Panic Disorder

viewHow a Panic Disorder Often Starts:

  1. Because a panic attack is such an aversive experience, a person learns to be hypervigilant or very “on-guard” for and sensitive to even the smallest internal sensations (e.g., change in heart rate), including those triggered by medication changes or cardiac or other medical problems. 
  2. When a person notices such a 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.  See diagram on next page.  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. 
    1. 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. 
    2. Because of the learned hypervigilance and fear of internal sensations, the individual commonly will react phobically to sensations caused by medications and by medication withdrawal. 
  3. Breathing & Panic.  Individuals with panic tend to breathe incorrectly, which often sets off the cycle and symptoms.
  4. 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 focuses on interoceptive exposure but involves a combination of:

  1. Breathing re-training (as long as it is not inadvertently used to block desensitization).   
    1. 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.
    2. This in turn can cause a number of symptoms including lightheadedness, dizziness, sense of unreality (derealization), blurred vision, confusion, and breathlessness.
  2. 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?!” 
  3. Interoceptive exposure & desensitization, which means desensitizing to internal sensations.  Dismantling studies indicate that this is the heart of treatment for panic. 
    1. With interoceptive exposure, in small doses, a person deliberately provokes internal sensations in controlled, measurable ways, followed by rest breaks. 
    2. A common way to accomplish interoceptive exposure 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 SNS arousal (though usually not a full panic attack). 
    3. 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. 
  4. In vivo exposure & 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. 
  5. Medication tapering.  The last phase of treatment can involve tapering of anxiolytic medications, depending on the individual situation. 

 Outcome Literature on Treatment of Panic Disorder.

  1. Barlow and Lehman (1996) reviewed 12 studies on the efficacy of CBT (cognitive-behavioral therapy) methods.  They found an average panic-free rate of 77% following behavioral treatment.
  2. Within CBT methods, those that include interoceptive exposure (IE) have the best outcome.
    1. In a study by Barlow & Craske (1989), 87% of the individuals who participated in the treatments that involved IE were free of panic at the end of treatment and these results were maintained at a 2-year follow up.
  3. CBT is effective for nocturnal panic attacks (Craske et al., 2005). 
  4. Warning:  don’t stop your medications abruptly and without speaking with your prescriber.  Stopping some of these medications abruptly can cause seizures or other problems. 
  5. CBT versus medications.  Although medications are sometimes helpful in the short run, panic treated with medications only results in a high relapse rate. 
    1. Klosko et al. (1990) found that at the end of treatment:
      1. Interoceptive treatment:  87% free of panic.
      2. Xanax (alprazolam):  50% free of panic.
      3. Placebo:  36% free of panic.
      4. Waiting list:  33% free of panic. 
  6. Panic:  combination approach .  This is the most common approach, but is not necessarily the best approach.  In a meta-analysis of 21 randomized trials with 1,700 patients published in Lancet (Roy-Byrne, Craske, & Stein, 2006): 
    1. Those treated with antidepressants (ADMs) + CBT did better than those treated with ADMs alone. 
    2. After treatment stopped, those who received ADMs + CBT continued to improve in contrast to those treated with ADMs only. 
    3. However, combo folks did no better than therapy alone. 
    4. CBT seemed to be most effective. 
    5. 2 large trials indicated that after medications were stopped, those who had combo did worse than CBT only group.  
    6. Again, don’t make any changes in your medications without consulting with your physician or prescriber.  If you are interested in getting off of your medications, we can address that as the last phase of treatment. 
  7. Effectiveness of CBT in “real world” conditions:  
    1. Comorbidity.  CBT for panic has been found to be effective when a person has both panic and another condition such as depression (Allen & Barlow, 2006). 
    2. Community mental health centers (Wade et al., 1998). 
    3. Primary care settings (Roy-Byrne et al., 2005). 

Overbreathing Problems.  For further information, see workbook.

    1. Anxiety or fear trigger an increase in breathing so that the large muscles have a good supply for fight-or-flight.  However, if there is no real physical work going on, then the oxygen is not being used up and hyperventilation occurs.  This can be subtle, building up over time. 
    2. Drop in CO2.  Proportionately, then, there is a drop in carbon dioxide (CO2) relative to levels of oxygen in the system.  Our systems are more sensitive to CO2 than to oxygen levels. 
    3. The drop in CO2 causes drop acidity of the blood, making it alkaline.
    4. The drop in CO2 and the drop in acid content then cause most of the physical changes experienced in panic. 
    5. The above cause a constriction in blood vessels around the body. 
    6. The hemoglobin increases its stickiness for oxygen. 
    7. Less oxygen is released from the blood stream to go out to various organs and tissues. 
    8. Although this chain of events is not a medical threat, it causes a number of symptoms. 
      1. In the central nervous system, this chain of events causes these symptoms: 
        1. Dizziness
        2. Lightheadedness
        3. Confusion
        4. Breathlessness
        5. Blurred vision
        6. Feelings of unreality. 
      2. In the peripheral nervous system
        1. Increased heart rate – to move more blood around the system.
        2. Numbness and tingling in the extremities.
        3. Cold, clammy hands. 
        4. Stiff muscles. 
      3. Other: 
        1. Sense of shortness of breath, sometimes with sense of choking or smothering. 
        2. Since over-breathing is hard work on the body, person may feel hot, flushed, and sweaty.  After a long enough period of over-breathing, person may feel tired and exhausted. 
        3. Since many people breathe incorrectly from their chest versus the diaphragm (belly breathing), the chest muscles may feel tired and there may be chest tightness from this.
        4. Yawning or sighing.  Often, individuals who over-breathe develop a habit of yawning or sighing, which actually makes the problem worse because the yawning or signing dumps a large amount of CO2 from the system quickly, further lowering the amount of CO2 in the blood. 
    9. Again, the above chain of events can be subtle, occurring at low enough levels that symptoms are not perceptible and then an imperceptible small change in breathing can push things beyond a threshold, causing a panic attack that might seem to have come out of the blue.  
For workbook suggestions and references click here

Please call the Health Psych Maine office at 207-872-5800 if you would like more information or to schedule an appointment.