Panic Disorder
 
Panic Disorder
Uncontrolled Anxiety: Understanding Panic Disorder With Agoraphobia
 
Anxiety is often described as one of the most common of the human emotions (Barlow, 2002). Most of us feel some degree of anxiety on a daily basis. When one is late for an appointment, has been called in to talk to their supervisor unexpectedly, or is watching one's children compete in an activity for the first time, one typically experiences anxiety. At these times one may notice sensations such as racing heart, sweating palms, or a general feeling of nervousness or agitation. In addition to being common, anxiety is considered to be a natural response to a real or perceived threat (Barlow, 2002). In the presence of threatening stimuli, this innate emotional response is often considered to be adaptive, resulting in the self-preservation of the organism (Barlow, 2002). When faced with a potential threat (e.g., oncoming traffic or an upcoming exam), the emotional state that motivates us to manage the threat (by either fighting or fleeing) is anxiety.  Therefore, anxiety is conceptualized as very useful at normal levels. When the experience of anxiety becomes too intense, occurs too frequently, or happens in situations where anxiety is uncommon, then this natural, self-preserving response may approach clinical severity and warrant treatment (Carter & Barlow, 1995).

Panic Disorder with Agoraphobia (PDA) is one condition characterized by uncontrollable periods of anxiety. PDA is one of the anxiety disorders that has gained increasingly more attention in empirical investigations studies in the past ten years. Recent research has focused on basic description of the problem (including symptom severity), the impact of the disorder on family members, and the examination of psychological and pharmacological approaches to treatment. The severity of panic disorder can vary from mild, where the person continues to function well in her or his daily life (maintains friendships, little reduction in work productivity, etc.), to extremely severe. In these latter cases, those suffering from PDA can become so severely housebound that they may find themselves confined to one or two rooms in their homes. Of some interest, there is also evidence that the symptoms of panic can be attenuated by the presence of a safety-signal. In the company of a safe-person, even severely agoraphobic patients may become more mobile and exhibit less avoidance behavior.

Early in the course of the disorder, approximately 85% of patients will make numerous visits to the emergency room (Katerndahl & Realini, 1995) with the belief that they are in imminent physical danger (e.g., heart attack).They may then slowly realise that they are not in real physical harm, but that they are suffering from uncontrollable anxiety. As their anxiety increases in frequency and severity, the patient will typically begin to exhibit avoidance behavior. It has been speculated that the avoidance behavior associated with PDA produces a level of dependence on family members that may negatively impact the functioning of the family. That is, as others are forced to assume more of the responsibility for the person afflicted with the condition, it is common for resentment to develop between family members. The resentment may then increase the stress level of the disordered person and consequently worsen their symptoms. The worsening of the symptoms, of course, may serve to increase the patient's dependency needs. Despite the clear interference created by PDA for the patient as well as those around them, there is ample evidence that even the most severe of patients can be treated with some degree of success.
 
 DIAGNOSIS ASSESSMENT

The diagnosis of panic disorder consists of two related parts. The first is the experience of unexpected rushes of anxiety or intense fear, or what is labeled a panic attack. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994), a panic attack is a discrete period of intense fear or distress that usually reaches maximum intensity in a short amount of time (typically less than 10 minutes). A fullblown attack consists of at least 4 physical and/or cognitive symptoms that may include heart racing, dizziness, blurred vision, depersonalization, fear of death, fear of losing control, trembling, sweating, and dyspnea. A limited symptom attack consists of less than 4 symptoms, but otherwise meets those same criteria as a full attack. These attacks can also be categorized as either unexpected or uncued, situationally bound, or situationally predisposed. Unexpected panic attacks are not associated with an identifiable trigger and seem to occur spontaneously or "out of the blue."Situationally bound attacks invariably occur upon exposure to, or in anticipation of a particular cue or trigger. For example, one may panic whenever one is in the car or a crowded grocery store. In contrast, situationally predisposed attacks are likely to occur upon exposure to certain cues or situations, but do not always occur. For example, one may panic most times when they attempt to enter an elevator, but may have occasions when they do not experience a panic attack in that situation. The diagnosis of Panic Disorder is assigned when the patient has experienced at least two unexpected panics, one of which must be followed by one of the following: (1) at least a month of persistent concern about having another attack; (2) persistent worry about the consequences of having an attack; or (3) significant behavioral change (APA, 1994).

