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Section 3
Processes for Panic Disorder

Question 3 | Test | Table of Contents

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In the previous section, we discussed three gradations of anxiety intensity, which were spontaneous anxiety; situational anxiety; and anticipatory anxiety.

In this section, we will examine three aspects to keep in mind when diagnosing clients. These three aspects are diagnostic differentiation; common panic disorder personality types; and panic disorder controlled by substance abuse.

Three Aspects of Diagnosing Clients

♦ #1 Diagnostic Differentiation
First, we will discuss the controversy surrounding panic disorder diagnosis. Today, there is a heightened debate over whether there truly is a difference between panic disorder and generalized anxiety. When I wish to determine the difference between the two, I find it helpful to examine the client’s physical symptoms and the duration of the symptoms.

The general symptoms of a panic attack vary from client to client, but I have found that the most common symptoms include respiratory complaints such as shortness of breath and chest pains, nervous system trouble, such as dizziness and tingling sensations, and gastrointestinal reactions, such as nausea and abdominal distress. Panic attacks, I have found, last from 20 to 30 minutes. Those clients who experience panic attacks lasting for hours or more are very rare and require specific attention. 

Chris was 28 years old and referred by an ENT colleague with a complaint of dizziness and balance loss. A complete workup, including audiologic assessment, had all proved noncontributory. The doctors suspected an emotional cause. Chris’s history showed his first episode of dizziness and unsteadiness to have occurred approximately three years previously. These attacks stopped after eight months and returned 28 months later.

After meeting Chris for the first time, I discovered that he had been having recurrent attacks of anxiety during which he trembled, felt dizzy and unsteady on his feet, and felt frustrated and scared. Chris’s behaviors began to verge on agoraphobia, showing a decrease in his general activity and social interaction. This behavior was entirely due to Chris’s fear that he would have an attack of dizziness if he went out. 

There was also clinical evidence of moderate depression. As you can see, due to Chris’s symptoms and the duration of the attacks, I could clearly diagnose Chris with panic disorder. 

♦ #2 Common Panic Disorder Personality Types
Second, let’s discuss the common personality types of those who develop panic disorder.  Twenty-five percent of clients afflicted with panic disorder share common personality traits of avoidance, low self-esteem, interpersonal hypersensitivity, somatization, hopelessness, and self-blame. Although many of these clients seem somewhat anxious and introverted, they are generally well functioning. 

I have also found that these clients greatly value control and feel anxious at even a suggestion of loss of control. However, the problem is not necessarily the loss of control, but rather the need for too much control to begin with. Most notably, clients with these personality traits tend to be passive-avoidant, which might contribute to their risk of developing agoraphobia. 

Dominic was a 30 year old panic disorder client of mine. After having his second attack of chest pains, Dominic drove himself to the emergency room, where they assured him that he was in no medical danger. Over the next year, Dominic would experience episodic panic attacks, many times resulting in a trip to the hospital. Because Dominic’s father died of a heart attack, he became increasingly afraid that he would die as well.

His hopeless and helpless demeanor during these times were in direct contrast to his usual independent and productive personality. At work, Dominic was known as a bright, conscientious achiever who had excellent potential. He had just recently been given a promotion and Dominic strongly wished his father could be alive to help him through these problem-fraught times. Dominic’s independence contrasted with the powerlessness he experiences during his panic attacks, which created an even larger source of anxiety.  

♦ Technique:  1-to-8 Count Breathing
Because Chris' and Dominic’s attacks were characterized by severe chest pains and tension, I suggested they try the 1-to-8 Count Breathing exercise the next time they felt a panic attack coming on and help was still a few minutes away. I recorded the following instructions on tape so that they could play it when their breathing became shallow.   

Step #1 - Take a deep, slow breath and close your eyes. Exhale fully and completely, making sure to get the last bit of air out of your lungs.
Step #2 - Breathe in again. As you inhale try to see the number 1 in your mind; at the same time, focus on the inhalation. Hold your breath for three seconds. 
Step #3 - Exhale, and as you breathe out the air fully and completely, mentally say "two" and visualize the number 2 in your mind.
Step #4 - Breathe in again and mentally say "three," focusing on the number 3 and the inhalation.  Hold your breath for three seconds. 
Step #5 - Exhale fully and completely, while mentally visualizing and saying 4.
Step #6 - Inhale, saying 5; exhale saying 6.
Step #7 - Remember to visualize the number and focus on the inhalation.
Step #8 - Inhale, saying 7; and exhale saying 8.
Step #9 - Repeat the entire sequence from 1 to 8.  Slowly open your eyes. 

By concentrating on their breathing instead of on their symptoms, Chris and Dominic can learn to relax themselves while they wait for help to arrive.

♦ #3 Panic Disorder Parading as Substance Abuse
In addition to diagnostic differentiation and common personality types, the third aspect in identifying anxiety is its relationship to substance abuse. Often, clients who experience panic disorders take such substances as alcohol, methadone, or other harmful remedies to suppress the panic they fear will overtake them.

Often, those who seek treatment for their alcohol or drug abuse are not receiving the right attention. They are treating their addiction and not the core of the problem, which are the panic attacks. Take a moment now and recall any of your clients who might be abusing substances. Could they be trying to keep their panic disorder at bay?

In this section, we discussed various aspects to keep in mind when diagnosing clients:  diagnostic differentiation; common panic disorder personality types; and panic disorder controlled by substance abuse.

In the next section, we will examine how four different conditions are connected with panic disorder. The four conditions we will discuss are inner ear disorders; menstruation and pregnancy; mitral valve prolapse; and enzyme impairment.  Also, I will discuss how to treat each condition separately from the panic disorders.

- Chen, Y., Lin, H., & Lee, H. (June 2009). Pregnancy outcomes among women with panic disorder — Do panic attacks during pregnancy matter? Journal of Affective Disorders, 120(1-3), 258-262. doi:10.1016/j.jad.2009.04.025
Reviewed 2023

Peer-Reviewed Journal Article References:
Barber, J. P., Milrod, B., Gallop, R., Solomonov, N., Rudden, M. G., McCarthy, K. S., & Chambless, D. L. (2020). Processes of therapeutic change: Results from the Cornell-Penn Study of Psychotherapies for Panic Disorder. Journal of Counseling Psychology, 67(2), 222–231. 

Chambless, D. L., Allred, K. M., Chen, F. F., McCarthy, K. S., Milrod, B., & Barber, J. P. (2017). Perceived criticism predicts outcome of psychotherapy for panic disorder: Replication and extension. Journal of Consulting and Clinical Psychology, 85(1), 37–44. 

Erceg-Hurn, D. M., & McEvoy, P. M. (2018). Bigger is better: Full-length versions of the Social Interaction Anxiety Scale and Social Phobia Scale outperform short forms at assessing treatment outcome. Psychological Assessment, 30(11), 1512–1526. 

Hourani, L., Tueller, S., Kizakevich, P., Strange, L., Lewis, G., Weimer, B., Morgan, J., Cooney, D., & Nelson, J. (2018). Effect of stress inoculation training with relaxation breathing on perceived stress and posttraumatic stress disorder in the military: A longitudinal study. International Journal of Stress Management, 25(S1), 124–136. 

Zilcha-Mano, S., McCarthy, K. S., Dinger, U., Chambless, D. L., Milrod, B. L., Kunik, L., & Barber, J. P. (2015). Are there subtypes of panic disorder? An interpersonal perspective. Journal of Consulting and Clinical Psychology, 83(5), 938–950.

QUESTION 3
What are three aspects to keep in mind when diagnosing potential panic disorder clients? To select and enter your answer go to Test.

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