Diagnostic Criteria for a Panic Attack:
A panic attack is an explicit period of extreme discomfort or fear where at least four of the following criteria develop abruptly and peak within 10 minutes of time:
- Palpitations, or excited heart rate
- Shortness of breath/smothered sensation
- Sensations of choking
- Chest discomfort or pain
- Nausea or abdominal discomfort
- Criteria continued
- Feeling faint, dizzy, unsteady, lightheaded
- Feelings of unreality or detachment from reality (depersonalization)
- Fear of losing control or “going crazy”
- Fear of death
- Numbness or tingling sensations
- Hot or cold flashes
Diagnostic Criteria for Agoraphobia
- Anxiety about being in places or situations from which escape might be difficult (or embarrassing), or in which one could possibly suffer a panic attack.
- These situations often include crowds, busses, bridges, trains (&autos), and places outside the home
- Note: if avoidance is limited to a few situations, it is probably a Phobia. If limited to only social situations, is probably a Social Phobia
- Situations (mentioned prior) are avoided, or endured with noticeable distress, & often anxiety about having a panic attack.
- Anxiety/phobic behavior not better accounted by another disorder.
Diagnostic Criteria for Panic Disorder (300.01)
- Unexpected, recurrent panic attacks (usually with no known catalyst reported)
- Attack followed by a minimum one month of concern about having additional attacks,
- Fear of consequences (losing control, dying, “going crazy”)
- Significant alteration of usual behavior related to previous attacks
- Attacks not due directly to drugs or physiology (i.e. cocaine, hyperthyroidism)
- Attacks not better accounted for by another diagnosis (i.e. social phobia, OCD, separation anxiety)
Diagnostic Criteria for Panic Disorder with Agoraphobia 300.21
- Maintains same criteria as 300.01.
- In addition: includes criteria for agoraphobia disorder.
The Diagnostic Interview
An in depth interview is the first step in establishing a diagnostic profile
Recommended: The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)
Assesses Anxiety, mood, & somatoform disorders. Screens for psychotic and drug conditions.
Do Not Diagnose!…until medical conditions are ruled out.
PD/PDA like symptoms can be facilitated by:
- Caffeine or Amphetamine intoxication
- Do Not Diagnose (Cont.)
- Caffeine/Amphetamine Intoxication
- Thyroid conditions
- Drug Withdrawal
- Pheochromocytoma (a rare adrenal gland tumor)
ALSO, the following can EXACERBATE PD/PDA
- Mitral Valve Prolapse (heart palpitations)
- Asthma (shortness of breath)
- Allergies (shortness f breath)
- Hypoglycemia (weakness/dizziness)
- Functional Analysis
- Various methods of assessment such as the Clinical Interview, Standardized Inventories (the Mobility Inventory, Anxiety
- Sensitivity Index, etc.), and Behavioral tests will provide the material for a full functional analysis.
- Functional Analysis
- Panic attack topography: Sensations, frequency, duration, apprehension (how often thinking about them), and type (expected or unexpected)
- Antecedents: Situational (where PA occurs), internal issues (thoughts of “the big one”)
- Misappraisals: Physical (heart attack), mental (going crazy), and social (others will think…)
- Functional Analysis (2)
- Behavioral reactions to PA: Escape (avoiding places), help seeking, protection (body checks, drugs)
- Behavioral RXNs to anticipation: Avoidance, cognitive avoidance, safety signals (carries meds, always knows where people are, etc.)
- Consequences: Family, work, leisure, social
- Functional Analysis (3)
- Assess general mood
Rationale for CBT treatment for PD/PDA
The success of CBT on PD/PDA is considered one of psychotherapies greatest achievements: 80-100% of clients in CBT treatment for PD/PDA will be without panic at the end of treatment. Such results are still existent during a 2 year follow-up and it is a higher rate than effective medications.
