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## Meet the editor

Robert W. Motta, Ph.D., ABPP, is a Professor Emeritus of Psychology and founder of the Child and Family Trauma Institute at Hofstra University, New York. There he served as the chairperson of the Psychology Department and founded an American Psychological Association (APA) accredited PsyD psychology doctoral program. He has published more than 100 scientific papers and book chapters as well as three books:

*Alternative Therapies for PTSD The Science of Mind-Body Treatments*; *Altered: A Trauma and PTSD Casebook*; and *Suicide.* Dr. Motta is board certified in cognitive-behavioral psychology and behavior therapy. He is the former president of the School Division of the New York Psychological Association and is licensed as a clinical psychologist and certified as a school psychologist.

### Contents


#### **Chapter 6 91**

The Effect of Physical Activity Intervention on Panic and Anxiety Symptoms in Children, Adolescents and Early Adulthoods: A Meta-Analysis *by Lin Wang and Yihao Liu*

#### **Chapter 7 113**

Evidence-Based Pharmacotherapies for Panic Disorder *by Seth Davin Norrholm*

## Preface

This book examines the psychological phenomenon of panic disorder. Specific examples are given involving cases that have been treated for the disorder with a variety of therapeutic interventions. These interventions include, but are not limited to, cognitive-behavioral psychotherapy, mindfulness meditation, exposure therapy, physical exercise, medications, immune system enhancers, and others. There is an exploration of both childhood and adult forms of panic that might take place in work environments. An effort is made to provide the reader with an understanding of panic disorder as a phenomenon that is distinct from more commonly seen anxiety attacks. Whereas anxiety may be experienced as an annoying and persistent discomfort, panic is a far more intense phenomenon. Panic attacks come on unexpectedly and afflict victims with an overwhelming sensation of dread and often a fear of complete annihilation. Panic is frequently associated with physiological sensations that are so extreme that the sufferer may feel that they are about to die. Once a panic attack is in progress there is little that can be done for the sufferer other than to provide them with support and encouragement and to simply be present for them and assure them that the attack will pass. In virtually all instances panic attacks are relatively brief episodes, although the book describes some rare cases in which panic can last for considerably longer time periods. Much about panic disorder remains unknown to this day, including why some are afflicted by it and some are not. This book is an effort to increase our understanding of panic disorder and how it can be managed.

> **Robert W. Motta** Psychology Department, Hofstra University, Hempstead, New York, USA

**1**

Section 1

Panic Disorder Perspectives

Section 1

## Panic Disorder Perspectives

#### **Chapter 1**

## Perspective Chapter: Panic Disorder – A Real-World Case Due to Covid

*Robert W. Motta*

#### **Abstract**

This chapter presents a "real-world" case of extreme panic disorder and details the treatments that were brought to bear in efforts to reduce the panic. Unlike most cases of panic which appear to arise unpredictably and from unknown causes and last for a short amount of time, this one was attributed to an underlying neurological condition and many of the extreme panic episodes persisted for full days. The condition producing this panic was autoimmune encephalitis which appears to have arisen because of a Covid infection. The eventual resolution of the panic disorder took almost 2 years of daily struggles and are detailed within the chapter.

**Keywords:** panic, Covid, autoimmune encephalitis, CBT, IVIG therapy, steroids, rituximab

#### **1. Introduction**

Many of the chapters in this book on the Psychology of Panic deal with important topics such as the etiologies of panic, its characteristics, its epidemiology, and interventions. What will be presented in this chapter is a real-world case of Jordan with whom I have been directly involved as a treating psychologist and who has experienced extreme and extended bouts of panic which appear to have resulted from Covid exposure and resulting neurological inflammation.

Before delving into the case, it is important to consider what a panic attack might be like on a personal level. The DSM-5 [1] provides specific criteria for defining panic and these specifics are addressed in more than one chapter in this book. But such analytic descriptions with their enumeration of a series of diagnostic criteria provide a somewhat antiseptic and emotionally detached view of a disorder that is difficult to identify with unless the reader has experienced panic attacks themselves. So let us try a different approach.

Imagine that you are driving home on a dark stormy night where the windswept rain is so intense that your car's windshield wipers, although on high, make the road ahead almost indistinguishable. You are on high alert and are driving slowly to avert any storm related difficulties and you can feel your heart beating because of the stress of driving through this intense storm. You come to a familiar railroad crossing and as you begin

to approach it you both hear and feel your car's engine begin to run rough and stumble. Suddenly the engine dies and although your foot is off the brake, the car comes to a stop directly on the railroad tracks. Your fear level is now intensified. You are stuck on the tracks. Suddenly, you see brightly flashing red lights and ringing and realize that the railroad barrier arms are coming down in front of and behind your car and are a signal of an approaching train. You are trapped between the barriers and your car is sitting right in the middle of the tracks. A bright white light begins to appear out of the drenching rain, and you hear the horn of the train growing louder as it is rapidly approaching. You now are desperately trying to restart the car to move it either backward or forward to get off the tracks. You are gripped by a wild fear of impending annihilation by a locomotive that is now clearly in view and growing both louder and larger. You can feel the vibrations of this massive train as it literally shakes the tracks that you and your car are sitting on. You are about to be crushed and now your body tenses as you close your eyes knowing that in the next instant you and your car will be annihilated.

That feeling of being completely out of control and unable to affect your environment while also experiencing the extremely intense fear of annihilation is what a panic attack might feel like. The level of fear is so intense that all reason and problem solving become nonexistent. It is as if the thinking part of the brain has been shut down and an animal-like, reflexive, fleeing or freezing response takes hold. The term "fear" does not do justice to what a panic attack might feel like. It is a primal experience that is far beyond fear. It is often unimaginably intense and renders the suffer helpless and frantic.

According to the *Diagnostic and statistical Manual of Mental Disorders* [1] under normal circumstances panic attacks are relatively brief and can come on suddenly and unexpectedly. For example, one can be in a relaxed state or even emerging from sleep and suddenly experience a panic attack. In Jordan's case the panic attacks would often go on for hours and often consume a major part of the day. These extended episodes of panic are unusual and were later seen as originating from nervous system impairment due to Covid infection.

#### **2. Case description**

I had seen Jordan on and off for several years for a series of relatively minor issues that might be described as problems of living. He had self-doubts about his capabilities although he was both bright and well educated. As a 51-year-old he experienced bouts of depression, but these too were relatively mild and might be better described as episodes of melancholy. He also had a relatively low-level generalized anxiety disorder. He seemed unable to develop long term committed relationships despite having dated numerous women who he met on a variety of dating apps. Jordan was able to live on his own in New York City but often received financial support from his twin sister and his mother. At the time of his decent into panic, he was working as an adjunct professor teaching a variety of graduate and undergraduate psychology courses and three different universities.

Jordan's mother became infected with the Covid virus at age 75 and experienced a series of long-haul symptoms that lasted nearly a year. These included body pains, extreme fatigue, balance problems, memory difficulties and disorientation. The doctors who ultimately treated Jordan believed that although he likely caught Covid from his mother and he initially experienced only mild to minimal symptoms of Covid, as time progressed his symptoms slowly began to worsen. Their final diagnosis was that

#### *Perspective Chapter: Panic Disorder – A Real-World Case Due to Covid DOI: http://dx.doi.org/10.5772/intechopen.106138*

his Covid infection triggered autoimmune encephalitis whereby the immune system, in an overreaction to viral infection, began attacking the healthy tissue of Jordan's brain.

According to Younger [2], viruses can attack the body and produce a response the follows a specific sequence. The first stage of this sequence is the viral infection. This is then followed by an immune response and this response is followed by and manifests itself as an inflammatory process. Infection, immune response, and inflammation is referred to by Younger as "I-cubed" (p. 7). The immune system responds to the newly present virus as a pathogen that exists in the nervous system and attacks the nervous system to ward of the invader. Over time a neural cycle develops in which panic or pain become almost reflexive behavioral responses to invasion by the pathogen [3]. Treatment is often aimed at reducing the inflammation that was caused by the body's overactive immune response. Common outcomes of the inflammatory response are pain, depression, anxiety, fatigue, and attention problems. In Jordan's case his primary responses were extreme anxiety and panic, debilitating fatigue, and moderate depression.

#### **3. Developmental course**

Jordan reached out to me while he was still employed as an adjunct professor. Although popular and well regarded as a capable instructor, he reported that he was experiencing increasingly intense bouts of anxiety and that he was having difficulty getting through his day. Normally he was at ease and confident as an instructor, but he was now experiencing feelings of failure and simply getting himself into the classroom to teach was becoming increasing frightening and difficult. He felt that he could not present the material clearly and that students were noticing that his lectures were more and more disorganized. His normal easygoing demeanor was being replaced by an unhappy, ill at ease presence. Although he was able to see his classes through until the end of the semester, he knew that he would be unable to return. The anxiety he was experiencing made the thought of returning to the classroom a challenge that he was unable to meet.

Over time he began to become increasing anxious and feel threatened in situations that were normally soothing to him. For example, he enjoyed going to his gym which had a swimming pool. Swimming for Jordan was a stress reliever and a form of meditation. He was able to clear his mind of daily problems while swimming back and forth in the pool. All of this changed following his Covid infection. Eventually the thought of immersing his head in water evoked extreme apprehension. His difficulties with the pool and with water became so troublesome that he found himself unable to even dangle his legs into water while sitting on the edge of the pool. This apprehension spread to the gym itself. The last time he went there, he had such an extreme panic reaction that the personnel at the gym called the police to remove him. The police arrived and Jordan refused to leave. A scuffle broke out and resulted in Jordan biting one of the officers. The police used a Taser on him, and he was taken to a jail cell. His sister was called to retrieve him. The police brought no charges as they saw Jordan as irrational and out of control.

Once in his sister's apartment, Jordan continued to be overwhelmed with panic and in an attempt to end his intense suffering, attempted to jump from a sixth story porch. His sister was able to convince him that he needed hospitalization. One the way to a well-known hospital in New York City, Jordan opened the car door, jumped out, and in what appeared to be a suicidal gesture, threw himself in front of oncoming

cars. When questioned about this extreme act he claimed that he was not really trying to kill himself but rather trying to end the intense pain brought on by panic. It was clear to all that Jordan was progressively descending into irrational behavior and thought in reaction to the pain of his extended panic attacks.

It is difficult to accurately convey the intense level of suffering brought on by Jordan's panic. He has used the term, "seizure" to describe the sudden grip of intense fear that unpredictably but regularly fell upon him. During one of these "seizures" he would often thrash around maniacally, smashing objects and even hitting those who were nearby. At one point he punched his mother in the face and the next day, on seeing her blackened eye, asked if she had fallen. He had no memory of having hit her. It was clear that his panic attacks were rendering him an irrational, frightened, and crazed individual who was often unaware of what he was doing and who later had only minimal recall of what his behavior had wrought.

#### **4. Secondary trauma**

Before delving into Jordan's treatment, it is important to consider the impact that his extreme panic attacks had on his family. When an individual is traumatized as was Jordan, their emotional distress is transferred to those who have a close bond with that person. Typically, this group includes family members but can also include other caretakers such as therapists, physicians, nurses, etc. [4]. The process by which trauma is transferred from one individual to those who have a close and extended relationship with that person is referred to as secondary traumatization [5]. In Jordan's case his sister, who was a twin, and his mother who presumably spread Covid to her son, suffered the emotional pain of Jordan's distress. They felt powerless to alleviate his pain despite valiant efforts to coordinate treatment teams, find hopefully effective treatment facilities, and obtain a veritable army of occupational therapists, health aides, psychologists, psychiatrists, dieticians, and others. They clearly felt Jordan's pain and agonized over their inability to find some magical combination of therapeutic elements that would stop the suffering of their beloved family member. Jordan's sister would often take it upon herself to advise the physicians of the appropriate modes of treatment based upon her frenzied search of the internet. This proved to be counterproductive because after a while the physicians began to become defensive and non-responsive to her incessant questioning of their decisions. What she eventually came to understand was that Jordan's treatment team was not being negligent or uncaring but that they simply did not know how to alleviate Jordan's torturous panic attacks and his occasional thrashing both of which appeared to be brought on by the inflammation and oversensitivity of his ailing nervous system.

#### **5. Psychological intervention**

In general, panic attacks are treated both psychologically and pharmacologically [6] and this section will spotlight the former. Cognitive-behavioral therapy (CBT) interventions are often used, and these are frequently coupled with breathing techniques and meditation. Prior to engaging in interventions, it is important to assure the patient that panic disorder is a known phenomenon that afflicts approximately 2–5% of the general population [7], that a panic attack is not life threatening, and that it is often associated with feelings of extreme dread, trembling, extremity numbness,

#### *Perspective Chapter: Panic Disorder – A Real-World Case Due to Covid DOI: http://dx.doi.org/10.5772/intechopen.106138*

disorientation, hyperventilation, dizziness, and other symptoms. It is not uncommon for patients who experience panic attacks to fear that they might die or become insane. Assurance that these are common beliefs during a panic attack can be helpful in lessening the dread that the panic sufferer may encounter. It is also often helpful to provide the panic victim with information sources to reduce the chances of engaging in catastrophic thinking. This providing of information and perspective can be seen as cognitively oriented intervention that helps to allay extremely negative and fatalistic beliefs.

Another CBT intervention specifically targeted Jordan's tendency toward catastrophic thinking. In his case the catastrophizing involved the belief that "My life is over," "I will never get better." Jordan and I worked together in such a way that allowed him to understand that there was no evidence to support such a negativistic view, and that there was abundant evidence that people recover from AE based panic. Jordan was encouraged to engage in his own scientifically based skepticism of such thoughts and was generally able to do so. This technique was practiced between episodes of panic because once in the throes of a panic attack, logical and rational thinking are unavailable to most sufferers.

