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Treatment of Panic-Related Anxiety Disorders

Mark Dombeck, Ph.D.

Most anxiety disorders are readily treatable with a combination of psychotherapy and medication. Learn the details of these treatments and other treatment options for generalized anxiety disorder, panic disorder, agoraphobia, social phobia, specific phobia, and post-traumatic stress disorder/acute stress disorder. Treatments for anxiety depend upon the specific disorder diagnosed by a trained mental health professional. Below you will find some general treatment guidelines for different Anxiety Disorders.

This document deals with the treatment of Panic and Agoraphobia. Other available documents deal with the treatment of Phobias, Trauma and Generalized Anxiety

Panic Disorder

Introduction

Panic attacks and panic disorder can be very disabling conditions for the people who suffer from them. Although panic attacks are not harmful or dangerous to the body, they often feel so frightening to those that experience them that sometimes the attacks can lead to avoidance of any activity or environment that have been associated with feelings of panic in the past. This can, in turn, lead to the more severe and disabling disorder of agoraphobia.

Panic attacks typically begin in young adulthood, but can occur at any time during an adult's life. A panic episode usually begins abruptly, without warning, and peaks in about 10 minutes. It can last anywhere from a few minutes to a half hour or longer. Panic attacks are characterized by a rapid heartbeat, sweating, trembling, and shortness of breath. Other symptoms can include chills, hot flashes, nausea, cramps, pain or tightness in the chest, derealization or depersonalization, a feeling that there is a lump in the throat, trouble swallowing and dizziness. Women are more likely than men to have panic attacks.
Research has demonstrated that the body's natural fight-or-flight response to danger is involved in having a panic attack. For example, if a grizzly bear came after you, your body would react instinctively. Your heart and breathing would speed up as your body readied itself for a life-threatening situation. A panic attack is really the body's flight-or-fight response system getting triggered without the presence of an actual external threat.

Panic disorder develops in individuals who have a genetic predisposition for having a sensitive central nervous system. When such an individual is exposed to a highly threatening external stressor, it causes a panic attack. The most common stressors that facilitate a first time panic attack usually includes: 1) experiencing a traumatic event, such as a rape or other assault, an earthquake, or the death of a loved one, 2) an extended period of chronic stress that depletes a person due to life demands, such as pressures at work, family, friends, academic pressures, health concerns, etc., 3) a medical procedure that causes the person to pay more attention than usual to his/her physical self, and 4) an adverse reaction to an illicit drug, usually marijuana, or to a prescription medication.

The initial panic attack sensitizes the central nervous system to symptoms of slight physiological arousal experienced from typical daily anxiety. Because the nervous system has become sensitized, the person begins to have anxiety/panic symptoms without the presence of any external threat. When the person starts to experience these symptoms such as dizziness or chest pain from the anxiety, the person interprets it as meaning that there has to be something internally wrong with them since there is no external threat causing the person to feel anxious.

Without the existence of an external threat to explain away the anxiety symptoms, the person becomes frightened about the anxiety symptoms themselves, thinking they are physical signs that something catastrophic is about to happen to them, such as having a heart attack or that they will go crazy. Their fear around the panic symptoms themselves then builds into a full-blown panic attack. Since panic attacks feel terrifying for most people, the fear then mostly becomes about the possibility of having another panic attack. Because of the intense fear around having another panic attack, the person has more panic attacks, and a vicious cycle evolves developing into panic disorder. Fortunately, with highly effective cognitive behavioral treatment interventions, panic disorder is a very treatable problem.

Treatment emphasizing a three-pronged approach is most effective in helping people overcome this disorder: education and information about panic disorder, cognitive-behavioral psychotherapy, and medication depending upon the severity and frequency of the panic attacks.

