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"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.
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.
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.
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