In Jordan's case a specific breathing exercise was also practiced that involved inhaling through the nose for 4 s, holding the breath for 5 s, and exhaling for 7 s. This exercise provided him with a tool to control the hyperventilation that he commonly experienced during a panic attack and reduced some the dizziness and tingling that were associated with this hyperventilation. He stated that the breathing exercise reduced the intensity of his panic but did not eliminate the disorder. He was clearly suffering but his pain was less than that which would normally be occurring without intervention. Unfortunately, it became apparent that unless I was guiding him in the controlled breathing exercise, he was unlikely to do it on his own. As I was unable to be with him daily to guide him through the breathing exercise, I taught the approach to his sister and mother with whom he spoke multiple times during the day. This helped considerably as they were able to get Jordan to engage in controlled breathing daily and often more than once during any given day.

Meditation techniques were coupled with the controlled breathing. Once Jordan had gained some level of control using the breathing techniques, a guided meditation was used. The meditation had to be guided because the concept of simply clearing his mind of intruding thoughts as is common in many forms of meditation, was beyond his capability given the ongoing panic disorder. One meditation that proved to be helpful was the "Mountain Meditation" [8] in that it provided the self-view of strength and imperviousness. The meditation is usually done in a sitting position where one directs one's attention to the characteristics of a mountain. One's lower extremities are viewed as the base of the mountain which is solid and imperturbable. The arms and shoulders are seen as projections from the mountain that are unchanged by winds, rain, or any other environmental events. The head as viewed as the top of the mountain that stands above and is unaffected by the travails and disturbances that people commonly encounter. The entire meditation takes approximately 20 min and emphasis is placed upon strength, endurance, and ability to be unmoved and unshaken. The images of strength and immobility help to counter the agitation and vulnerability commonly experienced by those enduring panic attacks. Other meditations were also used like the "Lake Meditation" which emphasizes stillness and tranquility [8]. Despite disturbances on the surface of the water, the lake ultimately returns to stillness and serenity. Imagining himself to have the characteristics of the lake helped Jordan to reduce his agitation.

A final form of psychological intervention for both Jordan and his family was supportive counseling. Jordan's illness seemed to come out of the blue and was terribly disruptive to him and extremely anxiety provoking to his mother and sister. Everyone seemed to benefit from encouragement and assurance that things would get better and that the brain had a natural tendency to move in the direction of self-repair and self-cure. A good example of this is the impressive recoveries made by those who have experienced brain damage due to strokes. Many of the functions lost to strokes are often recovered with various exercises that combine cognitive and physical activity. Jordan and his family were encouraged to read numerous anecdotal reports of people who recovered from the disability wrought by AE. These reports and the provision of emotional support went a long way in facilitating Jordan's eventual improvement.

#### **6. Pharmacological, medical, and physiological intervention**

When Jordan was first taken to the hospital following his initial irrational behaviors and attempts at self-injury, the hospital staff appeared to be at a loss. His doctors thought he had some form of psychosis and treated Jordan with antipsychotics, antianxiety and antidepression agents. The sedating effect that these medications resulted in some reduction of his anxious thrashing, but his panic disorder persisted, and he continued to verbalize the desire for his life to come to an end. The flailing about for some method of treating this agitated patient went on for several months until it was finally decided to do a spinal puncture. The results of this procedure led the involved neurologists and psychiatrists to conclude that he was suffering from autoimmune encephalitis. This diagnosis provided some direction for treatment, but the concept of a "cure" continued to be a distant hope.

Autoimmune encephalitis was first reported in the 1960s [9] and was initially described as limbic encephalitis (LE). LE encompassed symptoms including seizures, movement disorders, behavioral changes, mood disorders, cognitive impairment, and an altered level of consciousness. Except for the incoordination seen in movement disorders, Jordan appeared to be displaying all these symptoms. The disorder is now seen as affecting various brain structures, not just the limbic system, and is now termed AE or autoimmune encephalitis, a disorder involving the immune system's attack on various brain structures [10].

Having arrived at a diagnosis of AE, a twofold treatment was decided upon. The first was the use of steroids. The goal here was to reduce inflammation of the nervous system. The second line of attack was intravenous immunoglobulin (IVIG) infusion. The latter was aimed deactivating the immune system's attack on health neural tissue. Jordan received two such treatments of combined steroids and IVIG in the hope of a remission of his symptoms. However, the treatments not only proved ineffective in the short run, but it appeared that after the use of steroids his symptoms of agitation, panic, and thrashing became worse. Why this occurred is unclear because there were anecdotal reports from his treatment team that this intervention appeared to have reduced symptoms in other cases of AE that his physicians had encountered. On the other hand, there are researchers who report that available evidence shows that the combination of IVIG and steroid intervention continues to be ineffective for a significant number of patients suffering from AE [11]. The latter view certainly appeared to be valid in Jordan's case.

Given the obvious lack of progress in Jordan's behavior following two administrations of combined IVIG and steroids, the decision was made by his treatment team to

#### *Perspective Chapter: Panic Disorder – A Real-World Case Due to Covid DOI: http://dx.doi.org/10.5772/intechopen.106138*

provide him a second line of treatment called rituximab. Rituximab is a medication that is often used in the treatment of rheumatoid arthritis and is said to specifically inhibit B cells of the immune system. It is also used when the combined IVIG-steroid treatment fails stop the immune systems attack on healthy neural tissue that occurs in autoimmune encephalitis [12]. The rituximab treatment was done on two occasions approximately 6 weeks apart. One of the concerns voiced by Jordan's physicians was that because rituximab suppresses the immune system, the patient then becomes vulnerable to any potential infection to which he or she might be exposed. Jordan's treatment was taking place a time of increased infection rates of Covid in New York City so the concern for infection was realistic. In fact, the routine of the hospital was to isolate Jordan after the rituximab treatments. Visitors were required to be fully vaccinated, to wear masks, and to also wear latex gloves.

The idea that he might be immune compromised did nothing to help Jordan with his panic attacks. In the immediate aftermath of his rituximab treatments, he would be on the phone with his family all day. His sister once noted that that he had made approximately 150 calls on 1 day. Approximately 1 month after his last rituximab treatment, there did appear to be some diminishing of the intensity and frequency of Jordan's panic attacks. They were continuing to occur multiple time per day but there were periods, especially in the early afternoons, where he did seem to be less tormented by anxiety.

At around this time Jordan was transferred to another hospital in Yonkers, NY which specialized in the treatment of patients with specific neurological disorders such as encephalitis and traumatic brain injury. This hospital was one of the few placements that would accept him. The uncontrolled thrashing about and occasional breaking of objects in his hospital room during extreme panic attacks resulted in his being a patient that no one wanted in their facility. One novelty of his placement in Yonkers was that he was able to go outside unattended. He would occasionally go to a local basketball court to practice his shooting. Often the overstimulation of having been outside would precipitate a panic attack, so his increased freedom turned out to be a mixed blessing.

As a rule, physical exercise has beneficial effects on psychological and neurological functioning [13]. There is considerable speculation as to why this is the case but one of the more popular view sis known as the endorphin hypothesis [14]. Exercise is said to result in the release of the endogenous opiate beta-endorphin which is said to produce a calming effect on the nervous system and to result in mood elevation. The hypothesis is not without its critics who, among other critiques, note that beta endorphins do not cross the blood–brain barrier and therefore are unlikely to have an impact of neurological and psychological states. A competing hypothesis for the benefit of exercise is referred to as the endocannabinoid hypothesis [15]. Endocannabinoids, which are like the THC found in marijuana are released during exercise and are said to be capable of crossing the blood brain barrier. Regardless of theoretical view, it appears that in Jordan's case mild exercise such as shooting baskets or having a brief leisurely walk, proved beneficial in terms of reducing his level of panic, whereas more strenuous exercise had the opposite effect and precipitated intense panic reactions.

#### **7. Transition to supportive care**

Jordan was transferred to a private long-term care facility in Pennsylvania following his stay at the medical center in Yonkers, NY. At the time of his transfer Jordan

had been in and out of various hospitals and neurological care facilities for 22 months. It was only at the time of his latest transfer that his panic attacks began to subside. He continued to be moderately anxious, depressed, and often felt overwhelmed, but the extreme panic disorder that he endured for almost 2 years, now appeared to be a torturous event of the past.

The question that arises is what was responsible for the reduction in his panic attacks. It is possible that the psychological supports and interventions that were put in place eventually took hold and helped Jordan deal with his anxieties. It is also possible that the medical interventions such as IVIG, steroids, and rituximab brought about the panic reductions by reducing the immune system's response and inflammation. Mild exercise and family support might also be pointed to as having been beneficial to him. However, if we objectively view what is known in Jordan's case, we must come to the somewhat unsettling conclusion that any of these interventions or some combination of them were what proved beneficial. It is also possible that none of them were responsible for change and that the brain's tendency to move in the direction of self-healing, as is seen in cases of stroke, is what eventually brought about change, e.g., [16]. This self-healing position suggests that, given sufficient time and effort to change one's behavior, the brain itself is the healing agent.

#### **8. Conclusion**

Jordan now resides in a supportive care facility where he has psychologists, psychiatrists, nurses, and recreational therapists. He is kept socially engaged and participates in both individual and group psychotherapy. He is receiving therapeutic doses of antianxiety and antidepression agents but no neuroleptics and no immune system targeted medications. His panic attacks have subsided and plans are to integrate him into the community by encouraging him to attend various social events and attempt to find employment. Given Jordan's background as a psychology professor, there is some discussion of having him provide counseling services to others within the supportive care facility. His training and difficult experiences with a severe case of neurologically induced panic, make him an ideal candidate for such a position.

Jordan views himself and his situation realistically. He sees himself as having endured the neurological torment of autoimmune encephalitis and that, for reasons unknown to him, he is beginning to recover. He is thankful that the panic that once gripped his life is no longer present. Each new day brings further improvements in terms of his willingness to engage in social events, to participate in therapeutic activities, and in his overall hopefulness that he will continue to improve to the point where he can get back to his former life. My impression, as one of his treating psychologists, is that he will not only be able to regain that which he once had, but that the traumatic experiences he has endured because of his illness will have given him greater depth and perspective. There is a possibility that his overall functioning may be better than it was prior to his illness. This is a relatively common outcome that is seen among those who have lived through various forms of trauma [17]. At this point, his treatment team is of the opinion that Jordan will make a complete recovery.

*Perspective Chapter: Panic Disorder – A Real-World Case Due to Covid DOI: http://dx.doi.org/10.5772/intechopen.106138*

#### **Author details**

Robert W. Motta Hofstra University, Hempstead, NY, USA

\*Address all correspondence to: motta9182@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[2] Younger D. The Autoimmune Brain. Rowman & Littlefield; 2019

[3] Butler D, Mosley GL. The Explain Pain Protectometer Handbook (8315). NOI Group; 2015

[4] McCann L, Pearlman LA. Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress. 1990;**3**:131-149

[5] Motta RW. Secondary trauma. International Journal of Emergency Mental Health. 2008;**10**:291-298

[6] Bystritsky A, Khalsa SS, Cameron ME, Schiffman J. Current diagnosis and treatment of anxiety disorders. Psychiatry Investigation. 2013;**38**:30-57

[7] Baxter AJ, Vos T, Scott KM, Ferrari AJ, Whitehead HA. The global burden of anxiety disorders. Psychological Medicine. 2010;**44**:2363-2374

[8] Kabat-Zinn J. Wherever You Go There You Are: Mindfulness Meditation in Everyday Life*.* New York: Hyperion; 1994

[9] Corsellis JA, Goldberg GJ, Norton AR. "Limbic encephalitis" and its association with carcinoma. Brain. 1968;**91**(3):481-496

[10] Saraya AW, Worachotsueptrakun K, Vutipongsatorn K, Sonpee C, Hemachudha T. Differences and diversity of autoimmune encephalitis in 77 cases of a single tertiary care center. BMC Neurology;**19**:273

[11] Yang J, Xueya L. Immunotherapy for refractory autoimmune encephalitis. Frontiers of Immunology. 2021;**12**:790962. DOI: 10.3389/ fimmu.2021.790962

[12] Lancaster E. The diagnosis and treatment of autoimmune encephalitis. Journal of Clinical Neurology. 2016;**12**(1):1-13

[13] Manger TA, Motta RW. The impact of an exercise program on posttraumatic stress disorder, anxiety, and depression. International Journal of Emergency Mental Health. 2005;**7**:49-57

[14] Farrell PA, Gates WK, Mashud MG, Morgan WP. Increases in plasma betaendorphin immunoreactivity after treadmill running in humans. Journal of Applied Physiology. 1982;**52**:1245-1249

[15] Smaga L, Bystrowska B, Gawlinski D, Przegalinski R, Filip M. The endocannabinoid/endovanilloid system and depression. Current Neuropharmacology. 2014;**12**:462-474

[16] van der Kolk BA. The Body Keeps the Score. New York, NY: Viking

[17] Tedeschi RG, Calhoun LG. Posttraumatic Growth: Conceptual Foundations and Empirical Evidence. Lawrence Earlbaum; 2004

#### **Chapter 2**

## Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal

*Bhupendra Singh Gurung*

#### **Abstract**

Although panic attacks are not life-threatening, they can be terrifying and have a substantial impact on your quality of life. Treatment, on the other hand, can be quite effective. Little attention is paid to mental health in Nepal. There is no mental health law and the National Mental Health Policy formulated in 1997 has yet to come into full effect. Unspecified anxiety disorder (15.7%), adjustment disorder (13.9%), and post-traumatic stress disorder were the most frequently diagnosed conditions (8.3%). In 2018, the KCH CAP (OPD) cared for 2477 children, of whom 1529 were men and 948 were women. The most common diagnoses were anxiety disorder (524). Children ranging in age from 6 to 18 years old took part in the study. Nepal has one general hospital dedicated to mental illness and four private mental hospitals. Inpatient mental health care is provided primarily by 19 medical schools, 36 private−public hospitals, and many 27 public hospitals. The counseling situation in Nepal is largely poor. Advanced psychotherapy is provided by 35 clinical psychologists who are licensed practitioners in Nepal. In a 2018 research with 2477 individuals, 524 incidences of anxiety disorders were identified. Supervised counseling and psychotherapy practice is a relatively new concept in Nepal.

