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An Analysis of Uncued Panic Attacks in Panic Disorder
Jasmine Arthur-Jones and Bronwyn Fox

Role of fear triggering within uncued panic attacks are investigated. A model for the physiological structure of an uncued panic attack is developed by investigation into "energy" movement, dissociative experiences, physical symptoms, light and sound phenomenon, breathing, perceived physical changes. Also investigated meditation as an effective recovery method for Panic Disorder and Anxiety Disorder.

INTRODUCTION

Panic Disorder, the experience of Panic Attacks, was included for the first time in the DSM-111(1) in 1980. Over the last fourteen years, research has increased the knowledge and understanding of this Disorder which is clearly evident in the recently released DSM-4(2).

In 1980 Panic Disorder was diagnosed when a person experienced at least three panic attacks over a three week period. In the DSM-111 and the DSM-111R(3) there was no specific distinction made in the type of Panic attacks people experienced. While the DSM-111R acknowledged that the avoidance behavior (Agoraphobia) relating to the Panic Disorder was a result of a fear of having a Panic Attack, this lack of distinction upheld the prevailing view of the time that a panic attack and the avoidance behavior resulting from the attack was a "phobic" response to situations and/or places. Many of the earlier treatment methods for Panic Disorder/ Agoraphobia focused on gradual exposure to the avoided situation and/or place and did not directly deal with the panic attack itself.

Specific distinctions in the type of panic attacks experienced have now been clearly stated in the DSM-4. The first type of attack and the one which is pivotal to this paper is the "unexpected" (Uncued) panic attack in which the onset of the Panic Attack is not associated with a situational trigger, i.e. occurring spontaneously ("out of the blue").

The second is "situationally bound (cued) panic attacks, in which the panic attack almost invariably occurs immediately on exposure to or in anticipations of the situational cue or trigger.

The third is "situationally predisposed panic attacks, which are more likely to occur on exposure to the situational cue or trigger, but do not necessarily occur immediately after the exposure(2).

Agoraphobia in Panic Disorder is recognized "as anxiety about being in situations and places from which escape may be difficult or embarrassing or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic like symptoms(2)". Besides Agoraphobia, other secondary conditions and effects of Panic Disorder are major depression, drug and/or alcohol abuse and suicide(2).

Another feature of Panic Disorder included in the DSM-4 is the experience of nocturnal panic attacks which are said to occur between stage two and stage three of sleep(4).

The symptoms of a panic attack are described in the DSM-4 as a "discrete period of intense fear or discomfort in which four (or more) of the following symptoms developed abruptly and reached a peak within ten minutes. Palpitations, pounding heart or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of chocking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheadedness or faint, Derealisation or depersonalisation, fear of losing control or going crazy, fear of dying, numbness or tingling sensations, chills or hot flushes(2)."

Three internationally recognized experts in Panic Disorder describe a panic attack as follows:

"An intense recurring spasms of panic that start ... just below the breastbone and seem to spread like a white hot flame .. passing through the chest, up the spine, into the face, down the arms and even down into the groin to the tips of the toes"(5).

 

"The attacks start with a tingling feeling going up my spine which enters my head and causes a sensation of faintness and nausea(6).

 

"A rushing sensation of a hot flash through the body .. sometimes associated with a sick feeling and a sensation of fading out from the world but this faintness is more like a 'white out' than a 'black out' and that the head may literally feel light(7)."

Although no one particular cause for the uncued panic attack has been found, research is now beginning to show that people with Panic Disorder may have a history of abuse. A recent English study which used the DSM-111R classification instead of it's English counterpart found that 63.6% of women with Panic Disorder had experienced physical or sexual abuse or parental indifference as children(8). It is known from research into Dissociative Identity Disorder that people who have an abuse background can have an ability to dissociate. This ability to dissociate has also been noted in several studies relating to Panic Disorder/ Agoraphobia(9).

Rationale for the Development of Panic Attack Study

The majority of research and literature in the area of Panic Disorder, Anxiety Disorders and the secondary condition called Agoraphobia focuses mainly on the ongoing secondary effects of the Disorder in the lives of the sufferers. Very little research actually focuses on the cause/root of Panic Disorder, that being the panic attack (PA). Panic Disorder and Agoraphobia is highly dependent on the central experience of the panic attack. Greater insight needs to be gained into the physiological experience and dissociation aspects of the panic attack to investigate appropriate methods to assist in the recovery process. It is our intention to develop an instrument that can provide a systematic model of the actual experience of the panic attack.

