PSY 961PSY 961

PANIC DISORDER / PANIC DISORDER / AGORAPHOBIAAGORAPHOBIA

PANIC ATTACK - DSMPANIC ATTACK - DSM

DISCRETE PERIOD OF INTENSE FEAR OR DISCRETE PERIOD OF INTENSE FEAR OR DISCOMFORT WITH FOUR OF THE DISCOMFORT WITH FOUR OF THE FOLLOWING SYMPTOMS, REACHING A FOLLOWING SYMPTOMS, REACHING A PEAK IN 10 MINUTES.PEAK IN 10 MINUTES.

  ► PALPITATIONSPALPITATIONS► SWEATINGSWEATING► TREMBLING/SHAKINGTREMBLING/SHAKING► BREATHLESSNESSBREATHLESSNESS► CHOKINGCHOKING

► CHEST PAINCHEST PAIN► ABDOMINAL DISTRESSABDOMINAL DISTRESS► DIZZY/FAINTDIZZY/FAINT► UNREALITY/DETACHMENTUNREALITY/DETACHMENT► FEAR OF LOSING CONTROL OR GOING FEAR OF LOSING CONTROL OR GOING

CRAZYCRAZY► FEAR OF DYINGFEAR OF DYING► PARAESTHESIASPARAESTHESIAS► CHILLS OR HOT FLUSHESCHILLS OR HOT FLUSHES

MAY BE UNEXPECTED (UNCUED) OR SITUATIONALLY BOUND MAY BE UNEXPECTED (UNCUED) OR SITUATIONALLY BOUND (CUED)(CUED)

PD-W/O AG - DSMPD-W/O AG - DSM

A. BOTHA. BOTH       RECURRENT UNEXPECTED PANIC RECURRENT UNEXPECTED PANIC

ATTACKSATTACKS    ONE MONTH OR MORE OF PERSISTENT ONE MONTH OR MORE OF PERSISTENT

CONCERN OVER FUTURE ATTACKSCONCERN OVER FUTURE ATTACKS  B.B. ABSENCE OF AGORAPHOBIAABSENCE OF AGORAPHOBIA  C.C. NOT DIRECTLY DUE TO SUBSTANCE.NOT DIRECTLY DUE TO SUBSTANCE.

PD-W AG - DSMPD-W AG - DSM

A. BOTHA. BOTHRECURRENT UNEXPECTED PANIC RECURRENT UNEXPECTED PANIC ATTACKSATTACKS

            ONE MONTH OR MORE OF PERSISTENT ONE MONTH OR MORE OF PERSISTENT CONCERN OVER FUTURE ATTACKS CONCERN OVER FUTURE ATTACKS 

B.B. PRESENCE OF AGORAPHOBIA - ANXIETY PRESENCE OF AGORAPHOBIA - ANXIETY ABOUT PLACES WHERE ESCAPE MAY BE DIFFICULT ABOUT PLACES WHERE ESCAPE MAY BE DIFFICULT OR IN WHICH HELP MAY NOT BE AVAILABLE IN THE OR IN WHICH HELP MAY NOT BE AVAILABLE IN THE EVENT OF A PANIC ATTACKEVENT OF A PANIC ATTACKSITUATIONS ARE AVOIDED OR ENDURED WITH SITUATIONS ARE AVOIDED OR ENDURED WITH DISTRESS.DISTRESS.

  

FEATURES OF PANIC DISORDERFEATURES OF PANIC DISORDER

►ATTACKS, SPELLSATTACKS, SPELLS►OUT OF THE BLUEOUT OF THE BLUE►PHYSICAL DISEASE FEARPHYSICAL DISEASE FEAR►CASUALTYCASUALTY►MEDICAL SPECIALISTSMEDICAL SPECIALISTS►EXPLICIT MEMORY FOR ONSETEXPLICIT MEMORY FOR ONSET

HYPOCHONDRIASISHYPOCHONDRIASIS

►FEAR OF DISEASEFEAR OF DISEASE►BELIEF IN DISEASEBELIEF IN DISEASE►MISINTERPRETATION OF BENIGN MISINTERPRETATION OF BENIGN

