3 Anxiety Disorders: Panic Disorder and Agoraphobia

Question 1

List the DSM-5 criteria for Panic Attacks

Answer 1

An abrupt surge of intense fear or discomfort, peaks within minutes, includes 4 (or more) of the following symptoms

• Palpitations, accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed or faint
• chills or heat sensations
• Parenthesis (numbness or tingling sensations)
• Derealization or depersonalization
• Fear of losing control or “going crazy”
• Fear of dying

Question 2

Define Panic Attack

Answer 2

Extreme severe anxiety/fear reaction

Question 3

What are the two types of panic attacks?

Answer 3

Can occur in the context of any anxiety disorders

Expected (cued) Panic Attack

• Context: most anxiety disorders
• Trigger: specific or social phobias

Unexpected (uncued) attack

• unidentifiable trigger
• Context: Panic disorder
• Two unexpected panic attacks are needed for diagnosis

Question 4

List the DSM-5 criteria for Panic Disorders

Answer 4

A. A recurrent, unexpected panic attacks
B. Symptoms for >1month of either: Anxiety or worry about having another attack (1) and significant behaviour change related to the attack and avoidance (2)
C. Disturbance not attributable to the physiological effects of a substance
D. The disturbance is not better explained by another mental disorder

Question 5

List the DSM-5 criteria for Agoraphobia

Answer 5

A. Marked fear or anxiety about two (or more) of the following five situations (Using public transport (1), open spaces (2), enclosed spaces (3), standing in line or crowd (4), outside of home alone (5)
B. Fear or avoids these situations because of thoughts that escape might be difficult or help might not be available - may develop panic-like symptoms
C. Agoraphobic situations almost always provoke fear or anxiety
D. Agoraphobic situations are actively avoided, require companion, or endured with intense fear or anxiety

Question 6

Describe some major changes from DSM-4 and DSM-5

Answer 6

• DSM-4 agoraphobia diagnosed when panic disorder present and in DSM-5 they can be diagnosed separately
• DSM-4 didn’t specify how many situations and in DSM-5 it now does
• In DSM-4 they had to recognise whether it was unreasonable and in DSM-5 they don’t need to recognise its unreasonable

Question 7

What is some evidence for panic disorder and agoraphobia as separate disorders?

Answer 7

• Most individuals with agoraphobia do not experience panic symptoms -> epidemiological evidence shows 50% with agoraphobia do not show signs of panic attacks
• Comorbidity: Agoraphobia is associated with other disorders too, not just panic disorder
• Agoraphobia associated with other anxiety disorders whereas panic disorder associated with a broader range of disorders
• Different clinical course: Agoraphobia is more persistent/chronic than panic disorder

Question 8

What is longitudinal evidence for panic disorder and agoraphobia as separate disorders?

Answer 8

Agoraphobia just as frequently precedes panic attacks as panic attacks precede agoraphobia (therefore panic is not considered causal to developing agoraphobia)

Question 9

Describe the process of Panic disorders

Answer 9

Recurrent, unexpected panic attacks -> worry and anxiety about having more panic attacks -> changes behaviour significantly to minimise or avoid panic attacks

Question 10

What is the cognitive model of panic (Clark, 1986)

Answer 10

Suggests that panic attacks occur because certain bodily sensations are misinterpreted as indicating a catastrophe, such as a heart attack or loss of control

Question 11

How does the cognitive model of panic explain when it is perceived by heightened anxiety

Answer 11

• Anxiety in anticipation of an attack

- Heightened anxiety unrelated to the anticipation of panic

Question 12

Describe the cycle that would occur in anticipation of an attack in the cognitive model of behaviour?

Answer 12

Anxious in anticipation -> selectively focus on body -> notice unpleasant body sensation -> interpret as evidence of impending attack -> activate cycle

Question 13

Describe the cycle that would occur in heightened anxiety unrelated to the anticipation of panic

Answer 13

Have an argument with partner -> notice body sensation -> catastrophically interpret -> activate cycle

Question 14

Give an example of Anxiety in anticipation of an attack

Answer 14

Individuals with agoraphobia entering a supermarket where they previously had an attack

Question 15

How does the cognitive model of panic explain when it is not preceded by heightened anxiety “out of the blue”?

