Panic Disorder and Social Phobia - Essay Example

Abnormal Psychology The first change in our view οf panic disorder and the models we utilize to try to understand it involves the data reviewed in this volume by Craske, and to a lesser extent by Shear and Mammen and by Lydiard and Brawman-Mintzer, which place a clear focus on the childhood antecedents οf the adult anxiety disorders, in particular panic disorder and social phobia. The work οf Kagan, Reznick, and Snidman (1988) and others has documented that the relatively stable early childhood behavior pattern that Kagan et al. call behavioral inhibition may be one οf the best predictors οf adulthood anxiety disorders. It is probably the best illustration οf a temperament potentially involved in the etiology οf these disorders. The behaviors associated with the behavioral inhibition construct have been demonstrated to be stable over time; these children have been observed to develop an increase in anxiety disorders, particularly social phobia, as they mature. In addition, their relatives have been demonstrated to exhibit more anxiety disorders. Finally, and most pertinent to the articles in this volume, this childhood history has been shown to be predictive οf a poorer response to treatment οf panic disorder in adulthood. All this evidence suggests that behavioral inhibition, and the highly related separation anxiety in children, can serve as excellent models οf temperamental predispositions to anxiety that can probably predict adult anxiety disorders, as well as certain characteristics (e.g., treatment refractoriness) οf these disorders. This work "connects" adult anxiety disorders longitudinally to childhood issues, at least at the level οf the models we utilize to understand these disorders. In DSM-IV, for the first time, adult anxiety disorders are recognized as beginning in childhood. However, the extent to which adult anxiety disorders begin in childhood is still not determined; research is urgently needed but is difficult because οf its longitudinal nature. On the other hand, the evidence suggests that anxiety difficulties can wax and wane through childhood and routate into other problems over time. Also, there is a clear impact οf parental behavior on anxiety. Both these issues lead us to broaden our model οf these difficulties beyond mere temperament. A model οf a genetic predisposition or temperament that invariably, and with little other influence, develops into adult anxiety disorders does not seem to fit the data. Instead, there is strong evidence that different parenting behaviors affect the evolution οf anxiety difficulties in both positive and negative ways. However, the extent to which childhood anxious behaviors are either reinforced or reduced by parents is unclear. What is clear is that parents can make childhood anxiety worse by focusing on the possible negative outcomes οf the childrens activities or by providing frequent critical and negative feedback. In a cold and critical environment, children can and do develop an internal model οf themselves as fragile and incompetent. Further, parents who are anxious themselves can directly model and transmit their own specific fears, or fail to teach models οf facing and reducing anxiety and fears. There is recent and evolving evidence that use οf the family in teaching and therapy efforts with anxious children has powerful and important ameliorating effects. These articles also ask us to focus more on what may be a "sleeping giant" in this area. The research that suggests that 40-60% οf adult panic disorder and/or agoraphobic patients have had a childhood experience οf either sexual or physical abuse at an early age is striking and suggests that these traumatic experiences may figure more prominently in the actual etiology οf panic disorder than has been previously thought. It suggests that these types οf early overwhelming and uncontrolled experience may serve as the psychological and neurobiological substrates for lifelong anxiety problems. These experiences could be the cause οf the psychological difficulties that panic disorder adults experience in situations οf diminished control or domination, or even οf the neurobiological hypersensitivity that seems to underlie the multiple physical symptoms οf the adult panic disorder patient. However, very little οf our adult work with panic disorder patients includes clinical or research work in this area. There is as yet even little acknowledgment οf such a high incidence οf childhood abuse in the histories οf panic disorder patients. Treatment implications If we are to take the broader view οf the difficulties οf adult patients that is suggested by these articles and other recent understandings οf childhood anxiety, we would be more likely to understand anxiety disorders in adult patients as an accumulation οf both negative and positive lifetime events. We would be more likely to view the development οf panic disorder as involving positive and negative parenting interacting with temperament, rather than to adopt the cross-sectional view that is typically taken with the adult patient. The former view suggests that we understand adult difficulties and symptoms as often evolving over years οf the patients development, and probably involving a sequence οf positive and negative influences and events. Therefore, the adult patient in front οf us could even logically he seen to be a summation οf various, perhaps even definable, issues and events that have shaped his or her particular difficulties. This view would be consistent with what we know οf certain predictors οf poor response in adults, such as comorbid depression, personality disorders, alcoholism, or even socioeconomic status. It would lead us to adopt a model οf thinking about what has previously happened to this individual, what is happening now, and what will happen in the future. A couple οf case examples might make this point more clearly. For instance, one patient might have an inherited temperament that is predisposed to anxiety disorders, but in fact has no other genetic predispositions for any other psychiatric disorders. If this patient were also lucky enough to have an intact home and parents who modeled well how to deal with anxiety, and if he or she avoided traumatic events as a child, it would be easy to imagine that the patient might have a mild and relatively easy-to-treat case οf panic disorder as an adult. This case would be contrasted with a second patient who