Treatments for Panic Disorders

There are two kinds of effective treatment for panic attacks: antidepressant or anti-anxiety drugs and cognitive behavioral therapy. The antidepressants include tricyclics such as imipramine (Tofranil) and desipramine (Norpramin); monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil); and selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft). All these drugs affect norepinephrine or serotonin pathways in the brain. In most studies 60% to 80% of patients recover on an antidepressant and 20% to 30% on a placebo. Psychiatrists may also prescribe other drugs, especially the anticonvulsants valproate (Depakene) and carbamazepine (Tegretol) and the benzodiazepines alprazolam (Xanax) and lorazepam (Ativan).

Antidepressants have some drawbacks in treatments for panic disorder. They usually take several weeks to work, and they may eliminate panic attacks without affecting the even more disabling and demoralizing conditioned fear of panic attacks. About a third of patients cannot tolerate the side effects of the tricyclics, especially dry mouth, increased heart rate, and dizziness. These symptoms are especially troublesome for a patient who associates unusual physical sensations with the onset of panic. SSRIs have an advantage here, because their side effects are fewer and milder. Benzodiazepines also have few side effects, and unlike antidepressants, they begin to work immediately, but many patients find it difficult to quit taking them because of dependence and withdrawal symptoms. Benzodiazepines are also used to treat generalized anxiety, and they may provide relief from conditioned fear more than from panic itself.

Some patients have to take medications for panic disorder all their lives, but most are withdrawn from the drug within six months to several years after their symptoms improve. Unfortunately, they will often relapse unless they have further treatment, which usually means behavioral or cognitive therapy. Exposure therapy makes it possible to tolerate places and situations previously regarded as dangerous. Relaxation training reduces the physical sensations that provoke anxiety and panic. Cognitive restructuring corrects misinterpretations and develops self-confidence. Most patients practice these techniques daily under the supervision of an individual or group therapist for 10 to 20 weekly sessions. Some can work alone with an instruction manual or self-help book.
Confronting the feeling

A fundamental treatment is gradually intensified exposure to situations that provoke fear, sometimes called systematic densensitization. Patient and therapist arrange the situations in a hierarchy and the patient proceeds by small steps, practicing daily and recording the results for review by the therapist. At each stage the patient is reassured when no panic attack occurs, and eventually the expectation of panic is weakened. To put it in behavioral terms, the conditioned avoidance response is extinguished. It has been shown that exposure is effective even for patients who leave before their anxiety peaks, as long as they return repeatedly to the scene.

An alternative type of exposure treatment for panic disorder is implosion or flooding, in which the patient is encouraged to experience the uncomfortable situation as intensely as possible for as long as possible until it loses the power to cause fear. This treatment is quicker than graduated exposure, but relapse is apparently more common, and the patient is more likely to become terrified and quit.

In fact, many patients cannot tolerate even graduated exposure at first; 40% refuse the treatment. Sometimes they are helped by the presence of a therapist, family member, or friend who reassures them and serves as a model to imitate. The companion can also coach the patient, identify subtle forms of avoidance (such as standing near a wall or gripping a chair), and assign specific tasks.

Although exposure is ultimately a necessary part of treatments for panic disorder, if only as the proof of a cure, it has limitations as the sole therapeutic technique. It works best when the feared object is easy to identify, as in simple phobias, but anxious anticipation of a panic attack may develop in many different im-precisely defined situations. Besides, patients may need other kinds of therapy before they can successfully face what they fear. Above all, a single panic attack can undo the effect of weeks of exposure. Other therapeutic techniques mount a more direct assault on physical sensations of panic and the associated misinterpretations.
Taking control

Instead of (or in addition to) systematically desensitizing patients to external objects of fear, some therapists concentrate on altering the patient's response to internal sensations. In the procedure known as interoceptive exposure, patients may be encouraged to hold their breath, hyperventilate, spin in a chair, breathe through a straw, inhale carbon dioxide or take injections of sodium lactate in order to learn with their bodies that the feelings associated with panic do not indicate impending disaster. Patients can also be shown how to cut off panic at an early stage with muscle relaxation, self-hypnosis, and breath control, although this approach is sometimes questioned because they cannot learn to tolerate feelings they consistently ward off.

Cognitive therapy and its variants, including rational emotive therapy and self-instruction, provide another way to uncover and eliminate catastrophic misinterpretation of feelings and situations. Patients are asked to concentrate on the feared situations, analyze the associated thoughts and feelings, record them, and apply what they learn. They may be shown how to alter irrational assumptions, distract themselves with substitute activities, concentrate on neutral details of the situation, or give themselves reassuring suggestions and act as if those suggestions were true.
A therapeutic approach

Controlled research on psychotherapy is difficult because the placebo treatment cannot be disguised in the way a sugar pill is disguised as a drug. Given that limitation, reviews suggest that on average about 60% of patients in cognitive behavioral therapy improve, as compared with 25% given a placebo alternative (usually supportive or client-centered therapy, consisting of sympathetic listening, reassurance, and advice). Much of the improvement persists for at least two years. But the results of studies are inconsistent -- in some of them behavioral treatment has little advantage over the placebo -- and many patients who are successfully treated must continue to take drugs as well. About 20% refuse behavior therapy or drop out.

Many therapists prefer cognitive and behavioral therapies to drugs for treating panic disorders on the grounds that patients maintain their improvement longer and are less likely to relapse. There is evidence from recent research supporting that view. On the other hand, some patients need immediate relief and cannot tolerate the homework required by behavior therapy; and some therapists believe that panic disorder is a chronic neurophysiological malfunction, no more curable by short-term psychotherapy than manic-depressive disorder. A combination of drugs and behavior therapy may be better than either alone -- the drugs suppressing symptoms until the effects of behavior therapy can be felt.
More data needed

The long-term outcome in panic disorder is uncertain. Many patients need more than one round of treatment. A recent survey found that at times ranging from six months to seven years after treatment, 8% to 30% of patients were entirely free of panic attacks, 18% to 64% were no longer suffering from agoraphobia, and 33% to 60% were no longer seriously impaired. Patients with a poor outcome had usually had more frequent panic attacks for a longer time. They were also more likely to be unmarried and to have suffered from major depression. Another study found that five years after a variety of treatments, 73% were considerably improved but only 12% were completely free of the disorder, and for a large minority the overall outcome was poor even though they had many fewer panic attacks. More long-term studies are needed to clarify how much and what kind of treatment is needed for patients with symptoms of different severity and different degrees of demoralization.