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March / April 2004

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High Anxiety

Illustration by Heather Small

High Anxiety
Research on panic disorders by UMaine psychologists focuses on susceptibility and treatment options

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Anxiety and panic are normal. However, there are people whose anxiety and panic can rise to crippling levels of frequency and intensity.

Consider a person who becomes overcome by panic while driving on a dark stretch of forest-lined Route 11. She becomes so panic struck that she must turn around and head back home, despite being closer to her destination than her home.

Some people who experience panic attacks become acutely sensitized to the signs of an imminent attack. They can fear both the mounting signs of the attack and the attack itself. Paradoxically, their fear of an attack can insidiously feed the panic. This spiraling double-whammy of fear creates a self-fulfilling prophecy, bringing on the dreaded panic attack.

With an interest in panic disorders that reaches back more than a decade, researchers at the University of Maine are trying to tease out the characteristics of those susceptible to panic disorders and "anxiety sensitivity," the apprehension triggered by panic-attack symptoms. They also are trying to find out whether people who fit certain profiles are more amenable to less intensive therapy, thus lowering the cost of delivering treatment to rural residents.

Panic disorder, social phobia and agoraphobia (with or without panic) are diagnostic categories of anxiety disorders. Social phobia is marked by intense anxiety about being embarrassed or incapacitated in front of large groups of people. "Someone with a social phobia would not be running for president," says Geoffrey Thorpe, a psychology professor at the University of Maine.

Agoraphobics fear going into public places alone, whether crowded or deserted. Those with panic disorder accompanied by agoraphobia fear that they will have a panic attack when they are far from home or help.

Roughly 3.5 percent of the population suffers from panic disorder, while agoraphobia affects about 5 percent.

Panic and anxiety are not abnormal, says Jeffrey Hecker, head of UMaine's Psychology Department. "We're hardwired to panic (to save ourselves). Anxiety also is normal because it prepares us for future danger and to be on guard."

However, those with panic disorders often misinterpret bodily sensations. The slightest hint of something amiss makes them believe there is something catastrophically wrong that will lead them to lose control of their minds or bodies, or to die.

"With phobias and fears, people become more narrowly vigilant about the cause of their fear," explains Sandy Sigmon, an associate professor of psychology and director of clinical training at the university. "In panic disorder, they are vigilant about their bodily sensations."

An excessively heightened vigilance is known as "anxiety sensitivity." If a person cannot find a plausible external explanation to unexpected bodily sensations, a "vicious cycle" of reinforcing and amplifying sensations and fears ensues, Thorpe says.

Thorpe once had a client whose first symptom of panic was feeling flushed in the face. One day she came into his hot office and suddenly felt flush. She immediately feared the onset of a panic attack. Only when Thorpe explained that the office thermostat was broken did her fear recede. Any time she felt flushed, "she would alarm herself," he says.

According to Hecker, people begin to look for danger cues when they are anxious. This anticipatory anxiety raises their tension level and makes the panic attack more likely.

One of the striking facts about panic disorders is that roughly two-thirds of those afflicted are women. This made Sigmon curious to find out how women with panic disorder differentiate between the effects of their menstrual cycle and the symptoms they associate with a panic attack.

In a study published in 2000, Sigmon wrote, "The menstrual cycle may represent a regular opportunity for women with panic disorder to misinterpret ambiguous bodily sensations as threatening."

Sigmon says there was anecdotal evidence that women with panic disorder experienced more panic attacks in the pre-menstrual phase of the cycle. These women also tended to report more severe menstrual symptoms. Sigmon wondered if some women are able to discriminate between the sets of symptoms and whether this helps them to stave off a panic attack.

In the past few years, she has conducted a series of studies to find out. In the first study, she found that women with high anxiety sensitivity both reported more severe menstrual symptoms and greater changes in mood during the pre-menstrual phase, and responded with greater intensity to laboratory stimuli than a control group.

A second study found that women with high anxiety sensitivity reported more stereotypical beliefs about women's roles and more menstrual symptoms in general, regardless of the phase. These women also tended to pay more attention to their bodies during the cycle, and reported more physical sensations, and more severe ones, than a control group.

A third study revealed that during a "rumination task" in which women contemplated their thoughts, emotions and physical sensations those with high anxiety sensitivity were much more aroused and agitated than the control group.

In Sigmon's most recent research, women with panic disorder and a control group monitored all their physical sensations and feelings for 30 days. Daily, the women logged their feelings and recorded the severity. They also indicated what they thought was the cause.

"This is the part where I'm trying to figure out whether they discriminate between the sensations and whether that is helpful," says Sigmon, who is currently analyzing the data.

The goal of the treatment is to have the women learn that some physical sensations are not catastrophic. Preventing the onset of agitation, says Sigmon, may prevent the onslaught of panic.

Hecker is studying ways to deliver more cost-effective treatment to people with panic disorder who are far from UMaine treatment and research programs, and professional therapists.

Hecker and Thorpe are co-authors of the 1992 book, Agoraphobia and Panic: A Guide to Psychological Treatment. After a tour through Maine shortly following the book's publication, Hecker began receiving calls from people who couldn't get to the university to participate in research studies, and who said therapists were few and far between in their areas. Hecker wondered to what degree self-help books might benefit these residents living in rural areas in the state.

He began a study in which one group seeking treatment was given workbooks on panic disorders, while another group underwent the standard treatment of seeing a therapist. The people using the workbooks met with a therapist who guided them through the workbook, working with them "more like a coach or tutor than a therapist," Hecker says. However, this "self-directed" group only met with the therapist three times in a 12-week period, while members of the other group met with a therapist weekly.

He found that both treatments were equally effective. However, the workbook method was far less expensive. Compared to the standard course of treatment with a licensed psychologist, "we're delivering treatment through just a quarter of the visits," Hecker says.

Next, he set up another study with two conditions. In the first condition, participants were given the workbook and then met four times in small groups with a therapist. In the other condition, the researchers only used a single one-on-one meeting with a therapist, followed by three telephone calls to check on the participants' progress through the workbook.

Again, Hecker says, the research found no difference in the effectiveness of those treatments.

Now a third study is under way. The intervention used in this study is modeled on what could be done in a rural health clinic or with a family physician, according to Hecker. In this instance, someone with panic disorder would come into the office and be given the workbook, then would be shown a videotape that complements the workbook.

Hecker says he is trying is uncover the characteristics of those people who can really benefit from this "minimal therapist-contact" treatment and those who need a more intensive regimen.

One theory is that people with other psychological or personality disorders will need more than a workbook and telephone checkups, Hecker says. "We're anticipating that (combinations of disorders) will indicate people who will need more intensive treatment," he says.

by Gordon Bonin
March-April, 2004

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