Introduction

Panic attacks and panic disorder can be very disabling conditions for the people who suffer from them. Sometimes they can lead to avoidance of any activity or environment which has been associated with feelings of panic in the past. This can in turn lead to more severe and disabling disorders such as 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 heart beat, sweating, trembling, and a shortness of breath. Other symptoms can include chills, hot flashes, nausea, cramps, chest pain,  tightness in the throat, trouble swallowing and dizziness.

Women are more likely than men to have panic attacks.  Many researchers believe the body’s natural fight-or-flight response to danger is involved. 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.  Many of the same reactions occur in a panic attack. No obvious stressor is present, but something trips the body’s alarm system.

Treatment emphasizing a three-pronged approach is most effective in helping people overcome  this disorder: education, psychotherapy and medication.


Psychotherapy

Cognitive Behavioral Therapy (CBT) is the gold-standard treatment for panic disorder. It involves, education on the physiology, thoughts, and emotions involved in panic attacks; cognitive processing techniques, and behavioral techniques (breathing retraining, gradual interoceptive “panic” state exposure, and sometimes relaxation training). CT or BT alone have also shown to be effective.

Education is usually the first factor in psychotherapy treatment of this disorder. The patient can be instructed about 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. Individual psychotherapy is usually the preferred modality and its length is generally short-term, under 12 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.

Discussion of the client’s irrational fears (usually of dying, passing out, becoming embarrassed) during an attack is appropriate and often beneficial in the context of a supportive therapeutic relationship. A cognitive therapy approach in this area is best.

A behavioral approach emphasizing awareness of non-harmful internal states (in which patients often associate with the onset of a panic attack), graduated exposure to these benign biological processes (e.g., heart rate increase, dizziness), either with the therapist or alone (assigned for homework), and breathing retraining.

Biofeedback, a specific technique which allows the client to receive either audio or visual feedback about their body’s physiological responses while learning relaxation skills, has been applied in panic populations, but is becoming less popular as od late because it has received less-substantial research backing than CBT. Some recent research suggests that biofeedback can be effective if used in the context of cognitive-behavioral exposure therapy. This may be because CBT uses biofeedback in the vein of countering the tendency to avoid feared sensations (i.e., teach the patient NOT to force relaxation when encountered with a panic trigger). Rather, CBT aims to help the patient gain a sense of mastery in handling their anxiety by allowing the sensations to “ride out”; this helps the patient to learn by experience that these sensations are uncomfortable, but not dangerous.

When relaxation techniques are used in CBT among panic disorder patients, this is generally done outside the usual context for a patient’s having a panic attack. For example, patients may learn calming breathing techniques for use before going to bed.

Group therapy can often be used just as effectively to teach both relaxation skills and behavioral exposure. Psychoeducational groups in this area are often beneficial, especially for mild-to-moderate panic disorder cases.

Mindfulness-based techniques are also receiving growing support for treating a number of anxiety-related conditions. One of these is Acceptance and Commitment Therapy (ACT), which is a behavioral therapy that aims to change the relationship individuals have with their own thoughts and physical sensations that are feared or avoided. From the ACT standpoint, by decreasing an individual’s attachment to their distressing thoughts through guided exercises, and instead, by promoting acceptance of distressing states, people are taught to more-effectively focus on the present moment and act in line with their goals and life values–instead of out of fear. In the beginning of treatment, patients learn to identify and clarify their values and commit to making efforts to change ineffective behavioral tendencies that have not served to reduce their anxiety thus far. A strong therapeutic alliance between patient and therapist is essential for the successful completion of this therapy, as it may be difficult for patients to begin to approach their anxiety from a new angle.

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. However, when medication is needed, the most commonly-prescribed class of drugs for panic disorders are the benzodiazepines (such as clonazepam and alprazolam) and the SSRI antidepressants. 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.

Phillip W. Long, M.D. notes that, “Clonazepam (Klonopin, Rivotril) and alprazolam (Xanax), are the treatment of choice in the treatment of Panic Disorder.  Clonazepam and alprazolam are preferred to antidepressant drugs because of their less severe side effects.” He also states that it is preferred to try the anti-anxiety agents before moving on to the antidepressants because of the increased side-effect profiles. Xanax can be addicting for individuals and should be used with care. Treatment with either clonazepam or alprazolam should be discontinued by tapering it off slowly, because of the possibility of seizures with abrupt discontinuation.


Self-Help

Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Many support groups exist within communities throughout the world which 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.

Symptoms