Panic Attack

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Panic Attack
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Interaction of Genes and Early Environment in
Producing Adult Major Depression
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Discoveries from Behavioral Science

• Etiology of anxiety disorders involves
  fundamental emotional conditioning events
• Traumatic conditioning accounts incomplete
• Early panic attacks associated with interoceptive
  and exteroceptive cues that trigger constellation
  of behavioral and physiological responses
  collectively called anxiety
• These conditioning events influence performance
  without conscious awareness1
• Differential neurobiological bases of conscious
  vs unconscious conditioning processes now
  apparent using brain imaging procedures2

1. LeDoux JE. The Emotional Brain The Mysterious
Underpinnings of Emotional Life 1996. 2. Bouton
ME, Mineka S, Barlow DH . Psychol Rev .
2001108(1)4-32.
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The FutureTalking to the Amygdala
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Therapy and the Amygdala
PFC-L (thought)
PFC-M (extinction)
Talk Therapy
Cognitive Behavioral Therapy
AMYGDALA
Drug Therapy (Valium/SSRI)
The absence of direct connections from the PFR-L
to the amygdala may be related to why talk
therapy for psychiatric conditions that involve
amygdala-related conditions is relatively
inefficient (in terms of the amount of time
required to achieve a therapeutic effect).
Behavioral therapy (including cognitive
behavioral therapy) is less dependent on
conscious insight and more dependent on
extinction processes and on the development of
new associations, skills, and habits (that is, on
implicit learning). Some of these processes
(especially extinction) involve the PFC-M. The
direction connection of the PFC-M with the
amygdala may explain why cognitive behavioral
therapy is more efficient for certain
fear/anxiety-related problems.
From LeDoux, J. (2002). Synaptic self How
our brains become who we are. New York Penguin
Books.
6
Perceptual processing vs. Cognitive evaluation

• Perceptual processing (match) of threatening
  and fearful scenes was associated with a strong
  bilateral amygdala response
• Cognitive evaluation (label) of these same
  stimuli was associated with an attenuation of
  this response and a correlated increase in the
  response of the right ventral PFC
• From Hariri, A.R., Mattay, V.S., Tessitore, A.,
  Fera, F., Weinberger, D.R. (2003). Neocortical
  modulation of the amygdala reponse to fearful
  stimuli. Biological Psychiatry, 53, 494501.

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Cognitive-Behavioral Therapy, Imipramine, or
Their Combination for Panic Disorder A
Randomized Controlled Trial
NIMH Multicenter Collaborative Study
DH Barlow, Ph.D. Boston
Psychological Treatments JM Gorman, MD
Columbia Pharmacotherapy MK Shear, MD
Pittsburgh Psychological
Treatments SW Woods, MD Yale
Pharmacotherapy
Barlow DH et al. JAMA. 20002832529-2536.
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Study Time Line

• Phases and Durations

Major assessments done at baseline,
post-acute, post-maintenance, and post follow-up
IMI/PLA subjects entered maintenance only if
they were responders at post-acute
assessment.Barlow DH et al. JAMA.
20002832529-2536.
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Comparison of Baseline, Acute, and
MaintenanceTreatment for Intent-to-Treat (ITT)
Sample
N312
PDSS Average Item Score (0-4)
Treatment Condition
Barlow DH, et al. JAMA. 2000283(19)2529-2536.
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Posttreatment Relapse Rate
N312
Relapsed Within 6 months
Based on Clinical Global Improvement Scale (CGI)
for intent-to-follow patients.
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Comparison of Cognitive-BehavioralGroup
Treatment (CBGT) and phenelzine for social phobia
Plt.09 Plt.005 ?not assessed
Assessment
?
?
?
?
Posttreatment
Postmaintenance
6-Month Follow-Up
Statistical Comparisons
CBGT, PHEN gtPBO, ES
CBGTPHEN
CBGT?PHEN
PHENphenelzine. PBOpill placebo.
ESeducational-supportive group
treatment. Heimberg RG, et al. Arch Gen
Psychiatry. 199555(12)1133-1141. Liebowitz MR,
et al. Depress Anxiety. 199910(3)89-98.
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Specific Psychological Treatments (PT) vs.
Medication or Alternative Treatments, all since
1998, from the Journal of the American Medical
Association or the New England Journal of Medicine
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Specific Psychological Treatments (PT) vs.
Medication or Alternative Treatments, all since
1998, from the Journal of the American Medical
Association or the New England Journal of
Medicine, cont
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Treatment of Depression, 1987-1997 National
Trends

• Context Increasing recognition and treatment of
  depression
• 1987 1997
• Percent treated by medications 37.3 74.5
• Percent treated by psychotherapy 71.1 60.2
• From Olfson, M. Marcus, S.C., Druss, B.,
  Elinson, L., Tanielian, T., Pincus, H.A.
  (2002). National trends in the outpatient
  treatment of depression. Journal of the American
  Medical Association, 287, 203-209.

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Treatment of Depression, 1987-1997 National
Trends

• Context Increasing recognition and treatment of
  depression
• 1987 1997
• Percent treated by medications 37.3 74.5
• Percent treated by psychotherapy 71.1 60.2
• Percent treated by physician 68.9 87.3
• Percent treated by psychologist 29.8 19.1
• From Olfson, M. Marcus, S.C., Druss, B.,
  Elinson, L., Tanielian, T., Pincus, H.A.
  (2002). National trends in the outpatient
  treatment of depression. Journal of the American
  Medical Association, 287, 203-209.