Also, 50-80% of these clients are “cured” in that they have no symptomatology (and many of the remaining have only residual symptoms). However, as many as 50% of clients retain substantial symptomatology post-treatment. Especially those with agoraphobic issues. Also, some clients necessitate significantly longer periods of CBT before meaningful/improved In Vivo response occurs.
Basic Components of CBT for PD/PDA
- Breathing Retraining: this became a central component early for panic intervention because of the high instance of PD/PDA patients who report hyperventilatory symptoms. However, less than 50% of PD patients show a reductions in carbon dioxide. Therefore, hyperventilation might best be viewed as a stress-induce symptom that instigates fear.
- Interoceptive Exposure: purpose is to reduce the fear of one’s specific bodily cues (i.e. heart palpitations are harmless, and are not heart attacks).
In Vivo Exposure
Treatment Protocol (Session 1)
Goals of Session 1:
- Describe anxiety: and identify patterns of anxiety and places/situations in which it occurs. Investigate briefly when first occurred.
- Help patient in identifying antecedents: (situational, physical, and mental)
- Provide a treatment rationale & treatment description
- Introduce self monitoring/homework.
- Self Monitoring/Homework
- Keep in mind the “three-response system:” (when you are anxious, what do you feel, think, and do?)
- Log any panic attacks in the panic attack record. This is carried in the patients wallet and completed as soon as possible post-bellum any panic attack.
- Self Monitoring/Homework (2)
- The Daily Mood Log is used for to rate daily levels of depression, anxiety, and worry about PAs.
Goals of Session 2:
- Describe the physiology underlying anxiety and panicThe survival value and protective function of anxiety and panic (i.e. fight or flight)
- The physiological basis for sensations during a panic attack (sympathetic nervous functioning)
- The roll learned and cognitively directed fears and thoughts on panic sensations (panic attacks the seem to come from “out of the blue” are trigger by subtle internal cues)
- This information both reduces anxiety (and panic attacks) by decreasing uncertainty about panic attacks, and adds credibility/confidence to the CBT process.
- Homework (Session 2)
- Patients are instructed to read (and re-read) a handout on the physiological symptoms of anxiety and panic
- Patients are to develop an alternative conceptual framework and an objective versus subjective self monitoring awareness
- The therapist reassures clients the panic will subside as they persist in reading the material
Goals of Session 3
- clients asked to hyperventilate by breathing quickly and deep for 1½ minutes (to facilitate panic symptoms); after which the are instructed to sit, close their eyes and breath slowly until panic like symptoms have subsided
- 50-60% of clients report symptoms during the exercise emulated symptoms of a panic attack in vivo. However, because the environment is considered “safe” clients rate the experience as less anxiety provoking. This is important for the therapist to note—for it displays the significance of perceived safety on the degree of anxiety.
- The client is educated on breathing, in specific misinterpretations the client might possess about the issue of “overbreathing”
- The client is taught to breathe from the diaphragm, and to rely less on his/her chest muscles
- Client is instructed to concentrate on breathing by counting inhalation and thinking the word “relax” as he/she exhales
- Homework (Session 3)
- The integration of breathing exercises and cognitive control is emphasized.
- WARNING: On occasion clients mistakenly believe there are dire consequences should they fail in regulating their breathing, hence increasing anxiety and panic symptoms.
- Practice abdominal breathing BID, 10 min.
- Continue self-monitoring
Goals of Session 4
- Develop breathing control (at this point clients are instructed to practice slow breathing only in “safe” environments. Clients are discouraged to practice slow breathing in panic/anxiety situation, until they are skilled.
- Begin active cognitive restructuring.
- Clients are taught their thoughts are guesses, not facts!
- Furthermore, clients are taught the fallacy of their downward arrow thinking (Panic->Faint->embarrassment->overwhelming shame).
- Clients taught to observe their automatic thinking and self statements.
- Un-useful Statement/insufficient: “I feel terrible—something terrible might happen now!”
