Panic Disorder: Assessment, Treatment

Assessment

The most comprehensive and accurate diagnostic information emerges when the clinician uses open ended questions and em-pathic listening, combined with structured inquiry about specific events and symptoms. Useful structured interviews include the Structured Clinical Interview for DSM-IV (SCID-IV) and the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). A complete assessment for panic disorder also includes a gen-eral medical evaluation consisting of a medical history, review of organ systems, physical examination and blood tests. A general medical evaluation is important for identifying general medical conditions that mimic or exacerbate panic attacks or panic-like symptoms (e.g., seizure disorders, cardiac conditions, pheochro-mocytoma). These disorders should be investigated and treated before contemplating a course of panic disorder treatment. It is also important to rule out the other anxiety disorders and major depressive disorder as primary factors in the person’s panic at-tacks and avoidance prior to initiating treatment for panic disor-der (Figure 49.1).

Diagnostic information can be usefully supplemented by short self-report questionnaires to assess the severity of symp-toms and other variables. The Beck Depression Inventory and Beck Anxiety Inventory (Beck and Steer, 1987, 1993) are quick, reliable and valid measures that can be administered at the start of each treatment session to assess the severity of past-week general anxiety and depression. The Anxiety Sensitivity Index (Peterson and Reiss, 1992) is another useful short questionnaire that can be used to gauge the severity of the patient’s fear of bod-ily sensations. Scores on this scale can be used to assess whether treatment is altering the patient’s tendency catastrophically to misinterpret bodily sensations. This scale has good reliabil-ity and validity, is sensitive to treatment-related effects, and its post treatment scores predict who is likely to relapse after panic treatment.

Another useful questionnaire to monitor treatment progress is the Panic and Agoraphobia Scale (Bandelow, 1995). This 13-item scale was designed as a short, sensitive measure for treatment outcome studies. The patient is asked to rate the past-week frequency and/or severity of the following: 1) panic attacks, 2) agoraphobia, 3) anticipatory anxiety (i.e., worry about having an panic attack), 4) panic-related disability in various areas of functioning, and 5) worry about the health-related implications of panic (e.g., worry that panic attacks will lead to a heart attack). The Panic and Agoraphobia Scale has good reliability and valid-ity and is sensitive in detecting treatment-related change. It has the advantage of providing a broad assessment of many features of panic disorder and agoraphobia. A limitation is that it does not distinguish between full and limited symptom panic attacks or among the types of panics (i.e., unexpected, situationally bound, situationally predisposed). When asked to recall their attacks, pa-tients may have difficulty making these distinctions. Prospective (ongoing) monitoring is needed to provide this information.

To gain more detailed information on panic attacks, cli-nicians and clinical researchers are increasingly including some form of prospective monitoring in their assessment batteries. The most widely used are the panic attack records. The patient is provided with a definition of a panic attack and then given a pad of panic attack records that can be readily carried in a purse or pocket. The patient is instructed to carry the records at all times and to complete one record (sheet) for each full-blown or lim-ited symptom attack, soon after the attack occurs. Variants on the panic diaries developed by Barlow and colleagues (Barlow and Craske, 1994) are among the most informative and easy to use. These records are then reviewed during treatment sessions to glean information about the links among beliefs, bodily sensa-tions and safety behaviors, and to assess treatment progress.

Treatment

There are a number of approaches that can be taken in treating panic disorder with and without agoraphobia. Both single and combined treatment modalities are presented in Figure 49.2.