Panic disorder is characterized by unexpected panic attacks and fear of future attacks. Agoraphobia involves fear and avoidance of situations where escape may be difficult if a panic attack occurs. Common symptoms of panic attacks include shortness of breath, heart palpitations, and fear of losing control. Treatment involves medication like SSRIs or exposure-based psychotherapy to help patients face feared situations. Combined treatment of medication and psychotherapy is often most effective for reducing panic attacks and agoraphobic avoidance.

1. PANIC DISORDER
AND AGORAPHOBIA

2. • Panic Disorder
: Debilating anxiety disorder
: Individuals experience sever, unexpected panic attacks
that may think they are dying or losing control.
: Last up to 10 minutes
: Occur out of the blue
• Signs and Symptoms of Panic Disorder
Shortness of breath or hyperventilation
Heart palpitations or a racing heart
Chest pain or discomfort
Trembling or shaking
Choking feeling
Feeling unreal or detached from your surroundings
Sweating
Nausea or upset stomach
Feeling dizzy, light-headed, or faint
Numbness or tingling sensations
Hot or cold flashes
Fear of dying, losing control, or going crazy

3. • Agoraphobia
: Fear and avoidance of situations in which a person feels
unsafe or unable to esape to get home or to a hospital in
the event of a developing panic symptoms or other
physical symptoms.
: Fear of being in a public spaces or open spaces
: Coined in 1871 by Karl Westpal (German Physician)
: Greek word “agora” fear of the marketplace
: Most agoraphobic avoidance behavior is simply a
complication of severe unexpected panic attacks.

4. CLINICAL DESCRIPTION
• Some people experienced panic disorder without developing agoraphobia
while some develop agoraphobia without panic disorder.
• Diagnostic Criteria for Panic Disorder
A. Repeated panic attacks are present
B. Followed by one month or more of both the ff.:
a. worry about having panic attacks
b. maladaptive change in behavior
C. Not attributable to the physiological effects of substance or medical
condition
D. Not explained by another mental disorder

5. CLINICAL DESCRIPTION
• Diagnostic Criteria for Agoraphobia
A. Fear or Anxiety of the ff. situations:
a. Public Transportation (Buses, Trains, Subways
b. Open Spaces (Shopping Malls, Wide street, Supermarket)
c. Enclosed Spaces (Car, Restaurant, Theater, Elevators)
d. Standing in line or being in a crowd
e. Outside of home alone
B. Avoid those situations due to thinking that escape might be difficult
C. Agoraphobic situations provoke fear or anxiety
D. Agoraphobic situations are
a. Actively avoided
b. Require the presence of companion
c. Endure with intense fear or anxiety

6. CLINICAL DESCRIPTION
E. Fear or anxiety is out of proportion to the actual danger
F. Fear, anxiety or avoidance of these situations last up 6 months or more
G. Fear, anxiety or avoidance cause distress or impairment in social, or
occupational or other important areas of functioning.
H. If another medical condition is present, fear, anxiety or avoidance is
clearly excessive
I. Fear, anxiety or Avoidance is not better explained by another mental
disorder
• One way of coping with panic attack is by drugs and/or alcohol.
• Some individuals do not avoid agoraphobic situation but endure them with
intense dread (fear and anxiety)
• Patients with panic disorder with agoraphobic avoidance develop
interoceptive avoidance (avoidance of physical sensations)

7. CLINICAL DESCRIPTION
• Interoceptive daily activities typically avoided by people with agoraphobia.
a. Running up flights of stairs
b. Getting involved in heated debates
c. Walking outside in intense heat
d. Having showers with the doors and windows closed
e. Hot stuffy room/cars
f. Hot stuffy stores/malls
g. Having a sauna
h. Hiking
i. Walking outside in a very cold weather
j. Sports
k. Aerobics
l. Drinking coffee or any caffeinated beverages
m. Lifting heavy objects
n. Dancing
o. Watching horror/exciting movies
p. Eating heavy meals/chocolates
q. Getting angry

8. STATISTICS
• 2.7 percent of the population meet criteria of P.D during a given one-year
period.
• 4.7 percent met them at some point during their lives; 2/3 women.
• 1.4 percent develops agoraphobia without ever having a full-blown panic
attack.
• P.D occurs in early adult life. (From mid-teens 20-24 to 40 years of age.)
• Prepubescent children experience unexpected panic attacks, and
occasionally panic disorder, though this is a rare case. They are mostly have
symptoms of hyperventilation that may well be panic attacks.
• Initial unexpected panic attacks begin at/after puberty.
• P.D and agoraphobia decreases among the elderly, from 5.7% (ages 30-44)
to 2.0% less. (ages after 60)
• 75% of those who suffer agoraphobia are women.

9. CULTURAL INFLUENCES
• Prevalence rate of P.D were similar in United States, Canada, Puerto Rico,
New Zealand, Italy, Korea and Taiwan.
• Panic attacks among Iranian college student and is similar to those among
Western college student.
• Rates are also similar among different ethnic groups in the United states,
including: Afro-American.
• Somatic Symptoms of Anxiety may be emphasized in 3rd world cultures.
• Primarily somatic anxiety is marked by somatic events such as:
Stomachache, Headache, Muscle tension, Muscle aches, Increased
heart rate, Rapid breathing/Hyperventilation, Sweating, Shaking,
Nausea.

10. CULTURAL INFLUENCES
• Susto
: Fright disorder in Latin-America.
: Disorder characterized by sweating, increased heart-rate, and
insomnia, but not by reports of anxiety or fear.
• Ataques de nervios
: Anxiety-related, culturally defined syndrome common to Spanic-
Americans and Carribeans.
: Shouting uncontrollably or bursting into tears.
• Devon Hinton
: Psychiatrist/Antropologist.
: Discovered that Khmer (Cambodian) and Vietnamese both suffer f
from a high rate of P.D.
: Discovered that the concept of Khmer “Kyol Goeu” or “Wind
Overload” becomes the cause of Panic Attack.

