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Identifying and Treating Panic Disorder

By Nicole Bosse, PsyD
Lindner Center of HOPE, Staff Psychologist

What is panic disorder? Panic disorder consists of recurrent unexpected panic attacks, specifically a spike of intense anxiety
or discomfort that reaches a peak in minutes that is followed by four or more of the following symptoms: racing heart/palpitations, sweating, trembling/shaking, shortness of breath, feelings of choking, chest pain or discomfort, nausea, dizziness, chills or heat sensations, numbness or tingling in the hands or feet, derealization, fear of losing control or going crazy, and fear of dying. This has to occur in combination with fear and worry about having additional attacks, and a significant change in behavior related to the attacks, such as avoiding situations or activities that might bring on panic.

When treating panic disorder, it is treated mostly from a cognitive behavioral approach. The cognitive piece targets the person’s misappraisals about the panic. Individuals with panic disorder tend to overestimate the likelihood of panic occurrence, underestimate one’s ability to cope with panic, and exaggerate the negative consequences of panic attacks.

By helping the individual to identify the misappraisals and working on challenging them, individuals are less fused with their thoughts and can start to think differently about things rather than buy into their thoughts as facts.

The behavioral piece of the approach involves exposure therapy, specifically exposure to what situations they avoid, but also interoceptive exposures. Interoceptive exposures involve gradually exposing oneself to the physical sensations of the panic attack that are feared. Working with a therapist to identify the exposures that rank from low to high is important. Once this is identified, the patient and therapist work from the least distressing to the most distressing. The following are some examples of possible interoceptive exposures:

* Running in Place

* Holding breath

* Head shaking (side to side)

* Spinning in a chair

* Mirror staring

* All over muscle tensing

* Straw breathing

* Over breathing

* Head between legs

The therapist and the individual work to complete just one of these exposures, five times during the day for about 30-60 seconds. This is done repeatedly every day until the person habituates to that sensation before moving on to the next exercise.

 

Another exposure idea that is sometimes used is pretending to actually have a panic attack in a public area. This strategy is brought in when the person’s fear centers around the social consequences of having a panic attack, such as not wanting others to crowd around them or being embarrassed. For example, I have suggested that individual’s go to a store and practice sitting down somewhere to pretend they are dizzy or cannot catch their breath. This is a great strategy for teaching the person that what they typically fear in that situation is not as bad as they make it out in their mind. It actually usually ends up being pretty uneventful.

 

Exposures for the avoidance of situations is a little more specific for the person and their unique avoidances. Some common examples of avoidance that I have come across are the following: avoiding caffeine, avoiding intense exercise that increases their heart rate, avoiding being in a car, avoiding driving, avoiding going into stores, avoiding traveling far distances from one’s house, avoiding going places alone, avoiding going places without safety items (i.e., water, benzodiazepine, food, etc.), and avoiding places where the amount of time being there is uncertain (i.e., waiting in lines, sitting down at a restaurant, etc.)

Once the individual’s unique avoidances are identified, the therapist and individual work to create another hierarchy, ranking from low to high distress. For example, if someone avoids going certain distances from their house, some exposures could consist of walking down the street and gradually increasing the distance. A similar strategy could also be used for driving, gradually increasing the distance of driving from a person’s house. Similarly, for line waiting, the individual could practice waiting in lines and gradually increase the amount of time they wait in line, working up to actually waiting in the entire line and being uncertain of when it when it will end.

As you can see by the above described therapy, the main component is facing what the individual fears and letting the body learn that their anxiety will decrease without having to escape the situation. Panic disorder is a very treatable disorder, especially when engaging the correct therapy for it and when combined with the appropriate medication.