CBT and Panic Disorder Flashcards
What is panic?
- sensations include dizziness, shakiness etc
- increased HR, increased breathing / respiratory rate
The way you interpret the situation - dependent on whether you are feeling anxiety, going to have a panic cycle etc
Common Catastrophic misinterpretations
Dizziness = Faint Shakiness = Collapse Racing Heart = Heart Attack Tight Chest = Heart Attack Breathless = Suffocate Racing Thoughts = going 'crazy', losing control
Misinterpretation of common body functions!
Cognitive Model of Panic
- Clark (1988)
- Panic attacks - result from the catastrophic misinterpretation of certain bodily misinterpretations
- sensations - ones involved in normal anxiety responses
- perceive those sensations as much more dangerous than they really are
- feel as if those sensations are indicative of an immediately impending physical or mental disaster
- e.g. breathlessness = impending cessation of breathing and consequent death
Panic Cycle - Clark (1986; 1988)
Trigger stimulis (internal or external)
Perceived threat
Apprehension
Body sensations
Interpretation of sensations as catastrophic
- the way in which we interpret the trigger stimulus
- perceived threat - leads to a cycle
- the misinterpretation of body sensations/functions feeds the cycle of panic
Teachmen et al (2010)
Catastrophic misinterpretations as a predictor of symptom change during treatment for panic disorder
- change the misinterpretations = symptom reduction?
- measuring catastrophic misinterpretations of bodily sensations
- presented with ambiguous events and then asked to rate 3 alternative explanations for why the event may have occurred
- one was always negative, the other two being neutral and/or positive
- change in misinterpretations predicted subsequent reductions in overall symptom severity, panic attack frequency, distress and avoidance
What are the types of panic?
(1) Preceded by anxiety
(2) “Out of the blue”
Types of panic - Preceded by anxiety
Threat related trigger (anticipation of attack or anxiety regarding unrelated events) —->
Breathlessness, HR increase, Dizziness —->
Misinterpret sensations —->
PANIC
Types of Panic - “Out of the blue”
Innocuous event trigger (exercise, excitement, caffeine, standing up, sleep) —–>
Breathlessness, HR increase, Dizziness, Bodily changes during sleep —–>
Misinterpret sensations ——>
PANIC
“Safety-Seeking” and Panic
P’s have often experienced hundreds of thousands of panic attacks
- feared catastrophe does not / has not ever occurred
- BUT they continue to believe that catastrophe is imminent in subsequent panic disorder
—> seen through it so many times without the catastrophic event happening so WHY is there is this constant fear?
Panic - how do individuals maintain their panic?
- think that things will happen but it never does - constant threat is still there!
- go through the cycle so many time but never break out of it
Safety Seeking Behaviours
- avoidance of catastrophic events is based on their own actions
- failure to gain the experience necessary to realise that anxiety sensations will not lead to catastrophe
- need to change this!
- breaking the cycle by educating the P!
Safety seeking behaviours?
Panic = an anxiety disorder
- safety seeking behaviours - positive or negative
- key for psychological intervention
- have to try and disentangle all these behaviours
- get the P is understand what is really going on
- educate them about anxiety sensations
- identify these behaviours
- KEY - identifying the first time the P had a panic attack
- show them how they interpreted it the first time round
- remove the avoidance and escape SS behaviours
- have to demonstrate the catastrophic nature of sensations
Panic Attack - DSM-IV Definiton
- Abrupt surge of intense fear or discomfort
- Abrupt surge can occur from a calm or anxious state
- Reaches peak within minutes
- During which time, 4 of the following occur:
Panic Attack - DSM-IV Definiton
- symptoms to allow for classification
- palpitations, pounding / accelerated heart rate
- sweating
- sensations of shortness of breath or smothering
- trembling or shaking
- feeling dizzy, unsteady, lighthearted or faint
- feeling of choking
- chest pain or discomfort
- nausea or abdominal distress
- parethesias (numbness or tingling sensations)
- chills or heat sensations
- fear of losing control or going crazy
- fear of dying
- de-realisation (feelings or unreality) or depersonalisation (being detached from oneself)
DSM-V - Panic Disorder
(A) Recurrent unexpected Panic Attacks
(B) At least one of the attacks has been followed by 1 month (or more) of one of the following:
- persistent concern or worry about additional panic attacks of their consequences
- significant maladaptive change in behaviour related to the attacks
(C) Attacks are not restricted to the direct physiological effects of a substance or a general medical condition
(D) The panic attacks are not restricted to the symptoms of another mental disorder
Prevalence
- consistently high 12-month prevalence rates for panic disorder of about 2-3%
- lifetime prevalence - 3-7% for PD
> around 2.6% of the population are estimated to suffer from panic attacks / PD at sometime in our lives
Characteristics of PA/PD sufferers?
