Panic Disorder & Its Empirical Treatment

Introductory Exercise: What is Panic?

Explore the concept of Panic (i.e., what is it?) Consider normal vs. abnormal e.g., up to 40% of general population has panic attacks each year, but only a fraction go on to develop panic disorder; why? Is fear the same as anxiety? If so, how? Role of medications and psychosocial treatments Is there an issue with approaching treatment from a medical/biophysiological angle? Why or why not? Any exceptions?

Anxiety building blocks

Agoraphobia and Panic Attacks are not codable disorders in and of themselves. They are the necessary building blocks from which several codable anxiety disorders are constructed. AGORAPHOBIA: Fear of situations or places such as entering a store, where they might have trouble obtaining help of they become anxious. PANIC ATTACK: Brief episode in which a patient feels intense dread accompanied by a variety of physical and other symptoms (it begins suddenly and peaks rapidly). Question: Is anxiety the shadow of intelligence or the overwhelming specter of death and nothingness?

Agoraphobia

In Greek, agoraphobia literally means fear of the marketplace; however, in contemporary terms, it refers to the fear some people have in some places or situations where escape seems difficult (or embarrassing) or help would be unavailable if they should have anxiety symptoms. In German, words like platzschwindel and platzangst or just angst were used to describe this phenomenon. Open or public places such as theatres and crowded supermarkets qualify, and so does travel. Patients either avoid the feared place or situation, or, if confronted with it, suffer intense anxiety and require the presence of a companion or some other support or distractor. By itself, not codable, but can be part of building block for PDA, GSP, SP, OCD, PTSD, and in kids it shows up in Separation Anxiety Disorder

Panic Attack

Person experiences a sense of disaster that is usually accompanied by cardiac symptoms (palpitations, rapid heart beat) and trouble breathing (shortness of breath, chest pain). Attack usually begins abruptly (within 10 minutes or so, but more commonly within seconds or less than a minute) and rapidly builds to a peak. Attack usually lasts less than 30 minutes. May happen only a few times in a lifetime, or it may happen every week. of people experience nocturnal panic attacks. Many people change their behavior in reaction to these attacks, thinking/believing that they mean they are crazy or ill (PD).

Which symptoms: Full vs. Limited vs. Complex

4+ of the following symptoms are present

racing or irregular heart beat sweating trembling or shaking shortness of breath or smothering chest pain or discomfort nausea or abdominal distress dizziness or lightheadedness feeling detached from self or reality numbness or tingling sensations chills or hot flushes fear of losing control or going crazy* fear of dying*

Provides clues for alarming beliefs

Panic Disorder

PD is a common anxiety disorder in which the patient experiences panic attacks (usually many, but always more than one) and worries about having another (Fear of Fear). The PA are usually uncued, though situationally predisposed attacks and cued/situationally bound attacks can also occur.

Definition: . unexpected

About of people who experience panic disorder also experience agoraphobia, but obviously many do not! If it is present, it usually develops within weeks, as staying home usually (initially at least) helps prevent future attacks (i.e., safe areas). PAs are commonly experienced as excrutiating, and people will do just about anything to avoid them (and therein lies the problem).

300.21 Panic Disorder with Agoraphobia

Patient has recurrent Panic Attacks that are not expected. 1 month +, the patient has (1 or more):

Worry about more attacks Worry about the significance/meaning of attack (crazy, ill) Change in behavior exhibited (avoidance, escape)

Agoraphobia is present. Not due to GMC, substance, meds NOT BETTER ACCOUNTED FOR BY ANOTHER ANXIETY DISORDER

Panic attacks are SUPER common in other anx d/o

300.01 PD w/o Agoraphobia

PD occurring without the agoraphobic component. By implication, these patients are not as disabled by the condition than those with agoraphobia. Consider: GSP, SP, OCD, PTSD as explanation for anxiety where the panic is not the source per se.

Panic: Some Definitions

Panic

Intense, discrete episode of fear and anxiety, accompanied by great somatic discomfort and frightening thoughts
Vague to specific something is wrong vs. Im having a heart attack Significant distress and functional impairment Frequent safety/avoidance behaviors; apprehension of return of fear symptoms Agoraphobic avoidance Interoceptive avoidance Safety behaviors

Key aspect: Intolerance for physical sensation

Panic: Defining Features & Demographics

Panic

Lifetime prevalence: 1 3.5% Higher rates among women (2X) Young and old, but median onset is 24 years of age Bimodal distribution in age onset with peaks 15 24 and 45 - 54 Comorbidity and other disorders Social Phobia Generalized Anxiety Specific Phobia Obsessive-Compulsive Posttraumatic Stress Hypochondriasis Complex panic & limited symptom attacks R/O medical conditions that produce cardiac, neurological, and gastrointestinal problems

Presentation may differ across cultural groups

Hispanic clients may experience a different constellation of symptoms (*) that overlap with unexplained neurological sx (UNS; in US speak). This ataque de nervios is characterized by the following sx (Interian et al., 2005):

Behavioral

Somatic

Shouting* Striking at others* Falling to the ground* Trembling Heart palpitations Paralysis* Loss of consciousness Numbness/tingling Chest tightness Difficulty breathing Dizziness Fainting*

Additional possible symptoms include (from UNS)

Weakness* Balance difficulty* Amnesia* Vision or hearing changes (double or blurry vision, blindness, deafness)* Convulsion/seizure*

Screening / identification questions

Panic: Would you say you currently have times, lasting perhaps only seconds or minutes, when you feel a very sudden rush of intense fear or discomfort, which is accompanied by a racing heart, a shortness of breath, or dizziness? If not out of the blue, then what contingencies control? Places People Circumstances Panic attacks occur within other anxiety d/os (GSP, SP, OCD, PTSD), and commonly occur for approx 40% of general population

Panic disorder: Screening for and identifying medical conditions

A work-up which include the following:

1. 2. 3. 4.

