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By Professor Kevin Gournay

Most people with anxiety states are simply more alert and aroused than the general population. The chemical processes which underlie anxiety are complex but essentially lead to the body being put into an optimum state of preparedness. One way of looking at anxiety is that the body goes into this state of preparedness without a rational external reason. For many anxiety sufferers, there is a simple cure that activates an attack. This may be the sight of a spider, the thought of going shopping or talking to a large group of people. Attacks of anxiety-like this can be managed by the exposure-based approaches which have been shown to be so effective. Therefore gradually facing one’s fears and avoided situations in graduated doses of difficulty, perhaps with some attempt to change how you think about such situations, will lead the body eventually becoming used to those situations and no longer producing the state of arousal.

However, some sufferers seem to experience surges in arousal for no apparent reason. I have come across a very large number of patients who have become physiologically very aroused and hence develop an anxiety state although there is no particular source of anxiety in their lives. Perhaps these people are more prone to produce adrenalin than some people and for some reason, their system becomes more prone to spontaneous panic attacks. The other group of people who are more prone to spontaneous panic attacks are those who repeatedly encounter anxiety linked to a particular phobia or obsession. In these cases, the repeated episodes of anxiety have a generalised effect and after a while, the body seems to just produce surges of adrenalin for no apparent reason.

What then does one do about this?

To begin with, one must look at simple factors that pre-dispose sufferers to panic attacks. Being hungry or tired can often be a factor and simply eating regularly and getting plenty of sleep is one remedy likewise, some people report that they are more prone to these apparently spontaneous panic attacks after indulging in alcohol the day before. This association has been known for some time but, it is becoming clearer that large numbers of anxiety sufferers can develop panic attacks in response to alcohol. More recently I have seen a number of patients who have developed such spontaneous panic attacks in the aftermath of taking illicit drugs such as Marijuana or Ecstasy. In the latter cases, I have seen a worrying number of young people who have developed the severest states of panic disorder after even an isolated intake of this drug.

Sometimes, spontaneous panic attacks are not really spontaneous. There is a great deal of research that shows that sometimes the arousal which occurs when one gets angry can be misinterpreted as anxiety and sometimes a panic attack may actually be a feeling of anger that presents itself a little later after the original event which caused the problem. Sometimes, there are other factors that may produce anxiety that are not so obvious. For example, one patient of mine recently developed spontaneous panic after seemingly making a good recovery from her agoraphobia. I asked her to keep a diary and eventually, we isolated the cause of these “spontaneous” panics. She had recently taken a new job and the bus journey to work which she was enjoying for the first time in many years passed a funeral parlour on a daily basis. She, therefore, glanced at the funeral parlour on the way to work and this activated a very long-standing fear of death, and cancer in particular (she had had four close family members die while she was a teenager). Thus, it became clear that this lady’s “spontaneous” panic was not really so spontaneous and she is in treatment for her long-standing fear.

However, some panics appear to be genuinely spontaneous. The first thing to do is to keep a diary and record these panics, trying to also note what may have come before them so as to isolate a cause. Secondly, keep a note of what you eat and drink. In some cases, panic may be triggered by the intake of alcohol (as mentioned prior) or lots of strong black coffee. If a diary-keeping exercise does not reveal a cause, think about ways of gradually reducing your base “level of arousal”. Although things like relaxation training and Yoga may be helpful, it is worth considering adding regular systematic exercise to your routines. There is a great deal of evidence that shows that regular exercise, a  minimum of 20 minutes, 3 times a week, can reduce states of high arousal. It is also worth looking at your pattern of breathing and seeing whether you are hyperventilating. It may be that you are breathing rather rapidly from the top of your chest and, some tell-tale signs are the presence of pins and needles, yawning and sighing, feeling tired, or having muscle cramps. The remedy for this malady is slow, but not deep, diaphragmatic breathing. The ‘No Panic’ help-line will assist you, if required, in learning some simple breathing exercises.