Consistently heavy users of health services - especially PD with agoraphobia
28%-40% of PD P’s seek help at A and E at least once per year because of panic symptoms
Longitudinal studies of PD?
- “symptom progression model”
- panic is often a precursor to a somatoform or affective disorder, substance misuse etc
–> often a precursor to other disorders?
Jonge et a (2016) - Cross-national epidemiology of panic disorder and panic attacks in the world mental health survey
- background
- epidemiological date - limited
- lots of research - based on US samples
- important to study the characteristics of both cross-nationally given the evidence of PD differing substantially across cultures
- -> changing classification criteria too?
- not exactly helping the situation too!
Jonge et a (2016) - Cross-national epidemiology of panic disorder and panic attacks in the world mental health survey
- method and basic results
Looked at both low-lower-middle income countries as well as upper-income countries
- all countries combined lifetime prevalence = 13.2%
- significant differences in prevalence rates of PA’s and PD’s observed between country groups based on income level and on WHO regions
- higher prevalence rates in high income countries and countries in the region of the Americas, Western Pacific and Western Europe
Sociodemographic correlates included:
- early AOO, female gender, other employment states (largely unemployed), being divorced/separated/widowed, lower education and having a low household income – ALL ASSOCIATED
Jonge et a (2016) - Cross-national epidemiology of panic disorder and panic attacks in the world mental health survey
- further results / discussion
DSM-V lifetime prevalence for PD is 1.7%
- falls in line with other cross-national studies
- slightly less than predictions focused on US data only (2.2-4.8%)
- high levels of co-morbidity
- AGAIN - slightly lower than previous reports based on US data
- recurrent PA’s associated with a subsequent onset of a variety of mental disorders
Co-morbidity and Risk
Associated with a wide range of other disorders:
- MDD, bipolar disorder, dysthymic disorder, social phobia, specific phobia, GAD, OCD, substance misuse/dependence
About 50% of PD P’s also have a personality disorder - most commonly avoidant and dependent types
Risk of suicide and parasuicide - higher among PD P’s than many other psychiatric disorders (including depp.)
- BUT this is thought to be due to concomitant personality disorder and/or substance misuse
Assessment of Panic Disorder
Questions to clarify:
> IS IT PANIC DISORDER?
are PA’s associated with another diagnosis?
is it anxiety?
- cognitions - catastrophic dying related
- intensity - panic = greater intensity
- duration - panic = 2-20 minutes, anxiety = open-minded
are there co-morbid conditions?
is the client sufficiently stable and engaged for CBT?
Once the assessment of panic disorder has been established, what needs to be determined/established?
- where
- when
- frequency
- duration of panic (pre and post)
- course - how long P has panic, how it has developed over time
- what makes it worse, what makes it better
- impact the panic has upon life (especially avoidance)
significant relationships - consider engaging significant others
> identifying the first safety seeking behaviour - helps to identify problems and recover from it
- getting P’s to acknowledge the world isn’t out to get them - GOOD thing?
- get them to recognise the over-dramatisation of the panic?
Treatment
> 5 to 15 weekly sessions
joint investigation between the P and practitioner
curious practitioner stance, investigation of the problems
activities including:
- shared goals
- review of homework exercises, tape and diary at start of sessions
- recording sessions, with notes taken on salient points / challenges
- in session behavioural experiments
- homework developing in-session work
- monitor progress using S-R measurements - ‘panic diary’ and in session believe ratings
- –> Doing stuff to get the HR up up, talk about what is really happening
- changes in physiology are not the same as catastrophic events
Efficacy of CBT for PD?
Clark et al (1994)
- treatment - effective with 80-90% of service user within 5 to 20 sessions with less than 10% relapse at 1 year follow up
Fentz et al (2014)
- systematic review and meta-analysis saw strong support for CBT effectively improving panic self-efficacy, as indicated by both a large pre-post therapy overall effect size (1.41, from 28 studies)
What does the UK government recommend for the treatment for PD’s
NICE (2004; 2011)
- recommend the use of CBT
NICE Matrix guidelines
- MILD
4-6 hours online CBT / Biblio-therapy
NICE Matrix guidelines
- MODERATE
Therapist supported CBT (6-12 hours) augmented by bibliotherapy, fear fighter or group 8-18 hours
NICE Matrix guidelines
- SEVERE
Individual CBT therapy (16-20 sessions) with written material, CBT with medication is more effective than medication alone
- there is some evidence of trend for CBT plus antidepressants to have slightly greater effect in acute phase compared to CBT alone, but difference is not maintained at the 6-24 month follow up
NICE Matrix guidelines
- CHRONIC
individual CBT treatment, up to 20 sessions
