Treatment for Anxiety
Disorders
Panic
Anxiety Education
Management Services
Other Treatment Options
Behavioral Therapies
Another form of therapy some clients have received has been the
older style, graded exposure/desensitization programs, which do not
have any Cognitive component to them. Along with medication, this
may be the only other form of treatment people have received. Graded
exposure/desensitization does not cover the strategies used in Cognitive
Behavior Therapy and is simply exposure to situations and/ or
places people avoid. This type of treatment has been given to people
even if they do not have any associated avoidance behavior
(Agoraphobia). This has been particularly so in relation to people
with Panic Disorder.
The question many of our clients with Panic Disorder/Agoraphobia
ask is, 'exposure to what'? Many graded exposure programs treat the
avoidance behavior (Agoraphobia) in Panic Disorder as though it was
the situation or place which triggered the attack. Also much to
their confusion, clients who have Panic Disorder without any form of
avoidance behavior have been given such a program.
The rationale behind graded exposure programs is that when the
individual goes into avoided situations /or places and stays in that
situation or place, the anxiety and/or panic attack will peak and
slowly ebb away. In other words, the person will habituate to the
anxiety and panic attack in that situation or place. As many clients
say, even though the panic attack does subside, if they are not
directly frightened of the situation /or place, why would the
anxiety 'ebb away' when it has never done so before?
In the case of Panic Disorder, the 'uncued,' or 'spontaneous,'
Panic Attack (8) is the root cause of the disorder. Yet, despite the
latest literature, detailed and qualified in the Diagnostic and
Statistical Manual No. 4, this is still not being recognized by some
health professionals. DSM 4 states that Panic Disorder with
Agoraphobia is not a fear of situations and places, but is a fear of
the spontaneous Panic Attack, i.e., the trigger of the attack is
internal and is not based on external factors. The older style
graded exposure programs focus on external factors; and in thousands
of cases does not resolve the 'internal trigger' of the spontaneous
panic attack.
We are aware that a few mental health professionals are skeptical
about this criteria for Panic Disorder. From a client perspective,
DSM 4 (8) is the most accurate description of the Disorder ever
presented. While debates may continue on whether the cause of Panic
Disorder is biological or behavioral, DSM 4 clearly states our
clients' experience. Unfortunately, clients' experiences are not
taken into account if they do not fit other treatment paradigms.
Clients' frustration with this type of treatment was highlighted
during a pilot study. The pilot study was a prelude to a formal
study to evaluate the effectiveness of our Panic Anxiety
Management Workshops. Part of the pilot study involved clients
filling out a 'Fear Questionnaire', listing fears associated with
their Disorder. Some Panic Disorder clients expressed anger over the
questionnaire and its relevance to their Disorder. As a result of
their comments, the 'Fear Questionnaire' was excluded from the
formal study. (9)
Many older style graded exposure programs are built around
clients answers to this questionnaire. In some cases, the list of
fears include specific fears which predate the clients Panic Attacks
and have no relevance to their Disorder, yet they were incorporated
or became the main feature of the graded exposure program. This
little known, but crucial, fact has also been noted by researchers.
One such study showed, "half the simple (specific) phobias in
Panic Disorder had childhood onset and half had onset associated
with the onset of Panic Disorder". (10) Short-term Cognitive
Behavioral Therapy addresses the spontaneous panic attacks much more
effectively than these older style programs.
Hypnotherapy
We have now seen a considerable number of people who have used
hypnotherapy as the main treatment option. From their experience,
hypnotherapy is not a long-term answer. It is not a proactive
therapy and does not teach people to take control of their thoughts.
While the Disorder may abate for awhile, it comes back, usually more
severe than the first time.
If you want to use hypnotherapy, do so, but also be mindful you
do need to have Cognitive skills as well. For more on Hypnotherapy
as a treatment option: see Research: Panic & Anxiety Disorder
Treatment Needs Research Project: Treatment
options effectiveness, conclusions.
Psychotherapy
It is sometimes difficult for people to see the relevance of
psychotherapy in the treatment of their Disorder, but it can be of
substantial benefit for many of us. It is not so much going back
into childhood to find the root cause of the Disorder, although
people who have a background of abuse do need to deal with these
issues. Psychotherapy can be used to help us get more in touch with
our emotions and can teach us important lessons in how we relate to
not only ourselves, but the world around us. Psychotherapy can help
us in our overall personal growth and development.
We usually advise people to work with a CBT therapist first to
develop their cognitive skills and during or after recovery people
may then wish to see a psychotherapist to work through any personal
issues. For more on Psychotherapy as a treatment option: see
Research: Panic & Anxiety Disorder Treatment Needs Research
Project: Treatment
options effectiveness, conclusions.
Summary
The perception that we are the 'worry well' is compounded
when Medication or Behavioral only treatments
fail. The perception can be that people have too many
secondary gains to want to recover from their Disorder. This
is unfounded and unjust. What is not understood is that people
can't recover when there is minimal, or no understanding, of
the dynamics of the Disorders by both the treating therapists
and by the person themselves. The horrific personal costs bear
this out.
While we definitely agree there is a time and place for
medication in the treatment of the Disorders for some people,
medication doesn't give us control over our lives in the
long-term. Nor does it prevent future episodes or possible
long term reliance on health care services. Cognitive Behavior
Therapy is proactive as it enables us to participate in our
treatment and enables us to take control of our lives. This
can prevent future episodes with substantial benefits to
people with the Disorder and the health care budgets! |
RELATED TOPICS
RESEARCH
|
REFERENCES
1. Brayley, J., et al, (1991), Guidelines for the Prevention and
Management of Benzodiazapine Dependence, AGPS, Canberra.
2. Evans L, (1987), Panic Disorder, A New Definition to Anxiety,
Current Therapeutics, 11 : 19 - 21
3. Otto M.W., et al. (1994), 'Cognitive-Behavioural Treatment of
Panic Disorder: Considerations for the Treatment of Patients Over
the Long Term', Psychiatric Annals, 24:6
4. Michelson L, et al, (1990), Panic Disorder Cognitive -
Behavioural Treatment, Behav. Res. Ther 28, 2, pp 141 - 151
5. Evans, L. (1995), 'A Follow-up of an Agoraphobia Treatment
Program', Commonwealth Dept of Human Services and Health
6. Margraf J, et al, (1995) Technische Universitat Dresden, Germany,
cited in the World Congress of Behavioural & Cognitive Therapies
Abstract Book , Denmark, 1995
7. Salvador-Carulla L, et al, (1995), 'Costs and Offset Effect in
Panic Disorders', British Journal of Psychiatry 166 (suppl. 27) 23
-28
8. American Psychiatrists Association, (1994) Diagnostic &
Statistical Manual of Mental Disorders, Fourth Edition
9. Hafner J et al, (1996) Evaluation of a consumer driven Panic
Anxiety Management Workshops, Project no Dept Health and Family
Services
10. Argyle & Roth, 1990, 'The phenomenological study of 90
patients with panic disorder', Psychiatric Developments, 7,187-209
cited in Argyle N, Solyom C, and Solyom L, 1991 'The structure of
Phobias in Panic Disorder', British Journal of Psychiatry, 159,
378-382
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