Panic Disorder

Question 1

what is the spinothalamic pathway?

Answer 1

spinal cord -> thalamus -> hypothalamus -> insular cortex (terminates) -> goes to amygdala too

Question 2

where is the insular cortex and what does it do?

Answer 2

located deep within the brain and integrates information across modalities

Question 3

what is interoceptive awareness?

Answer 3

metacognition about interoception

Question 4

what is the interoceptive sensibility?

Answer 4

subjective interpretation

Question 5

what is interoceptive accuracy?

Answer 5

accuracy at detecting interoceptive signals relative to objective measure

Question 6

what is a neural indicator of interoception?

Answer 6

Heart-beat evoked potential -> neural signal approx 300 milliseconds after the R-wave heartbeat [we think this is the cortical index of that heartbeat of interoception]
* time-locked to R wave (point in cardiac cycle synchronising stimuli to the heart/phase of the cardiac cycle)

Question 7

What is an Inaugural moment?

Answer 7

Initial Sensory Map (without any prior experience)

Question 8

How does a predictive model suggest experience of body state is created?

Answer 8

Actively via prior experience and regulatory actions

Question 9

Is the insula cortex in both hemispheres?

Answer 9

Yes (there’s a left and right insular cortex)

Question 10

What can large uncorrected prediction errors lead to?

Answer 10

Maladaptive cognition AND maladaptive behaviours

Question 11

What isn’t a symptom of panic disorder?

Answer 11

Dyskinea

Question 12

Which is thought to be true of PD patients according to the study by Pauli et al., (1991)?

Answer 12

They catastrophise normal cardiac events [-> which leads to a change in their physiological state]

Question 13

what is mental health?

Answer 13

• allows accurate experience of the body and the self
• trust the body to provide consistent, reliable sensory information
• enable engagement in everyday activities
• impairments of this characteristic of many different mental health conditions
• more contemporary approaches to mental health i.e.
• Transdiagnostic approach to mental health -> identifying mechanisms that might be important across many mental health conditions
• Interoception implicated in many conditions
• Transdiagnostic mechanism

Question 14

Interoceptive symptoms are thought to be prominent features of many psychiatric disorders i.e. anxiety, depression and eating disorders. However, it’s unclear what the interoceptive deficit is but what are two reasons it potentially could be?

Answer 14

unclear whether it’s a different processing on interceptive signals or bias in reporting interoceptive signals

Question 15

Elliot and Pfeifer (2022) measured interoceptive sensibility (MAIA) and anxiety during COVID-19 via survey responses. What did they find?

Answer 15

interoceptive constructs correlate with anxiety
- worry, trust, attention regulation
- cardiac cycle and brain activity are also related to anxiety

Question 16

interoceptive accuracy [Adams et al. (2022)] looked at anxiety related to the cardiac domain as individuals tend to say they feel most anxiety within their heart. A meta-analysis of 55 studies during different measures interoceptive accuracy and anxiety (clinical and subthreshold samples). What did they find?

Answer 16

no relation between IA and anxiety and no effect of task or sample
- assumption that difficulty to detect heartbeats might make those more anxious or hypervillence of anxiety means we feel our heartbeat more

Question 17

Yoris et al. (2015) invested Interoceptive Awareness in 21 anxiety patients with panic attacks and 13 Health Controls.
- measured Heartbeat monitoring task and Metacognitions about interoception (via a questionnaire)

Method:
- Followed an audio-recording of a synchronic (1) heartbeat or non synchronic (2) heartbeat
- Monitored heartbeats without external feedback with two intervals
- Then repeated this while receiving simultaneous auditory feedback of their own heartbeat

Way did they find?

