their lifetimes, and it is about twice as commoninwomen. some pointintheirlifetimes,anditisabouttwice Nearly 5% of people intheUnitedStateswill have panicdisorderat as aresult,another panicattackandtomakebehavioralchanges as such about having to worry It iscommonforindividualswithpanicdisorder basic facts avoiding people,places,orthingstheyassociatewiththeattacks. Panic Disorder: There are several factors that contribute to the Disorder:to Panic contribute Therethat arefactors several dis- panic have will States United the in people of 5% Nearly open wide, of “fear means literally agoraphobia word The Panic disorder andagoraphobiaare twoseparatepsychiatric certain situationsisusuallyafearofpanickinginthosesituations. phobia after having panic attacks, the agora- stated cause of avoidance of develop who those For disorder. the of development the roleenvironmentala in and stressorsplay personality all ological, bi- genetic, that likely disorder,is panic it for and described those tion. promo- work a baby,getting a or having married, getting as such events, life positive significant be also could They job. a of loss or divorce, stress,one, financial loved of death a as such events ative neg- be could These adult. an as events stressfullife or childhood, during history illness extensive an trauma, loss, include can tors fac- These well. as disorder panic of development the to tributors ongoing attacks andrelated having behaviorchanges. then and place first the in attacks to panic vulnerable having person a makes symptoms, the of meaning the of misinterpretation the with tivity.combined hyperawareness, This sensi- anxiety high without those than sensations bodily of aware racing heart with having a heart attack). They also tend to be more a equating (e.g., dangerous as anxiety of symptoms misinterpret to tend sensitivity anxiety with sensitivity.Individuals anxiety of tendency towards experiencing negative emotions and high levels a are disorder panic for factors risk personality notable most the of Specifically,disorder. two panic of development the to tribute significant medicalproblems. have not do disorder panic with people many disorder,although monary disease (COPD), are associated with ahigherriskofpanic pul- obstructive chronic and asthma as such conditions, medical Certain levels. dioxide carbon body’s the in changes to sensitivity norepinephrine. Others believe panic disorder is associated with a and serotonin, GABA, specifically chemicals, brain in imbalance an as such disorder, panic of maintenance and to development the contribution biological a is there that believe scientists many example, disorder.For panic develop to someone for order in ent hypotheses. Inadditiontogenes,otherriskfactorsneedbepres- anxiety disorders tend to run in families, giving support to genetic other and Panic involved. likely are genes multiple that indicates disorder panic on research disorder,genetics panic of velopment events andenvironmental stressors. disorder andagoraphobia, including geneticandfamily history ofpanic There arefactors thatcontributetothedevelopmentofpanic several personality andpsychologicalfactors,stressful lifeevents and disorder orotheranxietymooddisorders,biologicalfactors, Agoraphobia: The causes for agoraphobia are very similar for con- often are factors environmental and events life Stressful con- also may factors risk psychological and style Personality Although much is unknown about the role of genes in the de- environmental stressors.

falling in the elderly). The situations almost always cause fear or fear cause always almost situations The elderly). the in falling or incapacitating embarrassing symptoms (such asfearofincontinence orfearof other or symptoms panic-like develop they if help receive not might they that fear Others them. escape to able be not will they that concerned are they because situations these 5) Beingoutsideofthehomealone 4) Beinginacrowd orstanding inline 3) Beinginenclosedplacessuch astheatersorstores 2) Beinginopenspaces,suchasparksoronbridges 1) Usingpublictransportation ing situations,foratleastsixmonthsorlonger: hibit high levels of fear or anxiety about at least two of the follow- Agoraphobia: disorder andgeneralizedanxietydisorder. stress post-traumatic as such disorders, anxiety other in seen also they might receive a diagnosis of specific phobia. Panic attacks are very specific type of fear, such as heights, flying, spiders, or blood, disorder. If a person only has panic attacks when confronted with a anxiety social with diagnosed be might they people, unfamiliar to tacks in fearful social situations, such as public speaking or talking stead of panic disorder. For example, if someone only has panic at- disorders,other disorder inwhichcasethe diagnosed in- be might psychiatric condition. Inaddition,panicattackscanoccurinother medical underlying an to due are symptoms the if diagnosed be tion, suchas hyperthyroidism or asthma. Panic disorder might not condi- medical another or substance a of effects the of result the (e.g., activities or avoiding crowds orexercising). situations certain of avoidance as