The second part of the diagnosis of panic disorder with agoraphobia is the experience of avoidance behavior. Agoraphobia (literally translated as "fear of open spaces") is defined as avoidance of activities, situations, or events from which escape might be difficult in the event of a panic attack (APA, 1994).Common agoraphobic situations and activities include crowds, stores, churches, movies, driving, closed spaces, being alone, drinking caffeine, hot showers, and sexual intercourse. Note that open spaces is not a typical situation. While PD may occur with or without agoraphobia,the two most often occur together (Baker, Patterson,& Barlow, 2002).The lifetime prevalence rate for panic disorder (with or without agoraphobia) is estimated to be between 1.5 and 3.5% (APA, 1994).
Medical Conditions that Mimic Panic Disorder There are several specific conditions that are associated with panic-like symptoms and should be evaluated prior to arriving at a diagnosis.These include hyper-thyroidism, hypoglycemia, menopause, mitral valve prolapse (MVP), congestive heart failure, and cardiac arrhythmias. For example, it has been estimated that approximately 95% of patients with hyperthyroidism report nervousness and periodic unexplained anxiety as primary symptoms (White & Barlow, 2002).This group further typically reports palpitations and dyspnea (two common symptoms of panic attacks). While the experience of MVP was previously thought to be a marker for the development of panic disorder, more recent studies suggest this is not the case (White & Barlow, 2002). In fact, most researchers agree that there is probably little value in distinguishing those with PDA and MVP from those with only PDA.

Assessment Devices There are many instruments designed to assess for panic disorder symptomatology. Most are either clinician administered diagnostic interviews or self-report measures. Obviously, the former would be the preferred method for arriving at a diagnosis of panic disorder. Diagnostic interviews allow for the use of clinical judgment and typically provide very comprehensive coverage of PDA as well as other Axis I conditions listed in DSM. The most commonly used are the ADIS-IV (Brown, Di Nardo, & Barlow, 1994), SCID-IV I\P (First, Spitzer, Gibbon, & Williams, 1996),and SADS-LA-IV (Fyer, Endicott, Mannuzza, & Klein, 1995). Each of these interviews has demonstrated adequate reliability and validity across many empirical investigations, and are typically considered the gold standard in most treatment outcome research. Part of the benefit to using such measures in the case of PDA is that the experience of frightening panic attacks may not be limited to PDA. Such attacks may also occur in cases of social phobia, specific phobia, generalized anxiety disorder and even depression.The use of a psychiatric interview is often the most reliable way of making differential diagnoses. As useful as they are, however, interviews are associated with the pragmatic problem of being lengthy (averaging approximately 3 hours to administer), and require extensive training to reach an acceptable level of expertise prior to using them independently. Less time consuming (and less detailed) are clinician-rated scales that are limited in scope to the phenomenology of panic. These types of devices are considerably less time consuming (taking from 10 to 30 minutes to administer).The choice of which measure to use will depend on the amount of time one has for administration and the type of information one is hoping to gather. For example, the Panic Attack Questionnaire-Revised (PAQ-R) gathers information about the severity and types of panic symptoms as well as information regarding situational triggers and the patient's coping responses (Cox, Norton, & Swinson, 1992).The Panic Disorder Severity Scale (PDSS) assesses only the seven key features of PDA including frequency of panic, distress during panic,focus on future attacks, interoceptive avoidance, situational avoidance, and interference in social and work functioning (Shear, Brown, Barlow, Money, Sholomskas, Woods, Gorman, Papp, 'i 997).