Answer 15

Perception of bodily sensation caused by another emotional state (happiness) or an innocuous event (e.g. getting up quickly and feeling dizzy) which is interpreted as catastrophic

Question 16

What is the aetiology of panic disorder?

Answer 16

The interaction of invulnerability giving rise to panic disorder

People who develop panic disorder tend to misinterpret their bodily sensations that accompany these panic attacks in a catastrophic manner

Question 17

Give an example of the aetiology of panic disorder

Answer 17

Walked up 10 flights of stairs and you feel in your body a few physical bodily sensations
-> Someone who is anxiety sensitive (biological factor) might say “something is wrong with me” due to the bodily sensations -> this increases anxiety and puts the body in flight or fight response and leads to a panic attack

Question 18

Explain the biological processes associated with Panic Disorder

Answer 18

When you beleive there is danger or there is real danger, our bodies go through:

Automatic arousal which includes increased heart rate, in sweating and muscle tension

Hyperventilation and anxious breaking -> disrupt levels of carb dioxide due to increased breathing

Question 19

How is panic disorder maintained?

Answer 19

• Catastrophic thoughts about normal or anxious physical sensations
• Over-estimating the probability that they will have a panic attack
• Over-estimating the cost of having a panic attack: thinking that the consequences of having a panic attack will be very serious or very negative

Question 20

How is panic disorder maintained in anxiety sensitivity and focus on internal sensations?

Answer 20

• Monitoring internal sensations

- Normal physical sensations fluctuate and can be misinterpreted as a threat

Question 21

How is panic disorder maintained in avoidance?

Answer 21

Situations that may trigger similar symptoms (i.e. exercise), that have led to panic attacks in the past, that are hard to escape from

Question 22

How is panic disorder maintained in safety behaviours?

Answer 22

Behaviours designed to abate anxiety symptoms (but ultimately maintain the symptoms)

Question 23

In what ways are panic disorder treated?

Answer 23

Cognitive Behavioural Therapy (Level 1 evidence)

Question 24

What is meant by level 1 evidence?

Answer 24

a meta-analysis or a systematic review of level 2 studies that included a quantitative analysis

Question 25

Describe the psychoeducation in Cognitive behavioural therapy for treating Panic Disorders

Answer 25

Have this unconscious bias to interpret in the wrong way -> Aspect of psychoeducation tells us all the different things that maintains panic and that gives the rationale of what to continue going for

Question 26

Describe the cognitive restructuring in Cognitive behavioural therapy for treating Panic Disorders

Answer 26

We do cognitive restructuring to attack some of these cognitive biases that we have about panic due to misinterpreting the thoughts that keep panic going we work at turning those thought patterns around

• Thought monitoring
• Identifying symptoms
• Identifying cognitions
• Cognitive challenging
• Safety behaviours/avoidance

Question 27

Describe the Interceptive exposure in Cognitive behavioural therapy for treating Panic Disorders

Answer 27

We fear these physiological symptoms that are associated with panic and we catastrophically misinterpret them and we try to stop them or avoid situations that they might come about so we need to expose ourselves to scenarios that bring on the symptoms - so clients are exposed to their own bodily sensations and doing this a sufficient number of times

Question 28

Describe the graded exposure (for agoraphobia) in Cognitive behavioural therapy

Answer 28

Gradual exposure to more and more fear until you can conquer your fear

Question 29

What are the steps involved in graded exposure in Cognitive Behavioural Therapy?

Answer 29

• Identify a first small step towards overcoming the feared situation
• Practice this step until it no longer causes anxiety
• Move on to a more difficult step and repeat the practice
• Continue this process until the person can manage the feared situation

Question 30

List the attributes of cognitive model of panic by Clark (1986)?

Answer 30

Trigger stimulus (internal or external): Perceived threat -> interpretation of sensations as catastrophic -> Body sensations -> Apprehension