Panic disorder

Question 1

What is a panic attack

Answer 1

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) symptoms occur
Heart palpitations
Trembling or shaking
Dizziness
Numbness and tingling
Nausea
Hyperventilation
Sweating
Chills and hot flushes

Question 2

Panic Disorder DSM 5 criteria

Answer 2

In order for panic attacks to be classified as a disorder:
A. There must be recurrent unexpected panic attacks.
B. followed by 1 month (or more) of: 1) persistent concern or worry about additional panic attacks or their consequences (e.g. losing control, having a heart attack, going crazy) 2) Maladaptive change in behaviour related to the attack (e.g. behaviours designed to avoid having panic attacks).
C. Not due to the physiological effects of a substance or another medical condition.
D. Not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to reminders of traumatic events, as in PTSD).

Question 3

Agoraphobia DSM 5 criteria

Answer 3

A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation
2. Being in open spaces
3. Being in enclosed spaces
4. Standing in line or being in a crowd
5. Being outside of the home alone
B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
E. The fear of anxiety is disproportion to the actual danger
F. The fear, anxiety, or avoidance is persistent (> 6 months).
G. It causes clinically significant distress or impairment in functioning.
Agoraphobia is diagnosed irrespective of the presence of panic disorder.

Question 4

Phobia DSM 5 criteria

Answer 4

A. Marked fear or anxiety about a specific object or situation (e.g. animals, flying, heights, seeing blood, thunder).
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.
E. The fear, anxiety or avoidance is persistent typically lasting for 6 months or more.
F. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder.

Question 5

Vicious Cycle of Panic

Answer 5

1. Trigger
2. Appraisal of threat
3. Emotion (anxiety)
4. Physical sensations of anxiety
5. Catastrophic misinterpretation of the physical sensations (I’m going to pass out, I’m going to die)
6. Avoidance/ escape
7. Temporary relied –> 1.

Question 6

Intervention for panic and phobias

Answer 6

Psychoeducation for fight or flight response
Panic diary (helps to select steps for graded exposure)
Graded exposure

Question 7

What is graded exposure

Answer 7

Confronting feared stimulus through exposure and reducing avoidance. Habituation is the mechanism of change.
• Exposure can be used for external situations (e.g. objects and animals) and also internal stimuli (e.g. increased heart rate, trembling and dizziness)
• It is import to select stimuli that are most relevant to the patient; situations or objects that are avoided and elicit anxiety.

Question 8

6 steps of graded exposure

Answer 8

1. Psychoeducation about graded exposure (habituation and the 4 principles of graded exposure)
2. Construct a graded exposure hierarchy
3. Set SMART goals for the first step on the hierarchy and plan out how to implement exposure for homework.
4. Implement exposure tasks
5. Review the exposure tasks using the graded exposure principles.
6. Repeat stage 3 if next step in hierarchy (as appropriate)

Question 9

Habituation

Answer 9

a decline in fear responses, particularly the physiological responses, over repeated exposures to fear provoking stimuli

• primary function is to reduce anxiety when exposed to the stimulus
• secondary function is that patient learns that nothing dangerous happens when they are exposed to the stimulus

Question 10

Extinction

Answer 10

anxiety reduction results from repeated encounters with anxiety provoking situations without aversive consequences (minimal anxiety response)

Question 11

Key principles of exposure

Answer 11

Barlow 1988
– Graded – Gradual confrontation to the feared stimulus, and enhance capacity to cope.
– Prolonged – Allow physiological response to decrease and habituation to occur. (until anxiety has reduced by at least 50% - varies across individuals (up to 2 hours).
– Repeated – Practised regularly between sessions. Emotional learning / facilitate habituation / allow extinction to take place.
– Without distraction –drop safety-seeking behaviours. Increasing exposure to feared stimuli. (patient learns that the physical reduction occurs on its own and not because of safety behaviours).

Question 12

Diaphragmatic breathing

Answer 12

• Diaphragmatic breathing should only be used if the patient is breathing in a way that increases the symptoms of panic e.g. chronic hyperventilation.
• It is not used to prevent a panic attack occurring.
• Be aware of it becoming a safety behaviour. (e.g. ‘the only reason I didn’t pass out is because I did my controlled breathing’)