- Useful for challenging misassumptions “I am afraid if I get too anxious when driving that I will drive off the side of the road and die!”
- Homework: Question odds, look at evidence for thoughts. Continue monitoring.
Goals of Session 5
- Enhanced breathing control
- Fixing a second cognitive error: Catastrophizing– is where a client views a situation as dangerous, unbearable, or catastrophic. “If I faint, people will think that I am weak; and that would be unbearable.” “The whole evening is ruined if I start to feel anxious.”
- Decatastophising: to realize the scenarios are not as bad as you first thought.
- How to manage/cope with bad situations.
- Teach that awfulizing physiological symptoms is to give them control.
Goals of Session 6
- Begin Interoceptive Exposure (IE)
- Clients are often not aware of the things they avoid to avoid the physical sensations that accompany them…
- Emotional discussions
- Suspenseful movies
- Steamy rooms (shower with door closed)
- Certain foods
- Stimulants (i.e. coffee)
The purpose of interoceptive exposure is to repeatedly induce the sensations that are feared, so that the fear response weakens.
- Clients are to rate their sensation intensity 0-8
- Shake head back and forth for 30 seconds
- Head between legs for 30 seconds, and lifting up quickly
- Running for 1 minute
- Holding breath for as long as possible
- Complete muscle tension for one minute
- Pushup position as long as possible
- Spinning in a swivel chair for 1 minute
- Breathing through a straw with plugged nose
- Breathing as slow as possible for 2 minutes
- Staring at a mirror for 2 minutes
If these don’t work, make them worse…
- Take a deep breath and hold it, then hyperventilate
- Wear heavy clothes in a heated room
- Choke the patient with a tongue depressor, a high collared sweater, or a necktie!
- Startle the client with a loud noise during relaxation!
Anxiety will often be lower in session than in vivo. Discussion can center on the misassumptions that make naturally occurring panic symptoms more frightening.
Goals of Session 7
- Repeat interoceptive exposure
- At this time clients are instructed to apply breathing control at times of anxiety
- Cognitive restructuring continues with “hypothesis testing,” which is experimental design to disconfirm catastrophic hypotheses.
- Test: will one fall if he/she does not lean on a wall while feeling dizzy? Will someone comment on how weird a client is, in public?
- More induction and coping in this session.
Goals of Session 8
- Continue interoceptive exposure and hypothesis testing.
- Review daily, in vivo, practice of IE
Goals of Session 9
- Extend interoceptive exposure to natural activities (i.e. exposure to daily tasks that have been dreaded or avoided outright).
- Eating avoided foods (spicy, filling)
- Saunas and steamy showers
- Suspenseful movies
- Disneyland rides
- Clients are requested to ID maladaptive cognitions and restructure prior to each activity. Remove safety signals (i.e. lucky charms, rituals, cell phones) if appropriate
Goals of Session 10
- Begin exposure to feared/avoided agoraphobic situations (in vivo)
- Be careful to remove safety behaviors/objects.
- An emphasis on pre-event cognitive restructuring
- In Vivo exposure: targets situations in which anxiety and panic are expected to occur, and from which escape is difficult (as opposed to IE in the therapy office).
- Rationale for In Vivo: Much like IE, prolonged exposure will lower the power of the feared situation. Amount of time devoted to In Vivo will be directly related to client’s agoraphobia
In Vivo Exposure WILL FAIL if:
- Haphazard designs/attempts
- Exposure too brief
- Exposures spaced too far apart
- Conducted without confidence/sense of mastery
- Conducted while maintaining catastrophising ideations
Goals of Session 11
- If possible, a spouse is introduced into counseling and coached on how to support the PDA partner with daily In Vivo exposures
- In Vivo exposures completed independently, or with a partner, over the last week are reviewed, and general principles are reinforced. Therapist feedback on cognitive restructuring and partner’s coaching techniques are provided, if necessary.