Treating Panic: Why it all started in the 80's
The 1980’s were the beginning of the “glory years” of cognitive-behavior therapy (CBT), in my humble opinion. After slow and steady advances in conceptualizing and treating panic, in the 1980’s, our understanding of panic really came together, especially in the CBT world. To understand modern approaches to treating panic, I’m going to walk you through some of the classic CBT texts on panic to show you how CBT researchers and practitioners developed the rationales and approaches that are now so commonly used. The foundational texts were written in the 80’s and as you may or not know, I love the 80s. So I am going to pepper this text with a few non sequitur references to that great time.
But first, let’s start in antiquity. Around 2000 years ago, around the “0080’s”, Epictetus, the Greek Stoic, when faced with racing, disturbing thoughts, advised us to say to that thought: “Impression, wait for me a little. Let me see who you are and what you represent. Let me test you”*. We learn by testing things out, by investigating, by becoming familiar with that which we fear. In the 8th century the monk Shantideva wrote a crucial Buddhist text called The Guide to the Bodhisattva’s Way of Life and in it he produced a similar sentiment as Epictetus in an even more pithy form by stating “everything is made easier through acquaintance”. At the heart of treating panic, and honestly treating all anxiety struggles, is acquainting with that which is feared.
Treatment of panic involves four major parts. The first part is education about emotions, thoughts and thinking and behaviors related to panic and the panic cycle. The second part involves working on cognition - reappraising the beliefs and ways of thinking that transmute body sensation anxiety into a panic attack. The third is interoceptive exposure - engaging with body sensations that you fear may cause panic. The fourth major part is real world exposures - engaging in environments that you fear may cause panic.
Cognitive-behavior therapy (CBT) has a history of relying on clinical and cognitive neuroscience and behavioral clinical trials to develop and test treatment approaches. Early outcomes from clinical trials have indicated that the fundamental strategies to treat panic involve: teaching individuals about the cycle of anxiety and panic, breath work, cognitive reframing, and relaxation exercises. But perhaps the most important treatment strategy is directly connecting with that which you fear. In clinical terms, we call this exposure therapy (I prefer the term “engagement” rather than exposure, but I’ll save that for another post). There are two general categories of exposure therapies - in vivo and interoceptive. In vivo exposure is just another way of saying engaging “in the real world” rather than while sitting in a therapy office. If your panic attacks tend to happen when you go to shopping malls or movie theaters, then treatment involves progressively working your way up to going to shopping malls to go to the Wherehouse to buy a “compact disc” of Freddy Mercury and Queen’s new album or a movie theater to see Ferris Beuller or Pretty in Pink (sneaky 80’s references). Interoceptive exposure refers to deliberately inducing in a progressive manner, unpleasant sensations (rapid heart rate for example) that might be related to triggering panic.
Education
Education, often called psychoeducation, is a primary treatment tool in all psychotherapy, but it is particularly important in CBT. Education about panic involves learning about anxiety on multiple levels - cognitive, emotionally, behaviorally, physically/biologically and also situationally. In CBT, psychoeducation often involves some discussion of the basics of learning. How do we learn to fear things and how do we learn to not fear things?
Reworking Beliefs and ways of thinking
Clark’s cognitive model of panic (1986) introduced a central term in the conceptualization of panic that emphasized cognition, or “thinking” in the development and in the treatment of panic. Clark emphasized that an essential piece in the cycle in of panic is a misappraisal of the meaning of a body sensation as being “catastrophic”. Clark starts by saying that panic can be induced physiologically through things like infusions of lactate or isoproterenol, inhalation of carbon dioxide or through voluntary hyperventilating. Clark then notes that these things rarely produce panic in people who do not have any history of panic attacks. He then suggests that it may not be the substances or activities themselves that induce panic symptoms, but the way the person psychologically interprets the meanings and implications of the symptoms they feel when intaking these substances or engaging in these activities. Clark states that some individuals tend to interpret unpleasant body sensations (dizziness, palpitations, shortness of breath) as having considerably more ominous or dangerous meanings that they actually do. Next, these folks intentionally or unintentionally engage in behaviors that amplify anxiety. Typically these behaviors include hyperventilating, repeating overthinking and focusing on symptoms of anxiety. This then loops back to the misinterpretation of the danger of these symptoms which then circles back to the “igniting” behaviors. This looping then leads to panic. What made Clark’s model so compelling at the time was the primacy of the interpretation of these bodily sensations as being catastrophic. This gave CBT therapists an “intervention point” - to focus on helping individuals become aware of these interpretations and then helping their clients re-interpret the meanings of these symptoms. Before this, psychotherapists tended to focus exclusively on helping clients seek insight into interpersonal relationships and early childhood as a treatment approach for treating panic. It’s hard to not over emphasize how revolutionary this way of thinking was for treating panic disorder.
