The document contains in-depth summaries of all of the obligatory readings for week 3 of the Anxiety and related disorders course. These are: 1) DSM-5 Panic disorder and Agoraphobia; 2) CBT, imipramine, or their combination for panic disorder: a RCT (Barlow et al., 2000); 3) Panic disorder (Roy-Byr...
1. CBT, imipramine, and their combination for panic disorder
Panic disorder = chronic condition associated with substantial reduction of life quality (functioning is
lower than in patients with heart conditions and diabetes).
Lifetime prevalence: 3%
PD manifests in a variety of physical symptoms hence, people often visit the emergency room.
The pharmacological criterion standard for PD = imipramine until the emergence of SSRIs.
There is evidence on possible synergistic effects of pharmacotherapy and psychosocial interventions on
phobic behavior., but in practice these two approaches are often parallel or even hostile.
Results:
o imipramine and CBT were both significantly superior to placebo for acute treatment phase
o after 6 months of maintenance, imipramine and CBT were still significantly more effective than
placebo
o among responders, imipramine produced a response of higher quality
o the 6-month maintenance response rate for combined therapy was sig. effective but not more
than just CBT
Combining imipramine and CBT has limited advantage acutely but more substantial advantage by the
end of maintenance.
2. Panic disorder (Roy-Byrne et al., 2006)
Lifetime prevalence: 5%
Can be very disabling, especially when complicated by agoraphobia (agoraphobic avoidance), associated
with substantial functional morbidity and reduced quality of life.
Costly for individuals and society: absenteeism and reduced workplace productivity.
Risks for developing a disorder:
o certain lifestyle factors (smoking – unclear causation)
o genetic and early experiential susceptibility factors (unclear precise mechanisms)
Several effective treatments (imprecise understanding):
o pharmacological
o cognitive-behavioral
Symptoms (previously)
o autonomic nervous system arousal
o catastrophic cognitions
o profound fatigue
o prominent role of stress and trauma possible area of causal overlap with PTSD
Of all the anxiety-related syndromes, panic disorder has been the most intensively studied during the
past 25 years.
Diagnosis and differential diagnosis
, Symptoms / DSM criteria:
o recurrent panic attacks, along with:
o worry about the possibility of future attacks
o phobic avoidance (staying away from places or situations in which the individual fears could elicit a
panic attack, where escape or obtaining help in the event of an attack would be unlikely or difficult)
Definition
o Panic attacks are sudden, unexpected paroxysmal bursts of severe anxiety, accompanied by several
physical symptoms.
o Symptoms can be progressive and disabling, especially if complicated by agoraphobia.
Differential diagnosis
o Agoraphobia without panic attacks is rarely seen in clinical settings.
o Not all agoraphobia is a consequence of panic (1/3 of agoraphobia happens before onset of panic).
o Not all panic attacks are indicative of panic disorder same constellation of symptoms in specific
phobias and social phobia.
o In other anxiety disorders, individual is keenly aware of the source of their fearful sensations,
whereas in panic disorder, these same types of sensations are unprovoked, unexplained, and often
occur out of the blue.
o Panic disorder mimics many medical conditions.
Epidemiology
o 12-month prevalence: 2.7%
o Lifetime prevalence: 4.7%
o More prevalent in females
o Onset in late adolesce or early adulthood
o Strong associations with agoraphobia and major depression rarely without comorbidity
o Can be main illness or secondary to another comorbid illness
o Predictors: childhood panic, behavioral inhibition, parents with panic disorder
o There is an increased risk of lifetime suicide attempts, even after adjustment for affective
comorbidity and other suicide risk factors
o Naturalistic prognosis in panic disorder, especially in the absence of agoraphobia, is better than that
of GAD and SAD
o Stress-diathesis model explains genesis and maintenance:
heritability of about 40%
familial environmental effects < 10%
unique environmental effects > 50%
environmental risk factors:
early life trauma or maltreatment
anxiety sensitivity
anxious temperament
neuroticism
stressful life events probably contribute to the timing of onset and maintenance
cigarette smoking and nicotine dependence in adolescence
Cause and pathological change
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