SIGNSSIGNS►RELUCTANCE TO BELIEVE GPRELUCTANCE TO BELIEVE GP►REASSURANCE SEEKINGREASSURANCE SEEKING

FEATURES OF FEATURES OF HYPOCHONDRIASISHYPOCHONDRIASIS

►EXAGGERATED ANXIETY RELATIVE EXAGGERATED ANXIETY RELATIVE TO DISEASETO DISEASE

►DRAMATIC, ANXIOUSDRAMATIC, ANXIOUS►OFTEN VERY OBSESSIONALOFTEN VERY OBSESSIONAL►FREQUENT DYSPHORIAFREQUENT DYSPHORIA►DEPENDENCE AND REASSURANCEDEPENDENCE AND REASSURANCE►HISTORY OF PHYSICAL AILMENTSHISTORY OF PHYSICAL AILMENTS

DEMOGRAPHICSDEMOGRAPHICS

AGE OF ONSETAGE OF ONSETMID 20’SMID 20’S

GENDERGENDER FEM – ESP FOR FEM – ESP FOR AG.AG.

COURSECOURSE FLUCTUATINGFLUCTUATING

IMPAIRMENTIMPAIRMENT MOD TO HIGHMOD TO HIGH

COMORBIDITYCOMORBIDITY HIGHHIGH

PRESENTATIONPRESENTATION MEDICALMEDICAL

MEAN AGE OF ONSET REPORTED BY MEAN AGE OF ONSET REPORTED BY PHOBICS - PHOBICS - ÖÖST (1987)ST (1987)

0

5

10

15

20

25

30

ANIMALSOCIALAGORACLAUSTRO

SIGNIFICANT SYMPTOMS IN 6 SIGNIFICANT SYMPTOMS IN 6 MONTHS – MONTHS – FAVA ET AL. (1988)FAVA ET AL. (1988)

0

2

4

6

8

10

12

14

16

18

HY

PO

CH

ON

D

GE

N. A

NX

.

AV

OID

AN

CE

LO

WE

NE

RG

Y

INSO

MN

IA

PANIC DISORDER

NON-CLIN

N O

F S

UB

JEC

TS

ANXIETY SENSITIVITY INDEX – ANXIETY SENSITIVITY INDEX – REISS ET AL.(1986)REISS ET AL.(1986)

► IT SCARES ME WHEN I FEEL SHAKYIT SCARES ME WHEN I FEEL SHAKY► IT SCARES ME WHEN I FEEL FAINTIT SCARES ME WHEN I FEEL FAINT► IT SCARES ME WHEN MY HEART IT SCARES ME WHEN MY HEART

BEATS RAPIDLYBEATS RAPIDLY►UNUSUAL BODY SENSATIONS UNUSUAL BODY SENSATIONS

SCARE MESCARE ME► IT SCARES ME WHEN I FEEL SHORT IT SCARES ME WHEN I FEEL SHORT

OF BREATHOF BREATH

ASI SCORES IN ANXIOUS ASI SCORES IN ANXIOUS INDIVIDUALS – INDIVIDUALS – TAYLOR ET AL TAYLOR ET AL

(1992)(1992)

DXDX MEAN MEAN ASIASI

PDPD 36.636.6

PTSDPTSD 31.631.6

GADGAD 26.226.2

OCDOCD 25.425.4

SOCIALSOCIAL 24.924.9

SPECIFICSPECIFIC 16.116.1

THREE MAIN FACTORS IN ASI – THREE MAIN FACTORS IN ASI – ZINBARG ET AL, 1997.ZINBARG ET AL, 1997.

