Transcript Psychopathology2e_c06_PPT

Chapter 6:
Panic Disorder (PD)
Joanna J. Arch
Lauren N. Landy
Michelle G. Craske
Diagnostic Criteria: Panic Attack
 Abrupt surge of intense fear or discomfort
 Characterized by a cluster of 13 physical and
cognitive symptoms
 For example, palpitations, shortness of breath,
paresthesias (tingling), trembling, derealization, fear of
dying or going crazy
 Discrete, sudden, abrupt onset,
 Symptoms peaking within minutes
 A full-blown panic attack = four or more symptoms
 Limited symptom attack = fewer than four symptoms.
Diagnosis: Panic Disorder and
Agoraphobia
 Panic Disorder (PD)
 Unexpected (or without an obvious trigger) panic attacks
 At least 1 month of persistent apprehension about the
recurrence of panic or a significant behavioral change
 Agoraphobia
 Marked fear or anxiety of situations from which escape
might be difficult or in which help might be unavailable in
the event of panic symptoms
 Agoraphobia diagnosis requires fear of at least two:
• Public transportation, open spaces, enclosed places, standing in
line or being in a crowd, or being outside of the home alone.
Diagnosis: DSM-5 Changes for
Panic Disorder and Agoraphobia
 A panic attack specifier may be applied to any
diagnosis
 PD and Agoraphobia (which now requires 2 or
more feared situations) are now separate (but
highly comorbid) disorders
 Many individuals in community settings exhibit the full
features of agoraphobia but have never had a full panic
attack or even panic-like symptoms
 Both require 6 months duration
Diagnosis: Differential Diagnosis
and Comorbidity
 PD is diagnosed when there are repeated unexpected
panic attacks and persistent apprehension about panic
attacks / behavioral change resulting from panic
attacks
 Panic attacks alone do not merit diagnosis as a disorder
 Commonly co-occurring Axis I conditions
 Social phobia, dysthymia, generalized anxiety disorder, major
depressive disorder, and substance abuse
 25% to 60% meet criteria for a personality disorder,
mostly avoidant or dependent personality disorder
Symptoms- Agoraphobia
 Agoraphobia pertains to fear and situational avoidance
for reasons beyond the occurrence of panic attack
 May fear and avoid situations for reasons related or unrelated
to panic attacks
 Individuals with PD vary widely in their degree of agoraphobia
 Agoraphobia tends to increase as history of panic
lengthens
 However, a significant proportion of individuals panic for many
years without developing agoraphobia
 Individuals with both agoraphobia and PD
 Significantly more impairment overall and greater distress
regarding the social consequences of panicking
Panic Symptoms: Cognitions
 Panic attacks are characterized by a unique action
tendency
 Urge to escape and, less often, urge to fight.
 Panic attacks usually involve elevated autonomic nervous
system arousal
 Often, but not always, include perceptions of imminent
threat, such as death, loss of control, or social ridicule
 Noncognitive panic: No perceptions of loss of
control, dying, or going crazy, despite the report of
intense fear and arousal
Symptoms: Nocturnal Panic
 A subset of individuals who have panic disorder
also experience nocturnal panic attacks. Nocturnal
panic refers to waking from sleep in a state of
panic with symptoms that are similar to panic
attacks that occur during wakeful states
 44% to 71% of individuals have nocturnal panic at
least once, and 30% to 45% report repeated
nocturnal panics
Symptoms: Maladaptive
Behaviors
 Avoidance of situations in which panic attacks are
expected to occur
 Avoidance of activities that induce panic-like
sensations
 Safety behaviors
 Experiential avoidance
Symptoms: Safety Behaviors
 Dysfunctional emotion regulation strategies because…
 Overrated or no real threat
 Prevent feared outcomes that are unlikely to happen
 Help individuals feel more protected and secure in the
event of a panic attack
 Checking to make sure that a bathroom or hospital is close by,
carrying anti-anxiety medication, including empty pill bottles
 Bringing along or checking on the location of a safe person, often a
spouse
 Safety signals
 Safe objects, persons, and situations sought via safety behaviors.