**Keywords:** anxiety disorder, panic disorder, prevalence, psychotherapy, and counseling

#### **1. Introduction**

In South Asia, between China and India, the Federal Democratic Republic of Nepal is a landlocked nation. Nepal has a varied topography, with the Tarai, or flat river plain, in the south, hilly areas in the center, and the high Himalayas in the north. The nation, which is divided into seven provinces (Pradesh), is a federal parliamentary republic, with Kathmandu serving as the capital [1].

In the general community, panic disorder is fairly prevalent. It is the anxiety illness that requires the most medical attention and is the most expensive in terms of mental health issues. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM) describes a panic attack as **"**an abrupt rush of extreme dread or discomfort**"** that reaches a peak in a matter of minutes. A panic episode is accompanied by four or more of a certain set of physical symptoms. The frequency of panic episodes might range from several times per day to only a few times a year. Attacks happen suddenly, which is a defining characteristic of panic disorder. Often, there is no clear cause of the panic episode. Nepalese aged 16 to 40 suffer from mental health problems, with cases on the rise among children as Nepal conducts its first national mental health survey. Psychiatrists warn that various studies also show that mental health affects people of all ages [2]. Nepal's population has reached 29,192,480, with a 10.18% rise in the last 10 years [3].

A survey has found that 30% of Nepal's population suffers from psychiatric problems. Mental health is not well-recognized or taken seriously in Nepal. The government spends less than 1% of its total budget on healthcare in this area. Although precise data are not available on the prevalence of mental disorders in Nepal, smallscale studies have shown the prevalence to be as high as 37.5% in rural communities. In March 1995, the New Communist Party of Nepal (Maoist) (**"**CPN (Maoist)**"**) began formulating a plan to launch an armed struggle, the so-called **"**People**'**s War,**"** against the government [3]. Nepal has seen a gradual increase in the incidence of depression, post-traumatic stress disorder, and suicide since the start of the conflict. Health experts estimate the rate of mental health problems in Nepal is as high as 30% [4].

On April 25, Nepal was hit by a magnitude 7.8 earthquake that caused severe damage to 1 of the country**'**s 75 districts. Two weeks after that, on May 12, another magnitude 7.3 earthquake struck, worsening the humanitarian situation.

Common forms of stress shown in rapid assessments weeks after the Nepal earthquake included fear, anxiety, sadness, anger, sleep disturbances, and increased risk of suicide. Lockdowns, curfews, self-isolation, social distancing, and quarantines brought by the coronavirus disease and COVID-19 pandemic are impacting the overall physical, mental, and social health of Nepalese people. WHO Nepal Office (WCO) assisted the Minister of Health and Population (MoHP) in developing his COVID-19 Mental Health and Psychological Support (MHPSS) intervention framework. World Health Organization (WHO) helped develop the legal and policy framework for the implementation of the National Mental Health Strategy and Plan of Action developed by the Minister of Health and Population (MoHP). This includes required guidelines, standard operating procedures (SoPs), and training manuals [5].

#### **1.1 Institutions**

College courses and degrees in modern psychology began their journey to Nepal in the late 20th century at Tribhuvan University. Likewise, their professional training in modern clinical psychology in the form of a Master of Philosophy (M.Phil) in Clinical Psychology began in the late 1990s at the Institute of Medicine, Tribhuvan University (IOM/TU). It, therefore, felt essential to present the growth and development clearly and comprehensively in a clear and comprehensive manner. Specialization and continuing education in the form of fellowships, doctoral and postdoctoral programs, and competency-based training cover various forms of assessment, psychotherapy, neuropsychological approaches, integration with neuroscience, and specific therapeutic modalities, should focus on hyper-specialization in cross-cultural approaches, etc. Two years of M. Phil. in Clinical Psychology can be complemented by a Ph.D. in clinical psychology or the PsyD program. This is possible by setting up an independent clinical psychology department in each institute. More specialists are needed in areas, such as cognitive behavioral therapy, dialectical behavioral therapy, mindfulness-based therapies, couples and marriage therapies, family therapies, sexual therapies, drug and addiction therapies, rehabilitation, and supervision [6].

**# Rate per 100,000 Generalist** Doctor 28,477<sup>30</sup> 96.0 Nurse 27,04031 91.1 Pharmacist 376132 12.7

**Specialist** Neurologist 25 0.1

Psychiatric Nurse 75

Psychiatrist 147 0.5 Clinical psychologist 35 0.12

Lay counselors ~700 2.4

#### *Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal DOI: http://dx.doi.org/10.5772/intechopen.107470*

#### **Table 1.**

*Human resource in mental health.*

#### **1.2 Human resources**

There are about 147 psychiatrists and 3 child psychiatrists in Nepal. Of these, 110 work in the private sector. It is estimated that there are more than 75 psychiatric nurses and 30 private psychiatrists (**Table 1**). Almost all specialists are concentrated in large urban areas. There are also an estimated 700 nonprofessional consultants working in the public sector. Specialized training in psychiatry is offered at several institutions, while training in clinical psychology is offered at only one institution. As a result, about 15**–**20 psychiatrists are added each year, compared to only 2**–**3 clinical psychologists. However, Nepal does not have training programs for subspecialties, such as substance abuse, child mental health, or mental health for the elderly [7].

Despite the high exposure of CAP patients in daily practice, early career psychiatrists (ECPs) say they are not well trained and there is no standardized CAP course for ECPs in Nepal. The desire of the ECP to receive additional training from the CAP is very encouraging and positive [8]. Existing training in psychiatry may not be sufficient to provide meaningful psychotherapy training opportunities for most ECPs in Nepal. It is encouraging that most patients want to continue their psychotherapy training, and there is room for improvement in current psychotherapy training [9].

#### **1.3 Healthcare facilities for mental health**

Nepal has one general hospital dedicated to mental illness and four private mental hospitals. Inpatient mental health care is provided in 36 private hospitals and 27 public hospitals. There are also three outpatient services for children and adolescents. Nepal has adopted the mhGAP tools to fit its context, in the form of the Community Mental Health Care Package 2017. Anxiety is one of the common mental disorders included. A set of psychotropic medications, including antipsychotics, antidepressants, anxiolytics, mood stabilizers, and antiepileptics are available at health facilities of all levels across Nepal. Medicines are prescribed by registered medical doctors. However, health assistants employed in primary health care also prescribe after receiving training and following certain government protocols. Counseling on psychosocial is short-duration training. Usually, such training has a time duration of 6 months [10].

#### **1.4 Psychosocial counseling and traditional practice**

The historical point of counseling in Nepal has been recorded since the early 1990s. After Nepalese-speaking Bhutanese citizens were deported from Bhutan to Nepal between 1993 and 1996. Places of refuge required not only basic needs but also emotional support. This host country, Nepal, then began to see the importance of counseling after seeing many mental and psychosocial issues [8].

From priests and shamans to doctors with western training, the medical profession has always played a significant role in Nepal. These experts use a stethoscope or a ritual to evaluate the issue. Therapy claims to be able to quiet the mind through rituals or to treat illness with medications. Psychotherapists and counselors are viewed as devoted siblings who wish to hear their patients**'** ideas, sentiments, and feelings. To address the crises of torture survivors, the Center for Victims of Torture (CVICT) employs client-centered problem-solving counseling. In addition to focusing on human rights, CVICT also emphasizes client needs, goals, and ideals, as well as empowerment and self-reliance. Most individuals who are familiar with the idea of counseling think that it is all about providing consolation and guidance [11].

Little attention is paid to mental health in Nepal. There is no mental health law and the National Mental Health Policy formulated in 1997 has yet to come into full effect. The counseling situation in Nepal is largely poor. The training courses are usually short and do not involve clinical practice. Training is mostly given by foreign trainers who are new to the cultural environment. Counseling is commonly misunderstood, often resulting in judgmental and uninformed implementation and sometimes wrong practices. The state of counseling is further complicated by the arbitrary application of the word **"**counselor**"** to anyone doing social work within a non-governmental organization (NGO) setting. The five-month paraprofessional course begins with a 3-week core training phase, followed by multiple cycles of alternating supervised internships and continuing education courses for increasingly advanced skills and subjects. Working with western-oriented therapeutic assumptions in a non-Western setting requires adjustments to increase cultural relevance [12]. To create qualified counselors, the MA in counseling psychology was introduced in 2017 [13]. Cognitive behavioral therapy is mainly used to address psychological problems by clinical psychologists whereas client-centered counseling is practiced by counselors [14].

A group of gestalt therapists from Europe, formed a Gestalt Psychotherapy Institute in Kathmandu, Nepal. For a group of psychologists and counselors who work with children, refugees, and victims of sexual abuse and torture, the institute would offer psychotherapy and counseling in the area along with a Gestalt psychotherapy training program that adheres to the international standards of the EAGT (European Association for Gestalt Therapy) [15]. The Nepal Youth Foundation (NYF) launched a program called Sandplay Therapy. This has shown to be incredibly beneficial for the youngsters [16].

Supervised counseling and psychotherapy practice is a relatively new concepunderin Nepal. In Nepal, supervised counseling practice is still a novel idea. The majority of it is unsupervised. The study found that students nowadays are handicapped by the overwhelming volume of western study material and the excessively hierarchical supervision they get. The participants understood that the concept of contextualized supervision training had a surprising amount of power [17].

#### **2. Prevalence and management**

The planning of the National Mental Health Survey, Nepal started in November 2017 and was carried out in January 2019 and was carried out in all 7 provinces of Nepal from January 2019 to January 2020. The total sample size of the survey was 15,088, including 9200 adults (ages 18 and older) and 5888 youth (ages 13 to 17). The data collection tool consisted of a sociodemographic questionnaire, a translated and adapted Nepalese version of the MINI International Neuropsychiatric Interview (MINI) 7.0.2 for DSM-5, a questionnaire on pathways to obtaining care/help-seeking behavior, and a questionnaire on Barriers to Accessing Care Nursing Assessment (BACE). The overall response rate for adult participation was 96.8% [18].

Worldwide, 10–20% of children and adolescents suffer from mental problems, with 50% of all onsets happening by age 14 and 75% occurring by age 25. A sizeable portion of the population is at risk of developing a mental condition because 40% of Nepal**'**s population is under the age of 18. Though previously largely disregarded by the health agenda, child and adolescent mental health concerns have lately come to attention in Nepal [19].

Before the pandemic, a number of studies were conducted on the prevalence of mental disorders in the Nepali population. A nationwide cross-sectional study conducted in 2013 among a representative sample of adults in Nepal using the Hospital Anxiety and Depression Scale (HADS) showed age and gender-adjusted point prevalence of anxiety of 16.2% [20].

A systematic review of studies on the mental health impact of the COVID-19 pandemic on the general population in different countries, including Nepal, showed relatively high rates of symptoms of anxiety, depression, post-traumatic stress disorder, mental distress, and stress [16]. Under this pretext, the psychosocial results of the Nepalese population should be examined. However, the effect of COVID-19 on psychosocial well-being in Nepal has now not been thoroughly studied (**Table 2**).

The outpatient clinic for Child and Adolescent Psychiatry (CAP) headed by Dr. Arun R. Kunwar has been operating at Kanti Children's Hospital (KCH) in Kathmandu since July 21, 2015. KCH is the first and only government children**'**s hospital in Nepal to offer specialized services for children and CAP is one of the few specialized services operated in this hospital. In 2018, the KCH CAP (OPD) cared for 2477 children, of whom 1529 were men and 948 were women. The most common diagnoses were anxiety disorder (524). Children ranging in age from 6 to 18 years old took part in the study. Seventy eight of the patients were diagnosed with general anxiety disorder (GAD), and 65 with separation anxiety. Whereas 62 people were diagnosed with social anxiety, 52 with obsessive**–**compulsive disorder (OCD), 64 with panic disorder, and 60 with physical fear of damage [21].

#### **2.1 Arm conflict and mental health in Nepal**

In 2008, 720 people participated in this cross-sectional survey. In the sample, 27.5% of participants reached the criterion for depression, 22.9% for anxiety, and 9.6% for PTSD [22]. Shakya et al. 2011 indicated that many psychiatric disorders had a significant political stressor during armed conflict. The study was conducted with 50 participants. Almost all participants had somatic symptoms followed by anxiety symptoms [23].


**Table 2.**

*Prevalence of mental disorder among adult participants aged 18 years and above.*

#### **2.2 Major earthquake and mental health in Nepal**

Little is known regarding what kind of psychological state disaster interventions are effective within the months following earthquakes in areas like the Asian nation. Given the inveterately disaster-prone context, communities should incline the mandatory tools to arrange for future natural hazards and to recover once disasters strike. With this in mind, a three-day integrated psychological state disaster response intervention for earthquake survivors in the Asian nation was designed. The community-based cluster intervention is culturally acceptable, includes header skills and community-building activities, and was tested employing a cluster comparison style. Social cohesion is related to psychological state symptoms, thus higher rates of depression and post traumatic stress disorder (PTSD) are related to lower social cohesion. Participation in a 3-day intervention ends up in a rise in disaster preparedness; a decrease in psychological state symptoms (depression, PTSD); and a rise in social cohesion. Six intervention teams, each with 20 participants, underwent the three-day psychological state integrated disaster readiness intervention at a similar time in every community. Six Nepali clinicians in the United Nations agency were experts in the native languages and were informed with the relevant subcultural team**'**s junction rectifier **of** the groups—two in every case. All of them have between 2 and 6 years of expertise in community leadership. Their academic backgrounds ranged from a three-year degree in scientific discipline to a six-month message certificate. Senior members of the analysis team, like the


*Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal DOI: http://dx.doi.org/10.5772/intechopen.107470*

#### **Table 3.**

*Disorder diagnosed during the visit to hospital***.**

second author, a doctorial level social worker/psychologist, and United Nations agency additionally provided on-the-spot oversight throughout implementation and educated facilitators over the fortnight. The temporary group-based intervention is also scaled up to be used not solely in the Asian nation but also in different nations that usually expertise earthquakes and different natural disasters [24].

