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CBT for Panic Disorder

Many people will experience a Panic Attack at some point in their lives, often as a result of extreme stress or anxiety.  When Panic attacks become a frequent event in our lives and they lead to us waiting for them to happen or having a negative impact on how we live our lives, then we may be experiencing Panic Disorder.

Panic Disorder is a treatable condition but many of the traditional ways of dealing with it (Breathing into a paper bag, for example) only give relief in the short term, and still leave the sufferer in fear of when the next panic attack will occur.

Cognitive Behavioural Therapy (CBT) is a tried and tested treatment for Panic Disorder and treats Panic symptoms for the long term.  This article takes you through a treatment model for treating your panic disorder so that when you decide to get CBT for Panic Disorder, you know what to expect.

CBT for Panic Disorder is available at Access CBT from our Clinic in Liverpool, Online (via skype or direct messaging) and by phone.  For more information please contact us on 07887 701 176 or email enquiries@accesscbt.co.uk

What is Panic Disorder?

To understand what panic disorder is, we first need to understand what a panic attack is.

A panic attack is a relatively brief burst of intense anxiety and discomfort and occurs alongside a range of physical symptoms which include:

      • Increased heartrate or palpitations
      • Feeling hot
      • Shakiness
      • Breathing more quickly and feeling short of breath
      • Sweating
      • Feeling dizzy
      • A sense of not being here or things being unreal (depersonalisation and derealisation)
      • Feeling like you are choking
      • Nausea

These symptoms are often accompanied by thoughts like, “I’m going to faint”, “I’m having a heart attack” or “I’m going to collapse.”  We’ll look at these types of thoughts and the effect that they have on keeping panic going later in the article.

Panic Attacks can become Panic Disorder when they increase in frequency, the individual spends a lot of time worrying when the next panic attack will occur and they change their behaviour to reduce the chances of having another one.

CBT for Panic Disorder

There are two main approaches to dealing with Panic Disorder using CBT.  Both of these approaches have been shown to be effective treatments and the difference in approach can be understood in terms of how we understand the main ingredient of therapeutic change – One model is more “Cognitive” as in it treats panic disorder by changing the way that you think, and the other is more “Behavioural” as in healing comes from exposure to feared symptoms and situations.  I tend to lean more to the Cognitive Model at Access CBT, but the other model is equally as effective.

I’m going to take you through the Cognitive Model of Panic Disorder here, but you can find out more about the more behavioural model by reading the manual for it here – Mastery of your Anxiety and Panic

The Cognitive Model of Panic Disorder

The Cognitive Model of Panic Disorder, developed initially by David M. Clark.  The model suggests that Panic Disorder occurs when an individual misinterprets normal anxiety symptoms as being something more “catastrophic” than just anxiety.

So for example, when someone experiences a symptom that is a normal part of our anxiety response, increased heartrate for example, they believe it to be something like a heart attack or other, similarly severe problem.  Because they believe the symptom to be something catastrophic, they then experience more anxiety and more symptoms.  They have entered into a panic cycle.

Now, what people do in response to this elevating spiral of anxiety is very important.  They will typically use any one of a number of what we call “safety behaviours”, pay extra attention to any possible indicators of another attack, or avoid reminders of the attack.  The problem with these responses is that they give relief from the panic symptoms in the short term, but they keep the problem going over the longer term because they never give us the opportunity to find out what would happen to the panic attack if we didn’t do them.  Let’s look at this in more detail…

Safety behaviours in Panic attacks

Safety behaviours in Panic Attacks can take many forms.  They give the individual the impression that they are actually reducing the likelihood of the “Catastrophic Misinterpretation” coming true.  For instance, someone who has the catastrophic misinterpretation of their racing heartrate as being an indication of them having a heart attack, might engage in a safety behaviour which tries to reduce their heartrate – things like try to stay calm, get reassurance from someone, or take an anti-anxiety medication.

Now, if getting reassurance from someone genuinely stopped people from having heart attacks, then we would have no need for defibrillators and crash units! But, when having a panic attack, because the Catastrophic misinterpretation doesn’t come true when the person uses their safety behaviour they make a link between the two.

In their mind, it goes something like: “I believed that I was going to have a heart attack then.  I managed to feel better after I got reassurance from my friend.  That means that if I get reassurance next time the problem occurs, then I’ll be safe.”

Safety behaviours such as this then keep the problem going because the individual never gets to find out what would happen if they just let the panic attack happen.

So how do we treat this?  Let’s have a look.

Step 1 – Considering a Psychological explanation

As we have seen, Panic Attacks occur when a person misinterprets normal anxiety symptoms as being something which is physically catastrophic.  At the time of the panic attack, they believe that something truly catastrophic is happening to them.  Therefore, a treatment for Panic Disorder would want to enable the person to consider an alternative belief for there panic attacks.

This is what the first phase of CBT treatment for Panic Disorder is about.  I’m going to detail two commonly used techniques in CBT which begin the process of getting you panic attack sufferer to contemplate a psychological explanation for their symptoms.  The first technique is what we call the “Paired Words Task” and the second is what we call “symptom induction” or “interoceptive exposure.”

