The Treatment of Panic Disorder
The Treatment of Anxiety Disorders
Now that we have reviewed the various theories and associated therapies that are used to treat anxiety disorders, we will turn our attention to specific anxiety disorders to describe the usual treatment approach for each disorder. However, it is important to bear in mind, that therapists tailor their treatment approach for each person.
Treatment for Panic Disorder
Panic Disorder is characterized by uncued panic attacks triggered by a false alarm. Cognitive-behavioral therapy for Panic Disorder usually begins with psychoeducation about the disorder. Psychoeducation assists therapy participants (and their family members) to better understand their disorder. This increased understanding serves an important therapeutic purpose. You may recall that two specific cognitive distortions result in an inaccurate appraisal of risk, leading to a subsequent increase in anxiety symptoms: 1) the overestimation of threat and 2) the underestimation of coping abilities. Psychoeducation enables therapy participants to make a more accurate appraisal of risk, and to improve their coping skills in the following ways:
Psychoeducation teaches therapy participants that the physical sensations of the fight-or-flight response are harmless. Therefore, persons-in-recovery learn to more accurately interpret the physical sensations they experience during a panic attack. This increased knowledge helps to reduce the anxiety resulting from an over-estimation of the risk posed by a panic attack. People with Panic Disorder are comforted to know that even though they may feel as though they are losing control, or having a heart attack, these symptoms are perfectly safe, and even adaptive in true situations of danger.
Similarly, people with Panic Disorder benefit from skills training to improve their coping skills through relaxation exercises and breath retraining. Breath retraining involves learning to consciously regulate breath during a panic attack, while relaxation training involves learning to consciously release muscle tension. The purpose of relaxation exercises and breath retraining is to "turn-off" the sympathetic nervous system, which becomes activated during fight-or-flight, and instead "turn-on" the parasympathetic nervous system. In addition, these new skills help to strengthen patients' appraisal of their coping skills; thereby further reducing 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, such as the tendency to misinterpret any physical sensation as dangerous or harmful, and the tendency to believe that certain situations "cause" panic attacks (leading to 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 psychoeducation, skills training, and cognitive therapy, the therapy participant is now ready to participate in the behavioral component of treatment called exposure and response prevention therapy. There are two separate components to the behavioral therapy for Panic Disorder. The first is called interoceptive cue exposure. This type of exposure is meant to desensitize 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 would 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.
Once the therapy participant has learned to become more relaxed in the presence of their physical sensations, the second type of exposure involves confronting the specific situations that typically precipitate their panic attacks, such as an elevator, driving over a bridge, and/or going to a crowded, public place. Due to the process of paired association, these neutral situations have become linked to the panic attacks and 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 psychoeducation, 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.