Psychotherapy

Education is usually the first factor in psychotherapy treatment of this disorder. Oftentimes, just receiving information about the fight-or flight response system and how that produces panic attacks in some people, helps to reduce anxiety symptoms right away. This is because for so many panic sufferers it often feels like such a mystery as to why they have such uncomfortable physical symptoms, especially if medical causes have been ruled out. So, receiving this type of information helps to greatly reduce their fears that the attacks themselves might somehow be dangerous or catastrophic, as well as clearing up much of the mystery around their symptoms.

The patient is instructed about the details of the body's "fight-or-flight" response and the associated physiological sensations. Learning to recognize and identify such sensations is usually an important initial step toward treatment of panic disorder. Treatment for panic disorder can be done in individual psychotherapy or group psychotherapy depending upon the individual's preferences and needs. The length of treatment is usually between 12-15 sessions. An emphasis on education, support, and the teaching of more effective coping strategies are usually the primary foci of therapy. Family therapy is usually unnecessary and inappropriate.

After the educational piece, therapy then teaches the patient relaxation and imagery techniques, especially deep breathing and progressive muscle relaxation. These are effective tools to be used during a panic attack to decrease immediate physiological distress and the accompanying emotional fears. The deep breathing especially is key since many of the uncomfortable physical symptoms the person experiences with panic, such as difficulty breathing and dizziness, are due to mild hyperventilation. Teaching a person how to breathe correctly greatly reduces panic symptoms and attacks.

Discussion of the client's irrational fears (usually of dying, passing out, becoming embarrassed) during an attack is essential in the context of a supportive therapeutic relationship. A cognitive or rational-emotive approach in this area is best. The therapist helps the patient identify maladaptive cognitive patterns such as overgeneralizing or catastrophizing that fuel the panic attacks. For example, if the patient's thought each time he/she feels mild chest pain is, "Oh boy, here it comes…I just know I am going to have a heart attack now" then the therapist helps the patient realize how he/she is misinterpreting these bodily signals and helps the patient develop an appropriate response to normal bodily sensations, such as "This is just a normal minor pain in my chest that is not going to hurt me and will go away soon." The therapist then helps the patient to replace irrational or maladaptive beliefs with more adaptive and realistic beliefs, which greatly helps to reduce the likelihood of having a panic attack.

The treatment for panic disorder also includes effective specific panic control techniques. These techniques include having the patient learn how to produce panic sensations on their own and then learn how to control them. This process takes away the scariness about some of the physical sensations people get with panic disorder.

A crucial feature of treatment for panic disorder is having the patient engage in self-monitoring of their panic attacks and moods, as well as completing homework assignments, which involve practicing the various relaxation and panic control techniques on their own. Both the self-monitoring and the practice assignments are crucial for the patient to reduce the likelihood of having panic attacks. Self-monitoring of panic attacks and moods helps the patient to see correlations about when the attacks happen and what may trigger them. Completing the practice assignments is the only way that the patient will benefit from the techniques to reduce panic and anxiety and learn long-term coping skills to manage future panic and anxiety symptoms.

In addition, a behavioral approach emphasizing graduated exposure to panic-inducing situations is most-often associated with related anxiety disorders, such as agoraphobia or social phobia. It may or may not be appropriate as a treatment approach, depending upon if the client has become agoraphobic and/or is engaging in avoidance of places and situations due to the panic attacks.

Group therapy can often be used just as effectively to teach relaxation and related panic control skills. Psychoeducational groups in this area are often beneficial because they allow other people with panic disorder the opportunity to realize that they are not alone with what they are experiencing, which also helps to alleviate some of the fear about panic attacks. Biofeedback, a specific technique that allows the client to receive either audio or visual feedback about their body's physiological responses while learning relaxation skills, is also an appropriate psychotherapeutic intervention.

All relaxation skills and assignments taught in the therapy sessions must be reinforced by daily exercises on the patient's part. This cannot be emphasized enough. If the client is unable or unwilling to complete daily homework assignments in practicing specific relaxation or monitoring skills, then therapy emphasizing such skill sets will likely be unsuccessful or less successful. This pro-active approach to change (and the expectations of the therapist that the client will agree to this approach) needs to be clearly explained at the onset of therapy. Discussing these expectations clearly up-front makes the success of such techniques much greater.

