PANIC DISORDER AND AGORAPHOBIA

•Panic Disorder : Debilating anxiety disorder : Individuals experience sever, unexpected panic attacks that may think they are dying or losing control. : Last up to 10 minutes : Occur out of the blue

•Signs and Symptoms of Panic Disorder Shortness of breath or hyperventilation

Heart palpitations or a racing heartChest pain or discomfortTrembling or shakingChoking feelingFeeling unreal or detached from your surroundings

SweatingNausea or upset stomachFeeling dizzy, light-headed, or faintNumbness or tingling sensationsHot or cold flashesFear of dying, losing control, or going crazy

•Agoraphobia : Fear and avoidance of situations in which a person feels unsafe or unable to esape to get home or to a hospital in the event of a developing panic symptoms or other physical symptoms. : Fear of being in a public spaces or open spaces : Coined in 1871 by Karl Westpal (German Physician) : Greek word “agora” fear of the marketplace : Most agoraphobic avoidance behavior is simply a complication of severe unexpected panic attacks.

CLINICAL DESCRIPTION• Some people experienced panic disorder without developing agoraphobia

while some develop agoraphobia without panic disorder.

• Diagnostic Criteria for Panic DisorderA. Repeated panic attacks are presentB. Followed by one month or more of both the ff.:

a. worry about having panic attacksb. maladaptive change in behavior

C. Not attributable to the physiological effects of substance or medical conditionD. Not explained by another mental disorder

CLINICAL DESCRIPTION• Diagnostic Criteria for Agoraphobia

A. Fear or Anxiety of the ff. situations:a. Public Transportation (Buses, Trains, Subwaysb. Open Spaces (Shopping Malls, Wide street, Supermarket)c. Enclosed Spaces (Car, Restaurant, Theater, Elevators)d. Standing in line or being in a crowde. Outside of home alone

B. Avoid those situations due to thinking that escape might be difficult

C. Agoraphobic situations provoke fear or anxietyD. Agoraphobic situations are

a. Actively avoidedb. Require the presence of companionc. Endure with intense fear or anxiety

CLINICAL DESCRIPTIONE. Fear or anxiety is out of proportion to the actual dangerF. Fear, anxiety or avoidance of these situations last up 6 months or

moreG. Fear, anxiety or avoidance cause distress or impairment in social, or

occupational or other important areas of functioning.H. If another medical condition is present, fear, anxiety or avoidance is

clearly excessiveI. Fear, anxiety or Avoidance is not better explained by another mental

disorder• One way of coping with panic attack is by drugs and/or alcohol.• Some individuals do not avoid agoraphobic situation but endure them with

intense dread (fear and anxiety)• Patients with panic disorder with agoraphobic avoidance develop

interoceptive avoidance (avoidance of physical sensations)

CLINICAL DESCRIPTION• Interoceptive daily activities typically avoided by people with agoraphobia.

a. Running up flights of stairsb. Getting involved in heated debatesc. Walking outside in intense heatd. Having showers with the doors and windows closede. Hot stuffy room/carsf. Hot stuffy stores/mallsg. Having a saunah. Hikingi. Walking outside in a very cold weatherj. Sportsk. Aerobicsl. Drinking coffee or any caffeinated beveragesm. Lifting heavy objectsn. Dancingo. Watching horror/exciting moviesp. Eating heavy meals/chocolatesq. Getting angry

STATISTICS• 2.7 percent of the population meet criteria of P.D during a given one-year

period.• 4.7 percent met them at some point during their lives; 2/3 women.• 1.4 percent develops agoraphobia without ever having a full-blown panic

attack.• P.D occurs in early adult life. (From mid-teens 20-24 to 40 years of age.)• Prepubescent children experience unexpected panic attacks, and

occasionally panic disorder, though this is a rare case. They are mostly have symptoms of hyperventilation that may well be panic attacks.

• Initial unexpected panic attacks begin at/after puberty.• P.D and agoraphobia decreases among the elderly, from 5.7% (ages 30-

44) to 2.0% less. (ages after 60)• 75% of those who suffer agoraphobia are women.

CULTURAL INFLUENCES• Prevalence rate of P.D were similar in United States, Canada, Puerto Rico,

New Zealand, Italy, Korea and Taiwan.• Panic attacks among Iranian college student and is similar to those

among Western college student.• Rates are also similar among different ethnic groups in the United states,

including: Afro-American.• Somatic Symptoms of Anxiety may be emphasized in 3rd world cultures.• Primarily somatic anxiety is marked by somatic events such as:

Stomachache, Headache, Muscle tension, Muscle aches, Increased heart rate, Rapid breathing/Hyperventilation, Sweating, Shaking, Nausea.

CULTURAL INFLUENCES• Susto

: Fright disorder in Latin-America.: Disorder characterized by sweating, increased heart-rate, and insomnia,

but not by reports of anxiety or fear.• Ataques de nervios

: Anxiety-related, culturally defined syndrome common to Spanic-Americans and Carribeans.

: Shouting uncontrollably or bursting into tears.• Devon Hinton

: Psychiatrist/Antropologist.: Discovered that Khmer (Cambodian) and Vietnamese both suffer f

from a high rate of P.D.: Discovered that the concept of Khmer “Kyol Goeu” or “Wind

Overload” becomes the cause of Panic Attack.

