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 Anxiety  Holistic-online.com

Cognitive-Behavioral Therapy (CBT) for Panic Disorders

This is a combination of cognitive therapy, which can modify or eliminate thought patterns contributing to the patient's symptoms, and behavioral therapy, which aims to help the patient change his or her behavior.

Typically the patient undergoing cognitive-behavioral therapy meets with a therapist for 1 to 3 hours a week. In the cognitive portion of the therapy, the therapist usually conducts a careful search for the thoughts and feelings that accompany the panic attacks. These mental events are discussed in terms of the "cognitive model" of panic attacks.

The cognitive model states that individuals with panic disorder often have distortions in their thinking, of which they may be unaware, and these may give rise to a cycle of fear.

The cycle is believed to operate this way: 

  1. First the individual feels a potentially worrisome sensation such as an increasing heart rate, tightened chest muscles, or a queasy stomach. This sensation may be triggered by some worry, an unpleasant mental image, a minor illness, or even exercise. 

  2. The person with panic disorder responds to the sensation by becoming anxious. 

  3. The initial anxiety triggers still more unpleasant sensations, which in turn heighten anxiety, giving rise to catastrophic thoughts. The person thinks "I am having a heart attack" or "I am going insane," or some similar thought.

  4.  As the vicious cycle continues, a panic attack results. The whole cycle might take only a few seconds, and the individual may not be aware of the initial sensations or thoughts.

Proponents of this theory point out that, with the help of a skilled therapist, people with panic disorder often can learn to recognize the earliest thoughts and feelings in this sequence and modify their responses to them. 

Cognitive-behavioral therapy (CBT) usually includes the following elements:

1. A therapist helps you identify the thinking patterns that lead you to misinterpret sensations and assume "the worst" is happening. These patterns of thinking are deeply ingrained, and it will take practice to notice them and then to change them.

Patients are taught that typical thoughts such as "That terrible feeling is getting worse!" or "I'm going to have a panic attack" or "I'm going to have a heart attack" can be replaced with substitutes such as "It's only uneasiness - it will pass" that help to reduce anxiety and ward off a panic attack. Specific procedures for accomplishing this are taught. By modifying thought patterns in this way, the patient gains more control over the problem.

Often the therapist will provide the patient with simple guidelines to follow when he or she can feel that a panic attack is approaching. 

See: Golden Rules For Coping With Panic

The behavioral portion of cognitive-behavioral therapy may involve systematic training in relaxation techniques. By learning to relax, the patient may acquire the ability to reduce generalized anxiety and stress that often sets the stage for panic attacks.

2. Breathing exercises are often included in the behavioral therapy. The patient learns to control his or her breathing and avoid hyperventilation - a pattern of rapid, shallow breathing that can trigger or exacerbate some people's panic attacks.

3. Another important aspect of behavioral therapy is exposure to internal sensations called interoceptive exposure. 

During interoceptive exposure, the therapist will do an individual assessment of internal sensations associated with panic. Depending on the assessment, the therapist may then encourage the patient to bring on some of the sensations of a panic attack by, for example, exercising to increase heart rate, breathing rapidly to trigger lightheadedness and respiratory symptoms, or spinning around to trigger dizziness. 

Exercises to produce feelings of unreality may also be used. Then the therapist teaches the patient to cope effectively with these sensations and to replace alarmist thoughts such as "I am going to die," with more appropriate ones, such as "It's just a little dizziness - I can handle it."

4. Another important aspect of behavioral therapy is "in vivo" or real-life exposure. The therapist and the patient determine whether the patient has been avoiding particular places and situations, and which patterns of avoidance are causing the patient problems. They agree to work on the avoidance behaviors that are most seriously interfering with the patient's life. For example, fear of driving may be of paramount importance for one patient, while inability to go to the grocery store may be, at most, handicapping for another.

Some therapists will go to an agoraphobic patient's home to conduct the initial sessions. Often therapists take their patients on excursions to shopping malls and other places the patients have been avoiding. Or they may accompany their patients who are trying to overcome fear of driving a car.

The patient approaches a feared situation gradually, attempting to stay in spite of rising levels of anxiety. In this way the patient sees that as frightening as the feelings are, they are not dangerous, and they do pass. On each attempt, the patient faces as much fear as he or she can stand. Patients find that with this step-by-step approach, aided by encouragement and skilled advice from the therapist, they can gradually master their fears and enter situations that had seemed unapproachable.

Many therapists assign the patient "homework" to do between sessions. Sometimes patients spend only a few sessions in one-on-one contact with a therapist and continue to work on their own with the aid of a printed manual.

Often the patient will join a therapy group with others striving to overcome panic disorder or phobias, meeting with them weekly to discuss progress, exchange encouragement, and receive guidance from the therapist.

Cognitive-behavioral therapy generally requires at least 8 to 12 weeks. Some people may need a longer time in treatment to learn and implement the skills. This kind of therapy, which is reported to have a low relapse rate, is effective in eliminating panic attacks or reducing their frequency. It also reduces anticipatory anxiety and the avoidance of feared situations.

CBT requires a motivated patient and a specially trained therapist. Make sure any therapist you work with has proper training and experience in this method of panic disorder treatment. Indeed, in some parts of the country, you may find limited access to professionals trained and experienced in CBT.

See Also: Contextual Therapy

Source: NIMH

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