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Panic and Exposure Therapy

First, the good news: Panic Disorder is very treatable. And the bad news isn’t so bad, really. It’s just that you have to be committed to the process of getting better and you will need to work hard. In this post I’ll explain what Panic Disorder is, describe an effective treatment approach, and explain why commonly used methods for relieving anxiety may actually exacerbate it.

What is Panic Disorder?
Agorophobia and other risks of Panic Disorder
How does one develop Panic Disorder?
The tenacity of the four Fs
Treatment overview
Don’t make it worse
My next post

What is Panic Disorder?

Those with Panic Disorder (PD) have a number of intense physical symptoms that typically last for 10 minutes or less, but attacks can continue for much longer if one rolls into another. They are extremely frightening and uncomfortable, especially if the person believes there may be something physically wrong with him or her. Physical symptoms may include rapid heart beat, shortness of breath, tingling of the extremities, dizziness, feeling of choking, trembling or shaking, stomach upset, chest pain, chills or hot flashes and the person may feel oddly unreal or detached from themselves. Not fun. People who have these attacks may think they are having a heart attack or stroke, that they are going crazy or may lose control, or feel very embarrassed and self-conscious. Attacks may be brought on by seeing something that frightens you, such as snakes, or they can be triggered by certain situations, such as being in a crowded place. Most attacks, however, seem to come out of the blue (although recent research has shown that physiological changes actually precede “sudden” attacks), which is a hallmark of Panic Disorder. Recent research has shown that stressful life events may exacerbate the severity of a person’s panic attacks. This may explain why new moms often experience Panic Disorder for the first time.

The person with panic often feels a desperate need to escape and will do anything to avoid experiencing another attack. Left untreated, the anxiety typically gets worse.

Many people with Panic Disorder end up going to the Emergency Room or their doctor’s office at some point because they think there must be something physically wrong with them. If you’re like many people, you may not believe the doctor when she says you had a panic attack. You may also feel embarrassed because you were so sure that you were having a heart attack. This is a normal response but it’s important not to let your feelings of embarrassment stop you from getting treated. In fact, it’s a good thing that you went to the doctor because we know that you’re in good physical health. We can now move on to treating the anxiety.

Agorophobia and other risks of Panic Disorder

Agoraphobia sometimes develops as a side-effect of Panic Disorder and is, generally, a fear of public or open spaces. It develops because the person has had panic attacks that have scared the person so much that he avoids the places and activities he has associated with the attacks; he has been conditioned to believe he will panic in such places and will be unable to escape. At this point his symptoms have a big impact on his life and may seriously affect his relationships, employment, activity level, sense of freedom, and likely even his sense of self. According to the American Psychological Assocation (APA), those with Panic Disorder are also at risk for developing:

  • debilitating phobias
  • depression and suicidality
  • alcohol and drug abuse
  • feeling less emotionally and physically healthy
  • fear of leaving home

Again, it doesn’t have to rule your life and the treatment is effective for the vast majority of people who seek it.

How does one develop Panic Disorder?

It is difficult to pinpoint the exact cause of PD. Most of those who have it have had some problems with anxiety for most of their lives. The latest data point to a genetic component. Drug use may lead to an initial attack and so can mounting stress and responsibilities; panic attacks often first surface in times of transition. Smoking cigarettes may exacerbate the problem and those who smoke have have poorer treatment outcomes. Sometimes the death of someone close to us can be a trigger. At other times, no likely cause can be identified. They typically begin before the age of 30.

The tenacity of the four Fs

Panic is adaptive in some situations. If we are hiking in the northern hills, round a corner and suddenly find ourselves face-to-face with a bear, then it’s a good thing our bodies act the way they do. This is when our sympathetic nervous system kicks in, and it’s a good thing. In those cases, we are likely to do one of four Fs, all of which may save us: 1. Freeze. Some animals sense movement, so if we don’t move, they may not be able to see us or think we’re a threat and leave us alone. 2. Faint. If the animal thinks we’re dead, then they’re likely to move on or just play with us a bit. 3. Flight. If you run, they may not give chase and perhaps you can escape. 4. Fight. As a last resort, fighting may work against smaller, weaker predators, especially if you have some sort of weapon.

What’s interesting is that the physical symptoms during a panic attack are all things that can help us in that rare, dangerous situation described above. When our heart rate increases, blood is pumped toward our major muscle groups, such as our quadriceps, so that we can run. Sweating not only cools the body, but it makes us more slippery so that a predator has a harder time grabbing us. Tingling or numbness in the fingers and toes helps to draw blood toward the major muscle groups but also makes it less likely that we will not bleed to death if our hands gets injured in a fight. Do you tend to get dizzy? That is often a result of hyperventilation; fainting would be F #2, playing dead (but it is very rare that people actually faint during panic attacks).