Medications

A lot of people who suffer from panic disorder can successfully be treated without resorting to the use of any medication. It is important to note that it is rarely appropriate to provide medication treatment alone without the use of psychotherapy to help educate and change the patient's behaviors related to their association of certain physiological sensations with fear. However, when medication is needed, the most commonly prescribed class of drugs for panic disorders are the SSRI antidepressant medications, such as Zoloft and Paxil, the tricyclic antidepressant medications, such as Imipramine, and the benzodiazepines (such as clonazepam and alprazolam). These medications can provide much relief from panic attacks and help the person get back to their normal level of functioning.

Choosing whether to try a benzodiazepine or an anti-depressant is a decision to be made with a psychiatrist and will depend on the severity of the symptoms as well as simply which one works best for each individual person. Benzodiazepines work quickly and can be taken just prior to a situation that might evoke a panic attack. However, benzodiazepines can produce strong physical and psychological dependence on the medication. They can also produce unpleasant side effects such as significant drowsiness that can impair the ability to function effectively throughout the day.

Antidepressant medications for anxiety include the SSRI medications, such as Zoloft and Paxil. These medications are taken on a continuous basis. While they usually have few side effects, they can produce headaches, nervousness, stomach upset, and changes in appetite, sleep, and libido. The other antidepressant medications prescribed for panic include the tricyclic, Imiprimane. This type of medication can produce anticholinergic effects such as dry mouth, dizziness, blurred vision, low blood pressure, and they can also affect cardiovascular functioning. The MAOI antidepressant medications can also be effective in treating panic, such as Nardil. The MAOI medications, though, require eating a strict diet that does not include foods high in the amine presser, Tyramine, such as cheese, beer, wine, fave beans, concentrated yeast extracts, and many more. Eating these foods while taking an MAOI can cause a severe hypertensive crisis, leading to stroke, heart attack, or even death. Because of the restrictions on one's diet, MAOIs are not commonly prescribed.

Self-Help

The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Many support groups exist within communities throughout the world that are devoted to helping individuals with this disorder share their commons experiences and feelings. Patients can be encouraged to try out new coping skills and relaxation skills with people they meet within support groups. They can be an important part of expanding the individual's skill set and develop new, healthier social relationships.

For those suffering from panic disorder, it is wise to engage in healthy lifestyle activities such as exercising, eating right, and getting enough rest. Engaging in these activities can be a great start to helping to reduce panic symptoms. This is because exercise, especially cardiovascular exercise, has been found to strengthen the communication center in the brain that affects the fight-or-flight response system to stress. Exercise also greatly relaxes the whole body, and improves mood.

Eating right by eating at regular intervals throughout the day is also very important in reducing panic and/or anxiety feelings. This is because if we go for long periods throughout the day where we do not get in enough calories, such as longer than 5-6 hours without something to eat, our blood sugar levels begin to fall. Some people are much more sensitive to the effects of low blood sugar, especially those who are prone to having panic attacks. When blood sugar levels fall, it can produce feelings of anxiety severe enough to cause a panic attack. Therefore, it is important to prevent the possibility of inducing a panic attack from low blood sugar by eating regularly throughout the day.

It is also important to get enough sleep, such as 7-9 hours a day. Research has demonstrated that a lack of sleep can produce physiologic arousal, especially in those with sensitive bodies. Again, this physiologic arousal can produce symptoms of anxiety and panic, such as feelings of unreality or depersonalization, nausea, and rapid heart rate, which can make it more likely someone will have a panic attack. Therefore, by getting enough rest a person can greatly diminish his/her chances of having a panic attack.

