Talk Therapy for Panic Disorder

Intense moments of fear that repeat are a common experience among those who enter into therapy.  For some, these moments come on very suddenly and spark thoughts that one could be having a heart attack or “losing their mind” or “being out of control.”  These moments often are accompanied by a variety of physical sensations that are very distressing, including feeling one’s heart race, trembling, sweating, dizziness, or the fear of fainting.  Even when these moments have subsided, many experience an intense fear that they may happen again, often without warning.  Some may even take measures that they believe will keep them safe, such as staying home or in places they deem safe as often as possible. 

While there are many ways in which the term “panic attack” may be used, the clinical definition of a panic attack is a specific period of time in which fear and uncomfortable symptoms develop quickly and reach a peak within minutes.  These attacks can include increased heart rate, sweating, trembling/shaking, shortness of breath or a sense of choking, chest pain, nausea or GI distress, numbness/tingling, chills or hot flashes, dizziness/faintness, feeling like things aren’t real, feeling like you’re “outside” of yourself, and fear of losing control, dying or going insane. 

Defining Panic Disorder 

While panic attacks are common for individuals with clinical anxiety, what differentiates the occasional panic attack from a diagnosis of panic disorder is the recurrent and unexpected nature of the attacks.  Take a person who struggles with health anxiety for instance.  They may have a panic attack when they believe they notice a new physical symptom, as they believe it may be the sign of an illness.  This attack was brought on by a clear trigger and the fear isn’t about the panic attack itself as much as the fear of becoming sick.   

Those with panic disorder will describe their attacks as seemingly “coming out of the blue” or having no obvious trigger.  Additionally, they will spend significant time and energy worrying about the possibility for another attack and either doing things they believe will prevent an attack or avoiding situation that they believe might trigger one. 

Some who experience these frequent and unexpected panic attacks may go to lengths to avoid situations they believe will bring on an attack or endure these situations with a great deal of distress.  These reactions can vary from the a more mild form of sitting in an aisle seat in a concert so they can escape quickly in the event of an attack, to more severe forms where an individual is essentially confined to their home for fear of experiencing an attack in a situation that is embarrassing or difficult to escape from. 

Medical Treatment 

Currently, the medical treatment of choice for panic disorder are SSRIs or serotonin-specific reuptake inhibitors.  This class of medications has been shown to be effective for those with recurring panic attacks. 

Many patients are also offered benzodiazepines to help reduce symptoms or prevent attacks.  This class of medications are effective at reducing symptoms, however their benefit should be considered along with the risk of physical dependence if used over longer periods of time, the potential for harmful withdrawal effects and the risk of abuse. 

Importantly, some studies have found that for those with panic disorder, once medication is stopped, a significant proportion of patients will experience their panic attacks and fears return. 

Cognitive Behavioral Therapy for Panic Disorder 

Cognitive Behavioral Therapy is an evidence-based talk therapy treatment that has been shown to be effective for a wide variety of mental health conditions.  It is a kind of therapy that places emphasis on the way you think, the things you do, and how you feel, and the way that these factors interact with one another. 

Viewing panic from the cognitive-behavioral perspective, there may be some individuals who are susceptible to experiencing panic, due to biological factors (e.g. anxiety/panic running in your family), events in one’s history (e.g. having experienced family members suffering from sudden illnesses), and situations (e.g. being under severe stress due to marital problems).   

Having one panic attack will not definitively lead to the collection of symptoms associated with panic disorder.  Many individuals will experience an initial panic attack and never go on to have the intense fear associated with them.  For others, a “fear of fear” may begin to develop.  Their initial attack may have been so distressing, that they come to fear similar situations happening to them again.  They may become hypervigilant to the sensations they experience in their body, alert to any signs that another attack may be oncoming or that anything else might “seem off.”  They could begin to avoid situations in which it would be difficult to escape from, such as avoiding long lines, driving long distances, being in tight crowds, or going to grocery stores.   

What results is a chronic anxious apprehension about panic symptoms that paradoxically makes it more likely that a panic attack will occur.  Once panic symptoms are noticed, a person will often make the attribution that a panic attack is on the verge of occurring (e.g. “oh no, it’s happening again and I can’t stop it”).  So many benign factors can cause these physiological sensations (e.g stress, physical exertion, caffeine/stimulants/other medications, heat, etc), but the misinterpretation of these symptoms as meaning something catastrophic leads to panic. 

Cognitive Behavioral Therapy for panic disorder targets this process or hypervigilance to physical cues and the misinterpretation of these cues as something awful.  Cognitive interventions are used to identify the specific conclusions that patients are making in these moments to test how accurate and helpful they are (e.g. “does this sensation of chest tightness *always* mean that you’re having a heart attack, or could it mean something else?”).  One of the main interventions is exposure, where therapists encourage their patients to engage in actions that will likely bring on some of these sensations (e.g. jumping jacks to increase heart rate) to “face their fear” in a way and demonstrate that these sensations, while uncomfortable, do not lead to the catastrophic outcomes that maintain their panic.  Structured breathing techniques are also used to help develop a coping response that will promote calm and reduce the intensity of some of the symptoms associated with panic. 

Choosing a Treatment 

Both medication and talk therapy options for panic disorder are comparable in terms of their outcomes, though there is some evidence that those who have experienced cognitive behavioral therapy may have longer-lasting positive effects of treatment even after they are done with sessions when compared to those who stop taking psychiatric medications.  Talking with your mental health provider to see what options might work best for you will help determine a choice that is in line with your best interests.