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Section 17
Crisis Intervention Techniques for Panic Disorder

Question 17 | Test | Table of Contents

Panic disorder is estimated to affect more than 4% of the U.S. population. It is assumed that this incident rate increases during crisis situations. While the professional literature is replete with references on the treatment of panic disorders, few authors address the use of nondrug treatment in conjunction with crisis intervention. This article provides an overview of the latest nonpharmacologic interventions for panic along with a description of their effectiveness in reducing the onset of svmptomatology as well as preventing relapse during crisis.

Assessment and Diagnosis
A comprehensive assessment protocol for diagnosing panic is quite com­plex and usually involves a structured interview in most clinical settings. Such interviews may be performed with the use of assessment instruments, such as the SCID (Structured Interview Schedule for DSM-III-R) (32) or the ADIS-R (Anxiety Disorders Interview Schedule-Revised). Unfortu­nately, such comprehensive assessment usually requires a considerable amount of time, which is not always available during crisis situations. Some abridged versions have been developed in recent studies in order to provide a more expedient method of assessment in crisis situations, for example, the Upjohn version of the SCID (SCID-UP-R) (32, 33).

It is recommended that a brief clinical interview be conducted that includes an excerpt from the panic section of the ADIS-R and screening questions that elicit the individual’s medical history (particularly cardiac or seizure disorders) along with all medication currently in use.

Some of the briefer diagnostic questionnaires may also help to pinpoint specific symptoms and to support information that has been obtained from the patient verbally. Such quick screening questionnaires include: the Beck Anxiety Inventory (BAI) (34), the Body Sensations Questionnaire (BSQ) (35), the Anxiety Sensitivity Index (ASI) (35), and the Zung Anxiety Scale (36), any of which can be completed in a matter of minutes. In addition, Table I includes some of the more important questions to ask during crisis situations:

Because much of the cognitive-behavioral literature stresses the impor­tance of relating symptoms to the misinterpretation of interoceptive cues and catastrophic cognitions (25, 26, 37-41), a formal system for linking panic symptoms to thoughts and emotional-behavioral responses is essen­tial. A recently developed assessment technique, known as the SAEB system (Symptoms-Automatic Thoughts-Emotions- Behavior), is recommended as an approach for helping panic sufferers recognize the link between their panic symptoms and their catastrophic responses to their initial bodily sensations in an emergency situation (39-43).

­Table 1. Questions for Crisis Intervention
1. Have you recently adjusted, discontinued or changed any medications either prescription or nonprescription?
2. Have you experienced any recent illness, deaths, change in relationship, job, financial situation in the past 6 months?
3. Have you recently experienced child birth, surgery or change in menstrual pattern?
4. Has anyone in your immediate family or family of origin experienced similar symptoms such as these?
5. Have you recently commenced or discontinued any use of tobacco, drug or alcohol?
6. Do you have any history of medical disorders, such as hypoglycemia, cardiac abnormalities, seizure disorder, etc.?
7. Do you have any history of experiencing these types of symptoms in the past?
8. Are you currently using stimulant/diet drugs, such as crank, speed, cocaine, crack, etc.?

The unique design of the SAEB system allows the treating clinician to align specific catastrophic thoughts and misinterpretations of symptoms with the onset of subsequent symptoms in a quick, expedient fashion. The system thus allows the panic victim to see the connections between stages of the escalation process setting the stage for the next step, which involves the treatment intervention (Figure 1).

This system is applied by having patients identify the beginning symp­tom of the panic episode. lithe individual has experienced more than one attack, it lends more credence to the repetitive sequence of each attack. For example; in Figure 1, a "spontaneous increase in heart rate" is often the initial symptom experienced by individuals at the onset of an attack. This can be followed by "difficulty breathing" and subsequently by "hot flashes and sweating" and so on. Once the symptoms have been aligned, the automatic thoughts accompanying each symptom are indicated along with the associated emotion and behavior. Vectors are then drawn in order to demonstrate to the patient in a collaborative fashion how the cata­strophic thought content may be in reaction to the autonomic symptoms experienced and how these thoughts contribute to the subsequent behav­ior and possibly to the subsequent escalation of the symptoms (39). This technique is demonstrated in detail in a previously published videotape (44) as well as in Dattilio and Salas-Auvert (14).

This SAEB system sets the stage for the implementation of several cognitive-behavioral treatment interventions that will be explained later in this article. It is recommended as a quick method of assessment for tracking the cognitive, affective, behavioral, and physiological sequence of panic. Pinpointing specific triggers of panic symptoms is another impor­tant aspect of assessment that has been emphasized in the literature (e.g., stress; hot, humid climates; and excessive exercise) (24,43). While the use of the SAEB system may be effective in obtaining the aforementioned goals, there is the possibility of placebo effects that may play a role in the temporary amelioration of symptoms. This is why the use of the technique should be followed by continual exposure to interoceptive cues.
- Dattilio, F. M. (2001). Crisis Intervention Techniques for Panic Disorder. American Journal of Psychotherapy, 55(3), 388-405. doi:10.1176/appi.psychotherapy.2001.55.3.388
The box directly below contains references for the above article.

Personal Reflection Exercise #3
The preceding section contained information about crisis interventions techniques for panic disorder.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Protocol for a multi-site randomized controlled trial of a stepped-care intervention for emergency department patients with panic-related anxiety

Sung, S. C., Lim, L., Lim, S. H., Finkelstein, E. A., Chin, S. L. H., Annathurai, A., Chakraborty, B., Strauman, T. J., Pollack, M. H., & Ong, M. E. H. (2022). Protocol for a multi-site randomized controlled trial of a stepped-care intervention for emergency department patients with panic-related anxiety. BMC psychiatry, 22(1), 795. https://doi.org/10.1186/s12888-022-04387-z


Peer-Reviewed Journal Article References:
Keefe, J. R., Huque, Z. M., DeRubeis, R. J., Barber, J. P., Milrod, B. L., & Chambless, D. L. (2019). In-session emotional expression predicts symptomatic and panic-specific reflective functioning improvements in panic-focused psychodynamic psychotherapy. Psychotherapy, 56(4), 514–525.

Loo, L.-M., Prince, J. B., & Correia, H. M. (2020). Exploring mindfulness attentional skills acquisition, psychological and physiological functioning and well-being: Using mindful breathing or mindful listening in a nonclinical sample.Psychomusicology: Music, Mind, and Brain. Advance online publication. 

Lotfalian, S., Spears, C. A., & Juliano, L. M. (2020). The effects of mindfulness-based yogic breathing on craving, affect, and smoking behavior. Psychology of Addictive Behaviors, 34(2), 351–359.

Naaz, S., Balachander, S., Srinivasa Murthy, N., MS, B., Sud, R., Saha, P., Narayanaswamy, J. C., Reddy YC, J., Jain, S., Purushottam, M., & Viswanath, B. (2020). Association of SAPAP3 allelic variants with symptom dimensions and pharmacological treatment response in obsessive–compulsive disorder. Experimental and Clinical Psychopharmacology. 

Nilsson, T., Falkenström, F., Perrin, S., Svensson, M., Johansson, H., & Sandell, R. (2021). Exploring termination setback in a psychodynamic therapy for panic disorder. Journal of Consulting and Clinical Psychology, 89(9), 762–772.

QUESTION 17
What is often the initial symptom experienced by individuals at the onset of a panic attack found in Figure 1? To select and enter your answer go to Test.

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