L3: Panic Disorder

Diagnostic criteria for PD

• Recurrent unexpected panic attacks

• At least one of the attacks has been followed by 1 month (or more) of one or more of the following:

  1. Persistent concern or worry about additional panic attacks or their consequences

  2. A significant maladaptive change in behaviour related to the attacks

Agoraphobia

• Marked fear of anxiety about two (or more) of the following situations:

  • Using public transport

  • Being in open spaces

  • Being in enclosed places

  • Standing in line or being in a crowd

  • Being outside or home alone

• Usually result from experiencing panic attacks

• Can have alternative causes such as epilepsy 

  • Why it is separated from PD (but usually overlap)

Features of PD and Agoraphobia

• 80-90% panic attacks develops after negative life event

• More prevalent in women

  • Around twice as likely 

• Female prevalence increases with higher avoidance

• Over 12 years less than 50% recover without treatment

PD: Behavioural Perspective

• Stimuli (internal or external) is conditioned with response and causes panic (only takes one instance)

• Generalisation of conditioning

• Individuals with PD show:

  • Greater generalisation of conditioned response

  • Slower extinction of conditioned anxiety

  • In studies those with PD more likely to develop a conditioning

PD Behavioural Therapy: Prolonged exposure

• Prolonged exposure to feared situations

  • Useful for 60-75% of people with agoraphobia and effects maintained at 2 & 4 year follow ups

PD Behavioural Therapy: Interoceptive exposure

• Interoceptive exposure to feared internal sensations (e.g. breath control vs. hyperventilation)

  • People engage in physiological behaviours that trigger that panic response , this works

PD: Cognitive Perspective

• Key to panic (in cognitive perspective) is the interpretations of the body sensations that we are experiencing that are actually neutral and typical of our body 

  • Catastrophic interpretation = panic

• In cognitive perspective thoughts (cognitive distortions) cause all other symptoms

What two factors in Shmidt et al. (1997) study lead to increased vulnerability to anxiety

1. Development of panic attack frequency

2. Mean depression ratings

PD Cognitive Perspective: Safety behaviours

• Can be used effectively early on in therapy (e.g.) exposure

• Eliminating safety behaviours is central in CBT

  • OR can they be used to increased perceived control during therapy

What can the cognitive theory NOT explain with PD?

Nocturnal Panic Attacks

• 44-71% experience at least one NPA, 30-45% endure repeated NPA

• Explained by interoceptive conditioning

  • Can only be explained through classical conditioning

• Managed with CBT

Steps in CBT for PD

1. Psycho-education

   • Provide justification for symptoms, less space for catastrophic interpretations

2. Self-monitoring of panic attacks

3. Identification of automatic thoughts and cognitive distortions

   • ABC model

4. Interoceptive exposure

5. Exposure to feared situations and bodily sensations (without safety behaviours)

   • 70-80% panic free at end of 8-14 weeks, up to 2 years follow up