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Chapter 6: Panic Disorder (PD) Joanna J. Arch Lauren N. Landy Michelle G. Craske Diagnostic Criteria: Panic Attack Abrupt surge of intense fear or discomfort Characterized by a cluster of 13 physical and cognitive symptoms For example, palpitations, shortness of breath, paresthesias (tingling), trembling, derealization, fear of dying or going crazy Discrete, sudden, abrupt onset, Symptoms peaking within minutes A full-blown panic attack = four or more symptoms Limited symptom attack = fewer than four symptoms. Diagnosis: Panic Disorder and Agoraphobia Panic Disorder (PD) Unexpected (or without an obvious trigger) panic attacks At least 1 month of persistent apprehension about the recurrence of panic or a significant behavioral change Agoraphobia Marked fear or anxiety of situations from which escape might be difficult or in which help might be unavailable in the event of panic symptoms Agoraphobia diagnosis requires fear of at least two: • Public transportation, open spaces, enclosed places, standing in line or being in a crowd, or being outside of the home alone. Diagnosis: DSM-5 Changes for Panic Disorder and Agoraphobia A panic attack specifier may be applied to any diagnosis PD and Agoraphobia (which now requires 2 or more feared situations) are now separate (but highly comorbid) disorders Many individuals in community settings exhibit the full features of agoraphobia but have never had a full panic attack or even panic-like symptoms Both require 6 months duration Diagnosis: Differential Diagnosis and Comorbidity PD is diagnosed when there are repeated unexpected panic attacks and persistent apprehension about panic attacks / behavioral change resulting from panic attacks Panic attacks alone do not merit diagnosis as a disorder Commonly co-occurring Axis I conditions Social phobia, dysthymia, generalized anxiety disorder, major depressive disorder, and substance abuse 25% to 60% meet criteria for a personality disorder, mostly avoidant or dependent personality disorder Symptoms- Agoraphobia Agoraphobia pertains to fear and situational avoidance for reasons beyond the occurrence of panic attack May fear and avoid situations for reasons related or unrelated to panic attacks Individuals with PD vary widely in their degree of agoraphobia Agoraphobia tends to increase as history of panic lengthens However, a significant proportion of individuals panic for many years without developing agoraphobia Individuals with both agoraphobia and PD Significantly more impairment overall and greater distress regarding the social consequences of panicking Panic Symptoms: Cognitions Panic attacks are characterized by a unique action tendency Urge to escape and, less often, urge to fight. Panic attacks usually involve elevated autonomic nervous system arousal Often, but not always, include perceptions of imminent threat, such as death, loss of control, or social ridicule Noncognitive panic: No perceptions of loss of control, dying, or going crazy, despite the report of intense fear and arousal Symptoms: Nocturnal Panic A subset of individuals who have panic disorder also experience nocturnal panic attacks. Nocturnal panic refers to waking from sleep in a state of panic with symptoms that are similar to panic attacks that occur during wakeful states 44% to 71% of individuals have nocturnal panic at least once, and 30% to 45% report repeated nocturnal panics Symptoms: Maladaptive Behaviors Avoidance of situations in which panic attacks are expected to occur Avoidance of activities that induce panic-like sensations Safety behaviors Experiential avoidance Symptoms: Safety Behaviors Dysfunctional emotion regulation strategies because… Overrated or no real threat Prevent feared outcomes that are unlikely to happen Help individuals feel more protected and secure in the event of a panic attack Checking to make sure that a bathroom or hospital is close by, carrying anti-anxiety medication, including empty pill bottles Bringing along or checking on the location of a safe person, often a spouse Safety signals Safe objects, persons, and situations sought via safety behaviors. For example, empty pill bottles, people such as the therapist or spouse Epidemiology 12-Month Prevalence: 2.4% to 2.7%, lifetime prevalence: 4.7% Treatment-seeking individuals with agoraphobia almost always have history of panic preceding development of their avoidance However, community samples have relatively high rates for agoraphobia without a history of panic disorder Modal age of onset for PD is between age 21 and 23 Psychological treatment usually sought around age ~34 Female to male ratio ~2:1 Females have much higher risk of agoraphobia Prognosis Panic disorder, particularly in combination with agoraphobia, tends to be highly chronic Prognosis in the absence of agoraphobia is more positive than for generalized anxiety disorder or social anxiety disorder Entails severe financial and interpersonal costs Over-utilize medical resources compared to individuals with other psychiatric disorders and general public With pharmacological treatment, only a minority of patients remit without subsequent relapse (~30%) 25% to 35% experience notable improvement, albeit with a waxing and waning course Etiology: Safety Behaviors and Signals Safety behaviors Reduce anxiety in the short term Maintain PD over long term by preventing disconfirmation of catastrophic predictions and/or the extinction of conditioned response Animal literature shows that the presence of safety signals functions as a conditioned inhibitor that interferes with extinction Exposure therapy targeting safety behavior and signals is more successful than exposure therapy alone Etiology: Interceptive Avoidance When a person… Is unwilling to remain in contact with particular bodily sensations, emotions, thoughts Takes steps to alter the form or frequency of these events Any form of distraction from anxiety and panic-related symptoms falls into this category For example watching TV, playing video games, and eating Thought suppression and emotion suppression are often counterproductive, facilitating the return of the very thought or emotion avoided Etiology: Cognitive Features Strong beliefs and fears of physical or mental harm arising from bodily sensations that are associated with panic Manipulation of