Non- pharmacological Management

of Panic Disorder with Agoraphobia

Presenter: Dr. Manu Sharma
Chairperson: Ms. Neethi
Introduction
Greek god Pan, god of flocks.
Hippocrates (400 B.C), Benedikt (1970)
Donald Klein- described the panic
syndrome & reported that it was
responsive to imipramine.
Isaac Marks- described panic attacks &
agoraphobic avoidance, treating effectively
with behavior therapy.
DSM-IV Diagnostic Criteria for Panic
Attack
A discrete period of intense fear or discomfort,
in which four (or more) of the following
symptoms developed abruptly and reached a
peak within 10 minutes:
1) palpitations, pounding heart, or accelerated
heart rate
2) sweating
3) trembling or shaking
4) sensations of shortness of breath or
smothering
5) feeling of choking
6) chest pain or discomfort
 7) nausea or abdominal distress
8) feeling dizzy, unsteady, lightheaded, or faint
9) derealization (feelings of unreality) or
depersonalization (being detached from
oneself)
10) fear of losing control or going crazy
11) fear of dying
12) paresthesias (numbness or tingling
sensations)
13) chills or hot flushes
Introduction
In some fewer than 4 symptoms occur.
Known as limited symptom attack
Panics may be situational (cued) or
spontaneous (uncued)
out of the blue
Can be nocturnal
DSM-IV Diagnostic Criteria for Panic
Disorder With or Without Agoraphobia
A. Both (1) and (2):
(1) recurrent unexpected Panic Attacks
(2) at least one of the attacks has been followed
by 1 month (or more) of one (or more) of the
following:
persistent concern about having additional
attacks
worry about the implications of the attack or
its consequences (e.g., losing control, having a
heart attack, "going crazy")
a significant change in behavior related to the
attacks
 B. Presence or Absence of Agoraphobia
C. The Panic Attacks are not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication) or a general medical
condition (e.g., hyperthyroidism).
D. The Panic Attacks not better accounted for
by another mental disorder, such as Social
Phobia, Specific Phobia, Obsessive-Compulsive
Disorder, Posttraumatic Stress Disorder, or
Separation Anxiety Disorder.
 DSM-IV Diagnostic Criteria for
Agoraphobia
A) anxiety about being in places or situations
from which escape might be difficult (or
embarrassing) or in which help may not be
available in the event of having an unexpected

or situationally predisposed Panic Attack or panic-

like symptoms.
Agoraphobic fears typically involve characteristic
clusters of situations that include being outside
the home alone; being in a crowd, or standing in a
line; being on a bridge; and traveling in a bus, train,
or automobile.
 B) The situations are avoided (e.g., travel
is restricted) or else are endured with
marked distress or with anxiety about
having a Panic Attack or panic-like
symptoms, or require the presence of a
companion.
C) The anxiety or phobic avoidance is not
better accounted for by another mental
disorder.
 DSM implies a temporal relationship
between panic attacks & agoraphobic
avoidance. Primacy is given to panic disorder.
ICD-10 does not imply a primacy of panic
attacks in its nosological structure.
Agoraphobia is listed under Phobic Anxiety
Disorders. Acknowledged to occur with or
without PanD
PanD is placed within a category of other
anxiety disorders
 Empirical studies favor the DSM rather
than ICD-10
In pts who seek treatment, PanD typically
occurs before agoraphobia
Agoraphobia is characterized less by a
fear of certain situations & more by a fear
of having a panic in those situations.
 Separation of the two disorders serves
descriptive function.
The extent to which a pt requires
treatment.
Uncommon to see an individual with long
standing panic attacks who has no
situational avoidance & vice-versa.
Etiology
Vulnerability- genetic, general anxiety
proneness (neuroticism), stressful life
events
Flight or fight responses are triggered.
Action tendencies of these responses are
triggered inappropriately
Hyperventilation- can cause and/or
exacerbate an attack.
the suffocation alarm hypothesis-
This model assumes that panic disorder is
characterized by a pathologically low
threshold for firing of an evolved suffocation
alarm,
which can be activated by a number of
biological (e.g., carbon dioxide inhalation)
and psychological challenge procedure (e.g.,
feeling of being trapped) that signal
impending loss of oxygen.
