Current theoretical models of panic disorder: Conceptual review and clinical implications

Objectives. - Panic disorder (PD) is defined by recurring and unexpected panic attacks accompanied by anticipatory anxiety about future attacks and their consequences. This generally involves avoiding situations and behaviors that can produce panic attacks (American Psychiatric Association [APA], 2013). Among anxiety disorders, PD is associated with some of the greatest burdens in terms of personal suffering, occupational disability, and societal cost. Since the introduction of PD in the DSM-III (1980) and the distinction of PD from generalized anxiety disorder following the work of Klein (1964), several biological and psychological theories of PD have been developed. These theories have highlighted several risk factors (for the onset, maintenance and relapse associated with the disorder) that have strongly influenced research on PD and have guided its treatment. However, a comprehensive and universally accepted theoretical framework of PD to guide its treatment is lacking. This article reviews the previously described theoretical frameworks of PD and related treatments while examining the strength of the scientific evidence supporting their validity as well as their limitations. Methodology. - A review of the literature was undertaken by searching PsycINFO database to list all the articles published between January 2000 and November 2020 and referring to a theoretical model or a conceptual framework of PD. The conceptual frameworks identified were reviewed based on the recent scientific researches to determine the strength of the evidence supporting their validity. Results. - Of the 928 articles initially identified, 54 referred to fourteen different conceptual frameworks relating to PD. Two models are exclusively biological: the false suffocation alarm and the neuroanatomical hypothesis of PD. Six models are psychological, one of which is psychodynamic and five are derived from the cognitive-behavioral paradigm. Finally, six models are integrative: triple vulnerability of Barlow, integrated cognitive vulnerability of Schmidt & Woolaway-Bickel, unified model of vulnerability of McGinn, causal model of Fava & Morton, causal model based on the evidence by Pilecki and integrated model of Busch. These models highlight biological, environmental, developmental and psychological vulnerability factors. Conclusion. - The analysis of these different models shows that few conceptual frameworks have been used consistently to guide the treatment of PD, and that not all frameworks are empirically well supported. The theoretical approaches that have strongly influenced the treatment of PD are the cognitive model of Clark, the expectation model of Reiss as well as the triple vulnerability model of Barlow. Although treatments based on these models benefit a large percentage of patients, at least 25% of patients are classified as resistant to these treatments. In addition, relapses and persistence of symptoms remain common results of these treatments. This suggests that other vulnerability factors such as emotional regulation skills should be taken into consideration and integrated into these models especially as several studies have suggested that research focused on emotion regulation may improve our understanding of panic. (C) 2021 Published by Elsevier Masson SAS.