This article is an excerpt from the forthcoming Practical CBT workshop on Treating Panic led by the author, Professor Patrick McGhee. You can find out more about the CPD webinar here
Panic disorder can be a severely debilitating illness but is often not fully understood by society at large. Around 20% of people report having had a least one panic attack in their lifetime. This should not be suprising as the panic response is a natural behavioural and emotional pattern which has evolved to protect us and take action when facing a sudden mortal danger. But in Panic Disorder (PD) this response occurs in the absence of any identifiably serious threat and affects about 1 in 25 of the general population. Sometimes these are a one-off, but for many there is a sense of a panic attack around any corner. This can lead in turn to the safety behaviour of avoiding engaging with the outside world at all and the characteristic pattern of panic disorder and agoraphobia, a combination affecting about 1% of people in general.
Importantly, research indicates that without treatment rates of suicide, substance abuse, and cardiovascular disease are higher in individuals with more intense panic disorder conditions.
Treatment of PD can be through psychotherapy such as CBT or through medicine. In terms of pharmaceutical approaches, SSRIs (Selective Serotonin Reuptake Inhibitors) will often be prescribed or occasionally a tricyclic antidepressant such as imipramine. In some cases the anti-epilepsy drug pregabiln will be offered, However, recent attempts to find drugs which augment behavioural interventions such as ERP (Exposure and Response Prevention) have met with mixed results (eg Hofmeijer-Sevink, et al, 2017)
Improving CBT for Panic Disorders – contemporary perspectives
In CBT the focus is on helping the client recognise biases and exaggeration in thoughts, facing the anxiety to learn the patterns of attentuation and basic relaxation techniques. Broader cognitive restructuring of rules, assumptions and core beliefs can help reduce the likelihood of relapse.
However, around 40% of clients in therapy do not respond positively to cognitive and behavioural treatments. So what can be done to improve techniques and help a wider cross-section of clients? Recent research has focused on additional behaviour interventions, client resistance, technology and the role of emotional regulation amongst other perspectives. Let’s look at these in turn and consider the clinical implications.
1 – Additional behavioural Interventions – Exercise
Bischoff et al (2018) found that adding aerobic exercise to the usual CBT treatments significantly improved outcomes for clients compared to those who only had CBT. Interestingly this benefit was not maintained over time as the CBT-only group continued to improve. This suggest that exercise can somehow ‘accelerate’ the benefits of exposure therapy for some clients.
2 – Monitoring Client Attitudes – Resistance in Session 2
Schwartz et al (2019) were keen to understand why some clients are resistant to forms of psychotherapeutic treatment. One of their interesting findings was that while different levels of client hostility to treatment had no effect on overall treatment outcome, expressed hostility in Session 2 (but not Session 1 or Session 3) predicted drop out rates. This suggests perhaps that some forms of resistance need not require significant therapist intervention (or withdrawal) but specific resistance at specific stages of therapy can be a red flag that needs focused exploration with the client.
3 – Treatment with Technology – Virtual Reality Therapy
Virtual Reality (VR) has been used in the treatment of some anxiety conditions, such as specific phobias, for some time. However, recently, its use in the treatment of PD has increased. One challenge here is the cost and mobility of traditional VR equipment which can be costly and difficult for clients to access. However, a new study by Shin et al (2021) showed that a self-guided mobile app could be used by clients in their everyday life to help manage their panic perspectives. The VR treatment group exhibited improvements in panic disorder symptoms, anxiety, and depression after only 4 weeks and even showed improved heart rate variability. This opens up the possiblity of cost-effective, self-managed VR treatments which can help clients face panic in their everday lives. It is interesting to reflect on what role the therapist has in this kind of treatment protocol.
4 – The Client’s control of thoughts and feelings – the role of Emotional Regulation
Strauss et al (2019) wanted to examine the ways in which cognitive reapprasials impact on perceptions of threat and the emotional reaction to situations in people suffering from Panic disorders. They found a complex pattern of results indicating that cognitive reappraisal did not change until the later stages of therapy and was generally not associated with positive clinical outcomes. By contrast suppression of emotions decreased significantly throughout therapy and had a srong impact on biased cognitions – and vice versa. As predicted symptom reduction followed decreases in suppression. Though patients did not differ in terms of emotional regulation from matched controls at either pre- or post-treatment. What can we take from this complicated pattern of results? Simply put it emphasises the importance of adaptive cognitive reappraisal as part of the treatment of PD alongside the examination of, and support for, emotional suppression.
Conclusion
Advances are being made in helping therapists improve the effectiveness of their interventions through more nuanced approaches to exercise, client attitudes, technology and emotional regulation alongside many others. As a therapist, being aware of these new ideas can help improve the support we offer clients trying to overcome panic attacks and agoraphobia. While some of the studies use sophisticated techniques in their design (to rule out artificial biases) usually the overall headlines are clear. We know that clinicians often prefer their own experience and stay inside their comfort zone in areas such as the treatment of panic disorders. But by engaging with new techniques and approaches we can all learn, and see that we can change our behaviours more than we probably thought.
And not panic.
This article is an excerpt from the forthcoming Practical CBT workshop on Treating Panic led by the author, Professor Patrick McGhee. You can find out more about the CPD webinar here
REFERENCES
Hofmeijer-Sevink, M. K., Duits, P., Rijkeboer, M. M., Hoogendoorn, A. W., van Megen, H. J., Vulink, N. C., Denys, D. A., van den Hout, Marcel A, van Balkom, A. J., & Cath, D. C. (2017). No effects of D-cycloserine enhancement in exposure with response prevention therapy in panic disorder with agoraphobia: A double-blind, randomized controlled trial. Journal of Clinical Psychopharmacology, 37(5), 531.Link
Bischoff, S., Wieder, G., Einsle, F., Petzold, M. B., Janßen, C., Mumm, J. L. M., Wittchen, H., Fydrich, T., Plag, J., & Ströhle, A. (2018). Running for extinction? aerobic exercise as an augmentation of exposure therapy in panic disorder with agoraphobia. Journal of Psychiatric Research, 101, 34-41. https://doi.org/10.1016/j.jpsychires.2018.03.001Link
Schwartz, R. A., Chambless, D. L., McCarthy, K. S., Milrod, B., & Barber, J. P. (2019). Client resistance predicts outcomes in cognitive-behavioral therapy for panic disorder. Psychotherapy Research, 29(8), 1020-1032. https://doi.org/10.1080/10503307.2018.1504174Link
Shin, B., Oh, J., Kim, B., Kim, H. E., Kim, H., Kim, S., & Kim, J. (2021). Effectiveness of self-guided virtual Reality–Based cognitive behavioral therapy for panic disorder: Randomized controlled trial. JMIR Mental Health, 8(11), e30590-e30590. https://doi.org/10.2196/30590Link
Strauss, A. Y., Kivity, Y., & Huppert, J. D. (2019). Emotion regulation strategies in cognitive behavioral therapy for panic disorder. Behavior Therapy, 50(3), 659-671. https://doi.org/10.1016/j.beth.2018.10.005Link
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