False Alarms and “Safe” Harbors: Panic Disorder and Agoraphobia John D. McKellar, PhD Clinical Psychologist Department of Veteran Affairs, Clinical Educator Stanford University

Panic Attack Panic Attack Abrupt episode of intense fear Sweating Trembling/shaking SOB Choking Dizziness Chills/hot flushes Paresthesias Palpitations Fear of dying Fear of loss of control Nausea/abdominal distress Derealization/ depersonalization Chest pain/discomfort Panic Attack Abrupt episode of intense fear Cue induced and non cue induced Associated cognitive and physical symptoms Short duration

Panic Disorder Panic disorder Agoraphobia Recurrent panic attacks Unexpected, spontaneous attacks At least one month of persistent concern about the attacks Agoraphobia Anxiety about being in a place where escape is difficult if a panic attack occurs Situations are avoided or endured with marked distress Occurs with and without panic d/o Imperfect diagnostic categories- lot’s of variability in severity

Interventions for Panic Disorder Panic Control Therapy The “Gold Standard” intervention May work with medication therapy but not with benzodiazepine medications. Antidepressants - Some evidence of benefit Benzodiazepines (Xanax, Valium, etc.) - Poor evidence of longterm benefit

Panic Control Therapy Education Relaxation and Challenging Negative Thoughts Exposure exercises (interoceptive) Exposure to feared situation (for agoraphobia)

Panic Control Therapy Education Fear responses can be adaptive to react to emergency situations When fear responses “misfire” we look for the source of threat In the absence of the threat we look to the physical symptoms as a threat (e.g., I am having a heart attack, Something is seriously wrong with me

Panic (and Generalized Anxiety Disorder) Catastrophic Thinking- negative interpretations about the outcome of physical sensations Shortness of breath, hyperventilation, pounding heart, dizziness, (physical symptoms) Increased Anxiety

Challenging Thoughts in Panic De-catastrophizing worksheet for panic attack: Catastrophizing Thoughts (What if…) De-catastrophizing (Is this possible/likely? So what!!!) What if I am having a heart attack? What has happened in the past? How likely is this? Have I ever had a heart attack? What is the probability I am having a heart attack?

Exposure Exercises Beginning Examples: Breathing in and out of a straw Holding one’s breathe for 30 seconds Breathing into a paper bag Holding full body tension Shaking one’s head back and forth Spinning around in a chair The point is to trigger “interoceptive” anxiety

ESCAPE Anxiety TIME

Exposure Exercises Next step: Panic Disorder: Trigger full blown panic attack Agoraphobia: Trigger full blown panic attack and then “expose” slowly to feared situations

ESCAPE Anxiety TIME

Self-help Resources Mastery of your Anxiety and Panic: Workbook (4th Edition)David Barlow and Michelle Craske