1. 1 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Slides & Handouts by Karen Clay Rhines, Ph.D. Panic Attacks! Dr. Michael Tulloch Slides by M. Tulloch, Ph.D.

2. 2 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Attack! "For me, a panic attack is almost a violent experience. I feel disconnected from reality. I feel like I'm losing control in a very extreme way. My heart pounds really hard, I feel like I can't get my breath, and there's an overwhelming feeling that things are crashing in on me." "I was sitting in a business seminar in a hotel and this thing came out of the blue. I felt like I was dying." "In between attacks there is this dread and anxiety that it's going to happen again. I'm afraid to go back to places where I've had an attack. Unless I get help, there soon won't be anyplace where I can go and feel safe from panic." Slides by M. Tulloch, Ph.D.

3. 3 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Attack Facts Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer. Panic disorder affects about 6 million American adults11 Panic disorder is twice as common in women as men.22 Panic attacks often begin in late adolescence or early adulthood,22 Not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited.33 Panic disorder is often accompanied by other serious problems, such as depression, drug abuse, or alcoholism.4,54,5

4. 4 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Risk Factors Adolecence or early adulthood Major life transitions perceived as stressful Graduating from college, getting married, having a first child Genetics If a family member has panic disorder, you have an increased risk Especially during a time in your life that is particularly stressful. Slides by M. Tulloch, Ph.D.

5. 5 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Untreated Outcomes People who have full-blown, repeated panic attacks can become very disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. For example, if a panic attack happened in an elevator, someone with panic disorder may develop a fear of elevators that could affect the choice of a job or an apartment, and restrict where that person can seek medical attention or enjoy entertainment. Some people's lives become so restricted that they avoid normal activities, such as grocery shopping or driving. About one-third become housebound or are able to confront a feared situation only when accompanied by a spouse or other trusted person. When the condition progresses this far, it is called agoraphobia, or fear of open spaces.

6. 6 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder Panic, an extreme anxiety reaction, can result when a real threat suddenly emerges The experience of “panic attacks,” however, is different Panic attacks are periodic, short bouts of panic that occur suddenly, reach a peak, and pass Sufferers often fear they will die, go crazy, or lose control Attacks happen in the absence of a real threat

7. 7 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder Anyone can experience a panic attack But some people have panic attacks - Repeatedly Unexpectedly Without apparent reason Diagnosis: Panic disorder Sufferers also experience dysfunctional changes in thinking and behavior as a result of the attacks Example: sufferer worries persistently about having an attack; plans behavior around possibility of future attack

8. 8 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4

9. 9 Panic Disorder Often (but not always) accompanied by agoraphobia From the Greek “fear of the marketplace” Afraid to leave home and travel to locations from which escape might be difficult or help unavailable Intensity may fluctuate [But DON”T use this as diagnostic!] There has only recently been a recognition of the link between agoraphobia and panic attacks (or panic-like symptoms) [But DON”T use this as diagnostic!]

10. 10 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder Two diagnoses: panic disorder with agoraphobia; panic disorder without agoraphobia ~3% of U.S. population affected in a given year ~5% of U.S. population affected at some point in their lives Likely to develop in late adolescence and early adulthood Women are twice as likely as men to be affected All ethnic groups are vulnerable to panic disorder ~ 35% of those with panic disorder are in treatment Slide modified by M. Tulloch, Ph.D.

11. 11 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Different from other Phobias Phobias that people with panic disorder develop do not come from: Fears of actual objects Fears of real events events Panic Disorders come from Fear of having another attack “Triggers” People will avoid certain objects or situations because They fear that these things will trigger another attack Classical Conditioning Fear Response paired with place/object/person/situation Generalization Slides by M. Tulloch, Ph.D.

