Cognitive Behavior Therapy for
Panic Disorder and Agoraphobia
William C. Sanderson, PhD

Lori is a 22 year old woman who graduated from college three months ago. She will be getting married in two months and will be moving with her husband to another state. Two weeks ago, while driving alone on a highway to visit her fiance, she began feeling extremely dizzy and lightheaded. Her hands were "tingling" and she felt nauseous. "I thought I was going to faint while driving - the car would go off the road - and I would be killed or severely injured!" Lori stopped the car, pulled onto the shoulder, and turned her emergency flasher on. A police car came by about twenty minutes later and rushed Lori to the hospital. She was kept overnight for observation. After extensive testing she was advised that she was in "perfect health." Surprised, she asked the doctor: "But why did I feel like I was going to faint?" The doctor replied: "You're probably just nervous about getting married and moving away." The doctor gave her a prescription for Xanax (a tranquilizer) and advised her to use it when she needed it during the next few months. But over the next few weeks she had these feelings every day. In addition to feeling faint, she would often experience a "dream-like" state (ie, feeling as though she was not really in the situation) that would last for several hours at a time. Lori was convinced that either she had a brain tumor or she was going crazy. She became afraid to leave the house, and never went out of the house without being accompanied by a member of her family. Lori also became quite depressed. She began crying much of the time, lost her appetite, and could not enjoy anything. Her parents became concerned and took her to a neurologist, cardiologist, and endocrinologist. She had a CAT scan, EKG, and extensive blood analysis. Each physician informed Lori that she was not physically ill. Lori noted that "Surprisingly, I was not at all relieved to hear this. I was sure that I had something wrong with me that was going undetected. The physicians were refusing to repeat the tests, saying it was unnecessary. I remained housebound, constantly in a state of fear, wondering when will I have another attack - fearing that one would be fatal."

WHAT IS A PANIC ATTACK?

The term panic attack was officially described by the American Psychiatric Association's classification system -- the DSM -- in 1980. Panic attacks are "discrete periods of intense fear or discomfort.... often there is a feeling of impending doom." At the very least, the first attack occurs unexpectedly--that is to say, it is not necessarily triggered by a situation which would cause one to experience anxiety. In addition, the DSM definition of panic requires the presence of at least four of the following symptoms (shortness of breath, dizziness, faintness, palpitations, trembling or shaking, choking, nausea, depersonalization, numbness or tingling sensations, flushes or chills, chest pain, fear of dying, fear of going crazy or of doing something uncontrolled). Thus, panic attacks can be best characterized as a sudden burst of intense fear accompanied by uncomfortable and uncontrollable physical sensations. Typically, the attacks appear to be spontaneous when their first occur. However, overtime, the attacks become associated with various situations that can eventually provoke the attacks.

WHAT IS PANIC DISORDER?

Panic Disorder is the official name listed in the DSM for the disorder from which patients suffer from repeated panic attacks. In addition to panic attacks, most patients with panic disorder often experience agoraphobia as well. Agoraphobia refers to the fear of going into certain situations because it may trigger a panic attack. This is often the most disabling part of the disorder, as it can greatly reduce one's ability to function. Common agoraphobia situations include shopping malls, bridges, elevators, planes, driving long distances, being at home alone, tunnels, buses/trains, and traveling a significant distance away from home. The level of agoraphobia in panic disorder patients is quite variable, and even fluctuates from time to time within an individual. Some patients are unable to leave their own home, others are able to leave home and hold a job but avoid many situations, and still others are frightened of many situations but do not avoid them.

In addition to panic disorder attacks and agoraphobia, patients with panic disorder often suffer from chronic anxiety and depression. The chronic anxiety is often related to the feeling that the attacks can happen at anytime, so patients become constantly on edge, waiting for the next attack to occur. Ironically, a patient will often "talk" him or herself into a panic attack just by worrying about it. The depression is often related to the feeling that his or her life is not going to get back to "normal." Patients often become sad, hopeless about the future, and suffer a loss of self-esteem. In some cases the depression becomes quite severe, and patients contemplate suicide to end their pain.

"I KNOW THERE IS SOMETHING PHYSICALLY WRONG WITH ME!"

This is the single most widely held belief by people who suffer from panic attacks, especially when the attacks first begin. Since panic attacks are composed of physical sensations, it is logical that patients believe there is a physical disturbance. Indeed, patients will go from doctor to doctor attempting to find an explanation of their symptoms. And despite the doctors reassurance that he or she is in good health, the patient continues to believe that something is being missed. Surprisingly, many panic disorder patients have told me that they wish that someone would find something wrong with them. What would cause a person to actually hope for a physical problem to be found? It is because the unknown is very frightening and people will imagine the worst. In my own practice, I have found that in almost all cases, telling panic disorder patients that there are many other people who complain of a similar problem; and providing an explanation about panic attacks, puts their mind at ease and results in their feeling somewhat better.

It is important to note that research does not suggest that panic attacks are caused by a disease or physical illness. It appears as though some people have a nervous system that reacts a bit more to stress. Many panic patients have their first attack during a period of chronic stress. Panic attacks may be the result of interpreting harmless physical sensations -- which and be very uncomfortable -- as being dangerous. Among the most common thoughts are: "I am having a heart attack," "I am going to faint or pass out," "I am going to lose control," "I am going to go crazy!" Having these thoughts will actually worsen the symptoms.

WHAT IS COGNITIVE BEHAVIOR THERAPY?

