Download Panic Attacks!

Panic Attacks!
Dr. Michael Tulloch
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
Slides & Handouts by Karen Clay Rhines, Ph.D.
Slides by M. Tulloch, Ph.D.
1
Attack!
"For me, a panic attack is almost a violent experience. I feel
disconnected from reality. I feel like I'm losing control in a very
extreme way. My heart pounds really hard, I feel like I can't get my
breath, and there's an overwhelming feeling that things are crashing
in on me."
"I was sitting in a business seminar in a hotel and this thing came out
of the blue. I felt like I was dying."
"In between attacks there is this dread and anxiety that it's going to
happen again. I'm afraid to go back to places where I've had an
attack. Unless I get help, there soon won't be anyplace where I can go
and feel safe from panic."
http://www.nimh.nih.gov/publicat/anxiety.cfm
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
Slides by M. Tulloch, Ph.D.
2
Panic Attack Facts

Panic attacks can occur at any time, even during sleep.

An attack usually peaks within 10 minutes, but some symptoms may last
much longer.

Panic disorder affects about 6 million American adults1

Panic disorder is twice as common in women as men.2

Panic attacks often begin in late adolescence or early adulthood,2

Not everyone who experiences panic attacks will develop panic disorder.
Many people have just one attack and never have another.

The tendency to develop panic attacks appears to be inherited.3

Panic disorder is often accompanied by other serious problems, such as
depression, drug abuse, or alcoholism.4,5
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
http://www.nimh.nih.gov/publicat/anxiety.cfm
3
Risk Factors

Adolecence or early adulthood

Major life transitions perceived as stressful


Graduating from college, getting married, having a first child
Genetics

If a family member has panic disorder, you have an increased risk

Especially during a time in your life that is particularly stressful.
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
Slides by M. Tulloch, Ph.D.
4
Untreated Outcomes

People who have full-blown, repeated panic attacks can become very
disabled by their condition and should seek treatment before they start
to avoid places or situations where panic attacks have occurred.

For example, if a panic attack happened in an elevator, someone with
panic disorder may develop a fear of elevators that could affect the
choice of a job or an apartment, and restrict where that person can seek
medical attention or enjoy entertainment.

Some people's lives become so restricted that they avoid normal
activities, such as grocery shopping or driving.

About one-third become housebound or are able to confront a feared
situation only when accompanied by a spouse or other trusted person.
When the condition progresses this far, it is called agoraphobia, or fear
of open spaces.
Comer, Fundamentals of Abnormal Psychology,
http://www.nimh.nih.gov/publicat/anxiety.cfm
5e – Chapter 4
5
Panic Disorder

Panic, an extreme anxiety reaction, can result when a
real threat suddenly emerges

The experience of “panic attacks,” however, is different

Panic attacks are periodic, short bouts of panic that occur
suddenly, reach a peak, and pass

Sufferers often fear they will die, go crazy, or lose control

Attacks happen in the absence of a real threat
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
6
Panic Disorder

Anyone can experience a panic attack

But some people have panic attacks  Repeatedly
 Unexpectedly
 Without

apparent reason
Diagnosis: Panic disorder

Sufferers also experience dysfunctional changes in
thinking and behavior as a result of the attacks

Example: sufferer worries persistently about having an attack;
plans behavior around possibility of future attack
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
7
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
8
Panic Disorder

Often (but not always) accompanied by agoraphobia

From the Greek “fear of the marketplace”

Afraid to leave home and travel to locations from which
escape might be difficult or help unavailable

Intensity may fluctuate

There has only recently been a recognition of the link
between agoraphobia and panic attacks (or panic-like
symptoms) [But DON”T use this as diagnostic!]
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
9
Panic Disorder

Two diagnoses: panic disorder with agoraphobia; panic
disorder without agoraphobia

~3% of U.S. population affected in a given year

~5% of U.S. population affected at some point in their lives

Likely to develop in late adolescence and early
adulthood

Women are twice as likely as men to be affected

All ethnic groups are vulnerable to panic disorder

~ 35% of those with panic disorder are in treatment
Slide modified by M. Tulloch, Ph.D.
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
10
Different from other Phobias

Phobias that people with panic disorder develop do not come from:




Fears of actual objects
Fears of real events events
Panic Disorders come from

Fear of having another attack

“Triggers”
People will avoid certain objects or situations because

They fear that these things will trigger another attack

Classical Conditioning


Fear Response paired with place/object/person/situation
Generalization
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
Slides by M. Tulloch, Ph.D.
11
Panic Disorder:
The Biological Perspective

What biological factors contribute to panic disorder?