12. 12 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Biological Perspective What biological factors contribute to panic disorder? Neurotransmitter responsible is believed to be norepinephrine Irregular in people with panic attacks Research suggests that panic reactions are related to changes in norepinephrine activity in the locus ceruleus Although norepinephrine is clearly linked to panic disorder, what goes wrong isn’t exactly understood May be excessive activity, deficient activity, or some other defect Other NTs and brain circuits seem to be involved

13. 13 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Biological Perspective It is also unclear why some people have such abnormalities in norepinephrine activity Inherited biological predisposition is one possibility Prevalence should be (and is) greater among close relatives Among monozygotic (MZ, or identical) twins = 24% Among dizygotic (DZ, or fraternal) twins = 11% Issue is still open to debate

14. 14 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Biological Perspective In the 1960s, it was recognized that people with panic disorder were not helped by benzodiazepines, but were helped by antidepressants Researchers worked backward from their understanding of antidepressant drugs [Which is still relatively poor] [Which is still relatively poor] See Am J Psychiatry 161:7, July 2004 for an interesting discussion of the appropriate use of benzodiazepines vs SSRIs. Apparently, current clinical experience is that the former is appropriate for treatment of symptoms but is subject to abuse so that SSRIs are more suitable for recurrent attacks and long term prophylactic treatment. Slide modified by M. Tulloch, Ph.D.

15. 15 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Biological Perspective Drug therapies Antidepressants are effective at preventing or reducing panic attacks Function at norepinephrine receptors in the panic brain circuit Bring at least some improvement to 80% of patients with panic disorder ~50% recover markedly or fully Require maintenance of drug therapy; otherwise relapse rates are high Some benzodiazepines (especially Xanax [alprazolam]) also have proved helpful Disagrees with previous slide

16. 16 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Biological Perspective Drug therapies Both antidepressants and benzodiazepines are also helpful in treating panic disorder with agoraphobia Break the cycle of attack, anticipation, and fear Combination treatment (medications + behavioral exposure therapy) may be more effective than either treatment alone

17. 17 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Venlafaxine: Mechanism of Action Is thought to work by strongly inhibiting reuptake of serotonin (or 5-HT) strongly inhibiting reuptake of norepinephrine weakly inhibiting the reuptake of dopamine It is thought that increasing the available amount of these neurotransmitters helps individuals suffering from depression. However, the medication's full mechanisms of action are not entirely understood.

18. 18 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Venlafaxine (SSRI) may cause side effects that mimic panic attacks * change in ability to taste food * loss of appetite * weight loss * uncontrollable shaking of a part of the body * pain, burning, numbness, or tingling in part of the body * muscle tightness * twitching * yawning * sweating * hot flashes or flushing * frequent urination * difficulty urinating * sore throat, chills, or other signs of infection * ringing in the ears * changes in sexual desire or ability * enlarged pupils * drowsiness * weakness or tiredness * dizziness * headache * nightmares * anxiety * nausea * vomiting * stomach pain * constipation * diarrhea * gas * heartburn * burping * dry mouth Slides by M. Tulloch, Ph.D. Caution

19. 19 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Cognitive Perspective Cognitive theorists and practitioners recognize that biological factors are only part of the cause of panic attacks In their view, full panic reactions are experienced only by people who misinterpret bodily events Cognitive treatment is aimed at correcting such misinterpretations

20. 20 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Cognitive Perspective Misinterpreting bodily sensations Panic-prone people may be overly (or especially) sensitive to certain bodily sensations and may misinterpret them as signs of a medical catastrophe; this leads to panic Why might some people be prone to such misinterpretations? One possibility: Experience more frequent or intense bodily sensations Another possibility: Experience abnormal sensations

21. 21 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Cognitive Perspective Misinterpreting bodily sensations Panic-prone people also have a high degree of “anxiety sensitivity” They focus on bodily sensations much of the time, are unable to assess the sensations logically, and interpret them as potentially harmful

22. 22 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Cognitive Perspective Cognitive therapy Attempts to correct people’s misinterpretations of their bodily sensations Step 1: Educate clients About panic in general About the causes of bodily sensations About their tendency to misinterpret the sensations Step 2: Teach clients to apply more accurate interpretations (especially when stressed) Step 3: Teach clients skills for coping with anxiety Examples: relaxation, breathing

