Panic Disorder and Agoraphobia Flashcards
What are the symptoms of panic disorder?
A. Recurrent, unexpected panic attacks in which at least four of the following symptoms occur: palpitations/pounding heart/accelerated heart rate, sweating, trembling, shortness of breath/smothering, feelings of choking, chest pain/discomfort, nausea, dizziness, child/heat sensations, paraesthesia, derealisation/depersonalisation, fear of losing control, or fear of dying.
B. At least one of the attacks has been followed by 1 month or more, of one or both of the following:
1. Persistent worry or concern about additional panic attacks or their consequences (e.g. losing control, having a heart attack, etc.)
2. A significant maladaptive change in behaviour related to the attacks (e.g. avoidance behaviours).
Panic attacks are brief but intense; usually reaching peak intensity in 10 minutes, with attacks usually subsiding in 20-30 minutes. They rarely last more than one hour. A correct diagnosis of panic disorder is often not made for years, due to the amount of physiological symptoms that could be attributed to other medical conditions.
What are the symptoms of agoraphobia?
A. Marked fear or anxiety about 2 or more of the following:
1. Using public transportation.
2. Being in open spaces.
3. Being in enclosed places.
4. Standing in line or being in a crowd.
B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms.
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
E. Out of proportion to the actual danger.
How heritable is panic disorder?
Panic disorder is moderately heritable- 33-43% of variance in liability due to genetics (Kendler et al, 2001). Genetic vulnerability manifests as neuroticism. Specific responsible genetic polymorphisms have been identified. Heritability at least partly specific for panic disorder, but overlap for panic disorder and phobias (Kendler et al. 1995).
What is the neurochemical basis of panic disorder? How can panic attacks be induced biochemically?
Noradrenaline strongly implicated. The amygdala believed to play a central role in panic attacks (responsible for fear). Amygdala stimulates the locus coeruleus, and other autonomic/neuroendocrine/behavioural responses in panic attacks (Gorman et al. 2000).] Amygdala central to the fear network. Connects to lower areas in the brain as well as higher areas such as the prefrontal cortex. Panic disorder occurs in abnormally sensitive fear networks- those with panic disorder show heightened startle responses to loud noise stimuli and slower habituation to such stimuli (Ludewig et al. 2005).
The conditioned anxiety of panic attacks that one experiences in panic disorder is thought to involve the hippocampus, also part of the limbic system. Probably involved in learned avoidance in agoraphobia (Gorman et al. 2000).
Panic attacks can be induced at much higher rates in individuals with panic disorder than those without, when they are exposed to infusions of sodium lactate, inhalations of air with altered CO2 levels, or ingesting large amounts of caffeine. These are known as panic-provocation procedures. However, they have very different (even mutually exclusive) neurobiological processes.
Two primary neurotransmitter systems most implicated- the noradrenergic and the serotonergic. The noradrenergic system can stimulate cardiovascular symptoms associated with panic (Gorman et al. 2000). Increased serotonergic activity decreases noradrenergic activity. This fits the most common treatment route of panic disorders- SSRIs. GABA has also been implicated in the anticipatory anxiety that many people with panic disorder have. GABA inhibits anxiety, and has been shown to be abnormally low in certain parts of the cortex in people with panic disorder (Goddard et al. 2001).
comprehensive learning theory of panic disorder?
Builds on the earlier theory that initial internal bodily sensations of anxiety or arousal become interceptive conditioned stimuli associated with higher levels of anxiety or arousal. Initial panic attacks become associated with initially neutral internal and external cues through an interoceptive conditioning process. One effect of this conditioning is that anxiety becomes conditioned to these CSs, and the more intense the panic attack, the more robust the conditioning (Forsyth et al. 2000).
Cognitive Theory of Panic
Clark (1986, 1997) theorised that individuals with panic disorder are hypersensitive to and tend to catastrophize the meaning of their bodily sensations. Frightening thoughts about their symptoms (such as heart palpitations or dizziness) may cause more physical symptoms, further fuelling catastrophic thoughts. This creates a vicious cycle which culminates into a panic attack. These thoughts are often barely out of the realm of consciousness, so the individual is not often aware of them- these are automatic thoughts.
What are the learning and cognitive explanations of results from panic provocation studies?
The agents in panic provocation studies produce arousal which mimics the physiological cues that normally precede a panic attack, or indicate an impending catastrophe. People with panic disorder misinterpret these symptoms as the beginning of a panic attack or heart attack, inducing the vicious cycle.
What role do safety behaviours have in maintaining panic disorder?
After experiencing hundreds or even thousands of panic attacks without having a heart attack, one would think that the catastrophizing thought process would disappear after being proved wrong so many times. However, disconfirmation does not occur as people with panic disorders engage in safety behaviours- e.g. breathing slowly or carrying anxiolytic medication with them. In treatment, it is important to recognise these safety behaviours so that the person can learn to drop them and so realise that the feared catastrophe will still not occur.
How do cognitive biases maintain panic?
People with panic disorder process ambiguous situations as more threatening. Their attention is automatically drawn to threatening information in their environment, such as words that represent things they fear (e.g. palpitations, numbness, or faint). This has been demonstrated in fMRI studies that show greater activation in brain areas involved in memory than controls when processing threatening material (Maddock et al. 2003).
Evaluate the effectiveness of medication in treating panic disorder.
Many people with panic disorder are prescribed anxiolytics from the benzodiazepine category such as alprazolam or clonazepam. People experience some symptom relief from these medications, with one major advantage is that they act extremely quickly (30-60 minutes) and so can be useful in acute situations of panic/anxiety. However, most people with moderate-high doses develop physiological dependence, resulting in unpleasant withdrawal symptoms. There are also some unpleasant side effects such as drowsiness, sedation and impaired cognitive and motor performance. Withdrawal is very slow and difficult, and it tends to precipitate relapse.
More “desirable” medications are antidepressants- primarily tricyclics, SSRIs, and SNRIs. One advantage is that they do not create physiological dependence, and can alleviate comorbid depressive symptoms. However, the can take up to 4 weeks to have any beneficial effect and so are not useful in acute situations. SSRIs can also have troubling side effects leading to high attrition.
Outline and evaluate CBT to treat panic disorder (interoceptive exposure, cognitive restructuring, and panic control treatment)
Interoceptive exposure involves deliberate exposure to feared internal sensations. People are asked to perform various exercises that elicit various internal sensations (e.g. spinning in chair, hyperventilating, running in place) and to stick with those sensations until they subside- allowing the client to habituate.
Cognitive restructuring helps the client to recognise their catastrophic thoughts, and that these may help maintain their panic attacks.
One integrative treatment of agoraphobia and panic disorder is panic control treatment. First, clients are educated about the nature of anxiety and panic and their adaptive functions. Second, people with panic disorder are taught how to control their breathing. Third, clients are taught about the logical errors they make and subject their NATs to logical reanalysis. Finally, they are exposed to feared situations and feared bodily sensations in order to build up tolerance. In many of the studies on this type of therapy, 70-90% of people were panic free at the end of 8-14 weeks of treatment, and gains were well maintained at 1-2 year follow-up (Arch & Craske, 2008; McCabe & Gifford, 2009).