 For example, empty pill bottles, people such as the therapist or
spouse
Epidemiology
 12-Month Prevalence: 2.4% to 2.7%, lifetime prevalence:
4.7%
 Treatment-seeking individuals with agoraphobia almost
always have history of panic preceding development of
their avoidance
 However, community samples have relatively high rates for
agoraphobia without a history of panic disorder
 Modal age of onset for PD is between age 21 and 23
 Psychological treatment usually sought around age ~34
 Female to male ratio ~2:1
 Females have much higher risk of agoraphobia
Prognosis
 Panic disorder, particularly in combination with agoraphobia, tends
to be highly chronic
 Prognosis in the absence of agoraphobia is more positive than for
generalized anxiety disorder or social anxiety disorder
 Entails severe financial and interpersonal costs
 Over-utilize medical resources compared to individuals with other
psychiatric disorders and general public
 With pharmacological treatment, only a minority of patients remit
without subsequent relapse (~30%)
 25% to 35% experience notable improvement, albeit with a
waxing and waning course
Etiology: Safety Behaviors and
Signals
 Safety behaviors
 Reduce anxiety in the short term
 Maintain PD over long term by preventing disconfirmation of
catastrophic predictions and/or the extinction of conditioned
response
 Animal literature shows that the presence of safety
signals functions as a conditioned inhibitor that
interferes with extinction
 Exposure therapy targeting safety behavior and signals
is more successful than exposure therapy alone
Etiology: Interceptive Avoidance
 When a person…
 Is unwilling to remain in contact with particular bodily
sensations, emotions, thoughts
 Takes steps to alter the form or frequency of these events
 Any form of distraction from anxiety and panic-related
symptoms falls into this category
 For example watching TV, playing video games, and eating
 Thought suppression and emotion suppression are
often counterproductive, facilitating the return of the
very thought or emotion avoided
Etiology: Cognitive Features
 Strong beliefs and fears of physical or mental harm
arising from bodily sensations that are associated
with panic
 Manipulation of appraisals can impact level of
distress over physical symptoms
Etiology- Emotions, Traits, and
Early Life Attachment
 Neuroticism: Proneness to experience negative
emotions in response to stressors is associated
with all anxiety disorders, including panic disorder
 Correlation between early insecure attachment and
the development of anxiety disorders later on in life
 Parenting behaviors predict offspring anxiety and
offspring anxiety molds parenting behaviors
Etiology: Childhood Illness
and Trauma
 Childhood experience with medical illness (in self
or others) increases risk for developing PD later on
 Childhood experiences of sexual and physical
abuse also increase risk for PD
 Link is stronger for panic disorder than for other anxiety
disorders
 Potentially traumatic events impose greater risk when
they occur during childhood rather than adulthood
Etiological Models- Barlow
 Panic attacks as false alarms in which a fight-or-
flight response is triggered in the absence of
threatening stimuli
 Panic attacks are relatively common in general
population, so why do only some people develop
panic disorder?
