Panic Disorder - A Case Report

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Saliha Büşra Selman [email protected] Abnormal Psychology (PSY 326) PANIC DISORDER WITHOUT AGARAPHOBIA: A CASE REPORT Eric was a 30-year-old man who took psychiatric treatment for panic attacks that troubled him for the past year. During a session, he reported that the attacks began “out of the blue” almost one year ago and for the past three months they became more frequently. He expressed that hearing music often stimulated his somatic symptoms and that he started to change his routines due to his worries about having a panic attack at an inappropriate time (Collison and Correll, 2011). In this paper, panic disorder will be analyzed through the case of Eric in terms of his diagnosis; etiology and epidemiology of panic disorder will be explained; possible treatments and prognosis of the panic disorder will be described. Diagnosis In the DSM-5 panic attack is described that it occurs in discrete period of intense fear or discomfort, in which four (or more) of the thirteen symptoms developed abruptly and reached a peak within 10 min (APA, 2013). In the Eric’s case, he complained about rapid breathing, shortness of breath, increased heart rate, trembling, sweating, and a feeling that he was detached from the world, which can be called by derealization or depersonalization. These 5 symptoms meet the criteria of DSM-5, which expresses that there must be 4 of 13 symptoms to qualify full-blown panic attack (APA, 2013). Also, he added that the attacks began “out of the blue” almost a year ago, and over the past three months they became more frequent. This statement fits the criteria of panic disorder that it must be recurrent and unexpected (APA, 2013). Moreover, he reported that his worries about having a panic attack at an inappropriate time made him change his daily routine. This phrase also meets the criteria that he has persistent concern about having additional attacks; he has worry about the implications of the attack or its consequences because he emphasized what if a panic attack occurs at an inappropriate time; furthermore, there is a significant change in behavior related to the attacks; that is, he altered his daily routine related with panic attacks, so these also suit the DSM-5 criteria for panic disorder (APA, 2013).

In addition, in the case of Eric, it might be said that there is no implication for agoraphobia because in agoraphobia the most general feared and avoided situations are streets and crowded areas such as shopping malls and theatres, so the focus of fear is different than panic disorder. Also, these symptoms cannot be better explained by social anxiety because in the cases of social anxiety, situational activators, such as exposure and social performance, stimulate fear and somatic symptoms, and the focus of fear in social anxiety is related with social situations, but in panic disorder it is fear of having a possible panic attack at any importunate place (Nigri Levitan et. al., 2013). Respectively, these symptoms are not result of specific phobia because in specific phobia, constant fear is associated with specific object or situation, and in the case of Eric, there is no such fear (Butcher et al., 2013). Likewise, the symptoms are not results of PTSD because in the Eric’s history, there is no direct or indirect experience of real danger to his life or to others that constitute a traumatic experience; instead, the panic attack comes “out of the blue” (Nigri Levitan et. al., 2013). In addition, obsessive-compulsive disorder does not reason of these symptoms because people with OCD often feel impulse to perform compulsive behaviors in response to an obsession, but in the case of Eric, there is no such certain rituals in response to fear, rather it is fear of having a panic attack in the near future (Butcher et al., 2013). Besides, there is no history of separation in the Eric’s case to have separation anxiety disorder. Consequentially, the panic attacks are not better accounted by another mental disorder, such as Social Phobia, Specific Phobia, OCD, PTSD or Separation Anxiety Disorder (APA, 2013). Finally, to diagnose these symptoms as a panic disorder, the panic attacks must not due to the direct physiological effects of a substance like drug use, or a general medical conditions such as cardiovascular system diseases, neurological system dysfunctions, endocrine system disorders, acute lung diseases, and other medical conditions (APA, 2013). Etiology Even though the exact cause unknown, genetic vulnerability, alterations in biochemical mechanisms, and psychosocial stressors that effect brain fear network can be cause of panic disorder (Dynamed). In the case of Eric, we should consider the genetic and biological factors that might be underlying causes of his panic disorder because family and twin studies

