Evidence-Based Reviews

Panic attacks: Help sufferers recover with cognitive-behavioral therapy

Current Psychiatry. 2005 December;4(12):51-60

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed, text rev). Washington, DC: American Psychiatric Association; 1994.

2. Otto MW, Deckersbach T. Cognitive-behavioral therapy for panic disorder: Theory, strategies, and outcome. In: Rosenbaum JF, Pollack M (eds). Panic disorder and its treatment. New York: Marcel Dekker; 1998.

3. Hettema, JM, Neale, MC, Kendler, KS. A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry 2001;158(10):1568-78.

4. Kendler KS, Gardner CO, Prescott CA. Panic syndromes in a population-based sample of male and female twins. Psychol Med 2001;31:989-1000.

5. Sandford JJ, Argyropoulos SV, Nutt DJ. The psychobiology of anxiolytic drugs. Part I: basic neurobiology. Pharmacol Ther 2000;88:197-212.

6. Millan MJ. The neurobiology and control of anxious states. Prog Neurobiol 2003;70:83-244.

7. Sanderson WC, Rego SA. Empirically supported psychological treatment of panic disorder and agoraphobia. Medscape. Available at www.medscape.com/viewprogram/350_pnt. Accessed Nov. 8, 2005.

8. Rayburn NR, Otto MW. Cognitive-behavioral therapy for panic disorder: a review of treatment elements, strategies, and outcomes. CNS Spectr 2003;8(5):356-62.

9. Craske MG, Barlow DH. Panic disorder and agoraphobia. In: Barlow DH (ed). Clinical handbook of psychological disorders: A step-by-step treatment manual. New York: Guilford Press; 2001;1-59.

10. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Arch Gen Psychiatry 2005;62:593-602.

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16. Royal Australian and New Zealand College of Psychiatrists. Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia. Aust NZ J Psychiatry 2003;37:641-56.Available at: www.ranzcp.org/publicarea/cpg.asp. Accessed Aug. 24, 2005.

17. Black DW, Wesner R, Bowers W, Gabel J. A comparison of fluvoxamine, cognitive therapy, and placebo in the treatment of panic disorder. Arch Gen Psychiatry 1993;31:383-94.

18. Dannon PN, Gon-Usishkin M, Gelbert A, et al. Cognitive behavioral group therapy in panic disorder patients: The efficacy of CBGT versus drug treatment. Ann Clin Psychiatry 2004;16:41-6.

19. Clark DM, Salkovskis PM, Hackmann A, et al. A comparison of cognitive therapy, applied relaxation, and imipramine in the treatment of panic disorder. Br J Psychiatry 1994;164:759-69.

20. Klosko JS, Barlow DH, Tassinari R, Cerny JA. A comparison of alprazolam and behavior therapy in treatment of panic disorder. J Consult Clin Psychol 1990;58:77-84.

21. Rapee RM, Craske MG, Barlow DH. Assessment instrument for panic disorder that includes fear of sensation-producing activities: The Albany Panic and Phobia Questionnaire. Anxiety 1995;1:114-22.

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24. Clum GA, Watkins PL, Borden JW, et al. A comparison of guided imaginal coping and imaginal exposure in the treatment of panic disorder. J Rational-Emotive & Cognitive Behavior Therapy 1993;11(4):179-93.

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29. Seligman L. Systems, strategies, and skills of counseling and psychotherapy. Saddle River, NJ: Prentice-Hall; 2001.

Other Behavioral Techniques

Imaginal exposure sessions can be created using visualizations of feared stimuli, gradually presented as with in vivo exposure. For example, as you recount a target scenario, ask the patient to imagine a progression of events or bodily cues that have led to panic attacks. The patient supplies SUDS ratings and refrains from imagining an avoidance or maladaptive response. You can tape-record the session for homework and assign the patient to listen to it and participate daily.

Imaginal exposure may help treat phobic avoidance (such as agoraphobic symptoms), but study results have been disappointing in panic symptoms.²⁴ However, this approach may help reluctant patients initiate in vivo exposure therapy.

Relaxation training—such as progressive muscle relaxation, visual imagery, or autogenic protocols—has shown mixed results in treating panic.^25,26 Relaxation may help patients cope with panic’s physiologic arousal, but it is not suitable as a singular intervention.

Breathing retraining. Because hyperventilation and panic symptoms are related, instruction and practice in slow, diaphragmatic breathing has long been a component of CBT for panic symptoms. Little evidence supports breathing retraining,⁹ although Meuret et al^27,28 have described a respiratory feedback paradigm that may reduce panic symptoms in appropriately selected patients.

Many studies that have assessed breathing retraining as monotherapy for panic have had methodologic flaws.²⁷

Building a Therapeutic Alliance

Successful therapists have been found to use empathic listening more than directives and explanations in the first therapy session.⁹ They understand the suffering from panic disorder and the value of listening as patients explain their symptoms, thoughts, and feelings. The rapport built during this initial interaction can help sustain motivation as the therapist then takes charge of subsequent sessions.

Among important skills for CBT therapists, Seligman²⁹ includes empathy, caring, warmth, and active listening, as well as the ability to:

be a teacher, scientist, and co-investigator
demystify treatment
engage clients as “active, knowledgeable, and responsible partners” in their therapy.

Finally, although CBT clinicians suggest tasks and interventions for this “shared endeavor,” patients are primarily responsible for change.

Related resources

Anxiety Disorders Association of America. www.adaa.org.
Craske M, Barlow D, Cary NC. Mastery of your anxiety and panic, (3rd ed). Therapist guide and client workbook. Oxford, UK: Oxford University Press; 2000.
Otto MW. Stopping anxiety medication: panic control therapy for benzodiazepine discontinuation. Therapist guide and patient workbook. Oxford, UK: Oxford University Press; 2004.
The Panic Center. Patient diaries and other self-help resources. www.paniccenter.net