such tacks, control, orhavingaheartattack). crazy,going as (such losing attacks the of consequences the about lowing foronemonthorlonger: 13) Fearofdying 12) Fearoflosingcontrol or“goingcrazy” 11) Feelingsofunreality orfeelingdetachedfrom oneself 10) Numbnessortingling 9) Chillsorheatsensations 8) Feelingdizzy, lightheaded,orfaint 7) Nauseaorabdominaldistress 6) Chestpainordiscomfort 5) Feelingsofchoking 4) Shortnessofbreath orsmotheringsensations 3) Trembling orshaking 2) Sweating 1) Heartpalpitationsorincreased heartrate least 4ofthefollowingsymptoms: anxiety, reaching itspeakwithinminutesandcharacterizedbyat intense of rush sudden a is attack panic Aout-of-the-blue). occur recurrent panic attacks, at least some of which are unexpected (i.e., Panic Disorder: cal causesofthesymptoms. medi- underlying out rule to important also is evaluation medical interview.A clinical thorough a with is disorders these diagnose blood test, CAT-scan, or any other laboratory test. The only way to 2) Significant, maladaptive behavior change relating to theat- to relating change behavior maladaptive Significant, 2) 1) Ongoing worry or concern about having more panic attacks or pro wt a igoi o aoahba er o avoids or fears agoraphobia of diagnosis a with person A ex- to needs person a agoraphobia, of diagnosis a Toreceive werenot attacks these that check to need would clinician The Additionally,fol- the of one least at experience must person a have must person disorder,a panic of diagnosis a Toreceive Panic disorder and agoraphobia cannotbediagnosed with a those disorders. instead ofagoraphobiaifsymptomsareaccounted forby better ic phobias,andseparationanxietydisorder, mightbediagnosed specif- depression, major as such avoidance, with associated ders post-traumatic stress disorder mightbediagnosed. Other disor diag- be might event, traumatic reminda that of places them avoid they If nosed. disorder anxiety social situations, social avoids only person the if example, by For diagnosis. health explained mental another better not are symptoms the that determine must avoidance mustbeclearlyexcessive. because of concerns related to a medical condition, the anxiety and situations these avoiding is person a If agoraphobia. of diagnosis a receive to order in functioning of areas major in impairment or distress significant cause must avoidance or fear The situations. these approaching in involved danger actual the with proportion anxiety in individuals with agoraphobia, and their fears are out of interview. A medical evaluation isalsoimportant to ruleoutunderlying disorders iswithathoroughThe onlywaytodiagnosethese clinical ial, o eev a igoi o aoahba te clinician the agoraphobia, of diagnosis a receive to Finally, medical causesofthesymptoms. symptoms - 3 WHAT ARE PANIC DISORDER AND AGORAPHOBIA? - MIRECC - FALL 2016 4 WHAT ARE PANIC DISORDER AND AGORAPHOBIA? - MIRECC - FALL 2016 prevalence of panic disorder significantly declines in old declines significantly disorder panic of prevalence the general, in and 45, age over be to onset the for common less is It adolescence. as early as begin could it although 20’s, such apracticeathome. in engage to relative their for space and time the giving by help can members family treatment, of part as practice mindfulness or non-scary alternative, consider thoughts about the attacks. to If the person is relativeengaging in a relaxation their with dangerous work not and are attacks panic that concept the reinforce can help members family Forexample, if relevant. help, to offer and homework the in engage to relative their encourage can members family and assignments, homework includes CBT support. vide therapist to learn specifics about the illness and how they can pro- therapy,in the with talk to members family for helpful be might it by givingreminders andproviding transportationtotheclinic. appointments psychotherapy to attendance support also can bers mem- Family medications. those taking regularly in support vide vide support. If medication is prescribed, family members can pro- pro- to and questions answer help to attend also could members visit a medical doctor for a thorough evaluation. If possible, family first to anxiety experiencing is who person the for important is It ways. many in recovery relative’s their support can agoraphobia panic symptoms. ring psychiatricdisorders compared tothosewithoutany co-occur of rates higher have attacks individuals panic subclinical with Even disorders. anxiety other and depression experience other co-occurring psychiatric disorders, such as also disorder panic have who individuals Often wane. and wax can that episodes experience others while symptoms, persistent more having some with individual, by varies der disor panic untreated of course The 65. age over adults er Panic Disorder: how familymemberscanhelp course ofillness tde hv son ht ate-sitd xoue therapy exposure partner-assisted that shown have Studies is agoraphobia and/or disorder panic with individual the If and/or disorder panic with individuals of members Family mid to low is disorder panic of onset of age average The - - - can wax and