show that there are genetic factors, which are related with increased risk of panic disorder. Data indicates that there is almost 30-40% heritability in panic disorder (Hae-Ran Na, 2011). Therefore, we should ask that whether his parents or relatives have panic disorder. Also, we should check the biochemical imbalances like amount of carbon dioxide because some researchers claimed that panic attacks are startling reactions results of biochemical abnormalities (Butcher et al., 2013). It is found that people with panic disorder experience more panic attacks when they have biological imbalances than normal people and people with other psychiatric disturbances. For instance, giving sodium lactate by intravenous route, inhalation of changed amounts of carbon dioxide, and taking large amounts of caffeine, which are panic provocation procedures, produce physical symptoms of panic disorder, such as increased heart rate, blood pressure and respiration (Butcher et al., 2013). Then, we should see over a few specific neurotransmitter activities like noradrenergic and serotonergic regulations that are important in panic attacks; noradrenalin activates specific brain locations and can stimulate cardiovascular signs related with panic (Butcher et al., 2013). Noradrenergic activity is changed by serotonergic activity, and one of the most commonly used medications of SSRIs, enhance serotonergic activity and reduce noradrenergic activity, so cardiovascular signs related with panic are lessened (Butcher et al., 2013). Moreover, we should scrutinize certain brain areas that are related with panic disorder such as locus coeruleus, which is a nucleus in the pons related with physiological responses to stress and panic, and norepinephrine is mainly synthesized in here, which is also associated with panic and amygdala (Benarroch, 2009). Also amygdala, which is involved in the emotion of fear, and when the central nucleus of amygdala is stimulated, locus coeruleus is stimulated much the same the other autonomic, neuroendocrine, and behavioral reactions that happen during panic attack (Butcher et al., 2013). Furthermore, we should take into consideration Eric’s fear network sensitivity because people who have oversensitive fear networks; they are more likely to develop panic disorder. Finally, genetic vulnerability is partially because of one of the personality traits of neuroticism, so we should check the personality traits that have a high heritable component. People who score high on neuroticism tend to experience more

anxiety, anger and depressed mood, and interpret ambiguous situations as threatening (Matthews et al., 1998). According to Eric, his father had a short temper and he tended to yell easily at both his wife and his son, Eric, so we may say that the father had neurotic behaviors. Therefore, it can be said that Eric may have more than normal level of hereditary neurotic features, which one of the cause of panic disorder, because people who score high on neuroticism tend to experience more anxiety, and this anxiety can lead to panic attacks. Corresponding genetic and biological parameters, psychosocial factors including learning, cognitive variations, perceived control, and anxiety sensitivity have an effect on panic disorder. Learning theory of panic disorder suggests that the first panic attacks become connected with firstly neutral internal (interoceptive) and external (exteroceptive) signals by the way of interoceptive conditioning (or exteroceptive conditioning) course (Butcher et al., 2013). Bodily sense perception of anxiety and arousal become conditioned to interoceptive or exteroceptive stimuli, and the next time, because internal or external cues become associated with panic, anticipatory and sometimes agoraphobic fear occurs (Butcher et al., 2013). This is about preoccupation of having another attack, especially in specific condition, and might develop agoraphobic avoidance in which related with panic attacks (Butcher et al., 2013). In the case of Eric, his panic disorder might be result of interoceptive or exteroceptive conditioning as learning theory explained. It means that after initial panic attack he may be developed conditioned fear of internal cues such as rapid breathing, and racing heart. Also, it can be said that most probably he developed exteroceptive conditioning associated with loud music blaring at a traffic light, and because of this, he changed his driving route to avoid as many traffic lights as possible, which can be referred as agoraphobic avoidance because anxiety has conditioned to particular context. Individuals who have elevated degree of and anxiety sensitivity are more likely to experience attacks and probably panic disorder; anxiety sensitivity is a traitlike belief that individuals assume that specific bodily signals may have detrimental results (Butcher et al., 2013). Schmidt (2000) studied that degree of anxiety sensitivity is an estimator of experiencing panic attacks during high degree of stressful times. Thus, it can be said that Eric may probably have higher degree of anxiety than normal.

