Panic Attacks

How to deal with panic attacks with CBT Therapy

What is a Panic Attack?


How to deal with Panic Attacks with CBT Therapy

Panic attacks are sudden and intense feelings of fear accompanied by several physical sensations which may be interpreted as dangerous by certain people under certain circumstances.

These attacks usually come on very suddenly and reach their peak within about 10 minutes, but the feeling of anxiety can take considerably longer to subside. During a panic attack the body's normal physiological reactions to real fear or danger occur inappropriately, at a time when there is no real threat.

According to Barlow (1988) in around 80% of cases the first panic attack coincides with a time when an individual finds himself in a very stressful situation, for example going to university, difficulties with personal relationships, or exposed to traumatic events. Some pleasant but highly stressful situations such as getting married or getting a new job may trigger panic attacks too.

What are the symptoms of a panic attack?

Typically, a first panic attack seems to come "out of the blue" occurring while a person is engaged in some ordinary activity like driving a car or walking to work.

In order to meet the criteria necessary for an accurate diagnosis of panic attack, at least four of the following symptoms must be present: palpitations or rapid heart rate; breathlessness or difficulty breathing; nausea or churning stomach, choking sensations, feelings of unsteadiness, dizziness, light headedness or faintness; trembling or shaking; sweating; hot flushes or chills; chest pain (or heaviness/chest discomfort, which may also be accompanied by pain on the left arm/ pressure in the head), numbness or tingling sensations (mainly in hands and feet, but sometimes in the face or head). It is not uncommon for people to experience feeling detached from reality (depersonalisation) or that their surroundings are unreal (de-realisation). People may also fear losing control, dying, or going mad while experiencing a panic attack.

Types of panic attacks

There are different types of panic attacks.

A. Nocturnal Panic Attacks

About 10% of all patients with panic disorder have nocturnal panic attacks. They happen when people sleep and are usually very intense. While happening, you may believe that you are suffocating, having a heart attack, a stroke or even dying. They do not occur in REM phase (when nightmares may happen) but during late Phase II or early Phase III (during early sleep from 30 minutes to 45 minutes).

Even when we sleep, we continue to monitor different physiological changes in our bodies. If you had panic attacks before and became worried about the significance of a particular sensation, it is likely that your alarm system wakes you up when your body experiences a change in a particular biological mechanism while sleeping that relates to that sensation e.g. changes in patterns of breathing or heartbeat leading to a nocturnal panic attack. Panic attacks at night will be mainly influenced by the events of the day, consumption of alcohol or drugs and a generally higher arousal due to the anxiety disorder of the person.

Whether or not you are suffering from nocturnal panic attacks, the effectiveness of the CBT treatment does not change. See more about what the treatment entails below.
B. Unexpected and spontaneous panic attacks (not cued).

These are typical attacks and they are a required feature for a diagnosis of panic disorder. Sometimes, a panic attack is confused with a heart attack or some other feared and imminent catastrophic outcome. Panic attacks occur without apparent reason.

C. Specific panic attacks (cued panic attacks)

These occur in relation to specific feared situations or places. It is normally associated with another disorder e.g. social anxiety (fear of people evaluating you negatively), OCD (when you resist a compulsion or you are experiencing a very distressing obsession) or PTSD (when a trigger reminding you of a traumatic event increases your hyperarousal)

D. Situational predisposed panic attacks. These are typical of panic disorder due to a perception of future threat leading to anticipatory anxiety.

Some people with panic disorder can be predisposed to having panic attacks in certain situations or places. They are likely to experience panic attacks if they have anticipatory anxiety about entering the situation or place. e.g. while driving, in a supermarket, giving a presentation.

Are panic attacks the same as panic disorder? What are the criteria necessary for a diagnosis of panic disorder?

A panic attack is not a mental disorder. In fact, more than one in five people experience one or more panic attacks in their lifetime (Kessler, 2006) but few go on to develop panic disorder or agoraphobia (anxiety disorders related to panic attacks).

If a person does not interpret the sensations present in the panic attacks as signs of imminent danger e.g. having a heart attack,/stroke fainting, choking, losing control, going mad, suffocating or dying, then it is not likely that those panic attacks will develop into panic disorder.