NOCTURNAL PANIC• 60% of the people with P.D have Nocturnal Attacks.• Happens at night and awakes you from sleep.• Panic Attacks occur more often between 1:30 am and 3:30 am.• Studied in a sleep laboratory where patients are attach to a

electroencephalograph. They occur during Delta wave or slow wave sleep.

• People with P.D often begin to panic when they start sinking into delta sleep and they awaken amid an attack.

• Cause of Nocturnal Panic• Change in stages of sleep to slow wave sleep produces physical sensation of

“letting go” that are frightening to an individual with P.D.• Nightmares

• Sleep apnea• Breathing disorder of patients with N.P.• Interruption of breathing while asleep that may feel like suffocation.

NOCTURNAL PANIC• Sleep Terrors:

• Occurs in children.• Screaming and getting out of bed.• Occur at later stage of sleep (stage four sleep) associated with Sleepwalking.

• Isolated Sleep Paralysis• Common at the Ethnic Group of U.S. (Afro-American)• Occur during transitional state between sleep and walking, when a person is either

falling asleep or waking up, but mostly waking up.• Occurrence of I.S.P were significantly higher in Afro-Amerian with P.D. (59.6%) a. White with P.D. (7.5%)b. Afro-American with A.D. (11.1%)c. White with A.D. (0%)d. Afro-American Community Volunteer. (23%)e. White Community Volunteer. (6%)• Americans with I.S.P had the history of trauma, P.D and Posttraumatic Stress than

Afro-Americans without I.S.P.

CAUSES • Agoraphobia: socially and culturally determined.• Panic attacks and Panic disorder: biologically and psychologically

determined.• Generalized Psychological Vulnerability + Generalized Biological

Vulnerability would lead to Stress, which leads to False Alarm (Somatic sensations) to a Learned Alarm, which then would be specific Psychological Vulnerability to anxious apprehension that will develop to Agrophobia, Panic Disorder, or Agoraphobia with P.D.

• 8-12% of the population has an unexpected panic attack due to stress. Only 5% develop anxiety, thereby, having panic disorder.

• David Clark: People with psychological vulnerability interpret physical sensations in a catastrophic way.

TREATMENT• MEDICATION

: Drugs that affect the noradrenergic, seratonergic, or GABA-benzodiazepine neurotransmitter system are effective in treating panic

disorder. They are the:a. High-potency benzodiazepinesb. Newer selective-serotonin reuptake inhibitors (SSRI)

b.1 Proxacb.2 Paxil

c. Seratonin-norepinephrine reuptake inhibitors (SNRI)c.1 Venlafaxine

TREATMENT• SSRI• Indicated drug for panic disorder• Sexual dysfunction occur in 75% or more of people taking this• High Potency benzodiazepine (Alprazolam or Xanax)• Commonly used for panic disorder • Work quickly but result to psychological and physical dependence and

addiction• Most widely used class of drugs in practice• Affect motor and cognitive functions• 60% of patients with P.D are free of panic as long as they stay on drugs• 20% or more stop taking before treatment is done thus relapse rate are

high

PSYCHOLOGICAL INTERVENTION

• Psychological treatments: Effective for P.D.: Reducing Agoraphobic avoidance using strategies, based on

exposure to feared situations.• Exposure-based Treatment

: Arranged conditions in which the patients can gradually face the feared situations and learn that there is nothing to fear.

: Example: Shopping in a supermarket for 30 minutes alone. Walking 5 blocks away from home. Driving on a busy high-way for 5 miles with spouse or alone. Eating in a restaurant, sitting in the middle. Watching a movie, while sitting in the middle of the row.

PSYCHOLOGICAL INTERVENTION

• Gradual exposure exercises: Combined with anxiety reducing coping mehanisms.: Examples: Relaxation or Breathing retaining.: 70% of the patients undergoing this treatment improve while their anxiety and panic are reduced and agoraphobic avoidance is greatly deminished.

• Effective Psychological Treatment: Treat panic disorder directly even in the absence of Agoraphobia.

• Panic Control Treatment (PCT): Exposing patients with panic disorder to the cluster of interoceptive (physical) sensations that remind them of their panic attacks.: Patients who received PCT have remained better after atleast 2

years.

PSYCHOLOGICAL INTERVENTION• Cognitive Therapy

: Basic attitudes and pereptions concerning the dangerousness of the feared by objectively harmless situation are identified and modified.• Nevertheless, some patients relapse over time. Multisite collaborative

team began investigating long-term strategies in the treatment of P.D including the usefulness of providing booster.

• Booster sessions produced significally lower relapse rate, (5.2%) and reduce work and social impairment compared with the assessment only condition without booster sessions (18.4%) at a 21 month follow up.

• Booster sessions aimed at re-inforcing acute treatment gains to prevent relapse and off-set disorder.

COMBINED PSYCHOLOGICAL AND DRUG TREATMENTS

• National Institute of Mental Health studied the separate and combined effects of Psychological and Drug treatments.

• Patients were randomized into 5 treatment conditions:a. Psychological treatment alone. (CBT)b. Drug treatment alone. (IMI)

c. A combined treatment condition (IMI + CBT)d. Placebo alone. (PBO)e. Placebo + CBT