There are also numerous self-report measures to assess various aspects of PDA.The advantage with these types of measures is that they are quick (5-10 minutes to complete), involve minimal clinician time, and also are reliable and valid measures of panic and avoidance behavior (but cannot be used to arrive at a diagnosis). Self-report measures have been designed to capture the major symptom categories associated with PDA: (1) Cognitions or the thoughts typically experienced during an attack or heightened anxiety, (2) sensation focused fear, and (3) avoidance behavior. An example of a cognitive measure is the Agoraphobics Cognitions Questionnaire (Chambless, Caputo, Bright, & Gallagher, 1984).This measure assesses the frequency of mal-adaptive thoughts such as"l am going to go crazy." An example of a sensation focused fear measure is the Anxiety
 
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Sensitivity Index (Peterson, & Reiss, 1993).This 16-item measure taps into the patient's fear over the physical, cognitive, and emotional consequences of anxiety. A sample item from this measure is "It scares me when my heart beats rapidly." An example of an avoidance measure is the Mobility Inventory for Agoraphobia (Chambless, et al., 1984).This scale measures the situational avoidance common among those with PDA (e.g., driving). What is unique about this scale is that it assesses the avoidance the patient exhibits when alone versus when they are accompanied (For a comprehensive and exhaustive review of clinician-rated and self-report measures of panic the reader is referred to Baker, Patterson, & Barlow, 2002).

THE IMPACT OF ETHNICITY ON THE EXPRESSION AND TREATMENT OF PDA

A s noted by Chambless and colleagues (1996), despite ample evidence of the effectiveness of  psychosocial treatments for PDA, the generalizability of these approaches to minority populations in general has rarely been tested. In fact, until recently the underlying assumption of the impressive results of psychotherapy for panic disorder is that the expression of anxiety and, consequently, response to treatment are culturally universal. While there is some evidence that some ethnically diverse populations (e.g., African American) manifest similar symptoms as Whites (Friedman & Paradis, 1991; Friedman, Paradis,& Hatch, 1994), there is a growing body of evidence suggesting that important symptom differences do exist between cultures. For example, DSM recognizes the presence of ataque de nervios as a culture bound syndrome among Hispanic populations.The description of ataque de nervios resembles that of panic attacks except that there is typically an absence of fear during the ataque and that they are more common during times of familial distress (APA, 1994).

Similarly, there is some evidence that African Americans diagnosed with PDA are more likely than other ethnic groups to report the experience of isolated sleep paralysis. One of the first indications that ISP may be a common manifestation of anxiety among African Americans was provided by Bell and colleagues who studied a group of African American patients diagnosed with ISP.They discovered approximately 36% of the sample experienced panic attacks and approximately 15% met criteria for panic disorder (Bell, Dixie-Bell, &Thompson, 1986). Friedman, Paradis,and Hatch (1994) also noted an elevated occurrence of ISP among African American subjects with panic disorder, compared to European American subjects with panic disorder. Further, there is some evidence that African Americans may have a slightly different expression of anxiety sensitivity that is characterized more by emotional control than concern about social evaluation (as is typical among White-Americans) (Carter, Miller, Sbrocco,Suchday,& Lewis, 1999). Further, an environment perceived as overprotective, strict, and demanding for African Americans was not associated with the expression of anxiety or depression as it was among White-Americans (Carter, Sbrocco, Lewis, & Freedman, 2001).These types of studies clearly suggest that some types of anxiety may be manifested differently depending on an individual's culture. Whether different cultural expressions of anxiety negatively (or positively) impact treatment is only beginning to be explored. At this point the results are mixed, with some studies suggesting that the efficacy of treatment is reduced when applied to different cultures (Chambless & Williams, 1995; Friedman & Paradis, 1991) and others finding no differences in treatment response between ethnic groups (Carter, Sbrocco, 2002).

