Panic at the wheel, in the lift, in the shop: why there

“Always the same three places. In a queue of traffic on the motorway, in the lift at work, and in that big supermarket near us. Nowhere else. As if panic kept a timetable.”

I hear versions of this sentence almost every week. People tell me with a kind of restrained puzzlement, because they can see it means something, they just do not know what. If panic were random, it would catch them everywhere. It does not.

And it really is not random. Only the explanation does not lie in the places themselves. Traffic, lifts and supermarkets do not have danger in common. They have something else in common, and once you see it, the list suddenly reads as entirely logical.

Three places, one shared feature

Take your own list and look at it. The motorway between two exits. A tunnel. A bridge. The lift. The queue at the till. The middle of a row in the theatre. The dentist’s chair. The hairdresser’s. A plane. A crowd at a concert. The meeting where you are the one speaking.

The shared feature is not height, enclosure or crowds. The shared feature is that these are places you cannot leave without someone noticing, or without something going wrong. You cannot step out of a traffic queue. You cannot get out of a lift between floors. You can leave the till queue, but you will abandon a full trolley and everyone will look.

The diagnostic criteria for agoraphobia do not describe a fear of open spaces, as is often assumed, but a fear of situations where escape might be difficult or help unavailable should panic-like symptoms appear. That is a more accurate description, and a more useful one.

What “hard to leave” means in practice

When I ask people what exactly seems terrible about a lift, they almost never say they are afraid it will fall. They say something like: “What if I go dizzy in there and cannot get out.”

Three different worries sit underneath, mixed differently in each person. The first is unavailable help: if something bad happens to me, nobody will reach me in time. The second is being trapped: I cannot stop when I want to. The third is exposure to onlookers: if I behave oddly, everyone will see.

For many people the third is the strongest, though it is the hardest to admit. In panic, shame about a possible attack is often a bigger motivator for avoidance than fear of the attack itself.

How a place gets linked to panic

Now the mechanism, because without it all of this stays description.

The first attack happened somewhere. The place did not cause it — usually it was the result of weeks or months of raised tension, poor sleep, perhaps illness or hormonal change. But when it happened, your nervous system was in the middle of a very intense experience, and in that state the brain learns fast. It took everything that was present at the time and stored it as a possible predictor.

What was present was not only the place and the lights. The bodily sensations were present too: the racing pulse, the hot face, the feeling of unreality. So the link is made twice over — the place gets tied to the attack, and the sensation gets tied to the attack. Bouton, Mineka and Barlow proposed exactly this kind of learning model for panic, one in which the conditioned cue is often internal rather than external.

The next time you step into the lift, the system fires before you have thought anything at all. The body gets a small jolt. You notice the jolt. Because you notice it, you take fright. And because you take fright, the jolt grows. Now the place looks like the cause, although at first it was only the backdrop.

Why the car

Driving is a special case, because it combines several things at once. You cannot stop when you like; you are responsible for others; and driving itself produces sensations that resemble panic.

The steady sliding of the road, the vibration, the fast movement across your peripheral vision — all of it gives the balance system information that does not match what the muscles report. In a sensitive person that produces mild dizziness. If you are tense, you will notice that dizziness and read it as the start of an attack.

That is why the motorway, the tunnel, the bridge and the traffic queue turn up so reliably on the list. All four remove the option of stopping. City driving is often perfectly bearable, because every two hundred metres you can turn right.

Why the lift

The lift is the most concentrated version of the same thing. The doors close, there is no exit, other people stand half a metre away looking at the floor. The ride lasts twenty seconds — long enough for the body to register a jolt, too short for the wave to pass on its own.

Something people often do in lifts is hold their breath. Not deliberately. Under tension, breathing turns shallow and fast, and many people stop altogether for a few seconds as they step through the doors. When they breathe again, they get the sensation of not having enough air — and that sensation confirms for them that something is wrong with the lift.

Why the supermarket

For a nervous system already on alert, a large shop is an exhausting environment. Fluorescent light with a slight flicker, high shelves that cut down the visual field, movement at the edges of vision, noise, warmth, many decisions in a short time.

Neurologists use the term visual vertigo for a related state: in some people a richly patterned environment by itself produces a feeling of instability. Shelves stacked with identical packaging are almost a laboratory example of such a pattern.

