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Panic Disorders and Agoraphobia: Step-by-Step

By: Daniel R. Gaita, MA


Summary
In reading the Clinical handbook of psychological disorders: A step-by-step
treatment manual (Barlow, 2014, pp. 161) I was invited by the promise of discussion of
recent years learning specific to neurological mechanisms of action in fear reduction and
effective treatment methods, for Panic Disorders and Agoraphobia. I was not let down. This
chapter served as a catlyst for my learning. More specifically:
Panic Attacks
Panic Attacks were defined concisely as sudden and abrupt discrete episodes of
intense fear or discomfort, which were also accompanied by both physical and cognitive
symptoms, which was followed by at least a month of concern over reoccurrence or
significant change in behavior. Additionally, panic disorder is being framed as recurrent and
unexpected panic attacks associated with strong action tendencies such as urges to escape
and the less often urge to fight that may be coupled with perceptions of imminent threat or
social ridicule with flight-fight response. Interesting of note was the finding that 40% of self
reported panic attacks were not associated with elevated heart rate as is often times claimed
by subjects (2). The differentiation of anxious arousal, which is described as more gradually
building anxiety, was helpful in clarifying determination (2). The additional detail about
catastrophic cognitions in the face of panic as a differentiating factor between panic disorder
and nonclinical panicking was also helpful (3). Partitioning generalized anxiety disorder
(GAD) from social anxiety by way of case scenarios helped enable a better comprehension
that the social anxiety aspect is more concerned with being judged negatively by others as a

consequence of a panic attack while GAD is more associated with worry about variables
regardless a social judgment or consequence (3).
Explanation of the distinct and highly comorbid incidence of panic disorder and
agoraphobia were detailed along with helpful and descriptive presenting features such as the
chronic anxiety, mood and disruptive disorders with a model onset age between late teens
and early adulthood for panic disorder with rare occurrence prior to age 14. Comorbid
expression of Axis I conditions of specific phobias, GAD, major depressive disorder,
dysthymia and substance abuse are also commonly co-occurring. Sadly, treatment seems to
be sought much later, around the age of 34 (4).
Also helpful was the differentiation, through case examples, of situational
antecedents (crowds, driving on freeway, being alone, aerobic activity etc.) vs. internal
antecedents (heart rate fluctuations, feeling lightheaded, hunger, weakness etc.) (23).
Research on Causes and Risk
Genetics and Temperament Anxiety and depression appear to be variable
expressions of heritable tendency towards neuroticism (6). Panic disorder has been linked to
a locus on chromosome 9&13. There is association with the adenosine receptor gene in
panic disorder. There exist a male-specific panic disorder link to an allele of the
neuropeptide S receptor gene on chromosome 7 that is not associated with schizophrenia or
attention deficit disorder (6).
Sensitivity to anxiety may relate to higher risk factor for panic disorder due to the
priming of fear reactivity to bodily sensations (7).
History of Medical Illness Parental poor health and personal experience with
respiratory disturbance as a youth predicted panic disorder at age 18 or 21. This finding is

more consistent of panic disorder compared to patients with anxiety disorder. Childhood
physical and sexual abuse may also prime panic disorder. Exposure to violence between
family members, generally interparental, also demonstrates an association with panic
disorder (7).
Treatment
Cognitive-Behavioral Therapy (CBT)
Research Following a string of listed studies covering multiple decades (10-16 &
24-31), the outcome converged on CBT as the best evidence based treatment strategy as
demonstrated through broad variation of applications with wide ranging research support of
its efficacy. Treatment durations can range from 10-20 weeks with some success in briefer 4
week interventions and some as short as 2 days (11). Studies remained mixed on whether
medications are more or less beneficial than CBT treatment alone or in combination (15).
However, D-Cycloserine in combination with Interoceptive Exposure for panic attacks
results in greater reduction in symptom severity due to its ability to weaken glutamate
receptors in the amygdala (29). Yet, therapy alone is considered more cost effective (16), and
implements standardized inventories and tailored behavioral testing methods according to
patient context and symptom severity (22,23).
Components of CBT Perhaps what has brought CBT to the forefront in treatment
modalities is the multitude of means within which it can be administered.
Education. All methods begin with an education of the nature of panic disorder, its
causes, and how it is perpetuated through cognitive, physical and behavioral response
systems in order to begin to correct common perceptual myths about panic symptoms.
Namely that one is going crazy, dying, or losing control(24).

Process. Then comes the process whereby a combination of methods such as Selfmonitoring (self awareness) through literal record keeping of both mood and attacks.
Breathing Retraining and Assisted Respiratory Training works for some but not all (24).
Applied Relaxation techniques such as progressive muscular relaxation (PMR) while
relatively ineffective for panic attacks showed promise when not used with exposure therapy
(25). And finally, Cognitive Restructuring, whereby the patient learns to recognize errors in
cognition so that they may generate alternative and non-catastrophic overestimations to
explain what is feared during a panic attack. Such techniques utilize variations of In Vivo &
Interoceptive Exposure (26), in order to extinguish conditional anxiety responses (27).
Choice of modality is based on patient symptom severity and response.
Response
This chapter was in information packed meta-analysis of meta-analysis that tears
open the variability and variety of useful cognitive behavioral therapy tools for the wideranging variations of panic disorder and agoraphobia. It serves as a proverbial Pandoras
box of research on both, prior hypothesized, and current efficacious modalities. It is a literal
playbook of the fine details that differentiate the definition and severity of these
psychological disorders. In doing so, also provides a twelve-session, detailed account of the
implementation of Cognitive Behavioral Treatment for panic disorder and agoraphobia.
Reference
Barlow, D. (ed). Clinical handbook of psychological disorders: A step-by-step treatment
manual (pp. 161). New York, NY: Guilford.