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How to treatment of panic disorder

Cognitive behavioural interventions

Some of the most successful treatment programmes for panic disorder have been based onClark’s aetiological model. Clark et al. (1994), for example, developed a two-phase treatment approach. The first phase involved teaching clients the cognitive model of panic. The second involved three elements:

relaxation to reduce physiological arousal at the time of stress

cognitive procedures to change panicogenic cognitions

behavioural procedures in order to control panic symptoms.

Relaxation involves learning to physically relax and to slow and control breathing. These techniques can be applied before potential panic attacks, for example, when approaching a situation where a panic attack has occurred previously, and during them. Cognitive procedures include self-instruction and cognitive challenge. The goal of the behavioural procedures is to teach the individual, through direct experience, that the outcome they fear at times of panic will not actually happen. Increasingly, therapists instigate the symptoms of panic within the therapy session and practise its control through the use of cognitive and relaxation techniques. Symptoms may be generated by a variety of procedures, including reading words linking bodily sensations and catastrophic outcomes, and hyperventilating.

These behavioural experiments can show how thoughts and behaviours influence symptoms previously considered the result of unknown factors and allow rehearsal of cognitive and relaxation panic control strategies. Once control over symptoms has been achieved within the therapy sessions, these skills can be used in real-life situations.

This may be done in a graduated process, starting with relatively easy circumstances and moving on to more diffi cult ones. By the end of therapy, over 80 per cent of individuals are typically panic-free, in contrast to about 12 per cent of those in no-treatment control groups. Clark et al., for example, reported outcomes following this approach, relaxation alone, a tricyclic (imipramine), and a waiting list control period. Participants in the CBT group took part in 12 sessions over three months, followed by up to three booster sessions over the following three months.

Imipramine was withdrawn after six months. At one-year follow-up, all three treatments proved more effective than no treatment. However, CBT was the most successful at this time, with 85 per cent of individuals being panic-free, in contrast to 60 per cent of those who received imipramine or who were taught relaxation. Of note is that 40 per cent of those receiving imipramine and 26 per cent of those receiving relaxation sought an alternative therapy in the year following the intervention. Only 5 per cent of the CBT group did so. This form of intervention may also be provided over the internet. Schneider et al., for example, gave people with panic disorder access to one of two web-based self-help programmes, combined with brief back-up telephone contact with a clinician.

One programme involved a CBT programme similar to that ofClarkand colleagues, with specifi c planned exposure to feared situations. The second group experienced a briefer CBT intervention and did not have a planned exposure programme. By the end of therapy, both groups evidenced signifi cant benefi ts on a variety of measures, and did not differ in the level of improvement achieved. However, by one-month follow-up, those who participated in the planned exposure programme showed more consistent gains.

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