ognitive-Behavioral Therapy (CBT):
Highly specific treatments for each of these anxiety disorders have been developed and have proven efficacy in well-controlled trials. New data and APA guidelines now support CBT as a first line treatment for Panic Disorder. CBT clearly enhances long-term outcomes.
Basic Principles of Cognitive-Behavioral Therapy (CBT) for Anxiety Disorders: Fundamental Law of Anxiety and Exposure Therapy
Anything that triggers anxiety tends to be avoided. If frightening objects or situations are avoided, they will become more frightening over time. If the avoidance is overcome, and frightening objects or situations are repeatedly confronted without leading to the anticipated dangerous outcome, they become less frightening. We call this desensitization, and it can only occur through exposure. Fear of any anxiety arousing object or situation can be desensitized by a properly managed and structured exposure program. When done properly it always works. So, whenever the clinical picture includes anxiety cued by specific objects or situations, exposure principles are important to the treatment.
Goal 1: Reduce fear of panic attacks themselves.
Primary technique: Cognitive restructuring
Approach: A central issue for most patients with panic disorder is an intense fear of the sensations they experience during a panic attack. These fears often include catastrophic misperceptions that something terrible may happen during a panic attack such as dying, having a heart attack, experiencing a stroke, fainting, smothering, going crazy or losing control. These "catastrophic misinterpretations" contribute to a "fear of fear" cycle that begins to trigger and intensify attacks in response to benign physiological experiences, like increased heart rate from rushing through the mall. Though the grave consequences that they fear never occur, patients are not easily convinced that they won't happen the next time. They continue to believe that they escaped catastrophe by fleeing and the next attack may finally bring it on.
Cognitive therapy is a form of psychotherapy that is used to help patients replace inaccurate, distorted, thinking with more accurate self-statements. In conducting cognitive therapy, the therapist works together with the patient to build a compelling argument that the patient's fears are irrational. Several sources of information are used to help patients think more accurately when their anxiety symptoms increase. One source of information is the patient's personal history of panic attacks. How many panic attacks, both large and small, have they experienced? How many predictions of catastrophe? How many actual catastrophes? A second source of information used to counter distorted thinking is the experiences of other panic disordered patients. How many patients with panic disorder seen at the anxiety clinic? (about 3,000 at last count), How many panic attacks in total? (many thousands) How many predicted catastrophes? (many thousands) How many actual catastrophes? (the answer is none, of course).
Another cognitive procedure is usually referred to as behavioral experiments. This technique is used to counter the commonly held belief that a particular patient's panic attacks are dangerous, different from the panic attacks that other patients experience. Most patients with panic disorder use several strategies in order to control their panic and prevent a catastrophe, including, fleeing the situation, taking a drink of water, eating something, or distracting themselves. During behavioral experiments, patients are asked to allow panic attacks to run their course, without interruption, in order to learn first hand that their panic attacks, like other patient's panic attacks, only seem to signal an impending calamity. So we say, "let the panic attack happen and let yourself experience it, using the cognitive techniques you are taught to help you through it; and it will become less frightening." This is very different from simple reassurance that nothing serious is wrong. Reassurance alone is not helpful and tends to undermine self-esteem. Patients need to know that we understand that they can't just talk themselves out of their fear. But we need to convince them that they can at least put up an argument. If practiced regularly, the cognitive techniques described above are often helpful in reducing the frequency and intensity of attacks.
Goal 2: Reduce fear of the physical symptoms associated with panic or anxiety (reduce anxiety sensitivity)
Technique: Exposure and desensitization to somatic cues
Approach: Systematic, paced, and repetitive exposure to the physical symptoms that they find most frightening. For those focused on cardiac symptoms and fear they are having a heart attack, we use exposure to the sensation of a pounding heart induced by exercise. For those focused on dizziness and fear of fainting, we use exposure to dizziness induced by spinning. For those frightened of lightheadedness or tingling, we use exposure to neurological symptoms induced by hyperventilation. The exposure process (called interoceptive exposure) is taught in session, and then practiced daily by patients in homework assignments.
Goal 3: Reduce fear and avoidance of agoraphobic situations
Technique: Exposure and desensitization
Approach: Systematic, paced, and repetitive exposure to the situations that are frightening and avoided. The exposure process is taught in session and then practiced daily by patients in homework assignments. The principle is very simple. If you are afraid of driving, the solution is to drive. If you are afraid of going to the mall, the solution is to go to the mall. The key is to accumulate sufficient exposure, properly paced, to allow the patient to sit through anxious distress long enough to allow it to extinguish, without removing themselves from exposure to the anxiogenic cues.