Answer 17

• no diff in interoceptive accuracy task
• difference in metacognition (threatening beliefs about the body) -> interpreted signals differently compared to those in the control
• detection of symptoms but how they are interpreted

Question 18

Pang et al. (2019)
* Heartbeat evoked potential (HEP) – Neural indicator of interoception (EEG)
* Time-locked to the R-wave ~300ms latency
* Generalised Anxiety Disorder (GAD) and health controls (HC) were two groups
* Examined HEP during resting state in 2 conditions:
- Eyes open (exteroception - more visual environment)
- Eyes closed (interoception - attending more internally)

What did they find?

Answer 18

In HC, HEP greater when eyes closed (attending more to interoception) compared to eyes open rest -> stronger neural responses to these heartbeats (greater focus in interoception with eyes closed)

In GAD, there’s no significant difference between conditions (reflects higher monitoring of interoception at all times, so they don’t get a facilitation effect of HEP when their eyes are closed, because they are already attending to it to it all the time at a higher extent)
- cortical response to heartbeats is greater in GAD
- reflects higher monitoring of interoception at all times at a higher extent

Question 19

How is the Insular Cortex potentially different in anxiety disorders?

Answer 19

insula is found to have abnormalities in structure and function across many different forms of anxiety disorders
- abnormality in perception or interpretation of internal bodily signals (is less clear)

Question 20

Etkin et al. (2007) conducted a Meta-analysis of brain activation for emotional processing across different anxiety disorders. Studies involved looked at…
* Social Phobia – exaggerated fear of negative scrutiny in social interactions
* Specific Phobia – irrational fear of something that poses little or no actual danger
* PTSD – anxiety and flashbacks triggered by a traumatic event
Combined data from multiple studies, including health controls with a normal fear response

What was found?

Answer 20

• patients with all three disorders demonstrated hypotheractivity (patients > comparison subjects) in the amygdala and insula
• this pattern of activation was also noted for healthy subjects experiencing anticipatory anxiety during fear conditions (looks like a normal response but patients were experiencing this at all times)
• an exaggerated fear response with shared neurobiology—might be reflected in shared neurobiology

Question 21

interoception and self-concept

Answer 21

• an important aspect of self is corporeal awareness
• perception, knowledge and evaluation of one’s own body as well as of other bodies (Berlucchi and Aglitoi, 2009)
• being aware of our internal state modulates our approach and distancing behaviours which, in turn, help us maintain and regain homeostasis but also to navigate social environment

Question 22

what does being aware of our internal state allow us to do?

Answer 22

modulates our approach and distancing behaviours which, in turn, help us maintain and regain homeostasis but also to navigate social environment

Question 23

Interception and Psychiatric Disorders

Answer 23

• recent interoception models suggest that interoceptive experience is not passively derived from visceral sensations
• interoceptive states are dynamically constructed in the brain using information from sensory predictions and regulatory actions (afferent and efferents) -> actively generated rather than passively received)
• experiences are dynamically constructed in the brain, using information from afferent inputs, sensory predictors and regulatory outputs (actively generated rather than just passively received)

Question 24

how does the insular cortex receive information?

Answer 24

• receives information about blood pressure and oxygenation, timing and strength of the heart rate etc

Question 25

what are predictors?

Answer 25

* classical theories suggest that cortical regions either reflect stimulus intensity or additive effects of intensity and expectations * if we base all our behaviours and thoughts on our sensory input, can we predict? predictors we use in everyday life and help us with coherent experiences and help us successfully navigate * predictive theories suggest perception is shaped by the integration of beliefs about the world with mismatches resulting from the comparison of these beliefs against sensory input * have certain expectations based on our previous experiences -> integrate and help create predictions thus shaping our experience

Question 25

how does the insula cortex send information?

Answer 25

top down regulations control of autonomic functions such as regulating the heartbeat and blood pressure (does right thing to be able to construct interception)

Question 26

what is predictive coding theory?