While panic used to serve the purpose of ensuring our survival in times of danger, our environment has changed. Apart from the occasional mugger, rarely do we encounter situations in which we need the four Fs. Rather, we may have arguments with loved ones or co-workers, need to make a speech, or have tight deadlines we need to meet. Still, on occasion, our bodies continue to rely on their old tricks. When that happens, we can re-train our bodies and brains to respond more appropriately.

Treatment overview

Organizations such as the National Institute of Mental Health (NIMH) and the American Psychological Association (APA), and the American Psychiatric Association recommend CBT as the treatment of choice for PD. Although medications are also endorsed, below I explain why I think they are typically unnecessary in treating PD and can actually complicate it. If you have true PD, then the treatment is fairly straightforward. I follow the recommendations of Barlow and Craske,who have created a treatment model that combines educational, relaxation, cognitive, and behavioral components. Technically, it is a branch of CBT called “exposure therapy.” In my opinion, it is far and away the best approach and takes, on average, 10-16 sessions, depending on the individual’s specific needs.

It is certainly easier to take a pill than it is to go to a therapist and follow through on treatment recommendations, but psychotherapy is a better way to go. For most people with Panic Disorder, medication is unnecessary and only complicate treatment (but treatment is still fairly straight-forward). One problem with taking medications alone is that you will likely have to continue taking them indefinitely if you do not want to re-experience panic attacks. Also, anti-anxiety medications are potentially addicting, and anti-depressants are both less effective for panic and can lead to rebound effects when stopped. However, in some cases, especially if a person is also very depressed or suicidal, medications are an important part of treatment for PD. Never stop medications on your own; there can be serious effects from doing so. Please follow the recommendations of your doctor.

Don’t make it worse

One of the biggest components of treatment include helping you to recognize when you’re using avoidance. For those with anxiety, avoidance is a key component in maintaining and exacerbating your symptoms. When you avoid something that you associate with symptoms of panic, you actually increase both your anxiety and the likelihood that you will panic. For example, if you avoid driving over bridges because you think you may panic while driving over one (and perhaps you have in the past), then you will teach your body and brain that it is, in fact, too dangerous to do so. Your avoidance and fear of bridges will likely increase and you could develop a severe phobia of bridges. Your risk of having a panic attack on a bridge also increases.

Avoidance also applies to panic attacks themselves. As scary and uncomfortable as a panic attack is, it is not dangerous. If you find yourself panicking, remind yourself that while it is very uncomfortable, it will not kill you. You do not need to try to escape it. Each time you try to escape it, you are turning up the volume on future attacks and you may lengthen the duration of the attack. Again, by using avoidance strategies, you are teaching your body that panic attacks are too dangerous and must be avoided at all costs. When your body learns this, it reacts by going into panic mode more easily. You brain learns that it needs to be on high alert and may interpret harmless bodily sensations (such as an increased heart rate during exercise) as dangerous — once again, sending your body into panic mode.

A good therapist can help you identify your avoidance behaviors and give you tools and information to help you manage any attacks you may have. You will be given activities to practice at home, which are a vital part of your healing process.

Often people with PD spend a lot of time on the internet, trying to find a medical reason for their symptoms. This will only make things worse. It’s likely that you’re looking to confirm that you are seriously ill, and you won’t stop until you find something truly frightening. Chances are, you’re young, in good health, and have been told so by your doctor. There is no good reason to doubt her. There is, however, good information on the internet about Panic Disorder. Still, be a skeptical consumer; just because it’s on the internet, does not make it true.

I love working with clients who have Panic Disorder. Those I have seen who have been motivated to follow through with treatment see dramatic results. Best of all, they rediscover how to enjoy life. What could be better than that?

My next post

For my next post, I will talk about how you can stop smoking. I’ll include a description of different treatment options and your chances for success.


Meuret, A; Rosenfield, D; Wilhelm, F; Zhou, E; Conrad, A; Ritz, T; Walton, T (2011). Do unexpected panic attacks occur spontaneously? Biological Psychiatry, 20, 985-91.

Moitra, E; Ingrid, D; Courtney, B; Bjornsson, A; Sibrava, N; Weisberg, R; Keller, M. (2011). Impact of stressful life events of the course of panic disorder. Journal of Affective Disorder, 134, 373-6.

Rosqvist, J (2005). Exposure Treatments for Anxiety Disorders: A Practitioner’s Guide to Concepts, Methods, and Evidence-Based Practice. New York: Taylor and Francis Group.


Comments on: "Panic and Exposure Therapy" (1)

  1. Boo Bullis said:

    Hi Dr. Karin,

    Great article. Very interesting and informative.


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