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Panic Disorder
How a Panic Disorder Often Starts:
Because a panic attack is such an uncomfortable experience, a person
learns to be hypervigilant to or oversensitive to even the smallest
internal sensations (e.g., change in heart rate), including those
triggered by medication changes or medical problems, such as cardiac
problems.
A vicious cycle can develop. When a person notices an internal sensation,
their sympathetic nervous system (SNS) activates, creating more sensations,
more SNS arousal, and so on, causing a positive feedback loop that
sometimes culminates in a panic attack. This is analogous to holding
a microphone next to a loudspeaker. An initial signal is picked up
by the microphone, amplified by the system, coming out the loudspeaker
with more intensity, getting further amplified by the system, etc.
So...
- A panic attack is extremely unpleasant and frightening. This cascading
of physiological and cognitive events reinforces the learning that
certain internal sensations are something to be feared.
- Because of the learned hypervigilance and fear of internal sensations,
the individual might also react phobically to sensations caused
by medications and by medication withdrawal.
- Agoraphobic avoidance. A person may then generalize the fear of
internal sensations to situations they associate with panic, especially
situations that are difficult to escape or get help in -- e.g.,
crowded places or being home alone.
The treatment with the best
outcome data involves a combination of:
- Relaxation training is typically the first step with an emphasis
on breathing retraining.
- Incorrect breathing associated with anxiety typically sets off
a chain of events leading to more alkaline blood, constriction of
blood vessels going to the brain and elsewhere, and a state where
the hemoglobin holds onto oxygen in the bloodstream.
- This in turn can cause a number of symptoms including lightheadedness,
dizziness, sense of unreality (derealization), blurred vision, confusion,
and breathlessness.
- Cognitive training to short-circuit anxiogenic thoughts that generate
further adrenalin release and other SNS arousal, thoughts such as:
''what if I have a panic attack?!'' ''What if I totally lose control?!''
- Interoceptive desensitization, which means desensitizing to internal
sensations.
- With interoceptive desensitization, in small doses, a person
deliberately provokes internal sensations in controlled, measurable
ways, followed by rest breaks.
- A common way to accomplish interoceptive desensitization is to
have a person breathe through a coffee stir for 30 seconds followed
by a rest break that might last several minutes. The restricted
breathing for 30 seconds will typically produce some internal sensations;
people with panic disorder often react to those sensations with
an extra layer of nervous system arousal (though usually not a full
panic attack).
- With repeated trials, a person learns through experience that
these internal sensations do not need to be feared - the individual
becomes less sensitized or desensitized to the internal sensation.
After repeated trials, when nothing catastrophic happens, the brain
learns (hippocampus & amygdala) to not fear the sensations, and
the SNS activation fades.
- In vivo desensitization. If an individual goes through this protocol
and is still fearful of situations such as crowded places, the next
phase of treatment involves desensitizing to such situations.
- Medication tapering. The last phase of treatment can involve tapering
of anxiolytic medications, depending on the individual situation.
Outcome Literature on Panic
Disorder.
- Barlow and Lehman (1996) reviewed 12 studies on the efficacy of
behavioral methods and found an average panic-free rate of 77% following
behavioral treatment.
- In controlled studies of interoceptive exposure treatments compared
to other treatments, those treatments that included interoceptive
exposure were found to be significantly superior to other treatments
such as muscle relaxation alone, or education or insight-oriented
treatments.
- In a study by Barlow & Craske (1989), 87% of the individuals that
participated in the two of four treatments that involved interoceptive
desensitization were free of panic at the end of treatment and these
results were maintained at a 2-year follow up.
- Individuals treated only with medications have a high relapse
rate.
- In a study by Brown and Barlow (1995) that included a 24-month
follow-up, one of their findings was that "Use of psychotropic medication
during treatment was associated with poorer outcome..." (p. 754).
- ''ith regard to panic disorder, there is presently no convincing
evidence that adding a benzodiazepine to an effective form of cognitive
behavior therapy significantly improves treatment outcome either
acutely or in the long term'' (Spiegel & Bruce, 1997, p. 777).
- When primary treatment consists of benzodiazepines, relapse rates
are typically around 50% (Marks et al., 1993) compared to much lower
relapse rates for behavioral treatment as noted in 4a above.
- In addition, some experts feel that medications such as benzodiazepines
actually interfere with behavioral outcome because the medications
suppress the anxiety necessary to actually complete the desensitization
effect (Spiegel & Bruce).
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