Chapter 6: Panic Disorder (PD) Joanna J. Arch Lauren N. Landy Michelle G. Craske.

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 attacksAt least 1 month of persistent apprehension about the

recurrence of panic or a significant behavioral changeAgoraphobia

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 AgoraphobiaA 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 attacksPanic attacks alone do not merit diagnosis as a disorder

Commonly co-occurring Axis I conditionsSocial 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 attackMay 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 lengthensHowever, a significant proportion of individuals panic for many

years without developing agoraphobia

Individuals with both agoraphobia and PDSignificantly 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 threatPrevent 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 bottlesBringing along or checking on the location of a safe person, often a

spouse

Safety signalsSafe 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 avoidanceHowever, 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 23Psychological treatment usually sought around age ~34

Female to male ratio ~2:1Females have much higher risk of agoraphobia

Prognosis

Panic disorder, particularly in combination with agoraphobia, tends to be highly chronicPrognosis in the absence of agoraphobia is more positive than

for generalized anxiety disorder or social anxiety disorder

Entails severe financial and interpersonal costsOver-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 termMaintain 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, thoughtsTakes steps to alter the form or frequency of these events

Any form of distraction from anxiety and panic-related symptoms falls into this categoryFor 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 PDLink is stronger for panic disorder than for other anxiety

disordersPotentially 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 sensitivityThe 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 attacksSevere 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 identifiedFirst factor loads heavily on neuroticism2nd 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 ReceptorsPatients 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 respondingPsychoeducation about panic to correct misconceptions

regarding panic symptomsCognitive restructuring to identify and correct distortions in

thinkingInteroceptive 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 estimatesTherapeutic 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 alone11 to 12 treatment sessions most common in studies

• 4 to 6 also works, but weaker

Group formats nearly as effective as individualSelf-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 effectiveWork 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 monthsTime-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 treatmentBy end of treatment CBT as effective as combined, better

than medication aloneOnce 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