Finally, remember that panic can do you no real harm. Obviously, therefore one needs to look at how one thinks about such panics and whether there is a pattern of catastrophic thinking. Therefore, if for example, you think during a panic attack that you might die of a heart attack or stroke, this needs to be treated as an irrational thought and you should practice writing down your irrational thoughts and countering them with rational responses. Thus, as you go along, you should record the irrational thought and think about every other reasonable way of considering the situation. In the cases of someone whose thoughts are of their heart-stopping, one might respond by saying anxiety puts the body into an optimum state of preparedness, one’s heart muscle is in a very healthy condition during increased arousal. Or one may say I have had these panic attacks on numerous occasions and I have had the same thought and I am still alive!! Such simple self-help methods can often be successful however, if spontaneous panic and catastrophic thinking is a problem that will not respond to self-help strategies you should consider asking for a referral to a suitable cognitive behaviour therapist and, again, it may be worthwhile asking the No Panic helpline for advice. In some cases, medication can be useful but, although not a last resort, I would certainly not consider medication until the person showed themselves to be resistant to self-help and professional cognitive behavioural intervention. I would be very interested to hear from any of you who have developed your own strategies for dealing with spontaneous panic.

Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.

How can No Panic help?
No Panic specialises in self-help recovery and our services include:
Providing people with the skills they need to manage their condition and work towards recovery.
Our aim is to give you all of the necessary advice, tools and support that you will need to recover and carry out this journey. No Panic Recovery Programs

By Professor Kevin Gournay

 

When I first came into contact with phobic patients in my work with Professor Isaac Marks at the Maudsley Hospital, some 30 years ago, I was quickly struck by how many female patients described the worsening of their symptoms in the few days before their periods. An increase not just in the general pre-menstrual symptoms but in the tendency to panic, to become more anxious and to experience a heightening of the physical symptoms of anxiety. In some patients, the pattern was different with anxiety occurring during menstruation or just after. However, in these patients, there was still a predictable, cyclical pattern. This clear pattern, of course, provides some evidence that anxiety is linked to hormone function, but as an American colleague of mine, Diane Chambless, pointed out some 15 years ago, is that the symptoms can become part of a self-fulfilling prophecy. However, there is nevertheless a great deal of biological research that shows that female hormones play an important part in the regulation of mood and probably in the manifestation of anxiety.

If one looks at the basic facts about adrenalin, it is only too clear that the above phenomena are linked. Hormones are chemical messengers and are produced by the ductless glands or so-called endocrine glands. So, for example, Insulin is produced by the pancreas to regulate blood sugar and the thyroid produces thyroxine, which regulates growth. The master gland of the hormone system is the pituitary, which is found beneath the brain, over the roof of the mouth. The balance between hormones is finely adjusted by the pituitary and the whole system stays in a state of equilibrium in good health. However, if one hormone is produced in either abnormally high or abnormally low accounts, there are effects on other hormones. The classic example of this occurs in Throtoxicosis, a condition where the thyroid gland becomes overactive and produces too much thyroxine. One of the first systems experienced by people with Thyrotoxicosis is very often acute anxiety and some of this stems from the ‘knock-on effect’ to the adrenalin glands and hence, an outpouring of adrenalin. The increase in adrenalin output leads to the unpleasant symptoms of anxiety.

Recent research has shown that the female hormone oestrogen has an effect on specific microscopic parts of the brain responsible for the regulation of a chemical called 5 – Hydroxytriptamine. This very important substance is mainly responsible for the regulation of mood. This helps to explain why anxiety symptoms can become more prominent after childbirth or in menopause, as well as in the few days before a period. However, this work unfortunately has not led to any specific treatment for this pre-menstrual anxiety. Many doctors now advocate the use of hormone replacement treatment in menopause and there is a wide array of evidence that suggests that this treatment can be very beneficial for the depression and anxiety which often emerge at this time. There are also those who suggest that hormone treatment can be used in postnatal depression and, indeed, the evidence seems to be clear that some people are helped by this treatment. However, for many women, pre-menstrual anxiety remains a significant problem and for those who already suffer from panic attacks and phobias, this phase in the month makes a distressing and handicapping condition even worse and is therefore dreaded. What can be done?

