"I was at home, watching TV, sitting on my favorite coach. It had been an exhausting day, but at last, I was at home. Suddenly, I noticed a strong beat in my heart, and it began again, the palpitations, the dizziness. I felt myself fainting. I couldn’t do anything at all to stop it, and the worst thing happened, I couldn’t breath. In just a moment I felt myself dying, it was a heart attack, I was sure this time. I called my wife and asked her to take me to hospital and again the same story: "It is a panic attack, you are not in danger at all". The doctor gave me a pill and I started feeling better in a while".

Panic disorder essential feature is the presence of unexpected panic attacks as the described above, which are attacks of fear or discomfort in which the individual experiences intense bodily sensations (palpitations, trembling, shortness of breath, etc.). These attacks have a sudden onset, build up to a peak rapidly (usually in 10 minutes or less), and are accompanied by a sense of imminent danger and an urge to escape. PD is usually accompanied by Agoraphobia (Ag) (Panic Disorder with Agoraphobia, PDA) (DSM-IV APA, 1994), namely, a cluster of fears whose common feature is 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 a panic attack or panic-like symptoms. This fear leads to a pervasive avoidance involving several situations: being outside one’s home alone, being in a crowd, travelling in a bus, automobile or train, being in an elevator or on a bridge, etc.

Patients with PDA show a persistent concern about the possible implications or consequences of the panic attacks, or they think the panic attack indicate the presence of a severe illness, despite repeated medical testing and reassurance. Others are convinced panic attacks are the indication that they are "going crazy", or losing control, or being emotionally weak. Many patients usually show constant or intermittent feelings of anxiety that are not focused on any specific situation, excessive worry about health, or about separation from loved ones. Moreover, the feature of "unexpectedness" of panic attacks, accompanied by the patients’ subjective perception that they have no control over the problem or over the somatic symptoms, leads to a sense of helplessness (Botella & Ballester, 1997).

PDA usually imply a significant change in the patients’ lives, and is often accompanied by several other problems, such as:

·        Important problems in interpersonal relationships: family, friends, work colleagues, etc.

·        Demoralization. They often attribute this problem to a lack of "strength" or "character".

·        Mayor Depressive Disorder (50%-65%).

·        Alcohol or medication intake to treat their anxiety.

·        High comorbidity with other Anxiety Disorders: such as Social Phobia (15%-30%), Obsessive-Compulsive Disorder (8%-10%), Specific Phobias (10%-20%), Generalized Anxiety Disorder (25%).

DSM-IV (APA, 1994) states that epidemiological studies throughout the world (APA, 1994, Kessler et al., 1994) indicate the lifetime prevalence or PD (with or without Ag) is ranging between 1,5% and 3,5%. To these data, we have to add the social and financial implications of PD. A high percentage of panic sufferers are in their most productive age, and a significant number of them drop out work, due to the incapacity the problem creates. Because of that, PDA is considered as an important public health problem, due to its high prevalence, its resistance to spontaneous remission, its comorbidity with other disorders such as alcoholism, drug abuse, and depression, and the important negative consequences to the panic sufferers quality of life. (Margraf, Barlow, Clark, & Telch, 1993).

Components: Psychoeducation, cognitive therapy, breathing re-training, in vivo exposure, VR exposure, and relapse prevention.

Psychoeducation

It consists of giving a clear explanation about what PDA is and of clarifying concepts such as fear and anxiety. The survival value of anxiety is addressed, as well as the fact that it is harmless. The different manifestations of anxiety are also discussed (physiological, cognitive, and behavioral). We highlight the central role that the cognitive component has in anxiety and, concretely, in the development of a panic attack. We expose a cognitive model of panic attacks and we encourage the patient to pose all the doubts and questions about the model. Then we propose the patient to carry out a behavioral exercise: we make the patient hyperventilate in order to learn more about the development of his/her panic attacks and about the role of hyperventilation in his panic attacks and its physiological effects.

Breathing re-training.

The goal of this component is to change a fast breathing pattern by a slow breathing pattern. A common response to anxiety provoking situations is hyperventilation. The consequences of hyperventilation are the intensification or the appearance of several physiological symptoms that intensify anxiety. In our treatment for PDA, patients are taught a slow breathing technique to face the anxiety provoking situations in a more effective way.

Cognitive therapy.

An important issue regarding our responses to events or situations is the way we interpret them, what we think about those situations and their meaning. The way we think will determine how we will feel about things. Sometimes we make erroneous interpretations that can lead to distressing feelings. Applying cognitive techniques means trying to behave as scientists do: test if our interpretations are right or wrong, find alternative ways of thinking about the situations that would lead to less distressing feelings and allow us to face the situations in a more competent way. In our treatment for panic disorder the therapist shows how to identify, challenge, and combat the catastrophic misinterpretations that the patient makes of his/her symptoms while having a panic attack. With the indications from the therapist, the patient learns to look for objective interpretations about the consequences of his/her bodily sensations during a panic attack. This is a better way of facing panic attacks and decrease panic frequency.

In vivo exposure and exposure to interoceptive cues.

If we met someone who wanted to ride a bicycle, but who fell down when he tried it, what would we advice him? Probably, we would tell that person to ride the bicycle again. The best way to overcome a fear is facing it. In vivo exposure consists of facing the fear provoking situations gradually and progressively, staying in the situation until the fear or anxiety goes down. In our treatment to panic disorder, we elaborate with the patient an individualized hierarchy with his/her feared situations and he/she carries out exposure exercises to face gradually those situations. Also, the patient exposes him/herself to the feared bodily sensations that appear in the panic attacks.

VR exposure.

This form of exposure presents some advantages if we compare it to traditional exposure: it provides safety to the patient and to the therapist; they can control the context generated by the computer at will and without risks, since it can be absolutely graded. Therefore, VR can be an intermediate step between the therapist's consulting room (where the patient feels safe and protected) and the real environment (so threatening for some patients that they decide not to face it). It is easier to repeat the same exposure tasks once and again without leaving the therapist’s office. This implies an important saving in cost and time. Finally, VR exposure allows designing a tailored hierarchy for the patient to expose him/herself to all the possible situations, and even to impossible ones. In our treatment of PDA, there are a great number of situations related to agoraphobic avoidance that the patient uses to avoid to prevent the occurrence of panic attacks. By means of the immersion in different VR scenarios, the person can face and overcome his/her fear.