Treatments for Panic disorder
Treatment list for Panic disorder: The list of treatments mentioned in various sources for Panic disorder includes the following list. Always seek professional medical advice about any treatment or change in treatment plans.
- High-potency benzodiazepines
Treatments of Panic disorder discussion: Studies have shown that proper treatment -- a type of psychotherapy called cognitive-behavioral therapy, medications, or possibly a combination of the two -- helps 70-80 percent of people with panic disorder. Significant improvement is usually seen within 6-8 weeks.
Cognitive-behavioral approaches teach patients how to view the panic situations differently and demonstrate ways to reduce anxiety, using breathing exercises or techniques to refocus attention, for example. Another technique used in cognitive-behavioral therapy, called exposure therapy, can often help alleviate the phobias that may result from panic disorder. In exposure therapy, people are very slowly exposed to the fearful situation until they become desensitized to it.
Some people find the greatest relief from panic disorder symptoms when they take certain prescription medications. Such medications, like cognitive-behavioral therapy, can help to prevent panic attacks or reduce their frequency and severity. Two types of medications that have been shown to be safe and effective in the treatment of panic disorder are antidepressants and benzodiazepines. 1
Unfortunately, some people are reluctant to pursue treatment. Perhaps they think their condition is not serious. Perhaps they feel embarrassed. They may blame themselves or have trouble asking for help. Perhaps they dislike the idea of medication or therapy. Or, maybe they have sought help but are frustrated because their condition was not diagnosed or treated effectively.
Do not let these or any other reasons stop you from getting proper treatment. If you have panic disorder, you should get whatever help is necessary to overcome it, just as you would for any serious medical illness.
Do not be discouraged if some people say, "It's nothing to worry about," "It's just stress," "It's all in your head," or "Snap out of it." While they often mean well, the fact is that most people who do not have panic disorder do not understand that it is REAL and, therefore, tend to doubt its seriousness.
Most importantly, do not try to numb the effects of panic attacks with alcohol or other drugs. This will only make the problem worse.2
Treatment for panic disorder can consist of taking a medication to adjust the chemicals in your body—just as you might take medicine to correct a thyroid imbalance.
Or treatment might involve working with a psychotherapist to gain more control over your anxieties--just as some people work with specialists to learn techniques to control migraine headaches or lower their blood pressure.
Research shows that both kinds of treatment can be very effective. For many patients, the combination of medication and psychotherapy appears to be more effective than either treatment alone. Early treatment can help keep panic disorder from progressing.
Cognitive-behavioral therapy (CBT) teaches you to anticipate and prepare yourself for the situations and bodily sensations that may trigger panic attacks. CBT usually includes the following elements:
- 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.
- A therapist can teach you breathing exercises that calm you and that
can prevent the overbreathing, or hyperventilation, that often occurs
during a panic attack.
- A therapist can help you gradually become less sensitive to the frightening bodily sensations and feelings of terror. This is done by helping you, step-by-step, to safely test yourself in the places and situations you've been avoiding.
CBT generally requires at least 8 to 12 weeks. Some people may need a longer time in treatment to learn the skills and put them into practice. Most panic disorder patients are successful in controlling or preventing their panic attacks after completing treatment with CBT.
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.
Several types of medication that alter the ways chemicals interact in the brain can reduce or prevent panic attacks and decrease anxiety. Two major categories of medication that have been shown to be safe and effective in the treatment of panic disorder are antidepressants and benzodiazepines.
Each medication works differently. Some work quickly and others more gradually. All of them have to be taken on a regular basis. Usually, treatment with medication lasts at least 6 months to a year. But within 8 weeks, you and your doctor should be able to assess whether it's effectively blocking the panic attacks. More details on medications can be found in the brochure "Understanding Panic Disorder."
Clinical experience suggests that for many patients with panic disorder, a combination of CBT and medication may be the best treatment. The National Institute of Mental Health (NIMH) is conducting a large study to confirm this and to help determine the kinds of patients most likely to need combined therapy2
From the beginning, it is important to be a full participant in your treatment. Be active and assertive. Ask questions. Maintain open communication with your treatment professional and let him or her know your concerns.