Actually, an individual’s sense of perceived control reduces the anxiety and even prevents panic (Butcher et al., 2013). For example, if a person assumes that he has power over the amount of carbondioxide that he inhales, his panic attack can become prevented in this way. Moreover, if there is a “safe” person together with a person with panic disorder during the panic provocation procedure, patients tend to experience less stress, anxiety, arousal and panic attack compared to someone who is alone (Butcher et al., 2013). Even though people have high level of anxiety sensitivity, if they have a sense of perceived control and anticipation about their life events, emotions, threatening situations, they might be protected against panic attacks as well as they might be protected against the agoraphobic fear (Butcher et al., 2013). Therefore, if Eric would have sense of control over the music, he would not experience panic. People with panic disorder are supersensitive to their physical sensations; they tend to immediately interpret these bodily sensations, and they prone to give meaning them in catastrophic way (Butcher et al., 2013). Even they do not conscious of their catastrophic way of thinking, these “automatic thoughts”, as Beck named them, stimulate panic. The cognitive theory suggests that individuals, who have catastrophic way of thinking and interpretations, are more likely to develop panic disorder; accordingly, if people with panic disorder change their cognitions concerning bodily sensations, it may reduce or even prevent panic (Butcher et al., 2013). In the Eric’s case, although we couldn’t see a statement including catastrophic way of interpretation of his bodily symptoms, or automatic thoughts, it is one of the most common features of individuals with panic disorder. Cognitive theory emphasizes the strong association between catastrophic way of interpretations of bodily symptoms and panic attacks; accordingly, panic disorder would not occur in people who do not have catastrophic way of thinking (Butcher et al., 2013). Finally, other possible risk factors should be taken into consideration for panic disorder. These are “significant life stressors”, “history of childhood sexual or physical abuse”, “anxious temperament” and “cigarette smoking in adolescents and young adults” because according to a study, smoking individuals have higher risk for panic disorder compared to nonsmoking population as well as other anxiety disorders (Dynamed).

Epidemiology The National Comorbidity Survey-Replication research stated that almost 4.7 percent of the adult population has had panic disorder with or without agoraphobia at a point of their lives. In the case of panic disorders, although statistics indicate that panic disorder more common in women, we should not overlook that men also have panic disorder, as in the case of Eric. Also, his age of 30 is convenient to develop panic disorder because it is known that the average age of onset of panic disorder is 23 to 34 years (Butcher et al., 2013). Moreover, epidemiological studies show that when panic disorder occurs for one time, it is more likely to become a chronic and disabling as seen in the Eric’s case; that is, his panic attacks has started almost one year ago and it continues, which indicates its chronicity; and he has started to alter his daily routine due to his excessive anxiety and worries about possible future panic attacks, which shows its disabling course. Consequentially, these information and findings seem suitable for panic disorder. Treatment Panic disorder has distressing and impairing course, and reduces quality of life of patients, so treatment is needed to remove symptoms that interfere functioning well. Pharmacotherapy and psychotherapies are the two most common and useful treatments for panic disorder. In the case of Eric, he prescribed with fluoxetine, which is from SSRIs category, and its dose increased every 6 to 8 weeks as it is expected because of the fact that SSRIs do not act very quickly and it takes at least about 4 weeks (Butcher et al., 2013). Also, his doctor gave him lorazepam, which is from benzodiazepines family, due to the fact that these drugs become active very fast, so they are useful in acute situations where Eric is having a panic attack (Butcher et al., 2013). Although, Eric reported that fluoxetine decreased his panic attacks in frequency, he complained about lorazepam. It can be said that Eric better tolerated fluoxetine from the SSRIs, as well as most of the patients (Butcher et al., 2013); however, the side effects of lorazepam made Eric feel tired and “numb” for a few hours after taking it, so he avoided using it. Yet, because it is useful for his acute panic attacks, which occurred while he was driving, when he did not use, he was late for work. In other words, this situation impaired his daily routine, so medications did

not live up to expectations. Although medications can lead symptom relief, the relapse rate is high (Wiborg et al., 1996). Even the combination of pharmacotherapy with antidepressants and benzodiazepines does not show lower relapse rate than only psychotherapy (Simon et al., 2002). Another study shows that there is 67% relapse rate in patients at least once over a 3-year duration (Toni et al., 2000). Moreover, the side effects of medications cause discontinuity or interference of a treatment as it is seen in the Eric’s case. Therefore, one of the most effective treatments is cognitive-behavioral therapies show great improvement in patients. After 2 years cognitive-behavioral therapy sessions, almost 70% of patients with panic disorder showed remission (Heldt et. al., 2011) and compared to pharmacological treatment cognitive behavioral therapy have significantly higher treatment effect size (Norton and Price 2007). CBT includes, education, breathing retraining, cognitive restructuring, interoceptive exposure, and in vivoexposure (Barlow et al., 1989). In education part, therapist teaches the course of panic disorder, the nature of attacks, the cognitive basis, behaviors that reinforce the panic circle and the treatment logic; then, breathing exercise is used to show how overbreathing can stimulate physical symptoms of panic attacks (White et al., 2002). There are two main techniques in CBT: interoceptive exposure and cognitive restructuring. The way of interoceptive exposure treatment is same as the idea of treatment of external agoraphobic situations, but in interoceptive exposure a patient is exposed feared internal sensations instead feared object or place (Butcher et al., 2013). On the other hand, cognitive restructuring technique mainly focuses on catastrophic automatic thoughts, which reinforce panic attacks. One kind is panic control treatment that works with both agoraphobic avoidance and panic attacks; usually, this treatment shows greater improvement than the original exposure-focused technique (Butcher et al., 2013). In the Eric’s case, although his psychiatrist chose the psychodynamic therapy, CBT can also be used. Then, his therapist would prefer panic control treatment, which is one of the most effective cognitive restructuring techniques for panic disorder; thus, they would work on his maladaptive thoughts and behaviors that maintain and increase anxiety and panic attacks (Hofmann et al., 1999). Also, PCT can be combined with situational exposure tasks, and it can be helpful for Eric because certain music is anxiety-provoking for him at a traffic light, so if he stays there until