TREATMENT OPTIONS

While panic disorder can be one of the more debilitating anxiety disorders listed in DSM-IV, there is adequate research suggesting that it can be successfully treated from a number of theoretical perspectives including behavioral,cognitive-behavioral, and pharmacological (Chambless, Sanderson, Shoham, Johnson,et al., 1996). Behavioral treatment for PDA typically consists of in-vivo exposure (Barlow, 2002).
With this procedure, the therapist typically begins by making a detailed hierarchy of the patient's feared and avoided situations. Beginning with the item that produces the least amount of fear, the patient is then instructed to enter each situation repeatedly until the fear subsides. At that point, they continue with the next item in the hierarchy. It should be noted that exposures can also be conducted with the assistance of the therapist, as self-directed exposures, or as massed, intense exposures.The choice of what type of exposure to conduct is largely determined by the patient's motivation and willingness to engage in exposures

Results from empirical investigations suggest that behavior therapy is effective in treating panic disorder. For example, Fava and colleagues (1995) conducted 12 sessions of graduated self-paced exposure and noted that over the 6 months of treatment, 87% of the patients were panic-free and considered much improved. At extended two-year follow-up, the 96% of those responding to treatment remained in full remission. At five and seven year follow-up, 77% and 67% remained in remission, suggesting a straightforward exposure treatment is quite effective.

Cognitive Behavioral Therapy for Panic Disorder: Cognitive Behavior Therapy (CBT) is a comprehensive treatment package that is designed to address each of the major components of panic and anxiety (cognitive, physiological, behavioral) in a systematic fashion.The specific procedures of this treatment approach has been described in detail elsewhere (see Barlow & Cerny, 1988). In general, the goal of treatment is to influence the cognitive aspects of panic and anxiety by providing accurate information regarding the nature of panic and to teach specific cognitive restructuring techniques that allow the patient to correct or modify the catastrophic cognitions underlying the experience of panic attacks. As well, the patient is taught to utilize diaphragmatic breathing to alleviate some of the physical sensations resulting from panic and hyperventilation.The patient is also taught to engage in systematic interoceptive exposure in an effort to break the connection between the experience of physiological sensations and their fearful response (Carter & Barlow, 1993). Similar to BT, the patient is given specific in-vivo exposure instructions and exercises to combat the avoidance behavior.

In the treatment of panic disorder, cognitive behavioral approaches such as Panic Control Therapy (PCT) have demonstrated empirical support for significantly reducing panic symptomatology (Beck, Stanley, Baldwin, Deagle,& Averill, 1994; Clark, Salkovkis, Hackman, Wells, Ludgate, & Gelder, 1999). For example, Barlow, Craske,Cerny, and Klosko (1989) compared the efficacy of applied progressive muscle relaxation, exposure plus cognitive restructuring, relaxation plus exposure plus cognitive restructuring, and a wait-list condition in the treatment of panic disorder with mild or no agoraphobic avoidance. In general, all treatment participants evidenced a significant reduction in panic and anxiety at the conclusion of the fifteen-week treatment. Furthermore, two-year follow-up data indicated that participants in the combined condition maintained treatment gains to a greater degree than the other two treatment groups (Craske, Brown, & Barlow, 1991).

Family Therapy Model of Panic Disorder: For some time, clinical observations have led mental health professionals to speculate on the complex connection between panic disorder with agoraphobia and interpersonal relationships. Goldstein and Chambless (1978) hypothesized the critical period for development of agoraphobia occurred during adolescence.
 
They believed that conflict between individuation and the desire to remain in a familiar environment can create physical symptoms of anxiety or early signs of panic. Conflict later in life may exacerbate the panic. For instance, after many years in a dissatisfying marriage, conflict might arise from both the desire to leave the marriage and the fear of not being self-sufficient.

Minuchin and Fishman (1981) described ways in which enmeshed families, where perceptions of self and others are poorly differentiated, experience extreme anxiety during times of stress and do not adapt well to change.Take for example the mother of a single child who experiences increased anxiety when her child becomes school-aged. The mother may develop anxiety attacks that subside in the child's presence, which may then create dependence on the child.The child may, in turn,feel important because he/she is being depended on. In this way, the family system is set up to both tolerate and enable the anxiety. A family therapist may then intervene, using restructuring techniques to alter dysfunctional transactional patterns that maintain the disorder.The therapist might, for example, instruct the mother and child to schedule time apart in an attempt to break the pattern of child as "safe person."Because change in any one part of the family system affects other parts of the system, one wonders how individual treatment of agoraphobia impacts the family system and further, what forces are in place to instigate a relapse.

