Sunday, October 4, 2009

ABC of Anxiety Disorder: Panic Disorder

ABC of Anxiety Disorder: Panic Disorder

By Dr Leow Chee Seng

Consultant,

Fellow of British Institute of Homeopathy (UK),

Certified Stress Management Consultant (IACT, USA),

We become anxious from time to time. For example, meeting with important person, changing a new job, concern over a new relationship creates anxiety. A person’s anxieties are about the future, whether long-term concerns about a new career.

The terms fears and anxiety is commonly used interchangeable. However, fear refers to an innate, almost biological based alarm response to a dangerous or life-threatening situation. Anxiety, in contrast, is more future oriented and global. The term anxiety is inordinately apprehensive, tense, and uneasy about the prospect of something terrible happening. Anxiety becomes clinically concern when it interferes with the ability to function in daily life, when a person enters a maladaptive state characterized by extreme physical and psychological reactions.

Referring to Diagnostic and Statistic Manual of Mental Disorder (DSM-IV-TR), panic disorder occurs in context of several disorders in this section, criteria sets for a panic attack is listed separately at the beginning.

Diagnostic features of panic attack

A panic attack is a period of intense fear or discomfort, during which a person experiences four or more of the following symptoms, which develop abruptly and reach a peak within 10 minutes:

· palpitations. pounding heart. or accelerated heart rate

  • · sweating
  • · trembling or shaking
  • · sensations of shortness of breath or smothering
  • · feeling of choking
  • · chest pain or discomfort
  • · nausea or abdominal distress
  • · feeling dizzy, unsteady, lightheaded. or faint
  • · derealization (feelings of unreality) or depersonalization (being detached from
  • · oneself)
  • · fear of losing control or going crazy
  • · fear of dying
  • · paresthesias (numbness or tingling sensations)
  • · chills or hot flushes (Reference: DSM-IV-TR)

Type of panic attack

There are three categories of panic attack mainly, unexpected panic attack, situational bound panic attack and situational predisposed panic attack. For unexpected panic attack, there is no situational cue or trigger. The second type of panic attack, situational bound panic attack occurs where a person has a tendency to have a panic attack in the situation but does not have one every time. For example, when one of my friends hears an ambulance siren, he begins to experience the symptoms of a panic attack. She could not work in a hospital especially in accident and emergency department. So, she finally settled herself in the area of public health. The last category of panic attack is situational predisposed panic attack where a person will have situational panic attack but not every time.

Biological Perspective

In trying to understand the cause and strategy to fight panic disorder, we should discuss both biological prospective and psychological prospective. However, in this article, I will focus more on psychological perspective.

In biological prospective, panic attack is associated with excess of noreponephrine in the amygdala, a structure in limbic system involved in fear. Besides, the disorder derives from defect in gamma-aminobutyric acid (GABA), a neurotransmitter with inhibitory effects on neurons.

According to anxiety sensitivity theory, people with panic disorder tend to interpret cognitive and somatic manifestation of stress and anxiety in a catastrophic manner. For example, they feel that they cannot breathe even others feel the situation is normal. This false alarm mechanism causes the person to hyperventilate and the person is thrown to a panic state.

Psychological perspective

Turning to psychological perspective, we focus on conditioned fear reactions as contributing to the development of panic attacks. This person relates bodily sensation with memories with the last attack, causing a full-brown panic attack to develop even before measurable biological changes have occurred. Over time, the individual begins to have panic attack before it happens.

David Barlow and his colleagues proposed in a cognitive-behavioural model that anxiety becomes an unmanageable problem for an individual through the development of vicious cycle. The diagram shows the cycle of panic attack.








Stress management techniques help in treatment of panic disorder. In this approach, the client learns systematically to alternative tensing and relaxation muscle all over the body, starting from forehead down to the feet. After stress management techniques, the client should be able to relax the whole body when confronting feared situation.

However, I like to use panic control therapy (PCT) developed by Barlow and his colleagues. This technique consists of cognitive restructuring, the development of an awareness of bodily cues associated with panic attacks, and breathing retraining. I found that clients treated with PCT show marked improvement, at levels comparable to improvement shown by clients treated with antianxiety medication. I would propose combination of both antianxiety medication and PCT should give a marked improve among clients.

During my training in counselling and psychotherapy, Prof Malik Badri, Professor of Psychology, Fellow of International Islamic University Malaysia explained that more comprehensive interventions involving cognitive techniques. He recommended in vivo exposure when treating individual with panic disorder, especially with those with agoraphobia. He taught me the use of graduated exposure, a procedure in which clients expose themselves to increasing greater anxiety-provoking situation. For example, Mr X finds visiting to large shopping malls to be emotionally overshelming. I would recommend that his exposure to stressful environments begin with a small shop in which he feels safe and relatively anxiety free. Step-by-step, Mr X would progress to environments that are higher list of anxiety provoking settings.

I have just completed attending training in conterconditioning. This technique is used to treat hyperventilation, a common symptom in panic attacks. In this approach, the client hyperventilates intentionally and begins slow breathing, a response that is incompatible with hyperventilation. In this training, the client can begin the slow breathing at the first signs of hyperventilation. Hence, the clients learn that it is possible to exert voluntary control over hyperventilation.

If the recommended psychological approach does not able to control anxiety of a person, the use of medication can help alleviate symptoms, with the most commonly prescribed being antianxiety and antidepresant medication.

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