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