11. NOCTURNAL PANIC
• 60% of the people with P.D have Nocturnal Attacks.
• Happens at night and awakes you from sleep.
• Panic Attacks occur more often between 1:30 am and 3:30 am.
• Studied in a sleep laboratory where patients are attach to a
electroencephalograph. They occur during Delta wave or slow wave sleep.
• People with P.D often begin to panic when they start sinking into delta sleep
and they awaken amid an attack.
• Cause of Nocturnal Panic
• Change in stages of sleep to slow wave sleep produces physical sensation of
“letting go” that are frightening to an individual with P.D.
• Nightmares
• Sleep apnea
• Breathing disorder of patients with N.P.
• Interruption of breathing while asleep that may feel like suffocation.

12. NOCTURNAL PANIC
• Sleep Terrors:
• Occurs in children.
• Screaming and getting out of bed.
• Occur at later stage of sleep (stage four sleep) associated with Sleepwalking.
• Isolated Sleep Paralysis
• Common at the Ethnic Group of U.S. (Afro-American)
• Occur during transitional state between sleep and walking, when a person is
either falling asleep or waking up, but mostly waking up.
• Occurrence of I.S.P were significantly higher in Afro-Amerian with P.D. (59.6%)
a. White with P.D. (7.5%)
b. Afro-American with A.D. (11.1%)
c. White with A.D. (0%)
d. Afro-American Community Volunteer. (23%)
e. White Community Volunteer. (6%)
• Americans with I.S.P had the history of trauma, P.D and Posttraumatic Stress than
Afro-Americans without I.S.P.

13. CAUSES
• Agoraphobia: socially and culturally determined.
• Panic attacks and Panic disorder: biologically and psychologically determined.
• Generalized Psychological Vulnerability + Generalized Biological Vulnerability
would lead to Stress, which leads to False Alarm (Somatic sensations) to a
Learned Alarm, which then would be specific Psychological Vulnerability to
anxious apprehension that will develop to Agrophobia, Panic Disorder, or
Agoraphobia with P.D.
• 8-12% of the population has an unexpected panic attack due to stress. Only 5%
develop anxiety, thereby, having panic disorder.
• David Clark: People with psychological vulnerability interpret physical
sensations in a catastrophic way.

14. TREATMENT
• MEDICATION
: Drugs that affect the noradrenergic, seratonergic, or GABA-
benzodiazepine neurotransmitter system are effective in treating panic
disorder. They are the:
a. High-potency benzodiazepines
b. Newer selective-serotonin reuptake inhibitors (SSRI)
b.1 Proxac
b.2 Paxil
c. Seratonin-norepinephrine reuptake inhibitors (SNRI)
c.1 Venlafaxine

15. TREATMENT
• SSRI
• Indicated drug for panic disorder
• Sexual dysfunction occur in 75% or more of people taking this
• High Potency benzodiazepine (Alprazolam or Xanax)
• Commonly used for panic disorder
• Work quickly but result to psychological and physical dependence and
addiction
• Most widely used class of drugs in practice
• Affect motor and cognitive functions
• 60% of patients with P.D are free of panic as long as they stay on drugs
• 20% or more stop taking before treatment is done thus relapse rate are high

16. PSYCHOLOGICAL INTERVENTION
• Psychological treatments
: Effective for P.D.
: Reducing Agoraphobic avoidance using strategies, based on
exposure to feared situations.
• Exposure-based Treatment
: Arranged conditions in which the patients can gradually face the
feared situations and learn that there is nothing to fear.
: Example: Shopping in a supermarket for 30 minutes alone.
Walking 5 blocks away from home.
Driving on a busy high-way for 5 miles with spouse or alone.
Eating in a restaurant, sitting in the middle.
Watching a movie, while sitting in the middle of the row.

17. PSYCHOLOGICAL INTERVENTION
• Gradual exposure exercises
: Combined with anxiety reducing coping mehanisms.
: Examples: Relaxation or Breathing retaining.
: 70% of the patients undergoing this treatment improve while their
anxiety and panic are reduced and agoraphobic avoidance is greatly
deminished.
• Effective Psychological Treatment
: Treat panic disorder directly even in the absence of Agoraphobia.
• Panic Control Treatment (PCT)
: Exposing patients with panic disorder to the cluster of interoceptive
(physical) sensations that remind them of their panic attacks.
: Patients who received PCT have remained better after atleast 2 years.

18. PSYCHOLOGICAL INTERVENTION
• Cognitive Therapy
: Basic attitudes and pereptions concerning the dangerousness of the
feared by objectively harmless situation are identified and modified.
• Nevertheless, some patients relapse over time. Multisite collaborative team
began investigating long-term strategies in the treatment of P.D including
the usefulness of providing booster.
• Booster sessions produced significally lower relapse rate, (5.2%) and reduce
work and social impairment compared with the assessment only condition
without booster sessions (18.4%) at a 21 month follow up.
• Booster sessions aimed at re-inforcing acute treatment gains to prevent
relapse and off-set disorder.

19. COMBINED PSYCHOLOGICAL AND
DRUG TREATMENTS
• National Institute of Mental Health studied the separate and combined
effects of Psychological and Drug treatments.
• Patients were randomized into 5 treatment conditions:
a. Psychological treatment alone. (CBT)
b. Drug treatment alone. (IMI)
c. A combined treatment condition (IMI + CBT)
d. Placebo alone. (PBO)
e. Placebo + CBT