Panic Disorder Flashcards
why do we have anxiety?
it’s our inbuilt threat system - designed to alert us
What is the physiology of anxiety?
Fight or flight response e.g. palpitations, shaking, sweating, nausea, dizziness etc
What behavioural consequences are there of anxiety?
desire to avoid or escape
What emotional consequences are there of anxiety?
Stress, worry, afraid, nervous, on edge
What cognitive consequences are there of anxiety?
- Inflated sense of danger
- Worry ‘what if…’
- Cognitive biases - attention to threat, interpretation of threat, inflated sense of danger (catastrophising - lots of different unhelpful thinking styles will creep in)
How are anxiety disorders characterised?
- fears out of proportion to the threat posed by the current situation
- recurrent or persistent
- limiting in terms of activities, goals, occupation or relationships
What are the DSM-5 criteria for panic disorder?
- Panic Attacks
- Worry/anxiety about panic attacks or avoidance
- not due to drugs/medical condition
- not another anxiety disorder
How does the DSM-5 define a panic attack?
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time 4 more symptoms occur.
The abrupt surge can occur from a calm state or an anxious state
What is the lifetime prevalence of panic disorder?
1.5-3.5%
What is the UK prevalence of panic disorder?
1.7%
What distinct feature is there of panic attacks that separates it from other anxiety disorders with panic attacks?
Intense fear of experiencing panic attacks
What biological theories are there of panic disorder?
- Hyperventilation
- Noradrenergic overactivity
What psychological theories are there of panic disorder?
- Classical conditioning
- Anxiety sensitivity
- Catastrophic misinterpretation of bodily sensations
- psychodynamic theory of panic
What is hyperventilation?
a rapid form of breathing that results in ventilation exceeding metabolic demand and has an end result of raising blood pH levels. a common feature of panic attacks
What did Ley (1987) suggest about hyperventilation theory?
That shortness of breath & heart palpitations are the cause of panic attacks rathe than the effect.
- affects CO2 levels, resulting in a rise in pH levels producing mild symptoms
- continues to rise and passes a critical point where tolerance gives way to alarm and fear
- sympathetic nervous system takes over, further exacerbating panic symptoms
What evidence is there for Ley’s hyperventilation theory?
- Biological challenge tests
- panic attacks induced by hyperventilation
- however. they’re only generated in individuals with a history of panic attacks
What did Klein (1993) suggest about hyperventilation theory?
Suffocation Alarm Theories
- panic attacks are due to a ‘suffocation monitor’ in the brain that mistakenly signals a lack of useful air, triggering the suffocation alarm system
- CO2 acts as a panic stimulus, suggesting suffocation may be imminent
- People prone to panic attacks have an oversensitive suffocation alarm system
What evidence is there for Klein’s suffocation alarm theory?
- People with panic disorder report more shortness of breath when anxious & greater fear of suffocation
- people without panic disorder focus on heart palpitations rather than respiratory symptoms
- however, whilst panic patients are hypersensitive to alterations in breathing, this is not specific to CO2
- cognitive symptoms, such as fear of dying or loss of control, were the most highly associated with a clinical panic attack
What is the noradrenergic overactivity theory?
People with panic disorder may have overactivity in the noradrenergic neurotransmitter system
What evidence is there for the noradrenergic overactivity theory?
- Drugs which increase noradrenergic function induce anxiety
- greater levels of norepinephrine have been shown to occur with anxiety conditions
- mechanism of action in some antidepressants maybe due to their ability to reduce central noradrenergic function
- people with panic may also be deficient in the GABA neurons that inhibit noradrenergic activity
What is the issue with the noradrenergic overactivity theory?
Is it a cause or effect?
How does classical conditioning explain panic disorder?
When stimuli, events or situations are paired with a panic attack, these conditioned stimuli then trigger panic when they are encountered again
Explain Clark’s Model of Panic Disorder
Trigger stimulus (internal or external) lead to perceived threats (e.g. i’m going to faint)
These perceived threats cause apprehensions (e.g. anxiety) and/or interpretations of physical sensations (e.g. thinking they’re having a heart attack).
These lead to physiological sensations (e.g. palpitations, sweating)
What is catastrophic misinterpretation?
- an appraisal that bodily sensations mean something terrible
- anxiety symptoms misinterpreted as being catastrophic
What evidence is there for catastrophic misinterpretations?
- Phobia patients with panic attacks have more anticipation of illness, death or loss of control
- bodily sensations are perceived first in panic attacks
- patients are more likely to have a panic attack when bodily sensations are induced by sodium lactate (increased heart rate and BP)
- CBT focused on catastrophic misinterpretation is effective in reducing panic attack frequency
- people with panic report catastrophic misinterpretation
What are safety behaviours?
activities intended to avoid the feared outcome
may lead to short term decrease in anxiety but maintain unhelpful beliefs in the long run
What should we do in CBT Assessment in Panic?
