A Psychological Anxiety Disease Panic Disorder - Research Paper Example

PANIC DISORDER Introduction Panic disorder is a psychological anxiety disease in which an individual has regular but unexplainable panic attacks at random intervals. Panic attacks are reactions to extreme stress or anxiety. They occur among 9% to 14% of the population. When random panic attacks occur regularly, they can be the symptom of panic disorder (Whalen and McKinney, 2007). Three to six million Americans suffer from panic disorder (Beamish et al, 2002); susceptibility is higher in women, and the condition occurs more commonly between mid-teens to forty years (Bouton et al, 2001). The prevalence of panic disorder in the United States is statistically significant, and several research studies have been conducted on various aspects of this mental disorder. The APA (2000: 429) defines a panic attack as “a discrete period in which there is a sudden onset of intense apprehension, fearfulness or terror, often associated with feelings of impending doom”. During these attacks, symptoms such as shortness of breath, palpitations, sweating, chest pain, choking or suffocating sensations, and fear of losing control of one’s mind are present. Panic disorder is the recurrence of unexpected panic attacks about which the patient experiences continuing anxiety and vulnerability, forcing them to be constantly vigilant. In about 30% of individuals with panic disorder, the commonly prevalent agoraphobia may be a comorbid condition. Agoraphobia is defined as “anxiety and avoidance of places or situations from which escape might be difficult or embarassing; or where help may not be available in the event of having a panic attack or panic-like symptoms” (APA, 2000: 429). The Research Statement This paper proposes to study the theories about Panic Disorder, and comprehensively evaluate research-based evidence about its causes, symptoms, comorbidity with other medical and psychological diseases, and the treatment options available. Discussion 1. Theories of Panic Disorder: Current perspectives on conditioning and associative learning support previous theories of classical conditioning. Early panic attacks cause conditioning towards anxiety and panic, in response to exteroceptive and interoceptive cues. “A modern learning theory approach provides the soundest base for future theoretical and empirical developments in the study of panic disorder” (Bouton et al, 2001: 25). Emotional learning by conditioning takes place; the presence of conditioned anxiety promotes and strengthens the next panic, which results in the individual’s decline towards panic disorder. According to modern learning theory the development of panic disorder is based on psychosocial, biological and neurobiological vulnerabilities in combination. According to Jacobs & Nadel (1999), panic can be analysed on the basis of three theoretical schemes: biological theories based on anatomy, physiology and endocrinology; behavioral theories rooted in past experiences and the present environment; and cognitive theories which relate to thought contents and mental processes occurring during a panic attack. The critical importance of neural development in the first panic attack is emphasized. The ways in which the brain is structured in early life impacts on an individual’s experience of the environment, and leads to particular consequences on the brain’s functioning. The authors’ systemic approach is to apply simultaneous interventions at the physiological, behavioral, emotional and cognitive levels. Throughout life, the person may remain susceptible to recurring panic disorder from unconditional effects of stimuli, unless the causal factors are eliminated. Gorman et al (2004) study the neurobiology of fear and avoidance, through considering developments in preclinical evidence on the neuroanatomy of conditioned fear in animals. The authors found that a panic attack was similar to the physiological and behavioral consequences of response to a conditioned fear stimulus. In animals, a fear network in the brain that is centred in the amygdala and interacting with the hippocampus and medial prefrontal cortex, involving projections from the amygdala to hypothalamic and brainstem sites are responsible for the conditioned fear responses. A similar fear network is considered to be involved in panic disorder. It is concluded from evidence that both stressful childhood events and inherited factors are responsible for the onset of panic disorder. Theories play a significant role of providing guidance, in mental health research and practice. Researchers state that a scientific and satisfactory theory is not only one from which statements can be derived, but which is capable of being empirically disproved. Roth et al (2005: 171) observe that “the catastrophic cognitions theory is least falsifiable because of the elusive nature of thoughts”. This theory relates to proneness of panic disorder patients to misinterpret autonomic sensations, as indicators of impending doom (Clark et al, 1997). When anxiety producing sensations are interpreted in a catastrophic fashion apprehension is increased, leading to a vicious circle that culminates in a panic attack (Clark et al, 1999). The vicious circle theory can be falsified only if the frightening internal sensations are specified. The suffocation false alarm theory lacks biological parameters that clearly distinguishes between dyspnea and panic anxiety. Since panic depends on specific thoughts, the connection between clinical phenomena and brain areas by the neuroanatomical hypothesis may be falsifiable (Roth et al, 2005). 