In order to diagnose panic disorder (PD), according to the DSM-IV, someone has to experience recurrent panic attacks (at least 2 of which appeared unexpectedly including 4 or more symptoms of the above mentioned ones) followed by at least 1 month of ONE or MORE of the following:

1- Persistent concern about having more panic attacks

2- Anxiety surrounding the implications or consequences of the attack (e.g. Losing control of oneself, having a heart attack, going crazy, fainting, choking, suffocating, etc.)

3 – Finally, the individual significantly changed their behaviour in order to avoid having another panic attack, for example by adopting safety behaviours (e.g. sitting next to an escape exit, being accompanied by someone when going out, avoid queues, drive with windows open, drinking sips of water frequently, etc.). A safety behaviour is anything a person does during a panic attack to minimise their distressing sensations. These are maladaptive and perpetuate the anxiety in the long term.

These unexpected panic attacks can interfere with a person's emotional life, relationships and ability to work.
John and Sylvia are both specialists in treating panic disorder with or without agoraphobia and they will be able to determine, after a thorough online assessment, whether or not you are suffering from panic disorder.

5. Agoraphobia with or without panic disorder

A. Agoraphobia with panic disorder
Approximately 33% to 50% of patients with panic disorder will also be diagnosed with agoraphobia. The fear of embarrassment plays a pivotal role, as most agoraphobics fear not only panic attacks, but also what other people may think if they see them having a panic attack (Bourne, 1990).

Panic disorder may progress to a more advanced state in which the person becomes afraid of being in any place or situation where escape might be difficult or help unavailable in the event of a panic attack. This condition is called agoraphobia. It affects at least a third of all people with panic disorder. Typically, people with agoraphobia fear being in crowds, waiting in a queue, crossing a bridge, entering shopping centres, malls, and using public transportation (or even their own car). Often, these people restrict themselves to a "zone of safety" that may include only the home or immediate neighbourhood.

Agoraphobia is a coping strategy involving avoidance, where the individual is heavily reliant on avoidance of the types of situations just mentioned. It is not just being afraid of being in open spaces or crowds. Agoraphobia is also diagnosed when the sufferer of panic attacks needs a companion to function. A person with agoraphobia typically leads a life of extreme dependency as well as great discomfort although there are different degrees in agoraphobia. Normally, the greater the avoidance of situations (agoraphobia), the longer the treatment will be.

B. Agoraphobia without panic disorder

While agoraphobia is likely to present in panic disorder, sometimes people may experience agoraphobia without having experienced panic attacks. In this particular case, the fear is limited to just ONE SYMPTOM with catastrophic perceived consequences, such as fear of losing control of the bladder, or bowels , vomiting, headaches (including pressure headaches) or fainting.

What is the best evidence-based treatment for panic disorder and agoraphobia?

According to the guidelines set up by the National Institute of Clinical Excellence (NICE), the more effective treatment for panic disorder, with or without agoraphobia is Cognitive Behavioural Therapy, online or face-to-face, effective from 75% to 94% of the cases in the long term.

However, not every CBT psychotherapist works with panic disorder the same way. There are two main CBT treatment packages, one more cognitively oriented (the Oxford-based Cognitive Therapy Treatment protocol) and the other more behavioural in nature (the Albany-based Panic Control Treatment developed by Barlow in 1989). While both protocols are equally effective, Sylvia and John only uses the Oxford-cognitive package developed by Clark, Salkovkis, Beck and colleagues (1989-1991) as this protocol seems to be better tolerated by patients(dropout rates for the Oxford protocol are only 3% compared with Barlow's protocol 12% to 16%). It is much more comfortable for patients because it is not based on exposure therapy, relaxation or breathing retraining. These last two methods may result in the development of safety behaviours, which may maintain the panic circle in the long term.

CBT treatment aims:

A. Firstly to reduce catastrophic misinterpretations and the hypervigilance that generates and maintains fear.
B. Eliminate all avoidance and safety seeking behaviours that maintain the vicious circle of panic and agoraphobia.
C. A very important objective for the cognitive model protocol is to test out the validity of the catastrophic and non catastrophic interpretations using both discussion techniques, cognitive restructuring and behavioural experiments.

