Beyond Fight or Flight: Panic Disorder

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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.

Episode Transcript

Eric (00:02):
Well, hi everybody, including you people up there in
the freezing north.
I'm looking in the old mailbagand Sandy from Albion, michigan,
asked for information thatwould be useful for the
licensing exam about panicdisorder.
Hi, my name's Eric Kwokman.

Linton (00:19):
And I'm Dr Linton Hutchinson.
Today we're going to focus onthe complexities, the diagnosis,
and treatment approaches ofpanic disorder.

Eric (00:34):
And let's start by clarifying what makes panic
disorder distinct.

Linton (00:36):
Can you break it down for us?
Sure, so when we look at panicdisorder, we're seeing
reoccurring unexpected panicattacks paired with persistent
worry about future attacks.
What makes this conditionunique is the behavioral changes
that occur in response to thoseattacks.

Eric (00:54):
Right, you are.
Panic attacks tend to hitsuddenly and intensely, unlike
anxiety, which tends to buildgradually, and they either occur
without any noticeable triggeror by specific situations.

Linton (01:11):
Well, I'm interested in how the different type of
attacks that a client has arecategorized.

Eric (01:18):
Well, there are three main types.
First, the unexpected attacks,like I mentioned, that come
without warning.
Then you have situationallybound attacks, which
consistently occur in specificsituations.
And the third type issituationally predisposed attack
, where exposure to a triggermight lead to an attack, but it

(01:39):
might not.

Linton (01:40):
So it's the unpredictability that often
leads to significant changes intheir behavior.
A client might start avoidingplaces where they had attacks
before, or situations where theyworry that help won't be
available.

Eric (01:54):
Yes, which makes it so that clients often create
elaborate avoidance strategiesTaking a longer route to work,
refusing to eat in certainrestaurants, avoiding exercise
which might increase their heartrate.
These changes can seriouslyimpact their work relationships,
basically their overall qualityof life.

Linton (02:14):
Wow, I had something like that happen to me.
I was in Publix right down thestreet and they ran out of
kimchi that I really like.
I ended up going to anotherstore farther away just to avoid
feeling disappointed.

Eric (02:29):
Well, what a stressful situation that must have been,
but I don't think that's exactlythe same thing, is it?

Linton (02:38):
You know maybe not what are the specific criteria for
diagnosing panic attacks.

Eric (02:44):
Well.
According to the DSM, diagnosisrequires recurrent unexpected
panic attacks followed by atleast one month of either
persistent concern aboutadditional attacks or
significant behavioral changes,and during the attacks a client
needs to experience four or morespecific symptoms.

Linton (03:04):
Uh-huh, and that can manifest as both physical and
cognitive.
Physical symptoms includesweating, trembling, shortness
of breath and chest pains.
Cognitive symptoms includederealization, fear of losing
control and fear of dying.
Some of them sound like theycould be symptoms of other

(03:25):
disorders.
So what are the differentials?

Eric (03:28):
Well, several anxiety disorders, including ones that
are substance-related andmedical condition-related.
Anxiety disorders aredifferential.
The key is the sudden onset andintensity.
Unlike anxiety, these symptomspeak within minutes and often
feel overwhelming to the clientin that short period of time.
So it's important to rule outthe medical conditions and

(03:51):
substance-related causes.
At its core, panic disorderinvolves a fear, of fear itself.

Linton (04:01):
Wasn't that what Churchill said during the Second
World War?

Eric (04:05):
Close.
I think you're thinking aboutour president, Franklin Delano
Roosevelt, who said those exactwords, but he wasn't talking
about this disorder.
He was talking about the GreatDepression.
A client developshypersensitivity to bodily
sensation and theirinterpretation.
That creates what's known asthe fear response cascade.

(04:26):
And how would you explain thatto a client?

Linton (04:30):
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 theirheartbeat is slightly faster.
They would interpret this as asign of an impeding heart attack
, and then this interpretationwould trigger more anxiety,

(04:53):
which then again increasesphysical symptoms like rabbit
heartbeat and shortness ofbreath no-transcript.

Eric (05:04):
Well, the best thing to do would be to focus on helping
clients recognize the pattern asit's happening and to work on
reframing those initialinterpretations and developing a
more balanced response tophysical sensations.

Linton (05:18):
So you're saying you would intentionally try to have
your client have a full-blownpanic attack during sessions?

Eric (05:24):
That's right, just for fun ?
No, of course not, buteventually you would work up to
it.
It's called in vivodesensitization.
You go gradually, but we'lltalk about that more later.

Linton (05:38):
Okay, that sounds like a plan With panic disorder.
Accurate assessment is veryimportant.
Let's go over some assessmenttools that have been found to be
effective.

Eric (05:48):
And that you might see on the exam.
Right, right, right One is thePanic Disorder Severity Scale,
which is widely used.
It helps measure attackfrequency, distress levels,
various types of impairment andit looks at seven key areas.
Areas frequency of attacks,associated distress,

(06:09):
anticipatory anxiety,agoraphobic fear, interoceptive
fear and both work and socialimpairment.

