1. Behavior Therapy Class

2. Treatment of Panic DisorderLecture Overview • Nature and epidemiology • Etiology • Empirically-supported treatments • Efficacy data • Moderator variables • Class discussion Behavior Therapy Class

3. Epidemiology of Panic Disorder • Defining features • Unexpected panic attacks Behavior Therapy Class

4. Distinguishing Featuresof Panic Attacks • Intensity • Sudden onset • Unexpected nature • *Urge to flee • Feeling of impending doom • Four or more “key symptoms” Behavior Therapy Class

5. Panic Attack Symptoms • Shortness of breath or smothering sensations • Dizziness or unsteadiness • Heart racing or pounding • Trembling or shaking • Sweating • Feelings of choking (feeling throat constrict) Behavior Therapy Class

6. Panic Attack Symptoms Cont. • Nausea or abdominal distress • Numbness or tingling sensations • Chest pain or discomfort • Feelings of unreality • Feeling of dying • Feeling of going crazy or losing control Behavior Therapy Class

7. Epidemiology of Panic Disorder • Defining features • Panic-related apprehension • Persistent worry about having more attacks • Unrealistic concern about the consequences of panic attacks • Changes in behavior to cope with fear of mpanic (safety behaviors) Behavior Therapy Class

8. Panic-Related Appraisals(Telch et al, 1989) • Perceived negative consequences of panic attacks • Physical • Social • Loss of control/mental illness • *Functional incapacitation Behavior Therapy Class

9. Panic-Related Appraisals(Telch et al, 1989) • Overestimate the likelihood of panic occurrence • Underestimate one’s ability to cope with panic • Exaggerate the negative consequences of panic attacks Behavior Therapy Class

10. Epidemiology of Panic Disorder • Prevalence • General population…………………. 3.5%* • Primary care………………………… 6 - 10% • Cardiologists………………………… 30-50% • Gender Distribution • 2 to 1 Women for PD uncomplicated • 4 to 1 Women for PD with agoraphobia *Data from the National Comorbidity Study - Kessler et al, (1994) Behavior Therapy Class

11. Epidemiology of Panic Disorder • Onset and course • Onset occurs early to mid 20s • Course is chronic Behavior Therapy Class

12. Consequences of Panic Disorder • Over utilization of medical services • Work social, and family disability • Substance abuse • Depression • Agoraphobia Behavior Therapy Class

13. What Causes Panic Disorder Behavior Therapy Class

14. Factors Associated With First Panic Attack • Stress • Drugs • Exercise • Hyperventilation • Relaxation/Meditation • Physical/Medical Conditions Behavior Therapy Class

15. Behavior Therapy Class

16. “Men are disturbed not bythings but by the views which they take of them”(Epictetus, 60 A.D.)“Meanings are not determined by situations, but we determine ourselves by the meanings we give to situations”(Adler, 1931) Behavior Therapy Class

17. Cognitive Model of Panic(Clarke, 1986) • Panic stems from a catastrophic misinterpretation of benign bodily sensations • Treatment is aimed at correcting the patient’s tendency to misperceive benign bodily sensations as threatening. Behavior Therapy Class

18. Heart racing………... Lightheadedness…… Breathlessness……… Dissociation………… Stomach distress…… Sweating……………. Muscle tightness…… Heart Attack Faint Suffocation Insanity Vomit Faint Choking Examples of Somatic Misinterpretation Behavior Therapy Class

19. Anxiety Sensitivity Construct “Fear of Anxiety” (Petersen & Reiss, 1987) “Perceived Negative Consequences of Anxiety” (Telch et al, 1989) Behavior Therapy Class

20. Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic • Elevated AS in panic disorder patients relative to normal and psychiatric controls Behavior Therapy Class

21. Anxiety Sensitivity Across the Anxiety Disorders Data from Taylor et al (1992) Journal of Anxiety Disorders, 6, 249-259. Behavior Therapy Class

22. Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic • Elevated AS increases panicogenic response to biologic challenge Behavior Therapy Class

23. Behavior Therapy Class

24. Behavior Therapy Class

25. Behavior Therapy Class

26. Behavior Therapy Class

27. Behavior Therapy Class

28. Panic in Response toCO2 Challenge Data taken from Telch & Harrington (under review) Behavior Therapy Class

29. Behavior Therapy Class

30. Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic • Prospective studies showing high AS increases risk for the development of panic attacks Behavior Therapy Class

31. Anxiety Sensitivity as a Risk Factor in Stress-Induced Panic Data from Schmidt et al (1999). Journal of Abnormal Psychology, 108, 532-537. Behavior Therapy Class

32. Anxiety Sensitivity and 12-Month Panic Incidence Data from Telch et al (in preparation) Behavior Therapy Class

33. 12-month Incidence of Unexpected Panic by ASI Scores Data from Telch et al (in preparation) Behavior Therapy Class

34. Anxiety Sensitivity andPanic-Related Apprehension Data from Telch et al (in preparation) Behavior Therapy Class

35. Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic • Interventions which lower AS reduce panic in response to biological challenge Behavior Therapy Class

36. Effects of CBT on CO2 Fear Data from Jaimez & Telch (in preparation) Behavior Therapy Class

37. Effects of CBT on CO2 Panic Data from Jaimez & Telch (in preparation) Behavior Therapy Class

38. Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic • Changes in AS mediate the effects of CBT of panic Behavior Therapy Class

39. Role of Fear of Fear in Mediating Treatment Response Data from Telch et al (in prep) Behavior Therapy Class

40. Treatment of Panic Disorder • Insight-oriented psychotherapies Behavior Therapy Class

41. Behavior Therapy Class

42. Treatment of Panic Disorder • Pharmacotherapy Behavior Therapy Class

43. Behavior Therapy Class

44. Medications with Established Efficacy in Panic Disorder • TCAs (e.g., imipramine) • MAOIs (e.g., phenelzine) • High-potency BZs (e.g., alprazolam) • SSRIs (e.g., paroxetine) Behavior Therapy Class

45. Cognitive-Behavioral Treatment of Panic Disorder Behavior Therapy Class

46. Behavior Therapy Class

47. Major Treatment Components of CBT for Panic Disorder • Education • Major Aim: • Provide information to enhance the patient’s knowledge concerning anxiety and panic and to reduce misconceptions that anxiety/panic are dangerous. • Strategy: • Didactic instruction and hand-outs Behavior Therapy Class

48. Major Treatment Components of CBT for Panic Disorder • Breathing retraining • Major Aim: • Teach the patient a coping skill that can be used to: (a) prevent hyperventilation and (b) manage anxiety • Strategy: • Training in diaphragmatic breathing Behavior Therapy Class

49. Major Treatment Components of CBT for Panic Disorder • Cognitive restructuring • Major Aim: • Teach patients to identify and correct faulty threat perceptions that are maintaining their panic/anxiety. • Strategy: Cognitive therapy techniques Behavior Therapy Class

50. Targets for Cognitive Intervention in Panic Disorder • Faulty beliefs about physical sensations • Overestimations in the likelihood of panic occurrence • Faulty beliefs about the the consequences of anxiety or panic • Faulty beliefs about coping strategies (e.G., Safety behaviors) • Faulty beliefs about CBT (e.g., treatment is designed to bring on panic attacks) Behavior Therapy Class