        • The paired words task – In this intervention, we present you with 2 lists of words.  One list names a list of physical experience, such as “breathlessness” and “Light-headedness.”  This list is paired with what we would think of as catastrophic associations to each item.  As the panic attack sufferer reads through the list, we get them to focus upon what is happening in their body.  We typically find that as they read each word pair, they start to notice aspects of the physical symptoms themselves, as their anxiety also kicks in.  From this, we then discuss why just reading a set of words on a page can actually lead a person to experience anxiety, catastrophic thoughts and physical sensations.  You can download a copy of paired words test for panic here.
        • Symptom Induction / Interoceptive exposure – In this intervention, we aim to use different techniques to bring on some of the physical sensations that people experience when they have a panic attack.  This serves two functions.  One function is that the panic attack sufferer experiences another cause for their feared sensation, that is, they get to find out that the feared sensation just might be caused by something else other than their catastrophic fear.  The second function of interoceptive exposure is to get the sufferer to get used to and expose themselves to the anxiety symptoms.  The more often that they do this, the less likely they are to fear them when they arise on a day to day basis.

Step 2 – Learning how to challenge unhelpful thinking

The initial cognitive approach to emotional problems has a central tenet which underpins it – How we think about things generates what we feel.

What this means in practice is that we are always in our day to day lives making sense of how to respond to the world based upon how we think about it.  We’ve already seen how catastrophic thoughts about our anxiety symptoms, leads to more and more anxiety symptoms until we end up having a panic attack.

CBT teaches us how to “catch” negative thoughts like this and then use different techniques to see how reliable and accurate the thoughts are.  If we arrive at the conclusion that our negative thoughts are not realistic, then we generate new ones which are more balanced, realistic and helpful for us.

Here are some of the typical techniques we use in learning how to change our thoughts in panic disorder.

      • Thought diaries – Thought diaries are the first step in learning how to catch our unhelpful thoughts in Panic Disorder.  One of the features of our day to day thinking is that our thoughts about our experiences are very automatic.  This means that we don’t always notice that the thoughts has actually been there and told us what to think about our experience before it has disappeared.  This is why people think that someone might think that being in a supermarket gives me a panic attack.  In reality it is the person’s thoughts about being in a supermarket that gives them a panic attack.  Catching thoughts using a thought diary is a simple way to begin noticing what the thoughts are, where we have them, and how they relate to our difficult emotions.
      • Thought challenging – Once we have learned to catch our negative thoughts and began to understand how they can lead to difficult feelings for us, we can then begin testing out whether they are a realistic thought in relation to our experiences.  So, if I think my increased breathing rate means I’m going to faint, and as yet, I’ve never actually fainted, then there is a high probability that my automatic thoughts are unrealistic.  We can begin to challenge our thoughts by checking out the actual evidence for and against them.  Or, we could look at the costs and benefits of believing the thoughts – do we need to think of an alternative, more helpful belief to explain our symptoms.  Take a look at my articles of challenging negative thoughts for more information on this phase of treatment.
      • Thought labelling – Another feature of our thinking is the tendency for us to sometimes adopt unhelpful thinking styles, in the form of biases, distortions and other logical errors.  We all are prone to this at times.  Thinking errors include things like catastrophisation, mind reading and fortune telling (you can read more about unhelpful thinking styles here) all contribute to emotional distress which may not be relevant to the situation we are in.  Thought labelling is the act of understanding the thoughts and relating them to the unhelpful thinking styles.  When we understand that we are using thought distortions and that they rarely give us an accurate view of the situation then we can make a decision to not respond to them.

Step 3 – Behavioural experiments

Once we have established that out thoughts in panic disorder are not necessarily giving us an accurate picture of our anxiety symptoms, and are in fact making them worse, we want to put this learning into action.

This is where Behavioural Experiments come in.

A behavioural experiment is where we take our belief (which we have probably already modified a little through cognitive restructuring) and test out what happens when we change our behaviour in relation to it.  So, if I have the belief that “I need to sit down when I panic or I might faint”, then we would test out what happens when we stay standing up when we have a panic attack.

Behavioural experiments are all about learning through experience.  It’s one thing to “know” that we won’t faint, but to really believe it we need to experience it.  Often this can be anxiety provoking to begin with and that’s to be expected, but using the techniques of CBT, we can get you to a point where you feel safe and ready enough to experiment with all of the unhelpful beliefs and behaviours which keep your panic attacks going.

Step 4 – Reclaiming your life

So you’ve learned about your anxiety symptoms, you know how to change your negative thoughts and you’ve got experience of experimenting with your symptoms and behaviours…what now?

Once all of the skills are in place, the ultimate phase of CBT for Panic Disorder is to reclaim your life.  All of those things that you haven’t been able to do because of your panic attacks, well, it’s time to tackle them.  This could mean things like picking your children up from school, going to the supermarket or going to a meeting at work.

With the therapist, the client will now set up more and more behavioural experiments to see exactly what happens when they put their new CBT skills into practice in their previously feared situations.  As they gain more and more experience of this, the client fears their panic and anxiety more and more until it is no longer something which they fear.  Recovery is now under way.

Book a session?

Access CBT can offer CBT therapy for Panic Disorder from our clinic in Liverpool and online to anywhere in the world.  To arrange for an appointment, or to find out more information, then call us on 07887 701 176 or email enquiries@accesscbt.co.uk

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