Cognitive Behavioral Therapy for Panic Disorder

Panic

Panic Disorder

A panic attack is a brief period that involves a sudden onset of intense apprehension, fear, or terror and the sense of impending doom. During a panic attack, symptoms of heart palpitations, shortness of breath, chest pain, choking sensations, and the fear of going crazy or losing control can be present. Panic attacks can be triggered by external (phobic object or situation) or internal (physiological arousal) stimuli (APA, 1994). While initial panic attacks are often triggered by biological factors affecting the nervous system, later on most clients develop a strong fear of additional panic attacks. Certain psychological factors, such as anticipatory anxiety and behavioral avoidance, tend to play a role in the recurrence of panic symptoms. For a diagnosis of panic disorder, there are two main criteria. One, the individual experiences recurrent unexpected panic attacks. Two, at least one of the attacks has been followed by a month of persistent concern or worry about additional panic attacks or their consequences; and/or maladaptive change in behaviors related to the attacks (behaviors designed to avoid having panic attacks by avoiding unfamiliar situations, for example) (APA, 2013). 

CBT for Panic Disorder

Cognitive-behavioral therapy has a proven track record when it comes to treating panic disorder. CBT is an effective treatment method that offers fast relief (Penava, Otto, Maki, & Pollack, 1995), has a high success rate, low drop-out rate and few side effects (Zuercher-White, 1997). CBT can help clients reduce their symptoms of panic, avoidance behavior, and co-occurring depression as well as provide lasting change (Craske, Brown, & Barlow, 1991). CBT can be very effective for clients who do not respond to medication well or those who choose psychological treatment alone because of its low risks and side-effects (Pollack, Otto, Kaspi, Hammerness, & Rosenbaum, 1994). Cognitive-behavioral therapy can be administered in individual or group formats, and both seem to provide equal benefits (Barlow, Craske, Cerny, & Klosko, 1989).

Cognitive-behavioral therapy for panic disorder can be conceptualized in terms of four components as outlined below. These components are not distinct stages and can be combined as needed to create optimal therapeutic success.

Initial Preparation for Therapy

The initial therapy sessions tend to focus on establishing rapport between client and therapist and to help prepare clients for the more active components of treatment. Clients need to feel that their therapist is competent, skilled, and experienced in the treatment of panic disorder. A strong alliance is helpful because clients are more likely to reveal their vulnerabilities and work on important issues with a supportive therapist. Moreover, a relationship based on trust will provide a calming influence in later sessions when clients are required to face feared situations.

It is also important for clients to learn about the nature of panic attacks and anxiety and correct their misconceptions about them. Most clients find it helpful to find out that panic symptoms are not indicative of them having a heart attack or going crazy (Rapee, Craske, & Barlow, 1989). Panic attacks are simply false-alarm reactions triggered by the misperception of danger. Clients also learn to recognize anticipatory anxiety and disrupt the process in which normal feelings of anxiety can lead to panic attacks. Sometimes, clients are encouraged to get a medical evaluation to rule out any physical conditions that can contribute to their symptoms, however, most patients will have already done that before turning to therapy.

Another essential part of the initial sessions is conducting a thorough assessment of the client’s presenting issue, history of treatment, previous diagnoses, medical conditions, etc. Therapists often use standardized questionnaires to inquire about client’s symptoms. Clients are often asked to self-monitor their anxiety symptoms, which can help identify precipitating factors to panic attacks.

Coping Skills Training

Relaxation training is often useful in the treatment of panic attacks. While relaxation training alone does not seem to be enough in itself to control panic attacks (Arntz & VanDenHout, 1996), it can produce a reduction in the general feelings of anxiety (Taylor, Kenigsberg, & Robinson, 1982). As part of relaxation training, clients can learn about progressive muscle relaxation as well as guided imagery to manage feelings of anticipatory anxiety.

Diaphragmatic breathing is similar to deep breathing used in relaxation but often counting is used to guide the rate of the client’s breathing. It can be done in an alert state with eyes open, which some clients find easier than relaxation.

