Panic Disorder, often referred to as PD, is an anxiety disorder characterized by recurrent

panic attacks. Emotion dysregulation, difficulties in managing one’s emotions, plays a large role

in PD patients and their panic attacks. The emotion dysregulation in many PD patients can be

attributed to cognitive reappraisal strategies, methods to change the meaning of a situation and

therefore the emotional responses that follow. Prior and during a panic attack, there is typically

no conscious cognitive reappraisal processes. However, the catastrophic cognition hypothesis

states that PD patients implicitly, or unconsciously, assess inadequate stimuli to trigger a violent

response and panic attacks. Therefore, the emotion dysregulation in those with PD experience is

a combination of the lack of conscious cognitive reappraisal and the presence of unconscious

catastrophic reappraisal mechanisms.

The purpose of this study was to look at the neuromechanisms of implicit cognitive

reappraisal in PD using self-reported measures of emotion, neuropsychological assessments, and

fMRI. It was hypothesized that those with PD would not be able to use implicit cognitive

reappraisal to appropriately adjust their emotional state when receiving neutral or positive

descriptions before viewing negative pictures. Those with PD would show greater negative

emotional response to negative stimuli and show less emotion regulation than the healthy control

group. It was further hypothesized that the emotion dysregulation in those with PD might be

attributed to inadequate top-down control during unconscious cognitive reappraisal.

Those in the study were all between the ages of 18 and 65, Chinese, right-handed, and did

not have any past or current medical or neurological conditions. Those in the PD group were

untreated and met the criteria for PD on the DSM-5. All participants did not take any

antipsychotic drugs for at least two weeks. In the study, participants were either given a

neutral/positive description before viewing a negative picture or a negative description before

viewing the negative image passively and told not to actively think. Participants were not aware

of the purpose of the study.

The study included many variables. One independent variable was the condition of panic

disorder. One group, the PD group, contained participants who met the DSM-5 for panic

disorder. The other group, the HC group, contained healthy participants with no known disorders

and were considered the control group. Another independent variable was the description given

to participants before viewing the negative image. Participants either received a nonnegative

description (NNEG-DESC) before viewing the negative image or a negative description (NEG-

DESC) before viewing the negative image. The dependent variables included the brain activity in

participants and their self-reported emotions. Brain activity was observed using fMRI.

Participants reported their emotions with several scales, including a four-point rating valence, the

Hamilton Anxiety Rating Scale (HAM-A), the Panic Disorder Severity Scale (PDSS), and

putting into perspective in the Cognitive Emotion Regulation Questionnaire (CERQ).

The results of the study showed that within the HC group, the NNEG-DESC significantly

decreased negative emotion valence ratings compared to the NEG-DESC. On the other hand,

there was a far less significant difference in negative emotion valence rating between NNEG-

DESC and NEG-DESC in the PD group. In the PD group, increased HAM-A scores and PDSS

scores were negatively correlated with right dIPFC and dmPFC activity. There was a positive

correlation between putting into perspective and right dIPFC and dmPFC activity.

From the results, it was concluded that emotional dysregulation in panic disorder is a

result of poor top-down automatic regulation of negative emotions. This means that those with

PD are not as successful at using implicit cognitive reappraisal strategies because of their

compromised ability to modulate emotional responses in the amygdala by activating prefrontal

regions like the dIPFC and dmPFC. It was also concluded that the lack of engagement in the

prefrontal cortex during implicit cognitive reappraisal is correlated with the severity of panic and

anxiety.

There were several limitations to the study. First off, this study aimed to specifically look

at implicit reappraisal and the brain activity associated with it. The results showed that the dIPFC

and dmPFC are activated during implicit reappraisal, but those regions are also related to explicit

reappraisal. Unconscious and conscious reappraisal should be compared. Secondly, some in the

PD group had PD along with another anxiety disorder or major depressive disorder. Some of the

results could be attributed to these other mental disorders. Third, the study is not longitudinal.

The same subjects should perform the same tasks over a period of time. Fourth, the study only

looked at the reappraisal tactic of reinterpretation, but psychological distancing should also be

studied and compared to reinterpretation. Fifth, there was lack of representation for different

demographics because all the subjects were Chinese. Lastly, the experimental tasks only

included negative images. Future studies should involve neutral images to differentiate the

reduction of negative response from non-negative descriptions and the increase of negative

response from negative descriptions.

The results from this study provide direction for future research on therapeutic methods

to treat panic disorder. Therapeutic methods should involve implicit reappraisal strategies. For

example, cognitive behavioral therapy could be very beneficial for those with panic disorder.

The study also provides direction for future research on neuromodulatory methods to treat panic

disorder. For example, transcranial magnetic stimulation could possibly help PD patients. Future

studies should be done to test the efficiency of these possible treatments. Other studies should

also be conducted to address each limitation of the study.