Cognitive Behavior Therapy (CBT) for panic disorder is a psychological treatment approach primarily developed by Dr. David Barlow at the Center for Anxiety Disorders in Boston, and by Dr. Aaron Beck at the Center for Cognitive Therapy, University of Pennsylvania School of Medicine, in Philadelphia. I worked closely with both Drs. Beck and Barlow, researching the nature of panic disorder, and testing the effectiveness of this treatment approach in large research studies. At both sites, and now confirmed from studies throughout the world, CBT was shown to be an effective treatment, leading to a reduction in panic attacks for a majority of patients. CBT is as effective as state-of-the-art medications in treating panic disorder.

CBT consists of the following components, each which will be described briefly: 1- Education, 2- Cognitive Restructuring, 3- Breathing Training, 4- Relaxation Exercises, 5- Situational Exposure, 6- Interoceptive Exposure. Each component is aimed at alleviating panic attacks, agoraphobic avoidance, chronic anxiety, and depression associated with panic disorder (note: clinician's may apply only those techniques that they determine are relevant to your problem).

Throughout treatment, patients are educated about panic attacks and the development of panic disorder. An understanding of panic disorder is believed to be an important part of the recovery process.

Cognitive restructuring, a major part of the treatment, is intended to correct distorted thinking about panic attacks. The goal is to have patients change their reaction to their emotional arousal and panic symptoms, and learn to deal effectively with anxiety provoking situations. During the early sessions of therapy, patients are asked to self-monitor their thoughts, assumptions, and beliefs during anxiety provoking situations and panic attacks. With the collaboration of the therapist, patients begin to appreciate the role of cognition, beliefs, and appraisals in the evocation or accentuation of anxiety and panic attacks. During the later sessions, patients are taught to re-evaluate the validity of these distorted thoughts, and change them to more rational, adaptive ones. In particular, patients' "catastrophic misinterpretations" of panic-related somatic cues -- the belief that these physical sensations are a sign that he or she is dying at that moment -- are addressed. Patients will repeatedly challenge their dysfunctional thoughts during treatment.

Breathing training teaches patients a pattern of slow, regular breathing which prevents hyperventilation, an uncomfortable symptom of and cue for panic attacks.

Relaxation exercises that involve progressive muscle tension are often incorporated to lower general anxiety levels.

Situational exposure consists of structured and repeated exposure to anxiety - and panic provoking ("phobic") situations. Based on the patient's individualized list of feared situations, he or she undergoes exposure to these situations while using coping strategies learned during therapy, beginning with the least feared and moving to the most feared. This typically takes place later on during therapy, once a patient feels more in control of panic attacks. The aim of situational exposure is to eliminate agoraphobia.

When necessary, Interoceptive exposure may be conducted. Interoceptive exposure involves the structured and repeated exposure to panic-like physical sensations. Based on the patient's individualized hierarchy of feared internal sensations (e.g., dizziness, palpitations), he or she undergoes systematic exposure to these sensations. The feared sensations may be produced using idiosyncratic methods such as controlled hyperventilation or physical exertion (e.g., running up a flight of stairs to get your heart racing). This is necessary because patient's often become fearful of harmless body sensations, such as those caused by exercise, caffeine, and excitement.

IS THIS TREATMENT FOR YOU?

As it may appear, the treatment requires a fair amount of work. Therefore, I encourage patients to enter only when they feel committed to overcoming their problem. Practicing what is covered during therapy sessions at home is essential to getting better.

You may feel that the treatment itself is anxiety provoking. After all, why would you want to go into situations which make you feel anxious? In my opinion, as well as many other clinicians and researchers in this field, one must confront his/her anxiety to get over it. However, please be assured that patients move at a rate at which they feel comfortable. Patients are given encouragement b the therapist to overcome this problem, but no one is pushed into doing something he or she is not ready for. The therapist understands the intense fear involved in this problem. The goal of the therapist is to prepare the patient to deal with each step in an effective manner using the techniques described above. The patient and therapist maintain a friendly, collaborative relationship. The therapy focuses on the present problem and how to alleviate it. If you are ready to make the commitment, and the treatment sounds sensible to you, then there is no reason to believe you can not get better. The good news is that nearly all patients involved in our treatment program will benefit and feel significantly better.

FOR MORE INFORMATION
The following books are recommended:

Peace from Nervous Suffering by Clare Weekes (Hawthorne, 1972).
Don't Panic: Taking Control of Anxiety Attacks by Reid Wilson. (Harper & Row, 1987).

Free information is available through the :
Anxiety Disorders Association of America (301-231-9350)
National Institute of Mental Health (1-800-64-PANIC)

FOR MORE INFORMATION ABOUT COGNITIVE THERAPY:

Dr. Sanderson is Associate Professor of Psychiatry and Director of the Cognitive Behavior Therapy Program at Albert Einstein College of Medicine/Montefiore Medical Center. He was an appointed adviser to the DSM-IV Anxiety Disorders Workgroup, and is currently a member of the American Psychological Association Division of Clinical Psychology's Task Force on Psychological Interventions (aimed at identifying empirically validated psychological interventions). He has published over 60 articles and chapters, primarily in the areas of anxiety, depression, and cognitive behavior therapy. Dr. Sanderson is a licensed clinical psychologist and specializes in the treatment of anxiety and depressive disorders
Telephone: 718-920-2933
Website: http://members.aol.com/sandersonw/