One of the most important discoveries in recent years is the role that exercise plays in mood and anxiety and in the last ten years there has been a number of research studies that conclude that exercise in the week before menstruation is very helpful in reducing the symptoms. The difficulty for many women is that they report that this is the time when they least feel like exercise and even those who are in a regular pattern sometimes curtail their activities. I have found in clinical practice that these phenomena are worth looking at and most women can be encouraged to increase rather than decrease their exercise in the pre-menstrual week. The other matter that should be addressed is the issue of the self-fulfilling prophecy. While there is clear evidence that hormones underpin the vulnerability to an increase in anxiety, there is also no doubt that surges in anxiety are less than inevitable. Indeed, if you look at the diaries of women over a number of months, it confirms what most women already know, i.e. that sometimes P.M.S. is not as bad as usual, however, sometimes it is worse! Therefore, trying to not become preoccupied with the forthcoming period and saying “I’ll see how I’ll see how I feel when the time comes!” is probably the best approach. If the pre-menstrual anxiety is very distressing, it may be worth keeping a diary for 3 or 4 cycles, writing down in the diary each day perhaps using a rating scale of 0 – 100 the severity of various symptoms. Thus, this diary should include a rating of anxiety and depression, but should also include any other symptoms such as breast tenderness, bloating, or craving for certain foodstuffs. This diary-keeping exercise may well be very helpful to your G.P. and in some cases, it may be worth referring a patient to an Endocrinologist so that more detailed blood tests could be taken to see if there is in fact any particular hormone imbalance that needs correction.

I would, however, point out that in my experience, 90% of these blood tests tend to come back as absolutely normal and there is little further that can be done. Sometimes, people are sent away from a long line of specialists with the words “ You’ll have to live with it” ringing in their ears. As I have stated above, exercise may in fact be one route to help with this problem, but it may also be worth trying remedies such as Evening Primrose oil. Some of the complementary therapies and in particular herbal remedies and acupuncture have been reported as effective by some of my patients. As a man, I can obviously not fully understand the problems that many women suffer from pre-menstrual anxiety. However, I have found that looking at this aspect of the problem and developing simple strategies to help reduce the symptoms has been useful. Therefore, whether your therapist is a man or a woman, if this is a problem to you, you should try to look at solving the difficulty rather than “trying to live with it.”

Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.

How can No Panic help?
No Panic specialises in self-help recovery and our services include:
Providing people with the skills they need to manage their condition and work towards recovery.
Our aim is to give you all of the necessary advice, tools and support that you will need to recover and carry out this journey. No Panic Recovery Programs

By Professor Kevin Gournay, former Patron of No Panic.

The first thing many people ask when they have serious anxiety problems is “Am I going mad?” 

Very often, people with anxiety states feel that they are teetering on the edge and that loss of control is imminent. Indeed, many people become obsessed with the idea that they will lose control in front of their family, friends or strangers and behave in a bizarre, inappropriate or even violent or a dangerous way.  These feelings of loss of control are triggered by high levels of arousal and consequent muscle tension.  Thus, if one feels “keyed up” for no apparent reason, the brain is alert to the possibility of action.  In turn, there is a misinterpretation, on the part of the sufferer, that something dreadful is going to happen. Other sufferers of anxiety (in all its shapes and forms) fear that their anxiety may progress to madness and they may be locked away in an institution.  Indeed some mental health professionals perpetrate the idea that serious mental illness, such as schizophrenia or manic depression can develop from an anxiety state.

This article is designed to put the matter straight.

