TR

Panic Disorder and Agoraphobia

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