Treatment of Panic and Agoraphobia

Dr. Andrew Page

Psychology, University of Western Australia

I. Diagnosis, frontline management, and intensive treatment overview.

A. Nature and presentation of main anxiety disorders

1. Panic

2. Phobias

3. Worry

4. Tension

B. Components of an intensive treatment programme for PAG

Rickels et al., (1993)

Boyer (1995) - SRIs

Components:

1. Education about anxiety and panic

2. Education about hyperventilation and techniques to control over-breathing

3. Relaxation

4. Graded exposure to feared situations

5. Interoceptive exposure to bodily sensations

6. Cognitive restructuring

Self-help approaches

C. Where Are We?

D. Strategies for Short-Term Management

· Support

· Tricyclics

· Move

a) Support

·Listen

·Lesson

·Listen before you lesson

PADAWA
PO Box 348
Midland 6056
Ph: 386 2694

b) Tricyclics

Motivate before you medicate

c) Move

Off your doorstep, or

Onto someone else’s

Anxiety is contagious: Don’t catch it!

II. Module 1 - “No-one understands”

A. Empathic education

1. Compare and contrast panic, fear, and anxiety.

Symptoms of panic attack

Four or more. Develop abruptly and peak in 10 minutes.

Symptoms	Worry	Anxiety	Fear
Heart: Palpitating, Pounding,Accelerated
Sweating
Trembling
Breath: Short, Smothering
Choking
Chest: Pain, Discomfort
Nausea, Abdominal Distress
Dizzy, Unsteady, Lightheaded
Derealisation/Depersonalisation
Fear Lose Control, Go Crazy
Fear Dying
Paraesthesias
Chills, Hot Flushes

2. Don’t be a know-it-all

What does “lose control” mean?

3. What is the experience of panic?

Interpret the experience in a way that makes sense of it

a) What is a panic?

b) What are the consequences of your panic?

c) How does your panic bring about these avoidances?

B. Biological and psychological approaches converge

Multiple physiological events may give rise to a panic attack, but the final common pathway is though a person’s thoughts

1. Stress

Physical

Psychological

1. Long-standing

2. Mystified

2. Trait Anxiety

General vulnerability

Andrews et al (1991):

Torgerson (1983)

Zinbarg & Barlow (1996)

People with anxiety disorders inherit a tendency to be a nervous person, rather than a tendency to develop a specific disorder

3. Overbreathing

4. True Alarms

What is the purpose of all of these changes?

5. False alarms

What has all this got to do with panic?

If this is an alarm reaction, designed to keep you safe, do you think it will kill you? Do you think that it would make you go mad? Do you think it would make you lose control?

Three strategies:

(a) replacing inaccurate with accurate information

(b) explaining origin (and benign nature) of symptoms

C. Cognitive model (Clark, 1986)

1. Treating components in the model

III. Module 1 (Cont)

A. Presenting cognitive model

1. Your patient’s experience of panic and agoraphobia

Consequences of panic? How are panic and avoidances linked?

2. Brief summary of three causes

Stress

Trait anxiety

Overbreathing

3. True Alarms

4. False Alarms

5. Present model

6. Request feedback

7. What is important feedback?

Misdiagnosis or comorbid diagnoses

“What do I do about it?”

8. Traps to Avoid

Be empathic

Beware trite advice

P: Panics are the most terrifying experience I’ve ever had. have you ever had a panic.

T1: Yes, I think I have. It was during the war when we were under fire ...

T2: Although I’ve been anxious, it sounds as if you have found panic attacks to be quite different from the anxiety which you used to feel.

P: When I’m having a panic, all my rational thoughts go out the window and I think I AM going to die of a heart attack.

T1: But you have had many clean ECGs, your cholesterol is low, and you are young. Everything points against you actually dying of a heart attack.

T2: It makes it difficult to stop the panic when the worry about dying becomes so overpowering.

P: I’ve had this problem for ten years. I’ve been to so many different therapists that it’s not funny, and I haven’t got better so far.

T1: Well, we use CBT here which is very successful and I’m very experienced. You should get better quickly.

T2: Having failed before it must have been hard to bring yourself along to the clinic. How did you motivate yourself.