►PHYSICAL CONCERNSPHYSICAL CONCERNS IT SCARES ME WHEN MY HEART BEATS IT SCARES ME WHEN MY HEART BEATS

RAPIDLYRAPIDLY►MENTAL INCAPACITATION CONCERNSMENTAL INCAPACITATION CONCERNS

WHEN I AM NERVOUS I WORRY THAT I AM WHEN I AM NERVOUS I WORRY THAT I AM MENTALLY ILLMENTALLY ILL

►SOCIAL CONCERNSSOCIAL CONCERNS IT IS IMPORTANT TO ME NOT TO APPEAR IT IS IMPORTANT TO ME NOT TO APPEAR

NERVOUSNERVOUS

LEARNING HISTORY IN PEOPLE WITH LEARNING HISTORY IN PEOPLE WITH PANIC DISORDER – PANIC DISORDER – EHLERS (1998)EHLERS (1998)

PDPD OADOAD NCNC

Ss sick role experiences – panic Ss sick role experiences – panic sxssxs

1.1a1.1a 0.8a0.8a 0.1b0.1b

Observation of parental sick role – Observation of parental sick role – panic sxspanic sxs

2.8a2.8a 1.8ab1.8ab 0.9b0.9b

Encouragement of sick role - Encouragement of sick role - coldscolds

1.41.4 1.51.5 1.11.1

LEARNING HISTORY IN PEOPLE HIGH LEARNING HISTORY IN PEOPLE HIGH VS LOW ON ASI – VS LOW ON ASI – WATT ET AL. (1998)WATT ET AL. (1998)

HI ASIHI ASI LO ASILO ASI

Ss sick role experiences – anx sxsSs sick role experiences – anx sxs 1.61.6 0.5*0.5*

Observation of parental sick role – Observation of parental sick role – anx sxsanx sxs

1.11.1 0.4*0.4*

Encouragement of sick role - coldsEncouragement of sick role - colds 2.52.5 1.7*1.7*

MODEL OF LEARNING HISTORY, AS, MODEL OF LEARNING HISTORY, AS, AND PANIC ATTACKS – AND PANIC ATTACKS – STEWART ET AL. STEWART ET AL.

(2001).(2001).

.00

LHQ NON-AROUSAL SXS

LHQ AROUSAL SXS

PHYSICAL CONCERN

PANIC ATTACKS

.39

.13

.40

.00

.24

PREDICTION OF ANXIETY PREDICTION OF ANXIETY DISORDERS DISORDERS (MALLER & REISS, (MALLER & REISS,

1992)1992)

1987 DX1987 DX 1984 – HIGH 1984 – HIGH ASIASI

1984 – LOW 1984 – LOW ASIASI

PANIC PANIC DISORDERDISORDER

88 11

GADGAD 33 11

SPECIFICSPECIFIC 55 00

SOCIAL SOCIAL 77 11

PANIC ATTACKS BY ASI QUARTILES – PANIC ATTACKS BY ASI QUARTILES – SCHMIDT ET AL. (1997)SCHMIDT ET AL. (1997)

0

2

4

6

8

10

12

14

LOWEST LOW-MID HIGH-MID HIGHEST

NU

MB

ER

OF

AT

TA

CK

S

QUARTILE

STRESS BEFORE ONSET – STRESS BEFORE ONSET – RAPEE ET AL. (1990)RAPEE ET AL. (1990)

010

2030

4050

6070

8090

100

PD OTHER ANX NONCLIN

% WITH ONEN. OF EVENTS

STRESS BEFORE ONSET – STRESS BEFORE ONSET – FARAVELLI (1985)FARAVELLI (1985)

02468

101214161820

11 10 9 8 7 6 5 4 3 2 1

PDNC

MONTHS

N. O

F E

VE

NT

S

IMPACT OF STRESS BEFORE IMPACT OF STRESS BEFORE ONSET – ONSET – RAPEE ET AL. (1990)RAPEE ET AL. (1990)

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

PD OTHER ANX NONCLIN

IMPACT

MAINTENANCE OF PANIC DISORDERMAINTENANCE OF PANIC DISORDER

TRIGGER

CHRONIC AROUSAL

PERIPHERAL PHYSIOLOGICAL

CHANGE

PANIC

DETECTION OF

AUTONOMIC SENSATIONS

ASSOCIATION WITH PHYSICAL

DANGER

ANTICIPATION OF FUTURE

PANIC

ATTENTIONAL RESOURCE

ALLOCATION TO BODY

RAPEE (1993). ADVANCES IN BEHAVIOUR RESEARCH AND THERAPY, 15, 85-102.

