Panic Disorder Treatment

What are some available options for treatment?
Treatment can bring significant relief to seventy to ninety 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 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.

Often the therapist will provide the patient with simple
guidelines to follow when he or she can feel that a panic attack
is approaching. One therapist has offered a set of strategies
that have helped some of her patients to cope with panic attacks.

Strategies for Coping with Panic

Remember that although your feelings and symptoms are very frightening, they are not dangerous or harmful.
Understand that what you are experiencing is just an exaggeration of your normal bodily reactions to stress.
Do not fight your feelings or try to wish them away. The more you are willing to face them, the less intense they will become.
Do not add to your panic by thinking about what “might” happen. If you find yourself asking “What if?” tell yourself “So what!”
Stay in the present. Notice what is really happening to you as opposed to what you think might happen.
Label your fear level from zero to ten and watch it go up and down. Notice that it does not stay at a very high level for more than a few seconds.
When you find yourself thinking about the fear, change your “what if” thinking. Focus on and carry out a simple and manageable task such as counting backward from from 100 by 3’s or snapping a rubber band on your wrist.
Notice that when you stop adding frightening thoughts to your fear, it begins to fade.
When the fear comes, expect and accept it. Wait and give it time to pass without running away from it.
Be proud of yourself for your progress thus far, and think about how good you will feel when you succeed this time.

(Courtesy Jerilyn Ross, M.A., L.I.C.S.W., The Ross Center for Anxiety and Related Disorders, Inc., Washington, DC. Adapted from Mathews et al., 1981.)

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, at 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.

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 three groups of medications most commonly used 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. Some information about each of
the classes of drugs follows.

The tricyclic antidepressants were the first medications shown to
have a beneficial effect against panic disorder. Imipramine is
the tricyclic most commonly used for this condition. When
imipramine is prescribed, the patient usually starts with small
daily doses that are increased every few days until an effective
dosage is reached. The slow introduction of imipramine helps
minimize side effects such as dry mouth, constipation, and
blurred vision. People with panic disorder, who are inclined to
be hypervigilant about physical sensations, often find these side
effects disturbing at the outset. Side effects usually fade
after the patient has been on the medication a few weeks.

It usually takes several weeks for imipramine to have a
beneficial effect on panic disorder. Most patients treated with
imipramine will be panic-free within a few weeks or months.
Treatment generally lasts from 6 to 12 months. Treatment for a
shorter period of time is possible, but there is substantial risk
that when imipramine is stopped, panic attacks will recur.
Extending the period of treatment to 6 months to a year may
reduce this risk of a relapse. When the treatment period is
complete, the dosage of imipramine is tapered over a period of
several weeks.

The high-potency benzodiazepines are a class of medications that
effectively reduce anxiety. Alprazolam, clonazepam, and
lorazepam are medications that belong to this class. They take
effect rapidly, have few bothersome side effects, and are well
tolerated by the majority of patients. However, some patients,
especially those who have had problems with alcohol or drug
dependency, may become dependent on benzodiazepines.

Generally, the physician prescribing one of these drugs starts
the patient on a low dose and gradually increases it until panic
attacks cease. This procedure minimizes side effects.

Treatment with high-potency benzodiazepines is usually continued
for 6 months to a year. One drawback of these medications is
that patients may experience withdrawal symptoms – malaise,
weakness, and other unpleasant effects – when the treatment is
discontinued. Reducing the dose gradually generally minimizes
these problems. There may also be a recurrence of panic attacks
after the medication is withdrawn.

Of the MAOIs, a class of antidepressants which have been shown to
be effective against panic disorder, phenelzine is the most
commonly used. Treatment with phenelzine usually starts with a
relatively low daily dosage that is increased gradually until
panic attacks cease or the patient reaches a maximum dosage of
about 100 milligrams a day.

Use of phenelzine or any other MAOI requires the patient to
observe exacting dietary restrictions, because there are foods
and prescription drugs and certain substances of abuse that can
interact with the MAOI to cause a sudden, dangerous rise in blood
pressure. All patients who are taking MAOIs should obtain their
physician’s guidance concerning dietary restrictions and should
consult with their physician before using any over-the-counter or
prescription medications.

As in the case of the high-potency benzodiazepines and
imipramine, treatment with phenelzine or another MAOI generally
lasts 6 months to a year. At the conclusion of the treatment
period, the medication is gradually tapered.

Newly available antidepressants such as fluoxetine (one of a
class of new agents called serotonin reuptake inhibitors) appear
to be effective in selected cases of panic disorder. As with
other anti-panic medications, it is important to start with very
small doses and gradually increase the dosage.

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.

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 4-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. By talking about these conflicts and gaining a better
understanding of them, the patient is helped to overcome the
problems. Often, psychodynamic treatment focuses on events of
the past and making the patient aware of the ramifications of
long-buried 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.

Adding massage therapy or yoga to a treatment program has generated positive results:
Anxiety and Massage

Anxiety and Yoga

Brain and Mental Health

References and Sources: Medline, Pubmed, National Institutes of Health

last update: February 2009