Opinion Therapies — 21 January 2013

Approximately 6 million individuals experience panic disorder each year. Panic disorder is characterized by recurrent, intense periods of anxiety/panic, which are often unprovoked, or, “out-of-the blue,” and are accompanied by anticipatory anxiety regarding the possibility of future attacks.

Panic disorder can be quite debilitating, sometimes accompanied by agoraphobia, or avoidance of pubic places due to fear of being in a setting or situation from which escape or finding help may be difficult.

Before we get to what DOES NOT work, let’s discuss what DOES work. Evidence for effective treatment of panic disorder is very well documented. The data show with great robust that cognitive behavioral therapy (CBT) is effective and is superior to a number of other treatment strategies.

Cognitive behavioral therapy for panic disorder often includes:

1) Psychoeducation – Education regarding the nature and course of the disorder; the autonomic nervous system and the fight-or-flight response; conceptualization of panic as the magnification and misinterpretation of somatic experiences which result in further physiological arousal and panic symptoms; treatment rationale; and, course of treatment.

2) Relaxation training – Learning to engage the relaxation response via training in diaphragmatic breathing; paced breathing; progressive muscle relaxation; or biofeedback.

3) Cognitive restructuring – Identifying the individual’s cognitive structure/sequence during panic; learning to identify cognitive distortions; challenging cognitive distortions; and restructuring these thoughts to be more realistic, accurate, and helpful.

4) Exposure – Eliciting panic symptoms and utilizing coping skills to reduce symptoms; creating a hierarchy (least anxiety-provoking to most anxiety-provoking) of avoided or distressing situations and exposing the individual to these experiences in a structured, systematic manner, allowing them to utilize their coping skills to minimize anxiety.

The KEY TO EFFECTIVE TREATMENT is creating mastery experiences, “I did it” experiences, in which the individual has a new emotional experience in these previously distressing situations, one of newly perceived control over anxiety.

You may have noticed that I have not mentioned medication yet.  While this is a blog about effective psychotherapy, psychotropic medication is an effective treatment option for many psychiatric disorders.

In the case of panic disorder, CBT has been shown to be as effective, and, in some studies, superior to psychotropic medication. Common medications approved for the treatment of panic disorder include: selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and benzodiadepines, which brings me to what DOES NOT work… actually, more of a caution and highlight of potential for unintentional maintenance of the problem…

(I step onto my “soap box.” ) Benzodiazepines (e.g., Xanax, Ativan, Klonopin) are frequently prescribed by physicians for patients who present with anxiety (and panic).  Often, when primary care physicians or psychiatrists prescribe these medications, these patients are at my door several months later, anxious, overwhelmed, and relying on their benzodiazepine for a small amount of temporary relief.  They cling to it, yet they report that it is not very helpful. Although it may “take the edge off,” the anxiety quickly returns to which they can only respond by taking another pill.

Thus, herein lies what DOES NOT work.  I truly enjoy treating panic disorder; I do. It is why I became a psychologist. But, time and time again, I see patients who present as prescribed benzodiazepines who are not likely to improve until they are no longer relying on benzodiazepines.  Here’s why:

1) There is a risk of physiological dependence. Yes, that’s right; it’s habit forming.

2) There is a risk of psychological dependence. So frequently, I see patients who are fearful of leaving benzodiazepines behind, as benzodiazepines have been their only source of potential relief, albeit minimal. Benzodiazepines can undermine CBT treatment, in this way, as it unintentionally validates their belief that they cannot control the anxiety and must rely on external forces to do so.

3) It can create a dysfunctional treatment response. As noted above, although it may “take the edge off,” the anxiety quickly returns to which they can only respond by taking another pill, as they have learned.

4) Most importantly, benzodiazepines can be counterproductive to CBT. The aforementioned problems notwithstanding, benzodiazepines, which enhance the action of the neurotransmitter, GABBA (Gamma Amino Butyric Acid), resulting in a “calming” or dulled excitatory response.  In essence, it dulls the emotional experience, thereby reducing the potential for anxiety/panic intensity.

Ay, here’s the rub, as a cognitive behavioral therapist, I WANT you to experience anxiety (in our planned, systematic manner) in order to have mastery experiences, experiences in which you are able to learn that you can, indeed, effectively use your newly acquired coping skills to control and minimize your anxiety.  If your ability to experience anxiety is blunted by benzodiazepines, you may be less likely to benefit from CBT and may have a higher potential for relapse.

I’ll step down off my “soap box” now.

What are your experiences?

As written by Marla Deibler on Psych Central.


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