Panic and Agoraphobia

Survival is central to all organisms, and responding to threat is an essential part of that mission along with nourishment and regeneration.The evolution of more biologically complex species has naturally given rise to more complex neuro-biological threat response systems. With language and introspection, emotional categories emerged to describe different cognitive-physiological states; and "fear" became the emotional label for certain types of physiological arousal associated with experiences and/or contexts of threat or perceived danger.

Anxiety is another emotional label that is even more ambiguous. It has become a popularized large bucket for emotional dimensions related to fear, vulnerability and performance. The term anxiety can refer to tension, stress, nervousness, uncomfortable states of physical arousal, anticipatory worry and even some instances of irritability.

In evolutionary terms, biologist see anxiety as a mid point on a continuum of fear activation that serves to prepare us for dangers or challenges that will be faced in the near future. Anxiety-defined in this way-thus primes a state of defensive readiness when there is time to anticipate and prepare for higher risk encounters or challenges detected on the horizon.

As a sentient species, complex language and imagination have allowed us to create in ways our biological ancestors could not. This has led to significant technological and medical innovations that have improved our quality of life. Unfortunately, human innovation has not been without costs, as it has resulted in mass death and destruction, while putting our planet and it's inhabitants at risk in ways others species could not.

In contrast, the reaction to imminent danger is the "fight or flight response", a call to action in which a suite of biological responses act in concert to increase strength and endurance to best face the intense demands of this moment. For example, blood pressure, heart rate, and blood sugars increase; blood flow is directed toward large muscle groups and away from the extremities; air passages in the lungs expand while muscles in the diaphragm contract; digestion slows and pupils dilate while peripheral vision is decreased.

Both the slow burn of anxious arousal and the intense burst of fight or flight have adaptive roles. The moderate activation of the former can be considered the alert system that primes vigilance and planning. In contrast, the fight or flight is the alarm for immediate intense action. In this "end-game" context the biological over-drive of fight or flight response and environment are exquisitely synchronized.

The biology of survival is now understood to rely, in part, on predictive models that generate simulations of likely future encounters with the environment, based on past conditions and circumstances. Likewise, the fight or flight response is called up when present circumstances are sufficiently associated either directly or indirectly with previously encountered extreme threats or dangers. When this alarm system accurately detects imminent threat, fight or flight is the adaptive best fit with the intense environmental demands of the moment. However, when this survival response meets the modern day human mind fight or flight diverges from its adaptive ancestral purpose.

Metacognition - The Problem of Knowing

Humans have knowledge of potential dangers along with a vast library of contexts and circumstances associated with real or perceived past threats, and use both to generate best-case predictive simulations of what we could be facing. This is done automatically, at lightening speed and outside of our awareness. However, the predictive advantages of the human mind come at a price: Knowing we are mortal and understanding our many vulnerabilities, amplifies the importance of preemptive threat detection. When faced with the imperative of survival humans turn to our evolutionary advantage: cognition and imagination. However, as with all highly sensitive systems of detection false positives are inevitable. Given the complex nature of human cognition this is even more likely. But in the case of an anxiously predisposed sentient mind, bias lowers the threshold for interpretation of danger and preemptive scanning. The this can result false perception of imminent threat, which, in turn, triggers an unjustified response of fight or flight.

Panic attacks: Fight or flight Out of Context

When other species mistakenly perceive threat and launch a fight or flight response, fear is naturally extinguished over time with subsequent, corrective non-threatening experiences in similar contexts. Presentient species do not direct attention to and "think about" the biological responses during a false alarm. They observe the absence of threat and de-escalate. of a survival reaction this straight line to correction. Humans, however, analyze both self and the environment. As a result, we do turn our interpretative lens toward all stimuli that is perceived and experienced during such a false alarm. Upon observing the absence of external danger, we turn our attention inward to waves of disturbing somatic storms that are "coming at us" Because this biological call to action is now occurring in a context devoid of imminent threat, fight or flight can not be channelled toward the intense physical challenges demanded when defensive aggression or flight is necessary.

Fear response falls on a continuum which is shaped by genetic predisposition, perinatal factors and environmental conditions. Individuals at the higher end of the continuum have elevated radar for danger and a lower threshold for the somatic responses associated with threat detection. Consequently, this group is more susceptible to experience false alarms of the fight or response as well as to catastrophic interpretations of the unexpected somatic storms that are unleashed when these occur.