Neurotransmitter responsible is believed to be norepinephrine

Irregular in people with panic attacks


Research suggests that panic reactions are related to changes in
norepinephrine activity in the locus ceruleus
Although norepinephrine is clearly linked to panic disorder,
what goes wrong isn’t exactly understood

May be excessive activity, deficient activity, or some other defect

Other NTs and brain circuits seem to be involved
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
12
Panic Disorder:
The Biological Perspective

It is also unclear why some people have such
abnormalities in norepinephrine activity

Inherited biological predisposition is one possibility


Prevalence should be (and is) greater among close relatives

Among monozygotic (MZ, or identical) twins = 24%

Among dizygotic (DZ, or fraternal) twins = 11%
Issue is still open to debate
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
13
Panic Disorder:
The Biological Perspective

In the 1960s, it was recognized that people with panic
disorder were not helped by benzodiazepines, but
were helped by antidepressants

Researchers worked backward from their
understanding of antidepressant drugs

[Which is still relatively poor]
See Am J Psychiatry 161:7, July 2004 for an interesting discussion of
the appropriate use of benzodiazepines vs SSRIs. Apparently, current
clinical experience is that the former is appropriate for treatment of
symptoms but is subject to abuse so that SSRIs are more suitable for
recurrent attacks and long term prophylactic treatment.
Slide modified by M. Tulloch, Ph.D.
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
14
Panic Disorder:
The Biological Perspective

Drug therapies

Antidepressants are effective at preventing or reducing panic
attacks

Function at norepinephrine receptors in the panic brain circuit

Bring at least some improvement to 80% of patients with panic
disorder



~50% recover markedly or fully
Require maintenance of drug therapy; otherwise relapse rates are high
Some benzodiazepines (especially Xanax [alprazolam]) also
have proved helpful
Disagrees
with
previous
slide
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
15
Panic Disorder:
The Biological Perspective

Drug therapies

Both antidepressants and benzodiazepines are also
helpful in treating panic disorder with agoraphobia


Break the cycle of attack, anticipation, and fear
Combination treatment (medications +
behavioral exposure therapy) may be more
effective than either treatment alone
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
16



Venlafaxine: Mechanism of Action
Is thought to work by

strongly inhibiting reuptake of serotonin (or 5-HT)

strongly inhibiting reuptake of norepinephrine

weakly inhibiting the reuptake of dopamine
It is thought that increasing the available amount of
these neurotransmitters helps individuals suffering from
depression. However, the medication's full mechanisms
of action are not entirely understood.
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
17
Venlafaxine (SSRI) may cause side
effects that mimic panic attacks
* change in ability to taste food
* loss of appetite
* weight loss
* uncontrollable shaking of a part of the body
* pain, burning, numbness, or tingling in part of
the body
* muscle tightness
* twitching
* yawning
* sweating
* hot flashes or flushing
* frequent urination
* difficulty urinating
* sore throat, chills, or other signs of infection
* drowsiness
* weakness or tiredness
* dizziness
* headache
* nightmares
* anxiety
* nausea
* vomiting
* stomach pain
* constipation
* diarrhea
* gas
* heartburn
* burping
* dry mouth
Caution
* ringing in the ears
* changes in sexual desire or ability
* enlarged pupils
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
Slides by M. Tulloch, Ph.D.
18
Panic Disorder:
The Cognitive Perspective

Cognitive theorists and practitioners recognize
that biological factors are only part of the cause
of panic attacks

In their view, full panic reactions are experienced
only by people who misinterpret bodily events

Cognitive treatment is aimed at correcting such
misinterpretations
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
19
Panic Disorder:
The Cognitive Perspective

Misinterpreting bodily sensations
Panic-prone people may be overly (or especially)
sensitive to certain bodily sensations and may
misinterpret them as signs of a medical catastrophe;
this leads to panic
 Why might some people be prone to such
misinterpretations?
 One possibility: Experience more frequent or
intense bodily sensations
 Another possibility: Experience abnormal
sensations

Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
20
Panic Disorder:
The Cognitive Perspective

Misinterpreting bodily sensations

Panic-prone people also have a high degree of “anxiety
sensitivity”

They focus on bodily sensations much of the time, are unable to
assess the sensations logically, and interpret them as potentially
harmful
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
21
Panic Disorder:
The Cognitive Perspective

Cognitive therapy

Attempts to correct people’s misinterpretations of their
bodily sensations

Step 1: Educate clients

About panic in general

About the causes of bodily sensations

About their tendency to misinterpret the sensations

Step 2: Teach clients to apply more accurate interpretations (especially
when stressed)

Step 3: Teach clients skills for coping with anxiety

Examples: relaxation, breathing
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
22
Panic Disorder:
The Cognitive Perspective

Cognitive therapy

May also use “biological challenge” procedures to
induce panic sensations


Induce physical sensations which cause feelings of panic:

Jump up and down

Run up a flight of steps
Practice coping strategies and making more accurate
interpretations
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
23
Panic Disorder:
The Cognitive Perspective


Cognitive therapy is often helpful in panic disorder

85% of treated patients are panic-free for two years compared
with 13% of control subjects

Only sometimes helpful for panic disorder with agoraphobia

At least as helpful as antidepressants
Combination therapy may be most effective

Still under investigation
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
24
Treatment Approaches

Cognitive Restructuring

Cognitive Therapy

Interoceptive Exposure

Relaxation Techniques

Medication

Support Groups

Relaxation Techniques
Based upon
materialoffrom
© 2007
American
Comer,
Fundamentals
Abnormal
Psychology,
5e –Psychological
Chapter 4 Association
25
Treatment - Info

The first part of therapy is largely informational

Many people are greatly helped by simply understanding exactly what
panic disorder is and how many others suffer from it.

Many people who suffer from panic disorder are worried that their panic
attacks mean they're 'going crazy' or that the panic might be or induce a
heart attack.

'Cognitive restructuring' (changing one's way of thinking) helps people
replace those thoughts with more realistic, positive ways of viewing the
attacks.
Based upon
materialoffrom
© 2007
American
Comer,
Fundamentals
Abnormal
Psychology,
5e –Psychological
Chapter 4 Association
26
Treatment - Cognitive

Cognitive therapy can help identify possible triggers for the attacks.

The trigger in an individual case could be something like


A thought

A situation

Something subtle like a slight change in heartbeat.
Therapy Goals

Understanding that the panic attack is separate and independent of the
trigger

Awareness of the trigger(s) so it begins to lose some of its power to
induce an attack.
Based upon
materialoffrom
© 2007
American
Comer,
Fundamentals
Abnormal
Psychology,
5e –Psychological
Chapter 4 Association
27
Treatment - Behavioral

Behavioral components of the therapy can consist of what some
clinicians call 'interoceptive exposure.'

Similar to the systematic desensitization used to cure phobias, but it
focuses on exposure to the actual physical sensations that someone
experiences during a panic attack.

Interoceptive exposure helps patients experience the symptoms of an
attack (elevated heart rate, hot flashes, sweating, etc.) in a controlled
setting

Teachs patients that symptoms need not develop into a full-blown attack.
Based upon
materialoffrom
© 2007
American
Comer,
Fundamentals
Abnormal
Psychology,
5e –Psychological
Chapter 4 Association
28
Treatment – Behavioral 2

Behavioral therapy is also used to deal with the situational avoidance
associated with panic attacks.

One very effective treatment for phobias is in vivo exposure

breaking a fearful situation down into small manageable steps

doing them one at a time until the most difficult level is mastered.
Based upon
materialoffrom
© 2007
American
Comer,
Fundamentals
Abnormal
Psychology,
5e –Psychological
Chapter 4 Association
29
Treatment - Medication

Sometimes medications may also be needed

Prescriptions may include

Anti-anxiety medications

Antidepressants

sometimes beta blockers

Used to control irregular heartbeats

“Absorbs” / counteracts adrenaline
Based upon
materialoffrom
© 2007
American
Comer,
Fundamentals
Abnormal
Psychology,
5e –Psychological
Chapter 4 Association
30
Treatment - Support

A support group with others who suffer from
panic disorder can be very helpful to some
people.