Hypothesis to be tested

In the development of the "Panic Attack Questionnaire" we sought to test a general hypothesis. This was the role of fear and the triggering of the adrenal 'fight and flight response' within the panic attack. It is generally assumed that a panic attack is the sudden rise of intense fear and is accompanied by the adrenalin related physical symptoms eg. increased heart rate. However, most Panic Disorder sufferers (uncued or spontaneous panic attacks) claim that the fear response arises after experiencing some dissociative experience or an overwhelming rush of energy that is not adrenalin. The goal was to investigate the distinction between the 'energy' experienced in a panic attack and that of the rush of adrenalin. Also to investigate the role of dissociative experiences and at what point does the fear response actually trigger a panic attack.

METHOD

The participants for the study included 36 adults diagnosed with Panic Disorder/Agoraphobia, 36 adults diagnosed with another Anxiety Disorder, and 23 non Anxiety Disorder adults. These participants were given the Panic Attack questionnaire to discriminate between anxiety/normal symptoms and panic attack experiences. All participants were older than 18 years and participated voluntarily.

The normal adults were primarily support persons for the people diagnosed as Panic Disorder and Anxiety Disorder. All of the Panic and Anxiety Disorder participants were approached through the Panic Anxiety Disorder Association Inc. and were from all States of Australia. All Panic and Anxiety Disorder participants were diagnosed according to DSM-11R criteria for their respective diagnostic groups.

Development of the Panic Attack Questionnaire...

A self-answer questionnaire was chosen for objectivity and cost-effectiveness to investigate the experiences of a large variety of participants. It eliminated the probability of interviewer bias. Questions were worded to be factual and mostly presented in a T/F format. In many sections of the questionnaire, room was allowed for the participants to represent "other" experiences that had not been specified.

The Panic Attack Questionnaire was divided in to four separate sections. The first section investigated primary statistical data such as gender, age, religion, primary diagnosis. Also T/F questions on initial triggers of the Anxiety/Panic Disorder, childhood trauma, frequency of panic/anxiety attacks and specific fear response questions.

Section 2 investigated 47 common symptoms associated with panic and anxiety attacks. Participants indicated if the symptoms was experiences prior, during, after a panic or anxiety attack or experienced continually or never experienced. Multiple categories could be selected eg. experienced increased pulse rate prior and during a panic attack.The next part of the section investigated 14 'energy' descriptors experienced prior/during a panic attack. Participants were asked to classify the 'energy' experienced as anxiety, panic, experienced then panic, experienced without fear, experienced in meditation or never experienced. Again, multiple categories could be selected eg. experienced as panic and as anxiety. Participants were asked to identify specific locations for where the 'energy' began and then the actual movement of these energies through the body. Unusual 'inner' sound, lights and physical jerking experiences were investigated. Thirteen common aspects of dissociation were investigated with participants once again asked to classify these experiences into the subcategories of anxiety, panic, experience then panic, experience without fear, experience in meditation or never experienced. The final part of Section 2 investigated breathing patterns experienced prior, during and after the panic/anxiety attack.

Section 3 investigated meditation effectiveness, prescribed medication effectiveness, physical changes and increased sensitivities that have occurred since the development of Panic/Anxiety Disorder.

Section4 consisted of the Dissociative Experiences Scale developed by E. Bernstein PhD and F.Putnam MD(15). The scale contains 27 items related directly to dissociation phenomena.

Methods of Data Analysis...

Scores of participants were subdivided according to normal, Panic Disorder and Anxiety Disorder. The questionnaire was divided into specific sub-sections to be analyzed individually per diagnostic grouping eg. symptoms, 'energy' descriptors. Comparisons of results focused mainly on differences in subjective experiences between Panic Disorder and the other Anxiety Disorders as the normal population experienced minimal aspects of panic or anxiety attack. Analysis of Anxiety Disorder results assisted in eliminating anxiety related experiences and therefore identifying Panic Disorder specific data. Many Anxiety Disorder participants report they experience panic attacks, but in reality experience limited symptom attacks (anxiety attacks). In this process, the mix of anxiety and panic related symptoms/experiences could be sifted and then analysed, the focus of the study being specific to study the uncued, spontaneous panic attack.

Correlations were performed on data relating to dependent experiences ie. 'energy descriptor and 'energy' movement, to identify specific physiological data on the structure of the uncued panic attack.

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