- Build relationship
- Gather information
- Socialise into the model (thoughts and feelings)
What kind of assessments can we do specific to panic?
- Diary measures of panic attacks
- Symptom-specific questionnaires e.g. panic disorder severity scale
What should we do in CBT Formulation of Panic?
- formulate collaboratively with the client
- use clark’s model
- help the client to understand the role of catastrophic misinterpretations
- work through the model with personalised examples for the individual
What should we do in CBT Intervention of Panic?
- test out the validity of cognitions
- focus on catastrophic misinterpretations
- review evidence for and against these cognitions
- behavioural experiments
- developing alternative cognitions
- maybe to a thought record with them
What common behavioural experiments are used in panic intervention?
- Reproduce symptoms of panic attacks (e.g. hyperventilation)
- ask clients to stay in the feared situation rather than avoid them or engage in safety behaviours
- make predictions and rate beliefs in this - then rate again afterwards
- usually involved exposure to the feared situation
What should we do in CBT Evaluation for Panic?
- evaluate treatment as you go along
- may include idiosyncratic measures (panic attack diary, fear of panic attack subjective units of distress)
- ask if they feel more capable to cope
What are the 6 processes involved in a maintaining negative beliefs in an anxiety disorder?
- safety-seeking behaviours
- attentional deployment
- spontaneous imagery
- emotional reasoning
- memory processes
- nature of the threat representations
explain attentional deployment.
- selective attention towards threat cues may play a role in the maintenance of anxiety disorders by enhancing the perception of threat
- attention towards threat cues and away from threat cues may both play a role in the maintenance of anxiety disorders
explain spontaneous imagery.
- spontaneously occurring mental images in which patients see their fears realised
-enhancing the perception of threat - images of physical and mental catastrophes
explain emotional reasoning
- creating an ‘emotional truth’ which creates feelings of anxiety, fear and apprehension in existing stressful situations
- patients use self-images and other anxiety-related interoceptive information to make erroneous inferences about how they appear to others
explain memory processes
2 types:
- Selective retrieval of negative memories and impressions of the observable self
- Apparent dissociation between explicit and implicit memory, specifically between recall and priming
explain the nature of the perceived threat
- out of the blue intense affect may be maintained because the threat cue that triggers the problem is out of awareness and so patients have difficulty recognising the inappropriateness of their reaction at the time it occurs
- affected by the way you interpret your initial normal intrusive recollections and other symptoms
- may engage in dysfunctional strategies that could prolong the intrusions
what is an empirically derived treatment?
- targeting maintenance processes will make therapy more effective and efficient
- developing with patients an idiosyncratic version of the cognitive model
- examining and modifying negative beliefs
what does cognitive therapy aim to do for anxiety disorders?
- educate
- verbal discussion techniques
- imagery modification
- attentional manipulations
- exposure to feared stimuli
- manipulation of safety behaviours
- behavioural experiments
What are the different types of safety-seeking behaviours?
- direct avoidance
- escape
- subtle avoidance
what are adaptive coping strategies?
something that individuals do in order to reduce anxiety, and does not maintain or worsen future responses to the same stimulus or stimuli
- lack of negative impact compared to safety-seeking behaviours
What 3 dimensions are used to distinguish between SS-Behaviours and helpful coping strategies?
- topology of the behaviour
- intention behind the behaviour
- consequences of the behaviour
what are direct avoidance behaviours?
- most obvious
- avoiding situations that have particular characteristics
what are escape behaviours?
- similar to direct avoidance
- includes leaving a particular room, building or area, or having to return to a perceived place of safety
what are subtle ss-behaviours?
- harder to distinguish from adaptive coping strategies
- include planned in advance or performed once the anxiety is experiences
- don’t seem to be safety behaviours but they are easier to identify based on the frequency with which they are reported by panic patients
- e.g. carrying a bottle of water or meds
what is an anxiety disorder?
a psychological disorder characterised by an excessive or aroused state and feelings of apprehension, uncertainty, and fear
what are the 6 main anxiety and stress-related disorders?
- specific phobias
- social anxiety disorder
- panic disorder
- generalised anxiety disorder (GAD)
- obsessive-compulsive disorder (OCD)
- post-traumatic stress disorder (PTSD)
what is panic?
a sudden uncontrollable fear or anxiety
what are biological challenge tests?
research in which panic attacks are induced by administering carbon dioxide enriched air or by encouraging hyperventilation
what is anxiety sensitivity?
fears or anxiety symptoms based on beliefs that such symptoms have harmful consequences (e.g. that a rapid heartbeat predicts an impending heart attack0
what is the Anxiety Sensitivity Index (ASI)?
a measure developed to measure anxiety sensitivity
What are the 3 common treatments for panic disorder?
- Structured Exposure Therapy
- CBT
- Drug Treatment
What drug treatments are effective?
Tricyclic antidepressants and benzodiazepines are an effective first-line treatment, but structured exposure therapy or CBT is as effective if not superior