Linton (06:20):
Man, you can tell that was written by a psychologist,
can't you?
Yes, you can.
There's also the Anxiety Sensitbody sensation questionnaire.
The asi gives us insight intohow clients interpret and
respond to anxiety relatedphysical symptoms.
It measures fears aboutphysical concerns, mental

(06:43):
incapacitation and socialevaluation.
The bsq helps identify whichbody sensations trigger the most
fear.

Eric (06:53):
And the mobility inventory for agoraphobia is used to
track changes in avoidancepatterns and the agoraphobic
conditions questionnaire is formapping out catastrophic
thinking patterns.

Linton (07:07):
And don't forget the Albany panic and phobia
questionnaire.
That is useful for identifyingspecific activities that produce
sensations similar to panicattacks.
This helps guide the client'sexposure hierarchy and for the
exam, you see that all of theseassessments, or at least most of
them, have the word panic inthem, so it will be really

(07:29):
obvious that you should selectthat on a question that is
regarding assessments.

Eric (07:35):
That's right.
They either have the word panicor agoraphobic, which is part
of that whole process.
Some of these comprehensiveassessments are to be used at
intake, some used as a follow-up, at regular intervals to track
progress and adjust treatmentplans accordingly.
Then panic attack records arereviewed weekly to identify any

(07:57):
emerging patterns or triggers.

Linton (08:00):
That sounds like a good transition to review some
effective treatment approachesthat might be on your licensing
exam regarding panic disorder.

Eric (08:10):
Well, you might start with psychoeducation about the
nature of panic and the fight orflight response, and then move
into cognitive restructuring andsome breathing techniques, Then
spend significant time mappingout the client's specific panic
cycle, identifying their uniquetriggers, sensations, thoughts
and behaviors.

Linton (08:30):
Okay For those of you that believe in cognitive
therapy, believe in cognitivetherapy they tend to focus what?
I'm a believer.
Okay, that will tend to focuson helping clients identifying
and changing their catastrophicthoughts and also work on
developing alternativeinterpretations of body

(08:52):
sensations.
Thought records areparticularly useful, especially
when tracking the intensity ofbeliefs before and after
restructuring.

Eric (09:03):
And another technique is with interoceptive exposure,
that is, controlled exercisesthat safely reproduce feared
situations like we were talkingabout before.
This could involve havingclients run in place to increase
their heart rate, breathethrough a straw to create mild
breathlessness, or spin in achair to induce dizziness, then

(09:24):
gradually progress to in vivoexposure Out in the world,
always moving at a pace thatfeels challenging but manageable
for the client Right and youmentioned breathing techniques.
That's right.
It turns out thatover-breathing can create many
of the sensation that clientsfear, like lightheadedness and

(09:46):
tingling.
The client will practicediaphragmatic breathing, first
in a calm state, then duringmild anxiety.

Linton (09:55):
Progressive muscle relaxation and mindful body
scanning have been particularlyuseful.
There's a long form and anabbreviated version, so what are
some challenges that therapistswould see when treating panic
disorder?

Eric (10:11):
Well, one frequent challenge is the client's
reluctance to give up the safetybehaviors that will actually
help them.
They often have elaboratesystems of coping, like we
talked about driving way out ofyour way to go to work or
anything that they feel isprotecting them but that
actually maintain and reinforcethe anxiety.

Linton (10:31):
I see that there's also medical reassurance seeking.
That's another common issue.
Clients often get caught in thecycle of repeated medical tests
and going to the emergency roomevery time that they have a
panic attack.
Those are the bare facts, and Ithink it's time for a quick

(10:51):
knowledge check.
Which of the following is notrequired for diagnosing panic
disorder?
According to the DSM?
The old not question Okay, shoot, all right.
A reoccurring unexpected panicattacks.
B one month of persistentconcern about future attacks.

(11:12):
C present of at least threephysical symptoms during attacks
.
Or.
D significant maladaptivebehavioral changes related to
those attacks.

Eric (11:26):
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 moresymptoms during panic attacks,
not three.
I got it.
This is an importantdistinction for accurate
diagnosis and one that you mightsee on the test, just like you

(11:46):
said.
Now I have one.
Which of the following is not aprognostic factor for panic
disorder A temperamental B,environmental, c, genetic, d
employment.

Linton (12:03):
Hmm, well, I'm not sure what temperamental means.

Eric (12:09):
Well, you've been that way , so you should know Okay.

Linton (12:13):
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 someof the jobs I've done over the
years, you would have to have meas a prime candidate for panic
disorder, especially at thedisco.

(12:36):
Yes, of course.
Any final thoughts about ourtopic, ez.

Eric (12:42):
Yes, remember, when you're taking the licensure exam, that
each narrative subject'sexperience with panic is going
to be unique, so your responseneeds to take that into account.
But, as we always say, it's inthere Absolutely.
Thank you all for listening.
Okay, see you later, ez Ciao.