Panic + Agoraphobia Flashcards
Define panic disorder
Panic disorder is an anxiety disorder characterized by recurring panic attacks, causing a series of intense episodes of extreme anxiety during panic attacks. It may also include significant behavioral changes, and ongoing worries about having other attacks.
Describe the diagnosis of panic disorder
Most people will have a panic attack once in their lifetime, however to be diagnosed with panic disorder the individual must experience recurrent, unexpected panic attacks which keep occurring.
This must be followed by at least 1month of persistent concerns and worrying about further panic attacks. This is coupled with significant non-beneficial modification of behaviour designed to avoid further attacks such as avoidance (agoraphobia is often a consequent diagnosis)
Define agoraphobia
A fear or anxiety of any place where the sufferer does not feel safe or feels trapped and is accompanied by a strong urge to escape to a safe place such as home
Describe the relationship between panic disorder and agoraphobia
The urge to escape/avoid unsafe places often is associated with the fear of having a panic attack and the consequences of an attack such as embarrassment. However, although agoraphobia is often preceded by panic attacks and disorder, it can occur independently of panic
Agoraphobic avoidance behavior is simply one of the learned consequences of having severe unexpected panic attacks.
If avoidance becomes widespread in panic disorder, panic disorder with agoraphobia is diagnosed.
Describe the diagnosis of agoraphobia
Distinct fear of situations where the individual is outside in a crowd or an open space
Situations are avoided or experienced with intense fear that they may panic etc
The individual experiences fear in at lease 2 different situation types and symptoms of anxiety or avoidance will last for 6months+
Fear causes difficulty in performing social or occupational activities and cannot be explained by the effects of other mental disorders
Describe prevalence
- 1.5 - 3% prevalence rate over 12month for panic and 0.4% for agoraphobia
- Both experienced more by women than men
- Onset common in adolescence/early adulthood or during a period of stress
- Cultural variance; Prevalence in some asian societies is low whilst in other cultures it is sometimes expressed in different symptoms such as Ataque de Nervios is an anxiety based disorder only found in Latin cultures
Define panic attacks
Discrete period of intense fear or discomfort, in which 4 (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes.
Palpitations, chest tight, dizziness, unreality, hot/cold, tingling, fear lose control, fear will die, shaking, choking, sweat, blurred vision, breathless
Common in all anxiety disorders, and occur in other disorders too.
Rationale for looking at biological explanations
Due to the intense nature of physical symptoms present in panic disorder and can be used to explain the nature of panic attacks
Describe original biological explanation of panic
Metabolic studies focus on how the human body processes particular substances. Many of these studies have shown that people with panic disorder are more sensitive to certain substances than are their non-panic counterparts.
It proposes that panic attacks may be caused by a dysfunctional respiratory system. People susceptible to panic are suggested to be more sensitive to substances such as sodium lactate and CO2, which are not believed to trigger any one neurotransmitter system, are believed to provoke panic attacks by stimulating the respiratory system.
ROLE OF HYPERVENTILATION - LEY (1987)
Is a common feature of panic attacks.
Hyperventilation may be causally related to panic attacks. During hyperventilation, there is an imbalance between oxygen inhaled and CO2 exhaled, so that more CO2 is exhaled than produced, thus lowering CO2 levels in the body. In an effort to compensate for the reduction in respiratory rate caused by hyperventilation, patients experience a host of symptoms, including shortness of breath, dizziness, trembling, and palpitations. The greater the loss of CO2 as a result of hyperventilation, the stronger these secondary symptoms
Evidence for original biological explanations of panic
Evidence mostly comes from biological challenge tests which is when panic attacks are induced by administering CO2 enriched air or by encouraging hyperventilation.
Overall, findings from these studies suggest that (a) patients with PD experience a greater number of panic attacks during administration of these substances, compared with normal controls and patients with other psychiatric disorders; (b) laboratory-provoked attacks resemble naturally occurring panic attacks; and (c) drugs used to treat PD also block laboratory-provoked panic attacks from occurring.
GORMAN 1990: Two maximal inhalations of 35% CO2 proved a very powerful stimulus. All subjects,
regardless of diagnosis, experienced substantial increases in anxiety level and ventilation. This effect undoubtedly obscured putative differences between patients and controls. Baseline anxiety scores were higher for the two patient groups than for the controls
Evaluation for biological explanation of panic
- A more HOLISTIC APPROACH is needed to fully explain panic disorder as a purely biological explanation is inconclusive.
– GORMAN etal 2001 Results from evidence using bio challenge tests showed that whilst physiological changes that provoke full blown attacks, it only does so in those with a history of panic even though physical changes are the same.
Therefore, this suggests that cognitive explanations must be explored as it would appear that a significant factor for the onset of panic attacks is the way the individual interprets the changes causes rather than the physical change itself. - INDIVIDUAL DIFFERENCES
Although the theory offered here provides an explanation of the process by which the panic attack develops, it does not explain why some people are susceptible to attacks while others are not.
- Also, although the theory can help to explain panic attacks which is a key feature of the disorder it fails to explain the other features such as the persistent fear that follows for the next few months = It is the catastrophic interpretations made by sufferers that causes panic - METHODOLOGY IS FLAWED: Using bio challenge tests prove to be difficult to evaluate and judge for panic, Gorman 1990 reported that the panic/no panic evaluation was difficult to make during 35% CO2 challenge for three reasons:
(1) the effect is very transitory,
(2) all subjects experienced great dyspnea, and
(3) we required that the subjects not verbally communicate their emotional reaction until 1 min after inhalation in order not to interrupt the respiratory monitoring. This difficulty is reflected in the fact that independent evaluation of six CO2 challenges in which the diagnostic blind was broken resulted in two disagreements with the attending psychiatrist about whether panic had occurred.
