Panic disorder (with or without Agarophobia)

Panic Disorder Epidemiology

 Isolated panic attack very common 27.7 %

 Panic disorder 1-2% of general population
 5-10% of primary care patients
 Onset bimodal 15-25 or 45-55
 Female/male ratio 2-3:1
 PanicDisorder ICD 10
 Episodic paroxysmal anxiety
 Recurrent attacks which are not restricted to any particular
situation
 Typical physiological symptoms of severe acute anxiety
 Secondary severe catastrophic fears
 Avoidance
 Fear of further attacks
 - should only be diagnosed in the absence of another
phobic disorder otherwise panic attack should be seen as
extention of the existing phobia
 For diagnosis: several attacks within 1 month
 Agoraphobia with or without Panic Attacks
ICD 10

 If patients with Panic Attacks are agoraphobic-

they will be classified under Agoraphobia
(with Panic Attacks) in ICD 10
 DSM 5

 In DSM 5 Panic Attacks and Agoraphobia are 2

separate diagnosis and both conditions would
have to be diagnosed and coded
 Panic attacks typically reach their peak within 10 min
and last around 30–45 min
 Most patients develop a fear of having further panic
attacks
 Around two-thirds of patients with panic disorder
develop agoraphobia, defined as fear in places or
situations from which escape might be difficult or in
the event of having a panic attack
 These situations include being in a crowd, being
outside the home, or using public transport: they are
either avoided or endured with significant personal
distress
 Panic Disorder

 Panic Disorder with Agoraphobia has a worse

prognosis

 Panic attacks without panic disorder is common

(22.7%)

 Between 18-45 % of patients with panic attacks also

suffer from nocturnal panic attacks
 Comorbidity

 Agoraphobia 30-50 %
 Depression: 40 – 80 %
 Substance abuse: 20 – 40 %
 Bipolar Disorder
 Other Anxiety Disorders
 Other physical or neurological disorders
 * Exercise

 Remember the stress response / fight or flight

response

 How do our modern stressful situations differ

from our life as “cavemen” ?

 What happens in a panic attack?

 Differential Diagnosis
 Cardiovascular Disease
 Angina
 CHF
 Hypertension
 Mitral valve prolapse
 Myocardial Infarction
 Paradoxical atrial tachycardia
 Pulmonary Disease
 Asthma
 Pulmonary embolism
 Drug intoxication or
withdrawal
 Neurological Disease
 CVA / TIA
 Epilepsy
 Meniere’s disease
 Migraine
 Tumor
 Endocrine Disease
 Carcinoid syndrome
 Hyperthyroidism
 Perimenopausal
 Pheochromocytoma
 Other
 SLE
 Systemic infection
 Heavy metal poisoning
 Case example Panic Disorder
(Julie)

 Panic attack video (12 min) with exercise

(underlying thoughts anxious and resulting
behaviours of patient and short
formulation)

 https://www.youtube.com/watch?v=Ii2F
HbtVJzc
How will having PD and Agoraphobia
affect somebodies life on the longterm ?
 Prognosis of Panic Disorder
 30 – 40 % become symptom free

 50 % with mild symptoms with little impairment

of function

 Cognitive and behavioural treatments including

graded exposure are highly effective

 10 – 20 % continue with significant impairment

 Some interesting facts about Panic Disorder
 Is frequently associated with genomic
duplication on Chr. 15
 Significant concordance rate for monozygotic
compared to dizygotic twins
 Association with childhood parental death or
separation from mother
 Pacemaker
 Excess caffeine
 Sympathomimetic drugs sodium lactate,
pentagastrin, carbon dioxide can induce panic
 Neurobiology of Panic
Norepinephrine:
 stimulation of LC (locus coeruleus) fear
( ablation of LC eliminates fear response )
 LC projects to multiple structures involved in
anxiety/fear (ie amygdala, periaqueductal grey,
entorrhinal cortex, hypothalamus)
 excitatory LC input mediated by glutamate,
CRF, substance P
 inhibitory via GABA receptors
 Neurobiology of Panic

