Cognitive Therapy and Panic Attacks

What is cognitive behavioral therapy?

Cognitive behavioral therapy (CBT) is a specific type of psychotherapy that focusing on the impact of cognitive processes. CBT teaches individuals to recognize emotional distress and harmful thoughts, and how their behaviors are impacted by these cognitions. CBT teaches individuals to adjust negative behaviors and emotional responses and develop more positive habits ^[1][2].

CBT helps individuals to recognize negative emotions and their associated behaviors while exploring ways to challenge and alter these patterns by using exposure, relaxation, and coping strategies ^[1][3].

For example, being afraid of having a panic attack might lead to avoidant behaviors and an increased risk of a panic attack in unplanned situations. CBT can help teach the reasons why fear can lead to avoidant behaviors and how to use structured behaviors to manage triggers and symptoms, thereby reducing or preventing anxieties and the occurrence of panic attacks ^[3][4].

Cognitive behavioral therapy techniques in the treatment of panic disorder

CBT is usually provided in around 12-20 sessions, each an hour long, over several weeks. Sessions may be face-to-face, over the internet, or through guided self-help exercises. CBT can involve the use of several of the different techniques listed belong ^[3][4].

Psychoeducation

Psychoeducation involves providing an explanation of panic disorder and the symptoms that can occur. For example, there are many physical sensations that occur during a panic attack that can contribute to a worsening and prolonging of the attack. Providing an understanding of the causes of these physical responses may help to reduce any associated fear.

Furthermore, it can be useful to gain a better understanding of the thoughts and emotions that can lead to harmful behaviors, and how CBT can help to change these cycles. This might be done by recording symptoms that occur, including physical symptoms, thoughts, and feelings, as this can help to improve awareness of the condition and specific triggers ^[5][6].

Cognitive restructuring

Cognitive restructuring involves recognizing and changing negative thoughts. For example, a racing heart during a panic attack might lead the individual to believe they are having a heart attack. These thoughts, and other overestimations of potential threats, can be challenged in order to find alternative thoughts.

This might be done by recording any experienced automatic negative thoughts. Automatic negative thoughts could include a fear of physical sensations or a judgment of the self or external world. The individual can then examine and evaluate these thoughts, looking for evidence to support or disprove the reality of the presenting threat, thus learning to identify a more positive and realistic alternative belief ^[1][5].

In vivo exposure

Exposure therapy can be provided in real-life situations, known as in vivo exposure. This involves a gradual exposure to anxiety-provoking situations, with the aim to reduce catastrophizing, fear, and avoidance.

The individual will compile a list of anxiety-provoking situations, from the least to the most feared. The individual will then start exposing themselves to the most manageable situation first and gradually work their way to the most feared situation ^[6][7].

This will help them to gain confidence in their ability to cope with anxiety and perceived threats. More confidence can reduce the need for safety behaviors, such as checking for exits or using their phone to avoid looking at people ^[1][5].

Flooding is also a way of utilizing in vivo exposure, in which the individual is exposed to their most feared situation immediately. There is some evidence to suggest that this can be effective, although gradual exposure is generally considered to be more effective and manageable ^[7].

Interoceptive exposure

Interoceptive exposure is an exposure technique related to the physical bodily sensations experienced during a panic attack. For example, the individual may be asked to do an exercise that raises their heart rate and induces sweating, all of which are symptoms of a panic attack.

This technique can demonstrate that these sensations are normal physical responses and may not always be a precursor to a panic attack, nor are they due to a heart attack or other severe health issues ^[2][7].

The individual can also learn that these sensations can be controlled or reduced, such as with the use of deep breathing exercises. This further demonstrates that there is no need to fear these physical symptoms when they occur, as they can be managed and controlled ^[5][8].

It is important to note that this technique is not appropriate for everyone, particularly those who have heart or respiratory conditions, as it may not be safe ^[8].

Progressive muscle relaxation

Progressive muscle relaxation is a technique used to reduce tension in the body and lower the potential for a stress response, thus helping to prevent or reduce panic attack symptoms.

The technique involves the voluntary tensing and relaxing of certain muscles or groups of muscles. This raises the individual’s awareness of the sensations involved in the tensing and relaxing of the muscles. Having this awareness can help them to recognize involuntary tension and prompt them to utilize their learned muscle relaxation techniques.

