Phobias & SAD and GAD & PD

• Dysfunctional neurotransmission at the serotonin receptors (5HT1A) may result in

anxiety or avoidant behavior (Deakin 1996)

• Activation of HPA Axis in panic disorder, may contribute to disruption of

hippocampal 5HT1A

neurotransmission (Lesch and Lerer 1991)

• Aberrant noradrenergic- serotonergic function (Boyer 1995)

• Serotonin depletion resulted in increased minute ventilation in panic disorder

patients

unaltered ventilatory function in controls (Kent et al., 1996)

• GABA = inhibitory neurotransmitter

• Benzodiazepines increase function of GABA

• global decrease in benzodiazepine binding

• with a peak decrease in orbitofrontal cortex, and insula, hippocampus in panic

disorder patients compared to healthy controls (Malzia et al., 1998)

• Injection of sodium lactate (panicogen) led to panic-like response in

GABA-blocked rats only (Shekhar 2006)

• Interaction GABA-glutamate interrupted in panic disorder

= substances that can induce panic attacks

• substances that influence HPA Axis

Yohimbine (noradrenaline increase)

coffein: adenosinergic (inhibitory) receptor antagonist

• Substances that influence lactate metabolism

sodium lactate, sodium bicarbonate, carbon dioxide

• Twin studies have attributed 30-40% of the variance for the liability to develop

panic disorder to genetic factors (Kendler et al., 2001; Scherrer et al. 2000)

• highly significant association between panic disorder in probands

and first degree relatives (Hettema et al. 2001)

• cholecystokinin, adenosine 2A, MAO A, and COMT genes.

• Dynamic Model:

panic attack = expression of an intense unconscious conflict (Bush et al. 1999)

core conflict of depencency and inadequacy (Shear et al. 1993)

Contemporary dynamic models: integration of biological and developmental stressors

(Milrod et al. 2004)

• Cognitive Behavioral Models

• Anxiety Sensitivity

• Core fear toward anxiety and its associated somatic symptoms

• Measured by anxiety sensitivity index

(Reiss et al. 1986)

• Significant predictor of the onset of panic in different patient populations

(e.g Ehlers 1995, Hayward et al. 2000; Maller and Reiss 1992)

• Ley (1985): hyperventilation theory : hyperventilation causes panic attacks

• Klein (1993): false suffocation alarm model: hyperventilation avoid panic

attacks

Person is hypersensitive to carbon dioxide levels ⇒ Minor drops in Oxygen result in false alarm "person is suffocating" ⇒ Panic Attack

First line treatments

• SSRI (Selective Serotonin Reuptake Inhibitors)

effective in many controlled studies ( e.g. Wade et al. 1997; Michelson et al 1998, 2000)

anxiolytic effect latency of 2-4 weeks

• Serotonin Norepinephrine Reuptake Inhibitors

effective in double blind placebo controlled studies (Bradwejn et al. 2005; Pollack et al. 1996)

Second line treatments

• Tricyclic antidepressants

frequency of adverse events is higher than for SSRI (Amore et al. 1999)

Third line treatments

• Benzodiazepines

anxiolytic effects immediately after oral intake, risk of dependency (Bradwejn 1993)

Cognitive behavioral therapy

“Panic control treatment”

(PCT, Craske et al., 2000, Hofmann & Spiegel, 1999)

Elements

• Education about anxiety and panic development

• Cognitive restructuration: identification and correction of thoughts /

false cognitions about anxiety and its consequences

• Training (reduction arousal, hyperventilation)

• Exposition, controlled hyperventilation

11-12 sessions, 3-4 months

Classical CBT Methods

• Hyperventilation

• Triggering bodily symptoms

• Deep breathing

• External focus

• mindfulness

Interoceptive exposure

Feared sensations become safe sensations:

• in the office with the therapist

• at home

• independent of the treatment context

Panic Cycle

Uh oh!

What if:

• This gets worse?

• I lose control?

• This is a stroke?

I have to control

this!

Relative Comfort

• Notice the sensation

• Do nothing to control it.

• Relax WITH

the sensation

Head rolling – 30 seconds - dizziness, disorientation

Hyperventilation – 1 minute - produces dizziness

lightheadedness, numbness, tingling, hot flushes, visual

distortion

Stair running – a few flights – produces breathlessness, a

pounding heart, heavy legs, trembling

Full body tension – 1 minute – produces trembling, heavy

muscles, numbness

Chair spinning – several times around – produces strong

dizziness, disorientation

Mirror (or hand) staring – 1 minute – produces derealization

• Efficacy between 87% and 75%

• Greater efficacy than relaxation therapy or control groups

• Greater efficacy than certain medicaments (e.g. alprazolam) and

similar to imipramine

• Long-term treatment with PCT is more effective than pharmacological

treatment

• Evidence of superiority from combined approach towards single treatment

not conclusive

• New developments: combination with self-help modules, therapy via

internet, electronic auto-observation