Interoceptive Exposure
At almost the same time, another blockbuster paper came out written by David Barlow and his team and included exposure therapy into panic treatment (Barlow et al 1989). His team’s approach integrated Beck and Emory’s approach to treating anxiety by focusing on re-evaluating on cognitive appraisals, predictions and prescriptions about self, handling anxiety and anxiety-triggering situations. They emphasized teaching clients to use tools like analyzing faulty logic, reattribution and reframing, exploring alternative beliefs, practicing decatastrophizing, and using hypothesis testing in anxiety triggering situations. All bedrock strategies in CBT.
But Barlow also speculated that panic attacks were a learned response conditioned automatically through associative or Pavlovian conditioning and operant conditioning. Simply put, in the process of living life and having distressing experiences at times, benign or mild body sensations (like dry mouth, mild dizziness, stomach tightness) and/or external stimuli like a busy crowd at a mall become paired with a danger signal + panic response. Over time, these body sensations become a conditioned trigger for panic. For example, imagine you are at Starcourt mall (or in my case, the Glendale Galleria), walking to Hot Dog on a Stick to get their giant fresh lemonade (sneaky 80’s references) and you feel flush or dizzy. Why do you feel this way? Because it happens sometimes. You get up too quick, you are little dehydrated, or maybe you are just prone to mild dizziness. But automatically, you start to feel anxious because that sensation might remind you of a panic attack you had. The anxiety builds, you might even start focusing on “what if I have a panic attack right here right now in from of all these people? This could escalate into a full blown panic attack, or you might leave the mall to prevent a panic attack. This pattern of behavior strengthens the relationship between the sensations, the mall and a panic response.
Barlow and colleagues emphasized repeated exposure to these benign physical sensations that arise early on before a full blown panic attack develops as a way to help the body “relearn” that these sensations are normal and do not need to trigger a panic attack. These techniques involved “bringing on” specific physical sensations related to panic - like hyperventilating for 30-60 seconds to bring on rapid breathing or doing jumping jacks to bring on a sensation of elevated heart rate. They coined the term interoceptive exposure as a technique in which the therapist leads the client through a set of exercises meant to stimulate these physical sensations. By repeatedly practicing engagement with these sensations, clients begin to learn to break the chain linking these sensations to the onset of panic.
There are a variety of exercises that fall under the umbrella of interoceptive exposures and cover intentionally produced body experiences such as dizziness, shortness of breath and rapid heart rate. Lee and colleagues (2006) broke down these exercises into four categories: neurological, gastrointestinal, cardiorespiratory and dissociative. In his book on panic disorder (Taylor 2000) Steven Taylor compiled a list of 17 exercises such as spinning around while standing up with arms stretched for 1min, breathing through a narrow straw without breathing through your nose for 2 min, etc. These exercises are typically of a short duration and are practiced in session 2-3x during a session and then practiced at home 3-5x a week. Before engaging in these exercises, a client is asked what their beliefs are about triggering these sensations (I will not be able to handle it, I will be anxious for a long time afterwards, etc). Then by deliberately engaging in the triggering behavior, the client gets to experience an “expectancy violation” - i.e. the bad event either didn’t happen, or was less intense than expected, or was very intense yet the client learned to manage them. This produces new associations and new ways of thinking about the triggered sensations either automatically or through debriefing conversations with the therapist.
Real world Exposure
Reintegrating into triggering situations is the last major aspect of panic treatment. Where do people experience panic? In their bedrooms? In their cars? In restaurants? How can we help people work on getting back to being in these situations?