23. 23 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Cognitive Perspective Cognitive therapy May also use “biological challenge” procedures to induce panic sensations Induce physical sensations which cause feelings of panic: Jump up and down Run up a flight of steps Practice coping strategies and making more accurate interpretations

24. 24 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Panic Disorder: The Cognitive Perspective Cognitive therapy is often helpful in panic disorder 85% of treated patients are panic-free for two years compared with 13% of control subjects Only sometimes helpful for panic disorder with agoraphobia At least as helpful as antidepressants Combination therapy may be most effective Still under investigation

25. 25 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Treatment Approaches Cognitive Restructuring Cognitive Therapy Interoceptive Exposure Relaxation Techniques Medication Support Groups Relaxation Techniques Based upon material from © 2007 American Psychological Association© 2007 American Psychological Association

26. 26 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Treatment - Info The first part of therapy is largely informational Many people are greatly helped by simply understanding exactly what panic disorder is and how many others suffer from it. Many people who suffer from panic disorder are worried that their panic attacks mean they're 'going crazy' or that the panic might be or induce a heart attack. 'Cognitive restructuring' (changing one's way of thinking) helps people replace those thoughts with more realistic, positive ways of viewing the attacks. Based upon material from © 2007 American Psychological Association© 2007 American Psychological Association

27. 27 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Treatment - Cognitive Cognitive therapy can help identify possible triggers for the attacks. The trigger in an individual case could be something like A thought A situation Something subtle like a slight change in heartbeat. Therapy Goals Understanding that the panic attack is separate and independent of the trigger Awareness of the trigger(s) so it begins to lose some of its power to induce an attack. Based upon material from © 2007 American Psychological Association© 2007 American Psychological Association

28. 28 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Treatment - Behavioral Behavioral components of the therapy can consist of what some clinicians call 'interoceptive exposure.' Similar to the systematic desensitization used to cure phobias, but it focuses on exposure to the actual physical sensations that someone experiences during a panic attack. Interoceptive exposure helps patients experience the symptoms of an attack (elevated heart rate, hot flashes, sweating, etc.) in a controlled setting Teachs patients that symptoms need not develop into a full-blown attack. Based upon material from © 2007 American Psychological Association© 2007 American Psychological Association

29. 29 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Treatment – Behavioral 2 Behavioral therapy is also used to deal with the situational avoidance associated with panic attacks. One very effective treatment for phobias is in vivo exposure breaking a fearful situation down into small manageable steps doing them one at a time until the most difficult level is mastered. Based upon material from © 2007 American Psychological Association© 2007 American Psychological Association

30. 30 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Treatment - Medication Sometimes medications may also be needed Prescriptions may include Anti-anxiety medications Antidepressants sometimes beta blockers Used to control irregular heartbeats “Absorbs” / counteracts adrenaline Based upon material from © 2007 American Psychological Association© 2007 American Psychological Association

31. 31 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Treatment - Support A support group with others who suffer from panic disorder can be very helpful to some people. It can't take the place of therapy, but it can be a useful adjunct. May also be helpful to family members Based upon material from © 2007 American Psychological Association© 2007 American Psychological Association

32. 32 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Treatment - Relaxation Relaxation techniques can further help someone 'flow through' an attack These techniques include breathing retraining and positive visualization Some experts have found that people with panic disorder tend to have slightly higher than average breathing rates Learning to slow breathing can help someone deal with a panic attack Mayprevent future attacks by maintaining feeling of control May prevent attacks by maintaining proper CO2 blood levels

33. 33 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Additional Resources International Handbook of Phobic and Anxiety Disorders in Children and Adolescents By Thomas H. Ollendick, Neville J. King, William Yule, Eds. Chapter 13 deals with Panic Disorder DSM-III-R Requirements for diagnosing Panic Attacks One unexpected, full symptom attack Four attacks or fears of an attack w/in four week period

34. 34 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 How can I tell if it's a Panic Attack? Slides by M. Tulloch, Ph.D.

35. 35 Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 4 Could it be something else (or something more)? http://www.adaa.org/GettingHelp/SelfHelpTests.asp