Lecture 8 - Panic Disorder and Agoraphobia

Question 1

PD & A - Description (3)

Answer 1

• recurrent, unexpected panic attacks, worry and anxiety about having panic attacks, and behaviour is changed to minimise or avoid having panic attacks. Panic attacks are when you feel a sense of dread, choking, shaky, rapid heartrate, wobbly legs and feel faint.
  
  • Prevalence – 2-3% of adults and adolescents, lower in non-Western countries. Low levels in preadolescence, peak is in adulthood (30-60 years), and lower again in older adults. 2:1 gender female to male. Lifetime prevalence of 6.8% in US, 3.5% in Aus.
  • Agoraphobia – fear of being in public places. Present not just for people with panic disorder – can be a fear of falling over, getting lost, etc. 1.7% 12 month prevalence. Similar life course. 2:1 gender.

Question 2

PD & A - Aetiology (3)

Answer 2

• Clark’s cognitive model of panic – triggering stimulus à perceived threat (out of proportion) à apprehension à body sensations (heart rate, sweating, etc.) à interpretation of these symptoms as catastrophic (confirms the threat). Those without PD don’t have a problem with these sensations in the same way. Anxiety in anticipation of the attack or unrelated heightened anxiety which is interpreted catastrophically. Can happen out of the blue as well
• Rapee model – trigger (external or internal) à physiological change à detection of physiological change à catastrophic attributions à PANIC à anticipation of future panic à attentional allocation to the detection of somatic symptoms, and chronic arousal and hyperalertness.
• Agoraphobia model – avoidance before panic, panic followed by agoraphobia (quickly or slowly). Panic à expectation of future panic à avoid situations in which panic might occur. Not great models for agoraphobia as separate from PD.

Question 3

PD & A - Assessment (4)

Answer 3

• clinical interview – detailed description of the most recent attack, list of situations, avoidance, modulators, belief about the panic, and medications.
  
  • Panic Disorder Severity Scale (PDSS) – clinician administered, over the past month, good reliability and validity. Self-report has been developed. 7 items – frequency, distress, severity of anticipation, fear/avoidance of agoraphobic situations and panic sensations, impairment in work/social functioning. 0-4 rating. Remission = <5 or 40% reduction.
  • Panic and Agoraphobia Scale (PAS) – clinician/self-report options. Attacks, avoidance, anticipation, disability and functional impairment, and worries. Past week. 0-4 rating. Good reliability and validity. 0-6/8 (in remission), 7/9-17/18 – mild, 18/19-28 – moderate, 29-39 severe, 40+ very severe.
  • Self-report – records of panic situations during the week.

Question 4

Diagnosis - PD

Answer 4

• recurrent, unexpected panic attacks with 4+ of these symptoms: accelerated heart rate, sweating, trembling and shaking, shortness of breath, choking sensations, chest pain or discomfort, nausea, dizzy/faint, chill/heat sensations, numbness or tingling, depersonalisation/derealisation, fearing losing control/going crazy, fear of dying.
  
  • Panic attacks – an abrupt surge of intense fear that reaches a peak within minutes. Can occur from a calm or anxious state, or nocturnally. These can be used as a specifier for all DSM anxiety disorders since they can occur across all of them.
  • Followed by worry or avoidance for at least one month.

Question 5

Diagnosis - Agoraphobia

Answer 5

• marked fear or anxiety about 2+ of the following: using public transportation, being in open spaces, being in enclosed spaces, standing in a line or being in a crowd, or being outside of the home alone. Avoids because thoughts that escape might be difficult or help might not be available in these situations if panic symptoms occur.
  
  • Actively avoided, require the presence of a companion or endured with intense anxiety.
  • Fear is out of proportion to the actual danger posed, and lasts for 6+ months. Presence of another medical condition (Parkinson’s, enuresis) could make that danger more realistic.
• Separate diagnoses – many with AG do not experience PA. 50% of AG do not have PD, both disorders can precede each other, and AG is associated with non-PD disorders as well (anxiety/mood vs anxiety/mood/substance etc.). AG is more persistent and chronic than PD.

Question 6

DSM5 Changes - PD & A

Answer 6

diagnoses are now separate, and consistent with the ICD. Simpler terminology to describe panic attacks, and must have 2+ agoraphobic fears to distinguish from phobias. Time 6+ months rather than none. No requirement for insight that the fear is unreasonable.

Question 7

PD & A - EBT

Answer 7

• Medication – pharmacologically decrease the sensitivity of the fear network and reduce the severity and frequency of PA. SSRIs, SNRIs, NRIs, TCAs, MAOIS, BZDs, and other drugs have all shown effects.
• Level 1 evidence for CBT, level 2 evidence for self-help and psychoeducation.
• Exposure is the treatment of choice, relaxation and breathing techniques; medication can have a stronger effect but is poorly tolerated. PMR and interoceptive exposure.
• Psychoeducation – CBT model, identifying negative thoughts. Helping them distinguish between PA symptoms and potential heart attacks.
• Cognitive restructuring – evaluating the accuracy of thoughts and challenging the distorted ones. For/against evidence, alternative explanations.
• Interoceptive exposure – inducing the physical sensations of a panic attack. Need to be frequent and of enough duration that catastrophic thoughts about the sensations are disconfirmed, and the conditioned response is extinguished.
• In vivo exposure for agoraphobia – graded exposure hierarchy.
• Panic attacks in session – stay calm, this too shall pass. Help them to utilise how they would normally manage them outside session. 10 minutes or less usually – give you an opportunity to see how panic attacks are experienced by them. Reassure them and slow breathing.
• Progressive muscle relaxation – lower anxiety and arousal. Help them remember what it feels like to be relaxed. Countering physical symptoms and sensations.
• Additional options – EMDR – recall situation and then clinician takes them through eye movements, emotional regulation therapy, more limited evidence.
• Modalities – individual OR group is better than mixed. AG treated to reduce PD. Duration of disorder and homework.