Treatment for Panic Disorder

Treatment can bring significant relief to 70 to 90 percent of people with panic disorder, and early treatment can help keep the disease from progressing to the later stages where agoraphobia develops.

Before undergoing any treatment for panic disorder, a person should undergo a thorough medical examination 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 arrhythmias, which are disturbances in the rhythm of the heartbeat, can cause symptoms resembling those of panic disorder.

Several effective treatments have been developed for panic disorder and agoraphobia. In 1991, a conference held at the National Institutes of Health (NIH) under the sponsorship of the National Institute of Mental Health and the Office of Medical Applications of Research, surveyed the available information on panic disorder and its treatment. The conferees concluded that a form of psychotherapy called cognitive-behavioral therapy and medications are both effective for panic disorder. A treatment should be selected according to the individual needs and preferences of the patient, the panel said, and any treatment that fails to produce an effect within 6 to 8 weeks should be reassessed.

Cognitive-Behavioral Therapy. 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 1 to 3 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 are often 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 exposure to internal sensations called interoceptive exposure. During interoceptive exposure the therapist will do an individual assessment of internal sensations associated with panic. Depending on the assessment, 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."

Another important aspect of behavioral therapy is "in vivo" or real-life exposure. The therapist and the patient determine whether the patient has been avoiding particular places and situations, and which patterns of avoidance are causing the patient problems. They agree to work on the avoidance behaviors that are most seriously interfering with the patient's life. For example, fear of driving may be of paramount importance for one patient, while inability to go to the grocery store may be most handicapping for another.

Some therapists will go to an agoraphobic patient's home to conduct the initial sessions. Often therapists take their patients on excursions to shopping malls and other places the patients have been avoiding. Or they may accompany their patients who are trying to overcome fear of driving a car.