Add the queue at the till — the moment when you are caught between a trolley in front and people behind — and you have precisely the combination of bodily sensation and no way out that an attack is built from. What is happening to the alarm system meanwhile I have described in the piece on anxiety in the brain.

Often the place is not the main culprit

Here is a turn I see in almost everyone. When we go through the last five attacks carefully, it usually emerges that they did not happen when the place was at its worst, but when the body was most primed.

Too little sleep. Two coffees on an empty stomach. Standing up too fast. Heat. A day before a period. Alcohol the night before and poorer sleep because of it. A hard workout. A cold on the way out.

In all these cases the body already has a fast pulse or some dizziness before you even walk in. The place then merely adds meaning. That is why the same person in the same shop has some visits that are entirely calm and some that are not. The shop is not different — you are.

This is also why I think it is worth checking physical reasons before we attribute everything to the mind. On what it means when the tests come back clear and the symptoms are still there, I have written in the piece on psychosomatic symptoms.

How the list spreads

Left to itself, avoidance does not stay with three places. It spreads by similarity.

First the motorway goes. Then the ring road, because stopping is hard there too. Then the bigger roundabout. Then driving alone. Then driving with a passenger who would see. Each time the boundary moves one step, and each time that step looks reasonable.

People do not notice this process for a long time, because every single sacrifice seems small and sensible. Only when you look back over a year do you see how far the space has shrunk. So at a first meeting I always ask what someone was doing two years ago and what they no longer do today. The answer often says more than a description of the attacks.

What this means for recovery

How the link is learnt also tells us how it is unlearnt. And here one thing surprises people.

New learning is tied to context. If you learn in one lift that no attack came, that knowledge does not transfer automatically to all lifts, all floors and all hours of the day. Michael Bouton showed this in a series of experiments: extinguished fear returns when the context changes, when time passes, and on an unexpected fresh encounter with the original trigger.

In practice this means the work has to be varied. Different lifts, different parts of town, different hours, sometimes tired, sometimes rested. Not to make it harder, but so that the new learning is not pinned to a single room. When people practise only in one familiar setting, the progress often does not survive the first big change. This is also why progress with panic is not a straight line — on how to recognise it, I have written among the signs that therapy is working.

When the place is not innocent

Now the section that argues against this explanation, because otherwise it would be too smooth.

First: sometimes the place is not just a backdrop. If someone has been in a road accident and has felt terrible in cars ever since, that is not conditioning to an innocent cue but a traumatic memory of a genuinely dangerous event. The approach is different; the work goes through processing the event, not only through returning to the road. On how such memories are written into the body, I have written in the piece on trauma in the body.

Second: some people genuinely feel unwell in shops and lifts for physical reasons. Vestibular disorders, benign paroxysmal positional vertigo, migraine with vestibular symptoms, low blood pressure, anaemia, thyroid problems, medication side effects — all of these can produce exactly the symptoms we attribute to panic. Jacob and colleagues warned back in the nineties that some people with agoraphobia have measurable vestibular impairment. If the dizziness also appears outside these situations, at home and at rest, that is a reason to see a doctor, not to draw up an exposure schedule. When the doctor comes first, I have described separately.

Third: for some people the first attack did not happen in these places at all. It happened at home, on the sofa, in front of the television. In them the fear did not attach to a place but to a bodily sensation, and the list of “dangerous places” appeared later, from thinking about where it would be worst. A conditioning account will not be the right key there.

And fourth, most simply: some situations are genuinely unpleasant for everybody. Forty-five minutes in stationary traffic in the heat is a bad experience for a person without panic too. Not every discomfort needs explaining as a symptom.

What to remember

What the places where panic appears have in common is that they are hard to leave, not that they are dangerous. The measure is not the space but access to an exit, to help and to privacy.

The link between the place and the attack is learnt. It forms during the first attack, when the brain records everything that was present at the time — bodily sensations included.

This is why being told the lift is safe does not help. You knew that already. Things change only through experience, and that experience has to be varied, not just repeated in the same spot.

Look at your last five attacks and you will often see that the state of your body that day predicts them better than the place does.

And if the dizziness or the pounding heart also turn up in calm circumstances, have a doctor look at it. Panic is a common explanation, but it is not the only one.