his anxiety subsides, it can be effective treatment (Hofmann et al., 1999). The combination of medication and CBT achieves a slightly higher result than either type of treatment alone, for short-term; people who took combined treatment reported less medication side effect, and less dropouts from the therapy sessions; however, in the long-term, again after medication is decreased (especially benzodiazepine medications), patients show more likely to relapse even they received combined therapy (Butcher et al., 2013). Possibly, it may be cause of patient’s misattribution, which positive progress of the sessions is associated with medication rather than their personal improvement (Butcher et al., 2013). Even though neurobiological or cognitive behavioral approaches are widely accepted models, psychodynamic therapy might contribute to the comprehension of people with panic disorder (Shear et al., 1993). Psychodynamic theory suggests that unconscious processes and childhood experiences have an affect on a person’s present behavior; thus, psychodynamic therapy is insight-oriented, and the aims are to make a patient conscious and make understand the impact of past on present behavior (Haggerty, 2006). It can be said that psychodynamic therapy gives patients occasion to explore unsolved internal conflicts, which stem from maladaptive interpersonal relationships, by free association method (Haggerty, 2006). Finally, expected responses to psychodynamic treatments are panic symptom relief and reduce in agoraphobic symptoms (Milrod et al., 2001). The psychiatrist of Eric chose psychodynamic therapy to examine his unconscious processes and childhood experiences, which might have an influence on his attacks, and they found out that his familial problems are the most probably underlying cause of his panic disorder. The music, which triggers his attacks, reminds his parents’ maladaptive relationship, and then his psychiatrist saw that he seemed angry for this situation rather than being upset, and then they realized that he did not express his angry in his childhood. In the therapy they discussed other issues, which trigger his attacks, emerged that have an association with his childhood. After reinterpretation of psychiatrist his panic attacks in a meaningful way, he became more comfortable exploring his unconscious anger, and Eric’s oversensitivity for the music disappeared and he achieved symptom relief.

Prognosis People with panic disorder have a poor prognosis if they are untreated because it has chronic course, and when patients drop treatments, they relapse frequently as expected; in contrast, if patients complete treatments, their long-term prognosis is often good, and approximately 65% of patients show remission almost within 6 months (Batelaan et al., 2010). If panic disorder comorbid with general medical conditions such as cardiovascular system diseases, the prognosis becomes relatively poor (Fleet et al., 2005). Also, when panic disorder co-occurs with major depression, generalized anxiety disorder, social phobia or obsessive-compulsive disorder, it becomes more severe, and this affects the course and prognosis of the panic disorder (Marshall, 1996). Remission rates in prognosis are being affected by sociodemographics (gender, age, education, socioeconomic status, having a partner), psychobiological factors (traumatic experiences in youth, neuroticism, self-esteem, absence of somatic disorder, parents without a psychiatric history of anxiety or depression), environmental factors (positive life event, negative life event, ongoing difficulty, social support), psychiatric factors (history of anxiety disorder, history of affective disorder, history of alcohol and drug disorder), and panic-related factors (frequency of panic at start of panic, functioning at start of panic, etc.) (Batelaan et al., 2010). It is found that there is statistically significant prediction in remission rate associated with female gender, high education, high self-esteem, low neuroticism, less ongoing difficulties, and low frequency of attacks at start of panics (Batelaan et al., 2010).

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