Answer 26

as lots of things in the world are stable (predictable) instead of processing all information, we just compare experience to predictions * predicts are faster than direct sensory information * updating predictions through errors help learning -> helping us to navigate our environment

Question 27

predictive coding theory in terms of interoception:

Answer 27

* predictive doing links physiological states to behaviours and emotions * prediction errors with interoception can lead to maladaptive emotions and behaviours - i.e. your heart beating every time you come to a specific place because you anticipate feeling nervous -> integrating social environment and prediction of the physiological state

Question 28

experience of body state in terms of predictions:

Answer 28

* inaugural moment: initial sensory map from the body without prior experience * map then modified by life experience - predicted sensory experience of encountering stimuli (internal or external) * insular cortex, amygdala, anterior cingulate, ventral medial prefrontal cortex is incorporated, bringing this together to create coherent experiences for a physiological state * experience of body state influenced by cognition (beliefs)

Question 29

the predicted body state is continually updated from afferent information and cognition, how does it do this?

Answer 29

* this process results in prediction errors * small errors are ignored * large errors are detected and regulated to maintain homeostasis * adapt predictions (next time, anticipate not being nervous) OR adopt physiological state (i.e. dealing with error and sending signals -> sending signals to insula to increase heart rate which will increase anxiety/induce it to the correct error) * want to get back to homeostasis and rest within the body

Question 30

the insular cortex is anatomically situated for detecting, what?

Answer 30

errors

Question 31

The Insular Cortex is a neural hub for, what?

Answer 31

combining information from visceral organs with cognition, emotion and exteroceptive sensory sign

Question 32

what do anatomical connections allow?

Answer 32

integration physiological state and cognition

Question 33

anatomical connections are linked to two key components of anxiety, what are they?

Answer 33

sympathetic hyperarousal (hypervelliance -> attending too much) and worry/illumination

Question 34

associations between physiological state, emotions and cognition require a brain region capable of what?

Answer 34

imitating and maintaining complex representations -> exactly what the insula does

Question 35

altered prediction signals provide what?

Answer 35

a process by which conditioning can occur -> pivotal in the development of pathological anxiety (but also different i.e. cravings and addictions)

Question 36

[Geuter et al. (2017)] * Heat pain paradigm with health participants - giving a stimulus that was either cold or hot, they received a signal letting them know if it was low, medium or high in head * Tested models of stimuli intensity a. cue you give, has no affect and same neural response dependent on the sensory input (stimulus) b. stimulus + expectation: what stimulus is and expectations driven by that cue c. mathmatical equation based on weighted responses matched against internal predictions) and prediction - influence physiological and neural responses (prediction + error). * The predictive coding is a weighted sum of the two components What was found?

Answer 36

* posterior ínsula exhibited neural patterns in line with detecting pain intensity - receives afferents from body (interoception) * anterior ínsula exhibited neural patterns in line with predictive coding of pain - integrates information from other modalities * these predicts are modality specific (pain -> can be very specific for a specific thing) rather than a general expectation of an aversive outcome (suggests why you might get specific aversions -> rather than a general aversion)

Question 37

in terms of the diagram, I'll never look at.. what was found?

Answer 37

anything in blue, best fit for the stimulus intensity model anything in orange, best fit for the stimulus prediction model -> all posterior parts of the insula (interoceptive signals go in, are all blue where we receive the information but mid and anterior insula (where connections and modalities begin to happen) directly map onto prediction model and what we know about insula anatomical structure

Question 38

psychiatric disorders

Answer 38

* large uncorrected prediction errors may lead to psychiatric conditions (and maladaptive behaviours) * maladaptive behaviours (i.e. avoidance and withdrawal) * maladaptive cognition (i.e. rumination and worry)

Question 39

how do psychiatric disorders work?

Answer 39

prior experiences -> predicted/expected bodily -> comparison to incoming afferent signals to your internal bodily state -(if there is no difference)-> minimal error and carry on as normal -(big difference)-> big error and regulatory actions might kick in i.e. regulatory body loop, which changes physiological state using top-down efferent pathway to increase heart rate but also maladaptive behaviour are made to cope / manage these errors

Question 40

adaptive corrective actions will lead to healthy outcomes such as..