Serotonin
 supported by efficacy of SSRIs
 major nuclei:
MRN limbic/ prefrontal cortex structures
 Mediates fear/ anticipatory anxiety
DRN prefrontal cortex, basal ganglia, thalamus,
LC, substantia nigra, periaqueductal grey
 Modulates cognitive/ behavioural components
 strong feedback relationship with LC
MRN: medial raphe nucleus DRN: dorsal raphe nucleus
 Neurobiology of Panic
 Amygdala key in conditioned fear aquisition/extinction
 LC: NE neurons
 Implicated in animal studies

 Strong feedback relationship with raphe

nuclei/5HTIncreased adrenergic activity
 Increased post synaptic response to serotonin
 Increased adrenergic activity
 Decreased sensitivity to GABA ( inhibitory)
 Increasing evidence re significance of NMDA receptor
in conditioning
 Provocation of Panic

 Acid-base balance / pCO2

 Lactate, bicarbonate, hypercapnia, hyperventilation
 Benzodiazepine receptors
 flumazenil, inverse agonists
 Noradrenergic system
 Yohimbine,TCA’s
 Serotonergic system
 mCPP, buspirone, SSRI’s
 Others
 Caffeine, CCK, hypoglycaemia, cognitive challenges
 Acid - base balance
 Anxious patients produce more lactate on exercise
than controls
 IV lactate produces panic
 specific for panic
 treatment with imipramine blocks effect
 arouses PD patients from sleep
 Mechanisms
 chemoreceptors more sensitive to pH and hypoxia
 induced metabolic alkalosis and hyperventilation
 Neuroimaging and Panic Disorder

  Temporal lobe MRI vol

 greatest with early onset and severity of illness

 High rate of septo-hippocampal abnormalities

(correlates with EEG abnormalities

 ? Hippocampal functional change

  PET glucose metabolism
  SPECT rCBF
 BAP Acute treatment
 ● Choose an evidence-based acute treatment [A]
 ● Take account of patient clinical features, needs and preference and local service
availability when choosing treatment, as pharmacological and psychological approaches
have broadly similar efficacy in acute treatment [S]
 ○ pharmacological: all SSRIs, some TCAs (clomipramine, desipramine, imipramine,
lofepramine) venlafaxine, reboxetine, some benzodiazepines (alprazolam, clonazepam,
diazepam, lorazepam), some anticonvulsants (gabapentin, sodium valproate) [A]
 ○ psychological: cognitive-behaviour therapy [A]
 ● Avoid prescribing propranolol, buspirone and bupropion [A]
 ● Consider an SSRI for first-line pharmacological treatment [S] Consider increasing
the dose if there is insufficient response
 ● Initial side effects can be minimised by slowly increasing the dose or by adding a
benzodiazepine for a few weeks [D]
 ● Advise the patient that treatment periods of up to 12 weeks may be needed to assess
efficacy
 BAP long term
 Longer-term treatment
 ● Continue drug treatment for at least six months in patients who have
responded to treatment [A]
 ● When stopping treatment, reduce the dose gradually over an extended
period to avoid discontinuation and rebound symptoms [A]: in the absence
of evidence a minimum of three months is recommended for this taper
period [D]
 Combination of drugs and psychological treatment
 ● Consider combining cognitive therapy with antidepressants as this has
greater efficacy and may reduce relapse rates better than drug treatment alone
[A]
 ● Consider combining cognitive therapy with benzodiazepines (being mindful
of potential long-term problems) as this probably has greater efficacy than
drug treatment alone [A]
 BAP When initial treatments fail

 ● Consider raising the dosage if the current dosage is

well tolerated [A]
 ● Consider switching to another evidence-based
treatment [D]
 ● Consider combining evidence-based treatments only
when there are no contraindications [S]
 ● Consider combining evidence-based pharmacological
and psychological treatments [A]
 ● Consider referral to regional or national specialist
services in treatment refractory patients [S]
Panic disorder- CBT
Model and Treament
 Panic Attacks
 Sudden increase in anxiety
 Accompanied by physical and mental symptoms (
dizziness, sweating, palpitations etc.)
 Common in all anxiety disorders as well as other
problems
 Panic Attack  Panic Disorder
 Panic Disorder
 Recurrent attacks
 Fear of further attacks

 “…almost invariably a secondary fear of dying, losing

control, going mad…” (ICD-10); “worry about the
implications of the attack” (DSM-IV)
 Not owing to other conditions
 With or without agoraphobia
 Catastrophic Interpretations of
bodily sensations

