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Current Trends in Clinical Psychology > CBT and Panic Disorder > Flashcards

CBT and Panic Disorder Flashcards

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1
Q

What is panic?

A
  • 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

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2
Q

Common Catastrophic misinterpretations

A 
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!

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3
Q

Cognitive Model of Panic

- Clark (1988)

A
  • 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
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4
Q

Panic Cycle - Clark (1986; 1988)

A

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
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5
Q

Teachmen et al (2010)

A

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
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6
Q

What are the types of panic?

A

(1) Preceded by anxiety

(2) “Out of the blue”

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7
Q

Types of panic - Preceded by anxiety

A

Threat related trigger (anticipation of attack or anxiety regarding unrelated events) —->

Breathlessness, HR increase, Dizziness —->

Misinterpret sensations —->

PANIC

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8
Q

Types of Panic - “Out of the blue”

A

Innocuous event trigger (exercise, excitement, caffeine, standing up, sleep) —–>

Breathlessness, HR increase, Dizziness, Bodily changes during sleep —–>

Misinterpret sensations ——>

PANIC

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9
Q

“Safety-Seeking” and Panic

A

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?

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10
Q

Panic - how do individuals maintain their panic?

A
  • 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!
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11
Q

Safety seeking behaviours?

A

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
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12
Q

Panic Attack - DSM-IV Definiton

A
  • 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:
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13
Q

Panic Attack - DSM-IV Definiton

- symptoms to allow for classification

A
  • 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)
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14
Q

DSM-V - Panic Disorder

A

(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

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15
Q

Prevalence

A
  • 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
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16
Q

Characteristics of PA/PD sufferers?

A

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

17
Q

Longitudinal studies of PD?

A
  • “symptom progression model”
  • panic is often a precursor to a somatoform or affective disorder, substance misuse etc

–> often a precursor to other disorders?

18
Q

Jonge et a (2016) - Cross-national epidemiology of panic disorder and panic attacks in the world mental health survey
- background

A
  • 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!
19
Q

Jonge et a (2016) - Cross-national epidemiology of panic disorder and panic attacks in the world mental health survey
- method and basic results

A

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

20
Q

Jonge et a (2016) - Cross-national epidemiology of panic disorder and panic attacks in the world mental health survey
- further results / discussion

A

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
21
Q

Co-morbidity and Risk

A

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

22
Q

Assessment of Panic Disorder

A

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?

23
Q

Once the assessment of panic disorder has been established, what needs to be determined/established?

A
  • 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?
24
Q

Treatment

A

> 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
25
Q

Efficacy of CBT for PD?

A

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)

26
Q

What does the UK government recommend for the treatment for PD’s

A

NICE (2004; 2011)

- recommend the use of CBT

27
Q

NICE Matrix guidelines

- MILD

A

4-6 hours online CBT / Biblio-therapy

28
Q

NICE Matrix guidelines

- MODERATE

A

Therapist supported CBT (6-12 hours) augmented by bibliotherapy, fear fighter or group 8-18 hours

29
Q

NICE Matrix guidelines

- SEVERE

A

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
30
Q

NICE Matrix guidelines

- CHRONIC

A

individual CBT treatment, up to 20 sessions

Current Trends in Clinical Psychology (5 decks)

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