Ph.D. Doctoral Dissertation Peter Kyriakoulis School of Psychology, Faculty of Arts, Health and Design, Swinburne University of Technology March 2019 The efficacy of cold facial immersion and the diving response in treating panic disorder Supervisors: Prof. David Liley, Dr. Mark Schier, Prof. Michael Kyrios & Prof. Greg Murray i Table of Contents Table of Contents Table of Contents ................................................................................................ ii Abstract ....................................................................................................... xii DECLARATION.............................................................................................. xiv ACKNOWLEDGEMENTS .............................................................................. xv List of Tables ......................................................................................................... ...................................................................................................... xvi List of Abbreviations........................................................................................ xxi Overview of Thesis ......................................................................................... xxiii Chapter 1 PANIC DISORDER ....................................................................... 1 Panic Disorder and Panic Attacks .................................................. 2 The Aetiology of Panic Disorder ..................................................... 5 Psychological Theories of PD Aetiology .................................................. 5 Conditioning Theories .......................................................... 5 Modern Learning Theory ..................................................... 7 Cognitive Theories ............................................................... 9 Anxiety Sensitivity Theory ................................................. 11 Biological Theories of PD Aetiology ..................................................... 13 Genetic Theories ................................................................ 13 Hormone Theory ................................................................ 14 Metabolic Theories............................................................. 15 ii Table of Contents Neurochemical Theory ....................................................... 19 Respiratory and Hyperventilation Theories ......................... 21 Neuroanatomical Theories .................................................. 27 Summary ................................................................................................ 31 Physiology of Panic ........................................................................ 34 Treatments of Panic Disorder ....................................................... 36 Cognitive Behavioural Therapy (CBT)................................................... 40 Acceptance and Commitment Therapy (ACT) ..................... 43 In Vivo Exposure and Virtual Reality Exposure ................... 47 Psychodynamic Therapy ........................................................................ 50 Breathing Training ................................................................................. 50 Breathing Training Treatments ............................................ 52 Pharmacological Treatments ................................................................. 56 Summary of Chapter ..................................................................... 58 Chapter 2 The Diving Response and its Applications ................................... 60 Breath-holding (Apnea)................................................................. 60 The Diving Response (DR) ............................................................ 60 Breath-holding and Cold Facial Immersion ................................. 64 Free diving and Breath-Holding ................................................... 71 Individual Determinants in Breath-Hold Diving ..................................... 73 Adaptive Changes during Breath-hold and Apnea training ........ 77 Clinical Implications of the Diving Response ......................................... 89 Summary ............................................................................................... 91 iii Table of Contents Chapter 3 Respiration and Panic Disorder ................................................... 92 Respiration..................................................................................... 92 Breathing and Chemosensitivity ............................................................. 95 Physiological Abnormalities and Disturbances in Panic Disorder .................................................................................................................. 98 Panic Disorder and hypersensitivity to Carbon Dioxide ........................ 101 Carbon Dioxide and it role in Chemosensation ..................................... 105 Respiratory Provocation Tests .................................................... 110 Carbon Dioxide (CO2) ......................................................................... 110 Hyperventilation .................................................................................. 112 Breath-holding ..................................................................................... 112 Implications of the Diving Response in Treating Panic Disorder ................................................................................................................ 114 Research aims .............................................................................. 121 Chapter 4 OVERALL METHODOLOGY ................................................. 123 Overview of methodology ............................................................ 123 Ethics Approval ........................................................................... 123 Informed Consent ........................................................................ 124 Clinical Participants .................................................................... 125 Inclusion and Exclusion Criteria for participants with panic disorder. ............................................................................................... 125 iv Table of Contents Recruitment of Clinical Participants ..................................................... 126 Control Participants .................................................................... 127 Inclusion and Exclusion Criteria for participants with panic disorder. ............................................................................................... 127 Recruitment of Control Participants ..................................................... 128 Overall Procedure ....................................................................... 130 Psychological Measures ....................................................................... 131 The Anxiety Sensitivity Index .......................................... 131 The Beck Anxiety Inventory ............................................ 131 The Discomfort Intolerance Scale ..................................... 132 The State-Trait Anxiety Inventory .................................... 132 The Panic Attack Cognitions Questionnaire...................... 133 The Acute Panic Inventory ............................................... 133 The Visual Analog Scale .................................................. 134 The Center for Epidemiological Studies Depression Scale 134 Physiological Measures ........................................................................ 135 Respiratory Challenges and Cold Facial Immersion Task ..................... 135 Breath-hold challenge....................................................... 135 Cold Facial Immersion Task ............................................. 136 CO2 Challenge .................................................................. 136 Physiological Materials ........................................................................ 137 Electrocardiogram (ECG) ................................................. 137 Pulse Oximeter ................................................................. 137 CO2 Inhalation Materials .................................................. 138 v Table of Contents Chapter 5 PRELIMINARY INVESTIGATION: RESPIRATORY CHALLENGES AND COLD FACIAL IMMERSION ............. 139 Aim ............................................................................................... 139 Hypotheses ................................................................................... 140 Hypothesis 1 ........................................................................................ 140 Hypothesis 2 ........................................................................................ 140 Hypothesis 3 ........................................................................................ 140 Hypothesis 4 ........................................................................................ 140 Hypothesis 5 ........................................................................................ 140 Method ......................................................................................... 141 Participants .......................................................................................... 141 Health Screening .................................................................................. 142 Research Design .................................................................................. 142 Measures.............................................................................................