2. Causes of Panic Disorder: Conditioning in Panic Disorder: To test the assumption that increased conditionability is a crucial factor in the etiology and maintenance of panic disorder, Michael et al (2007) investigated the acquisition and extinction of conditioned responses to aversive stimuli in panic disorder. The results of the study indicate that individuals with panic disorder do not show larger conditioned responses during acquisition than control participants. However, panic disorder patients showed enhanced conditionability with respect to extinction. Post-traumatic Stress Disorders: Post traumatic stress disorder is “characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma” (APA, 2000: 429). Gassner (2004) states that patients who suffer from panic disorder are people who have undergone trauma because of insufficient protection and emotional neglect during a childhood of “overwhelming catastrophic childhood experiences” (p.222). Catastrophic Misinterpretations: Patients with panic disorder are prone to misinterpret harmless bodily or internal and environmental or external stimuli as dangerous and catastrophic. This may be due to failure to stop automatically evoked fear responses or inability to control them through more sophisticated and consciously controlled cognitive processes (Windmann et al, 2002). Consciously being attentive to internal signals is a normal adaptive process. Schmidt et al (1997) conducted a research study on whether body vigilance is manifested in an exaggerated manner among those with panic disorder. They found that there is intense fear and worry about bodily sensations in individuals with panic disorder. A history of past panic attacks , anxiety symptoms, susceptibility and sensitivity directly correlate to the degree of vigilance that an individual exercises. “Excessive body vigilance is a natural consequence of learning to fear bodily sensations, and therefore part of the behavioral sequelae of developing panic disorder” (Schmidt et al, 1997: 214). The possibility of perceiving threatening interoceptive cues increases with rise in attentional focus on the body. A vicious circle is created with greater fear and autonomic arousal resulting from increased perception of threat cues. The Body Vigilance Scale appears to be psychometrically sound in both clinical and nonclinical samples. The scale provides a measure of behavioral sequelae that may relate more accurately to the experience of panic disorder than commonly used behavioral measures of phobic avoidance. The authors recommend that routine assessment of patients with panic disorder should include measurement of body vigilance to provide a more comprehensive assessment of behavioral sequelae that are distinct from phobic avoidance, anxiety sensitivity, panic and anxiety symptoms. Anxiety Sensitivity: Schmidt, Lerew & Jackson (1997) investigated whether anxiety sensitivity served as a premorbid vulnerability or risk factor for the development of panic disorder. The prospective controlled research trial. A large percentage of high scorers on the Anxiety Sensitivity Index experienced a panic attack during the five week follow up period after the five weeks of highly stressful period of time. Anxiety sensitivity also led to anxiety symptomatology, disability and functional impairment. The authors concluded that the data underscored the evidence for anxiety sensitivity as a risk factor in the development of panic disorder and other anxiety conditions. 3. Characteristic Symptoms of Panic Disorder: For the diagnosis of panic disorder, APA (2000) requires that patients experience at least 4 out of a list of 13 symptoms during their panic attacks. Among these, the fear of dying, of going crazy or doing something uncontrolled are cognitive symptoms, indicate feared outcomes, and are both based on misinterpretation of body sensations (Clark et al, 1997). Some physical symptoms are: a sense of suffocation, sweating, dizziness, faintness, tachycardia, paralyzing terror, trembling, shaking, chills, hot flashes, etc. A panic attack is an excruciating experience of terror. Patients experience a sense of approaching doom, and the physical symptoms such as racing heart beats increases the feeling of panic and danger. Nearly a half of individuals afflicted with panic disorder develop the symptoms of agoraphobia. These patients prefer to avoid threatening situations and they protect themselves by remaining housebound. Agoraphobic symptoms appear to be secondary to the fear of having panic attacks or the fear of the physical symptoms themselves (Gassner, 2004). Attentional Fixation in Panic Disorder: According to Wenzel et al (2006: 65), clinical observations have revealed that patients with panic disorder “describe a fixation on their distressing physical and psychological symptoms and an inability to access corrective information during panic attacks”. The Attentional Fixation Questionnaire (AFQ) was used in a sample of panic patients participating in three cognitive therapy clinical trials: at intake, during treatment and at termination. The preliminary data obtained from the study reveal that attentional fixation is an important dimension of cognition in relation to panic disorder. 4. Comorbidity with Other Medical and Psychological Conditions: Researchers have linked irritable bowel syndrome with panic disorder, since the symptoms for both conditions are highly stress-sensitive. The sufferers of either condition might find themselves trapped in a loop, whereby the occurrence of either disorder may trigger the other in a continuous cycle (Saxbe, 2005). The occurrence of depression as a comorbid condition of anxiety, especially in the advanced stages of panic disorder makes it hard to distinguish between the neural and cognitive processes that form the basis for both the disorders. Depressive symptoms are more closely linked to abnormal conscious evaluation processes; while panic and anxiety symptoms may be more closely related to “the proposed deficits in automatic processes” (Windmann et al, 2002: 367). Panic disorders occur often with agoraphobia. Childhood stress factors of significant intensity are generally found to result in agoraphobia, where the individual chooses the safety of remaining housebound rather than confront situations or people. The two conditions of panic disorder and agoraphobia may increase in intensity together and decline together; or agoraphobia may continue even though the panic attacks may reduced or cease altogether (Gassner, 2004). Iketani et al (2002) found from their research study that patients with panic disorder as well as agoraphobia had perfectionistic beliefs and tendencies which were believed to be risk factors for the development of agoraphobia. Hence it is suggested that cognitive behavioral therapy for the patients should be targeted on these beliefs and tendencies. 