Agoraphobia

Introduction

People suffering with agoraphobia experience intense anxiety or panic attacks about being in situations or places in which help might be unavailable if they needed it or in which escape from the situation might be difficult if they needed to get home. However, being all alone at home can also be a dreaded situation because of the fear that that no one would be around to help if something were to happen to him/her. Another fear of agoraphobics is of being in situations or places in which they might do something embarrassing in public such as vomit, faint, not speak clearly, or have a bowel movement because of their anxiety levels. Because their fears limit their ability to go wherever they want to and move about feely in the world, they often feel that they are living within their own mental prison.

The most common situations and/or places that tend to be associated with agoraphobia include shopping malls, standing in line, driving, taking public transportation, restaurants, theaters, being a long way from home, staying at home alone, wide streets, going under tunnels or over bridges, supermarkets, crowds, planes, elevators, and escalators. Agoraphobia exists on a continuum of severity from mild in which a person white knuckles or endures through situations that raise anxiety levels, to severe in which another person refuses to leave the house at all or who will only leave the house with a trusted companion. People generally develop agoraphobia between the ages of 23 to 29, however most do not seek out help until around the age of 34.

Agoraphobia usually develops out of the behavioral response to a panic attack. More women than men are likely to develop agoraphobia as a response to a panic attack. Usually what happens is that if a person experiences a panic attack then he/she associates that particular location of where the panic attack happened with fear or possible threat. However, as the cycle of panic takes over, the person begins to generalize his/her response to feeling afraid in any place that panic symptoms may occur and the person would not be able to receive help or escape from the situation. As the person feels more and more vulnerable wondering what must be wrong that they are experiencing panic symptoms, the person also starts to feel more of a need to be dependent on others and feels that he/she can not handle the demands of being out in public places on his/her own.

While the majority of people with agoraphobia also have panic disorder (link to symptom page for panic disorder), that is not the case with all agoraphobics. There are some people who only have agoraphobia and have never had a panic attack, but that is a rare situation. Therefore, while panic disorder and agoraphobia are highly interrelated, they are separate disorders. For those who only have agoraphobia, they experience acute anxiety symptoms in particular places, which leads to avoidance and/or endurance of being in those places. For those with agoraphobia and panic disorder, it is vital to receive treatments for both that specifically target panic disorder (link to treatment page for panic disorder) as well as agoraphobia since they involve somewhat different treatment interventions.

Psychotherapy

The most effective psychotherapeutic treatment approach to date for agoraphobia is called situational exposure. This is a cognitive-behavioral technique that involves having the patient create a hierarchy of places and situations that are least to most anxiety producing. The patient is then accompanied by the therapist and confronts in vivo the place or situation that seems the least scary and builds up to the most scary.

If the patient begins to feel anxious or a panic attack coming on, the therapist helps the patient utilize relaxation skills such as deep breathing to reduce the anxiety or panic. As the patient is able to handle exposure to a feared situation or place without having anxiety or panic, the patient moves on to the next place or situation on his/her hierarchy list. Studies have found that longer and more continuous sessions in which the patient is exposed to the feared place or situation seem to be somewhat more effective than shorter more interrupted sessions.

Supplemental to the sessions with the therapist, the patient is expected to try and engage in exposure to feared places and situations with a trusted companion in- between therapy sessions. This way the patient can continue to practice exposure throughout the week as well as start to associate their ability to have success experiences on their own and with a variety of people. Cognitive therapy is also used to help challenge the patient's irrational cognitive beliefs that feed the anxiety or the panic about being in specific places or situations. The therapist helps the patient replace these irrational beliefs with more realistic and adaptive belief systems to help reduce the fear and anxiety.

When compared with medications for treating agoraphobia, situational exposure is the treatment of choice for agoraphobia since it helps the patients confront the actual fears, a process which leads to long-term change. Medications can help alleviate anxiety or panic symptoms while someone is presently taking them, however they do not help a patient learn how to control the symptoms themselves or how to work through the fears that cause the symptoms.