Neurosis is a term which covers a whole array of mental health problems, ranging from anxiety and simple phobias to severe and long-standing obsessive/compulsive disorder.  In between the term captures mild and moderate levels of depression, stress reactions of one sort or another and an array of conditions which are probably best seen as exaggerated forms of normal thinking, behaviour and feelings.  Indeed who amongst us has not had some neurotic reaction, whether it be an anxiety attack, an obsessive thought, or a reaction to stressful life events?  On the other hand, psychosis refers to very specific conditions and these are largely covered by two umbrella categories, i.e. schizophrenia and manic depressive disorder.  Schizophrenia is probably best seen as an umbrella term to cover a variety of different conditions, but these are essentially characterized by a condition wherein the personality fragments and the sufferer is handicapped in a wide range of areas.  Schizophrenia sometimes comes on acutely and then disappears.  However, in the majority of cases, it is a condition which has a waxing and waning course, often leading to a very impoverished life.  Sufferers often have hallucinations and delusions, i.e. they hear voices and suffer false beliefs, which are impervious to any logical reasoning, in addition, their thoughts show considerable disorder.

Sometimes there is a lack of coherent speech and general motivation to lead a normal life is impaired and personality behaviour and drive deteriorate over time.  Schizophrenia is present in perhaps 1% of the population and is probably caused by a number of different biological factors.  Increasingly, it is being seen as a neurological illness rather than a mental health problem caused by stresses and strains.  Although some people with schizophrenia suffer anxiety.  It is impossible for people with anxiety disorders to develop schizophrenia as a result of their anxiety disorder.  Anxiety sufferers should be reassured that they cannot develop schizophrenia as part of their anxiety state, no matter how bad the anxiety becomes.  The symptoms of schizophrenia and the deteriorating course can be linked to changes in the brain structure and functioning, which are entirely different from those associated with anxiety.

Manic depression is also a severe condition, often running a lifelong course where there are violent swings in mood.  We all, of course, have “ups and downs” in the way we feel, but manic depressives swing from a very extreme form of elation and over-activity to the depths of despair, with the condition becoming so bad that people are sometimes in a stupor, being unable to feed themselves or even get out of bed.  The person may swing from one state to another but, commonly they may be deeply depressed with spells of normality in between, with only rare periods of elation.  These spells of elation and over-activity are called “hypomania”.  During this phase, the person often loses contact with reality and may hear voices.  The depression experienced by sufferers of anxiety and cannot be explained by external circumstances.  People with anxiety states can feel profoundly depressed but usually, this depression is a direct result of feeling chronically anxious. Again it is impossible for anxiety depression to become manic depression.

On a more optimistic front, new treatments, mostly medication, are being involved for both schizophrenia and manic depressive illnesses although, it must be noted that cognitive behaviour therapy techniques are being developed for both conditions.  New techniques in examining the brain with magnetic resonance imaging and other forms of scanning are helping neuro-scientists to understand the pathology of these conditions.

At the Institute of Psychiatry where I work, a great deal of research is being carried out on both schizophrenia and manic depression.  The more one sees these conditions, the more one realises that they are very different from anxiety disorders.

Readers of this article should therefore know that the distinction between neurosis and psychosis is very clear and that you as an anxiety sufferer will not cross the boundary.

Neurosis Or Psychosis?  Some Further Thoughts

Several years ago, I was asked to write an article about the difference between neurosis and psychosis and to address that people suffering from anxiety states have that that “they are going mad”.  Subsequently, the article titled Neurosis or Psychosis? was published in a No Panic support email.  In this article, I argue very strongly that it was impossible for anxiety states to develop into schizophrenia or for anxiety to develop into manic depression.  In this, I simply wished to reassure readers who had fears of going mad that this would not happen.  Subsequently, I have had a letter from a lady who suffers from psychosis, which has caused me to think more about this topic and perhaps offer some further clarification.  The main point of the article was to reassure anxiety sufferers that they could not go “mad”.   I did not consider other aspects of the relationship between neurosis and psychosis.  Perhaps I should have mentioned that, as schizophrenia and manic depression are fairly common conditions (about 1% of the population will suffer from schizophrenia during their lifetime) it is, of course, possible that some sufferers of schizophrenia and manic depression will also have very commonly occurring anxiety states, panic attacks and obsessive-compulsive disorder.  Therefore these individuals are in need of assistance for both problems and I know, of course there are some members of No Panic who also suffer psychotic illnesses, such as schizophrenia and manic depression but derive a lot of benefits from their membership of No Panic in helping with their anxiety-related symptoms.  The lady who wrote to me recently made the point that, very often, drugs are the only intervention on offer for people with psychosis and it is clear to me that sufferers of schizophrenia and manic depression often need considerable psychological treatment in addition.  The recent guidelines from the National Institute for Clinical Excellence (NICE) made it clear that sufferers of schizophrenia should be availed of cognitive behaviour therapy for their psychotic symptoms.  There is now a great deal of evidence to show that these symptoms can be helped with CBT.  In turn, therefore it is very reasonable to suggest that CBT and other evidence-based approaches be used to help people with anxiety states who may also suffer from schizophrenia.