HOWEVER… in the broader context of laboratory-based research into panic attacks, it is worth remembering Rachman’s (1988) caution that the experimental conditions under which these panics are induced offer, by their nature, far greater control than is available in clinically occurring panics.
- However, high PRACTICAL IMPLICATIONS, as this theory contributes to understanding real world triggers for panic attacks. Smoking and PD have been positively associated in several epidemiological studies (Amering et al., 1999; Isensee et al., 2003; Pohl et al., 1992). Breslau and Klein (1999) and Breslau et al. (2004) found that current daily smoking increased the onset risk for panic attack and PD. Quitting smoking sharply reduces risk of panic onset.
- One of the major implications of bio models is that the panic attacks themselves should be a focus of treatment. This is a positive step since, even though the attacks are an important source of suffering and their alleviation may be crucial for permanent recovery, previous treatment approaches tended to neglect them. The poor prognosis of agora- phobia as opposed to simple phobias (Marks, 1970) as well as the relapses of agoraphobics occurring even after successful behaviour therapy may be due to recurring panic attacks.
- Challenge paradigms are ethically concerning as researchers should only use them when the effects on the patient is transitory and informed consent must be taken.
Describe more recent biological explanation of panic
KLEIN etal (1998) have demonstrated that acute hyperventilation fails to reliably produce panic attacks among panic disorder patients. They also found that air enriched with 5 percent carbon dioxide frequently induced panic attacks in panic disorder patients, which is exactly the opposite of the prediction of the hyperventilation theory.
Proposes that PD is result of a dysfunctional suffocation monitor (a “false suffocation alarm”).
Throughout the course of evolution, a highly sensitive “alarm system” has developed to detect when an organism is in danger of suffocation. High CO2 levels usually serve as an indicator that the organism is in danger of imminent suffocation, since high levels of CO2 correspond with low levels of oxygen.
Klein suggests that for PD patients their suffocation monitor becomes hypersensitive to CO2, with low levels of CO2 becoming a signal for low oxygen supply. As a result, the brain’s suffocation monitor incorrectly signals a lack of oxygen, and thus triggers a false suffocation alarm. He hypothesizes that since PD patients believe they are suffocating, (a) they experience shortness of breath and (b) they begin hyperventilating in order to keep CO2 levels well below the suffocation threshold. Therefore, rather than cause panic attacks, hyperventilation is a consequence and actually a defense against panic onset.
Klein suggests that “respiratory” panicogens such as sodium lactate, CO2, and isoproterenol elicit a false suffocation alarm (ie, a panic attack). Conversely, “neurochemical” panicogens such as yohimbine, caffeine, and mCPP produce general autonomic surges or changes similar to those created by fear, stress, or pain.
Describe the cognitive model of panic
CATASTROPHIC MISINTERPRETATION
Proposes that panic attacks occur when individuals perceive certain somatic sensations as considerably more dangerous than they truly are, and then interpret them to mean that they are about to experience sudden, imminent disaster (Negative interpretation bias that triggers anxiety which triggers panic attacks)
Clark (1988) believes that these “catastrophic misinterpretations” may arise not only from fear but also from a variety of other emotions (eg, anger) or from other stimuli (eg, caffeine, exercise).
The vicious cycle culminating in a panic attack develops when a stimulus perceived as threatening creates a feeling of apprehension. If the somatic sensations that accompany this state of apprehension are catastrophically misinterpreted, the individual experiences a further increase in apprehension, followed by elevated somatic sensations and and anxiety symptoms, until a full-blown panic attack occurs.
Evidence for cognitive model of panic
- Laboratory-provoked attacks may lead to similar physiological sensations in PD patients and normal controls, but only PD patients who catastrophically misinterpret these sensations will go on to develop panic attacks.
- - ANDERSON etal (1989) found that individuals will experience panic attack when they have been told they will receive CO2 but are only given compressed air. Suggesting it is the misinterpretation that leads to the anxiety not the physical change. - EHLERS+BREUER (1992) found that individual with panic disorder attend to and discriminate their bodily sensations more closely that normals. PD patients themselves report having thoughts of imminent danger during their panic attacks (eg, heart attacks, insanity) and report that these thoughts typically occur after they notice specific bodily sensation, provides convincing support for the cognitive model of panic.
- Additional support for Clark’s cognitive model comes from studies demonstrating that panic attacks can be alleviated with cognitive techniques, such as cognitive restructuring, which attempt to challenge and substitute catastrophic misinterpretations with rational thoughts.
Evaluation of cognitive model of panic
+ It has been argued by critics that the cognitive model does not explain why PD patients continue to misinterpret these somatic sensations despite evidence to the contrary (ie, when the catastrophic predictions do not come true).
However, since PD patients take a variety of precautions to prevent the occurrence of an attack (eg, avoid or escape situations in which they are likely to occur), it is likely that they never truly learn that their panic attacks will not lead to catastrophes no matter what safeguards they may use.
- Problems for cognitive theory include the fact that panic attacks can occur in panic patients in the absence of detectable cata- strophic cognitions. For example, patients may experience nocturnal panic attacks. Alternatively, they may sometimes have diurnal attacks without antecedent cognitions when the cognitions should have been readily detectable
