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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.