Unspecified anxiety disorder (15.7%), adjustment disorder (13.9%), and posttraumatic stress disorder were the most frequently diagnosed conditions (8.3%) shown in **Table 3** [19]. Ten papers were identified, all involving 7876 participants. Two studies reported post-traumatic stress symptoms 10.**7–51%** prevalence of 10.**7–51%** in earthquake-affected children and adolescents in the Kathmandu district of Nepal. Another study reported that 53.2% of former child soldiers achieved the cut-o score for PTSD. The clinical prevalence of anxiety disorders has been reported as 18.8 to 24.4%, in different clinical samples of children and adolescents [25].

#### **2.3 COVID-19 pandemic and mental health in Nepal**

Utilizing a multistage proportionate stratified random selection method, a crosssection web-based study design was conducted with 422 Nepalese individuals in the provinces of Bagmati, Gandaki, and Lumbini (**Table 4**). To measure the severity of


#### **Table 4.**

*Sample size of each district.*

depression, stress, and anxiety, the DASS-21 tool was employed. Only 77.5% of whom reported experiencing no stress during lockdown experienced extremely high levels of anxiety [26].

There has been a negative impact on children and adolescents**'** (C&A) access to mental health care throughout Nepal. The mental health of C&A has been impacted by factors, such as school closures, home confinement, lockdowns, transportation issues, uncertainty, disruption of routine, and fear of infection. A suitable strategy to meet these objectives is an online platform. With this in mind, a multi-tiered children and adolescent mental health (CAMH) intervention model was created. It makes use of an online platform to train mental health professionals throughout Nepal, who would then organize sessions for C&A, teachers, parents, and caregivers and connect them to local and remote CAMH services via tele-consultation. With the goal of reaching 40,000 C&A, parents, teachers, and caregivers, this began as a trial program in June 2020 and will run through the end of February 2021. By November 2020, 1415 sessions had been successfully completed using this technique.

Reaching 28,597 people, out of them, 12,026 are parents, teachers, and caregivers from all 7 provinces of Nepal, making up 16,571 child and adolescent (C&A). The multi-tier intervention has been described in this research as a workable approach for resource-constrained settings and low middle-income countries (LMIC) like Nepal. It addresses the COVID-19-related CAMH problems [27].

#### **2.4 Management**

Similar to Western ethnopsychology, Nepali ethnopsychology (**Figure 1**) offers various divisions of the self (see **Figure 1**). The physical body (Nepali: jiu or saarir), heart-mind (man), brain-mind (dimaag), spirit (saato), soul (atma), and one**'**s social standing (ijjat) are the primary components. The family (pariwaar), which includes the extended family, and the spiritual realm, particularly connections with one**'**s ancestors**'** deities, are additional significant divisions (kuldevta) (**Table 5**). The heart-mind and the brain-mind are important subjects in the treatment of mental illness. Memory and emotion are stored in the heart-mind. Psychotherapies including *Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal DOI: http://dx.doi.org/10.5772/intechopen.107470*




#### **Table 5.**

*Components of Nepali ethnopsychology in therapy modalities.*

cognitive behavior therapy, interpersonal therapy, and dialectical behavior therapy can all benefit from the use of Nepali ethnopsychology. Any of these ways must have an excellent therapist who simultaneously doubles as an ethnographer [28].

The CVICT personnel received training in the Emotional Freedom Technique (EFT), a novel form of therapy, in 1997. This therapy is based on the idea that disturbances in the energy field are what trigger unfavorable feelings. It is a streamlined variation of Thought Field Therapy (TFT) that was created by Gary Craig. It is quite easy to use. Focusing on the issue while lightly touching an acupuncture meridian constitutes this technique. A year later, eye movement desensitization and reprocessing (EMDR) was introduced. A therapy for PTSD that has been empirically demonstrated to be successful (these are post-trauma symptoms, which include nightmares, palpitation, fear, intrusive thoughts, anger, re-experiencing, and bodily pains). These techniques were successfully used for excessive fears, traumatic memories, anxiety, depression, medically unexplained pain, and guilt. There have been cases where one resolved issue leads to another chain of issues, which are treated during consecutive visits [29].

To provide therapeutic recovery to the Bhutanese refugees in Nepal, a communitybased group intervention was started. During the Maoist insurgency, group therapy was further utilized and expanded to include war victims in the post-conflict period. Out of several interventions, the International Committee of the Red Cross (ICRC)'s Hateymalo Program, the Problem Management Plus (PM+) group therapy model from the World Health Organization (WHO), Group Interpersonal Therapy (IPT) for teenagers, Dialectical Behavioral Therapy in Nepali (DBT-N) in minority women

*Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal DOI: http://dx.doi.org/10.5772/intechopen.107470*

groups, and Common Thread (sajha-dhago) for women were some of the programs examined [30].

In order to prioritize mental, neurological, and drug use problems, the World Health Organization (WHO) introduced the mental health Gap Action Program (mhGAP) in 2008. The goal of mhGAP is to make it easier for nonspecialized healthcare professionals to deliver evidence-based interventions in basic healthcare settings. In addition, mhGAP promotes expanding access to mental health services by integrating mental health into primary healthcare [31].

#### **2.5 Management in earthquake**

In a resource-constrained rural Nepali setting, this research discusses the manualized, cross-cultural adaption of traditional dialectical behavior therapy (DBT) employing an iterative, collaborative, and phasic process approach. It was conducted with one particular subcultural group in rural Nepal, which was identified by its location, its religious preferences, its gender, and its line of work [32].

Tribhuvan University Teaching Hospital [13] promptly developed a 24-hour critical incident crisis management help center, and bed-to-bed psychological assistance was offered in the triage rooms and wards. PFA, trauma therapy, and appropriate psychiatric and nursing care were all delivered immediately by psychiatrists, clinical psychologists, nurses, and residents. The majority of the clients had anxiety disorders, including acute stress reaction (ASR) (44%), acute stress disorder (ASD) (9%), and anxiety disorders not otherwise specified (NOS) (18%). There was counseling for trauma, trauma-focused CBT, and behavioral treatments [33].

#### **2.6 Trauma-focused therapies**

A team of local nonspecialist mental health volunteers was trained to identify survivors with PTSD using the PTSD checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. They were trained to deliver either shortened versions of narrative exposure therapy (NET)-revised or group-based control-focused behavioral treatment (CFBT). All adult survivors (aged 18 and above) in Bhaktpur fulfilling the DSM-5 criteria for PTSD were randomly offered either individual NET-R or group CFBT over a period of 2 weeks at the survey base hotel.

Therapists were offered daily on-site supervision by the trainers. All 58 participants who had received a provisional diagnosis of PTSD were randomly split into two groups, with 29 receiving individual NET-R treatments and the other half receiving group CFBT twice, 2 weeks apart. According to the results of the study, CFBT groups based on self-help manuals may be more suitable for rural populations with lower levels of education. Local mental health personnel can be taught brief trauma therapy quickly [34].

#### **2.7 Psychosocial management in COVID-19**

With cooperation with the Nepal Association of Clinical Psychologists, WCO also assisted in the national adaptation and translation of the International Federation of the Red Cross Guideline on Remote Psychological First Aid. This publication acted as a manual for adapting the psychosocial support delivery to the particular issues faced by the epidemic. This procedure for delivering PFA remotely was explained to at least 120 counselors [34]. Since the COVID-19 pandemic, it is anticipated that mental

problems including depression and anxiety would become more common. Together with the Nepal Association of Clinical Psychologists, the WHO/International Committee of the Red Cross Guideline of Psychological First Aid was also translated and modified for the local environment. More than 40,000 people received psychosocial support in some way; more than 20,000 children and adolescents were offered crucial mental health support; and WHO Country Office for Nepal also hosted regular meetings (mental health subcluster meetings) to coordinate activities among partners. As a result of coordinated efforts, these outcomes were achieved [35].

#### **2.8 The multi-tiered CAMH intervention model**

In this intervention model, COVID-19 has been taken as one of the stressors that could adversely affect CAMH. The model incorporates basic psychosocial support for management of stress, tailored more toward COVID-19 related stress, but is not limited to it. This also includes identification and management of CAMH problems locally, and remotely through link with tele-consultation services. The same framework can be used for management of CAMH issues due to other stressors as well. This is a multi-tier model because it includes training of mental health professionals by master trainers through Training of Trainers (TOTs) sessions intervention model, COVID-19 has been taken as one of the stressors that could adversely affect CAMH. The model incorporates basic psychosocial support for management of stress, tailored more toward COVID- 19 related stress, but is not limited to it. This also includes identification and management of CAMH problems locally, and remotely through a link with tele-consultation services. The same framework can be used for management of CAMH issues due to other stressors as well. This is a multi-tier model because it includes training of mental health professionals by master trainers through Training of Trainers (TOTs) sessions (**Figure 2**). The strategy includes fundamental psychological assistance for stress management, albeit it is not just for COVID-19-related stress. This also involves local and distant

#### **Figure 2.**

*Flowchart of multi-tiered CAMH intervention phases.*

#### *Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal DOI: http://dx.doi.org/10.5772/intechopen.107470*

management of CAMH issues via connections to teleconsultation services. The same strategy was applied to managing CAMH symptoms brought on by additional stresses. This strategy has several levels (**Table 6**) since it includes the training of mental health professionals by master trainers through Training of Trainers (TOT) sessions, and the TOT recipients will then lead sessions with C&A, parents, teachers, and other caregivers.

The incorporation of psychotherapy in psychiatric training was noted by more than two-thirds of ECPs. The majority (67.6%) stated that it required training, while the majority (45%) stated that it only covers theoretical topics. About one-third had expertise in psychotherapy training, mostly in cognitive-behavioral treatment (CBT) (**Table 7**) [36].

It was considerably less frequent to have experience with interpersonal, family, or other treatments. **Table 8**, shows that among those who had received psychotherapy training, just half were happy with it. The duration of their psychiatric monitoring, which was stated to be elective by 50% of those who received it, was reportedly less than 50 hours [36].


#### **Table 6.**

*Multi-tiered CAMH intervention.*


#### **Table 7.**

*Demographic details and psychotherapy training.*


#### **Table 8.**

*Respondent's experience in psychotherapy.*

#### **3. Conclusions**

Since the war, a significant earthquake, and the COVID-19 epidemic, there have been increased reports of mental health problems. Panic disorder is one of the most prevalent mental health conditions. In addition to DSM-5, ICD-10 is the diagnostic code most frequently employed by practitioners. Panic disorder is one of the conditions that is frequently identified. Patients with panic disorder get both medication treatment and psychotherapy, as well as deep breathing exercises and progressive muscular relaxation. Cognitive behavior therapy is the therapy that is used the most frequently. A research report generally does not contain case studies of recognized panic disorder. Although there is a specific study on other problems, such as substance use disorders, schizophrenia, mood disorders, anxiety, and depression. On the subject of panic disorder particularly, the little study is done. In the country**'**s capital, there is a greater concentration of mental health services. Access to the service might be challenging for people who live in rural locations. As a result, there is a great probability

*Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal DOI: http://dx.doi.org/10.5772/intechopen.107470*

that they will not receive proper care in addition to the traditional healer. Small-scale surveys and one nationwide survey both demonstrate the prevalence of panic disorder. However, there is relatively little research done on counseling and psychotherapy. The need for psychotherapeutic management is growing at the moment, but there is a lack of public awareness. Long-term treatment built on academic training should be implemented as part of national health policy. More resources and attention should be devoted to mental health in Nepal than are currently being done.

#### **Acknowledgements**

The author would like to thank Dr. Arun Raj Kunwar MD, Head of Child and Adolescent Psychiatry Mental Health (CAPMH) Unit, Kanti Children's Hospital, Dr. Jasmin Ma MD, Project Manager, Child and Adolescent Psychiatry Mental Health (CAPMH) Unit, Kanti Children's Hospital, Child Workers in Nepal Concerned Centre (CWIN), Dr. Binod Dangal MD, Pasupati Chaulagain Memorial Hospital, and the team of Nepalese Association of Clinical Psychology.

#### **Conflict of interest**

"The authors declare no conflict of interest."

