What Is Panic Disorder?
Panic Attacks
According to the DSM-5-TR, a panic attack involves a sudden peak of anxiety, including at least four of the following symptoms:
- Accelerated heart rate or pounding heart
- Sweating
- Shortness of breath
- Choking sensation
- Chest pain/discomfort
- Trembling
- Nausea
- Dizziness, unsteadiness
- Numbness/Tingling
- Hot flushes or chills
- Derealization or depersonalization
- Fear of dying
- Fear of losing control or going crazy
When recurring over time and accompanied by ongoing fear about future panic attacks and their consequences – resulting in a significant impact on functioning – a diagnosis of panic disorder is typically assigned. Risk factors for panic disorder include: genetic factors/family history, anxiety sensitivity (experiencing anxiety about anxiety), exposure to stressful life events, a childhood history of abuse or neglect, the presence of medical problems (e.g., heart arrhythmias, asthma), and drug or alcohol misuse.
Agoraphobia
In some cases, panic disorder is accompanied by agoraphobia. This condition involves fear of experiencing panic attack symptoms in at least two of the following situations, in which escape or assistance might be inaccessible:
- Using public transportation
- Being in open spaces
- Being in enclosed spaces
- Standing in line or being in a crowd
- Being outside of the home alone
Agoraphobia must occur for six months or longer to be diagnosed; it also involves avoidance of the above situations, only approaching them with the presence of a “safe” person, or tolerating them with significant distress.
The CBT Model of Panic Disorder
The CBT (Cognitive Behavioral Therapy) Model of Panic Disorder (Clark, 1986) suggests that the disorder develops when an external stressor or biological state sets off a physiological “alarm reaction.” This experience might include panic attack symptoms, such as heart palpitations, shortness of breath, chest pain, or numbness or tingling.
But these symptoms alone aren’t enough to cause panic disorder. What does is when we interpret these symptoms to mean something is dangerously wrong with our health. We assume catastrophic consequences, such as significant illness or looming death. Consequently, we begin to scan our bodies for these symptoms. We recall past panic attacks, and becoming hypervigilant to them occurring again. Our anxiety and fear increase, resulting in a “tense and protect” state. Here, we contract muscles throughout the body to guard against pain or stress. This experience heightens the alarm reaction, and we become stuck in a distressing loop of symptoms, monitoring, and reactions. In this way, we develop a conditioned fear of certain body sensations; we associate specific symptoms with danger and discomfort, responding to them with increased fear over time.
CBT Panic Disorder Treatment
Psychoeducation
Often, the first step in treating panic disorder is providing information about what causes and maintains the symptoms. Here, individuals with panic disorder learn about what initiates and exacerbates the alarm reaction, including catastrophic thinking and “tense and protect” responses. The role of escape and avoidance (as alluring as they are) in maintaining symptoms is emphasized, and the rationale for cognitive and behavioral interventions is discussed.
Cognitive Interventions for Panic
It’s important to understand that much of the anxiety driving panic disorder results from several core fears: 1) Fear of death or dying (e.g., “I’m going to die!” “I’m having a [insert dangerous medical symptom]!” 2) Fears of losing control (e.g., “I’m going crazy!” “I’m losing control!”) 3) Fears of embarrassment or shame (e.g., “I’m going to humiliate myself!” “People are going to see me freak out!”)
Cognitive interventions for panic disorder focus on increased mindfulness of catastrophic thinking patterns, tracing the relationship between these thoughts and panic symptoms. Cognitive therapy involves developing more realistic and adaptive thought patterns, and reframing responses to anxiety symptoms. As a whole, this creates more mindfulness and neutrality in how we experience our bodily sensations and make predictions about the future.
Interoceptive Exposures
CBT interventions for panic disorder also involve a behavioral component, namely exposure to feared sensations. The goal is to learn to tolerate these sensations and reduce the negative expectations associated with them. Here, we elicit sensations on purpose (e.g., shortness of breath, dizziness, a rapid heart rate) to give us practice in managing these sensations and realizing that they don’t signal the dangerous outcomes we’ve assigned to them.
In this way, we experientially increase our capacity to have uncomfortable experiences without engaging in the “tense and protect” response, escaping or avoiding situations, or engaging in behaviors that help us feel safe in the moment but become problematic over time (what we refer to as “safety behaviors”). Examples of interoceptive exposures include spinning in a chair (to produce dizziness), tensing all of the muscles (to produce numbness or trembling), and walking into a hot, humid room (to produce heat intolerance or feelings of suffocation). If you think about it, experiencing dizziness, for example, can be significantly scary at first. But after multiple exposures to this sensation, it becomes easier to tolerate. As we acclimate to these sensations, we can gradually increase the difficulty of the exposures.
The goal of interoceptive (internal) exposures is to move from calamity (e.g., “Oh no! Maybe I’m having a heart attack. I should go to the ER,”) to neutrality (e.g., observing and allowing sensations, thoughts, and feelings). Exposures can occur in vivo (e.g., being in actual situations like a hot, humid room) or imaginally (e.g., visualizing being in a hot, humid room). Imaginal exposures can be a helpful way to begin these challenges or to use when in vivo exposures aren’t practical.
Exposure Hierarchies
Before beginning interoceptive exposures, it’s important to create an exposure hierarchy that identifies different feared sensations, from easiest to most challenging. After creating a hierarchy, systematic exposures are practiced, starting with the easier ones and gradually working our way up. When engaging in exposures, it’s important to limit safety behaviors. This looks like facing our fears instead of avoiding them; we avoid relying on checking behaviors (e.g., checking our breathing, heart rate, etc.), using relaxation or other techniques to minimize the symptoms (e.g., asking for reassurance, looking up symptoms online, taking anti-anxiety medication), and distracting from the discomfort. Over time, we experience reduced distress with the same physiological sensations.
Treatment Efficacy
CBT is an evidence-based intervention for panic disorder. It can be used instead of anxiety medication or in concert with medication to enhance its effects. Research shows that CBT is significantly effective in decreasing panic disorder symptoms and maintaining these benefits over time. If you are currently struggling with panic disorder, reach out to us at Gatewell to learn how CBT interventions can help free you from this often debilitating condition.