Cognitive behavior therapy for panic attacks?

The people I’ve met who get panic attacks describe them as very powerful — and very negative — experiences: Sudden, intense surges of anxiety are accompanied by uncomfortable physical symptoms that resemble the “fight or flight” response evoked by real dangers. The heart rate increases, blood is routed to leg and arm muscles, and you feel aroused, alert, and afraid. It is extraordinarily distressing when these symptoms appear without an obvious cause. During a panic attack, people often think they are having a life-threatening medical crisis — for example a heart attack or respiratory illness.

Panic attacks are surprisingly common, affecting up to 4% of the population. Since attacks often come without warning, sufferers may spend much time and emotional energy anticipating and worrying about the next one. They may begin to avoid situations that they fear will trigger an attack and places (like airplanes and theaters) where a quick getaway would be impossible or embarrassing.

Many people seek antianxiety medication, which works quickly and well. But people are sometimes surprised to learn that psychotherapy can be helpful too.

Cognitive behavior therapy (CBT) is a good treatment for panic attacks. The simplest behavioral understanding of panic anxiety is based on the idea that conditioned learning (learning by association) causes a neutral stimulus or situation to evoke the same response as a true danger. Exposure therapy aims to eliminate the faulty association by helping patients confront the feared situation with a therapist’s support. This treatment works best when a specific stimulus for the panic attacks can be identified (a classic example is fear of flying).

Cognitive behavioral therapy goes beyond stimulus-response patterns to look at thoughts, or cognitions. The therapist tries to understand the meaning of the threat and why it causes panic, then works on substituting more rational interpretations. In panic disorder, the patient must pay particular attention to misinterpretations of the body’s responses.

Treatment can be enhanced by homework and by telephone contact to provide support and answer questions. Keeping a diary and using workbooks and other educational materials are also helpful. Investigators have also begun to consider computer-based tools.

Medication can increase a patient’s tolerance for exposure to uncomfortable situations. In general, it is about as effective as cognitive behavioral therapy in the treatment of panic disorder. Some studies suggest that medication has an advantage in the early going and CBT is better for preventing relapse. Many experts think it is best to combine the two, but others worry that medication suppresses fear too quickly. In a few studies, patients taking medication along with cognitive behavioral therapy were slightly more likely to relapse than those receiving CBT alone.

Most panic patients see a family doctor first, and family doctors have historically provided them with medication only. If the results of one study are any indication, that could now change. The study showed that general practitioners could provide CBT using only modest resources, and without elaborate training. Even inexperienced therapists could quickly achieve good results in a few visits by following a manual. The study also showed that when a psychotherapist participated in the physician’s practice, doctors were more likely to refer patients to psychotherapy and patients were more likely to accept it.

It is reasonable for a person with panic disorder to choose CBT or medication or both. Medication can quickly reduce suffering from severe physical symptoms. Cognitive behavioral techniques help patients control symptoms and improve overall well-being. The upshot is that, one way or another, most people with panic attacks will be able to get significant relief.

Have you experienced panic attacks? What’s helped? Have you tried medication, psychotherapy, or both?

Dr. Michael Miller has been on staff of the Beth Israel Deaconess Medical Center, a large teaching hospital in Boston, for more than 25 years. He is also an Assistant Professor of Psychiatry at Harvard Medical School.

Anxiety and Phobias

Anxiety disorders—which include panic attacks, post-traumatic stress disorder, obsessive-compulsive disorder, and phobias—are among the most common mental illnesses, affecting about 23 million American adults. Thankfully, never before have there been so many therapies to help control anxiety. Coping With Anxiety and Phobias is a special report from Harvard Medical School that provides up-to-date information on these treatments, as well as information on the many types of anxiety disorders, their symptoms, causes, and getting a proper diagnosis.

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