Beyond Fight or Flight: Panic Disorder

Panic disorder remains one of the most frequently misunderstood anxiety conditions in clinical practice and on licensing exams. We dive deep into what makes this disorder truly distinct from general anxiety - the sudden, intense nature of panic attacks compared to anxiety's gradual build.

For therapists and students preparing for licensing exams, understanding the three types of panic attacks is crucial. Unexpected attacks strike without warning, situationally bound attacks consistently occur in specific contexts, and situationally predisposed attacks may or may not occur upon exposure to triggers. This unpredictability creates elaborate avoidance strategies that significantly impact clients' quality of life.

The DSM diagnostic criteria requires recurrent unexpected panic attacks followed by at least one month of persistent concern or behavioral changes, with four or more specific symptoms during attacks. At the core of this disorder lies what we call the "fear response cascade" - a self-perpetuating cycle where bodily sensations are catastrophically misinterpreted, triggering more anxiety and physical symptoms.

We explore essential assessment tools like the Panic Disorder Severity Scale and the Anxiety Sensitivity Index, which help clinicians track symptoms and guide treatment. Effective approaches combine psychoeducation, cognitive restructuring, and breathing techniques, progressing to interoceptive exposure and in vivo desensitization.

Common challenges in treatment include clients' reluctance to abandon safety behaviors and patterns of medical reassurance seeking. Whether you're studying for exams or working with clients experiencing panic, this episode provides clear, practical guidance for understanding and treating this complex condition. Subscribe for more clinical insights and exam preparation tips!

If you need to study for your national licensing exam, try the free samplers at: LicensureExams


This podcast is not associated with the NBCC, AMFTRB, ASW, ANCC, NASP, NAADAC, CCMC, NCPG, CRCC, or any state or governmental agency responsible for licensure.

Chapters

• 0:00 Introduction to Panic Disorder
• 1:49 Types and Behavioral Changes
• 3:13 Diagnostic Criteria and Differentials
• 5:52 Assessment Tools for Panic Disorder
• 8:19 Effective Treatment Approaches
• 11:40 Challenges and Knowledge Check

Transcript

Eric: 0:07

Well, hi everybody, including you people up there in the freezing north. I'm looking in the old mailbag and Sandy from Albion, michigan, asked for information that would be useful for the licensing exam about panic disorder. Hi, my name's Eric Kwokman.

Linton: 0:24

And I'm Dr Linton Hutchinson. Today we're going to focus on the complexities, the diagnosis, and treatment approaches of panic disorder.

Eric: 0:39

And let's start by clarifying what makes panic disorder distinct.

Linton: 0:41

Can you break it down for us? Sure, so when we look at panic disorder, we're seeing reoccurring unexpected panic attacks paired with persistent worry about future attacks. What makes this condition unique is the behavioral changes that occur in response to those attacks.

Eric: 0:59

Right, you are. Panic attacks tend to hit suddenly and intensely, unlike anxiety, which tends to build gradually, and they either occur without any noticeable trigger or by specific situations.

Linton: 1:15

Well, I'm interested in how the different type of attacks that a client has are categorized.

Eric: 1:23

Well, there are three main types. First, the unexpected attacks, like I mentioned, that come without warning. Then you have situationally bound attacks, which consistently occur in specific situations. And the third type is situationally predisposed attack, where exposure to a trigger might lead to an attack, but it might not.

Linton: 1:45

So it's the unpredictability that often leads to significant changes in their behavior. A client might start avoiding places where they had attacks before, or situations where they worry that help won't be available.

Eric: 1:59

Yes, which makes it so that clients often create elaborate avoidance strategies Taking a longer route to work, refusing to eat in certain restaurants, avoiding exercise which might increase their heart rate. These changes can seriously impact their work relationships, basically their overall quality of life.

Linton: 2:19

Wow, I had something like that happen to me. I was in Publix right down the street and they ran out of kimchi that I really like. I ended up going to another store farther away just to avoid feeling disappointed.

Eric: 2:34

Well, what a stressful situation that must have been, but I don't think that's exactly the same thing, is it?

Linton: 2:43

You know maybe not what are the specific criteria for diagnosing panic attacks.

Eric: 2:49

Well. According to the DSM, diagnosis requires recurrent unexpected panic attacks followed by at least one month of either persistent concern about additional attacks or significant behavioral changes, and during the attacks a client needs to experience four or more specific symptoms.

Linton: 3:09

Uh-huh, and that can manifest as both physical and cognitive. Physical symptoms include sweating, trembling, shortness of breath and chest pains. Cognitive symptoms include derealization, fear of losing control and fear of dying. Some of them sound like they could be symptoms of other disorders. So what are the differentials?

Eric: 3:33

Well, several anxiety disorders, including ones that are substance-related and medical condition-related. Anxiety disorders are differential. The key is the sudden onset and intensity. Unlike anxiety, these symptoms peak within minutes and often feel overwhelming to the client in that short period of time. So it's important to rule out the medical conditions and substance-related causes. At its core, panic disorder involves a fear, of fear itself.

Linton: 4:06

Wasn't that what Churchill said during the Second World War?

Eric: 4:10

Close. I think you're thinking about our president, Franklin Delano Roosevelt, who said those exact words, but he wasn't talking about this disorder. He was talking about the Great Depression. A client develops hypersensitivity to bodily sensation and their interpretation. That creates what's known as the fear response cascade. And how would you explain that to a client?

Linton: 4:35

I guess I just wouldn't they just have to take it on faith? No, no, actually. I'd use some clear examples. They would notice that their heartbeat is slightly faster. They would interpret this as a sign of an impeding heart attack, and then this interpretation would trigger more anxiety, which then again increases physical symptoms like rabbit heartbeat and shortness of breath no-transcript.

