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