Cognitive model of panic
Interoceptive conditioning-
Bodily sensations become conditioned stimuli
for the conditioned response to panic.
Pts become hyperalert for bodily sensations
& interpret these as a sign of oncoming panic.
Generalization of fear & external situations
become anxiety provokingagoraphobia.
Treatments attempt to extinguish fear of
fear by systematic exposure to internal
sensations.
 Vicious Circle model by Clark (1986)
Trigger
Perceived bodily sensations
Catastrophe related Attempts to
thoughts increase
Situations Apprehension respiration

Perception of
hyperventilati
imminent or
on
present threat

Avoidance &
Safety Behavior Perceived
breathlessnes
Misinterpretation Bodily or s
mental
sensations
Case Description
Mrs. S, a 33 yr old housewife, presented to
the OPD after reading a magazine article
describing hypochondriasis. For the past 10
yrs, she has received far too many medical
investigations because of her belief that she
is having a heart attack.
HOPI- 10 yrs ago, while attending a gym
class following birth of her only child , she
noticed a dramatic increase in her heart
rate. Afraid she was going to die of a heart
attack, she also noted that her breathing
became difficult, tingling in her hands, her
muscles became stiff, sweating, trembling,
intense stabbing pains in the chest. She left
her baby at the class & ran for help..
 An ECG was done-NAD. From that time on, a
pattern developed in which at least 3
times/month she notices palpitations, becomes
frightened that they signal a heart attack &
seeks reassuring medical advice.
Since the first heart attack, Mrs.S has had
great difficulty going on her own to places
where medical help wouldnt be available
quickly.
She can travel alone, provided she takes her
mobile phone with her, for she perceives that
this would enable her to contact emergency
services. Even so, she avoids crowded banks,
malls, theatres in case her escape is blocked.
Without her phone she doesnt leave home.
 The disorder had a clear onset, which the
sufferer dated to her first panic attack
Avoidance to situations developed
subsequent to panic attack, because she
feared the consequences of having an
attack in certain situations.
Dramatic sympathetic arousal, the true
origin of which was unclear to the pt &
subsequently misinterpreted as a sign of
serious physical pathology.
Assessment
1. Panic frequency, severity, duration
2. Panic-related phobia
3. Anticipatory anxiety
4. Impairment in general QOL
5. Global problem severity
Panic Attacks Symptom Questionnaire
(PASQ), Agoraphobic Cognitions
Questionnaire (ACQ), Body Sensations
Questionnaire (BSQ)
 Mobility Inventory ( Chambless et al., 1985)
lists agoraphobic situations that are rated in
terms of degree of avoidance, both when
alone & accompanied.
Anxiety Sensitivity Index ( Reiss et al.,
1986) measures threatening beliefs about
bodily sensations.
Albany Panic & Phobia questionnaire
assesses fear & avoidance of activities that
produce frightening physical sensations as
well as more typical agoraphobic situations.
Aims of Treatment
The control of panic attacks
Cessation of fear-driven avoidance
Reduction of vulnerability
CBT
The most effective psychological treatment for panic
disorder with agoraphobia to date is cognitive-
behavior therapy (CBT).
This treatment is usually delivered in 12 weekly 60-
min individual treatment sessions but can also be
conducted in a small group format.
Between each session, the patients are given clearly
specified homework assignments to practice the
newly acquired skills that are discussed in treatment.
In addition, patients are expected to complete daily
monitoring forms in order to identify specific panic
attack triggers. These serve the purpose of
monitoring the patients progress and enhancing the
patients sense of predictability and controllability.
CBT
the Panic Control Treatment protocol (PCT)
developed by David H. Barlow and his
colleagues.
consists of the following components:
(a) education about the nature of anxiety
and panic;
(b) training in slow breathing;
(c) cognitive restructuring;
(d) interoceptive exposure exercises;
(e) in vivo situational exposure exercises for
individuals with high levels of agoraphobia.
A. Education about the Nature of
Anxiety and Panic
During the first two sessions, patients are
taught about the nature and function of
fear and its nervous system correlates.
A three-component model is utilized, in
which the dimensions of anxiety are
grouped into physical, cognitive, and
behavioral categories.
 The physical component includes bodily changes
(e.g., neurological, hormonal, cardiovascular) and
their associated somatic sensations (e.g.,
shortness of breath, palpitations, lightheadedness).
