Panic Disorder

Prevalence

5% lifetime prev (Kessler 2005) -Women at least 2x as likely. Panic disorder vs. panic attacks in other disorders (ex: social phobia) -Are they one and the same (Craske 1991), or are they fundamentally different based on different cognitions (Rapee 1993).

Comorbidity

Agoraphobia: about 50% of panic disorder patients in community samples have agoraphobia (Taylor et al). -Agoraphobia without panic is rare. -Occupational status and sex predictive of agoraphobia Lifetime comorbidity of another Axis I (regardless of time overlap) = 80% (Kessler 2006). -Comorbidity most common with other anxiety disorders and MDD; also substance abuse. Personality disorders: 25 - 60% comorbid, most commonly for avoidant or dependent (Craske & Barlow). -Associated with greater severity of panic disorder both pre- and post-tx, but rate of improvement of panic/fear symptoms not affected

Treatment: Medications

Barlow (2000) large RCT: No benefit of combining CBT with meds for panic. In fact, increased relapse rate afterward if meds were withdrawn.

Assessment

Clinician -ADIS-IV -SCID -Med evaluation to rule out med condition (e.g., mitral valve prolapse) Self-report -Anxiety Sensitivity Index (ASI) - threatening perceptions of bodily sx; good psychometric props; able to distinguish between panic and other anx disorders -Panic Disorder Severity Scale (PDSS) -Trait measures of anxiety - STAI and BAI (probably will not distinguish panic specifically)

Other Treatment Considerations

Comorbid depression -Related to poorer outcome, dropout Group is as effective as individual. -Some conflicting results, as Sharp (2004) reported better outcomes in individual than group in primary care setting. Also, 95% of people on the waitlist said they would prefer individual. Self-directed tx (occurs in patient's natural setting, workbook, manual, internet) can be effective, but not as great for those with more severe panic, or with more comorbidities. Therapist style/interactions may be important at different points in therapy (Keijsers 1995) -Session 1 empathy related to better outcome, Session 1 directiveness related to poorer outcome -Session 3 directiveness related to better outcome, Session 3 empathy related to poorer outcome.

Cognitive Causal/Maintenance Factors

Controllability and predictability: Panic provocation experiment (Sanderson et. al., 1989). -CO2 challenge with panic disorder patients. Patients were told that when a light was on, they could turn down the CO2 (In reality, the knob did not do anything, "illusion of control"). All patients received same CO2 induction. -For one group, light was on. These patients were signif less likely to have a panic attack than the other group, whose light did not turn on. Catastrophic misinterpretations of bodily sensations (Clark) -Over 40% of self-reported panic attacks were not associated with increase in HR. Anxiety sensitivity ("fear of fear", not a misinterpretation) -ASI distinguishes panic disorder patients from other anxiety disorder groups -But not really

Interpersonal Causal/Maintenance Factors

Dependency can develop in agoraphobic individuals (e.g., significant other checks on me, does not make me go out, etc).

Treatment: CBT

Description -Education, breathing retraining/applied relaxation, cognitive restructuring, exposure Evidence - highly efficacious -Barlow (2000) large RCT: CBT comparable to imipramine tx from pre to post. CBT better at 6-mo -Hofmann, examined cognitive mediation (2007): Changes in panic cognitions mediated changes in panic severity for those getting CBT (did not see the effect in those getting meds only).

Physiological Causal/Maintenance Factors

Excessively active fear network (Gorman et al 2000: amygdala, hippocampus, mpfc, hypothalamus, brainstem) -According to this view, the fear network becomes sensitized or conditioned to respond to panic-inducing sensations/situations.

Biological and Genetic Causal/Maintenance Factors

Heritability: 23 to 43% (Kendler, 2006). -Barlow: Likely a biological vulnerability to initial spontaneous attack

Personality

Neuroticism associated with panic -Longitudinal studies: N predicts adolescent panic attacks (Hayward 2000) Greater interoceptive awareness is a trait that may predispose to panic (not really well researched Ehlers 1996). -Perhaps elevated on the Hypochondriasis scale of MMPI ? High BIS

Course

Onset primarily in late adolescence or mid-30s. Poor QoL: poorer physical health, financial dependency, alcohol abuse 72% report a stressful life event around the time of their first panic attack (Craske 1990) First attack is terrifying, ~20% reported ER trip (Shulman 1994). Common pattern then is numerous visits to health professionals, meds, and avoidance within first year. -First attack typically occurs outside of the home.

Behavioral Causal/Maintenance Factors

True/false alarms (Barlow 2002) -Fear is hard-wired for life-threatening events (true alarm), but can be activated in the absence of trigger (false alarm). -Classical conditioning - interoceptive cues become associated with the original false alarm.