In the past couple of posts, we have been talking about how some people are able to move past a panic attack experience, while others get stuck in the panic place. As a refresher, there are three reasons why someone transcends from having a simple panic attack to developing panic disorder: 1) Selective attention and hypervigilance; 2) Safety behaviors; and 3) Avoidance. This post is Part III of a three-part series. I will discuss how avoidance plays a role in the development of panic disorder.
Safety behaviors, discussed in the last post, are a subtle type of avoidance. However, people who develop panic disorder also engage in outright avoidance. They might stop going to places or avoid circumstances that remind them of a panic attack or trigger panic symptoms. Typically, these places or circumstances trigger panic because the person has had a panic attack in that situation before. For example, if someone had a panic attack in an elevator, they will likely start to avoid taking elevators. If someone had a panic attack in crowded situations, they will likely avoid going to places with crowds, whether it be a concert or even a crowded restaurant or coffee shop. In addition to places, people with panic can also start to avoid things that trigger symptoms that remind them of panic. For example, if feeling hot is a situation that triggers panic, they might avoid using the heater or wearing clothes that make them feel hot. As you might imagine, the types of situations and places that one might begin to avoid is endless.
So, what is the problem here? The more someone avoids the feared situation or place, the worse the anxiety becomes. Avoidance begets more avoidance. The particular place or situation becomes the proverbial ‘monster in the closet’ and the person’s fear only grows. At first, someone might only avoid super crowded places but soon enough they start to avoid being in any place in which they worry they might not be able to escape (e.g., a coffee shop, a car with friends). Eventually, they might stop leaving the house at all. One of the key factors in determining whether someone has developed Panic Disorder is to assess the extent to which their fear of panic impairs their daily functioning. If someone is avoiding multiple places or situations in order to not have a panic attack, indeed it has begun to impact their day-to-day living.
Cognitive Behavioral Therapy and Exposure Therapy are very effective treatments to help someone overcome Panic Disorder. It starts with helping the individual reshape how they see bodily sensations as threatening. Once they have developed strong cognitive restructuring skills, we then help them address their avoidant behavior. We systematically expose them to their feared situations and places until they learn that they are not threatening or dangerous in any way.