wane. Between one-third toone-halfofpeoplewillhave Between wax andwane. can having morethat episodes experience symptoms, whileothers persistent The courseof untreated panicdisordervariesby individual, with some encouraging treatment (medication and psychotherapy),assistingwith disorders, suchasanxiety, mood,and/orsubstanceusedisorders. psychiatric co-occurring have also agoraphobia with individuals 40. Agoraphobia tends to be a chronic illness if left untreated. Most age after onset an have will individuals of third a age, younger a is later - in the mid to late 20’s. While most develop the disorder at onset of age average the agoraphobia, of onset the to prior attacks panic have not do who those for For onset teens. late of is individuals age those average the agoraphobia; of onset the to prior attacks panic have will people of one-half to one-third Between Agoraphobia: relative. towardstheir empathy and morewarmth and frustration less feel may disorder the of part a are behaviors of types these that stand the freeway,on or going driving out to restaurants).store, Family members the who under to going (e.g., people most for easy are their symptoms are dangerous, or have difficulty doing things that not or whether about reassurance for ask frequently attack, panic a having of fear for minute last the at cancel plans, making avoid might disorders these with person a example, For relatives. to ing frustrat- quite be can agoraphobia and disorder panic of aspects situations bythemselves. with the goal situations, being that the person those would eventually go into those into them accompany initially to offer can bers are situations that the person is completely avoiding, family mem- there If relative. their with practice exposure encourage can bers mem- Family agoraphobia. and panic of symptoms reduce helps disorder and/oragoraphobiainmanyways.Somewaysinclude Family memberscanhelptheprocess ofrecovering from panic Lastly, family members can provide emotional support. Some treatment homework,andproviding emotional support. panic attackspriortotheonsetofagoraphobia. - during their panic attacks. Diaphragmatic breathing is also a relax - those whoexperience shortnessofbreath,chest pain,or dizziness for helpful particularly be might lungs, the in oxygen more and breaths deeper to leads which breathing, of type This breathing. belly or breathing, diaphragmatic is disorder panic for used often strategy relaxation of type One people. most for symptoms panic relaxation training alone that is probably not agreesufficient to fully professionals alleviate most but medication, and/or conjunction CBT in with used be can It attacks. panic and anxiety ducing Relaxation Training are notscaryordangerous. they that learn and situations feared approach frequently and ly exposure therapy, individuals with agoraphobia will systematical- vivo in in engaging By treatment. of element exposure vivo in the plan onintroducing andcontinuingthese avoided activities. having an attack, the therapist will work with them to strategically of fear for caffeine drinking or exercising avoiding is example, someone if For attacks. panic the of result a as they avoiding be that might activities and places, people, the face to starts atically system- person a Finally,which exposures,in vivo in utilizes CBT themselves. symptoms the eventually and panic of symptoms ing exercises are very effective for alleviating the distress of experienc- trolledway. exposure these first, at uncomfortable often Although exercises to bring on the symptoms of anxiety and panic in a con- panic attacks. Interoceptive with exposure involves engaging associated in specific sensations bodily the of fear their overcome ple more realistic andlessfrightening. instructing themonhowtochangethesethoughtsmake and attacks, the about thoughts scary their of aware be to people disorder,panic about teaching education providingthrough done of their panic attacks, in order to help make them less scary. This is morerealisticview a have person the help to treatmentis of goals ance of situations thattheyassociate with theattacks.Oneof avoid- as such behaviors, their in changes make often they 3) and sensations, making them more vulnerable to experiencing attacks, bodily their to attuned overly are they scary,2) or dangerous as attacks panic their misinterpret disorder panic with individuals symptoms andapplythetechniqueslearnedintherapysessions. panic their monitor can person the that so “homework,” of form the in sessions between done is CBT of work the of Much them. with associated changes behavior and fear the decrease nificantly sig- as well as attacks, panic eliminate or significantly reduce to is CBT of CBT.goal of The principles the on based are that manuals usually on a weekly basis. There are also some self-help books and format, group or individual an in provided be can that treatment nation is often preferred for more severe cases. CBT is a structured combi- a whereas cases, milder for own its on effectively utilized be often can CBT medications. with conjunction in or alone be used can which (CBT), therapy behavior