In fact, often when a person is just placed on medications for the treatment of agoraphobia or panic disorder, the person's symptoms seem better while taking the medications. However, as soon as the person stops taking the medications the symptoms come back with as much intensity. Also, therapists have found that sometimes when a patient is on medications for anxiety symptoms while undergoing psychotherapeutic treatments, that the medications can sometimes undermine the patient's progress in therapy because the affect of the medication can blind the patient to really knowing how well he/she is doing in therapy.
Therefore, it is strongly recommended that a person engage in psychotherapy utilizing situational exposure to treat agoraphobia and that medication be used only as an adjunct to therapy if someone's symptoms are more severe.

Medications

If a person suffering from agoraphobia has moderate to severe symptoms in which the anxiety or panic is so intense that the person needs more immediate relief, than the following psychotropic medications are prescribed. There are a variety of medications that can be used as an adjunct to treat agoraphobia. Two medications that are widely prescribed for agoraphobia are Alprazolam (Xanax) and Imipramine (Tofranil).

Alprazolam is an anti-anxiety agent in the benzodiazepine family. Benzodiazepines are short acting medications that are good for relieving anxiety that is stimulated by specific stressors. A dose is usually taken approximately 45 minutes before exposure to the stressor. Or, if a person is experiencing more chronic anxiety, daily doses taken at specific times can ward off anxiety in which there are multiple stressors that are unpredictable. The problem with benzodiazepines is that they are highly addictive often producing physiological and psychological dependence on them to relieve symptoms and feel good. Because of these characteristics of benzodiazepines they should only be prescribed to people who do not have a history of prior addictions and they need to be prescribed with caution to anyone who may use them.

Imipramine is a tricyclic antidepressant medication that has been shown to have some success with treating agoraphobia because it seems to reduce avoidance symptoms. However, like most tricyclic antidepressant medications there are often a variety of side effects. These kinds of medications often produce what are called anticholinergic side effects, which include poor memory and confusion, dry mouth, low blood pressure, constipation, dry eyes, and nasal congestion. These symptoms often go away after a few weeks, but some can remain. Tricyclic medications can also affect cardiovascular functioning, so they are contraindicated for those with heart difficulties.

The SSRI (Selective Serotonin Re-Uptake Inhibitor) antidepressant medications, such as Paxil and Zoloft, can also be used to treat agoraphobia because they act on reducing anxiety symptoms. These antidepressants tend to be best tolerated by people because they have far fewer side effects than the tricyclics. The most common side effects of SSRIs include headache, nervousness, nausea, diarrhea, change in sleep and/or appetite, and decrease in libido.

Self-Help

It is important whenever a person is having symptoms typical of anxiety or panic that they receive a medical examination to rule out the possibility that the symptoms are being caused by a medical problem. Once it has been determined whether the symptoms are from anxiety or due to a medical problem it is easier to treat the symptoms correctly, which is all a part of taking care of oneself.

Other self help strategies include bolstering your degree of social support by reaching out to others who may be experiencing similar symptoms of agoraphobia who can really understand what you are experiencing. There are many support groups available now for agoraphobia and if you are housebound there are online support groups or ways to communicate with others who have agoraphobia.

Self help activities should include empowering other aspects of self to fight the sense of vulnerability and powerlessness experienced by most agoraphobics. These activities could include exercising and eating right to feel stronger inside and out, getting enough rest, and reading about agoraphobia and building a strong knowledge base to help further understanding of the causes and treatments for agoraphobia since knowledge is power. Try and make a pact with yourself that this is time to focus on strengthening yourself emotionally and psychologically so it is okay to say no to the demands of others. Also, devise a plan of treatment strategies you will be willing to try out by a specific date so that you know you are working towards getting better and that this period of lack of freedoms, loneliness, and dependence is meant to only be temporary.

Reference:
Summarized from "Panic Disorder and Agoraphobia", by Craske, Michelle and Barlow, David. In Clinical Handbook of Psychological Disorders. Barlow, David. The Guilford Press, 1993.