Clinical Description

• Unexpected panic attacks

• Anxiety, worry, or fear of another attack

• Persists for 1 month or more

• Agoraphobia

  • Fear or avoidance of situations/events

  • Concern about being unable to escape or get help in the event of panic symptoms or other unpleasant physical symptoms (e.g., incontinence, vomiting, falling)

• Avoidance can be persistent

• Use and abuse of drugs and alcohol

• Interoceptive avoidance

• Statistics

  • 2.7% (year)

  • 4.7% (life)

  • Female: male = 2:1

  • Acute onset, most common in young adulthood (e.g. ages 20-24)

Special populations

• Children

  • Hyperventilation is a common symptom

  • Earlier cognitive development > fewer cognitive symptoms (e.g. less fear of dying)

• Elderly

  • Health focus is more common

  • Changes in prevalence – decreases with age

Diagnostic Criteria for Panic Disorder

• Recurrent unexpected panic attaches

• At least one attach has been followed by significant worry or maladaptive change in behavior

• Not attributable to substance use

• Not better explained by another mental disorder

Diagnostic Criteria for Agoraphobia

• Marked fear/anxiety for two or more: public transportation, open spaces, enclosed spaces, standing in line, being outside the home alone

• Avoids these situations

• Situations always provoke fear

• Anxiety not proportional to real danger

• Significant distress

• Anxiety is excessive

• Not better explained by another mental disorder

Gender and Culture

• Social/gender roles

  • ~75% of those with agoraphobia are female

• Cultural factors

  • Similar prevalence rates across cultures

  • Variable symptom expression

  • Somatic symptoms more emphasized than emotional symptoms in developing countries

Nocturnal Panic

• 60% with panic disorder experience nocturnal attacks

  • Occur in non-REM sleep

  • Occur during delta/slow wave sleep

• Caused by deep relaxation,

  • Sensations of “letting go” are anxiety provoking to people with panic attacks

• Sleep terrors

• Isolated sleep paralysis

Causes of Nocturnal Panic

• Generalized biological vulnerability

  • Alarm reaction to stress

• Cues get associated with situations

  • Conditioning occurs

• Generalized psychological vulnerability

  • Anxiety about future attacks

  • Hypervigilance

  • Increase interoceptive awareness

Panic Treatment

• Medications

  • Multiple systems affected by medication

    • serotonergic

    • noradrenergic

    • GABA

  • Benzodiazepines (e.g. Ativan)

  • SSRIs (e.g., Prozac and Paxil)

  • High relapse rates after discontinuation of medication

• Psychological intervention

  • Exposure-based

  • Reality testing

  • Relaxation and breathing skills

  • Example: Panic control treatment (PCT)

    • Exposure to interoceptive cues

    • Cognitive therapy

    • Relaxation/breathing

• Combined psychological and drug treatments

  • No better than CBT or drugs alone

  • CBT = better long term