 Palpitations -

 Shortness of Breath -

 Dizziness -
 Catastrophic Interpretations of
bodily sensations

 Palpitations - Heart Attack, Death

 Shortness of Breath - “Choking”

Death

 Dizziness - Coma, Death

 Panic Model (after Clark, 1986)

Internal or External Trigger

Perceived threat

Anxiety

Catastrophic
Physical/Cognitive Symptoms
Misinterpretation

Avoidance & Safety

Seeking Behaviours
 Salkovskis, Clark & Gelder (1996)
 People take logical action to avoid the
catastrophe
 If you fear you are fainting you
 Hold object, hold person,
 If you fear you are having a heart attack
 Sit down and keep still
 If you fear you act stupidly you or lose control
 Control your behaviour, move slowly, find an escape
route
 Panic Model (after Clark, 1986)

Internal or External Trigger

Perceived threat

Anxiety

Catastrophic
Physical/Cognitive Symptoms
Misinterpretation

Impacts
on Impacts
learning on
Avoidance & Safety
survival symptoms
Seeking Behaviours
 Example

Walks into unfamiliar crowded place

I could get lost here

Anxious

I’m having a stroke

or a heart attack Breathes hard; light headed, heart pounds

?
Get out fast; breathe slowly; sit down
Carry mobile & NHS Direct No
 Model-informed Assessment
 Symptoms
 What are the key symptoms of anxiety that trouble the client?
 Indications of concurrent physical problems
 Catastrophic misinterpretation,
 The nature of the feared consequence will significantly guide
diagnosis e.g. I’m having a heart attack
 Avoidance, and safety behaviours, secondary problems:
 Avoidance leads to restriction of activities which can lead to
depression
 Shame/guilt re problem
 Alcohol use as coping strategy
 Impact on relationships
 Exercise: re-formulating client’s panic problems on
basis of workshop learning
 Behaviour & learning
 Why don’t people learn?
 Existing behaviour explains survival
 An adequate explanation may be taken as a sufficient
explanation
 A satisfactory explanation inhibits exploration

 Current patterns of experience and related behaviour

combine to construct a coherent whole
 coherence is convincing
 Coherence-based thinking may inhibit empirical thinking
Practice!
 History taking
 Specific example
 Thoughts , feelings, behaviours
 What is the key threat?

 Check the example is typical

 Frequency
 Avoidance
 Safety Behaviours
 Historical – first panic attack, pattern since then
 Treatment
 Development of shared understanding (formulation) ;
psycho-education
 Identify that the threat is fear of physical symptoms of
anxiety- which creates a vicious cycle
 Cognitive techniques- develop alternative explanations
for the physical symptoms
 Behavioural experiments/ Symptom Provocation tests-
allow patients to experience feared physical symptoms
without the feared catastrophe happening
 Attentional training
 Psycho-education
 Psycho-education:
 Fight Flight mechanisms
 Effects of adrenaline

 Safety seeking behaviours

 Avoidance: its logic & effects

 Selective attention
 The rationale for exposure
Habituation versus
escape
Escape
Habituation

anxiety

time Escape provides relief in the short-term, but in the long-term makes the
problem worse, through negative reinforcement. On the other hand,
exposure is uncomfortable in the short-term, but provides long-term
benefit through habituation within & between exposure contacts. 40
 Psychoeducation
 Fight/ flight
 Adrenaline effects
 Case
 Example
 Feared cognition
 Cognitive techniques:
 Evidence for/ against
 Physical symptoms of anxiety
What are they for, what might people experience?

 Increase in heart rate and strength of heart beat

 Enables blood and oxygen to be pumped around the body faster
 Experience of palpitations or heart pounding.
 An increase in the rate and depth of breathing
 Allows more oxygen into the body
 You may notice sighing, yawning, breathlessness, smothering, tightness,
pain in the chest. Low CO2 causes constriction of blood vessels in the
head, leading to reduced oxygen in the brain which can cause short term
dizziness and visual disturbances. Hyperventilation also leads to
numbness, tingling particularly in hands and feet and around the mouth,
and can lead to pins and needles and muscle cramps in the extremities.
 A redistribution of blood from areas that aren’t as vital to those
that are
 E.g. away from fingers, toes
 Pale finger, toes, numbness and tingling in fingers/ toes
 Physical symptoms of anxiety
What are they for, what might people experience?