cognitive is agoraphobia Cognitive BehaviorTherapy(CBT) ications. Should You What Know” (pages 6-7) provides general Agoraphobia: information about these med- and Disorder Panic for cation “Medi- titled, section The agoraphobia. and disorder panic treat Medication oe hrpss s rlxto tann a a ehd f re- of method a as training relaxation use therapists Some on be likely would emphasis the agoraphobia, for CBT With A technique called interoceptive exposure is used to help peo- CBT forpanicdisorder1) assumptions that: is basedonthe and disorder panic for treatments effective most the of One to used be can that medications of types different are There to lessenandfeellessscary. behaviors. Thus, acceptance of one’s anxiety can cause the anxiety avoidance and thoughts negative with it into feeding than rather anxiety,their observe to people teach can mindfulness oraphobia, tional states, such as anxiety. For those with panic disorder and ag- their bodies. They can learn to be more accepting of negative emo- in changes and emotions their to reactive less be to learn can ness mindful- practice regularly who People breath. the change to ing try- actually without breath, one’s on sit attention focus to and quietly is way common One mindfulness. practice to ways many many people find practicing mindfulness to be relaxing. There are people some what to think, mindfulness Contrary and relaxation are not the same medication. thing, although and/or CBT with Mindfulness andAcceptancePractices reducing generalizedanxiety. tensing and relaxing different muscles in the body, can also lead to progressive muscle relaxation, a type of relaxation which involves then reduce one’s susceptibility to having a panic attack. Likewise, anxiety,might generalized which more treating for strategy ation Treatments forpanicdisorderandagoraphobiaincludecognitive Mindfulness is another technique often used in conjunction in used often technique another is Mindfulness behavior therapy, relaxation training,and mindfulnessand acceptance practices. treatment 5 WHAT ARE PANIC DISORDER AND AGORAPHOBIA? - MIRECC - FALL 2016 6 WHAT ARE PANIC DISORDER AND AGORAPHOBIA? - MIRECC - FALL 2016 AND SEROTONINMODULATORS SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) have forgotten. ble up on doses of your antidepressant to “catch up” on those you dou- Never regularlytime. next scheduled the at medication your resume and dose forgotten the skip just taken, been have should when youremember it.Ifitismore thanthree hoursafterthedose missed you if your regularis: time by three thumb hours or less, you of should take that dose rule safe a dose, a take to forget you if disorder, panic for medications antidepressant taking When • about doctor how tocorrectly stopit. your to talk medication, your taking stop to want you If supervision. doctor’s your under stopped be only should Medication relapse. a cause can medication your better.Stopping arefeeling you if even medications, your taking stop abruptly not • To prevent the panic disorder from coming back or worsening,do might recommend longertermtreatment. symp- disorder,panic doctor of the case severemore a have of you If toms. relapse a to lead may earlier treatment Discontinuing ue treatment. It is typical for treatment to continue for 6-9 months. • Once you have responded to treatment, it is important to contin- not working.Giveittime! it’s think you because medication your taking stop don’t So toms. weeks before you can expect to see positive changes in your symp- • Antidepressants mustbetakenasprescribed forthree tofour rotransmitters: serotonin, norepinephrine, and/ordopamine. • Antidepressant medications work to increase the following neu- You shoulddiscussmedicationchoiceswithyourdoctor. considerably. varies disorder panic treating in effectiveness their for evidence the here, listed are antidepressants available many anxiety treating While disorder. panic treat in to used commonly successful are and disorders be to found been have pression, de- for developed initially while medications, Antidepressant • Antidepressant Medications ence oneormore severe symptoms. severe side effects. Contact your doctor immediately if you experi- or become bothersome. In rare cases, these medications can cause persist listed effects side common the of any if doctor your with Check days. few a in subside and tolerable are experience ically typ- people effects side The effects. side minor or effects side no have people many but effects, side cause may medications •All improved anddonotgiveupsearching fortherightmedication! to find a good fit. Let your doctor know if your symptoms have not to open Be another. trying anothermedication or combination of medications in order for well as do not may person one for well works anxiety.What your to regard with desire you provements im- the to lead not may try first you medication the Sometimes • rotransmitters believedtoregulate anxietyandmood. gamma-aminobutyr ic acid(GABA),serotonin, norepinephrine, ordopamine;neu- modulating by work medications These • medications, benzodiazepines,andanticonvulsants. antidepressantinclude