It can't take the place of therapy, but it can be a
useful adjunct.

May also be helpful to family members
Based upon
materialoffrom
© 2007
American
Comer,
Fundamentals
Abnormal
Psychology,
5e –Psychological
Chapter 4 Association
31
Treatment - Relaxation

Relaxation techniques can further help someone 'flow through' an attack

These techniques include breathing retraining and positive visualization

Some experts have found that people with panic disorder tend to have
slightly higher than average breathing rates

Learning to slow breathing can help someone deal with a panic attack

Mayprevent future attacks by maintaining feeling of control

May prevent attacks by maintaining proper CO2 blood levels
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
32
Additional Resources
Guide t o Tre a t m e nt
Find a The ra pist
Sha re y our St ory , Re a d Ot he rs’ in ‘St orie s of H ope ’
Ta ke a Se lf- Te st
H e lp a Fa m ily Me m be r
http://www.adaa.org/
International Handbook of Phobic and Anxiety Disorders
in Children and Adolescents
By Thomas H. Ollendick, Neville J. King, William Yule, Eds.
• Chapter 13 deals with Panic Disorder
• DSM-III-R Requirements for diagnosing Panic Attacks
• One unexpected, full symptom attack
• Four attacks or fears of an attack w/in four week period
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
33
How can I tell if it's a
Panic Attack?
Y e s or no? Are y ou t roubled by :
Ye s No
Repeat ed, unex pect ed " at t ack s" during w hich y o u suddenly are o v erco m e by int ense fear
o r disco m fo rt , fo r no apparent reaso n?
During t his a t t a ck , did y ou e x pe rie nce a ny of t he se sy m pt om s?
Ye s No
Po unding heart
Ye s No
Sw eat ing
Ye s No
Trem bling o r shak ing
Ye s No
Sho rt ness o f breat h
Ye s No
Cho k ing
Ye s No
Chest pain
Ye s No
Nausea o r abdo m inal disco m fo rt
Ye s No
" Jelly " legs
Ye s No
Diz z iness
Ye s No
Feelings o f unrealit y o r being det ached fro m y o urself
Ye s No
Fear o f dy ing
Ye s No
Num bness o r t ingling sensat io ns
Ye s No
Chills o r ho t flashes
Ye s No
Do y o u ex perience a fear o f places o r sit uat io ns w here get t ing help o r escape m ight be difficult , such as in a cro
Ye s No
Do es being unable t o t rav el w it ho ut a co m panio n t ro uble y o u?
For a t le a st one m ont h follow ing a n a t t a ck , ha v e y ou:
Ye s No
Felt persist ent co ncern abo ut hav ing ano t her o ne?
Ye s No
Wo rried abo ut hav ing a heart at t ack o r go ing " craz y " ?
Ye s No
Changed y o ur behav io r t o acco m m o dat e t he at t ack ?
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
Slides by M. Tulloch, Ph.D.
34
Could it be something else
(or something more)?
Hav ing more t han one illness at t he same t ime c an make it dif f ic ult t o diagnose and t reat
t he dif f erent c ondit ions. I llnesses t hat somet imes c omplic at e an anxiet y disorder inc lude
depression and subst anc e abuse. Wit h t his in mind, please t ake a minut e t o answ er t he
f ollow ing quest ions:
Y e s No
Hav e y ou experienc ed c hanges in sleeping or eat ing habit s?
Y e s No
Y e s No
Y e s No
More da y s t ha n not , do y ou fe e l:
Sad or depressed?
Disint erest ed in lif e?
Wort hless or guilt y ?
Ye s
Ye s
Ye s
Ye s
During t he la st y e a r, ha s t he use of a lcohol or drugs:
Result ed in y our f ailure t o f ulf ill responsibilit ies w it h w ork, sc hool, or f amily ?
Plac ed y ou in a dangerous sit uat ion, suc h as driv ing a c ar under t he inf luenc e?
Got t en y ou arrest ed?
Cont inued despit e c ausing problems f or y ou and/ or y our lov ed ones?
No
No
No
No
http://www.adaa.org/GettingHelp/SelfHelpTests.asp
Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4
35