The cognitive component consists of thoughts,
images, and impulses that accompany anxiety or
fear (e.g., thoughts of dying, images of losing
control, impulses to run).
The behavioral component contains behaviors
that are associated with anxiety (e.g., pacing,
carrying a safety object, or simply avoiding or
escaping the situation).
 The therapist then explains that the goal of
treatment is to learn skills for controlling each
of the three components of anxiety.
patients are taught slow, diaphragmatic
breathing.
patients are taught to critically examine, based
on past experience and logical reasoning,
their estimations of the likelihood that a feared
event will occur, the probable consequences if it
should occur,
their ability to cope with these consequences.
In addition, they are assisted in designing and
conducting behavioral experiments to test their
predictions.
 Panic diaries- used for keeping a daily
symptom record.
Left hand side is used to record the
situations in which a panic attack
occurred, sensations experienced, rating
of severity (0-100) & frequency per day.
Right hand side is used to record the
negative thoughts, his rate of belief in it
(0-100) & rational response to those
thoughts during the course of the therapy.
 The last column is for recording the re-
rating of belief in negative interpretation.
When specific symptoms are the main
concern, individualized diaries are used.
For e.g., individualized diary for a patient
with frequent urge for urination.
B. Breathing Retraining
patients are taught a breathing technique
that encourages slow, diaphragmatic
breathing over fast chest breathing.
the patients are usually asked to first
voluntarily hyperventilate by standing and
breathing fast and deeply, as if blowing up a
big balloon, for approximately 1 min.
This exercise typically induces intense and
unpleasant bodily sensations which often
resemble some of the sensations that
patients experience during a panic attack.
 Once the symptoms have abated, the
therapist educates the patients about the
physiological basis of hyperventilation and
suggests that this may often be associated
with panic attack episodes.
It is then suggested that chronic
hyperventilation, which may be caused by
relatively fast and shallow chest breathing,
might lower the threshold and therefore
increase the risk for experiencing recurrent
panic attacks.
 In the next step, the therapist introduces
a breathing control technique, which
encourages patients to rely on the
diaphragm rather than on chest muscles
when breathing.
patients are instructed to concentrate on
their breathing by counting their
inhalations and thinking the word relax
on exhalations.
 patients are further taught a technique to
slow the rate of breathing with the goal of
comfortably spanning a full inhalation and
exhalation cycle over 6 sec.
practice diaphragmatic breathing at least
two times a day, for at least 10 min for
each of the remaining sessions.
Applied relaxation
Entails training in Progressive Muscular
Relaxation until patients are skilled in a
cue-control relaxation, at which point
relaxation is used as a coping skill for
practicing items from a hierarchy of
anxiety-provoking tasks.
 A theoretical basis for relaxation for panic
attacks has not been elaborated, beyond
the provision of a somatic counter
response to muscular tension that is likely
to occur during anxiety & panic.
C. Cognitive Restructuring
Suggesting that thoughts are hypotheses or
guesses rather than facts.
The therapist explores the patients thinking
errors that are typically associated with
panic attacks.
The first error is probability overestimation,
or jumping to negative conclusions and
treating negative events as probable when in
fact they are unlikely to occur.
The second error is catastrophic thinking, or
blowing things out of proportion.
 The method for countering overestimation
errors is to question the evidence for
probability judgments.
Pts are encouraged to examine the evidence for
these predictions, while considering alternative,
more realistic hypotheses.
This is best done in a Socratic style (i.e., leading
questions) so that patients examine the content
of their statements and reach alternative
explanations.
Typical kinds of catastrophic thoughts are If I
faint people will think that I am weak and this
would be unbearable, or If people notice my
anxiety, I will make a fool of myself and I could
not deal with this.
D. Interoceptive Exposure
To change maladaptive anxiety behaviors,
patients learn to engage in graded
therapeutic exposure to cues they associate
with panic attacks.
focuses primarily on internal cues,
specifically, frightening bodily sensations.
Activities that are avoided because of the
associated physical sensations may not be
immediately obvious to patients.
 The purpose is to repeatedly induce
sensations that are feared and to weaken the
fear response through habituating and
learning that no actual danger results.
In addition, the repeated inductions allow
practice in applying the cognitive techniques
and breathing strategies.