These disorderagoraphobia. panic and for effective very are that medications of types different are There • medication: whatyoushouldknow Vortioxetine (Brintellix) Vilazodone (Viibryd) Sertraline (Zoloft) Paroxetine (Paxil) Fluvoxamine (Luvox) Fluoxetine (Prozac) Escitalopram (Lexapro) Citalopram (Celexa) - MONOAMINE OXIDASEINHIBITORS (MAOIs) TRICYCLICS ANDTETRACYCLICS(TCA ATYPICAL ANTIDEPRESSANTS INHIBITORS (SNRI SEROTONIN ANDNOREPINEPHRINEREUPTAKE for thepatient. determine dosagesandthebesttreatment ence and knowledge of the patient, must The treating physician, relyingonexperi- benefits of taking a particular medication. making anevaluationastotherisksand cal adviceforindividual problemsorfor treatment and is not intended as medi- does not constitute medical advice or medicines mentioned. This information ofthe interactions or effects, side tions, cover allpossibleuses, actions, precau- disorder and agoraphobia. Itdoesnot panic about medication for formation This handoutprovidesonlygeneralin- Tranylcypromine (Parnate) Selegiline (Emsam)patch Phenelzine (Nardil) Trimipramine (Surmontil) Protriptyline (Vivactil) Nortriptyline (Pamelor) Maprotiline (Ludiomil) Imipramine (Tofranil) Doxepin (SinequanorAdapin) Desipramine (NorpraminorPertofrane) Clomipramine (Anafranil) Amoxapine (Asendin) Amitriptyline (ElavilorEndep) Trazodone (Desyrel) Nefazodone (Serzone) Mirtazapine (Remeron) Bupropion (Wellbutrin) Venlafaxine (Effexor) Levomilnacepran (Fetzima) Duloxetine (Cymbalta) Desvenlafaxine (Pristiq) s) s ANDTECA) diazepines on a regular basis are at risk for dependency and with- benzo- • Benzodiazepinesmaybehabit-forming.Thosewhotake tolerate this,soImusttakeamedicationimmediately.can’t I message: opposite the themselves giving are dangerous.they fact, not In are attacks panic that learn to chance the selves them- depriving are anxiety,they increased feel or attack panic a have they when as such basis, needed as an on benzodiazepine a strumental in recovering from panic disorder. When a person takes and can be tolerated. Becoming less fearful of the panic attack is in- attacks are uncomfortable and unpleasant, they are not dangerous panic while that learn to sufferer panic disorder,the for panic is CBT, especially for psychotherapy of goals the be of should One basis avoided. needed as an on benzodiazepines of use The • tidepressant. an- the of benefits the experiencing are they once benzodiazepine the off individual the taper might doctor the Hence, diazepines. benzo- than strategy management medication long-term better a usually is antidepressant an of Use antidepressant. an on started getting is person a as benzodiazepine a prescribe doctors Many strategy. treatment long-term best the not are for they people, short-term, most the in effective be can benzodiazepines While • taken. for last day,a to up hours several can being is medication what on depending effects the quickly and hour), quite half effects a than the less in feel (sometimes can medications these of Users • might beprescribed tobetakenonaregular schedule. • Benzodiazepinescanbetakenonanasneededbasis(p.r.n.) or neurotransmitter GABA,whichhasacalmingeffect. the of effects the anxiety.enhancing for by work Benzodiazepines • Benzodiazepines are a different type of medication that are used Benzodiazepines neurotransmitter. excitatory an is which glutamate, decrease they that believed also rotransmitter, is It neu- brain. the on effect calming a has which GABA, the increasing by work to believed are Anticonvulsants • do notrespond toatrialofantidepressants. with panic disorder.individuals They are generally reservedfor for patients who helpful are and mood control help also they but seizures, treat to used usually are medications Anticonvulsant • Anticonvulsant Medications used simultaneouslywithalcoholoropiatemedications. concentration, and reduce short term memory. They should not be • Benzodiazepinescancausedrowsiness, impair coordination and problems. - abuse substance of history a with people to prescribed be not might benzodiazepines properties, addictive these of Because medication. the off coming when withdrawal of symptoms rience their of expe- also may They effect. desired the dosage get to order in medication the increase to need might Individuals drawal. Oxcarbazepine (Trileptel) Carbamazepine (Tegretol) Valproic Acid(Depakote) Lorazepam (Ativan) Clonazepam (Klonopin) Alprazolam (Xanax) 7 WHAT ARE PANIC DISORDER AND AGORAPHOBIA? - MIRECC - FALL 2016 RT P SE A E C I D F

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R E E N T T N A E L C IL L LN A E IC SS IN R CL ESE N & ARCH, EDUCATIO

MENTAL ILLNESS RESEARCH, EDUCATION AND CLINICAL CENTER VA Desert Pacific Healthcare Network Long Beach VA Healthcare System Education and Dissemination Unit 06/116A 5901 E. 7th Street Long Beach, CA 90822

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Noosha Niv, PhD 1, 2 Bonnie Zucker, PhD 1 Christopher Reist, MD, MBA 1, 3

1VA Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC) 2UCLA Department of Psychiatry and Biobehavioral Sciences 3UCI Department of Psychiatry and Human Behavior