IV. Module 2 - “But I already do deep breathing!”

A. Role of hyperventilation

(a) hyperventilation syndrome has overlap with panic

(b) hyperventilation occurs during panic

1. Cause, Consequence, or Exacerbater?

From Page (1993)

B. Presenting to clients

1. Normal Breathing Cycle

2. Hyperventilation

3. Types

a) Panting

b) Sighing, Yawning or Gasping

c) Habitual Overbreathing

4. Recognising

a) Speed (> 12 at rest)

b)

c) Depth

d)

e) Sighs and yawns

f)

g) Gasps

h)

i) Situations that can increase breathing rate

· Worry

· Irregular eating

· Coffee, tea, smoking

· Alcohol

· Breathing through mouth

· Menstruation

· Walking and talking too quickly

C. Practice

1. Normal Breathing Cycle

1. Oxygen: Mouth ð Lungs ð Blood

2. Binds to red blood cells

3. Used by cells, and carbon dioxide ð blood ð expired

4. How is oxygen released? Relative balance

5. Check understanding

2. Hyperventilation

1. Anxious but don’t flee?

2. Relative balance changes

3. Direct consequences (centrally & peripherally) and indirect

4. Long-term habituation

3. Types

1. Panting

2. Sighing, Yawning or Gasping

3. Habitual Overbreathing

D. Treatment - slowed breathing

Slow breathing technique is as follows:

1. Stop

2. Hold breath and count to 10 (seconds)

3. Breathe out slowly, saying “relax” (through nose)

4. Breathe in and out in a six second cycle

5. At end of each minute return to step two if symptoms haven’t gone away.

How do you teach it?

When do they use it?

Give clients an exercise:

	8:00 AM		12 NOON		6:00 PM		10:00 PM
Date	Before	After	Before	After	Before	After	Before	After

From Andrews et al. (1994)

1. Expect that breathing will get worse

2. Expect to become pre-occupied

3. Two mistakes - starting too late and finishing too early.

4. Slow, but large breaths.

V. Module 3 - “But you can’t relax when you have a panic”

A. Theory of Relaxation

1. Reduce general arousal (everyday and before exposure)

2. Assist in exposure

B. Possible risks

1. Relaxation Induced Anxiety

2. Thoughts Wandering

VI. Module 3 - “You don’t seriously mean that I need to get on a real train?”

A. Theory of exposure

What is the goal of exposure?

1. Clum & Knowles (1991): What predicts avoidance?

1. Not severity of frequency of panics

2. Not Age of onset

3. Not duration of panic or location of first panic (unclear)

4. Negative outcome expectancies

5. Perception of link between situation and panic occurrence

6. Self-efficacy

Therefore, exposure should aim to:

1. Change outcome expectancies (instruction and experience)

2. Modify perception of link (change causal assumptions)

3. Enhance self-efficacy (teach control strategies)

2. How much anxiety?

Aim to habituate anxiety, therefore as much as possible

Aim to change cognitions, therefore as much as is manageable

3. How much anxiety buffering?

B. Principles

1. Resemblance of Real Situations

2. More Frequent

3. Longer (until anxiety ò) Better

4. Don’t Permit Escape ... But

5. Change Cognitions

6. Graded not necessary, but more pleasant

C. Rationale

Panics are frightening

Avoidance is sensible ... but counterproductive

Best remedy is to control panic using relaxation and breathing control and straight thinking (next) and stay in situation until anxiety decreases

List situations and rank in terms of need to avoid

Break situations down into smaller steps.

Hints for breaking goals down into steps (must fade out):

1. Do in company or with companion

2. Quiet or peak hour

3. Distance from home/safety

4. Duration

5. Therapist accompany

How to practice the steps:

1. Use relaxation before you go out

2. Mentally rehearse at the end of relaxation

3. Perform activities in a slow relaxed manner

4. Monitor breathing rate

5. When anxious: Stop, breathe, wait until OK

6. Don’t leave until calming down and remain as long as possible

7. Reward yourself for success

D. Problems with grading

1. Possible objections

a) Dispense with steps

Some patients

Other patients:

b) Too many steps or go slowly

c) Therapist timidity

d) Distraction

Functional exposure

e) Safety signals

Cue	Frequency
Anxiety Medication	48%
Food or Drink	14%
Bags, Bracelets, or Objects	6%
Smelling Salts or Antacids	4%
Paper Bag	4%
Religious Symbols	4%
Torch, Money, Radio	3%
Reading Material	3%
Alcohol	3%
Relaxation Tapes, Coping Statements	2%