 Muscle tension
 Preparation for fight
 Acyes/ pains, trembling, shaking, later exhaustion
 Decreased activity of the digestive system
 More energy to fight / flight systems
 May notice decrease in salivation- dry mouth. Nausea, heavy stomach
 Widening of the pupils of the eyes
 Lets more light and enables you to better scan the environment
 Blurred vision, spots before the eyes, light too bright
 Increase in sweating
 More slippery, harder to grab, cooling the body
 Resources for panic disorder
 octc.co.uk booklets- understanding panic £2.75
 www.cci.health.wa.gov.au- under resources for
consumers, good modules on panic. Module
1&2 describe symptoms of anxiety and provide
explanation for them.
 www.getselfhelp.co.uk wide range of materials
and links
 www.livinglifetothefull online version of five
areas approach by Chris Williams
 Points of intervention
Reappraisal of
initial threat
(may indicate Internal or External Trigger
other disorder
or none)
Attention
Perceived threat
al
Processes
Anxiety

Catastrophic
Physical/Cognitive Symptoms
Misinterpretation

Impacts
on Impacts
learning on
Avoidance & Safety
survival symptoms
Seeking Behaviours
 Points of intervention

Verbal re- Internal or External Trigger

interpretation
methods
Attention
Perceived threat
al
Processes
Anxiety

Catastrophic
Physical/Cognitive Symptoms
Misinterpretation

Impacts
on Impacts
learning on
Avoidance & Safety
survival symptoms
Seeking Behaviours
 Points of intervention

Behavioural Internal or External Trigger

tests (in-
session; in-
situ) Attention
Perceived threat
al
Processes
Anxiety

Catastrophic
Physical/Cognitive Symptoms
Misinterpretation

Impacts
on Impacts
learning on
Avoidance & Safety
survival symptoms
Seeking Behaviours
 Case A
 Prediction ‘I’m going to collapse’
 Test out in session
 Bring on symptoms with hyperventilation
 Encourage him to stay standing until anxiety has
reduced
 Able to get anxiety up to 40%, I’m going to
collapse 80%.
 First time ever stood up to, and found out that
he didn’t collapse
 Symptom Provocation
 Symptom provocation needs to map onto specific
troublesome symptoms for the individual
 E.g hyperventilation:
 Cautions in the use of:
 Asthma, Heart, Blood pressure, pregnancy
 Rapid breathing for long enough to provoke raised anxiety &
key cognitions, note sensations induced, ratings of distress,
and belief in catastrophic misinterpretation, drop or increase
ssbs.
 What other methods might be used to trigger what
other symptoms?
 Points of intervention
Attentional
retraining

Internal or External Trigger

Attentional
Perceived threat
Processes

Anxiety

Catastrophic
Physical/Cognitive Symptoms
Misinterpretation

Impacts
on Impacts
learning on
Avoidance & Safety
survival symptoms
Seeking Behaviours
 Attention
 Attention in states of fear is biased towards risk
 Material available to awareness will limit appraisal of risk
 Training attention  distraction, but a balancing of awareness
 Address avoidance & safety
behaviours
 Pros and Cons of existing strategies
 Validating current coping: many clients self-blaming/self-shaming, thus
reducing self-efficacy, thus decreasing likelihood of engaging in new
behaviour
 Testing of specific predictions
 Engaging curiosity rather than self-driving imperatives
 Test in-session wherever possible
 Balance tolerable against therapist-presence as SB
 Increase or decrease behaviours & study effect?
 Drop behaviours in feared situations
 Hierarchies
 In-situ therapist assistance
 Caution re the evolution of new safety behaviours
 Summary
 Misinterpretations of sensation in Panic Disorder are
understandable mistakes
 Behaviours logically follow thought
 Maintenance of unhelpful belief = unfortunate side-effect
of behaviour
 Vigilance increases proportion of negative information available
to client
 Arousal creates new sensations
 The non event is attributed to the safety behaviour
 Behavioural change is the acid test of CBT of panic
disorder
References
BAP guidelines accessable via
website
 References

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