Answer 40

* intact learning * recovery * resiliency

Question 41

while maladaptive corrective action leads to illness states such as...

Answer 41

* exaggerated symptom intensity * symptom misinterpretation * autonomic hypervigilance * bodily preoccupation * worry/rumination * cognitive distortion * avoidance/escape behaviours

Question 42

what has been proposed about individuals (with psychiatric disorders) and interoceptive disorders?

Answer 42

focus more on bodily sensations -> may inhibit greater interoceptive predictive signals -> detect more predictive errors * prediction of future aversive physical states may trigger aversive physical states (i.e. worrying about worrying may cause more anxiety as well as anxiety, worry and avoidance behaviours)

Question 43

how can we categorise panic disorder?

Answer 43

regular sudden attacks of panic or fear * panic attack -> sudden onset of interoceptive signals, associated with fear/panic, dizziness, dyspnea (shortness of breath), palpitations, feeling of impending doom or death

Question 44

what does studies suggest about the insula for those with panic disorder?

Answer 44

increase grey matter volume in the insula (situated in posterior insula cortex -> influx of where all the signals come in) -> insula relating to their symptoms?

Question 45

what might panic disorder patients misattribute their attacks about?

Answer 45

* misattribute symptoms as a heart attack despite the physiological heart being healthy -> hypervelliance (anticipating of a physiological state which isn't there or catastrophizing of normal increases in heart rate) - also misattribute events occurring at the same time as associated triggers -> leading to avoidance behaviours (greater cause of this) * experience anxiety over bodily signals, maladaptive behaviours and cognition

Question 46

what is panic disorder cycle?

Answer 46

* external/internal event trigger -> increase in heart rate -> because misinterpreted * perceived normal increase in heart rate as potentially catastrophic (interoceptive - interpretation of cardiac disease) * lead to heart rate acceleration and anxiety * avoidance behaviours arise (withdrawal, agoraphobia etc) - vicious cycle which will continue

Question 47

[Pauli et al., 1991] 28 patients with panic attacks and 20 healthy controls went under 24 hours of ECG monitoring (heart rate) -> were asked to note down cardiac perceptions, anxiety and activities (minus sport). What did they find?

Answer 47

* similar variations in actual heart rate * panic attack patients rated higher levels of anxiety with associated cardiac perception (noticed heart beating -> greater anxiety than control -> shortening between cardiac cycle and increase in heart rate) * anxiety experienced in relation to heart perception, not related to anxiety level * PD patients reported a similar number of cardiac perceptions compared to control - could just be an artefact :/ * PD patients felt more anxiety over perceived changes in heart rate, leading to further actual increase in heart rate

Question 48

what is the issue with bodily state in PD patients?

Answer 48

they experience a mismatch between actual and experienced bodily state -> anxiety over normal changes in cardio output * regulate actual bodily state to minimise the mismatch -> increase heart rates -> further exacerbated anxiety -> vicious cycle repeats

Question 49

what does the cycle suggest about panic disorder?

Answer 49

* cognitive states can further perpetuate PD symptoms * self is a manifestation of past and present cognitive, affective and body state experiences * past experiences can lead to maladaptive cognition expecting to experience certain physiological states and thus further perpetuate PD and panic attacks

Question 50

what causes these maladaptive errors?

Answer 50

BELIEF * changes in internal state of the individual, which may be due to an increased attentional biases toward threat, past trauma or belief * beliefs used to interpret internal bodily signals -> causing you to misinterpret these body signals * external cues or internal thoughts generate anticipation of aversive body states that set up a body prediction error -> which goes onto perpetuate maladaptive cognitions

Question 51

self-processing

Answer 51

when we look at maladaptive cognition states, leading to prediction errors, the insula cortex is a key area -> explains differences in PD insula cortex structures

Question 52

worrying is associated with increased activity where?

Answer 52

prefrontal cortex, striatum, and insula (Hoehn-Saric et al. 2004)

Question 53

guilt is linked to the?

