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Panic Attack

Panic Attack. Interaction of Genes and Early Environment in Producing Adult Major Depression. Discoveries from Behavioral Science. Etiology of anxiety disorders involves fundamental emotional conditioning events Traumatic conditioning accounts incomplete

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Panic Attack

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  1. Panic Attack

  2. Interaction of Genes and Early Environment in Producing Adult Major Depression (Caspi et al., 2003)

  3. Discoveries from Behavioral Science • Etiology of anxiety disorders involves fundamental emotional conditioning events • Traumatic conditioning accounts incomplete • Early panic attacks associated with interoceptive and exteroceptive cues that trigger constellation of behavioral and physiological responses collectively called anxiety • These conditioning events influence performance without conscious awareness1 • Differential neurobiological bases of conscious vs unconscious conditioning processes now apparent using brain imaging procedures2 1. LeDoux JE. The Emotional Brain: The Mysterious Underpinnings of Emotional Life; 1996.2. Bouton ME, Mineka S, & Barlow DH . Psychol Rev . 2001;108(1):4-32.

  4. The Future:Talking to the Amygdala

  5. Therapy and the Amygdala PFC-L (thought) PFC-M (extinction) Talk Therapy Cognitive Behavioral Therapy AMYGDALA Drug Therapy (Valium/SSRI) The absence of direct connections from the PFR-L to the amygdala may be related to why talk therapy for psychiatric conditions that involve amygdala-related conditions is relatively inefficient (in terms of the amount of time required to achieve a therapeutic effect). Behavioral therapy (including cognitive behavioral therapy) is less dependent on conscious insight and more dependent on extinction processes and on the development of new associations, skills, and habits (that is, on implicit learning). Some of these processes (especially extinction) involve the PFC-M. The direction connection of the PFC-M with the amygdala may explain why cognitive behavioral therapy is more efficient for certain fear/anxiety-related problems. From: LeDoux, J. (2002). Synaptic self: How our brains become who we are. New York: Penguin Books.

  6. Perceptual processing vs. Cognitive evaluation • Perceptual processing (“match”) of threatening and fearful scenes was associated with a strong bilateral amygdala response • Cognitive evaluation (“label”) of these same stimuli was associated with an attenuation of this response and a correlated increase in the response of the right ventral PFC From: Hariri, A.R., Mattay, V.S., Tessitore, A., Fera, F., & Weinberger, D.R. (2003). Neocortical modulation of the amygdala reponse to fearful stimuli. Biological Psychiatry, 53, 494—501.

  7. NIMH Multicenter Collaborative Study Cognitive-Behavioral Therapy, Imipramine, or Their Combination for Panic Disorder: A Randomized Controlled Trial DH Barlow, Ph.D. Boston Psychological Treatments JM Gorman, MD Columbia Pharmacotherapy MK Shear, MD Pittsburgh Psychological Treatments SW Woods, MDYale Pharmacotherapy Barlow DH et al. JAMA. 2000;283:2529-2536.

  8. Phases and Durations Pre Acute Maintenance* Follow-Up 2 wk 12 wk 6 mo 6 mo Study Time Line Major assessments done at baseline, post-acute, post-maintenance, and post follow-up *IMI/PLA subjects entered maintenance only if they were responders at post-acute assessment.Barlow DH et al. JAMA. 2000;283:2529-2536.

  9. Comparison of Baseline, Acute, and MaintenanceTreatment for Intent-to-Treat (ITT) Sample N=312 PDSS Average Item Score (0-4) Treatment Condition Barlow DH, et al. JAMA. 2000;283(19):2529-2536.

  10. Posttreatment Relapse Rate N=312 % Relapsed Within 6 months Based on Clinical Global Improvement Scale (CGI) for intent-to-follow patients.

  11. Comparison of Cognitive-BehavioralGroup Treatment (CBGT) and phenelzine for social phobia *P<.09 **P<.005 =not assessed % Assessment     Posttreatment Postmaintenance 6-Month Follow-Up Statistical Comparisons CBGT, PHEN >PBO, ES** CBGT=PHEN CBGTPHEN* PHEN=phenelzine. PBO=pill placebo. ES=educational-supportive group treatment. Heimberg RG, et al. Arch Gen Psychiatry. 1995;55(12):1133-1141. Liebowitz MR, et al. Depress Anxiety. 1999;10(3):89-98.

  12. Specific Psychological Treatments (PT) vs. Medication or Alternative Treatments, all since 1998, from the Journal of the American Medical Association or the New England Journal of Medicine

  13. Specific Psychological Treatments (PT) vs. Medication or Alternative Treatments, all since 1998, from the Journal of the American Medical Association or the New England Journal of Medicine, con’t

  14. Treatment of Depression, 1987-1997: National Trends • Context: Increasing recognition and treatment of depression 19871997 Percent treated by medications 37.3% 74.5% Percent treated by psychotherapy 71.1% 60.2% From: Olfson, M. Marcus, S.C., Druss, B., Elinson, L., Tanielian, T., & Pincus, H.A. (2002). National trends in the outpatient treatment of depression. Journal of the American Medical Association, 287, 203-209.

  15. Treatment of Depression, 1987-1997: National Trends • Context: Increasing recognition and treatment of depression 19871997 Percent treated by medications 37.3% 74.5% Percent treated by psychotherapy 71.1% 60.2% Percent treated by physician 68.9% 87.3% Percent treated by psychologist 29.8% 19.1% From: Olfson, M. Marcus, S.C., Druss, B., Elinson, L., Tanielian, T., & Pincus, H.A. (2002). National trends in the outpatient treatment of depression. Journal of the American Medical Association, 287, 203-209.

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