Beyond Fight or Flight: Panic Disorder

Well , hi everybody , including you people up there in the freezing north . I'm looking in the old mailbag and Sandy from Albion , michigan , asked for information that would be useful for the licensing exam about panic disorder . Hi , my name's Eric Kwokman .

And I'm Dr Linton Hutchinson . Today we're going to focus on the complexities , the diagnosis , and treatment approaches of panic disorder .

And let's start by clarifying what makes panic disorder distinct .

Can you break it down for us ? Sure , so when we look at panic disorder , we're seeing reoccurring unexpected panic attacks paired with persistent worry about future attacks . What makes this condition unique is the behavioral changes that occur in response to those attacks .

Right , you are . Panic attacks tend to hit suddenly and intensely , unlike anxiety , which tends to build gradually , and they either occur without any noticeable trigger or by specific situations .

Well , I'm interested in how the different type of attacks that a client has are categorized .

Well , there are three main types . First , the unexpected attacks , like I mentioned , that come without warning . Then you have situationally bound attacks , which consistently occur in specific situations . And the third type is situationally predisposed attack , where exposure to a trigger might lead to an attack , but it might not .

So it's the unpredictability that often leads to significant changes

Yes , which makes it so that clients often create elaborate avoidance strategies Taking a longer route to work , refusing to eat in certain restaurants , avoiding exercise which might increase their heart rate . These changes can seriously impact their work relationships , basically their overall quality of life .

Wow , I had something like that happen to me . I was in Publix right down the street and they ran out of kimchi that I really like . I ended up going to another store farther away just to avoid feeling disappointed .

Well , what a stressful situation that must have been , but I don't think that's exactly the same thing , is it ?

You know maybe not what are the specific criteria for diagnosing panic attacks .

Well . According to the DSM , diagnosis requires recurrent unexpected panic attacks followed by at least one month of either persistent concern about additional attacks or significant behavioral changes , and during the attacks a client needs to experience four or more specific symptoms .

Uh-huh , and that can manifest as both physical and cognitive

Well , several anxiety disorders , including ones that are substance-related and medical condition-related . Anxiety disorders are differential . The key is the sudden onset and intensity . Unlike anxiety , these symptoms peak within minutes and often feel overwhelming to the client in that short period of time .

Wasn't that what Churchill said during the Second World War ?

Close . I think you're thinking about our president , Franklin Delano Roosevelt , who said those exact words , but he wasn't talking about this disorder . He was talking about the Great Depression . A client develops hypersensitivity to bodily sensation and their interpretation . That creates what's known as the fear response cascade . And how would you explain that to a client ?

I guess I just wouldn't they just have to take it on faith ? No , no , actually . I'd use some clear examples . They would notice that their heartbeat is slightly faster .

Well , the best thing to do would be to focus on helping clients recognize the pattern as it's happening and to work on reframing those initial interpretations and developing a more balanced response to physical sensations .

So you're saying you would intentionally try to have your client have a full-blown panic attack during sessions ?

That's right , just for fun ? No , of course not , but eventually you would work up to it . It's called in vivo desensitization . You go gradually , but we'll talk about that more later .

Okay , that sounds like a plan With panic disorder . Accurate assessment is very important . Let's go over some assessment tools that have been found to be effective

And that you might see on the exam . Right , right , right One is the Panic Disorder Severity Scale , which is widely used . It helps measure attack frequency , distress levels , various types of impairment and it looks at seven key areas .

Man , you can tell that was written by a psychologist , can't you ? Yes , you can . There's also the Anxiety Sensit body sensation questionnaire . The asi gives us insight into how clients interpret and respond to anxiety related physical symptoms . It measures fears about physical concerns , mental incapacitation and social evaluation .

And the mobility inventory for agoraphobia is used to track changes in avoidance patterns and the agoraphobic conditions questionnaire is for mapping out catastrophic thinking patterns .

And don't forget the Albany panic and phobia questionnaire . That is useful for identifying specific activities that produce sensations similar to panic attacks .

That's right . They either have the word panic or agoraphobic , which is part of that whole process . Some of these comprehensive assessments are to be used at intake , some used as a follow-up , at regular intervals to track progress and adjust treatment plans accordingly . Then panic attack records are reviewed weekly to identify any emerging patterns or triggers .

That sounds like a good transition to review some effective treatment approaches that might be on your licensing exam regarding panic disorder .

Well , you might start with psychoeducation about the nature of panic and the

Okay For those of you that believe in cognitive therapy , believe in cognitive therapy they tend to focus what ? I'm a believer . Okay , that will tend to focus on helping clients identifying and changing their catastrophic thoughts and also work on developing alternative interpretations of body sensations .

And another technique is with interoceptive exposure , that is , controlled exercises that safely reproduce feared situations like we were talking about before .

Progressive muscle relaxation and mindful body scanning have been particularly useful . There's a long form and an abbreviated version , so what are some challenges that therapists would see when treating panic disorder ?

Well , one frequent challenge is the client's reluctance to give up the safety behaviors that will actually help them . They often have elaborate systems of coping , like we talked about driving way out of your way to go to work or anything that they feel is protecting them but that actually maintain and reinforce the anxiety .

I see that there's also medical reassurance seeking . That's another common issue . Clients often get caught in the cycle of repeated medical tests and going to the emergency room every time that they have a panic attack . Those are the bare facts , and I think it's time for a quick knowledge check . Which of the following is not required for diagnosing panic disorder ?

Oh , so you didn't think I was listening to what I just said a few minutes ago . The correct answer is C Linton . The DSM requires four or more

Hmm , well , I'm not sure what temperamental means .

Well , you've been that way , so you should know Okay .

Environmental , genetic or employment Hard choices , but I'm going to say D unemployment . Not unemployment but employment . Yeah well , we've all been there . Yeah well , if you've seen some of the jobs I've done over the years , you would have to have me as a prime candidate for panic disorder , especially at the disco . Yes , of course .

Yes , remember , when you're taking the licensure exam , that each narrative subject's experience with panic is going to be unique , so your response needs to take that into account . But , as we always say , it's in there Absolutely . Thank you all for listening . Okay , see you later , ez Ciao .