chap 4 panic disorder

panic attack (PA)

abrupt surge of intese fear or discomfort that is diagnosed by the presence of 4 or more of 13 physical & cognitive symptoms

sudden, abrupt surge of intense fear or discomfort peaks within minutes (instead of grdually building anxious arousal) — abrupt sruge can happen from an anxious or calm baseline state

13 physical & cogntive symptoms of panic attacks (PAs)

palpitations, pounding heart or accelerated heart rate

sweating

trembling or shaking

sensation of shortness of breath or smothering

feeling of choking

chest pain or discomfort

nausea or abdominal distress

feeling dizzy, unsteady, lightheaded or faint

chills or heat sensations

paresthesias (numbness or tingling sensations)

derealization (feelings of unreality) or depersonalization (being detached from oneself)

fear of losing control or going crazy

fear of dying

full blown panic attack VS limited symptom panic attack

full blown attack: 4 or more symptoms

limited symptom attack: fewer than 4 symptoms

panic disorder

repeated unexpectred panic attacks (ex. attacks that happen without a trigger) + at least one month of persistent worry/concern about the reccurence of panic or its consequences or significant maladaptive behavioural changes (related to the attacks)

behavioural changes may include avoidance of activites in which PAs are expected to occur (particularly physiologically arousing activites ex. execise, unfamiliar places, scary movies, etc.) OR safety behvaiours (ex. frequent attendance at medical facilities for fear of a medical probkem ex. heart attack, stoke)

agoraphobia

marked by fear/anxiety about situations from which escape might be difficult or in which help might be unavailable in the event of panic-like or other incapacitating symptoms

diagnosis of agoraphobia requires (fear of) at least 2 of the following (5) situations: public transportation (ex. planes), open spaces (ex. parking lots), enclosed spaces (ex. shops), standing in line or being in a crowd, and being ouside of the home alone

PAs often happen in the context of agoraphobia

Panic Attacks: Association with Disorders & Distinction from Panic Disorder

PAs often happen in context of anxiety disorders, substance disorder & other psychiatric conditions

PA are marker of psychopathology — predictive of onset of diff disorders, their course & severity

PAs are expected or confined to the context of that disorder — what distinguishes PAs associated with other disorders from those for panic attack disorder (ex. PA only hapens when encounter trauma cue for PTSD disorder)

but w/ panic disorder, PAs happen unexpectedly (repeatedly — tho can happen expectedly as well) & focus of concern is physical and mental helath consequences of the PA themselves

PAs can also happen in the absese of a psychiatric disorder — ~1/3 of ppl who reported having at least one PA in their lifetime did NOT meet the criteria for another DSM disorder

panic attacks & fight or flight

PA represent activation of fight or flight system

they usually involve elevated autonomic nervous system arousal, needed to supported the fight-flight activity

but urgency to escape, autonomic arousal, and perception NOT present in EVERY self-reported occurence of panic (sometimes it’s sympathetic, other times non-activation)

severe PAs are more autonomically-based

noncogntive panic

when perceptions of loss of control, dying or going crazy are reduted, depite the report of intense arousal

nocturnal panic attacks

waking up from sleep in a state of panic with symptoms that are very similar to panic attacks tht occur during wakeful states

relatively common among ppl with panic disorder — 44%-71% reporting nocturnal panic at least once, AND 30%-45% reporting repeated nocturnal panics

*does not refer to waking from sleep & panicking after a lapse of waking time or nighttime arousal due to nightmares or enviro stmulis

*diff from sleep terros & apnea

history of panic disorder (in DSM-III)

panic disorder 1st reagrded as diagnostic entity in DSM-III

before then, PAs were sondiered general neurosis — named things like “soldier’s heart”, etc.

in DSM-II agoraphobia considerd a seperate disorder that may or may not be associated w/ PAs, — led to redefinition of agorapboic as secondary response to panic attacks in DSM-III-R

panic disorder and agoraphobia in DSM-5

in DSM-5, panic disorder & agoraphobia are again considered two distinct, but highly comorbid disorders

—this bc of large # of ppl who show full features of agoraphobia but don’t report ever having had a full-blown attack or panic-like symptoms

so the 13 symptoms PAs remain unchanged from DSM-IV to DSM-5, but some recognition for culture panic symptoms that may be associated w/ PAs (ex. uncontrollable crying, sore neck)

Agoraphobia, Panic Disorder, and Comorbidity Trends

ppl w/ agoraphobia who are seeking treatment often have history of panic that came beofre the dev of their avoidance behaviour

agoraphobia without history of panic disorder occurs ~1/3 the rate of panic disorder — ppl who panic are less likely to seek help

panic disorder (w/ or without agoraphobia) often has at least one other mental or chronic physical disorder — ppl w/ panic disorder meet criteria for avergae of 4.5 additional (mental or physical) disorders

age of onset for panic disorders

often early adulthood btwn ages of 21 to 23, but lots of variability in onset period —lots of teens (13 to 17yrs) have panic attacks

proposed bimodal dist for onset at ages 17 and 39, w/ mean of 25 yrs

treatment often sought at much later age ~34 yrs

ratio of females to males with panic disorder around 2:1 — this ratio shifts even more towards women as lvl of agoraphobia gets worse

panic disorder in children vs adolescents

panic disorder in children & adolescents tends to be chronic & comobic w/ other anxity, mood & disruptive disorders

onset as early as 6 yrs ‘

physiological symptoms of PAs similar for both + adults, but adolescents are more likley than children to report a fear of going crazy

— this intepreation of physiological symptoms may differentiate childr from adolescent panic; while children are more likely to apply external explanations for panic, adolescents are more likley to apply

avoidance of particular situations

predictors of agoraphobia

interoceptive avoidance

safety behaviours

“safe person”

“safety signals”

experiential avoidance

panic disorder & bodily sensations

manipulation of appraisals & distress

memory & panic disorder