Answer 53

left anterior insular cortex (Shin et al. 2000)

Question 54

sad self-relevant autobiographical memories are linked to?

Answer 54

activation in the ventral insula (Liotti et al. 2000)

Question 55

what is the somatic error hypothesis?

Answer 55

a predictive error coding theory * psychiatric disorder (i.e. anxiety) may be a result of mismatches between anticipated and incoming bodily signals * somatic errors -> body state predicted by the brain differ from the afferent signals of the body state

Question 56

what do somatic errors cause?

Answer 56

* compensatory behaviour = psychiatric symptomology * prediction error causes cognitive and emotional symptomology * actions to reduce the discomfort and stress (i.e. agoraphobic) -> causes avoidance behaviours * brain overregulating the system, predictions detected from actual body state -> need to appoint where these predictions are detached from overly bodily state (and this is why panic disorder builds and builds)

Question 57

what did Dresler et al., (2011) research find?

Answer 57

patients suffering panic attacks in the fMRI scanner lead to termination of testing * one removed beginning of discomfort * one removed once in full panic attack patients removed from the scanner first (prior to panic attack) only observed a decrease in prefrontal cortex activity * decline in top-down control of emotions (maladaptive cognition of anticipation) * top-down cognitive component in onset of panic attacks

Question 58

what is a somatic error?

Answer 58

body state predicted by the brain differs from the afferent signals of the body state

Question 59

how did patients feel panic in the scanner?

Answer 59

cognition/belief (scanner narrow [anticipating panic]) -> predicted body state of anxiety (increased heart rate, sweating, dizziness) -(error)-> actual body state [not the same as predicted] -> regulatory system update actual body state [increase heart rate to get rid of the error] -> changes actual body state [raised heart rate, increases anxiety -> believe heart rate is increasing and increasing, more anxiety and so on, in a vicious cycle]

Question 60

panic (without an example)

Answer 60

cognitions/beliefs -> predicted body state of anxiety -(error)-> actual body state -> regulatory system update actual body state -> changes actual body state -> believe heart rate is increasing etc., increasing anxiety

Question 61

what did full panic attack participants demonstrated?

Answer 61

significant insula and amygdala activity

Question 62

what is insula activity linked to?

Answer 62

discomfort feeling (detect prediction errors -> full on panic attack)

Question 63

what is amygdala activity linked to?

Answer 63

panic (fit into system, signals from insula going back out of the body to change the heart rate which goes back into the brain)

Question 64

what does this tell us about panic disorder?

Answer 64

* Maladaptive cognitions may be caused by initial deficits in predictive bodily state * Go on to perpetuate further the disorder through learned associations and deficits in top-down regulation * Insula is the hub with connections to prefrontal cortex, limbic system (including amygdala) and sensory interoceptive afferents

Question 65

what is maladaptive cognition caused by?

Answer 65

initial deficits in predictive bodily state

Question 66

how is the disorder further perpetuated?

Answer 66

through learned associations and deficits in top-down regulation

Question 67

the insula is the hub of?

Answer 67

connections to prefrontal cortex, limbic system (incl amygdala) and sensory interoceptive afferents

Question 68

what is more strongly associated with anxiety?

Answer 68

metacognition and interpretations

Question 69

where do bodily states actively generate from in the brain?

Answer 69

sensory inputs and regulatory actions

Question 70

what is our experienced based on?

Answer 70

future predictions and past experiences as well as current inputs

Question 71

what does somatic error hypothesis suggest?

Answer 71

large mismatches in predicted and actual states can lead to psychiatric conditions such as PD

Question 72

what does panic disorder result from?

Answer 72

mismatch between actual and predicted state (interpreting normal cardiac changes as catastrophic)

Question 73

what behaviours reduce mismatch (i.e. increased heart rate)

Answer 73

compensatory

Question 74

what may further perpetuate panic disorder?

Answer 74

further anxiety, maladaptive behaviours and cognitions