Anxiety Disorders 273
leading to anticipatory anxiety. In turn, this anxiety increases activity in his sympa-
thetic nervous system, which is what causes the breathing and heart rate changes
that he feared. In this way, the man may trigger his own panic attack. Figure 7.6
illustrates these three factors and their feedback loops.
Treating Panic Disorder and Agoraphobia
Earl Campbell received treatment for his panic disorder—medication, cognitive-
behavior therapy (CBT), and social support—which targeted all three types of
neuropsychosocial factors. Let’s examine the various types of treatments commonly
used for panic disorder.
Targeting Neurological Factors: Medication
To treat panic disorder, a psychiatrist or another type of health care provider licensed
to prescribe medication may recommend an antidepressant or a benzodiazepine.
Benzodiazepines are prescribed as a short-term remedy; the benzodiazepines alpra-
zolam(Xanax) and clonazepam (Klonapin) affect the targeted symptoms within
36 hours, and they need not be taken regularly. One of these drugs might be pre-
scribed during a short but especially stressful period. Side effects of benzodiazepines
mainly include drowsiness and slowed reaction times, and patients can suffer with-
drawal or develop tolerance to the medications when they are taken for an extended
period of time (see Chapter 4). For these reasons, an antidepressant such as an SNRI,
an SSRI, or a TCA (tricyclic antidepressant) such as clomipramine may be a better
long-term medication. These medications can take up to 10 days to have an effect
and may be prescribed at a lower dose than is usual for depression (Gorman & Kent,
1999; Kasper & Resinger, 2001). After Campbell’s panic attacks were diagnosed, he
initially relied on medication as his sole treatment; like most people, though, when
he stopped taking the medication or forgot to take a pill, his symptoms returned.
Such recurrences motivated him to make use of other types of treatments.
Targeting Psychological Factors
CBT is the fi rst-line treatment for panic disorder because it has the most enduring
benefi cial effects of any treatment (Cloos, 2005). In fact, patients with either type of
panic disorder (that arising primarily because of learning or that arising primarily
through a lower threshold for detecting suffocation) profi t to equal degrees from
CBT (Taylor, Woody, et al., 1996). Moreover, CBT methods can even be effective in
a self-help format, with minimal therapist contact (Carlbring & Andersson, 2006;
Carlbring et al., 2005).
Effective CBT methods can emphasize either the behavioral or the cognitiveaspects of change. Specifi cally, as discussed in the following sections, behavioral
methods focus on the bodily signals of arousal and panic and on the avoidance be-
haviors, whereas cognitive methods focus on the misappraisal of bodily sensations
and on the mistaken inferences about them. A meta-analysis of the effects of treat-
ment for panic disorder that combined behavioral and cognitive methods found that
over half of patients who completed treatment improved and remained improved 2
years later (Westen & Morrison, 2001).
Behavioral Methods: Relaxation Training, Breathing Retraining, and Exposure
For people with panic disorder, any bodily arousal can lead to a fi ght-or-fl ight re-
sponse. To help counter this excessive response to arousal, therapists may teach
patients breathing retraining and relaxation techniques to stop the progression from
bodily arousal to panic attack and to increase a sense of control over bodily sensa-
tions. Campbell reported how he learned to take “long deep breaths and relax my
body completely when panic struck. This is very diffi cult; at fi rst I didn’t believe I
could do it. I somehow had to convince myself that the attack was not really hap-
pening. I had to fi ght it off by relaxing myself” (Campbell & Ruane, 1999, p. 119).
Other behavioral methods, such as exposure, focus on the patient’s tendencyto avoid activities that produce certain bodily sensations (such as not exercising in