Treatment of Panic DisorderPanic 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 that 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 throad, trouble swallowing and diziness.

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.

Before undergoing any treatment for panic disorder, a person should undergo a thorough medical examination (e.g., a physical) to rule out other possible causes of the distressing symptoms. This is necessary because a number of other conditions — such as excessive levels of thyroid hormone, certain types of epilepsy, or cardiac arrhythmia (disturbances in the rhythm of the heartbeat) — can cause symptoms resembling those of panic disorder.

Psychotherapy for Panic Disorder

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.

Therapy can also teach relaxation and imagery techniques. These can be used during a panic attack to decrease immediate physiological distress and the accompanying emotional fears. 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 or rational-emotive approach in this area is best. 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 the client’s specific issues.

Group therapy can often be used just as effectively to teach relaxation and related skills. Psychoeducational groups in this area are often beneficial. 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, is also an appropriate psychotherapeutic intervention.

All relaxation skills and assignments taught in therapy session 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 imagery 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.

Cognitive-Behavioral Therapy (CBT)

This is a combination of cognitive therapy, which can modify or eliminate thought patterns contributing to the patient’s symptoms, and behavioral therapy, which aims to help the patient to change his or her behavior.

Typically the patient undergoing cognitive-behavioral therapy meets with a therapist for one to three hours a week. In the cognitive portion of the therapy, the therapist usually conducts a careful search for the thoughts and feelings that accompany the panic attacks. These mental events are discussed in terms of the “cognitive model” of panic attacks.

The cognitive model states that individuals with panic disorder often have distortions in their thinking, of which they may be unaware, and these may give rise to a cycle of fear. The cycle is believed to operate this way: First the individual feels a potentially worrisome sensation such as an increasing heart rate, tightened chest muscles, or a queasy stomach. This sensation may be triggered by some worry, an unpleasant mental image, a minor illness, or even exercise. The person with panic disorder responds to the sensation by becoming anxious. The initial anxiety triggers still more unpleasant sensations, which in turn heighten anxiety, giving rise to catastrophic thoughts. The person thinks, “I am having a heart attack” or “I am going insane,” or some similar thought. As the vicious cycle continues, a panic attack results. The whole cycle might take only a few seconds, and the individual may not be aware of the initial sensations or thoughts.

Proponents of this theory point out that, with the help of a skilled therapist, people with panic disorder often can learn to recognize the earliest thoughts and feelings in this sequence and modify their responses to them. Patients are taught that typical thoughts such as “That terrible feeling is getting worse!” or “I’m going to have a panic attack” or “I’m going to have a heart attack” can be replaced with substitutes such as “It’s only uneasiness; it will pass” that help to reduce anxiety and ward off a panic attack. Specific procedures for accomplishing this are taught. By modifying thought patterns in this way, the patient gains more control over the problem.

In cognitive therapy, discussions between the patient and the therapist are not usually focused on the patient’s past, as is the case with some forms of psychotherapy. Instead, conversations focus on the difficulties and successes the patient is having at the present time, and on skills the patient needs to learn.

The behavioral portion of cognitive-behavioral therapy may involve systematic training in relaxation techniques. By learning to relax, the patient may acquire the ability to reduce generalized anxiety and stress that often sets the stage for panic attacks.

Breathing exercises often are included in the behavioral therapy. The patient learns to control his or her breathing and avoid hyperventilation — a pattern of rapid, shallow breathing that can trigger or exacerbate some people’s panic attacks.

Another important aspect of behavioral therapy is becoming attuned and aware of one’s internal sensations. During this process, the therapist helps a person become more aware of their internal sensations associated with panic. Depending on each individual, the therapist may then encourage the patient to bring on some of the sensations of a panic attack by, for example, exercising to increase heart rate, breathing rapidly to trigger lightheadedness and respiratory symptoms, or spinning around to trigger dizziness. Exercises to produce feelings of unreality may also be used. Then the therapist teaches the patient to cope effectively with these sensations and to replace alarmist thoughts such as “I am going to die,” with more appropriate ones, such as “It’s just a little dizziness; I can handle it.”