This technique should be practiced regularly and when relaxed, so that it can be properly applied in anxiety-provoking situations or during a panic attack ^[2][5].

This technique might also be utilized during exposure therapy to help improve the individual’s ability to relax in a stressful situation. This helps to desensitize them to these circumstances ^[7].

Breathing retraining

Breathing rates may increase prior to a panic attack, which can cause an intense fear of not being able to breathe and an increase in symptom severity ^[2].

As such, breathing retraining can be useful in slowing the breathing rate and helping to reduce panic attack symptoms. Retraining involves the teaching of slow and controlled breathing techniques, which should be practiced in calm situations to enable the effective use of the technique during an anxiety-provoking situation or panic attack ^[3][5].

How effective is CBT in treating panic attacks?

Research has shown that CBT is generally a very effective treatment in the management of most anxiety disorders, particularly panic disorder. It has been shown to reduce the severity and frequency of panic attacks in around two thirds of those who engage in this type of therapy and is more effective than other types of psychotherapy for this condition ^[4][6].

However, effectiveness may vary from person to person. Some individuals may find that they do not experience any further panic attacks following treatment, and others may find that, although their symptoms may have reduced, they are not entirely free of anxiety or panic attacks ^[3].

It is likely that various techniques within CBT treatment have different responses and effects. Some studies show that exposure therapy is very effective as a sole treatment, while others suggest that it is more effective when utilized in combination with cognitive restructuring. As such, it is unclear which combination of CBT techniques is the most effective in the treatment of panic disorder ^[3][4][6].

It is thought that face-to-face sessions may be more effective than those provided online or as self-help exercises. Face-to-face session are shown to improve adherence to treatment and provide the best environment in which to learn and practice specific techniques ^[3][4].

Research shows that, in some cases, the combination of CBT and antidepressants can be more effective in the treatment of panic disorder than either treatment alone ^[1][4].

What to look for in a therapist

Finding the right therapist will depend on what you are looking for. Some things to consider when searching for a therapist might include ^[4][9]:

• Ask your doctor or mental health professional to suggest someone they know and recommend.
• Check that the therapist has a license to practice.
• Ask the therapist if they have experience in certain areas that will apply to you, such as working with children or adults, specific mental health conditions, and specific types of therapy.
• Ask about practical considerations, such as their location, the cost of their services, and the number of sessions they will provide.

After gathering the necessary information and finding someone that seems right for you, try a session with them. It may be that you are happy with your choice and can continue working with them, or you may not feel comfortable and instead decide to keep looking.

It is important to find a therapist with whom you feel able to build a positive therapeutic relationship, as this will be crucial to ensuring effective treatment. You might need to meet several therapists before finding the right one for you ^[9].

Alternative treatments for panic attacks

Therapy

Other types of therapy might also be useful to treat panic attacks or panic disorder, such as other forms of psychotherapy, interpersonal therapy, or group therapy. All of these options can provide a space to discuss any underlying causes or triggers that may be contributing to your symptoms and help you to find ways to manage your anxieties, distress, and physical symptoms ^[1][3].

Medication

Medication can be prescribed to treat panic disorder, which might include ^[4][10]:

• Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) can be effective at managing symptoms of panic disorder. If SSRIs are not effective, you may be prescribed a serotonin norepinephrine reuptake inhibitor (SNRI) or a tricyclic antidepressant (TCA), which can also be effective.
• Beta-blockers: Beta-blockers can help to reduce the physical symptoms of a panic attack, so can be useful when utilized as a short-term or fast-acting treatment.
• Anti-anxiety medications: Benzodiazepines, such as clonazepam, are also fast-acting and can help to rapidly reduce symptoms of anxiety and panic attacks. Although these are not commonly prescribed as a long-term medication due to the risk of abuse and dependency.

Self-care

Looking after your physical and mental wellbeing can help to prevent the occurrence of panic attacks, which may include ^[4][11]:

• Eating healthily
• Engaging in regular exercise
• Relaxation techniques
• Mindfulness
• Yoga and meditation
• Avoiding drugs, alcohol, and caffeine