They may include physical exercises like
jogging, climbing upstairs,
emotional discussions, suspenseful movies,
steamy bathrooms, drinking coffee, and other
arousing activities.
 During exposure, patients deliberately
provoke physical sensations like smothering,
dizziness, or tachycardia by means of
exercises such as breathing through a thin
cocktail straw, hyperventilating, spinning, or
strenuous physical exercise.
These exercises are done initially during
treatment sessions, with therapist modeling,
and subsequently by patients at home.
 E. In Vivo Situational Exposure
Exposure therapy typically begins with the
construction of a hierarchy of feared situations,
the pts are encouraged to enter real life
situations repeatedly, starting with easier ones,
and remain until anxiety diminishes.
Before conducting the exercises, the therapist
needs to thoroughly explore any forms of
avoidance and anxiety reducing strategies that
patients typically use.
Ideal situations at the beginning of the
exposures are situations that are under the
therapists control and in which escape and
avoidance strategies are difficult.
 There are various ways in which exposure
can be conducted:-
Therapist- directed vs self-directed
exposure
Massed vs spaced exposure
Graduated vs intense exposure
Endurance vs controlled escape
Attention vs distraction.
 Massed vs spaced exposure- 3-4 hours
per day, 5 days a week.
Long, continuous sessions are generally
considered more effective than shorter
or interrupted sessions
The optimal rate for repeating exposure
is vague.
 Foa et al., (1980) compared 10 weekly
sessions with 10 daily sessions of in vivo
exposure therapy for 11 patients with
agoraphobia
Short- term superior effects were
apparent following massed treatment.
 Barlow (1988) suggested that spaced
exposure is preferred for the following
reasons:-
Drop out rates are higher for massed
exposures
Relapse rates are higher following massed
exposures
Rapid changes are more stressful for the
family.
 Graduated vs Intense exposure
(Spifgenbaum, 1988)
After 8 months, it was shown to be equally
effective.
However, those receiving graded exposure
reported most difficulty.
Intense exposure was shown to be
superior after 5 yrs F/U assessment.
 Controlled escape vs Endurance
Endurance model of fear extinction states
that continuation of an exposure trial is
done until anxiety reaches a peak.
Barlow (1968) reported successful results
without endurance of high levels of anxiety
in fear situations.
Dasilva (1984) reported that max fear
elicitation was not necessary for extiction.
 Attention vs Distraction (Ceraske et al,
1989)
Exposure is most functional when attention is
directed at the phobic object & when external
distraction is minimal.
Pts monitor bodily sensations & thoughts, also
use thought stopping & self focus statements
to interrupt distraction.
In some, taught to use self distraction tasks
during in vivo exposure.
Studies have not shown one to superior to the
other.
 Exposure should be combined with
instructions regarding the true causes of
panics & anxiety management strategies.
Exposure
The strongest and most consistently
demonstrated treatments for
agoraphobia.
Shown to be superior to placebo.
Greater the exposure exercises resemble
the real situations avoided by individuals,
better the outcome.
The more frequently & greater duration
of confrontation of feared situation,
higher is the end state functioning.
Conclusion
Combining imipramine and CBT had
limited advantage acutely but more
substantial advantage in the longer term.
Six months after treatment
discontinuation, however, people were
more likely to maintain their treatment
gains if they received PCT, either alone or
in combination with a pill placebo.
Conclusion
It is not known at present which components of
CBT are most important for treatment efficacy
or whether they all contribute uniquely to
efficacy.
Panic pts with high levels of agoraphobia seem to
respond best to in vivo situational exposure.
Pts with moderate or mild agoraphobia seem to
respond best to CBT protocols that combine
cognitive restructuring, psychoeducation,
interoceptive exposure exercises, and breathing
retraining and relaxation exercises.
Conclusion
In a meta-analysis of 43 controlled studies of treatment
for panic disorder, the largest mean effect size was
obtained for
the combination of cognitive therapy plus interoceptive
exposure (.88),
followed by CBT without interoceptive exposure (.68),
CBT plus medication (.56), and
medication alone (.47).
Moreover, dropout rates from CBT were lower than
dropout rates from medication conditions (alone or in
combination with therapy).
Another review by the Cochrane Collaboration found
21 trials comparing CBT to medications and their
combination. Results suggested that combination
treatment is superior to medication alone.
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