Part 2 in the Common Symptoms of Panic Disorder Series

In my previous article, I discussed panic attacks and Panic Disorder. I spoke about what Panic Disorder is and outlined how it can be treated, using both medication and cognitive behavior therapy. In this article, I continue to discuss the treatment of Panic Disorder, outlining some therapy options.

The Immediate Treatment Objective

The objective in treatment is to obtain at least a 12-month period free of symptoms, before tapering and discontinuing drug therapy (Bourin & Lambert, 2002). Because of higher than 50% incidences of co-mobidity with other psychiatric illnesses, such as obsessive-compulsive disorder, post-traumatic stress syndrome, and depression, diagnosis and treatment options can be complicated (Bourin & Lambert, 2002). In acute cases, benzodiazepines are used to help the patient gain some equilibrium. However, the prolonged use of this class of drug is detrimental because of the risk of dependence and withdrawal symptoms. The drugs most commonly used are selective serotonin reuptake inhibitors (SSRIs). However, side effects can also be a detriment with SSRIs and can include some increased anxiety, nausea, and sexual dysfunction (Bourin & Lambert, 2002). Many therapists are also including cognitive behavior therapy (CBT) together with drug therapy. Studies have found that patients who are treated only with drugs, and without CBT, will often relapse as soon as the drugs are discontinued.

Long-Term Care for Panic Disorder: Drug Options

Long-term care for PD is usually managed using one of three different types of antidepressants, namely, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). TCAs were used before the SSRIs became available and commonly used. Gorman, Liebowitz, Fyer, and Stein have hypothesized that these medications decrease the excitability of the brainstem areas regulated by norepinephrine (NA) and/or serotonin (as cited in Beamish, Granello, & Belcastro, 2002). The TCAs can take up to eight weeks to become effective, which is often a discouragement for those who are suffering. TCAs are also anticholinergic, and can cause a dry mouth, constipation, blurred vision, and memory difficulties (Noyes, Garvey, Cook, & Samuelson, 1989, as cited in Beamish, Granello, & Belcastro, 2002) and have dangerous cardiovascular effects (Bourin & Lambert, 2002). MAOIs are some of the most potent drugs used for treatment of PD. However, the patient needs to adhere to a tyramine-free diet for two to three days before taking the medication, and to continue it for two weeks after discontinuing the MAO drug therapy. Foods containing tyramine include cheese, smoked or pickled fish, fermented meats, red wines, beef or chicken liver, and overripe figs and bananas. There is also a list of foods to be eaten in moderation (Beamish, Granello, & Belcastro, 2002). Most people are put off by the diet and opt for SSRIs instead. SSRIs have become the drug of choice for the long-term management of PD, mainly because the side-effects are much more tolerable. SSRIs do not initially affect the firing rate of norepinephrine (NA), a neurotransmitter that regulates part of the autonomic nervous system responsible for a fight or flight response to stressful stimuli. However, sustained use of SSRIs appear to gradually decrease the rate of firing of NA neurons under stressful conditions (Blier, 2000).

Cognitive Behavior Therapy

Used together with SSRI drug therapy, cognitive behavioral therapy (CBT) appears to be the treatment of choice for anxiety disorders, including PD. Cognitive responses involve ascertaining when there is imminent danger, and setting in motion a response of fight or flight. Panic attacks are not set off by real danger, but by an escalating spiral of misinterpreting benign bodily sensations, which escalates the body’s response in fight or flight and finally triggers a panic attack (Beamish, Granello, & Belcastro, 2002).

Reinterpreting Bodily Sensations

CBT seeks to assist patients in reinterpreting the bodily sensations that trigger panic attacks. Individuals are trained to recognize the negative thoughts that can lead to the fight or flight response, and to replace them with thoughts that counteract the thought-sequences that lead to an attack. Some patients are helped by keeping a log that describes each attack. They record what their feelings were at the time, the intensity of those feelings, the thought-sequences that led to the attack, and what a realistic response may have been in that situation (Beamish, Granello, & Belcastro, 2002). In CBT, patients are given repeated exposure – called interoceptive exposure – to bodily sensations that are connected to the fear response, with the motive of desensitizing them (Schmidt & Woolaway-Bickel, 2000). Cognitive restructuring also includes distracting the patient from the ‘symptoms’ with a splash of cold water, the snap of a rubber band, or the shouting of positive responses. Breathing control techniques are often included in CBT as many patients will hyperventilate during a panic attack. The retraining techniques teach patients how to breathe slowly and deeply and show them how hyperventilation can actually cause some panic attacks. Instructions are given in how to breathe from the diaphragm rather than the chest. While breathing training alone is not effective, when combined with CBT it appears to help patients avoid spiraling into a panic attack (Beamish, Granello, & Belcastro, 2002).

Christian Counseling to Help You Deal with Panic Attacks

As a Christian counselor, I have witnessed how stressful panic disorders can be for my clients. However, I have also seen them respond well to a combination of treatments. Christian counseling can provide a safe space in which to learn how to control your thoughts and take charge of your life.

Photos “Outraged at the World,” courtesy of Krzysztof Dabrowski, Flickr CreativeCommons (CC BY 2.0); “Chrysanthemum,” courtesy of WhiteFire4114,


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