In the article, I drew attention to the difficulties produced by schizophrenia and manic depression and, in particular, described impaired motivation.  In my original newsletter article, I was of course, talking in generalities and I do, of course, appreciate that some people with schizophrenia do retain good motivation to lead a normal life and often make valiant efforts to continue functioning despite suffering from a very debilitating illness.

In conclusion, therefore, I wanted to add some afterthoughts and also indicate that anxiety states are very commonplace and widespread and that they accompany a range of other problems.  I further believe that No Panic has a great deal to offer sufferers of anxiety states and related conditions and that, as an organisation, we should be inclusive, rather than exclusive.  I recall discussing the nature of anxiety with Colin Hammond, the founder of No Panic, more than a decade ago and I remember us discussing the fact that anxiety states were very similar across, literally, millions of people in this country, but that each sufferer is a unique individual with their own particular expression of their problem.  When I see patients as a treating specialist, I have to keep at the forefront of my mind, that the person in front of me is a unique individual with a unique constellation of factors relating to background, upbringing, beliefs, culture and the way that their problems manifest themselves.  Anxiety is a great leveller and I know, by my own experience that sufferers come from every walk of life and every background that you can think of.  Perhaps in my earliest article, I did not emphasise enough the way that different people manifest their particular problems, but overall, I wish to stand by my basic assertions in that article and to reassure those who have such fears, that anxiety problems don’t make you go mad!

 

Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.

How can No Panic help?
No Panic specialises in self-help recovery and our services include:
Providing people with the skills they need to manage their condition and work towards recovery.
Our aim is to give you all of the necessary advice, tools and support that you will need to recover and carry out this journey. No Panic Recovery Programs

By Professor Kevin Gournay

Agoraphobia was a term coined by the German neurologist Westphal in 1871. In his original description, Westphal described four patients (all men) who had attacks of anxiety in public places. Interestingly, he described how several of them used alcohol to reduce their fears. The term ‘agoraphobia’ derives from the Greek, the word ‘agora’ meaning the market place. This term, Westphal felt was appropriate because it described how people felt vulnerable in public places and in particular where there was no obvious exit. At the same time, another neurologist, Benedikt, coined another term (Platzschwindel) which translated from the German, means dizziness in public places. Over the years, this syndrome has been called many things, one of the most convoluted terms being the “phobic anxiety depersonalisation syndrome!”

In its fully developed form, agoraphobia probably affects between ½ and 1% of the population, i.e. about 1½ million people in the United Kingdom but, in a less severe form up to 1 in 8 people, i.e. about 7 million, may be troubled by some agoraphobic symptoms. More recently, the American classification system has defined agoraphobia as part of a more general panic disorder and sees panic as being the central feature from which all fears stem. This is a concept which is currently open to some dispute, but there is no doubt that panic attacks form a considerable component of agoraphobic anxiety. With regard to incidence, it is probable that up to 1 in 3 of us may have a panic attack during our lifetime and certainly, at any one time, about 3% of the population may be experiencing panic attacks.

