Panic disorder is a condition characterised by recurring panic attacks- regular bouts of intense and debilitating fear without any apparent cause, coupled with increased levels of fear regarding future attacks. This review summarises current research into panic disorder, focussing on the effectiveness of treatments, modulating variables within treatment, increasing treatment availability and preventing panic before it begins.
Causes of Panic Disorder
The development of panic disorder often begins following a single panic attack. Many people will suffer from a single attack and then quickly recover with no further distress, but some people come to fear having another attack and are constantly on alert for the warning signs. Such people are ironically more likely to have future attacks due to being overly sensitive to changes in their body and interpreting small biological changes as being the start of a panic attack, triggering further fear and ultimately bringing about further panic.
Researchers believe that many people with panic disorder possess a genetic or biological vulnerability which causes them to react particularly strongly to stress. Such people often also have a sense that events around them are uncontrollable and unpredictable, making them more susceptible to panic attacks brought about by interpreting bodily sensations as being catastrophic. Anxiety sensitivity, a similar trait which indicates increased reaction to the physical aspects of fear, is also linked to the development of panic disorder.
Based on this model, overcoming panic disorder is a case of learning to experience fear and bodily sensations relating to fear without them escalating into a full panic attack. Treatments aim to de-sensitize patients to bodily sensations, stopping them interpreting minor fear and normal body sensations as being the start of a panic attack. This is done through behaviour experiments where patients are encouraged to face their feared situations and sensations in order to learn that they pose no harm. As catastrophic interpretations reduce so too does the likelihood of an attack.
Treatment of Panic Disorder
Cognitive behavioural therapy is one of the most effective treatments for panic disorder and is a real success story for modern psychological research. Treatment efficacy is around 60% for CBT, and other forms of treatment show similar levels of success. Treatment rates are similar in clinical trials and in community based settings, suggesting that the principles of panic disorder treatment are universal and can be delivered by non CBT experts just as effectively. However, it is interesting to note that treatment efficacy has not improved since it was developed in the 1980s, with some studies even showing that success rates have decreased since then.
Panic Disorder Treatment Innovations
Given that panic disorder treatment does not universally lead to the elimination of symptoms, it is vital that we continue to innovate and refine the treatment process. One avenue of enquiry has focussed on combining CBT with medication such as SSRIs and SNRIs, but this appears to have little long term effect.
Research has also examined whether intensive treatment for several hours a day, several days per week has any better effect than treatment which is spaced over several weeks (as CBT usually is), but again there is no solid evidence that this is any more effective.
One potential new factor which could help improve panic treatment is exercise. The link between exercise and sound mental health is well established, and exercise may further enhance panic disorder treatment by providing exposure to some of the feared sensations (racing heart, breathlessness etc) in a safe context so as to desensitize patients to them. Preliminary research shows that exercise can be effective in reducing panic as well as reducing anxiety sensitivity. Another possible means of improving CBT for panic disorder could be to combine it with traditional psychodynamic therapy, thereby treating the condition through two different underlying processes, possibly enhancing treatment efficacy.
Modulating Variables in Panic Disorder Treatment
Research has shown that our understanding of panic disorder as being a function of traits like anxiety sensitivity and vulnerability to stress are accurate, in that anxiety sensitivity is a key mediating variable in treatment effectiveness. Changes in the interpretation of panic “warning signs” predicted both short term and long term gains from treatment.
Comorbidity. Panic disorder is often diagnosed alongside (comorbid) with other anxiety disorders, mood disorders such as depression, and substance abuse disorders. Some disorders, particularly personality disorders, can reduce the effectiveness of panic treatment, while CBT treatment for panic can have a beneficial effect on a variety of other disorders such as anxiety and phobias.
Dissemination, or spreading the availability of evidence-based treatment, is a crucial step in the treatment of any disorder, including panic. Most individuals with panic disorder do not receive proper evidence based treatment, despite its high success rates and proven record.
One method of improving access to treatment is by making use of online self-help resources. Treatments on a self-directed basis using books have proven highly effective given that the principles of panic treatment are relatively straightforward to understand and implement, and online resources could enhance the self help experience through interactive activities and tools to monitor performance. Success rates for such online programs have been examined and found to be similar to those for face to face therapy.
Prevention of Panic
The most cost-effective means of treating panic disorder would be to prevent its development in the first place. Research into this is relatively rare but shows that it is possible. One study focussing on preventing anxiety in children utilised a combination of relaxation training, cognitive work, attention training and parental support and led to significant reductions in anxiety levels after the intervention.
Specific interventions for preventing the onset of panic disorder are also promising. Training at-risk individuals on breathing techniques, educating them on the panic process and helping them practice exposure reduced the risk of developing panic disorder significantly.
Treatment for panic disorder is well established and has a proven record of reducing symptoms for the majority of patients. However, recent years of research have largely failed to improve upon the existing framework for treating panic disorder. New avenues of treatment need to be developed and tested, while also utilising technology to increase access to high quality treatment. Stopping the onset of panic disorder though preventative work is also a high priority and future research should aim to improve this process.
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