Panic Disorder

The 2005 U.S. National Comorbidity Survey Replication observed that people with panic disorder also struggle with other mental health problems such as specific and social phobias, generalized anxiety disorder, post-traumatic stress disorder, depression, dysthymia, bipolar disorder, attention-deficit/hyperactivity disorder, and intermittent explosive disorder. Other studies have observed that many people with panic disorder also suffer with drug and alcohol problems.

Panic disorder is also common among people struggling with some kind of personality disorder, such as a paranoid personality, dependent personality, obsessive-compulsive personality, antisocial personality, and schizoid personality.

A 1996 report published by the World Health Organization and the Harvard School of Public Health stated that panic disorder was the fifth most disabling mental health problem in the developed world. It’s estimated that almost 1 to 2 percent of the general population will suffer with panic disorder in any given year, and approximately 5 percent of the population will experience panic disorder at some point in their lives.

By some estimates, approximately two million adults in the United States suffer with panic disorder each year. Most often, panic disorder develops in the teenage or early adult years. One-third to one-half of the people with panic disorder will also develop agoraphobia, usually within the first year of experiencing recurrent, untreated panic attacks. However, not everyone who has panic attacks will develop panic disorder. It’s estimated that 3 to 5 percent of the general population has panic attacks every year without worrying about the recurrence of the attacks and without changing their behaviors.

According to findings from the National Institute of Mental Health Epidemiologic Catchment Area Program, over one million people are treated for panic disorder each year in the United States. Sadly, however, many people wait as long as ten years before seeking treatment for this illness. This is unfortunate, considering that cognitive behavioral therapy is a very effective treatment for panic disorder with or without agoraphobia. In a study reported in the professional journal Behavior Therapy, the cognitive behavioral treatment for panic disorder helped 85 percent of the patients become panic free, and two years later 81 percent of them were still panic free, all without using medications.

However, despite the successes of cognitive behavioral therapy, most patients are initially prescribed medications for their panic attacks because they first seek treatment from a medical professional. Antidepressant medications such as fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft) are usually the initial medications prescribed. However, faster acting antianxiety medications such as diazepam (Valium) and alprazolam (Xanax) are also used.

These medications can all be effective for the short-term treatment of panic attacks. However, in long-term treatment studies, one of which was reported in 2000 in the Journal of the American Medical Association, the use of cognitive behavioral therapy was superior to the use of medications and provided more benefits, including lower relapse rates. In fact, unless it’s immediately necessary, antianxiety and antidepressant medications are not recommended for the treatment of panic attacks. The potential problem is that people on medications might start to rely on medications for relief instead of relying on the skills they’ve developed in cognitive behavioral therapy.

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

The CBT treatment for panic disorder is usually composed of seven steps:

1. Conduct an assessment and provide education
2. Develop controlled, diaphragmatic breathing skills to resist hyperventilation
3. Challenge and correct anxious thinking using a risk assessment
4. Engage in safe and systematic exposure to panic-inducing symptoms
5. Engage in exposure to feared events to treat agoraphobia
6. Develop skills to cope with chronic worries
7. Prevent relapse

Step 1: Conduct an Assessment and Provide Education

The first step in the CBT treatment for panic disorder is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with panic disorder and not some other similar problem. Once people have been diagnosed with panic disorder, it’s important that they understand the basic nature and causes of the problem, especially the fight-or-flight nervous system response (as highlighted above). It’s also important for people with panic disorder to learn the truth about their worst fears, sometimes called the focal fears of panic disorder. For example, many people with panic disorder are afraid that they are going to faint, when, in fact, during most panic attacks people’s blood pressure actually rises, which prevents them from fainting.

It’s also important for the person to understand that CBT is an active form of treatment that requires him or her to do work outside of the therapy session.