Agoraphobia has its classic onset in early adult life, the peak ages being between 18 and 30. It is very rare for agoraphobia to develop from its beginnings after the age of 30 although, some people appear in outpatients clinics in their 30s and 40s, stating that this is the first episode. However, in many of these people, you can find a history of fear situations during school life and transient episodes of anxiety in public places at other times in their life. If, however, phobic symptoms truly start without any history whatsoever in the 40s or 50s, it is likely that they are part of another syndrome, possibly a depressive illness. Agoraphobia is not a fear of open spaces although, some people with agoraphobia may be afraid in such situations, it is principally a fear of situations in which escape is perceived as difficult and/or help is not perceived as being readily available. Therefore, people may often be able to travel long distances alone or go into crowded public places providing that they know that help is at hand. I have one particular patient of my recollection who was able to travel anywhere on his own throughout the United Kingdom provided he had a mobile telephone with him, so that if he had a panic attack, he felt that he could contact the emergency services (needless to say, he never needed to use it). However, if for some reason he was deprived of his mobile phone, he could not travel beyond a few hundred yards from his house. As most of you know, people with agoraphobia are extremely good at hiding their fears from the outside world and often people mask their symptoms effectively for many years, or even a lifetime.

With regard to sex differences, men are much more likely to hide their fears than women and although we think that there are probably almost as many male agoraphobics as women, the number of men who come to outpatient clinics is a ¼ or less of the number of women who attend. Men are certainly not as good at facing up to the fact that they have a fear and this is probably a very strong socially conditioned response. For example, many men say quite openly that they see the admission of fear as being synonymous with being a wimp or being week in some way.

I have carried out research in the field of agoraphobia since 1979 and this research has looked at both the nature of the syndrome and the outcome of treatment. So, what do we know about this condition?

Cause

The cause of agoraphobia remains a mystery and it is probably more true to say that it is a matter of a number of causes rather than one single cause. Probably, most people with agoraphobia are biologically pre-programmed in the sense that they produce adrenalin more readily than other people do. Secondly, we know that growing up among people who show avoidance traits in their behaviour can lead to avoidance behaviour developing in offspring. We know that separation experiences during childhood can be quite important and a very large number of agoraphobics have been separated from their mother or father.

We also know that agoraphobia may be associated with stressful life events and that people who suffer repeated stresses can often develop phobic symptoms. Sometimes, people develop agoraphobia following frightening experiences and the best examples of this is to be found in people who perhaps have been trapped in a fire, a lift or a motor car involved in an accident. These people often develop agoraphobic symptoms. However, it is interesting to note that there are many people trapped in such situations who do not go on to develop phobic symptoms and, thus, one really has to consider the possibility that there is a predisposition both biological and psychological to this syndrome.

Treatment

Before behaviour therapy, the treatment outlook for people with agoraphobia was not good. Psychoanalytic psychotherapy was often used on people but the outcomes with this approach were very poor. Similarly, the drug treatments which were used many years ago often led to major problems.

The first behavioural attempts to treat agoraphobia were those of systematic desensitisation, i.e. teaching people to relax in association with imagining various phobic situations. However, 25 years ago exposure in real life was developed as a central treatment for agoraphobia and this involved a therapist taking the patient into the phobic situations and keeping them there for long enough so that their symptoms reduced. These exposure exercises often lasted for 2-3 hours at a minimum.

While exposure in real life has remained the mainstay of treatment, therapist aided exposure is much less used today. Professor Isaac Marks at the Institute of Psychiatry, the world’s leading expert in this area, argues that exposure treatments can be as effective using self-help material, computer programmes or therapist instruction and he has a great deal of research evidence to support this proposition. In recent years, cognitive therapy has developed and all over the world, psychologists and psychiatrists are applying cognitive therapy principles to agoraphobia and panic attacks. While there is some evidence that cognitive therapy is useful in the treatment of panic attacks, there is as yet little evidence that cognitive therapy adds much to the outcome of exposure treatments. This controversial area is continuing to be subjected to research enquiry and I am sure that over the years we will see new emerging approaches. However, I am sure that exposure will remain an absolute prerequisite.