A panic attack is a state of fear paralysis brought on by such a false alarm of the fight or flight response.Thus, panic, particularly in the early stages,Lacking real external threat, the biological systems intended for survival cannot be channelled into action. Instead, they are experienced as a disturbing cacophony of sensations and malaise that is misinterpreted as potentially life-threatening.: increased heart rate need for intense exertion, is perceived as pounding heart that that could signal ; diaphragmatic tightening typical during high cardio-pulmonary demand, suddenly feels like inability to take a full breath, triggering fears of suffocation; blood flow away from the extremities that would limit bleeding and pain adaptive during physical aggression or flight over rugged terrain, when idle, is experienced instead as alarming sensations of numbness or tingling.

Panic attack generally last between 3 and 20 minutes. ultimately counter balancing biological systems act to slow the body down. Even after the episode has passed, residual anxious arousal can, at times, persist for hours. Exhaustion commonly follows episodes along with a sense of profound "relief" of having "made it through" and even "survived" the attack. Although this postscript is inferred from misinterpretation, the fear of near extinction is so immersive and feels so real that the experience is filed away "as if" one had just survived a near- death moment.

The impossible Escape, Fear of Fear in Panic Predictive Models and

As explained above, predictive models reference previous experiences to form best-guess simulations of the environment we are facing presently. However, panic confuses purpose in biology, as post-panic predictions are not drawn from real experiences but from the somatic storm of the false alarm that is misinterpreted as threatening. This illusion of "body as predator" is a predictive paradox of escape from self without resolution that merely fuels recurring panic

Although the adaptive behaviors that evolved to survive real imminent danger are suddenly rendered useless during these episodes, the mission to survive remains. In panic, this is manifested in avoidance and "safety-seeking behaviors", defined simply as those actions taken to diminish fear or the sources of fear. Interestingly, in panic disorder the most common SBs- distraction [competing movement, fidgeting, touching tapping, drinking liquids etc], the search for refuge [ seeking reassurance from others] and symptom control [checking behaviors such as trying to get a deep breath or checking pulse]- can be viewed as forms of response to or escape from the threat of the somatic self. Likewise, not engaging in activities that increase heart rate, breathing or dizziness can be seen as avoidance of these somatic "threats"

Safety behaviors and avoidance are biologically intuitive, and they, indeed, do provide short term comfort and relief. Safety behaviors, however, are quite the false friend, as there can be no resolution or relief from imagined dangers that do not exist. More problematic and pernicious is that safety behaviors further imbue the panic narrative with an as-if-real quality that merely breaths life into illusion. This "no-exit" paradox inevitably further increases the frequency and intensity of episodes that drop down like tornados, wreaking havoc wherever they land.

From Fear of Panic to Fear of Context: The Genesis of Agoraphobia

Panic imbues the places where attacks occur with the mission of threat survival inherited from the fight or flight response. Consequently, once panic becomes frequent, an expanding geography of contexts become contaminated with both threat perception and survival imperative. These ever growing context cues are, thus, incorporated into existing predictive models in anticipation of threat. This chain of survival responses, leading up to context, in the presence of real danger is adaptive. However, in the false alarm of panic, this sequence leads to contexts corrupted by illusion that cue "threats" that do not exist.

If safety behaviors are a protective response to the sensations of panic, avoidance is the default reaction when the perception of danger is cued by context. As explained previously, safety behaviors play an essential role in elevating the status of panic from episode to condition. Beyond breathing further life into the illusion that panic is, avoidance progressively undermines one's quality of life, as it limits activity and strangles freedom of movement. Insidious and pernicious, if unchecked, avoidance inevitably leads to functional impairment and, at times, even disability.

In 1871 the term agoraphobia [from the Greek word, agora, place of assembly and phobia, fear of a specific objects], was coined by the German neurologist, Karl Friedrich Westphal to describe this type of avoidance related to anxiety. Westphal observed that some of the male patients he treated, reported experiences of severe anxiety and dread in certain public areas of the nearby city. He noted the disabling nature of these intense fears, as these patients would completely avoid such places. Over the past 150 years, agoraphobia, as first described by Westphal, has been formally incorporated into the clinical literature and ever-evolving diagnostic reference manuals.