#### **Appendices and nomenclature**



### **Author details**

Bhupendra Singh Gurung Children and Adolescents Psychiatry Mental Health (CAPMH) Unit, Kanti Children's Hospital, Pasupati Chaulagain Memorial Hospital, Kathmandu, Nepal

\*Address all correspondence to: tamubhupendra@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal DOI: http://dx.doi.org/10.5772/intechopen.107470*

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[24] Shakya S, Psychiatric morbidity pattern in a patient after earthquake an at Tribhuvan University Teaching Hospital Nepal. Journal of the Institute of Medicine. 2017. p. 39. Available from: https://www.researchgate.net/ publication/324223472\_Psychiatric\_ morbidity\_pattern\_in\_patient\_after\_ earthquake\_at\_Tribhuvan\_University\_ Teaching\_Hospital\_Nepal [7/29/2022]

[25] Basnet S, Bhandari B, Gaire B, Sharma P, Shrestha RM. Depression, stress and anxiety among residents of Nepal during COVID-19 Lockdown. Journal of Advanced Academic Research. 2021;**8**(1):53-62

[26] Karki U, Dhonju G, Rai Y, Kunwar A. Child and Adolescent Mental Health in Nepal. 2019. p. 30. Available from: https://www.researchgate.net/ publication/335789345\_Child\_and\_ Adolescent\_Mental\_Health\_in\_Nepal. [7/28/2022]

[27] Kohrt B, Maharjan S, Timsina D, Griffith J. Applying Nepali ethnopsychology to psychotherapy for the treatment of mental illness and prevention of suicide among Bhutanese refugees. Annals of Anthropological Practice. 2012. p. 36. DOI: 10.1111/j.2153- 9588.2012.01094.x. Available from:

#### *Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal DOI: http://dx.doi.org/10.5772/intechopen.107470*

https://www.researchgate.net/ publication/264726087\_Applying\_ Nepali:ethnopsychology\_to\_ psychotherapy\_for\_the\_treatment\_of\_ mental\_illness\_and\_prevention\_of\_ suicide\_among\_Bhutanese\_refugees [8/1/2022]

[28] Available from: https://www. researchgate.net/publication/342436204\_ Using\_Psychotherapy\_with\_Torture\_ Survivors\_in\_Nepal

[29] Adhikari Y, Group Therapeutic Interventions in Nepal: Review of Research and Practices. 2022. Available from: https://www.researchgate. net/publication/360141999\_Group\_ Therapeutic\_Interventions\_In\_Nepal\_ Review\_Of\_Research\_And\_Practices

[30] mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings: Mental Health Gap Action Programme (mhGAP). Geneva: World Health Organization; 2010. Available from: https://www.ncbi.nlm.nih.gov/ books/NBK138690/

[31] Ramaiya MK, Fiorillo D, Regmi U, Robins CJ, Kohrt BA. A cultural adaptation of dialectical behavior therapy in Nepal. Cognitive and Behavioral Practice. 2017;24(4):428- 444. DOI: 10.1016/j.cbpra.2016.12.005. PMID: 29056846; PMCID: PMC5645023. [7/27/2022]

[32] Rana M. Issues and challenges of Nepal earthquake 2015 on mental health services. 2016. Available from: https://www.researchgate.net/ publication/336936782\_Issues\_and\_ Challenges\_of\_Nepal\_Earthquake\_2015\_ on\_Mental\_Health\_Services

[33] Jha A et al. Identification and treatment of Nepal 2015 earthquake survivors with posttraumatic stress disorder by nonspecialist volunteers: An exploratory cross-sectional study. Indian Journal of Psychiatry. 2017;**59**(3):320- 327. DOI: 10.4103/psychiatry. IndianJPsychiatry\_236\_16 7/26/2022

[34] Available from: https://www. who.int/about/accountability/ results/who-results-report-2020-mtr/ country-story/2020/nepal-mentalhealth#:~:text=More%20than%20 4%25%20of%20Nepal's,worsened%20 after%20COVID%2019%20pandemic

[35] Available from: https:// www.who.int/nepal/news/ detail/07-04-2021-addressing-themental-health-needs-of-the-nepalipeople-during-the-covid-19-pandemic [7/26/2022]

[36] Dhonju G, Kunwar A, Karki U, Devkota N, Bista I, Sah R. Identification and management of covid-19 related child and adolescent mental health problems: A multi-tier intervention model. Frontiers in Public Health. 2021. p. 8. DOI: 10.3389/ fpubh.2020.590002. Available from: https://www.researchgate.net/ publication/349047801\_Identification\_ and\_Management\_of\_COVID-19\_Related\_Child\_and\_Adolescent\_ Mental\_Health\_Problems\_A\_Multi-Tier\_Intervention\_Model

Section 2

## Panic in Childhood and Work Settings

#### **Chapter 3**

## Pediatric Panic Disorder, Review of Art Therapy as Supportive and Palliative Intervention

*Kaveh Moghaddam*

#### **Abstract**

A panic attack is defined as an episode of intense fear and anxiety including both physical symptoms and fearful thoughts. Panic disorder (PD) is diagnosed when a child has recurring panic attacks and ongoing concern about having more attacks for longer than 1 month. Children and teens with panic disorder sometimes avoid going places or avoid engaging in activities out of fear that a panic attack might occur. Although individual panic attacks are common, panic attacks that occur repeatedly are rare. They typically happen in only one to three percent of children and teens. Panic disorder usually does not affect children before the teenage years. Palliative and supportive interventions such as art therapy and family-based interventions are approaches that can help to reduction of this disorder's symptoms, especially in children and teens. In this chapter, these issues will be illustrated and the practical methods will be presented.

**Keywords:** panic disorder, palliative and supportive interventions, art therapy, pediatric

### **1. Introduction (definition of pediatric panic disorder)**


#### **1.1 The symptoms of panic disorder in children and teens**

The children and adolescents with PD can experience the symptoms such as heart palpitations, difficulty breathing, sweating, hot or cold flashes, dizziness, trembling, numbness or tingling in the limbs, fear of dying or losing control, feeling as if one is in a dream, fear of going crazy, and sometimes feeling like one needs to "escape" during a panic attack. Cognition of these symptoms is very important, because parents and families can inform the pediatric psychiatry emergency for primary intervention [2].

Panic symptoms often can emerge quickly (within 10 minutes). Sometimes, the symptoms will be last for minutes or hours. Also, the children or teens may avoid from being alone or participating in kindergarten, schools, parks, or other places and need their caregivers or parents for leaving home [2].

#### **1.2 Etiology, diagnosis, assessment and treatment**

According to studies and researches, panic disorder etiology can be emerged by the biological, environmental, and social factors which can lead to disorder. For example, fear of animals, sexual or physical abuse, post traumatic stress disorder (PTSD), aggressive parents, problems in schools, high schools, and preschools, parent's divorce, and mental trauma can lead to panic disorder in children and teens [2]. For the most valid assessment in these children and teens, the Multidimensional Anxiety Scale for Children, the Screen for Child Anxiety and Related Emotional Disorders (SCARED), and the Spence Children's Anxiety Scale (SCAS) can be applied [3–5]. Sometimes, additional assessments as projective tests such as CAT, DAP (Drawing a Person), HTP (House-Tree-Person), DAF (Drawing a Family), and DAS (Drawing a School) may be useful. Because, drawing and paintings have projective elements in which we can see fears, anxiety, and stress in the form of drawing, size, colors, etc. [6, 7].

For treatment and psychological intervention, CBT (cognitive-behavioral therapy) and family education for control of the symptoms are the most common interventions and will be useful. Sometimes, medication may be necessary, especially in the acute cases [2].

#### **2. Psychosocial problems and art therapy as a palliative and supportive intervention (family-based art therapy)**

Psychosocial problems are highly prevalent among children and adolescents with an estimated prevalence of 10–20% worldwide [8, 9]. These problems can severely interfere with everyday functioning [10, 11].

Psychosocial problems in children and adolescents are a considerable expense to society and an important reason for using health care. But, most of all psychosocial problems can have a major impact on the future of the child's life [12]. For improvement of the psychological problems, especially anxiety, depression, and panic disorders, we can use cognition therapy, behavioral therapy, CBT, psychoanalytic intervention, and family counseling. But sometimes, one of the most important approaches in which children and teens with psychological problems can benefit is "Art Therapy" or AT [6, 7].

AT is one of the most important supportive-palliative interventions usually called family-based art therapy in which the children and adolescences can achieve their

#### *Pediatric Panic Disorder, Review of Art Therapy as Supportive and Palliative Intervention DOI: http://dx.doi.org/10.5772/intechopen.107007*

main abilities before their psychological problems, and also their families and parents participate in art therapy sessions actively [6, 13, 14]. Traditionally, AT is (among others) used to improve self-esteem and self-awareness, cultivate emotional resilience, enhance social skills, and reduce distress [15].

AT is a dynamic approach in which client and therapist create and will be created as soon as possible. In AT, the process in which changes are occurred will be more important and the art making result is less important, because all of the psychological changes will be occurred in the dynamic art process. Then, art therapist and art modalities such as painting, clay, crafts, and collage are the facilitators [16]. Also, art therapy approaches can be applied from infancy to adults, and the parents (in the most of cases "Mothers") have an important role in the art therapy process as a dynamic process in which the relationship between child and his or her parents will be reinforced [17, 18].

#### **2.1 Art therapy approaches and the process relieve stress in panic and anxiety**

We can explain the three art therapy approaches as follows: the humanistic art therapy, cognitive-behavioral art therapy, and expressive art therapy. All of these approaches are as palliative and supportive interventions which can be applied in the treatment of anxiety and panic attacks in children and adults. In the first approach which be called as the third force psychology, the clients are seen as a human not as a patient, because they are persons who suffer from a lot of problems such as anxiety and depression and the psychotherapists and art therapists have to support and help them by self-actualization. Josef Gary, an art therapist, has performed this approach according to three factors: 1. emphasis on solving the life problems, 2. encourage to self-actualization via creative expression, and 3. emphasis on self-esteem and attachment in the private relationships and social interaction and also survey for the life goals. Cognitive-behavioral art therapy is the second approach in which the cognition of the client will be changed via art therapy process, and finally he or she can achieve to self-actualization. And finally, in the third approach, art therapist can apply a large range of art modalities such as drama, dance/movement, music, and poetry/writing for the improvement of creativity in client and self-expression. Therefore, the third approach is called creative art therapy. The client's family and parents can involve in all of the art therapy approaches mentioned earlier. Therefore, we can call them as family-based art therapy intervention which can be applied for all the children and teens with psychological disorders such as panic, anxiety, and learning disorders and children with special needs. All of the mentioned art therapy approaches have common therapeutic objectives such as improvement of self-esteem, self-actualization, self-awareness, self-control, reinforcement of "ego," and projection of negative thoughts and feelings in children and teens via art works and activities [6, 13, 14].

Some of the art therapy techniques which can be applied for children and teens with panic and anxiety disorders are as follows: family painting, free association painting, collage, crafts, and clay. In all of these techniques, art therapist applies art modality instead of talking with client directly. Because, the children and teens can talk about their feelings by paintings and the other visual arts better than direct talking [14, 16]. **Figures 1**–**3** show the art works of clients who suffer from panic and anxiety. They have been referred, and both of them have participated in art therapy sessions along with their parents. Therefore, their art therapy sessions contained family-based art therapy program [6]. In all the techniques mentioned before such

**Figure 1.** *Sheida, 9 years old girl, who illustrates her mother in her paintings.*

**Figure 2.** *Maziar, 17 years old boy, who illustrates fears and anxiety in his paintings.*

as family painting, free association painting, collage, crafts, and clay, the therapist has focused on the client's changes during the art therapy sessions. They emphasize on therapeutic objectives such as improvement of self-esteem, self-actualization, self-awareness, self-control and reinforcement of "ego," and projection of negative thoughts and feelings in children and teens via art works and activities. Also, the client's family members and parents (especially mothers) are involved in the art therapy process actively [6, 7].

*Pediatric Panic Disorder, Review of Art Therapy as Supportive and Palliative Intervention DOI: http://dx.doi.org/10.5772/intechopen.107007*

#### **Figure 3.** *Maziar and his fears.*

Now the two case studies which have been investigated by the author are as follows:

Case study 1.

Sheida is a 9-year-old girl who suffers from panic disorder and has experienced anxiety since 2014. She had avoided from being in popular places, and withdrawal, anxiety, dizziness, trembling, numbness or tingling in the limbs, fear of dying or losing control, and feeling as if one is in a dream in this client could be observed. All of these symptoms caused secondary problems such as academic and family interaction problems. During art therapy sessions, creative art therapy was applied. She liked music and painting together. At first, she has been evaluated by projective psychological tests, and then family-based art therapy program was performed for her and her parents. Her mother had very important role in her tension release because she has applied family painting and free paintings and collage actively. They drew the fearful situations in their paintings and drawings and talked about their emotions together. The art therapist could facilitate the process of emotional release by talking about her paintings and help her in better cognition of ego. After five sessions, Sheida could overcome the loss of control and withdrawal. Also, she could participate in peer group activities such as painting and clay. Now, it seems that Sheida could show better selfesteem, self-control, and self-awareness and can control her anxiety by art making activities [6, 7].

Case study 2.

Maziar is a 17-year-old boy who lives with his parents, and he shows pathological phobia about animals like cat, dog, and birds. This kind of phobia leads to panic attacks, and he could not be calmed. He was resisting about attendance in park, streets, and crowded places without his parents and also showed obsession and stereotypical behaviors which disrupt his function. After necessary projective assessments, art therapy process special creative art therapy approach has been applied for him and his parents for 2 years. At first, he was illustrating fearful items like animals in his paintings, and then his parent (mother) involved in family-based art therapy program actively. He could talk about his fears and anxiety about animals step by step, and he could show better self-esteem and self-control while dealing with animals. Now, he has better self-esteem and shows interest in group plays with peers. **Figures 2** and **3** show his anxiety and fears [6, 7].

#### **2.2 Literature review about art therapy and anxiety disorder**

Some researchers have focused on the effectiveness of art therapy in anxiety and panic disorders such as Albertini who explain art therapy program in the treatment of agoraphobia and applying free paintings which can help clients for emotional expression [19], or Griffith who has explained brief cognitive-behavioral art therapy for anxiety disorders in her MS thesis. She has illustrated that art therapy can be useful in insight and cognition change in clients with panic and anxiety disorder. Indeed, she has applied cognitive-behavioral art therapy approach [20]. Also, Rosal has explained cognitive-behavioral art therapy in the research which can be useful for clients with anxiety [21]. Daneshmandi et al. have emphasized the effectiveness of family-based art therapy on children with generalized anxiety disorder (GAD) in their research [22]. Kheradmand et al. have investigated the effectiveness of art therapy on mental disorders such as anxiety and panic disorders in children [23]. Also, Hinz has investigated the effectiveness of art therapy assessment and treatment planning as an expressive therapy [24].

#### **3. Conclusion**

Panic disorder is one of the psychological disorders which can be observed in children and teens. Heart palpitations, difficulty breathing, sweating, hot or cold flashes, dizziness, trembling, numbness or tingling in the limbs, fear of dying or losing control, feeling as if one is in a dream, fear of going crazy, and sometimes feeling like one needs to "escape" are the symptoms which can be observed during panic attacks in children and teens.

For the assessment of these children and teens, the Multidimensional Anxiety Scale for Children, the Screen for Child Anxiety and Related Emotional Disorders (SCARED), and the Spence Children's Anxiety Scale (SCAS) can be applied. Not only CBT is one of the most common interventions which can be used for children and teens who suffer from panic disorder, but also art therapy as a palliative and supportive intervention can be useful for them. The common art mediums used within the art therapy process include painting, drawing, sculpture, collage, and photography. Three art therapy approaches are as follows: the humanistic art therapy, cognitivebehavioral art therapy, and expressive art therapy which all of them can be effective in panic and anxiety disorders. According to studies and researches, in art therapy process, art therapist can change the cognition, emotion, and behavior of the client by art modalities. Art therapy can be useful for children and teens too, because they can show their fears, anxiety, and emotions better than adults by paintings and other visual arts. Therefore, their paintings and drawings contain the meaningful messages which can be interpreted by the psychologist and art therapists. For the best outcomes of the art therapy, it can be followed by the children's family and parents at home as the family-based art therapy intervention. Finally, it is suggested that for the best anxiety and panic management, art therapy interventions are applied beside the other interventions such as play therapy, cognition therapy, and psychotherapy at clinics and schools.

