Treatment for Panic Disorder
Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.We previously described this disorder and reviewed its diagnostic criteria.
Panic Disorder is characterized by uncued panic attacks triggered by a false alarm. Cognitive-behavioral therapy for Panic Disorder usually begins with psycho-education about the disorder. Psycho-education assists therapy participants and their family members to better understand the disorder. This increased understanding serves an important therapeutic purpose. You may recall that two specific cognitive distortions result in an inaccurate appraisal of risk. This inaccurate appraisal of risk subsequently leads to an increase in anxiety symptoms. These are: 1) the overestimation of threat and 2) the underestimation of coping abilities. Psycho-education allows for a more accurate appraisal of risk and an improvement in coping skills. This combination serves to limit or eliminate panic attacks.
Psycho-education teaches therapy participants that the physical sensations of the fight-or-flight response are harmless. Therefore, persons-in-recovery learn to interpret the physical sensations that occur during a panic attack. This increased knowledge reduces the anxiety resulting from an over-estimation of the risk posed by a panic attack. People with Panic Disorder are comforted to know that although it seems like they are losing control or having a heart attack, these panic symptoms are not dangerous.
Similarly, people with Panic Disorder can benefit from skills training to improve their coping skills. This is achieved by learning relaxation exercises and breath retraining. Breath retraining involves learning to consciously regulate breath during a panic attack. During relaxation training, people learn to consciously release muscle tension. The purpose of relaxation exercises and breath retraining is to "turn-off" the sympathetic nervous system. As we discussed in the section on biology, the sympathetic nervous system becomes activated during fight-or-flight. By controlling breath and relaxation, the opposite nervous system (parasympathetic) is activated. This blocks or prevents the fight-or-flight response.
These new skills help to strengthen patients' appraisal of their coping skills. This new appraisal further reduces their anxiety. These skills can be taught during individual therapy sessions or in a skills-training group.
In addition to psycho-education and skills training, cognitive therapy also helps persons-in-recovery to identify, and target, disorder-specific dysfunctional thoughts. In the case of panic disorder, there is a tendency to misinterpret any physical sensation as dangerous or harmful. Another erroneous belief is that certain situations "cause" panic attacks. This leads to an avoidance of those situations. Furthermore, the relationship between underlying life stressors and the initial, uncued panic attacks may be explored. Therapy participants are encouraged to develop strategies to reduce or eliminate these stressors.
After receiving psycho-education, skills training, and cognitive therapy, the therapy participant is now ready to participate in the behavioral component of treatment. This portion of treatment is called exposure and response prevention therapy. There are two separate components to the behavioral therapy for Panic Disorder. The first component tackles the anxious response to symptoms. The second component addresses the situations that prompt panic attacks.
The first component is called interoceptive cue exposure. This type of exposure desensitizes the participant to their specific physical sensations of a panic attack while refraining from his/her typical avoidance or safety behaviors. For example, if a person tends to experience rapid heart rate and perspiration during an attack, the therapist might instruct this person to run up and down stairs in the heat to mimic those same uncomfortable sensations. With repeated practice, the person will no longer become anxious when experiencing these sensations.
Having learned to relax in the presence of their physical sensations, the participant is ready for the second step. The second type of exposure involves confronting the specific situations that typically precipitate their panic attacks. Some common examples include elevators, bridges, and crowded, public places. However, these situations are unique to each person. Therefore, it could just as easily be a grocery store, or driving to work. Due to the process of paired association, these neutral situations have become linked to the panic attacks. Because of this pairing, these neutral, non-threatening circumstances now spontaneously precipitate a panic attack. Therapy participants may practice their relaxation and breath techniques during exposure to prevent a panic attack from occurring. With practice, the fearful response becomes extinguished; i.e., the exposure to these feared situations, without a panic attack, allows the fear to fade away. In one important study, the combination of interoceptive cue exposure, along with cognitive therapy, led to 85% of the participants being panic-free (Barlow, Craske, Cerny, & Klosko, 1989).
Despite psycho-education, skills training, and cognitive therapy, some people are unable or unwilling to tolerate exposure therapy. For these people a variety of approaches are still available. Some people with Panic Disorder may benefit from the addition of medication. In addition, the therapist may decide to take a different approach by assisting therapy participants learn to tolerate and accept their symptoms. Both Dialectical Behavior Therapy and Acceptance and Commitment Therapy are useful tools in this regard.
Resources
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Articles
- What is Anxiety?
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The Biopsychosocial Model of Anxiety
- The Biopsychosocial Model: Causes of Pathological Anxiety
- Biological Explanations of Anxiety Disorders
- Biological Explanations of Anxiety: Part II
- Biological Explanations of Anxiety: Part III
- Biological Explanations of Anxiety: Part IV
- Psychological Explanations of Anxiety Disorders
- Psychological Explanations: Part II
- Social Explanations of Anxiety Disorders
- Development & Maintenance of Anxiety Disorders
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Classification & Diagnosis of Anxiety Disorders
- The Classification and Diagnosis of Anxiety Disorders
- Panic Attacks: A Classic Symptom of Several Anxiety Disorders
- Panic Disorder
- Separation Anxiety Disorder
- Selective Mutism
- Agoraphobia
- Specific Phobias and Social Anxiety Disorder (Social Phobia)
- Generalized Anxiety Disorder (GAD)
- Other Anxiety-Related Disorders
- Anxiety and Other Psychiatric Disorders
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Anxiety Disorder Theories and Therapies
- Anxiety Disorders: Theories and Therapies
- Behavioral Learning Theory and Associated Therapies
- Operant Conditioning
- Operant Conditioning and Avoidance Learning
- Contemporary Views of Behavioral Learning Theory
- Behavioral Therapies for Anxiety Disorders
- Cognitive Theory and Associated Therapies
- Cognitive Therapy
- Cognitive-Behavioral Therapy
- Adjunct Therapies
- Pharmacologic Treatments (Medication)
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Treatment of Anxiety Disorders
- Treatment for Separation Anxiety Disorder
- Treatment for Selective Mutism
- Treatment for Panic Disorder
- Treatment for Specific Phobias and Treatment for Social Anxiety Disorder (Social Phobia)
- Treatment for Generalized Anxiety Disorder (GAD)
- Treatment for Obsessive-Compulsive Spectrum Disorders (OCSDs)
- Conclusion
- Anxiety Disorder References & Additonal Resources
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- Anxiety
- Anxiety Disorders
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- Phobic and Anxiety Disorders in Children and Adolescents
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- Stress
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- Treating Anxiety Disorders: A Unified Protocol
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- Managing Anxiety in Youth: More Action Than Talk
- Treatment of Social Anxiety Disorder
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- Recent Advances in Anxiety - Children/Adolescents
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More Information
- Wise Counsel Interview Transcript: An Interview with David Barlow, Ph.D. on the Nature and Treatment of Anxiety and Panic Disorders
- Wise Counsel Interview Transcript: An Interview with Dr. Michelle Craske on Anxiety Disorders Research and Treatment
- Wise Counsel Interview Transcript: An Interview with Richard Heimberg, Ph.D. on Anxiety Research and Treatment
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