Cognitive Behavioral Therapy for Panic Disorder
Status: Strong Research Support
Many cognitive-behavioral treatments for panic disorder have strong research support; these tend to include both cognitive and exposure-based components. The underlying premise of cognitive therapy assumes that anxious patients experience distorted, dysfunctional thoughts, especially about the catastrophic consequences of certain bodily sensations. Cognitive therapy aims to help the person identify, challenge, and modify dysfunctional ideas related to panic symptoms. This is often achieved through Socratic dialogue with the therapist, and through homework assignments in which the patient is instructed to identify and challenge negative automatic thoughts. Avoidance of panic and panic-cues is targeted through exposure-based components of CBT for panic disorder, including both in vivo (e.g., going to crowded places or driving in traffic) and interoceptive (e.g., bodily sensations) exposures. Interoceptive exposure refers to exposure to bodily sensations and feelings; thus, during interoceptive exposure, patients will deliberately simulate and experience physical sensations such as dizziness, a racing heart, and difficulty breathing. Through interoceptive exposure, patients learn that these physical experiences are aversive, but not dangerous, and do not lead to feared consequences (e.g., death, losing control, going crazy). Patients habituate to their anxiety surrounding these sensations after repeated interoceptive exposures. Most CBT protocols include in-depth psychoeducation about fear and panic attacks, and these treatments tend to last 12 – 16 sessions total; CBT for panic can be delivered in individual and group formats. Many CBT treatments include a relaxation component, although there is some controversy over whether to focus on breathing retraining (cf. Meuret, Wilhelm, Ritz, & Roth, 2003; Schmidt, Woolaway-Bickel, Trakowski, et al., 2000; Taylor, 2001).
Key References (in reverse chronological order)
Landon, T.M., & Barlow, D.H. (2004). Cognitive-behavioral treatment for panic disorder: Current status. Journal of Psychiatric Practice, 10, 211-226.
Craske, M.G., DeCola, J.P., Sachs, A.D., & Pontillo, D.C. (2003). Panic control treatment for agoraphobia. Journal of Anxiety Disorders, 17, 321-333.
Barlow, D.H., Gorman, J.M., Shear, M.K., & Woods, S.W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. Journal of the American Medical Association, 283, 2529-2536.
Beck, A.T., Emery, G., & Greenberg, R.L. (1990). Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books.
Barlow, D.H., Craske, M.G., Cerny, & J.A., Klosko, J.S. (1989). Behavioral treatment of panic disorder.Behavior Therapy, 20, 261-282.
Barlow, D.H., & Craske, M.G. (2000). Mastery of your anxiety and panic. New York: Oxford University Press.
Barlow, D.H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: The Guilford Press.
The Center for Anxiety and Related Disorders (http://www.bu.edu/anxiety/) has resources and offers intensive treatment for adolescent and adult anxiety disorders, including panic disorder with or without agoraphobia.
Additionally, Dr. David Barlow’s website (http://www.bu.edu/anxiety/dhb/) contains information about published books, treatment manuals, and upcoming talks and workshops – many of his publications are on panic disorder and its treatment.
The Association for Behavioral and Cognitive Therapies has previously offered workshops with training in exposure-based therapy for panic at its annual conference. Check www.abct.org for future training opportunities.
The Beck Institute in Bala Cynwyd, PA, offers week-long training in general cognitive therapy, including applications for anxiety disorders. See www.beckinstitute.org for more information.