Every patient responds differently, but it is important to know that none of the treatments for panic disorder works instantly. So, you must stick with a particular treatment for at least 8 weeks to see if it works. If you do not see significant improvement within that time, you and your treatment professional can adjust your treatment plan. It may take a bit of trial and error before you find what works best for you. Be patient and be sure to communicate with your treatment professional. Of course, if at any time you feel uncomfortable with the professional you have chosen or don't think your treatment is going well, you should feel free to consider seeking a second opinion or even changing providers.
If your treatment involves medication, talk with your doctor about how often and in what manner your dosage will be monitored. No matter what medication you are taking, your doctor is likely to start you on a low dose and gradually increase it to the full dose. You should know that every medication has side effects, but they usually become tolerated or diminish with time. If side effects become a problem, the doctor may advise you to stop taking the medication and to wait a week or so before trying another medication. When your treatment is near an end, your doctor will taper the dosage gradually.2
Before undergoing any treatment for panic disorder, a person should undergo a thorough medical examination to rule out other possible causes of the distressing symptoms. This is necessary because a number of other conditions, such as excessive levels of thyroid hormone, certain types of epilepsy, or cardiac arrhythmias, which are disturbances in the rhythm of the heartbeat, can cause symptoms resembling those of panic disorder.
Several effective treatments have been developed for panic disorder and agoraphobia. In 1991, a conference held at the National Institutes of Health (NIH) under the sponsorship of the National Institute of Mental Health and the Office of Medical Applications of Research, surveyed the available information on panic disorder and its treatment. The conferees concluded that a form of psychotherapy called cognitive-behavioral therapy and medications are both effective for panic disorder. A treatment should be selected according to the individual needs and preferences of the patient, the panel said, and any treatment that fails to produce an effect within 6 to 8 weeks should be reassessed.
Cognitive-Behavioral Therapy. 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: 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. The person with panic disorder responds to the sensation by becoming anxious. 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. 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. 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.3
In cognitive therapy, discussions between the patient and the therapist are not usually focused on the patient's past, as is the case with some forms of psychotherapy. Instead, conversations focus on the difficulties and successes the patient is having at the present time, and on skills the patient needs to learn.
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.
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.
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."
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.
Treatment with Medications. In this treatment approach, which is also called pharmacotherapy, a prescription medication is used both to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety. When patients find that their panic attacks are less frequent and severe, they are increasingly able to venture into situations that had been off-limits to them. In this way, they benefit from exposure to previously feared situations as well as from the medication.
The three groups of medications most commonly used are the tricyclic antidepressants, the high-potency benzodiazepines, and the monoamine oxidase inhibitors (MAOIs). Determination of which drug to use is based on considerations of safety, efficacy, and the personal needs and preferences of the patient. Some information about each of the classes of drugs follows.
The tricyclic antidepressants were the first medications shown to have a beneficial effect against panic disorder. Imipramine is the tricyclic most commonly used for this condition. When imipramine is prescribed, the patient usually starts with small daily doses that are increased every few days until an effective dosage is reached. The slow introduction of imipramine helps minimize side effects such as dry mouth, constipation, and blurred vision. People with panic disorder, who are inclined to be hypervigilant about physical sensations, often find these side effects disturbing at the outset. Side effects usually fade after the patient has been on the medication a few weeks.
It usually takes several weeks for imipramine to have a beneficial effect on panic disorder. Most patients treated with imipramine will be panic-free within a few weeks or months. Treatment generally lasts from 6 to 12 months. Treatment for a shorter period of time is possible, but there is substantial risk that when imipramine is stopped, panic attacks will recur. Extending the period of treatment to 6 months to a year may reduce this risk of a relapse. When the treatment period is complete, the dosage of imipramine is tapered over a period of several weeks.
