Zal (1990, p. 136) states that it can indeed be a very fragile and emotionally battered individual that comes to your office for evaluation. An adequate treatment plan for panic disorder must therefore comprise many specific aspects. The first of course is to make the diagnosis and share it confidently and directly with the patient. As the first person to encounter the patient with some understanding of his or her symptoms, you are in a unique position to do an enormous therapeutic service by giving them a clear, precise definition of their illness and once and for all showing them that their symptoms have meaning. Let them know that it is only since 1980 that panic disorder has a name and that it is only during this decade that even psychiatry is beginning to understand this malady.

Making the diagnosis requires that you think about and elicit specific information. This will also require that you take into consideration the differential diagnosis issues mentioned in Chapter 4. Start out by listening carefully to both the feeling tone and the facts that they present in their initial chief complaint. Ask questions and look for the pieces of the puzzle that they have forgotten to include. Review all information about prior physical evaluations, special tests, and consultations. Do a medical history by system review. Suggest any additional physical modalities or tests that you feel will be helpful in making a differential diagnosis. Review all medications taken for either physical or emotional reasons.

Take a careful psychiatric history, including a mental status examination. Ask about prior psychiatric treatment or hospitalization. Ask about drug or alcohol use. Particularly question the history of the panic symptoms

Certain amount of anxiety is normal reported (Austrian, 2000, p. 11), and it is appropriate in situations that may be new, may involve performance, or may be unpleasant but unavoidable. Anxiety is an anticipatory signal that there is a conscious or unconscious threat to life, emotional stability, or equilibrium. It may be anticipated or it may be experienced without warning. Cause and sources may be known or elusive. In most instances, anxiety may be annoying but is a normal emotion and can be dealt with. Anxiety becomes a disorder when it interferes with the individual's daily living demands and perhaps also with the needs and lives of close family and friends. It is then most often an intra-psychic response to an unrecognized threat, as opposed to fear, which is almost always a response to an external, known threat that is non-confrontational in origin.

Greenberg (1991, p. 25), described a model of anxiety in which an 'emergency response system' is activated by the organism's perception of danger. The system evolved to abet survival, in the face of actual physical danger, by preparing the organism for aggression or escape (fight, flight) or inhibiting it from sudden movement (faint, freeze). But the 'emergency response' may itself alarm the individual, as it generates disturbing body sensations and transient cognitive dysfunctions that may themselves be perceived as sources of danger: racing heart, feelings of dizziness or weakness, a sense of unreality, other discomforts. When the emergency response is activated, as in a panic attack, fear and anxiety accelerate rapidly, and rational thinking is undermined. The terrifying experience tends to increase apprehensiveness, predisposing the sufferer to experience more symptoms. A vicious spiral of fearful expectations and frightening symptoms is established.

According to this model, distorted perceptions of danger play an important part in this spiral. In a vulnerable 'mode', patients tend to overestimate danger and underestimate their capacity for coping. The distorted appraisals may affect their responses to psychosocial stress and also to internal experiences, such as the sensations that come into play with the emergency response system. In the case of panic disorder, anxiety-related sensations (such as lightheadedness, rapid heartbeat, breathlessness, choking feelings), as well as other physical and emotional changes the person cannot easily explain, tend to become the target of misinterpretations. When feared sensations occur, thoughts and images of catastrophe are triggered: 'What if my throat closes up completely? I might choke to death!' 'The world looks blurred and funny. I must be going crazy!' And dysfunctional coping strategies may be invoked: 'Chest pain -- maybe a heart attack this time! Better not be alone.' The thoughts and images (states the model) tend to increase anxiety, accelerating the vicious spiral of fear and symptoms. Further, the belief that symptoms foretell catastrophe contributes to phobic dependency and avoidance. Identifying the catastrophic misinterpretations of symptoms should be the initial focus in treating panic disorders. (Beck, Emery & Greenberg, 1985, p. 19)...

The specific groups of symptoms associated with anxiety, for example, correspond to the functions of specific primal systems and subsystems (cognitive, affective, behavioral, and physiological), which are integrated into the master system -- namely, the psychobiological or organism totality. These component systems are not isolated from each other, and their operations are generally coordinated and integrated by the master system. The master system is designed to carry out certain objectives (such as self-preservation, feeding, or breeding), and the specific systems operate together to implement that "master plan." These objectives are labeled "adaptational" in that they are derived from evolutionary principles relevant to survival of a particular lineage in a given environment. The operation of both the master system and the component systems varies according to demands at a particular time. Thus, specific primal responses to life-threatening situations (such as fight, flight, freeze, or faint) will differ from each other as well as from responses involved in feeding and breeding -- even though the same system is employed. Emergencies involve total mobilization of all systems for action; whereas in feeding, certain subsystems are activated, and others deactivated.
Tuma & Maser (1985, p. 421), described certain procedures such as desensitization and flooding have been developed to dissociate fear responses from the stimuli that evoke them by exposing the patient to these stimuli under "therapeutic" conditions. Social skills enhancement and assertion training were developed for individuals who suffer from social fears or inadequacies. Although they focus on competency in environmental interactions, these techniques also invariably include exposure to feared situations. Cognitive therapies directed at reducing fear by modifying thought habits usually encourage patients to expose themselves to feared situations using the new cognitive skills acquired in therapy.

Panic attacks are not unique to panic disorder reported (Mclean & Woody, 2001, p. 131), occurring regularly across the anxiety disorders, but there is a difference in the case of panic disorder. In other anxiety disorders, panic attacks are always triggered by a stimulus related to the specific disorder, such as walking into the airport for fear of flying, or suddenly confronting a contaminant for a client with obsessive compulsive disorder. In contrast, panic attacks that occur as a part of panic disorder are not cued by a frightening stimulus, at least in the beginning. Compared to those with other anxiety disorders, individuals with panic disorder more often experience prominent cognitive symptoms of fear of dying, going crazy, or losing control, as well as somatic symptoms of numbness or tingling, dizziness, difficulty breathing, and feelings of unreality.

In 1967, Eysenck proposed that behavior is determined largely by two higher-order dimensional traits -- introversion-extraversion and neuroticism-stability. The underlying dimensions of introversion and neuroticism were posited to predispose to anxiety and depression. That is, emotionally unstable (i.e., neurotic) introverts were considered at risk for acquiring conditioned anxiety responses because of a hyper arousal. Neuroticism was related to elevated autonomic arousal, as governed by the limbic system, and introversion was related to high levels of cortical arousal controlled by the reticular formation of the cortex. There is some evidence for higher cortical arousal in "introverts," but there is less evidence for elevated autonomic reactivity to stress in "neurotics" attributes the latter to the law of initial values. That is, "neurotics" differ from controls in tonic levels of heart rate, blood pressure, and blood flow, suggesting higher sympathetic activity but a limited capacity to increase physiological responding to stressful tasks (Craske, 1999, p. 59)

In one's first session (Greenberg, 1991), reports that one should elicit a description of the sensations, thoughts, images, emotions, and impulses that typically occur during the panic attack. We 'socialize' the patient to the idea that thoughts and beliefs can be contributing to the panic attacks, and we try to 'normalize' anxiety -- help the patient see anxiety responses as part of the body's normal repertoire. For 'homework', the patient makes further observations about thoughts and images during periods of anxiety and panic.

We use these data to define the mistaken ideas the patient holds about specific symptoms and about panic generally. The Panic Belief Questionnaire compiles forty-two of these beliefs into a scale which we are now administering to panic patients. The beliefs seem…