*Pediatric Panic Disorder, Review of Art Therapy as Supportive and Palliative Intervention DOI: http://dx.doi.org/10.5772/intechopen.107007*

### **A. Appendices**

### **A.1 Anxiety**

Art therapy Art therapy process Cognitive-behavioral art therapy Expressive art therapy Family-based art therapy Humanistic art therapy Self-expression Self-awareness Stress Supportive and palliative interventions Panic disorder

### **Author details**

Kaveh Moghaddam Exceptional Children Psychology and Art Therapist, Assistant Professor of Islamic Azad University, Tehran, Iran

\*Address all correspondence to: kaveh\_m\_2000@yahoo.com; dockm1358@yahoo.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Andrew L, Hardy S, Saleh A, Ryee M, Willing L. Pediatric panic disorder. Available from: http://www. childrensnational.org. 2021

[2] Ganji M. Abnormal Psychology Based on DSM –V. 3rd ed. Tehran, Iran: Savalan Publication; 2021. pp. 707-710

[3] March JS, Parker JD, Sullivan K, Stallings P, Conners CK. The multidimensional anxiety scale for children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;**36**(4):554-565

[4] Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the screen for child anxiety related emotional disorders (SCARED): A replication study. Journal of the American Academy of Child and Adolescent Psychiatry. 1999;**38**(10):1230-1236

[5] Spence SH. A measure of anxiety symptoms among children. Behaviour Research and Therapy. 1998;**36**:545-566

[6] Moghaddam K. editor. Art Tehrapy and Anxiety. Workshop of the First Razavi International Anxiety Congress; Mashhad Iran; 2012

[7] Moghaddam K. editor. The role of painting and drawing on evaluation and treatment of anxiety in children. First Razavi International Anxiety Congress; Mashhad. Iran. 8-9 Oct 2012

[8] Kieling C, Baker-Henningham H, Belfer M, Conti G, Ertem I, Omigbodun O, et al. Child and adolescent mental health worldwide: Evidence for action. The Lancet. 2011;**378**(9801):1515-1525

[9] Child and adolescent mental health. World Health Organization. 2018 [cited 2018]

[10] Bhosale S, Singru S, Khismatrao D. Study of psychosocial problems among adolescent students in Pune, India. Al Ameen Journal of Medical Sciences. 2015;**8**(2):150-155

[11] Veldman K, Reijneveld SA, Ortiz JA, Verhulst FC, Bültmann U. Mental health trajectories from childhood to young adulthood affect the educational and employment status of young adults: Results from the TRAILS study. Journal of Epidemiology and Community Health. 2015;**69**(6):588-593

[12] Smith JP, Smith GC. Long-term economic costs of psychological problems during childhood. Social Science & Medicine. 2010;**71**(1):110-115

[13] Moghaddam K. Painting and Clay Therapy in Children and Adolescents with Autism Spectrum Disorder. Tehran. Iran: Narvan Publication; 2021. pp. 44-53

[14] Moghaddam K. Design and Effectiveness of the Family-based Art Therapy Program on the Marital Satisfaction of Parents,Verbal Skills, Social Interactions and Stereptypical Behaviors of the Autistic Children [Science and Research Branch]. Tehran: Islamic Azad University; 2015

[15] Facts, figures and helpful resources from AATA (American Art Therapy Association). Available from: https://multibriefs.com/briefs/aata/ review122117.pdf2017

*Pediatric Panic Disorder, Review of Art Therapy as Supportive and Palliative Intervention DOI: http://dx.doi.org/10.5772/intechopen.107007*

[16] Zadeh Mohammadi A. Art Therapy, an Introduction of Art Therapy Special for Groups. Tehran, Iran: Ghatreh Publication; 2010. pp. 18-20

[17] Case C, Dalley T. Art Therapy with Children From Infancy to Adolescence. USA & UK, Newyork & London: Routledge; 2008. pp. 20-24

[18] Case C, Dalley T. Working with Children in Art Therapy. 2nd ed. UK, London: Routledge; 2006. pp. 30-31

[19] Albertini C. Contribution of art therapy in the treatment of agoraphobia with panic disorder USA. American Journal of Art Therapy. 2001;**40**(2):137- 147 Online ISSN:0007-4764

[20] Grifith FJ. Brief cognitive behavioral art therapy for anxiety disorders. [Thesis for MS] USA: Yale University; 2013.

[21] Rosal M. Cognitive behavioral art therapy, [Thesis in MS]. USA: Florida State University; 2001

[22] Danshmandi E, Jahan F. The effectiveness of family-centred art therapy on anxiety sensitivity, inefficient attitudes, and coping of students with generalizad anxiety disorder (GAD). Journal of Exceptional Children Empowerment. 2021;**12.4**(37):38-48. DOI: 10.22034/ CECIRANJ.2021.259157.1525

[23] Kheradmand F, Abdollahin D, Mahmoodi R. The effectivenss of art therapy on mental disorders. Available from: http://Civilica.com/doc/778635 (OSConf 02-167)

[24] Hinz L. Enhancing art therapy assessment & treatment planning with the expressive therapies continuum. [Thesis]. USA: Dominican University of California; 2016

#### **Chapter 4**

## Panic Disorder and Burnout in the Workplace: Review of the Evidence and Recommendations for Future Research

*Olga Lainidi, Eva Tzioti, Maria Spiliou, Panagiota Koutsimani and Anthony Montgomery*

#### **Abstract**

Both panic disorders and burnout are significant challenges in the workplace. However, to date knowledge in these areas has progressed in parallel and there have been few attempts to systematically connect these overlapping syndromes. The objectives of this chapter are to address this gap in the literature by addressing the following: how panic disorder symptoms can be masked under the "burnout-umbrella" meaning they can go under-the-radar, how the overlap between sub-clinical anxiety physical symptoms and panic disorder symptoms might lead to the latter remaining undiagnosed, and the extent to which burnout can contribute to experiencing panic disorder symptoms. Particularly, we will focus on professions that require high levels of emotional labor (e.g., healthcare employees, teaching professions) and which are characterized by pathological altruism, where individuals feel that they are not allowed to experience a panic attack in their work environment—and if they do, they will have to hide it. Moreover, such hiding leads to increased feelings of guilt and apathy, which in turn increases the likelihood of a depressive symptomatology to be developed. Finally, we argue that the field is hampered by the fact that employees are less likely to report the real intensity of their anxiety and stress-related symptoms.

**Keywords:** panic attack, burnout, anxiety, workplace stress, workplace well-being

#### **1. Introduction**

Panic disorder is a significant challenge in the workplace. Personal stories of experiencing a panic attack at work or because of work-related stressors can be easily found in anecdotal evidence, blogs, and informal conversations. However, the literature looking directly into the relationship between work stressors and panic disorder is scarce, and we believe does not reflect the real extent of the issue nor what workrelated problems can be hidden behind employees' panic attacks. For example, the concept of "workplace phobia" (WP) – which from a clinical perspective is characterized by similar symptoms as agoraphobia – however, has had very limited research

interest, as a quick search with no time restrictions on some of the main databases (e.g., Pub Med) yields only eight results with the words "workplace phobia" in their title. While WP incorporates psychophysiological symptoms that manifest upon exposure (*in vivo* or *in vitro*) to the workplace, it is considered to be mainly characterized by avoidant behaviors and there is insufficient evidence to consider how often it might manifest in the form of panic attacks [1, 2].

Asai et al. [3] explored the relationships between job stressors (e.g., job strain; effort reward imbalance; workplace social support) and panic attack/panic disorder in a Japanese working population. Panic attacks/disorders were measured by selfreport. The results indicated that for the Japanese working population, high effort/ reward imbalance is more likely to lead to PA/PD compared with low effort/reward imbalance. Of course, the clinical psychology literature has indicated cultural differences in the definitions and experiences of anxiety among different countries that might result from the differences in sociocultural norms, values, and expectations [4]. As such, findings on the subject might differ by different cultures/countries.

More is known about the prevalence of panic attacks among healthcare professional after the COVID-19 pandemic compared with either pre-pandemic times or other occupations. Alonso et al., [5] in their longitudinal study on the impact of COVID-19 on Spanish healthcare workers, measured probable current mental disorders including major depressive disorder (MDD), Generalized Anxiety Disorder (GAD), Post-Traumatic Stress Disorder (PTSD), and Substance Used Disorders (SUDs) and work-related factors (e.g., care center preparedness, weekly working hours) among other variables. Panic attacks were measured as the number of panic attacks experienced in the 30 days prior to the interview. The prevalence of Panic Attacks was 23.9% at baseline and 19.5% at 4-month follow-up; MDD, GAD, and PTSD followed a similar tendency, however, there was a slight increase in selfreported SUDs. Panic attacks have also been recently studied among teachers with evidence suggesting that teachers may suffer from panic attacks and anxiety and often feel alone and unsupported [6].

In the following sections, we identify some reasons behind the lack of clear evidence on the relationship between work stressors and panic attacks as well as potential ways that this kind of evidence could potentially help us understand better the literature around work stress and burnout.

#### **2. Job Burnout and panic disorder: the missing links**

#### **2.1 Job Burnout**

The increasing evidence on occupational burnout among different professional groups has highlighted that burnout is potentially a "human" aspect of work, meaning that all individuals might experience burnout symptoms at some point in their life in most occupations. While this book focuses on panic disorder, we believe that we cannot position panic disorder in the workplace well-being literature without discussing the relationship between burnout and anxiety. Though experiences of burnout have appeared across cultures and history for a very long time, the systematic study of burnout did not start until the 1970s, when Freudenberger [7] described occupational burnout for the first time, focusing on the experiences of weariness and/or exhaustion as a result of the work demands in one's occupation. Christina Maslach later defined burnout as a psychological syndrome that involves a prolonged response to chronic

#### *Panic Disorder and Burnout in the Workplace: Review of the Evidence and Recommendations… DOI: http://dx.doi.org/10.5772/intechopen.107533*

emotional and interpersonal stressors on the job [8]. The three key dimensions of job burnout are exhaustion, feelings of cynicism/depersonalization, and a sense of professional inefficacy/lack of accomplishment [9]. Exhaustion is the individual stress dimension of burnout, and it refers to feelings of being physically overextended and depleted of one's emotional resources; cynicism (or depersonalization) refers to a negative, callous, or excessively detached response to other people; and inefficacy (or lack of accomplishment) refers to a decline in one's feelings of competence and successful achievement in one's work [10].

There is significant debate over the "nature" of burnout; in a nutshell, some researchers support the conceptualization of burnout as a *psychological condition that reflects some disordered functioning in the individual*, and as such, should be approached as a psychological disorder [11]. Thus, we should advocate for solutions on the individual level. Other researchers, however, support that burnout is an *organizational problem* [12]; thus, we advocate for solutions on the organizational level. Over time, there have been several suggestions regarding burnout being the same as or an expression of *depression or/and anxiety or/and stress*. There is still some disagreement over the causes and mechanisms of job burnout, as not everyone gets burnt out by doing the same job in the same organization; it does not take the same time for all individuals to experience feelings of burnout; people respond to burnout differently; some professions might exacerbate either of the dimensions more or faster than others.

Despite the literature suggesting that burnout should be viewed as a psychological condition, it is not classified as a disorder by the American Psychiatric Association in their latest Diagnostic and Statistical Manual [13]. However, it has been added in the latest International Disease Classification (ICD-11) by the World Health Organization [14] as a "syndrome that results from chronic workplace stress that has not been successfully managed," providing the three dimensions of exhaustion, cynicism, and professional efficacy as its manifestation. As it is included in the section related to employment/unemployment, it has been suggested that the ICD-11 definition reflects an occupational phenomenon and not a medical condition, and as such the emphasis should be put on the work environment and the fact that job demands and resources are in a mismatch, thus not allowing the person to do their work in a meaningful and non-distressing way.

#### **2.2 Burnout and panic disorder**

As panic attack disorder is one of the anxiety disorders [13], in order to better understand the literature around panic disorder in the workplace, it is important that we first briefly discuss the relationship between job burnout and anxiety. To this end, both burnout and anxiety share a significant positive relationship with neuroticism [15]—a personality trait that indicates emotional instability and sensitivity to stress. Thus, the higher the neuroticism, the more likely that somebody will experience anxiety and/or burnout. Extroversion, on the other hand, has been found to have a negative relationship with burnout and with anxiety [15]; thus, the more extroverted someone is, the less likely it is for them to experience anxiety and/or burnout. Metaanalytic findings have also suggested that job burnout is a predictor of 12 somatic diseases, including coronary heart disease, headaches, respiratory diseases, and early mortality (before the age of 45 years old) [16]. This increases the need for further research on the extent to which stress-response mechanisms are in fact underlying burnout in a way similar to anxiety disorders. So, if the two actually share important physiological and psychological mechanisms, can job burnout exacerbate the

experience of panic attacks? Can work contribute so much to anxiety that employees experience panic attacks in or out of the workplace?

The direct evidence linking job burnout and panic disorder is limited [17]. From a physiological point of view, burnout and panic disorder share common neural circuits as frontal and limbic brain structures appear to underlie both syndromes. Indeed, meta-analytic findings show that there is a significant relationship between burnout and anxiety [18] while there has been some evidence in favor of a common neurobiological basis. A systematic review regarding the potential impact of burnout on limbic brain structures has concluded that there is an impact in terms of HPA dysregulation (hypothalamus-pituitary-adrenal axis), impaired neurogenesis, and limbic structures atrophy; this could be an indication that stress is an integral part of burnout from a physiological perspective that could be further expressed in the form of a comorbid anxiety disorder, especially when no other measures are taken to relieve the stress caused by burnout [19].