 Fear of fear, which is termed anxiety sensitivity
 The tendency to interpret anxiety symptoms as
dangerous and threatening
Etiological Model: Clark
 Catastrophic misappraisals of bodily sensations,
(e.g., panic bodily sensations are signs of
imminent death) are central to the development
and maintenance of panic disorder
 Criticized because cannot account for nocturnal
and noncognitive panic
Etiological Model: Interoceptive
Fear Conditioning
 Low-level somatic sensations of arousal or anxiety
(e.g., elevated heart rate) become conditioned
stimuli due to their association with intense fear,
pain, or distress
 Interoceptive conditioned responses are not
dependent on conscious awareness of triggering
cues and are observed even under anesthesia
Biological Etiology- Sympathetic
Activation
 Sympathetic nervous system activation during
reported panic attacks for ~60% of self-reported
panic attacks
 Severe panic attacks are more autonomically based
 Self-reported panic without autonomic activation may
reflect anticipatory anxiety rather than true panic
Biological Etiology: Genetics
 Heritability of panic disorder accounts for
approximately 30% to 40% of the variance
 Two broad but distinct genetic factors have been
identified
 First factor loads heavily on neuroticism
 2nd associated with symptoms of fear (i.e.,
breathlessness, heart pounding)
 Identified risk genes encode for serotonin
transporter/receptor, and adenosine receptor, but
findings are mixed overall
Biological Etiology: Amygdala
and GABA
 Amygdala
 Triggers the anxiety and panic response by activating
hypothalamus (HPA axis and autonomic system), locus
ceruleus (heart rate and blood pressures), and
parabrachial nucleus (changes in respiration)
 Patients have alterations in the amygdala and associated
structures
 GABA/Benzodiazepine Receptors
 Patients have lower benzodiazepine receptor density in
amygdala, perihippocampal areas, and frontocortical
areas
Treatments: CBT
 Major forms of CBT for panic include:
 Goal: Obtain corrective information that disconfirms fearful
misappraisals and eventually lessens fear responding
 Psychoeducation about panic to correct misconceptions
regarding panic symptoms
 Cognitive restructuring to identify and correct distortions in
thinking
 Interoceptive exposure to feared bodily sensations (e.g.,
spinning in a chair to induce dizziness)
 In vivo exposure to feared situations (e.g., driving)
 Sometimes breathing retraining to help patients cope with
panic and anxiety
During Treatments: Ongoing
Assessment Needed
 Retrospective recall of past episodes of panic and
anxiety may inflate estimates of panic frequency
and intensity which may contribute to
apprehension about future panic
 Ongoing self-monitoring yields more accurate, less
inflated estimates
 Therapeutic tool
 Contributes to increased objective self-awareness
essential to cognitive behavior therapy
Treatments: CBT Efficacy
 Large effect sizes for symptoms as well as
improvement in functioning; used to treat
nocturnal panic attacks and to prevent relapse
after discontinuation of benzodiazepines
 Improves symptoms of comorbid conditions
(e.g., depression)
 Benefits maintained over long term with trend
toward continuing improvement over time
 Similar findings in real-world clinic settings
Treatments: CBT for
Agoraphobia
 Treatment involves more situational exposure than
CBT for panic disorder alone
 Generally slightly less effective than CBT for cases
of panic disorder with no or minimal agoraphobia
 Often continuing improvement over time after
formal treatments end
 ~18.5% of clients relapse over a period of 5 to 7
years after successful exposure-based treatment
for agoraphobia
Treatments: What Makes
CBT Work?
 Combination of exposure, relaxation, and breathing
retraining has the highest effect size followed by
exposure alone
 11 to 12 treatment sessions most common in studies
• 4 to 6 also works, but weaker
 Group formats nearly as effective as individual
 Self-directed treatments work for highly motivated and
educated
 Cognitive therapy can be effective even when
conducted in full isolation from exposure and
behavioral procedures but it does not improve outcome
when added to in vivo exposure treatment for
agoraphobia
Treatment- Pharmacotherapy
Comparison
 Selective serotonin reuptake inhibitors (SSRIs) are the
medication of choice
 Medium- to large-effect sizes compared to placebo. Studies show
long-term efficacy up to 1 year
 Benzodiazepines also effective
 Work rapidly and are even better tolerated than very tolerable SSRI
class of agents.
 Limited by risk of physiological dependence and by the risk of abuse
 Discontinuation of medication results in relapse rate
between 25% and 50% within 6 months
 Time-limited withdrawal syndrome, which may serve as an
interoceptive stimulus for panic disorder relapse
Treatment: Psychotherapy and
Pharmacotherapy Comparison
 Combined treatment with antidepressants and CBT
is superior to antidepressants alone and to CBT
alone during treatment
 By end of treatment CBT as effective as combined, better
than medication alone
 Once medication is discontinued, combined treatment
may reduce the long-term effectiveness of CBT.
 CBT (in group format) without meds represents the most
cost-effective and durable first-line treatment for panic
disorder