Cognitive Behavior Therapy

 by Sue




Cognitive Behavior Therapy (CBT) for panic disorder is a psychological treatment approach primarily developed by Dr. David Barlow at the Center for Anxiety Disorders in Boston, and by Dr. Aaron Beck at the Center for Cognitive Therapy, University of Pennsylvania School of Medicine, in Philadelphia. I worked closely with both Drs. Beck and Barlow, researching the nature of panic disorder, and testing the effectiveness of this treatment approach in large research studies. At both sites, and now confirmed from studies throughout the world, CBT was shown to be an effective treatment, leading to a reduction in panic attacks for a majority of patients. CBT is as effective as state-of-the-art medications in treating panic disorder.

CBT consists of the following components, each which will be described briefly: 1- Education, 2- Cognitive Restructuring, 3- Breathing Training, 4- Relaxation Exercises, 5- Situational Exposure, 6- Interoceptive Exposure. Each component is aimed at alleviating panic attacks, agoraphobic avoidance, chronic anxiety, and depression associated with panic disorder (note: clinician's may apply only those techniques that they determine are relevant to your problem).

Throughout treatment, patients are educated about panic attacks and the development of panic disorder. An understanding of panic disorder is believed to be an important part of the recovery process.

Cognitive restructuring, a major part of the treatment, is intended to correct distorted thinking about panic attacks. The goal is to have patients change their reaction to their emotional arousal and panic symptoms, and learn to deal effectively with anxiety provoking situations. During the early sessions of therapy, patients are asked to self-monitor their thoughts, assumptions, and beliefs during anxiety provoking situations and panic attacks. With the collaboration of the therapist, patients begin to appreciate the role of cognition, beliefs, and appraisals in the evocation or accentuation of anxiety and panic attacks. During the later sessions, patients are taught to re-evaluate the validity of these distorted thoughts, and change them to more rational, adaptive ones. In particular, patients' "catastrophic misinterpretations" of panic-related somatic cues -- the belief that these physical sensations are a sign that he or she is dying at that moment -- are addressed. Patients will repeatedly challenge their dysfunctional thoughts during treatment.

Breathing training teaches patients a pattern of slow, regular breathing which prevents hyperventilation, an uncomfortable symptom of and cue for panic attacks.

Relaxation exercises that involve progressive muscle tension are often incorporated to lower general anxiety levels.

Situational exposure consists of structured and repeated exposure to anxiety - and panic provoking ("phobic") situations. Based on the patient's individualized list of feared situations, he or she undergoes exposure to these situations while using coping strategies learned during therapy, beginning with the least feared and moving to the most feared. This typically takes place later on during therapy, once a patient feels more in control of panic attacks. The aim of situational exposure is to eliminate agoraphobia.

When necessary, Interoceptive exposure may be conducted. Interoceptive exposure involves the structured and repeated exposure to panic-like physical sensations. Based on the patient's individualized hierarchy of feared internal sensations (e.g., dizziness, palpitations), he or she undergoes systematic exposure to these sensations. The feared sensations may be produced using idiosyncratic methods such as controlled hyperventilation or physical exertion (e.g., running up a flight of stairs to get your heart racing). This is necessary because patient's often become fearful of harmless body sensations, such as those caused by exercise, caffeine, and excitement.