Les modèles théoriques actuels du trouble panique : examen conceptuel et implications cliniques

Parmi les troubles anxieux, le trouble panique est associé à certains des plus grands fardeaux en termes de souffrance personnelle, de déficience professionnelle et de coût sociétal. Cet article passe en revue les modèles théoriques de ce trouble afin de déterminer leurs évolutions, leurs limites et les perspectives théoriques et cliniques qui en découlent. Pour ce faire, une revue de la littérature a été entreprise à partir de la base de données PsycINFO. Sur les 928 articles identifiés, 54 faisaient référence à 14 modèles théoriques du trouble panique. Les résultats montrent que la plupart des modèles ne sont pas empiriquement bien étayés et que peu ont été utilisés de manière cohérente pour guider le traitement de ce trouble. Bien que les traitements basés sur ces modèles bénéficient à un grand pourcentage de patients, au moins 25 % des patients sont classés comme résistants à ces traitements. De plus, les rechutes ne sont pas rares. La conclusion discute des limites des modèles existants et propose des recommandations pour améliorer les modèles actuels du trouble panique. 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. 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. 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. 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.