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Treatments for Anxiety Disorder
This is a combination of cognitive therapy, which can modify or eliminate
thought patterns contributing to the patient's symptoms, and behavioral
therapy, which aims to help the patient to change his or her behavior.
Typically the patient undergoing cognitive-behavioral therapy meets
with a therapist for 1 to 3 hours a week. In the cognitive portion of
the therapy, the therapist usually conducts a careful search for the
thoughts and feelings that accompany the panic attacks. These mental
events are discussed in terms of the "cognitive model" of
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 cycle is believed to operate
this way: First the individual feels a potentially worrisome sensation
such as an increasing heart rate, tightened chest muscles, or a queasy
stomach. This sensation may be triggered by some worry, an unpleasant
mental image, a minor illness, or even exercise. The person with panic
disorder responds to the sensation by becoming anxious. The initial
anxiety triggers still more unpleasant sensations, which in turn heighten
anxiety, giving rise to catastrophic thoughts. The person thinks "I
am having a heart attack" or "I am going insane," or
some similar thought. As the vicious cycle continues, a panic attack
results. The whole cycle might take only a few seconds, and the individual
may not be aware of the initial sensations or thoughts.
Proponents of this theory point out that, with the help of a skilled
therapist, people with panic disorder often can learn to recognize the
earliestthoughts and feelings in this sequence and modify their responses
to them. Patients are taught that typical thoughts such as "That
terrible feeling is getting worse!" or "I'm going to have
a panic attack" or "I'm going to have a heart attack"
can be replaced with substitutes such as "It's only uneasinessit
will pass" that help to reduce anxiety and ward off a panic attack.
Specific procedures for accomplishing this are taught. By modifying
thought patterns in this way, the patient gains more control over the
Often the therapist will provide the patient with simple guidelines
to follow when he or she can feel that a panic attack is approaching.
One therapist has offered a set of strategies that have helped some
of her patients to cope with panic attacks.
In cognitive therapy, discussions between the patient and the therapist
are not usually focused on the patient's past, as is the case with some
forms of psychotherapy. Instead, conversations focus on the difficulties
and successes the patient is having at the present time, and on skills
the patient needs to learn.
The behavioral portion of cognitive-behavioral therapy may involve
systematic training in relaxation techniques. By learning to relax,
the patient may acquire the ability to reduce generalized anxiety and
stress that often sets the stage for panic attacks.
Breathing exercises are often included in the behavioral therapy. The
patient learns to control his or her breathing and avoid hyperventilationa
pattern of rapid, shallow breathing that can trigger or exacerbate some
people's panic attacks.
Another important aspect of behavioral therapy is exposure to internal
sensations called interoceptive exposure. During interoceptive exposure
the therapist will do an individual assessment of internal sensations
associated withpanic. Depending on the assessment, the therapist may
then encourage the patient to bring on some of the sensations of a panic
attack by, for example, exercising to increase heart rate, breathing
rapidly to trigger lightheadedness and respiratory symptoms, or spinning
around to trigger dizziness.
Exercises to produce feelings of unreality may also be used. Then the
therapist teaches the patient to cope effectively with these sensations
and to replace alarmist thoughts such as "I am going to die,"
with more appropriate ones, such as "It's just a little dizzinessm,
I can handle it."
Another important aspect of behavioral therapy is "in vivo"
or real-life exposure. The therapist and the patient determine whether
the patient has been avoiding particular places and situations, and
which patterns of avoidance are causing the patient problems. They agree
to work on the avoidance behaviors that are most seriously interfering
with the patient's life. For example, fear of driving may be of paramount
importance for one patient, while inability to go to the grocery store
may be most handicapping for another.
Some therapists will go to an agoraphobic patient's home to conduct
the initial sessions. Often therapists take their patients on excursions
to shopping malls and other places the patients have been avoiding.
Or they may accompany their patients who are trying to overcome fear
of driving a car.
The patient approaches a feared situation gradually, attempting to
stay in spite of rising levels of anxiety. In this way the patient sees
that as frightening as the feelings are, they are not dangerous, and
they do pass. On each attempt, the patient faces as much fear as he
or she can stand. Patients find that with this step-by-step approach,
aided by encouragement and skilled advice from the therapist, they can
gradually master their fears and enter situations that had seemed unapproachable.
Many therapists assign the patient "homework" to do between
sessions. Sometimes patients spend only a few sessions in one-on-one
contact with a therapist and continue to work on their own with the
aid of a printed manual.
Often the patient will join a therapy group with others striving to
overcome panic disorder or phobias, meeting with them weekly to discuss
progress, exchange encouragement, and receive guidance from the therapist.
Cognitive-behavioral therapy generally requires at least 8 to 12 weeks.
Some people may need a longer time in treatment to learn and implement
the skills. This kind of therapy, which is reported to have a low relapse
rate, is effective ineliminating panic attacks or reducing their frequency.
It also reduces anticipatory anxiety and the avoidance of feared situations.
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