This is a combination of cognitive therapy, which modifies or eliminates thought patterns contributing to the patient's symptoms, and behavioral therapy, which helps the patient to change his or her resulting behavior. With the assistance of a skilled therapist, those with panic disorder often succeed in learning to recognize their earliest thoughts and feelings in a panic sequence and modify their responses to them. Patients are taught that typical thoughts such as "I am having a heart attack" can be replaced with substitute such as "This is only uneasiness and it will pass". This substitution helps to reduce anxiety and ward off a panic attack and helps the patient gain more control over the problem.

Typically the patient undergoing cognitive-behavioral therapy meets with a therapist for 1 to 3 hours a week with occasional "homework" between sessions. Some patients spend only a few sessions in therapy and continue to work on their own from an assigned workbook. Many patients opt for weekly group therapy for support from others striving to overcome panic disorder.

In the cognitive portion of the therapy, the therapist usually conducts a careful search for the thoughts and feelings that accompany the 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 whole cycle may only take a few seconds with the individual not even being aware of the initial sensations or thoughts.


In this cycle, the individual feels a potentially worrisome sensation such as an increasing heart rate, tightened chest muscles, or a queasy stomach. The triggering event could be some worry, an unpleasant mental image, a minor illness, or even exercise. The person with panic disorder responds by becoming anxious and this anxiety triggers more unpleasant sensations which heightens anxiety even further and gives rise to catastrophic thoughts. As the vicious cycle continues, a panic attack results.

In cognitive therapy, discussions revolve around present trials and accomplishments. Often the therapist provides guidelines or strategies for coping with panic attacks and the skills necessary to diffuse the thought process.

The behavioral portion of cognitive-behavioral therapy may focus on relaxation techniques. Learning to relax helps to reduce generalized anxiety and stess that often precludes panic attacks. Breathing excercises help the patient avoid hyperventilation which can trigger or intensify panic attacks.

Another focus of behavioral therapy is exposure to internal sensations called interoceptive exposure. This involves the therapist assessing the patient's internal sensations associated with panic. Depending on the assessment, the therapist may then encourage the patient to induce a panic attack by exercising to increase heart rate, breathing rapidly to trigger lightheadedness and respiratory symptoms, or spinning around to trigger dizziness. Then the therapist teaches the patient to cope effectively with these sensations and to replace alarmist thoughts such with more appropriate ones.

Behavioral therapy also includes "in vivo" or real-life exposure. The therapist and the patient determine which avoidance behaviors are most interfering with the patient's life and agree to work on those troublesome behaviors together.

Patients approach their feared situations gradually and are encouraged to continue in spite of increasing anxiety. They only attempt to face as much fear as they can stand. In doing so, they learn to realize that as frightening as the feelings are, they cannot hurt them, and will pass. These sessions help the patients to master their fears and take control of situations that had seemed unapproachable.

Cognitive-behavioral therapy generally requires at least 8 to 12 weeks with some patients requiring more time to build their skills. This therapy offers a low relapse rate and is extremely effective in eliminating or reducing panic attacks, anticipatory anxiety and avoidance behaviors.



In pharmacotherapy, a prescription medication prevents panic attacks or reduces their frequency and severity and decreases anticipatory anxiety. Patients are able to venture out of their "safety zones" when their panic and anxiety decreases and they benefit from exposure to previously feared situations as well as from the medication.

There are four groups of medications most commonly used in the treatment of panic disorder and agoraphobia: tricyclic antidepressants, high-potency benzodiazepines, monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs). The personal needs and preferences of each patient, as well as safety and efficacy determines which drug should be used for treatment. Keep in mind that everyone is different and it may take you and your doctor several trys at different types of medications to find the one that works best for you. The following provides some general information about each class of medications.

The tricyclic antidepressants were the first medications shown to have a beneficial effect against panic disorder. Imipramine is a common example. Patients usually start with small daily doses that are increased every few days until an effective dosage is reached. This slow introduction helps minimize side effects such as dry mouth, constipation, and blurred vision. Panic sufferers often find these side effects disturbing when starting up treatment as they are hypersensitive to physical sensations. However, these effects usually fade in a few weeks.

It usually takes several weeks for patients to reap benefits from trycyclics. Most patients will be panic-free within a few weeks or months. Treatment generally lasts from 6 to 12 months as there is great risk of panic recurrence when treated for a shorter length of time. Dosages are tapered off over a period of several weeks at the end of treatment.

High-potency benzodiazepines effectively reduce anxiety. Alprazolam, clonazepam, and lorazepam are medications that belong to this class. The effects of this type of medication are rapid and they have few bothersome side-effects. They are also well tolerated by the majority of patients. However, these are potentially habit-forming, especially for those who have had problems with alcohol or drug dependency.

Generally, benzodiazepines are first prescribed in low doses and gradually increased until panic attacks cease as this minimizes side effects. Treatment continues for 6-12 months with gradual reduction of dosage to minimize possible withdrawal symptoms at discontinuation. In addition to these symptoms, panic attacks may also recur when the medication is no longer taken.

This class of antidepressants has also been shown to be effective against panic disorder. Phenelzine is a common example. Treatment with an MAOI usually begins with relatively low daily doses. This prescription is increased gradually until panic attacks cease or the patient reaches maximum dosage. Treatment generally lasts 6 - 12 months and medication is gradually tapered at the conclusion of this period.

MAOI medications require patients to observe exacting dietary restrictions. This is a precaution against food and drug interaction with the MAOI to cause a sudden and dangerous rise in blood pressure. All patients on MAOI treatment need medical guidance concerning these restrictions and must consult with their physician before using any over-the-counter or prescription medications.

These are the newest antidepressants such as fluvoxamine, fluoxetine, and sertraline. The SSRIs are very effective in treating depression and suppressing panic, as well as controlling obsessive thoughts as well. They are usually given in gradually increasing dosages until an effect is apparent. It may take up to 4 weeks to feel the benefit of these medications and for possible side effects, such as drowsiness or nervousness, to dissipate. Treatment is typically as long as medically necessary but no shorter than
6 - 12 months, with gradually decreasing dosages at discontinuation.

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