Clients, who suffer from panic attacks, often misperceive and misinterpret normal reactions of tension or anxiety and mislabel these feelings as a panic attacks (Clark & Ehlers, 1993). These misinterpretations need to be challenged through discussion and behavioral exercises (Salkovskis & Clark, 1991) or by estimating the likelihood that the catastrophic event will actually occur (Clum, 1990). Then clients can learn to replace these faulty interpretations with more realistic ones (Clark et al., 1994). 

Coping statements can also be helpful by cultivating a sense of safety, predictability, and control over events and physical sensations. Moreover, clients can learn to view stressful situations as opportunities to change and grow.

Exposure to the Feared Stimuli

Exposure sessions help clients learn that they can experience the symptoms of arousal without the feared consequences (Barlow & Cerny, 1988). Interoceptive exercises allow clients to confront the physical sensations associated with panic without letting them spiral into a panic attack. For instance, bodily spinning or hyperventilation can be used in session to induce feelings of dizziness or lightheadedness. 

In imaginal exposure, the therapist reads the script of the feared situation to the client in session over and over until the client’s anxiety subsides.

In vivo exposure is used to help clients reduce their tendency to avoid situations that often elicit a panic attack (Clum, 1990). Sometimes a hierarchy of challenging situations is created and the client gradually works through the steps with the help of the therapist. Eventually clients develop the attitude that they will deliberately seek out and confront difficult situations.

Relapse Prevention

When clients have made considerable headway in therapy, they may not need weekly sessions anymore. However, temporary lapses can occur and clients need to learn that these can be useful areas for continued growth and learning and do not mean that they have lost all progress. Relapse prevention also includes helping clients seek out situations that are perceived as threatening. Learning to view difficult situations as challenges makes clients stronger and more able to utilize their coping skills on a regular basis.

References

OVERHOLSTER, J.C. (2000). Cognitive-behavioral treatment of panic disorder. Psychotherapy, 37, 247-256.

PENAVA, S., OTTO, M., MAKI, K., & POLLACK, M. (1998). Rate of improvement during cognitive-behavioral group treatment for panic disorder. Behavior Research and Therapy, 36, 665-673.

ZUERCHER-WHTTE, E. (1997). Treating panic disorder and agoraphobia: A step-by-step clinical guide. Oakland, CA: NewHarbinger.

RASKE, M., BROWN, T., & BARLOW, D. (1991). Behavioral treatment of panic disorder. A two-year follow-up. Behavior Therapy, 22, 289-304.

POLLACK, M., OTTO, M., KASPI, S., HAMMERNESS, P., &

ROSENBAUM, J. (1994). Cognitive behavior therapy for treatment-refractory panic disorder. Journal of Clinical Psychiatry, 55, 200-205.

BARLOW, D., CRASKE, M., CERNY, J., & KLOSKO, J. (1989). Behavioral treatment of panic disorder. Behavior Therapy, 20, 261-282.

RAPEE, R., CRASKE, M., & BARLOW, D. (1989). Psychoeducation. In C. Lindemann (Ed.), Handbook of phobia therapy: Rapid symptom relief in anxiety disorders (pp. 225- 236). Northvale, NJ: Jason Arooson.

RNTZ, A., & VANDENHOUT, M. (1996). Psychological treatments of panic disorder without agoraphobia: Cognitive therapy versus applied relaxation. Behavior Research and Therapy, 34, 113-121.

TAYLOR, C. B., KENTOSBERO, M., & ROBINSON, J. (1982). A controlled comparison of relaxation and diazepam in panic disorder. Journal of Clinical Psychiatry, 43, 423-425.

CLARK, D. M., & EHLERS, A. (1993). An overview of the cognitive theory and treatment of panic disorder. Applied and Preventive Psychology, 2, 131-139.

SALKOVSHS, P., & CLARK, D. (1991). Cognitive therapy for panic attacks. Journal of Cognitive Psychotherapy, 5,215- 226.

CLUM, G. A. (1990). Coping with panic: A drug-free approach to dealing with anxiety attacks. Belmont, CA: Brooks/Cole.

CLARK, D. M., SALKOVSKIS, P., HACKMANN, A., MIDDLETON, H., ANASTASIADES, P., & GELDER, M. (1994). A comparison of cognitive therapy, applied relaxation, and imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164, 759-769.

BARLOW, D., & CERNY, J. (1988). Psychological treatment of panic. New York: Guilford.

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