What does cognitive therapy for panic disorder entail using the Oxford protocol?

Cognitive therapy for panic disorder was developed by Clark, Salkovskis, Beck and colleagues (1989, 1991) and focuses on directly changing an individual's misinterpretations of bodily sensations.

The components of the Oxford-based protocol are based purely on cognitive therapy with the addition of behavioural experiments. The treatment comprises of the following components:

1. Assessment of your panic attacks

2. Review of a recent panic attack in order to derive the graphical representation of the vicious circle model (case formulation). We also promote learning about what your sensations mean from a biological point of view, but demonstrated in a Socratic manner and we outline the treatment plan tailored to your particular clinical needs.

3. Discussion techniques. 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.

4. Cognitive restructuring is a major part of the treatment, and 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 online sessions, patients are taught to re-evaluate the validity of these distorted thoughts, and change them to more rational, adaptive ones. Patients will repeatedly challenge their dysfunctional thoughts during treatment. Based on the theory that you may be experiencing a medical condition rather than an anxiety problem, Sylvia and John will facilitate situations where you will be able to gather evidence to support either one theory or the other. Other beliefs are also targeted and modified, increasing your level of distress or possible depression such as, "I am weak if I am not able to cope with my panic attacks", "I need to always be with someone in a supermarket or I may faint", etc.

5. Another technique used to address your interpretations in the course of cognitive therapy is called "Behavioural Experiments". These are experiments we design in session to test whether your predictions are accurate regarding your sensations when feeling panicky, the usefulness of your safety behaviours, or the consequences of your panic. Conclusions derived from these experiments will be part of gathering evidence whether Theory 1 (you really have a medical problem leading to the symptoms) or Theory 2 (you have a worry problem which maintain the panic symptoms) is more correct.

For example, if you believed that rapid heartbeat is the precedent of a heart attack, then we design a Behavioural experiment whereby we need to induce that sensation and see if it leads to a heart attack. When the person repeats the experiment a number of times, the conviction about having a heart attack should decrease, unless the patient is engaging in some sort of safety behaviour or use safety objects.

6. Monitoring of anxiety and homework are continuously assigned throughout the protocol to consolidate treatment gains. Setting homework and being committed to doing what may have been agreed on in session is an essential component of any CBT treatment. A commitment to the online CBT programme and trying to complete all the necessary tasks is likely to make the treatment successful.

7. The behaviorual aspect of the therapy is focused on eliminating your avoidance, safety behaviours, use of safety objects and signals.

In comparison, what treatments are more effective for panic disorder?

Research has shown that for most patients, there will be a positive response to both cognitive behavioural and pharmacological treatments, however, CBT is more effective in the long term (74% to 94%), has lower relapse rates of around 5%, and has fewer dropouts than pharmacological treatments.

Less effective than online CBT would be applied relaxation. This method was devised by Ost and Westling in 1995, and even though they are not as successful as CBT these methods can represent effective treatment for 47% to 58% of patients, with therapeutic gains maintained at a 1 year follow up. However, NICE guidelines does not recommend applied relaxation as first line of intervention because CBT is much more effective. Sylvia and John use the best methods recommended by NICE guidelines to obtain the best possible result in the shortest period of time.

Relaxation techniques are not the most effective treatment for panic disorder and therefore are not used by Sylvia or John.

What does not work for panic disorder?

There is a lack of evidence to support the use of the following interventions in panic disorder:

1. Hypnosis
2. Interpersonal therapy
3. Neurolinguistic programming (NLP)
4. Problem solving
5. Progressive muscular relaxation
6. Psychodynamic therapy
7. Solution focused therapy
8. Stress control or management
9. EMDR (Eye Movement Desensitisation Reprocessing Therapy). While Sylvia and John are fully qualified Level II EMDR therapists, they do not use EMDR for panic disorder as there is no scientific evidence that it is effective for treating panic disorder.
10. Benzodiazepines e.g. Alprazolam, diazepam, etc. It may be effective while being taken (although it can become highly addictive). However, the rate of relapse within a year is 95%. In fact, taking this medication while undertaking a course of Cognitive Behavioural Therapy may render the treatment ineffective and they should be reduced as soon as possible or results are likely to be poor.

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