also has an inherited anxious temperament, as well as an inherited predisposition to depression and alcoholism (a common occurrence). If he or she also had absent or poor parenting and adverse events and trauma in the developmental years, this person could easily have multiple negative prognostic factors, for example, comorbid depression, substance abuse, personality disorder, and lower socioeconomic status. It is easy to see that the life course, with or without treatment for this second individual, would be radically different. It is also easy to see that the therapeutic needs οf these two individuals would also be quite different. The complicated patient would need more, as well as different, kinds οf therapeutic assistance than the less complicated patient. It has been suggested for years that relatively simple treatment for panic disorder works in a large percentage οf patients. This treatment model includes relatively simple elements οf education, exposure, cognitive restructuring, and medications when needed. The articles in this volume and in the literature continue to support this approach as highly effective and perhaps as effective as more complex cognitive-behavioral treatments or even combinations οf sophisticated cognitive-behavioral exposure treatments combined with medications. The authors represented herein suggest that this simple approach, in which patients are educated by reading materials and encouraged to expose themselves in a systematic fashion to what they are afraid of, when coupled with cognitive restructuring around their catastrophic thinking about the implication οf panic attacks, and panic medications if needed, does in fact work. However, perhaps this approach works best for simple, noncomorbid patients. Some οf the data presented in this volume are supportive οf the hypothesis that it is the complex patients with various comorbid complications who do not respond well to this approach. Perhaps the depressed patient, the substance abusing patient described by DuPont in this volume, or the personality-disordered panic disorder patient needs more than the simple approach. The articles herein suggest that the simple approach, plus treatment for the added complex features οf more complicated patients, is what does work. For instance, severely depressed panic disorder patients who do not respond to a benzodiazepine alone may require the addition οf an antidepressant to convert them into responders. Similarly, as reviewed in this volume by DuPont, substance-abusing panic disorder patients respond only when both aspects οf their condition are treated well, and usually separately. Similarly, there are patients with personality difficulties and disorders that respond to the addition οf either individual or couple psychotherapy. By extension, treatment οf a younger panic disorder patient presumably requires the elements οf the simple treatment οf panic disorder plus whatever is required because οf their particular stage οf development, especially involvement οf their parents. This multifocal approach to treatment is better geared to the full range οf patients with panic disorder. Before leaving this point, it is necessary to briefly focus attention on what is different at the various stages and presentations οf the illness. For instance, the child patient is quite different cognitively from adolescent and adult patients. The anxiety sensitivity that is so prominent in the catastrophic overreaction to physical symptoms in adult panic patients is not present until adolescence, and cognitive issues focus on different areas in children. Also, the parental relationship would be an essential issue in the treatment οf children, as would exploration for physical abuse. In adults, the issues beyond the panic symptomatology would be more likely to involve relationship issues with spouses and difficulties with parenting. As a field, we should be cognizant οf the negative effects οf both routine and extraordinary stresses in adults such as childbirth, miscarriage, or loss οf a child, and the potential οf these events to elicit, and certainly worsen, difficulties with anxiety. In the elderly, psychosocial issues, diminished physical capacity, and reduction in hearing and visual acuity require very different approaches for effective treatment. Necessity for greater case finding The articles in this volume and the bulk οf recent research suggest that our field needs to take a much more aggressive stance toward finding new cases οf anxiety disorders. It seems clear that many more people with anxiety difficulties exist than come to attention. Certainly we need to make part οf our evaluation οf any panic disorder patient a questioning for anxiety disorders in the immediate relatives. This is rewarded by finding new cases οf the same or highly related anxiety disorders somewhere between one third to two thirds οf the times we look. These articles particularly underscore the importance οf paying attention to the children οf anxious patients. Not only do they have a higher genetic possibility οf having an anxiety problem, but differences in parenting styles may also make them more vulnerable to anxiety problems. We should be paying more attention to potential negative effects οf the parental anxiety disorders on the children. Evidence plainly indicates that the type οf attitudes and difficulties anxious parents have, such as anxiety, withdrawal, irritability, fearfulness, and the like, all have anxiety-producing effects on their children. This is one οf the clearest areas for preventive psychiatry that we have. We should also be looking at situations in childhood where there is a high likelihood that an anxiety disorder has the potential to evolve. Certainly, the school-refusal child is someone who needs to be evaluated for panic disorder. However, there is also a high likelihood that children who have marked difficulties in giving book reports or speeches in front οf others, or who are obviously shy, will have an increase in anxiety disorders, both as children and adults. Also, as is pointed out in this volume, even defiant behavior in some children is in response to anxiety difficulties. It is well known that perhaps one οf the richest case-finding strategies in terms οf yield will be aggressive screening οf patients seeing nonpsychiatric physicians. In particular, the percentage οf unrecognized panic disorder patients seeing cardiologists, gastroenterologists, and pulmonary specialists is