From Barlow (1988)

Remember yourself

Old treatment techniques

f) Failure of fear to habituate

(a) thoughts maintain the anxiety

(b) aren’t using anxiety reducing techniques

g) Ungradable goals

h) Confusing means and ends

Aim is not to do the exercise, but to control anxiety when doing it

E. Interoceptive Exposure

1. Theory

One trigger of panic is bodily sensations that are misinterpreted.

The aims are to:

(a) produce sensations repeatedly until they no longer trigger anxiety

(b) disprove beliefs about these sensations

Aim is not to produce a panic, but produce the sensations

Face the fear or you will fear its face!

2. Exercises

a) Hyperventilation

b) Shaking head

c) Head between legs

d) Step-ups

e) Breath holding

f) Body tension

g) Spinning

h) Breathing through straw

3. Ratings

	*Unpleasant.*	*Fear*	*Similarity*	*Rank*
Hyperventilation
Shaking head
Head between legs
Step-ups
Breath holding
Body tension
Spinning
Breathe thru straw

What if person wimps out?

4. Producing panic is daily life

F. Practice

VII. Module 4 - “Are you saying its all in my head?”

A. Cognitive model

1. Specifics in panic

2. General application: Easy as ABC

3. Objection to pre-empt: Thoughts not conscious

I live in a house; We must house the poor.

Emergency surgery.

B. Challenging and disputing

Socratic

Three strategies are:

1. What is the evidence for what you believe?

2. What is the worst thing that could happen?

3. What thinking errors am I making?

a) All or nothing.

“Panics are dangerous”

b) Using ultimatums.

“No-one has a fear like mine”

c) Condemning self on basis of single event.

“Avoided exposure, therefore a failure”

d) Concentrating on weaknesses and forgetting strengths.

“I haven’t beaten my agoraphobia yet, I’m a failure and that’s just typical.”

e) Overestimating chances of disaster.

“I couldn’t hyperventilate because something would go wrong.”

f) Exaggerating importance of events.

“My breathing rate isn’t decreasing as fast as everyone else.”

g) Fretting about the way things ought to be.

“I ought to be better by now.”

h) I can’t change the situations.

“I’ll never get over my phobia.”

i) Predicting the future.

“I’m a nervous person, I’ll always be afraid.”

4. I’m going crazy

5. I’m losing control

6. I’m having a heart attack

7. What if doctors have been wrong and I’ve only got weeks to live

8. I could faint. That would be awful because people would think I’m strange.

9. If I got dizzy in the car I could swerve and hit someone.

Expect understanding to be gradual

C. Possible objections

1. My fear is reasonable

2. Irrational thoughts come too quickly to challenge

VIII. Tips, Traps, and Your Questions

A. Role of partner in treatment?

A misconception

Successful treatment associated with improvements in marital satisfaction

No adverse effects of treatment on marriages where spouses were actively involved has been found

Effect of prior marital dissatisfaction on treatment outcomes disappears when spouses are involved in treatment

Partners who are involved encourage independence and autonomy in their partner

B. Enhancing Motivation

Miller and Rollnick (1991)

1. Expressing Empathy

2. Developing Discrepancies

3. Avoiding Argumentation

4. Rolling with resistance

P: I’m having a bad day. I don't think I can do my assignment today.

T1: You have to face your fears. Remember, avoidance makes fears worse. You’ll just have to go out and do it.

T2: When we planned the assignment yesterday you felt that it was achievable. How are you going to get yourself to be able to achieve the task?

P: I did everything right, but I had a panic anyway. Your treatment just isn’t working.

T1: We know the treatments are effective. What did you do wrong.

T2: Even though you battled hard to manage the anxiety, the panic broke through. Let’s try to work though what happened. Tell me everything right from the beginning.