appraisals can impact level of distress over physical symptoms Etiology- Emotions, Traits, and Early Life Attachment Neuroticism: Proneness to experience negative emotions in response to stressors is associated with all anxiety disorders, including panic disorder Correlation between early insecure attachment and the development of anxiety disorders later on in life Parenting behaviors predict offspring anxiety and offspring anxiety molds parenting behaviors Etiology: Childhood Illness and Trauma Childhood experience with medical illness (in self or others) increases risk for developing PD later on Childhood experiences of sexual and physical abuse also increase risk for PD Link is stronger for panic disorder than for other anxiety disorders Potentially traumatic events impose greater risk when they occur during childhood rather than adulthood Etiological Models- Barlow Panic attacks as false alarms in which a fight-or- flight response is triggered in the absence of threatening stimuli Panic attacks are relatively common in general population, so why do only some people develop panic disorder? Fear of fear, which is termed anxiety sensitivity The tendency to interpret anxiety symptoms as dangerous and threatening Etiological Model: Clark Catastrophic misappraisals of bodily sensations, (e.g., panic bodily sensations are signs of imminent death) are central to the development and maintenance of panic disorder Criticized because cannot account for nocturnal and noncognitive panic Etiological Model: Interoceptive Fear Conditioning Low-level somatic sensations of arousal or anxiety (e.g., elevated heart rate) become conditioned stimuli due to their association with intense fear, pain, or distress Interoceptive conditioned responses are not dependent on conscious awareness of triggering cues and are observed even under anesthesia Biological Etiology- Sympathetic Activation Sympathetic nervous system activation during reported panic attacks for ~60% of self-reported panic attacks Severe panic attacks are more autonomically based Self-reported panic without autonomic activation may reflect anticipatory anxiety rather than true panic Biological Etiology: Genetics Heritability of panic disorder accounts for approximately 30% to 40% of the variance Two broad but distinct genetic factors have been identified First factor loads heavily on neuroticism 2nd associated with symptoms of fear (i.e., breathlessness, heart pounding) Identified risk genes encode for serotonin transporter/receptor, and adenosine receptor, but findings are mixed overall Biological Etiology: Amygdala and GABA Amygdala Triggers the anxiety and panic response by activating hypothalamus (HPA axis and autonomic system), locus ceruleus (heart rate and blood pressures), and parabrachial nucleus (changes in respiration) Patients have alterations in the amygdala and associated structures GABA/Benzodiazepine Receptors Patients have lower benzodiazepine receptor density in amygdala, perihippocampal areas, and frontocortical areas Treatments: CBT Major forms of CBT for panic include: Goal: Obtain corrective information that disconfirms fearful misappraisals and eventually lessens fear responding Psychoeducation about panic to correct misconceptions regarding panic symptoms Cognitive restructuring to identify and correct distortions in thinking Interoceptive exposure to feared bodily sensations (e.g., spinning in a chair to induce dizziness) In vivo exposure to feared situations (e.g., driving) Sometimes breathing retraining to help patients cope with panic and anxiety During Treatments: Ongoing Assessment Needed Retrospective recall of past episodes of panic and anxiety may inflate estimates of panic frequency and intensity which may contribute to apprehension about future panic Ongoing self-monitoring yields more accurate, less inflated estimates Therapeutic tool Contributes to increased objective self-awareness essential to cognitive behavior therapy Treatments: CBT Efficacy Large effect sizes for symptoms as well as improvement in functioning; used to treat nocturnal panic attacks and to prevent relapse after discontinuation of benzodiazepines Improves symptoms of comorbid conditions (e.g., depression) Benefits maintained over long term with trend toward continuing improvement over time Similar findings in real-world clinic settings Treatments: CBT for Agoraphobia Treatment involves more situational exposure than CBT for panic disorder alone Generally slightly less effective than CBT for cases of panic disorder with no or minimal agoraphobia Often continuing improvement over time after formal treatments end ~18.5% of clients relapse over a period of 5 to 7 years after successful exposure-based treatment for agoraphobia Treatments: What Makes CBT Work? Combination of exposure, relaxation, and breathing retraining has the highest effect size followed by exposure alone 11 to 12 treatment sessions most common in studies • 4 to 6 also works, but weaker Group formats nearly as effective as individual Self-directed treatments work for highly motivated and educated Cognitive therapy can be effective even when conducted in full isolation from exposure and behavioral procedures but it does not improve outcome when added to in vivo exposure treatment for agoraphobia Treatment- Pharmacotherapy Comparison Selective serotonin reuptake inhibitors (SSRIs) are the medication of choice Medium- to large-effect sizes compared to placebo. Studies show long-term efficacy up to 1 year Benzodiazepines also effective Work rapidly and are even better tolerated than very tolerable SSRI class of agents. Limited by risk of physiological dependence and by the risk of abuse Discontinuation of medication results in relapse rate between 25% and 50% within 6 months Time-limited withdrawal syndrome, which may serve as an interoceptive stimulus for panic disorder relapse Treatment: Psychotherapy and Pharmacotherapy Comparison Combined treatment with antidepressants and CBT is superior to antidepressants alone and to CBT alone during treatment By end of treatment CBT as effective as combined, better than medication alone Once medication is discontinued, combined treatment may reduce the long-term effectiveness of CBT. CBT (in group format) without meds represents the most cost-effective and durable first-line treatment for panic disorder