The hypothesized importance of relationship issues among agoraphobics has led several investigators to examine the impact of treatment on the relationship and vice versa. In general, however, the results are mixed. Several studies found evidence that clients'pre-treatment level of marital satisfaction, in part, predicts treatment outcome. While significant improvement over the course of treatment was noted for all patients involved, those rated as "better" adjusted maritally, improved most (Hafner, 1984; Milton & Hafner, 1979; Monteiro, Marks, & Ramm, 1985). In each of these studies, treatment largely consisted of in-vivo exposure conducted over a short period of time (usually 2 weeks).There have also been investigations contradicting the relationship between marital satisfaction and treatment outcome (Arrindell, Emmelkamp, & Sanderman, 1986; Craske, Burton, & Barlow 1989; Emmelkamp, 1980). Treatment in these studies, again, consisted of in-vivo exposure, except in one case (Craske et al., 1989) which was cognitive behavioral.

Researchers have also attempted to incorporate the patient's spouse directly into treatment. Only seven investigations have been conducted in this manner, thereby making firm conclusions difficult. Although spousal involvement theoretically does not detract from treatment, available studies offer contradictory results as to its effectiveness. For example Barlow, Mavissakalian, and Hay (1981) used spouses as co-therapists and instructed them to elaborate on techniques learned in sessions and to assist their wives with between-session exposure exercises. Some couples reported that improvement in severity of agoraphobia resulted in improvement in marital satisfaction. Some couples, however, reported that improvement in agoraphobia was correlated with a decline in marital satisfaction. Interestingly, at least three earlier studies (Hafner, 1984; Milton & Hafner, 1979) also noted that the relationships of some agoraphobics were adversely affected by treatment success,at least initially. Such results, therefore, provide some support for the notion that agoraphobics and their partners may both be dependent on disordered behavior (Goldstein & Chambless, 1978).Two more recent, controlled trials also found greater efficacy for including the spouse directly in treatment (Barlow, O'Brien, & Last, 1984; Himadi, Cerny, Barlow, Cohen, & O'Brien, 1986) that was maintained over a 2-year follow-up period (Cerny, Barlow, Craske, & Himadi, 1987).

Pharmacotherapy for Panic Disorder

While a variety of psychological treatments for panic disorder have demonstrated efficacy, pharmacotherapy appears to be a viable option for some patients.Typical pharmacological treatment of PDA includes anti-anxiety medications, tricyclic antidepressants, or selective serotonin re-uptake inhibitors (SSRI's) (Barlow, 2002). The most common anti-anxiety medications are benzodiazepines (BZs) including alprazolam, clonazepam and lorazepam.These medications have demonstrated efficacy and are generally considered safe, quick acting, and as having a lower side-effect profile than other types of medications. The difficulty with these drugs is that the patient can develop physiological dependence with long-term usage that can result in withdrawal symptoms (e.g., nervousness, sleep disturbance) when the medication is discontinued (Barlow, 2002).Tricyclic antidepressants (TCAs) like imipramine and clomipramine have also been used successfully. Clinical trials with these medications that suggest they are effective in blocking panic attacks, and that imipramine in particular works better than placebo and as well as the high-potency benzodiazepines (although the BZs typically work faster). However, the TCAs typically have more side effects than the BZs.The last class of medication is the SSRIs such as fluoxetine and fluvoxamine.The SSRIs seem to work about as well as the other classes of agents, but are better tolerated than the TCAs and are less prone to dependence than the BZs.