Four key brain regions that are implicated in burnout and panic disorder are the prefrontal cortex (PFC), the cingulate cortex, the amygdala, and the hippocampus.

Burned-out employees and individuals suffering from panic attack disorder show deactivation of the prefrontal and cingulate cortex, reduced hippocampal activation, and an increased amygdala engagement [20–22]. The PFC is mainly responsible for executive functions such as inhibition, working memory, and decision-making; a set of cognitive functions that support goal-directed behavior and adaptive responses—thus, it is no surprise that a fundamental symptom of burnout and panic attack disorder is the sense of lack of control. The cingulate cortex is involved—among others—in the formation and processing of emotions; the hippocampus is a key area for learning and memory while the amygdala is mostly known about its role in emotional responses. Disconnection between the frontal and limbic brain regions results in behaviors and emotions common to burnout and panic attack disorder as well (e.g., lack of control, feeling of detachment, difficulty in regulating one's emotions), as well as to anxiety disorders generally.

These physiological responses are mediated by "bottom-up" and "top-down" processes. The "bottom-up" process, as the term suggests, involves the ventral nervous system; i.e., the amygdala and the hypothalamus. The amygdala is responsible for appraising and detecting threatening stimuli and regulates the hypothalamus, which, in turn, controls the neuroendocrine response toward the stressful stimulus [23]. The "top-down" (i.e., the dorsal nervous system) process includes the PFC and hippocampal brain regions. One major role of the PFC is to regulate the neuroendocrine response, the effects of the stress hormones in the amygdala and the hippocampus [24], and negative emotions [25]. In layman's terms, when the working environment cultivates stressful situations (e.g., strict deadlines, toxic supervisors/coworkers etc.), the bottom-up network perceives these situations as threats that need to be dealt with by fighting or fleeing. Prolonged activation of the bottom-up network leads to a dysregulation of the top-down network; thus, the individual is no longer able to evaluate and manage the environmental stimuli in a more rational manner. Meanwhile, extended stressful periods ultimately result in an under-activated top-down network that is unable to effectively assess the incoming environmental stimuli and hence, inhibit the over-activation of the bottom-up network. This process leads to a limited ability in appraising the (in)significance of the environmental stimuli; making the individual more vulnerable to the stressful situations they encounter in both their work and personal lives, and thus more susceptible in burnout and/or panic attacks.

All in all, this underlying common physiological mechanism not only indicates that the onset of one of the two disorders can exacerbate (or initiate) the symptoms of

#### *Panic Disorder and Burnout in the Workplace: Review of the Evidence and Recommendations… DOI: http://dx.doi.org/10.5772/intechopen.107533*

the other disorder, but also suggests that the distinction between the two syndromes based on a limited array of diagnostic techniques can be a tricky and difficult task. Neuroimaging techniques, for instance, are an essential diagnostic tool in the field of neuroscience as they aid experts to gain a better understanding of the neurobiological mechanisms responsible for the expression of a set of behaviors, assisting this way the differential diagnosis. All the same, one could argue that both burnout and panic disorder fall under the umbrella of stress, hence the common neurobiological background of the two syndromes and the likelihood of the two syndromes co-occurring come as no surprise. An observation that also raises the question if and in what way and degree burnout and panic attack disorder are differentiated from each other. Therefore, the shared mechanism between the two syndromes demands careful and detailed screening with the use of thorough clinical interviews for detecting burnout or panic disorder or a potential comorbidity of the two, if burnout is approached as a psychological disorder (based on the previously discussed debate on the nature of burnout). On the other hand, approaching burnout as an organizational problem allows considering the possibility of burnout being a cause of stress–and thus a cause of panic attacks. The context of one's thoughts, emotions, and behavior should be taken into consideration when assessing for psychological disorders that fall under the spectrum of anxiety. Indicatively, [17] reported a significant positive relationship between job burnout and panic disorders among nurses in Canada; nurses reporting higher burnout levels were 23 times more likely to screen positive for panic disorder while 20.3% of Canadian nurses were positively screened for panic disorder. However, the cross-sectional design of the study does not provide information regarding the causal linkages between the two syndromes. That is, are burned-out employees more sensitive to panic attacks; and if so, how burnout severity and duration affect the onset/duration of these panic attacks? Is there a specific burnout dimension that shows stronger associations with panic attack disorder? On the other hand, do individuals who have been diagnosed with panic attack disorder develop burnout more often compared with the individuals with no such diagnosis—perhaps, due to the emotional wear out that accompanies (frequent) panic attacks? We need to look further into the relationship between burnout and panic attack disorder.

The aforementioned ICD-11 classification [14] highlights that when "diagnosing" burnout, it is important to rule out any potential adjustment disorders; anxiety disorders and mood disorders (i.e., depression). Meanwhile, in the literature it remains unclear whether and to what extent burnout can be differentiated from anxiety or depression as well as whether burnout can "exist" without some level of anxiety and/or depressive symptoms, even of subclinical level. The activation of the HPA axis has also been linked to anticipatory anxiety, which in turn can increase the probability of a panic attack [26]. Research on the relationship between anxiety and job burnout, however, is not "anxietydisorder" specific, in that research related to occupational health and workplace wellbeing mostly consists of self-reported measures of anxiety (e.g., HADS, STAI, etc.) [18], thus measuring the very common psychological condition of responding to stressors on a cognitive, emotional, behavioral, or physiological level in general, and the state/trait anxiety dimensions are usually not controlled for.

#### *2.2.1 How can burnout be linked to panic disorder?*

Though burnout seems to share variance with depression, anxiety and anxietyrelated disorders [18, 19], existing evidence indicates that burnout and anxiety are not overlapping constructs [18]; this suggests that this is probably the case with burnout

and panic disorder as well. As mentioned before, very little has been reported on the relationship between burnout and panic attacks, though we believe that further exploration of that relationship could help us better understand the nature of burnout and its relationship to anxiety. One of the main difficulties in burnout research is the inability to identify when somebody starts experiencing burnout symptoms, as these do not appear in an acute form and can build up over days, weeks, months, or years of exposure to a profession or a work environment or work-related stressors. Moreover, not all professionals in the same profession experience burnout working in different organizations and not all employees of the same organization experience burnout [27]—as burnout highly varies within and between individuals. We believe that exploring the relationship between burnout and panic attacks/disorder can provide some significant benefits that can shed more light on the burnout literature. For example, unlike burnout, panic attacks are "episodic," which means that it is probably easier for an employee to recall when they experienced their first panic attack compared with when they started experiencing burnout symptoms. The symptoms experienced during a panic attack are probably clearer and more agreed upon by clinicians and researchers (see chapter of this book on what is a panic attack) compared with those of burnout, which makes identifying burnout more challenging than diagnosing panic attacks. On many occasions, employees might not be aware that they have started to feel burnt out until the subjective experience of their work starts having a spillover effect on other aspects of their life (e.g., quality of sleep; health-related behaviors; interpersonal stress, depressed/cynical mood, etc.). However, it is more likely that they will start noticing physical symptoms of stress that might resemble to those of a panic attack, even if they have not experienced a complete panic attack yet—and not consider that experience as being necessarily work-driven. This might also contribute to our understanding of the burnout-anxiety-depression timeline as still it is not clear which comes first: anxiety, burnout, or depression; and whether these appear in some chronological order or as a vicious cycle with stress being in the center. For example, do entry-level employees experience physical stress symptoms more intensely than their senior counterparts, if the latter are emotionally exhausted and more cynical toward their job demands (i.e., higher burnout level)?

Obviously, the aforementioned relationships are more complicated than linear, direct effects, and we do not expect that one pathway might be sufficient to explain how the experience of panic attack symptoms relates to burnout or vice versa. To that end, we propose three initial pathways as potential starting points. These are merely suggestions and hypotheses aiming to drive an interest in the relationship between burnout and panic attack symptomatology.

The first pathway is related to the sense of control/autonomy that employees might experience in their work environment. Karasek 's [28] model of workplace stress—the demand-control model—suggests that while high job expectations are not inherently detrimental, they might cause stress if they are combined with little room for control. The importance of having a sense of control as a psychological resource is known to have stress-buffering effects in and out of the work-related literature. Many researchers have since corroborated these findings; when given greater job control, employees exhibit lower levels of anxiety and role overload, but when given less job control, employees exhibit higher levels of worry and a sense of role overload [29, 30]. Low or no sense of control over one's environment (work) can be a significant stressor that could possibly initiate a strong stress response leading to panic attack symptoms. This is expected to be more common among lower-ranking workers, who usually have a lot less control and autonomy. Interestingly, such a hypothesis was tested on

#### *Panic Disorder and Burnout in the Workplace: Review of the Evidence and Recommendations… DOI: http://dx.doi.org/10.5772/intechopen.107533*

non-primates, showing an interesting link between social rank and stress. In particular, studying baboons, Sapolsky [31] found that lower ranking individuals in a society of baboons that had less control due to their hierarchy, had also higher levels of cortisol, the stress hormone. Building on this rationale, a study from Harvard in 2022 [32] came to test these findings in the workplace, by researching the relationship between leaders, control, and stress. Up to that point being a leader had been portrayed as being extremely stressful in both the social scientific and practitioner literatures, as the higher rank one holds in their workplace, the higher the responsibilities—and the higher the expected levels of stress. However, research on leaders' physiology came to contradict that. Leaders have a unique psychological resource—a sense of control—that may act as a stress-reduction mechanism and was seen by their lower cortisol levels and self-reports on stress. To that end, further research into biomarkers of stress, experiences of panic attack symptoms, and screening for panic disorder among workers with low sense of control/autonomy is required to examine whether looking into physiological stress due to low control/autonomy will actually contribute to redesigning jobs and healthy workplaces for lower-ranking positions more effectively than diagnosing burnout has. What is more, cognitive neuroscience could also focus on the extent to which brain functioning and thus, cognitive functioning affect stress responses; e.g., do employees with low sense of control demonstrate by nature a "top-down" deactivation (and thus, lower executive function skills) and "bottom-up" over-activation?

The second pathway looks at work-related stress beyond "working in a stressful environment" but in fact as a source of "survival anxiety," since job security is critical for meeting the foundational physiological and psychological needs in order to survive. A recent study on the effects of income and job loss on mental health indicated that panic attacks are significantly more common among individuals experiencing income loss. de Miquel et al. [33] focused specifically on employees with job loss and income loss during the COVID-19 Pandemic indicating that approximately 11% of the participants had experienced at least one panic attack in the last 30 days and income loss was identified as a significant predictor of panic attacks with the highest odds ratio compared to depression and PTSD. The relationship between income loss and panic attacks remained significant in the model adjusting for age, gender, marital status, and educational level. For people experiencing income loss, the probability of experiencing at least one panic attack was 39% higher compared with individuals who did not experience an income loss. Panic attacks are, thus, a stress response to the uncertainty and insecurity caused by a work-related income loss; this highlights the overarching effect of work-related stressors as for a majority of people work-related income is crucial for survival, as perceived financial stress partially mediated the relationship between income loss and presence of panic attacks. This study highlighted that these workrelated stressors are not only related to the work environment (e.g., toxic leadership, relationships with colleagues, etc.) but also to the realistic role that having a job plays in having an income that allows for meeting physiological and psychological needs. To that end, panic attack symptoms are expected to be more common among employees with low job security; minimum wage employees; employees who are at risk of job loss and/or income loss/reduction and could be ignored or misdiagnosed as burnout due to the emotional exhaustion or pessimist stance toward their work.

The third pathway is related to the aspects of emotional and personal involvement in one's profession through what is known as emotional labor. Emotional labor is based on the idea that employees are often forced to display emotions at odds with what they truly feel and is the result of the groundbreaking work of sociologist

Arlie Hochschild [34]. A good example for the understanding of emotional labor is the teaching profession. Being a teacher implies a considerable amount of personal involvement, availability, and constant interaction with others. Further occupational stressors may also be present, such as tremendous workloads [6] and imbalance between social and emotional demands [35]. Teachers who have higher job involvement are significantly more likely to develop anxiety disorder symptoms [36]. In addition, burnout symptoms are commonly developed among individuals in teaching positions; however, it is not something that is openly discussed due to the stigma around it. Maslach's three-dimensional model of burnout [8] applies for teaching positions as well, involving emotional exhaustion, depersonalization, reduced productivity, and decreased personal accomplishment. These represent great losses in the educational field for both teachers and learners. However, teachers are invited to control and regulate their emotional expressions in the classroom, and this involves tremendous effort for emotional suppression and regulation, which might lead to increased stress levels that could result in panic attacks. The latter might happen in the workplace or be "brought home"; in the latter case, it is less likely for the individual to identify the panic attack as work-related. Working as a teacher involves maintaining professionalism through all kinds of interactions, inside and outside the classroom. The pressure to remain constantly strong and emotionally available and the feeling of failure when this cannot be delivered have a great impact in teachers' well-being. Furthermore, it is very common that expressing emotional exhaustion, work overload, and burnout carries a big amount of guilt, as these are assumed to be part of the job. This might sometimes mean that teaching positions require plenty of personal time and dedication, which are frequently taken in the cost of private life. Most of these negative emotions and feelings, however, cannot not be displayed and experienced at work, where teachers are expected to display emotions that are aligned with their professional identity, leading a form of a dark cycle where burnout is symptomatic of anxiety and panic attacks, trying to remain professional in the classroom.

#### **3. Are work-related panic attacks going under the radar?**

The answer is YES—but it is difficult to demonstrate this via empirical research, and our supposition is corroborated by anecdotal evidence, informal conversations and "off the record" interviews, pop-psychology articles, and blog pieces. While there is an increasing research interest regarding the relationship between anxiety and workplace well-being and work-place stressors, the specificity of the scientific knowledge on the topic is significantly limited by (some) critical factors:

#### **3.1 Research tools measuring anxiety "in general"—and not always!**

Most of the literature looking into anxiety/stress in the workplace fails to report on experiences of physiological stress symptoms, including panic attack symptomatology. We will use the well-known Hospital Anxiety Depression Scale (HADS) [37] as an example to further explain. HADS is probably the most common tool used to measure anxiety in studies related to workplace well-being and anxiety in the workplace; meta-analytic findings suggest that studies that used the HADS reported stronger relationships between burnout and anxiety compared to studies that used other scales, while interestingly the relationship was slightly less strong among healthcare professional than in the general employed population. These limitations

#### *Panic Disorder and Burnout in the Workplace: Review of the Evidence and Recommendations… DOI: http://dx.doi.org/10.5772/intechopen.107533*

can be further highlighted by the fact that between 2013 and 2018, only one longitudinal study was identified on the relationship between anxiety and burnout [18].

