"I feel like I'm dying!" - Treating Panic Attacks

The classical conditioning paradigm has not been a particularly useful model for conceptualizing the etiology of panic disorder (Dittrich et al., 1983); however, it does provide a useful explanation of how panic disorder is maintained. According to Wolpe (1958), once the auto-nomic arousal associated with anxiety is experienced, a cycle of interoceptive conditioning may be created so that future autonomic responses elicit anxiety. This behavioral model of panic disorder suggests that somatic processes lead to autonomic arousal, which is followed by physiological symptoms of panic. This causes apprehension and arousal, which in turn cause further symptoms of panic (Hibbert & Chan, 1989).

A number of somatic cues have been reported to precede a panic attack, including hyperventilation (Shulman, Cox, Swinson, Kuch, & Reichman, 1994), heightened cardiac activity (Margraf & Ehlers, 1991), and symptoms associated with prodromal depression or anxiety (Lelliott, Marks, McNamee, & Tobena, 1989). It has been proposed that the reestablishment of normal bodily functioning will eliminate the somatic cues that often lead to panic attacks.

Support for a behavioral component of panic attacks comes primarily from studies in which panic is reduced in individuals who are able to identify and control internal somatic symptoms that trigger the episodes. Recent studies on panic disorder have suggested that exposure to internal cues, such as feared bodily sensations, often experimentally induced by hyperventilation or exercise, can ameliorate the symptomatology associated with anxiety attacks (Margraf et al., 1993).

Hyperventilation has been considered one of the primary causes of panic disorder (Hibbert & Chan, 1989). The hyperventilation model (HV) states that panic results from dysfunctional breathing patterns that cause chronic hyperventilation (Michelson et al., 1990). Individuals with panic disorder report that voluntary overbreathing for 2 minutes reproduces a state similar to their naturally occurring attacks. The HV model is the basis for the behavioral intervention of breathing retraining in the treatment of panic disorder (Hibbert & Chan, 1989).

Although few studies exist that explore the efficacy of behavioral treatment of panic disorder used alone, there is considerable evidence that this model has had a modest impact on decreasing the severity of panic attacks. A number of studies have explored the efficacy of relaxation, breathing retraining, and exposure therapy in the treatment of panic disorder. These studies have focused on comparisons between behavioral techniques and cognitive therapy, cognitive-behavioral therapy, supportive therapy, and control groups.

Relaxation and Meditation Therapy
Relaxation therapy is based on Wolpe's (1958,1969) reciprocal inhibition theory. Outcome research on the efficacy of this treatment has produced mixed results. Relaxation training, in general, seems to have limited effectiveness in the treatment of panic disorder.

One study found that progressive muscle relaxation was significantly more effective than no treatment in the reduction of intensity in panic attacks (Barlow, Craske, Cerny, & Klosko, 1989); however, no differences were found in the frequency of panic attacks at the termination of treatment or at follow-up. Relaxation training in combination with other cognitive-behavioral techniques was found to be superior to relaxation training alone. A higher dropout rate was found in the relaxation training group, 33% compared with 6% in the cognitive-behavioral group. In addition, the relaxation alone condition was more susceptible to relapse at follow-up. Another study has reported similar results (Clark, Salkovskis, Hackman, & Gelder, 1991).

In a study comparing progressive relaxation and applied relaxation, applied relaxation was found to be superior in ameliorating symptoms of panic (Ost, 1988). Progressive relaxation is a tension-release technique in which muscle groups are first tensed and then relaxed (Lazarus, 1971). In applied relaxation, the first signs of an impending panic attack are observed, followed by the use of a rapid relaxation technique before the onset of a full-blown attack. All of the participants in the applied relaxation group were panic-free, both at the end of treatment and at the follow-up. Of those in the progressive relaxation group, 71% were panic-free at the end of treatment and 51% at follow-up. Such findings need to be considered in terms of the reality that the study suffered from several methodological problems including no control group and small sample size. In addition, relaxation may be an important adjunct to panic disorder treatment, but these studies suggest that other treatments may be more efficacious (Margraf et al., 1993).

Some preliminary success with a meditation-based stress reduction program for panic disordered individuals has been reported. Kabat-Zinn et al. (1992) investigated the effectiveness of a transcendental meditation program. In comparison with controls, there was a significant reduction in the number of panic attacks in the meditation group. This improvement was maintained at a 3-month follow-up, as compared with the control group. Unfortunately, a very small sample size and the inclusion of a cognitive stress reduction component make the results difficult to interpret.

Breathing Retraining
The overall goal of breathing retraining is a reduction of the respiratory rate. In a review of the breathing retraining literature, Garssen, de Ruiter, and van Dyck (1992) found it to be an effective technique for the treatment of panic disorder: however, their review suggested that it is most effective when used in combination with cognitive interventions. When used alone, some studies found breathing retraining no more effective than a placebo treatment (Garssen et al., 1992; Hibbert & Chan, 1989; Klosko, Barlow, Tassinari, & Cerny, 1990). In addition, the technique has been found to work equally well with panic-disordered individuals regardless of the presence of hyperventilation. This calls into doubt the importance of hyperventilation as a necessary factor for panic attacks (Garssen et al., 1992).
- Beamish, Patricia et al.; Outcome Studies in the Treatment of Panic Disorder: A Review; Journal of Counseling & Development; May/Jun 1996; Vol. 74 Issue 5, p460-467

Personal Reflection Exercise #10
The preceding section contained information about a review of common panic disorder treatments.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 24
What is one of the primary causes of panic disorder identified by Beamish? Record the letter of the correct answer the Answer Booklet.