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.

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.

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!

References

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