Real world exposures are conducted via a road map - a hierarchical listing of situations ranked in increasing distress intensity, with the most triggering situations listed at the top and the least triggering situations at the bottom. Therapist and client work together and start at the middle or lower middle of the list. Either in session or as homework the client practices being in those situations. Real world exposures are challenging - there are alot of variables at play. But they can be very helpful to clients. Therapists who work within the Acceptance and Commitment Therapy (ACT) framework of CBT prefer to scrap the hierarchy of feared situations and instead develop a listing of desired behaviors (going to a movie, taking a flight somewhere) and creating a roadmap to help the client engage these behaviors in those situations and not avoid being in situations they want to be in. ACT therapists emphasize that the most important factor in real world engagement is the desirability of being in the situation (“it’s important to me”) rather than the degree of distress the situation might trigger.
There is some indication that real world exposures are useful, but are NOT as essential to successful treatment as interoceptive exposures. Craske and colleagues (2006) compared interoceptive exposure treatment versus interoceptive + real world exposure treatment and found that the reductions in panic attacks were similar for both groups. Alessandro Pompoli and Toshi Furukawa (2017) published a review of 72 studies with a total 4064 patients with panic disorder. In their statistical review of these studies, Pompoli and Furukawa found that interoceptive exposure treatment had better outcomes than real world exposure treatment.
So, if you are getting treatment for panic, one take home message is that doing interoceptive exposures is very helpful and that doing real world exposures may be helpful, but you need to do the interoceptive exposures as well.
What about breath work or muscle relaxation? It works, people like it, but it doesn’t work as well as exposure.
Remember 5-4-3-2-1 breathing? Google panic treatment and you will find lots of write ups about how to do it. It seems like a reasonable idea that teaching people to slow their breath or to relax would be a useful technique for helping people with panic. Early treatment studies done in Barlow’s lab compared relaxation training versus cognitive therapy + exposure training (Barlow 1989) and found that both were clinically helpful in reducing panic attacks. But they noticed that cognitive training + exposure therapy group had a larger number of people reporting having zero panic attacks in the period after treatment was complete. Plus, a 2 year follow up study with the same sample found that the benefits of relaxation training did not hold up well over time, but the benefits of cognitive training + exposure training held up remarkably well and actually improved over time (Craske et al, 1991). This framed relaxation techniques as helpful but limited. These studies were ground breaking at the time but had very small sample sizes. Since those studies, many, many clinical trials seem to indicate the same thing. In the review analysis done by Pompoli and Furukawa (2017) examining 72 separate studies on panic disorder treatments, they found some interesting results on breathing retraining and muscle relaxation. They concluded that education, cognitive training and exposure therapy, specifically interoceptive exposure, were the best CBT strategies to use in terms of symptom reduction and remission rates and that muscle relaxation and breath focused strategies were the “least helpful” strategies for treating panic attacks. Yet they found that study participants liked having breathing retraining exercises to practice. So breath work helps, but not as much as you’d think, but people like doing them. So about 30 years after Barlow and Craske’s initial small pilot study findings on treating panic have held strong. Sorry to sound repetitive, but it will really help to do the interoceptive exposures. Don’t skimp on them!
The take home message
The 1980’s gave us the Showtime Lakers, Prince, Madonna, and fabulous fashion (remember Kajagoogoo and Spandau Ballet?). It also gave us the foundations of CBT based panic treatment and in the ensuing years, through a number of clinical trials and basic science studies have spelled out the important components of treatment. Psychoeducation, reworking how you interpret body sensations that are unpleasant and associated with panic, and interoceptive and real world exposures. Each component involves learning - learning about how our body learns to react with panic and perpetuate avoidance behaviors that strengthen the panic cycle (Barlow 1989), learning about the roles of cognitive appraisal in the panic cycle and how to work on it in treatment (Clark, 1986) and how engaging in exercises that trigger body sensations associated with panic helps our body learn new ways to handle these sensation instead of trying to escape or avoid them.
References
Alessandro Pompoli et al 2017. Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis
Barlow 1989. Behavioral treatment of panic disorder
Clark, 1986. A cognitive approach to panic
Craske, Brown & Barlow 1991. Behavioral treatment of panic disorder: A two-year follow-up -
Craske, DeCola, Sachs, Pontillo Panic control treatment for agoraphobia
Taylor 2000. Understanding and Treating Panic Disorder: Cognitive-Behavioural Approaches. Link to the Book
* I read the Epictetus quote was in an excellent book by Donald Robertson called The Philosophy of Cognitive-Behavioural Therapy.