The results of exposure on its own are very good and probably 70% of people who complete programmes will achieve 70% or more recovery. However, many people drop out of treatment or fail to complete an adequate trial. Some of my research indicated that some people have difficulty tolerating exposure treatment and for this group of people, cognitive therapy may be helpful as a preparation. However, as most of you know, there is no way round the central truth that, in order to combat a fear, one needs, eventually, to face up to it!!

Self-help groups such as ‘No Panic’ provide a mainstay for the population of people with phobic anxiety in this country, as treatment resources are still desperately short. Unfortunately, although we have many skilled and very competent nurses, doctors and psychologists who have received the proper training in behaviour therapy, there are by no means sufficient numbers to treat the phobic population that exists. As mentioned above, self-help approaches can be very effective and, providing the correct ingredients of treatment are used, i.e. central emphasis on exposure and how it is applied, there is no doubt that the ‘No Panic’ volunteers can achieve outcomes which compare favourably with health professionals.

The main principles of exposure are:

1. Exposure must be prolonged. You must stay in the situation until your fear starts to go. This may take a long time – often several hours.
2. Short periods of exposure without experiencing a reduction in symptoms can be harmful.
3. Exposure should be regular.
4. Try and involve the family as co-therapists.
5. Buy some self-help literature.
6. Avoid the use of alcohol at all costs.
7. If you are taking medication, this must be discussed with someone who has expertise both in behaviour therapy and in the area of pharmacology. I believe the research evidence is that very few people with agoraphobia should be prescribed medication as a first line of treatment and that medication may achieve some short term gains but, in the long term, there is still a question mark over its usefulness.
8. If self-help is not working and you feel that you would benefit from professional treatment go to your GP and request a referral to a suitably qualified therapist. Insist on receiving behavioural therapy for your phobic condition. This is a universally recognised treatment and in my view it is your right to be referred. Under the new funding arrangements in the NHS, your GP should have access to referral to a specialist resource outside your immediate area if, local treatment facilities do not exist.

Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.

By Professor Kevin Gournay

Dysmorphophobia, which has been re-named Body Dysmorphic Disorder is one whereby there is a preoccupation with one’s appearance and this leads to considerable distress. I am currently engaged in some research on the nature and treatment of this condition but it is a common accompaniment of phobic and obsessional states. People who suffer from this condition may often develop a concern about their appearance and specifically worry about the size of their nose, other facial features or, indeed, virtually any part of their body. The preoccupation is usually so severe that sufferers may spend several hours each day thinking about their perceived defect and engaging in a whole range of checking and avoidance behaviour. It is not uncommon to find that people who appear to have social phobia or agoraphobia in fact suffer from this condition because they are concerned about how other people may judge their physical appearance.

One of the commonest ways that this condition shows is in association with an eating disorder (most commonly Anorexia Nervosa where people commonly perceive themselves as fat, whereas the truth is that they are indeed very slim. In general, patients with this problem can intellectually accept that their appearance is within normal limits but, at another “emotional” level, they are concerned with their body and perceive it to be abnormal, disgusting or both.  Sometimes, patients go to tremendous lengths to cover up their perceived defects, for example, patients may use sunglasses, makeup or clothing to hide the parts of their body which they feel are abnormal.

Doctor David Veale, myself and some other colleagues are currently researching this condition and we have just conducted a large scale survey and a preliminary trial to treatment. Very often patients with this condition have a more than moderate degree of depression, have a phobia of social situations and roughly one-third of them have Obsessive/Compulsive Disorder. The preoccupation is such that around 40% of the people we have seen have attempted suicide. Many patients we have seen have sought help from plastic surgeons and dermatologists and, indeed, some of the people have had repeated attempts to surgically correct their perceived difficulty but still remain dissatisfied.

In the treatment trial we have carried out, we have used cognitive/behaviour therapy to help people deal with their problems. In particular, we have used exposure-based treatments to help them break their pattern of avoidance behaviour and face up to the situations they commonly avoid. In addition, we have attempted to help them defeat the negative automatic pattern of thinking which tends to build as more avoidance takes place. Preliminary results show that patients can achieve quite good results from this form of treatment although, we have to accept that some patients remain in a depressed condition. This may therefore be one of those states whereby treatment with cognitive/behaviour therapy needs to be augmented by the use of antidepressant medication. We are currently considering the possibility of researching the effectiveness of treatment with combined cognitive/behaviour therapy and one of the newer antidepressants.

Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.

How can No Panic help?
No Panic specialises in self-help recovery and our services include:
Providing people with the skills they need to manage their condition and work towards recovery.
Our aim is to give you all of the necessary advice, tools and support that you will need to recover and carry out this journey. No Panic Recovery Programs

Towards the end of 2008, some research was published in the European Heart Journal, which as part of a larger study looked at the links between panic disorder and heart disease. The results of this study were reported fairly widely and one particular article, in the DailyMail, entitled “Panic attack sufferers’ increased heart risk” led the No Panic telephone lines being deluged with calls from panic attack sufferers and, in particular, many calls from people who had previously been reassured that panic attacks do not lead to heart attacks.

The first thing to say is that the stark headline does not accurately represent the very complex findings of the study – for example, while there appeared to be some relationship between an increased level of heart disease in people with a history of panic attacks, on the other hand, the study also showed that people with panic attacks had lower death rates from heart attacks. One of the other difficulties with such research is an issue of “correlation.” Simply put, correlation means that one factor is statistically linked to another factor and, in the case of this study, it appears that, statistically, the more likely you are to have panic attacks, the more likely you are to develop heart disease. However, correlation does not mean cause. Causation of heart disease might well be due to other factors. Thus, for example, it might be that people with panic attacks are less likely to take the requisite amount of physical exercise, might be more liable to smoke or might eat an unhealthy diet. Thus, research such as this is often difficult to interpret. However, regarding the topics of smoking, diet and exercise, the research evidence is much more clear and each of these three factors are very much associated with levels of heart disease. We also know that other factors, such as a genetic predisposition, are also associated with heart disease and such a disposition is very unlikely to be associated in any significant way with panic attacks.

Perhaps we should return to some basics ; First, panic attack sufferers should be well-advised to pay attention to various issues such as diet, exercise and smoking. Indeed, patients presenting to me with panic and other related anxiety disorders, who are overweight, do not do any exercise, smoke and eat unhealthy foods, are likely to get somewhat of an ear-bashing from me regarding these topics. I usually say in a very straightforward manner that, as well as attempting various psychological strategies known to improve the condition of people with anxiety disorders, it is essential that clinicians such myself pay attention to improving physical health. It is absolutely clear that people who lose some weight and begin a reasonable and sustained pattern of exercise do much better than patients who remain overweight and sedentary. I also believe that many people with panic disorders, because of their condition simply let their attention to health matters slip, possibly because they have given up or because of poor self-esteem. Paying attention to improving your physical health and making yourself a priority seems to me to be of central importance.

Finally, it is important that we all avail ourselves of a proportionate amount of health screening, ensuring that those of us – particularly over a certain age – have regular checks of blood pressure and that although symptoms such as shortness of breath and chest pain may be part of panic attacks, those suffering such symptoms should go to their GP and have the basis of these symptoms properly checked out.

The article also raises the old topic of whether one can die in the midst of a panic attack. My answer to this question is quite simple – and that is for 33 years I have seen a very large number of patients with panic attacks. Each and every one of them has suffered a large number of episodes. I cannot remember any patient dying during a panic attack.

One also needs to remember that panic is characterised by an outpouring of adrenaline and this the very substance that is used in resuscitation attempts because of its beneficial action on the heart. Anxiety is a state of fight or flight and in such a condition, the body is in an optimum state of preparedness. Thus, our vital organs, including our hearts, are flooded with oxygenated blood; this I think being the reason why deaths are very unlikely to occur during panic attacks.

By No Panic’s President and Co-Founder: Professor Kevin Gournay

Professor Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. 

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Our aim is to give you all of the necessary advice, tools and support that you will need to recover and carry out this journey. No Panic Recovery Programs