An outline of psychotherapy for panic disorder
Below is a brief outline of the major components of psychotherapy for panic disorder.
CONTENTS
(1) Assessment
(2) Education
(3) Understanding the costs of avoidance and safety behaviors
(4) Reappraisal of your fear of panic attacks
(5) Exposure therapy
(6) Additional useful skills: Relaxation and mindfulness
(1) Assessment
Assessment for panic disorder
The criteria for panic disorder is: Recurrent unexpected panic attacks and at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: a persistent concern about having additional attacks, worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy"), or a significant change in behavior related to the attacks.
History of panic attacks, including frequency.
Assessment for related conditions
Agoraphobia; Phobias; Health anxiety; Social anxiety; OCD; PTSD; mood disorders
Feared sensations and situations: What sensations and situations do you fear, and why are they feared?
Behavior related to panic attacks
What situations or activities do you avoid due to a fear of panic attacks?
How do you cope when panic attacks occur?
Medical examination
If you have not had a complete physical examination by your primary physician since the panic attacks began or within 12 months (whichever is later), please obtain one.
(2) Education
Information about panic disorder
A panic attack is an unnecessary activation of the stress response (aka, fight, flight, or freeze).
Basic information about the stress response.
Panic disorder is a learned fear reaction to the sensations of the stress response. This learned fear is both conscious and automatic.
This learned fear reaction is maintained by avoidance and safety behaviors which prevent learning that the sensations of the stress response are not dangerous (although they can be uncomfortable).
Safety behaviors can include leaving situations when uncomfortable, protective rules and rituals, support objects, support people, and trying to suppress or control the fear.
Information about panic disorder treatment
Cognitive Behavioral Therapy (CBT) for Panic Disorder (which includes Exposure Therapy) is the most effective form of treatment for Panic Disorder. Most people who complete CBT no longer experience impairment due to a fear of panic attacks. It typically requires between 12-15 sessions.
Some medications may be helpful. However, a commonly prescribed type of medication for anxiety and panic (benzodiazepines) are intended only for short-term (e.g., from a few days to a month) or infrequent and intermittent use, and longer-term use can lead to physiological dependence and a reduced ability to cope with anxiety.
(3) Understanding the costs of avoidance and safety behaviors.
Considering how well have these strategies worked and what they have cost you.
Functional effects of anxiety control efforts
In what ways does attempting to avoid or control anxiety affect your life?
What do these efforts cost you in terms of time, effort, missed opportunities, or other costs?
In what ways do these efforts affect important areas of your life, such as self-care, relationships, work?
Consideration of valued directions and goals
If anxiety was no longer an issue for you, what would you do differently?
What would you do more of and what would you do less of?
What goals would you pursue?
How would things be different in important areas of your life, such as self-care, relationships, work?
(4) Reappraisal of your fear of panic attacks
Examine the degree to which your fears of panic attacks actually have occurred.
After considering the available evidence, what fears remain?
(5) Exposure therapy
Exposure therapy involves a series of exercises that create the opportunity for patients to learn that what they fear is not dangerous. These exercises are collaboratively designed by therapist and patient, and patients engage in them voluntarily. There are several types of exposure exercises:
Interoceptive exposure involves a series of exercises intended to activate feared sensations.
Situational exposure involves engaging in activities and going to places that have been avoided.
Imaginal exposure involves imagining engaging in activities, and may be helpful as a prelude to situational exposure.
(6) Additional useful skills: Relaxation and mindfulness
Relaxation skills and mindfulness skills can be developed with deliberate practice, and are useful for stress and anxiety management. They can support a person's willingness to experience the psychological and physical discomfort of facing triggers for anxiety. It is important to not use these skills to attempt to suppress or control anxiety as this will lead to more anxiety.
Relaxation skills include the use diaphragmatic breathing, muscle relaxation, and/or mental imagery to activate the "relaxation response". Many people with Panic Disorder hyperventilate during a panic attack, and learning how to breathe properly will be helpful in preventing hyperventilation.
Mindfulness skills involve practicing observing one's internal experience (thoughts, emotions, and physical sensations) in the present moment with an attitude of openness and acceptance while refraining from attachment or avoidance.