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Section 23
Panic Disorder: Nature, Assessment, and Treatment

Question 23 | Test | Table of Contents

Introduction
Panic disorder is characterized by sudden attacks of intense fear and panic. It is a common psychological disorder, which can, unfortunately, affect many aspects of the person's life. Beck (1976) suggests that exaggerated thoughts of danger are a central feature of anxiety disorders.

These features are particularly prominent in panic disorder. Contemporary literature based on the work of Beck discusses how people innocently, but catastrophically, misinterpret certain bodily sensations (Clark 1986). These misinterpretations can lead people to think that there is an immediate impending physical or mental disaster, e.g. perceiving palpitations as evidence of an imminent heart attack (Clark 1988).

Case study
Debbie (not her real name) is a 23-year-old underwriter who was referred by a consultant psychiatrist for a cognitive-behavioral assessment, following a road traffic accident (RTA). She complained of panic attacks and an inability to drive her car or travel as a passenger apart from with her partner.

The panic attacks began a few days following the RTA ten months previously. They occurred approximately twice each week particularly when away from home, in crowds, when she felt hot, or traveling in cars. She experienced anxiety symptoms of feeling hot, heart racing, choking sensation, her thoughts were: Tm suffocating, collapsing, fainting, losing control, going to vomit, or I'm going crazy'. This would lead her to use various safety and avoidance behaviors, such as, sitting down, controlling her breathing, trying to relax, controlling her mind, leaving the situation, using distraction, checking her pulse and attempting to be with someone.

Due to the above symptoms and thoughts Debbie began to avoid once pleasurable situations, places and people. She would only travel to work by train. She stopped socializing due to her avoidance of driving. Her hobbies of attending the gym were affected due to physical injuries from the RTA resulting in weight gain and poor body image. Her relationship with her partner became strained as she relied on him for travel and disliked being alone.

This case study provides an account of how severe panic attacks can be, not just In terms of the effect on the sufferer's psychological health (self-esteem, anxiety and mood) but on how someone's behavior can affect relationships, social life. Work, and hobbies.

Case-specific measures A range of standard case-specific measures can be incorporated into the assessment and are widely available from nurse therapists and psychologists who practice CBT; these have been well documented in previous CPD articles (see Rogers and Gournay 2000),

Asking the patient to keep daily panic diaries from the first session allows the clinician/ nurse to gather information where the patient has panic attacks, the typical symptoms noticed and accompanying thoughts and what the patient did (behaviour) to cope (e.g., escape and avoidance with the use of safety behaviors). This procedure helps patients to start to view their panic attacks as being linked to bodily symptoms, their appraisal of these strange bodily feelings, and how their behaviour may fuel the problem. For example,

Debbie continued to avoid driving or traveling as a passenger and did not accept new information that cars did not cause her panic attacks. Rather it was her appraisal of bodily symptoms while in cars that was crucial,

Psychological and social aspects
The psychological effects of panic disorder may vary from person to person. However, there are four main strands, which are;
1. Behavioral: individuals often escape and avoid situations where they have experienced panic attacks or endure them with marked apprehension. Typical behaviors (safety behaviors) which individuals often adopt include: placing self to the ground or sitting, making efforts to control breathing, using distraction, checking their pulse, holding onto someone or something etc- These need to be identified and eliminated during treatment to challenge the individual's unhelpful beliefs.

2. Cognitive: Individuals often hold unhelpful beliefs and assumptions regarding anxiety and panic which include; 'My heart racing means I'm having a panic attack or dying; my racing thoughts or mind going blank equals I'm going crazy; my panic attack will never end!' These beliefs, when anxious, fuel anxiety symptoms and produce panic attacks. Again, these are tackled in treatment with the aim to challenge their validity.

3. Affective and physiological responses: Individuals report living in fear from the next panic attack, which will lead to some form of catastrophe, as above. These individuals are often clinically depressed or feeling 'on edge' for much of their waking day resulting in feeling drained and fed-up.

4. Social Functioning: The effects of avoiding situations can lead to a decline in social functioning e.g. reduced ability to travel, avoiding crowded situations and places, becoming dingy and dependant on others for support. In severe cases people feel unable to work, shop or look after the home and children, resulting in relationship strain.
- Short, N., & Kitchiner, N. J. (2002). Panic disorder: Nature, assessment and treatment. Mental Health Practice, 5(7), 33-38. doi:10.7748/mhp2002.04.5.7.33.c1716
The box directly below contains references for the above article.

Personal Reflection Exercise #9
The preceding section contained information about the nature, assessment and treatment of panic disorder.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
The Bergen 4-day treatment for panic disorder:
replication and implementation in a new clinic

Iversen, H. M., Eide, T. O., Harvold, M., Solem, S., Kvale, G., Hansen, B., & Hagen, K. (2022). The Bergen 4-day treatment for panic disorder: replication and implementation in a new clinic. BMC psychiatry, 22(1), 728. https://doi.org/10.1186/s12888-022-04380-6


Peer-Reviewed Journal Article References:
Niileksela, C. R., Ghosh, A., & Janis, R. A. (2020). Dynamic changes in generalized anxiety and depression during counseling.Journal of Counseling Psychology. Advance online publication.

Probst, T., Berger, T., Meyer, B., Späth, C., Schröder, J., Hohagen, F., Moritz, S., & Klein, J. P. (2020). Social phobia moderates the outcome in the EVIDENT study: A randomized controlled trial on an Internet-based psychological intervention for mild to moderate depressive symptoms. Journal of Consulting and Clinical Psychology, 88(1), 82–89.

Reese, E. D., Conway, C. C., Anand, D., Bauer, D. J., & Daughters, S. B. (2019). Distress tolerance trajectories following substance use treatment. Journal of Consulting and Clinical Psychology, 87(7), 645–656. 

QUESTION 23
What are the four main strands of psychological/social effects of panic disorder? To select and enter your answer go to Test.

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