ONSET OF PANIC DISORDER – BARLOW (2002)

COLOUR-NAMING IN SOCIAL PHOBIA COLOUR-NAMING IN SOCIAL PHOBIA

AND PANIC DISORDER AND PANIC DISORDER - - HOPE ET AL. HOPE ET AL. (1991)(1991)

COLOUR-NAMING IN SOCIAL PHOBIA COLOUR-NAMING IN SOCIAL PHOBIA

AND PANIC DISORDER AND PANIC DISORDER - - HOPE ET AL. HOPE ET AL. (1991)(1991)

-1

0

1

2

3

4

5

6

7

8

PD SOC.P.

SOC.PHYS.

INT

ER

FE

RE

NC

E I

ND

EX

WORD TYPE

PROBE DETECTION LATENCY – PROBE DETECTION LATENCY – ASMUNDSON ET AL (1992)ASMUNDSON ET AL (1992)

-35

-30

-25

-20

-15

-10

-5

0

5

10

PD NC

PHYS THREATSOC THREAT

THREAT INTERPRETATIONS – THREAT INTERPRETATIONS – HARVEY ET AL. (1993)HARVEY ET AL. (1993)

0

0.51

1.52

2.53

3.54

4.55

INTERNAL EXTERNAL

PDSOCNC

REACTION TIMES TO TARGET REACTION TIMES TO TARGET WORD – WORD – SCHNIERING & RAPEE (1997)SCHNIERING & RAPEE (1997)

660

680

700

720

740

760

780

800

820

PD NC

THREAT - RELATED

THREAT - UNRELATED

NEUTRAL - RELATED

NEUTRAL - UNRELATED

MS

PANIC ATTACK TO BIOLOGICAL PANIC ATTACK TO BIOLOGICAL CHALLENGE – CHALLENGE –

RAPEE ET AL. (1992)RAPEE ET AL. (1992)

0

10

20

30

40

50

60

70

PDA PD GAD SOC NC

HYPERVENTCO2

INTENSITY OF PANIC TO COINTENSITY OF PANIC TO CO22 - - RAPEE ET AL. (1986)RAPEE ET AL. (1986)

INTENSITY OF PANIC TO COINTENSITY OF PANIC TO CO22 - - RAPEE ET AL. (1986)RAPEE ET AL. (1986)

0

1

2

3

4

5

6

SOC. P. PD

EXPLANATION

NO EXPLANATION

PANIC TO CO2PANIC TO CO2SANDERSON ET AL. (1990)SANDERSON ET AL. (1990)

PANIC TO CO2PANIC TO CO2SANDERSON ET AL. (1990)SANDERSON ET AL. (1990)

0

10

20

30

40

50

60

70

80

CONTROL NO CONTROL

PERCENTPANIC ATTACKS

HYPERVENTILATION THEORY OF HYPERVENTILATION THEORY OF PANICPANIC

CHRONIC OVERBREATHING

LOW Ph

ACUTE OVERBREATHING

DROP IN pCO2

SOMATIC SYMPTOMS

INCREASED LIKELIHOOD

PD VS PDA – PD VS PDA – RAPEE & MURRELL (1988)RAPEE & MURRELL (1988)

MINMIN MODMOD SEVERESEVERE

SITUATIONS SITUATIONS TRIGGERTRIGGER

4343 6565 8484

CAN AVOID CAN AVOID ONSETONSET

6262 8181 9696

FQ - SOCIALFQ - SOCIAL 10.810.8 12.512.5 17.817.8

ASSERTIVENESSASSERTIVENESS 60.260.2 62.262.2 78.778.7

EPQ-NEPQ-N 15.915.9 16.616.6 20.920.9

PD VS PDA – PD VS PDA – TELCH ET AL. (1989)TELCH ET AL. (1989)

PDPD PDAPDA

BDIBDI 11.611.6 22.422.4

PHYS CONSEQS OF PHYS CONSEQS OF PANICPANIC

20.520.5 26.226.2

SOCIAL CONSEQS OF SOCIAL CONSEQS OF PANICPANIC

17.917.9 31.231.2

LOSS OF CONTROL LOSS OF CONTROL OVER PANICOVER PANIC

13.713.7 25.325.3