Eric: 5:09

Well, the best thing to do would be to focus on helping clients recognize the pattern as it's happening and to work on reframing those initial interpretations and developing a more balanced response to physical sensations.

Linton: 5:23

So you're saying you would intentionally try to have your client have a full-blown panic attack during sessions?

Eric: 5:29

That's right, just for fun? No, of course not, but eventually you would work up to it. It's called in vivo desensitization. You go gradually, but we'll talk about that more later.

Linton: 5:43

Okay, that sounds like a plan With panic disorder. Accurate assessment is very important. Let's go over some assessment tools that have been found to be effective.

Eric: 5:53

And that you might see on the exam. Right, right, right One is the Panic Disorder Severity Scale, which is widely used. It helps measure attack frequency, distress levels, various types of impairment and it looks at seven key areas. Areas frequency of attacks, associated distress, anticipatory anxiety, agoraphobic fear, interoceptive fear and both work and social impairment.

Linton: 6:25

Man, you can tell that was written by a psychologist, can't you? Yes, you can. There's also the Anxiety Sensit body sensation questionnaire. The asi gives us insight into how clients interpret and respond to anxiety related physical symptoms. It measures fears about physical concerns, mental incapacitation and social evaluation. The bsq helps identify which body sensations trigger the most fear.

Eric: 6:58

And the mobility inventory for agoraphobia is used to track changes in avoidance patterns and the agoraphobic conditions questionnaire is for mapping out catastrophic thinking patterns.

Linton: 7:11

And don't forget the Albany panic and phobia questionnaire. That is useful for identifying specific activities that produce sensations similar to panic attacks. This helps guide the client's exposure hierarchy and for the exam, you see that all of these assessments, or at least most of them, have the word panic in them, so it will be really obvious that you should select that on a question that is regarding assessments.

Eric: 7:39

That's right. They either have the word panic or agoraphobic, which is part of that whole process. Some of these comprehensive assessments are to be used at intake, some used as a follow-up, at regular intervals to track progress and adjust treatment plans accordingly. Then panic attack records are reviewed weekly to identify any emerging patterns or triggers.

Linton: 8:05

That sounds like a good transition to review some effective treatment approaches that might be on your licensing exam regarding panic disorder.

Eric: 8:15

Well, you might start with psychoeducation about the nature of panic and the fight or flight response, and then move into cognitive restructuring and some breathing techniques, Then spend significant time mapping out the client's specific panic cycle, identifying their unique triggers, sensations, thoughts and behaviors.

Linton: 8:35

Okay For those of you that believe in cognitive therapy, believe in cognitive therapy they tend to focus what? I'm a believer. Okay, that will tend to focus on helping clients identifying and changing their catastrophic thoughts and also work on developing alternative interpretations of body sensations. Thought records are particularly useful, especially when tracking the intensity of beliefs before and after restructuring.

Eric: 9:08

And another technique is with interoceptive exposure, that is, controlled exercises that safely reproduce feared situations like we were talking about before. This could involve having clients run in place to increase their heart rate, breathe through a straw to create mild breathlessness, or spin in a chair to induce dizziness, then gradually progress to in vivo exposure Out in the world, always moving at a pace that feels challenging but manageable for the client Right and you mentioned breathing techniques.

Eric: 9:43

That's right. It turns out that over-breathing can create many of the sensation that clients fear, like lightheadedness and tingling. The client will practice diaphragmatic breathing, first in a calm state, then during mild anxiety.

Linton: 10:00

Progressive muscle relaxation and mindful body scanning have been particularly useful. There's a long form and an abbreviated version, so what are some challenges that therapists would see when treating panic disorder?

Eric: 10:16

Well, one frequent challenge is the client's reluctance to give up the safety behaviors that will actually help them. They often have elaborate systems of coping, like we talked about driving way out of your way to go to work or anything that they feel is protecting them but that actually maintain and reinforce the anxiety.

Linton: 10:36

I see that there's also medical reassurance seeking. That's another common issue. Clients often get caught in the cycle of repeated medical tests and going to the emergency room every time that they have a panic attack. Those are the bare facts, and I think it's time for a quick knowledge check. Which of the following is not required for diagnosing panic disorder? According to the DSM?

Linton: 11:05

The old not question Okay, shoot, all right. A reoccurring unexpected panic attacks. B one month of persistent concern about future attacks. C present of at least three physical symptoms during attacks. Or. D significant maladaptive behavioral changes related to those attacks.

Eric: 11:31

Oh, so you didn't think I was listening to what I just said a few minutes ago. The correct answer is C Linton. The DSM requires four or more symptoms during panic attacks, not three. I got it. This is an important distinction for accurate diagnosis and one that you might see on the test, just like you said. Now I have one. Which of the following is not a prognostic factor for panic disorder A temperamental B, environmental, c, genetic, d employment.

Linton: 12:08

Hmm, well, I'm not sure what temperamental means.

Eric: 12:13

Well, you've been that way, so you should know Okay.

Linton: 12:18

Environmental, genetic or employment Hard choices, but I'm going to say D unemployment. Not unemployment but employment. Yeah well, we've all been there. Yeah well, if you've seen some of the jobs I've done over the years, you would have to have me as a prime candidate for panic disorder, especially at the disco. Yes, of course. Any final thoughts about our topic, ez.

Eric: 12:47

Yes, remember, when you're taking the licensure exam, that each narrative subject's experience with panic is going to be unique, so your response needs to take that into account. But, as we always say, it's in there Absolutely. Thank you all for listening. Okay, see you later, ez Ciao.