Panic Disorder: Cognitive–Behavioral Therapy

Cognitive–Behavioral Therapy

CBT treatment packages include a number of components, such as psychoeducation (e.g., information about the cognitive model of panic), breathing retraining, cognitive restructuring, relaxa-tion exercises, interoceptive exposure and situational exposure. Breathing retraining involves teaching the patient to breathe with the diaphragm rather than with the chest muscles. Cognitive restructuring focuses on challenging patient’s beliefs about the dangerousness of bodily sensations (e.g., challenging the belief that palpitations lead to heart attacks). Interoceptive exposure involves inducing feared bodily sensations to further teach pa-tients that the sensations are harmless. Situational exposure in-volves activities that bring the patient into feared situations such as shopping malls, bridges, or tunnels. Despite the advantages of exposure exercises, they are medically contraindicated in some cases. For example, a hyperventilation exercise would not be used in a patient with severe asthma.

A large body of evidence shows that CBT is effective in reducing panic attacks, agoraphobia and associated symptoms such as depression. However, not all CBT interventions may be necessary. Interoceptive exposure, situational exposure and cognitive restructuring are the most widely used and supported interventions. Several studies suggest that breathing retraining reduces panic frequency. However, recent research casts doubt about the importance of hyperventilation in producing panic at-tacks. This suggests that breathing retraining may only be useful for a minority of patients, for which chest breathing or hyper-ventilation plays a role in producing panic symptoms. Breathing retraining may be counterproductive if it prevents patients from learning that their catastrophic beliefs are unfounded. Given these concerns, breathing retraining should be used sparingly in the treatment of panic disorder. If used at all, the clinician should ensure that the patient understands that breathing exercises are used to remove unpleasant but harmless sensations. Interoceptive exposure and cognitive restructuring are important for helping patients learn that the sensations are not dangerous.

How effective is CBT compared with other therapies? A small but growing literature suggests that the efficacy of CBT is equal to or greater than that of alprazolam and imipramine at post treatment. Future research is needed to compare CBT with other pharmacotherapies, such as SSRIs. Preliminary evidence suggests that CBT is effective in treating patients who have failed to respond to pharmacotherapies. Follow-up studies suggest that CBT is effective in the long term and is likely to be more effec-tive than short-term pharmacological treatment. It is not known whether drug treatments would be as effective as CBT if patients remained on their medications. Any conclusions about the long-term efficacy of panic treatments are necessarily tentative be-cause patients sometimes seek additional treatment during the follow-up interval.