Step 2: Develop Controlled, Diaphragmatic Breathing Skills to Resist Hyperventilation

The second step is to learn controlled, diaphragmatic breathing skills. The diaphragm is a muscle at the bottom of the lungs that helps a person breathe in a slow, rhythmic way. This is important to learn because many people who struggle with panic disorder have a habit of hyperventilating, a rapid, deep breathing pattern that often causes them to feel light-headed. This by itself can sometimes trigger a panic attack. Controlled diaphragmatic breathing—inhaling and exhaling to a slow, even count—can correct hyperventilation and slow down or prevent other symptoms of panic attacks. In general, diaphragmatic breathing also helps many people feel calmer, especially when confronted with anxiety-provoking situations.

Step 3: Challenge and Correct Anxious Thinking Using a Risk Assessment

The third step of the CBT treatment for panic disorder is to challenge and correct anxious thoughts by using a risk assessment thought log. Negative thoughts are often the cause of anxious feelings. At the most observable level are automatic thoughts. People with panic disorder often think and say automatic fearful thoughts to themselves prior to panic attacks. Two examples of automatic thoughts might be “I’m going to lose control” and “I’m choking and I’m going to die.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels anxious or afraid.

The initial stages of the CBT treatment for panic disorder will be spent identifying and reevaluating these errors in thinking using a risk assessment thought log. First, the risk assessment will help the person with panic disorder identify cognitive distortions, unhelpful thinking styles that perpetuate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life.

Next, the risk assessment thought log will help the person identify the situations that trigger the panic attacks and the automatic thoughts that accompany those situations. For example, a person might notice that every time he goes shopping he starts to feel light-headed and then he thinks, “I’m going to faint and look foolish.” In this example, the risk assessment would help that person identify evidence that both supports and refutes his prediction, and help him create a more well-balanced thought that eases his anxiety. Using the previous example, in support of the automatic thought, the man might say, “I’d look stupid if I passed out in the store,” but refute the thought by noting, “I’ve never actually passed out in a store before, no matter how bad I’ve felt.” Then, using these two thoughts, the man might come up with a healthier alternative thought: “Just because I sometimes feel light-headed, it doesn’t mean that I’ll faint and look foolish.”

The goal of this exercise is to lessen the strength of the initial automatic thought and therefore also lessen the person’s level of anxiety. The exercise can also help the person figure out the actual risk of a feared event taking place and help the person decide what he or she would do if the worst did happen.

As the work on challenging automatic thoughts continues, a person using a thought log will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to panic attacks. These core beliefs, often called schemas, include thoughts like “I’m a failure,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought log and other techniques.

Step 4: Engage in Safe and Systematic Exposure to Panic-Inducing Symptoms

As was stated in this introduction to panic disorder, most people who struggle with this problem have developed a fear of bodily sensations, such as a change in heartbeat or sweaty palms. As a result, they frequently monitor their bodies for these “symptoms,” and when they detect one, it’s often enough to trigger a panic attack. However, the truth is that all of us feel sensations like these; they are part of the normal experience of being alive. Thus, part of the CBT treatment for panic disorder is to renormalize these physical sensations and to help people master their fear by exposing them to those sensations in a safe and systematic way. This is often called interoceptive exposure. It’s very important to the success of the treatment that the person refrain from using safety behaviors while engaging in these exposures; examples include carrying medication in a pocket “just in case,” or having a safety person present during the exposure. These safety behaviors limit the effectiveness of the exposure.

Step 5: Engage in Exposure to Feared Events to Treat Agoraphobia

Just as people with panic disorder need to be exposed to feared bodily sensations, they also need help overcoming feared events, places, and situations if they also struggle with agoraphobia. This includes getting out of their homes, going out to public places, and engaging in other feared (but rationally safe) activities in a safe and systematic way. People who have both panic disorder and agoraphobia should be encouraged to confront these fears as early as possible in treatment. And again, it’s important to the success of the treatment that they refrain from safety behaviors during the exposure.

Step 6: Develop Skills to Cope with Chronic Worries

People with panic disorder often need to learn other specific skills to cope with chronic worries that may or may not be linked to their panic attacks. These skills often include stress reduction skills, relaxation techniques, and assertive communication skills.

Step 7: Prevent Relapse

Finally, the last step of the CBT treatment for panic disorder is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning panic disorder in order to take steps to prevent relapse.