The patient approaches a feared situation gradually, attempting to stay in spite of rising levels of anxiety. In this way the patient sees that as frightening as the feelings are, they are not dangerous, and they do pass. On each attempt, the patient faces as much fear as he or she can stand. Patients find that with this step-by-step approach, aided by encouragement and skilled advice from the therapist, they can gradually master their fears and enter situations that had seemed unapproachable.

Many therapists assign the patient "homework" to do between sessions. Sometimes patients spend only a few sessions in one-on-one contact with a therapist and continue to work on their own with the aid of a printed manual.

Often the patient will join a therapy group with others striving to overcome panic disorder or phobias, meeting with them weekly to discuss progress, exchange encouragement, and receive guidance from the therapist.

Cognitive-behavioral therapy generally requires at least 8 to 12 weeks. Some people may need a longer time in treatment to learn and implement the skills. This kind of therapy, which is reported to have a low relapse rate, is effective in eliminating panic attacks or reducing their frequency. It also reduces anticipatory anxiety and the avoidance of feared situations.

Treatment with Medications. In this treatment approach, which is also called pharmacotherapy, a prescription medication is used both to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety. When patients find that their panic attacks are less frequent and severe, they are increasingly able to venture into situations that had been off-limits to them. In this way, they benefit from exposure to previously feared situations as well as from the medication.

The selective serotonin reuptake inhibitors (SSRIs) are now the first line of medication treatment for panic disorder. Other commonly used medications are the tricyclic antidepressants, the high-potency benzodiazepines, and the monoamine oxidase inhibitors (MAOIs). Determination of which drug to use is based on considerations of safety, efficacy, and the personal needs and preferences of the patient. More information about these medications can be found in the NIMH publication, Medications in the Library.

Scientists supported by NIMH are seeking ways to improve drug treatment for panic disorder. Studies are underway to determine the optimal duration of treatment with medications, who they are most likely to help, and how to moderate problems associated with withdrawal.

What to Do if a Family Member Has an Anxiety Disorder

1. Don't make assumptions about what the affected person needs; ask them.
2. Be predictable; don't surprise them.
3. Let the person with the disorder set the pace for recovery.
4. Find something positive in every experience. If the affected person is only able to go partway to a particular goal, such as a movie theater or party, consider that an achievement rather than a failure.
5. Don't enable avoidance: negotiate with the person with panic disorder to take one step forward when he or she wants to avoid something.
6. Don't sacrifice your own life and build resentments.
7. Don't panic when the person with the disorder panics.
8. Remember that it's all right to be anxious yourself; it's natural for you to be concerned and even worried about the person with the disorder.
9. Be patient and accepting, but don't settle for the affected person being permanently disabled.
10. Say: "You can do it no matter how you feel. I am proud of you. Tell me what you need now. Breathe slow and low. Stay in the present. It's not the place what's bothering you, it's the thought. I know that what you are feeling is painful, but it's not dangerous. You are courageous."

Don't say: "Relax. Calm down. Don't be anxious. Let's see if you can do this (i.e., setting up a test for the affected person). You can fight this. What should we do next? Don't be ridiculous. You have to stay. Don't be a coward.

Adapted from Sally Winston, D.Psy., The Anxiety and Stress Disorders Institute of Maryland, Towson, MD, 1992.

Combination Treatments. Many believe that a combination of medication and cognitive-behavioral therapy represents the best alternative for the treatment of panic disorder. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate. However, there is a need for more research studies to determine whether this is in fact the case.

Comparing medications and psychological treatments, and determining how well they work in combination, is the goal of several NIMH-supported studies. The largest of these is a 5-year clinical trial that will include 480 patients and involve four centers at the State University of New York at Albany, Cornell University, Hillside Hospital/Columbia University, and Yale University. This study is designed to determine how treatment with imipramine compares with a cognitive-behavioral approach, and whether combining the two yields benefits over either method alone.

Psychodynamic Treatment. This is a form of "talk therapy" in which the therapist and the patient, working together, seek to uncover emotional conflicts that may underlie the patient's problems.

Although psychodynamic approaches may help to relieve the stress that contributes to panic attacks, they do not seem to stop the attacks directly. In fact, there is no scientific evidence that this form of therapy by itself is effective in helping people to overcome panic disorder or agoraphobia. However, if a patient's panic disorder occurs along with some broader and pre-existing emotional disturbance, psychodynamic treatment may be a helpful addition to the overall treatment program.

next: The Importance of Getting Treatment for Panic Disorder or Where to Get Help for Panic Disorder