remarkably high. The case can easily be made that certain types οf patients should all be screened for panic disorder. This would include the patients being worked up for palpitations, where there is a high incidence οf panic disorder. The majority οf patients who are worked up for a pheochromocytoma have panic disorder. Patients with atypical chest pain, especially those visiting in emergency rooms, have a high instance οf unrecognized panic disorder. Similarly, in the gastroenterology clinic, a large number οf patients with irritable bowel syndrome or other functional gastrointestinal disturbances have panic disorder. Neurologists frequently see patients for dizziness, weakness, and even syncopal-like episodes and fail to recognize the underlying panic disorder. Somewhere between 10-30% οf patients in primary care have panic disorder, and they represent a significant percentage οf the patients who return to see the doctor with multiple physical complaints but with negative workups. What should we be doing differently? What do these articles and this perspective lead us to do differently? Certainly, we should be expending more effort in case finding. However, what would we do, for instance, when we find children who have symptoms suggestive οf a beginning panic disorder or even full-blown panic disorder? The literature suggests that if the full syndrome is present, treatments that have been shown to work in adults should be utilized with the children. However, if we find children with beginning difficulties, perhaps children οf parents with panic disorder, attention to the pertinent developmental issues could have an important positive effect. For instance, work with the parents to decrease any harmful effects οf negative parenting would be important. Parents need to be encouraged to support exposure to anxiety-provoking situations in a positive fashion and to model and reward independent and competent functioning while decreasing negative messages and rewarding autonomy. Fearful modeling in ambiguous situations has been shown to have negative effects on children. Parents may need help in recognizing that children need to be given increased control over their world, particularly over their play, eating, and independence behaviors. If the child has developed an anxiety disorder, gradual exposure, modeling, practice, relaxation training, role play, family education, and medications have been shown to be effective. We need to be quicker to think about and involve families in the treatment οf anxious children and adolescents. In a similar fashion, it is clear that we need to pay more attention to the possibility that children have been physically or sexually traumatized. The percentages reported in several studies now suggest that perhaps even the majority οf adult panic disorder and agoraphobic patients have been abused as children. It is unclear how this relates to the adult anxiety disorders, or what the implications for treatment are. (Roy-Byrne 2006) This is an area that urgently needs clinical and research attention. These articles focus increased attention on the complicating factors in panic disorder patients. First οf all is a greater emphasis on the context οf the beginning, and current, situation οf patients presenting for treatment. For younger patients, this clearly involves the family. For the elderly, it involves medical and psychosocial issues οf considerable importance. We now understand that the complicating issues οf substance abuse, depression, and social phobia require, and respond to, specific and separate attention, beyond basic treatment οf the panic disorder. Often this means the involvement οf different therapies and different medications. Finally, it can be considered that these articles suggest that a greater emphasis on psychotherapy οf a focused nature is important in the proper treatment οf the full range οf patients with panic disorder. Many issues, like personality difficulties, can and do complicate the treatment οf panic disorder and are a prominent negative prognostic factor. As a field, we have moved from a time when psychodynamic psychotherapy was the principal treatment οf these conditions, although research suggested that this approach was largely ineffective. In the last several decades, specific pharmacotherapies, and then specific cognitive-behavioral therapies, have been developed that are effective treatments for panic disorder. However, as we now approach the full spectrum οf panic disorder patients, who range from the simple to the complex with the frequently comorbid conditions that are less responsive to current treatments, the potential role οf psychotherapy οf a specific nature being developed by Shear and colleagues (1993) needs particular attention from a clinical and research perspective. Also, issues for families οf children with anxiety disorders, and issues for couples involving a panic-disordered adult deserve more attention. The research οf Shear and colleagues (1993) οf a relatively focused psychotherapy seems quite promising. They are empirically demonstrating in controlled trials that psychotherapy is effective when it focuses on issues most pertinent to panic disorder patients. This approach encourages exploration οf issues around separation and attachment and related issues οf feelings οf being dominated, assertive, and so on. Attention to these unexpressed and even unacknowledged feelings that frequently precipitate panic symptomatology is often quite effective, even in relatively brief psychotherapy. Conclusion The articles in this volume underscore the importance οf a broader view οf the etiology and treatment οf panic disorder, providing increased clarity to the evolving literature about the causes and treatments οf panic disorder across the life span and across multiple presentations οf panic disorder. The volume provides insight into why treatment may not be as effective as we might wish. It also provides direction for future clinical and research strategies to improve the treatment οf panic disorder patients. Works Cited Kagan, J., Reznick, J. S., & Snidman, N. (1988). Biological bases οf childhood shyness. Science, 240, 167-171. Roy-Byrne, Peter P; Craske, Michelle G; Stein, Murray B. Lancet , (2006) Panic disorder. Vol. 368 Issue 9540, p1023-1032 Shear, M. K., Cooper, A. M., Klerman, G. L., Busch, F. N., & Shapiro, T. (1993). A psychodynamic model οf panic disorder. American Journal οf Psychiatry, 150, 859-866. Read More