John Donahue is a 45-year-old high school principal who has suffered from panic attacks for 15 years. His symptoms include intense fear, heart palpitations, nausea, dizziness, and fears of losing control. He meets the criteria for panic disorder with agoraphobia. John likely developed this disorder due to genetic and social factors like his family history of anxiety disorders and stressful life events. His condition is maintained by safety behaviors, cognitions about panic attacks being dangerous, and anticipatory anxiety. Treatment involves cognitive behavioral therapy and exposure therapy, with John gradually facing feared situations to overcome his avoidance.

1. Panic Disorder with Agoraphobia a case presentation vanessa villamia sochat abnormal psychology July 11, 2008

2. Panic Disorder with Agoraphobia An Introduction

3. WHO is our client? WHAT are his symptoms and diagnosis? WHY did he develop this disorder? HOW do we treat it? Outline

4. WHO WHAT WHY HOW ? Who is our client? John Donahue DEMOGRAPHICS Forty five years ago High school principal Father of three CLINICAL HISTORY First attack 15 years ago Alcoholism Anxiety Clinic What does John think of his attacks?

5. WHO WHAT WHY HOW ? An example of John’s typical panic attack

6. WHO WHAT WHY HOW ? Symptoms of panic attack Intense apprehension and terror Impending doom Labored breathing Heart palpitations Nausea, chest pain Choking and smothering Dizziness Sweating Trembling Depersonalization Derealization Fears of losing control, going crazy Panic Disorder with Agoraphobia “ Anxiety about situations which would be embarrassing or difficult to escape if panic symptoms occurred” What are his symptoms  Diagnosis? Symptoms of panic attack Intense apprehension and terror Impending doom Labored breathing Heart palpitations Nausea, chest pain Choking and smothering Dizziness Sweating Trembling Depersonalization Derealization Fears of losing control , going crazy Do John’s symptoms fit the disorder? recurrent unexpected panic attacks at least 1 of attacks followed by month of concern about having another attack concern about consequences of attack change in behavior because of attacks

7. Axis I: 300.21 Panic disorder with agoraphobia Axis II: No diagnosis on axis II Axis III: None Axis IV: Relocation to new state, job change, stressful work schedule Axis V: Global assessment of functioning = 58 WHO WHAT WHY HOW ? What is John’s official DSM-IV-TR diagnosis? DMS-IV-TR Diagnosis Based on: Anxiety about situations/events Avoidance of these situations/events Anxiety not better accounted for by another disorder!

8. WHO WHAT WHY HOW ? Integrative Model of Causes and Maintenance of Panic Disorder Genetic factors Social Factors Physiological Factors Cognition (personality) Life Events Why did he develop this disorder? Etiology of Panic Disorder with Agoraphobia “ Fear of Fear” Hypothesis

9. Genetic vulnerability to alarm reaction Psychological problems on mother's side: * mother alcoholic, panic disorder with agoraphobia anxious woman constantly concerned with her and her children's physiological symptoms, worried a lot * maternal grandfather and two aunts abused alcohol * maternal grandmother and another aunt - panic disorder * sister and younger brother , nothing WHO WHAT WHY HOW ? Why did he develop this disorder? Genetic factors

10. Stressful environment triggers vulnerability Interoceptive conditioning (learned alarms) WHO WHAT WHY HOW ? Why did he develop this disorder? s ocial/environment factors Behavioral Factors Physiological/biological Factors

11. WHO WHAT WHY HOW ? Why did he develop this disorder? cognition Safety behaviors and safety signals 24 access to anti anxiety medication driving to side of road holding onto stationary objects remaining near walls Safety behaviors serve to maintain beliefs about the consequences of panic Lack of control over environment More attentive to signs of threat

12. WHO WHAT WHY HOW ? Negative life event Anxiety Somatic symptoms First panic attack Fear symptoms Panic disorder Psychological and biological vulnerability Belief that symptoms dangerous Why did he develop this disorder? The big picture GENETIC SOCIAL/ENVIRONMENTAL BEHAVIORAL COGNITIVE

13. Summary of maintaining factors panic disorder panic attack symptoms agoraphobic situations cognitions associated with panic attacks anticipatory anxiety safety behaviors and signals WHO WHAT WHY HOW ? Why does he still have it?

14. Exposure treatment Cognitive behavioral treatment Panic Control Treatment (PCT) Situational exposure (with relaxation technique) WHO WHAT WHY HOW ? How do we treat it? In vivo exposure Situational (in vivo) exposure 1) making list of situations that are avoided 2) arranging the list in a hierarchical fashion from least to most avoided 3) beginning with least difficult situations

15. WHO WHAT WHY HOW ? How do we treat it? Course of treatment OUTCOME: panic and medication free 6 months after final session

16. Why might women outnumber men? Why do men turn to substance abuse, and women to avoidance? How might a psychoanalytical paradigm explain not perceiving to have a sense of control? Medication? Why is remaining in feared situations important for in vivo exposure? Public awareness of this disorder? How would you respond? Advantages and disadvantages of having spouse/friend? WHO WHAT WHY HOW ? Discussion

17. Works Cited Brown, Timothy. Casebook in abnormal psychology . Thomson Higher Education, Belmont CA, 2007: 18-35. Kring, Ann. Abnormal Psychology . John Wiley and Sons, United States, 20077: 121-155. Panic Disorder and Agoraphobia. http://en.wikipedia.org/wiki/Agoraphobia WHO WHAT WHY HOW ?