Panic Disorder

Panic Disorder is defined in the fifth version of the Diagnostic and Statistical Manual (DSM V ) of the American Psychiatric Association “as recurring, unexpected panic attacks characterized by an abrupt surge of intense fear or discomfort that reaches a peak within minutes. During the initial episodes of panic, symptoms are often misinterpreted as signs of life-threatening medical condition-such as heart attack, stroke, acute respiratory failure, suffocation, choking leading suffocation-or permanent psychosis.This perception of imminent threat to survival or sanity often results in emergency medical care being sought. Attacks can occur unexpectedly; or they can be triggered by specific activities or being in certain places. Attacks can also occur during sleep "nocturnal panic" causing the person to awaken in a state of full-blown panic. As noted above, episodes can last from approximately between 5 and 20 minutes. Because of their intensity, anticipatory worry about subsequent attacks gives rise to "protective" response or safety behaviors as well as avoidance, which, in turn, influences actions, choices, including important life decisions.

In order to meet DSM criteria for Panic Disorder, there must be at least one attack followed by one month or more fearing additional attacks, during which 4 or more of the following 13 symptoms are present:

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Shortness of breath or feeling of smothering
  • Feelings of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, or faint
  • Chills or heat sensations
  • Paresthesias (ie, numbness or tingling sensations)
  • Derealization (ie, feeling of unreality) or depersonalization (ie, being detached from oneself)
  • Fear of losing control or going crazy
  • Fear of dying

Agoraphobia is historically defined as fear and avoidance of places, situations or even activities where escape might be difficult or where help might not be available if something dangerous, very embarrassing or highly disturbing were to happen. Although this phenomenon most commonly occurs within the context of panic disorder, other forms of anxiety can lead to agoraphobia, such as fear of incontinence, social anxiety or specific phobias. Agoraphobic avoidance is far-reaching. Common examples include large indoor or outdoor spaces, from grocery stores to concert venues, bridges, being alone at home or in public, being in crowds, elevators, traveling by train, car, particularly driving on highways and airplane travel.

Agoraphobia With Panic

Agoraphobia with panic represents a particularly pernicious combination. As noted above, when context triggers panic, agoraphobic avoidance is the "survival" response. The comfort and "sense" of safety, unfortunately reinforces the false narrative of threat associated with panic and these contexts, which then spread across many areas of a person's life. This cycle of fear and retreat is progressive and limits movement to the point where one becomes trapped and ultimately isolated in an agoraphobic nightmare. untreated this can lead to serious limitations in one's life and, at times, disability.


The estimated lifetime prevalence of panic in the general population is between 1.5 and 3.5 %. Women are twice as likely to experience panic than are men; although the clinical features of the disorder are similar across the genders.

Treatment - Panic Control Therapy

Panic Control Treatment (PCT)- a patchwork of CBT methods, adapted to the treatment of panic by American psychologist David Barlow in the 1980s. Through years new generations of researchers, working with Barlow at the Center for Anxiety and Related Disorders at Boston University, have developed trans-diagnostic approaches for anxiety. targeted key aspects of the cycle of panic for change, particularly fight-or-flight false alarm, the catastrophic misinterpretation of this misdirected biological survival reaction, along with maladaptive "safety behaviors" Nonetheless, the PCT is still considered a first line approach for panic disorder.
Michelle Craske and UK researcher David Clark

My treatment approach builds on the core components of PCT models of Barlow, Craske and Clark. But is blended with the Inferential Based Approach used in the treatment of Obsessive Compulsive disorder

Phases of Treatment
  • Education about the fight or flight response, false alarms, associative learning, predictive simulations and understanding their evolutionary significance
  • Anxiety management strategies
  • Changing self talk and relevant maladaptive core beliefs
  • Facing and habituating to what is feared and avoided
Treatment Components
  • Initial assessment
  • Education about the nature and physiology of anxiety and panic
  • Fight or flight response: it's evolutionary roots, physiology and purpose
  • Normalizing and de-catastrophizing the fight or flight response
  • Associative learning and conditioned responses
  • Predictive models: their function and relationship to panic
  • Monitoring of panic symptoms
  • Defining the panic symptom profile
  • Defining specific triggers
  • Mapping of avoidance and safety-seeking behaviors
  • Ongoing monitoring of tasks and symptoms
  • Self-soothing techniques such as breathing control strategies and relaxation training
  • Cognitive strategies and interventions (challenging and reframing catastrophic misinterpretations of body sensations, decastrophizing fears)
  • Identifying core beliefs or vulnerable self narratives present in catastrophic interpretations
  • Exposure and desensitization to feared body sensations
  • Symptom induction exposure (“interoceptive exposure”)
  • Progressive situational exposure to avoided activities and places, reversing agoraphobic avoidance
  • Relapse prevention strategies and maintenance goals
  • Stress management strategies
  • Recovery and resetting of life goals.

© 2023 Robert Safion, M.Ed.

Treatment of Obsessional Spectrum Anxiety

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