HADS was designed to help measure anxiety symptoms in patient/hospital settings (e.g., patients with coronary heart disease), and there is no evidence of a latent variable structure, being frequently criticized for not being sensitive enough to differentiate between depression and anxiety as clearly as claimed [38]. A 10-year systematic review [38] revealed anomalous factor loadings of both anxiety and depression items on depression and anxiety respectively or on both factors. This suggests that some of the items included in the HADS do not represent clearly depressive or anxiety symptoms, as these could be potentially present in both cases. With regard to the experience of somatic symptoms that might be an indicator of anxiety or panic attacks, no somatic items had been included in the construction of this scale—mostly due to the fact that the scale was designed for hospital/patient samples, and thus, somatic symptoms are expected to be common due to health conditions (e.g., cardiovascular heart disease) [39]. The scale includes one item that reads "I get sudden feelings of panic" (answered on a four-point Likert scale), which, although at a face validity level seems relevant to panic disorder, the phrasing "feelings of panic" is up for interpretation by each participant; the word "panic" when used in daily life and not in clinical/psychological contexts might indicate excessive worry, intense fear or anxiety, feelings of helplessness, or "not knowing what to do," anticipation anxiety, distress (etc.). Thus, one of the most widely used measures for anxiety in studies looking into working populations does not have any references to somatic symptoms or the experience of panic attacks, as it has been developed to be administered to patient/hospital samples. In that case, if participants from working populations experience panic attacks or even somatic symptoms that can indicate panic-disorder risk, this is most likely to go under radar due to the instruments that are most commonly used in quantitative studies. In practical terms, this mean that if the employees of an organization are screened for anxiety with the use of the HADS, the screening results will not provide any information on whether any of the employees suffer or are at risk of suffering from panic attacks. Thus, despite the findings connecting work with anxiety—such as the relationship between anxiety and job burnout—the evidence on how/whether work contributes to panic attacks and/or panic disorders is rare and cannot be validly deduced from screening instruments such as the HADS.

#### **3.2 A technocratic approach to anxiety among working populations: differentiating or compartmentalizing?**

Measuring anxiety in working populations has almost become a "habit," especially when researchers include measures of burnout in their studies. Moreover, there are references to work-related anxiety [40]; job anxiety [41] or job-related anxiety, which is separated into team-job related anxiety and individual job-related anxiety [42]; employee anxiety[43]; to these we would also like to add other closely related concepts such as work stress [44]; work-related stress [45]; job-related stress [46]; job stress [47]; occupational stress [48]; organizational stress [49]. This is indicative of one of the well-recognized difficulties in conducting research related to stress and anxiety, as discrepancies in the operationalization and definition of the concepts are wide and very common, while each field and discipline is looking at stress and anxiety from different perspectives. There is no consensus as to whether stress and anxiety are independent variables (i.e., causes or contributing factors), whether they are outcomes (i.e., results from other causes and contributing factors), or whether they are

mediating processes critical in understanding how work-related life impacts overall mental and physical health and general quality of life. Especially in the work-related literature, the almost nonexistent experimental studies along with the very few longitudinal studies with limited validity regarding causal models testing and the overwhelming number of cross-sectional studies have led to a reciprocal understanding of the relationship between the different types of work-related stressors and anxiety outcomes. In this difficult to navigate literature, the use of generic anxiety measures as explained before makes practical implications even more difficult to delineate, as although we know that during difficult times at work, working populations are more likely to report higher anxiety levels, our understanding of what type of anxiety symptoms they are experiencing, when and where those symptoms are more intense as well as their meaning-making process is extremely limited. In addition, although the compartmentalization of anxiety might make it easier for quantitative analysis, the proof that work anxiety is indeed a "distinct" construct that is mainly the result of work-related stressors is also mostly built on theoretical assumptions and cross-sectional data; and in the meantime, there is no proof that work-related anxiety cannot be reduced by improving out-of-work quality of life or is different to anxiety induced from a toxic family culture. Such an assumption suggests that "compartmentalizing" anxiety into types based on the sphere of life might have some practical benefits, but it could also lead to several potential methodological artifacts, especially given that work life is mostly explored without controlling for personal and family life variables when it comes to quantitative research. We are not in any way implying that work life cannot be the main source of anxiety in a person's life; our concerns are related to the potential biases stemming from quantitative research that might overlook individual (e.g., personality, predisposition etc.) and out-of-work factors (e.g., contextual and socio-cultural factors) that could be significant in explaining work related anxiety.

We should be careful not to throw the baby out with the bathwater; of course, the research on work and anxiety has produced significant findings and has highlighted that working populations are undergoing extreme amounts of anxiety and stress to meet work demands—and many times beyond what is necessary for the job to be done (e.g., working with toxic supervisors). The identification of work-related mental health challenges is a very important step in creating healthy workplaces, and the work of several scholars has served as a milestone in advancing our understanding of the real impact that work life has on people's mental health [50, 51]. We wonder, however, whether this approach has now limited practical implications mainly driven by the need to produce generalizable and representative findings that serve the methodological axioms of quantitative research, which sometimes might result in a metaphysical obsession with method [52] rather than with how to identify who needs support and how we can provide it better. And while there are several taxonomies and sub-definitions of stress and anxiety for working populations, very little has been reported in studies regarding how often, e.g., employees in different professions and industries experience panic attacks in the work environment or out of it, when are panic attacks more likely to happen (e.g., prior, during, or after the shift), what percentage of affected employees seek help, whether they share this information with supervisors and coworkers, whether panic attacks at work are exacerbated during work-related crises or times of personal difficulty (etc). The need to address this gap in the literature becomes even more evident considering the several blogs, pop-psychology articles, personal testimonies, and anecdotal evidence that panic attacks in the workplace or panic attacks triggered by work demands are in fact very common. Articles and blog pieces entitled "Managing a Panic Attack

#### *Panic Disorder and Burnout in the Workplace: Review of the Evidence and Recommendations… DOI: http://dx.doi.org/10.5772/intechopen.107533*

at Work"1 "Managing your panic Disorder at Work 2 "I had a panic attack at work. This is what happened 3 "What to do when a Panic Attack hits at work 4 frequently include information transferred from general therapeutic protocols for anxiety and panic attacks (e.g., CBT; Mindfulness etc.) in the form of tips. One article, however, entitled "My stressful job is giving me panic attacks, but I feel guilty leaving <sup>5</sup> by Alison Greens, owner of the blog "Ask a Manager <sup>6</sup> can help further understand the complexity of dealing with panic attacks (e.g., CBT; Mindfulness etc.) in the form of tips. One article, however, entitled "My stressful job is giving me panic attacks, but I feel guilty leaving" by Alison Greens, owner of the blog "Ask a Manager" can help further understand the complexity of dealing with panic attacks at work or because of work, which goes beyond collecting data on the relationship between anxiety and burnout: employees and managers need support and help making sense out of the subjective experience of having a panic attack and what to do when it happens or when an employee informs them that they have been having panic attacks. The latter article highlights the guilt that employees might be experiencing when considering leaving a job that is potentially contributing to the decline of their mental and/or physical health, which in this case might also stem from a need for the employee to feel valuable and needed by their team and organization; e.g., "I cannot abandon my team because they need me"; "I feel guilty towards the manager who offered me the job," etc. Clinical literature supports that guilt is a key theme when it comes to mental health disorders [53], and literature on burnout has showcased that employees very often experience feelings of guilt as they cannot cope with the job demands due to insufficient resources (personal or organizational) [54]. And to that end, although compartmentalizing anxiety might help quantitative researchers, a multidisciplinary view of anxiety in the workplace might be more productive when looking into the experiences of the working populations.

#### **3.3 "It's your fault you can't handle the pressure": panic attacks as "personal weakness" and the idolization of resilience**

Work stress has been a major research topic especially with regard to healthcare professionals—not surprisingly so, as healthcare professionals rank among the top burnt-out work groups [55, 56]. All the available evidence points to the fact that the most healthcare systems in the world (e.g., the NHS in the UK) are under considerable stress. The overwhelming majority of healthcare workers wake up every day motivated to positively impact the patients they serve. Employees with a high calling intensity (such as healthcare professionals) are especially prone to the detrimental effects of emotionally disturbing work. The drive for healthcare employees, for example, to "keep going" and "get the job done" has a dark side referred to as pathological altruism, which refers to behaviors that attempt to promote the welfare of another but can have pernicious long-term consequences for the care giver [57].

<sup>1</sup> https://hbr.org/2022/03/managing-a-panic-attack-at-work#:~:text=Common%20triggers%20at% 20work%20include,Racing%20heart%20rate

<sup>2</sup> https://www.verywellmind.com/panic-disorder-and-the-workplace-2584191

<sup>3</sup> https://www.abc.net.au/everyday/i-had-a-panic-attack-at-work-this-is-what-happened/101115920

<sup>4</sup> https://www.forbes.com/sites/stephaniesarkis/2019/11/21/what-to-do-when-a-panic-attack-hits-at -work/?sh=252b9b869427

<sup>5</sup> https://www.thecut.com/article/my-job-started-giving-me-panic-attacks.html

<sup>6</sup> https://www.askamanager.org/about

Such an approach very frequently idolizes resilience—in the sense of enduring hardship at any cost—to a degree that being able to handle any hardship, stress, and difficulties happening at or stemming from one's job becomes a badge of honor. Healthcare can exploit the professional ethic of healthcare professionals, which results in a form of dysfunctional professionalism that supports maladaptive healthcare structures in education and practice and which can influence staff at all levels.

We believe that this culture of "performance first" no matter the cost and the admiration of abnormally resilient employees has been transferred to many sectors and industries over time and has been further exacerbated by the economic crises, as these give permission to organizations and employers to use the "limited resources" narrative when imposing extreme demands on employees with non-equivalent benefits. The culture of "performance first" implies that showing any sign of difficulty to deal with work demands is a weakness and as such it is not "allowed." Personal stories from blogs include references to occasions when employees have managed to "press pause" on an upcoming anxiety or panic attack until they find themselves in a space where nobody can witness this "proof of personal weakness." A work culture like this adds more stress to an already stressful work life where, for example, meeting tight deadlines is one of the most valued attributes for corporate executives or managing to care for a disproportionate number of patients during a pandemic is one of the most valued attributes for nurses. Such cultures usually involve a non-speaking-up dimension as well, where employees feel that they are not actually allowed to express themselves and if they do so, this might have serious consequences. Therefore, symptoms of anxiety and panic disorder are more likely to be developed and usually left unattended. But the fact remains that having the "resilience" to endure the aforementioned along with several other stressors in both one's work and personal life has been an idolized profile for a very long time; this means that employees are less likely to openly communicate facing mental health difficulties, including experiencing panic attacks in or outside of work. Is it, then, any surprise that these highly motivated individuals feel numb or cynical toward interventions that seek to increase their "resilience" or "engagement"?

#### **4. Recommendations and conclusions**

Our knowledge about panic disorders in the workplace is significantly limited. This is an evidence gap when we consider the unclear field of coexisting and partially overlapping conditions that exists with the more frequently studied phenomena of burnout, stress, and anxiety. Moreover, a more fine-grained understanding of panic disorder and panic attacks in relation to work stressors might help better understand the role of the stress response mechanism in burnout.

This chapter has demonstrated that quantitative organizational researchers have ignored or overlooked the panic symptomatology in their use of generic scales (e.g., HADS) that purport to measure anxiety. We can speculate that panic disorders are more easily viewed as being under the remit of clinical psychology rather than that of occupational/organizational research. However, this is a missed opportunity as concepts such as rumination have been successfully imported from clinical psychology into occupational/organizational psychology. Additionally, panic disorders have the potential to help understand the nexus between work and non-work domains better, in that a panic disorder is more likely to be "brought home" in occupations with high levels of burnout.

*Panic Disorder and Burnout in the Workplace: Review of the Evidence and Recommendations… DOI: http://dx.doi.org/10.5772/intechopen.107533*

#### **5. Summary of main points**

Panic attacks are often described by psychologists as "attacks" taking place to notify the person that there is something wrong in their lives. Lack of control in one's life could be a reason a panic attack can occur—a red button alarm that is flashing and screams danger. The experience is acute and extremely uncomfortable as the person experiencing it thinks that death is near. The danger might not be "real"—they are not actually dying—but they might have a low control over their lives that is causing this overwhelming feeling of fear and lack of safety. If we could use a metaphor to describe it, the experience of stressful work can be like that of an animal facing grave danger but is locked in a cage and cannot act toward its safety. Work environments with low sense of psychological safety can resemble a cage, meaning that they limit the employees' ability for control and autonomy; this results in a sense of helplessness, which can lead to high stress levels and potentially panic attacks. The culture of stress and the strict hierarchies is common in most sectors and industries, with employees facing high demands, little control, and often a lack of empathy and attention to well-being. A closer focus on experiences of panic symptoms with the use of interviews (qualitative research) and scales measuring physiological stress symptoms/panic attack symptoms (quantitative research) will contribute to our understanding of how to create healthier workplaces.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Olga Lainidi1 \*, Eva Tzioti2 , Maria Spiliou3 , Panagiota Koutsimani4 and Anthony Montgomery5

1 University of Leeds, Leeds, UK

2 Mediterranean College, Thessaloniki, Greece

3 Aristotle University of Thessaloniki, Greece

4 University of Macedonia, Thessaloniki, Greece

5 Northumbria University, Newcastle, UK

\*Address all correspondence to: lndolga@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section 3