Of some interest, in the largest controlled trial of panic disorder, Barlow and colleagues (2000) compared the combination of PCT and imipramine to each treatment alone and a placebo condition. All three active treatments were equally effective in reducing panic symptoms and superior to the placebo conditions at the end of active treatment and the initial 9-month follow-up period. However, at the end of an extended 15-month follow-up, the gains exhibited in the medication conditions had been lost, while those observed in the PCT condition were maintained.This suggests that while medication is as effective as psychotherapy, the gains from psychotherapy are considerably more durable (Barlow, Gorman, Shear, & Woods, 2000). Anxiety sensitivity (AS). AS is typically defined as the concern and/or fear associated with the physiological, evaluative, and cognitive concomitants of anxiety. An individual with elevated anxiety sensitivity will be more likely to interpret symptoms of anxiety (racing heartbeat, sweating palms, dizziness, breathlessness, etc.) as signs of impending doom than someone less sensitive to their anxious sensations (Reiss, Peterson, Gursky, & McNally, 1986). Elevated levels of AS has been linked to the expression of panic and to the development of the disorder.

Ataques de Nervios: This is a culture-bound syndrome that occurs primarily among Hispanics.The symptoms mimic those of panic attack and may also include uncontrollable crying, shouting, trembling,and verbal and physical aggression. Dissociative experiences and fainting episodes may occur in some ataques and not in others.Those who have such ataques may also display amnesia for what occurred during the ataque. Interoceptive conditioning. The learned association between internal cues and fear.
Interoceptive exposure: Exposure to fearful sensations in a gradual, systematic manner in an effort to disrupt the intero-ceptive conditioning.

Isolated Sleep Paralysis (ISP): ISP may best be described as an altered state of consciousness while one is falling asleep or awakening that culminates in the brief inability to move or speak.The temporary paralysis is typically followed by a panic-like attack and intense fear.

Safety-signal: Safety-signals are conditions that indicate a feared or aversive stimulus will not occur. As such, safety-signals serve to inhibit anxiety and avoidance behavior. There are no physical limits to what constitutes a safety-signal. They may be inanimate objects such as a car, a specific room in the home, or an empty medication bottle, but they are most often other people.
 

Conclusion

It is clear that panic disorder with agoraphobia is a disorder that can severely affect the individual as well as their family structure. Despite the severity of the condition, however, what has been learned through research about PDA in the past decade is encouraging. We are keenly aware that PDA consists of behavioral (avoidance), cognitive (negative thinking), and physiological (actual panic attack) disturbances that are easily discernable by both the patient and mental health professional.The field is also aware that part of the difficulty with this disorder is that the symptoms of PDA can often mimic and be mimicked by medical conditions such as hyperthyroidism and that the symptoms can fluctuate within an individual. PDA can also be associated with the occurrence of major depressive episodes (often resulting from the change in their lifestyle) or substance abuse (particularly alcohol) in an effort to control the symptoms. Importantly, there are now a variety of effective treatments that can greatly reduce the severity of panic symptoms. Despite the current state of knowledge regarding this disorder, however, there are numerous issues that remain insufficiently addressed in the literature. For example, comparatively little is known about cultural variations in panic and their impact on treatment. While there is evidence that family involvement is likely to be beneficial to treatment outcome, there is virtually no information about how involved family members need to be in the treatment process or whether such an approach is likely to produce better results than individual treatment. Little is also known about variables that may predispose one to develop PDA, or whether early identification can be used to develop preventative care strategies. It seems that the more we uncover about this and related conditions, the more certain we are that we have only scratched the surface.

ABOUT THE AUTHOR
 
MICHELEH.CARTER received his Ph.D. in clinical psychology from Vanderbilt University. He completed three years postdoctoral training under the direction of David H. Barlow at the Center for Stress and Anxiety Disorders, University at Albany, State University of New York. He is currently an associate professor in clinical psychology and Director of the M.A. Program in psychology at American University. Dr.Carter's primary interest and expertise is in anxiety disorders and cross-cultural psychology. He has published numerous articles in journals such Journal of Abnormal Psychology, Psychological Assessment, Behaviour Research and Therapy, and iheJournalof Anxiety Disorders. He has also published several book chapters, and has made numerous professional presentations on the topics of anxiety and culture.

REFERENCES

AMERICAN PSYCHIATRIC  ASSOCIATION. (1994). Diagnostic and Statistical manual of menta

Resource: Family Therapy Magazine