The high-potency benzodiazepines are a class of medications that effectively reduce anxiety. Alprazolam, clonazepam, and lorazepam are medications that belong to this class. They take effect rapidly, have few bothersome side effects, and are well tolerated by the majority of patients. However, some patients, especially those who have had problems with alcohol or drug dependency, may become dependent on benzodiazepines.
Generally, the physician prescribing one of these drugs starts the patient on a low dose and gradually increases it until panic attacks cease. This procedure minimizes side effects.
Treatment with high-potency benzodiazepines is usually continued for 6 months to a year. One drawback of these medications is that patients may experience withdrawal symptoms – malaise, weakness, and other unpleasant effects – when the treatment is discontinued. Reducing the dose gradually generally minimizes these problems. There may also be a recurrence of panic attacks after the medication is withdrawn.
Of the MAOIs, a class of antidepressants which have been shown to be effective against panic disorder, phenelzine is the most commonly used. Treatment with phenelzine usually starts with a relatively low daily dosage that is increased gradually until panic attacks cease or the patient reaches a maximum dosage of about 100 milligrams a day.
Use of phenelzine or any other MAOI requires the patient to observe exacting dietary restrictions, because there are foods and prescription drugs and certain substances of abuse that can interact with the MAOI to cause a sudden, dangerous rise in blood pressure. All patients who are taking MAOIs should obtain their physician's guidance concerning dietary restrictions and should consult with their physician before using any over-the-counter or prescription medications.
As in the case of the high-potency benzodiazepines and imipramine, treatment with phenelzine or another MAOI generally lasts 6 months to a year. At the conclusion of the treatment period, the medication is gradually tapered.
Newly available antidepressants such as fluoxetine (one of a class of new agents called serotonin reuptake inhibitors) appear to be effective in selected cases of panic disorder. As with other anti-panic medications, it is important to start with very small doses and gradually increase the dosage.
Scientists supported by NIMH are seeking ways to improve drug treatment for panic disorder. Studies are underway to determine the optimal duration of treatment with medications, who they are most likely to help, and how to moderate problems associated with withdrawal.
Combination Treatments. Many believe that a combination of medication and cognitive-behavioral therapy represents the best alternative for the treatment of panic disorder. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate. However, there is a need for more research studies to determine whether this is in fact the case.
Comparing medications and psychological treatments, and determining how well they work in combination, is the goal of several NIMH-supported studies. The largest of these is a 4-year clinical trial that will include 480 patients and involve four centers at the State University of New York at Albany, Cornell University, Hillside Hospital/Columbia University, and Yale University. This study is designed to determine how treatment with imipramine compares with a cognitive-behavioral approach, and whether combining the two yields benefits over either method alone.
Psychodynamic Treatment. This is a form of "talk therapy" in which the therapist and the patient, working together, seek to uncover emotional conflicts that may underlie the patient's problems. By talking about these conflicts and gaining a better understanding of them, the patient is helped to overcome the problems. Often, psychodynamic treatment focuses on events of the past and making the patient aware of the ramifications of long-buried problems.
Although psychodynamic approaches may help to relieve the stress that contributes to panic attacks, they do not seem to stop the attacks directly. In fact, there is no scientific evidence that this form of therapy by itself is effective in helping people to overcome panic disorder or agoraphobia. However, if a patient's panic disorder occurs along with some broader and pre-existing emotional disturbance, psychodynamic treatment may be a helpful addition to the overall treatment program.3
Self-help and support groups are the least expensive
approach to managing panic disorder, and are helpful for some people. A
group of about 5 to 10 people meet weekly and share their experiences,
encouraging each other to venture into feared situations and cope
effectively with panic attacks. Group members are in charge of the
sessions. Often family members are invited to attend these groups, and at
times a therapist or other panic disorder expert may be brought in to
share insights with group members. Information on self-help groups in
specific areas of the country can be obtained from the Anxiety Disorders
Association of America.
1. excerpt from Panic Disorder: NWHIC
2. excerpt from Getting Treatment for Panic Disorder: NIMH
3. excerpt from Understanding Panic Disorder: NIMH
Last revision: July 1, 2003
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