Complete medical, psychiatric, and social history Physical and neurological examination Family history Medication and drug history

Substances: marijuana, cocaine, caffeine, amphetamines (including diet pills), general anastetics, over-the-counter medications (e.g., pseudoephedrine) ETOH: can cause anxiety, but also used to cope

5. 6.

Electrocardiogram in patients over 40 years of age Lab tests, including complete blood count, chemical panel, thyroid function test, and any other tests that may be indicated from the history
Anemia, angina, arrhythmia, asthma, chronic obstructive pulmonary disease, Cushings disease, electrolyte disturbance, epilepsy, hyperthyroidism, hypoglycemia, mitral valve prolapse (?), parathyroid disorders, pheochromocytoma, pulmonary embolus, transient ischemic attacks

Looking for:

Panic Instruments

Mobility Inventory

Assesses avoided situations

Chambless, D.L., Caputo, G.C., Jasin, S.E., Gracely, E.J., and Wiliams, C. (1985). The Mobility Inventory for Agoraphobia. Behavioral Research and Therapy, 23, 3544.

Fear Questionnaire

Assesses agoraphobic avoidance

(also social phobia, blood-injury phobia)

Marks, I.M, & Mathews, A.M. (1978). Brief standard self-rating for phobic patients. Behavior Research and Therapy, 17, 263-267.

Panic Attack Record

self-monitoring form for panic

BAI & Body Sensations Questionnaire have reliable valid Spanish translations (Novy et al., 2001) Beck Depression Inventory

Depression & SI should be assessed regularly

Specific CBT treatment for Panic

Teaches patient somatic skills (diaphragmatic breathing, progressive / passive muscular relaxation, autogenic training, visualization / meditation, mindfulness) so they can reduce the frequency of panic, reduce panic attack intensity and duration when they occur Teaches patient to distinguish between fearful (subjective) thinking and more reasonable, scientifically / statistically objective thinking (i.e., critical, creative, and meaningful thinking), and strategies for questioning accuracy of reasoning while in stressful situations Allow patient to become more familiar and used to sensory experiences through various exposure techniques, in safe settings first and then in progressively more challenging situations and circumstances Each component aims at increasing tolerance for physical sensation and at allowing the patient to become a clearer, more objective thinker

Gould, R.A., Otto, M.W., Pollack, M.H. (1995). A meta-analysis of treatment outcome for panic disorder. Clinical Psychology Review, 15(8), 819-844

Panic D/O: ESTs

Reviewed 42 studies, 75 separate comparisons

Treatment Pharmacotherapy Antidepressants Benzodiazepines Cognitive-Behavior Therapy IE + CBT
Effect Size Panic Free

.47 .55 58% .40 61% .63 70% .88

Slippage of Treatment Effects Pharmacotherapy -.46 Pharmacotherapy + EX -.07 CBT +.06

Panic D/O ESTs (cont.)

Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, and their combination for panic disorder: A randomized controlled trial. Journal of the American Medical Association, 283(19), 2529-2536.

312 patients were randomly assigned to one of Acute Phase Maint. Phase Follow-up following: Responders* Responders* after 6
Responders* after 12 weekly sessions (3 months) additional monthly

sessions

after 6 months w/ no further tx

CBT Alone
Imipramine Alone

67% 74%
39% 84% 80%

73% 80%
38% 90% 76%

85% 60%
NA 50% 83%

Placebo Alone
CBT + Imipramine

CBT + Placebo

* Percentage of Treatment Completers Rated as Responders on the Panic Disorder Severity Scale (2+ = much improved)

Problems

Fear of underlying causes (e.g. defectiveness, insanity)

Assess the facts, gather evidence

Fear of having anxious feelings (emotional perfectionism)

Review adaptiveness of anxiety Assess & challenge the beliefs about the meaning of anxiety

Noncompliance w/ homework

Assess & challenge beliefs about homework Ensure homework has been modeled & practiced in-session reduce amount or intensity of homework Introduce therapist guided exposure & fade out
develop new exercises assess role of therapist as a safety blanket

Failure to induce panic sx w/ interoceptive exposure

Common medications in anxiety treatment

Three basic categories of antidepressants useful to panic

Selective Serotonin Reuptake Inhibitors (SSRIs)

Do NOT use with MAOIs fatal serotonergic syndrome may result Look out for Paxil Flu on short acting SSRIs (Paxil, Luvox)

Mask withdrawal symptoms with one week Prozac prescription

Tricyclic Antidepressants

Can use with SSRIs to augment when SSRIs alone are not entirely effective Caution: SSRIs inhibit Hepatic cytochrome P-450 2D/3A4/1A2, which are liver enzymes which are supposed to metabolize tricyclic antidepressants can lead to unanticipated, alarmingly high blood levels = anticholinergic toxicity Can be difficult to take Diet restictions (Tyramine can produce fatal hypertensive crisis)

Monoamine Oxidase Inhibitors (MAOIs)

Benzodiazepines

Most commonly prescribed CNS depressants (depress all its functions) 10% of users suffer MDD due to Benzo long-term use Whenever possible, use short half-life (Xanax vs. Klonopin)

Major caveats with medications

Primarily with Benzodiazepines, but with any medication which significantly and drastically reduce sensory information May make patient hypersensitive to any little, tiny bit of sensation

Patient position: They want to feel next to nothing Problem: So long as they are alive, they will feel Solution: Make patient more tolerant, not less tolerant

May interfere with habituation

Habituation = 50% reduction in arousal / anxiety Floor effect and suppressed arousal capacity may prevent repeated habituation, thereby preventing extinction

May attribute less to personal agency for change and autonomy for personal reality with medications