5. Treatment Options for Panic Disorder: Cognitive behavioral treatments: Behavioral cognitive treatments follow a particular sequence for maximum efficacy: Learning: when the patient understands details about the illness, the symptoms, and the treatment plan, from the therapist. Monitoring: the patient keeps a record of his panic attacks and related anxiety producing situations. Rethinking: the patient learns to change his/ her interpretation of the physical symptoms from catastrophic to realistic (Campbell, 2001). Therapists often treat panic by exposure therapy, by which the patient is required to confront feared settings of increasing intensity. Treatment is by exposing the patient to physical sensations of panic: by spinning the affected individual in circles to make them dizzy, having them inhale carbon dioxide, breathe through a straw or jog to raise their heart rates. This is done so that patients learn that those physical sensations do not signal impending doom; hence they overcome their fear, resist panic, and finally prevent it altogether (Saxbe, 2005). During cognitive-behavioral treatment, panic disorder patients show decreased body vigilance, along with reduction in anxiety symptoms. Anxiety sensitivity was related to body vigilance and predicted changes in body vigilance during treatment (Schmidt et al, 1997). Kenardy et al (2003: 1068) state that cognitive behavioral therapy (CBT) is the psychological treatment of choice for panic disorder, but cost-effectiveness has to be maintained. The authors conducted a research study to evaluate the efficacy of computer augmented CBT in comparison with therapist delivered CBT. They concluded that computers could be used as an innovative tool for providing cognitive behavioral therapy. Medications to Treat Panic Disorder: Desensitization of the fear network involving projections from the amygdala to the hypothalamus and brainstem, is achieved by means of medications that affect the serotonin system. “Effective psychosocial treatments may also reduce contextual fear and cognitive misattributions at the level of the prefrontal cortex and hippocampus. Neuroimaging studies should help clarify whether these hypotheses are correct” state Gorman et al (2004: 426). Pharamacological treatment of panic disorder often include antidepressants, benzo-diazepines, and other types of medications. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) & monoamine oxidase inhibitors (MAOI’s), have been effective in treating panic disorder when paired with psychotherapy (Katon, 2006). The use of benzodiazepine alprazolam in the treatment of panic disorder has been beneficial, but in the long term it may lead to drug dependency problems. “Since panic may be mediated by a dysfunction of serotonin neuronal pathways, there is a rationale for treatment with antidepressants that modulate serotonergic systems” (Kasper & Resinger, 2001: 307). In clinical trials, The antidepressants in the SSRI group of drugs, completely eliminated panic attacks in 36% – 86% of patients and did not give rise to adverse side effects even in the long term. Patient compliance could also be ensured. There is a high incidence of comorbid depression among panic disorder patients, and for such cases, antidepressants are more effective than benzodiazepine. Panic disorder being a chronic and disabling condition, long term treatment is necessary. Hence the therapy is required to be well tolerated by the patient, should ensure complete and permanent recovery from panic disorder, and give relief from anticipatory anxiety. It is advocated that a combination of cognitive behavioral therapy with medications is most effective in treating panic disorder, and comorbidities if present. Conclusion This paper has highlighted the theories about Panic Disorder, evaluated research-based evidence about its causes, symptoms, comorbidity with other conditions such as depression, agoraphobia and irritable bowel syndrome, and effective treatment by a combination of cognitive behavioral therapy and medication. The highly disabling cognitive as well as physical symptoms of panic disorder causes a deep rooted fear psychosis which manifests as recurrent panic attacks. Loss of quality of life due is difficult to adapt to: abnormal methods for self-protection and anxiety avoidance, such as remaining home-bound when unwilling to confront particular situations; and due to chronic dread of the severe physical symptoms of panic disorder. In contemporary medicine, due to earlier detection the complications of untreated panic disorder is significantly reduced. There is new hope of recovery due to the availability of effective treatments and ongoing research, for patients with panic disorder (Gorman et al, 2004). References APA (American Psychiatric Association). (2000). Diagnostic and statistical manual of mental disorders, (Revised 4th ed.). Washington, DC: American Psychiatric Publications. Beamish, P. M., Granello, D. H., & Belcastro, A. L. (2002). Treatment of panic disorder: practical guidelines. 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