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Panic attack is an exaggerated perception of danger. Panic disorder on the hand is a recurrent, unexpected panic attack. These attacks include a variety of physical and mental symptoms. One major marker is that the individual is often afraid and worries about repeated attacks. These fears result in abnormal changes in behavior.
This article provides a treatment plan for panic disorder. It also acts as a guide for mental health therapists who play a crucial role in managing clients with panic disorder.
DSM-5-TR Classification of Panic Disorder
The DSM-5-TR outlines the following as the diagnostic criteria for panic disorder:
A. Recurrent unexpected panic attacks
A panic attack is an abrupt surge of intense fear or discomfort. It reaches a peak within minutes. During this time, four (or more) of the following symptoms occur:
- Palpitations, pounding heart, or accelerated heart rate.
- Sweating.
- Trembling or shaking.
- Sensations of shortness of breath or smothering.
- Feelings of choking.
- Chest pain or discomfort.
- Nausea or abdominal distress.
- Feeling dizzy, unsteady, lightheaded.
- Chills or heat sensations.
- Paresthesias (numbness or tingling sensations).
- Derealization or depersonalization.
- Fear of losing control or “going crazy.”
- Fear of dying.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
- A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of certain people, activities or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance.
D. The disturbance is not better explained by another mental disorder.
Types of Treatment Plans for Panic Disorder
1. Cognitive Behavioral Therapy (CBT)
CBT is usually recommended as the first-line treatment for panic disorder. The goal of cognitive behavioral therapy is to recognize and alter the negative thought patterns that trigger panic attacks. The essence of this therapy is to lessen the symptoms clients face and enable them to cope when they face the distressing situations. Therapists teach clients to develop more realistic and alternative ways of interpreting those perceived catastrophic events.
2. Exposure Therapy
Reduces avoidance behaviors and debunks catastrophic beliefs. It does this by systematically and gradually confronting feared stimuli (internal and external). There are three types of exposure: in vivo (real-life scenarios), interoceptive (physical sensations) and imaginal (visualization).
3. Acceptance and Commitment Therapy (ACT)
This therapy encourages the client to accept their thoughts, emotions and physical sensations without judgement. It also helps the client to identify their values and take actions toward these values.
4. Dialectical Behavioral Therapy (DBT)
Uses mindfulness skills to increase awareness of the present moment in order to reduce anxiety. It also helps clients to develop distress-tolerating skills to regulate emotions.
5. Psychodynamic Psychotherapy
Examines the emotional significance of panic symptoms. It also traces their connections to unconscious conflicts and past experiences.
Treatment Plan for Panic Attack Examples
Below are examples of various treatment modalities for panic attack:
Cognitive Behavioral Therapy (CBT) Treatment Plan
Goal:
To reduce panic attacks and minimize avoidance behaviors related to panic triggers. CBT is aimed at identifying and changing negative thoughts and behaviors to more positive and realistic ones.
Treatment Plan:
Conduct Assessment and Psychoeducation (Sessions 1-2)
- Thoroughly assess for symptoms and how they impact the client’s daily functioning.
- Educate the client on panic disorder, the “fight or flight” response, and principles of CBT.
- Teach the client how to self-monitor symptoms and triggers using thought recording.
Deep Breathing and Relaxation Techniques (Sessions 3)
- Teach the client diaphragmatic breathing and progressive muscle relaxation to manage physiological symptoms.
Cognitive Restructuring (Sessions 4-6)
- Identify and challenge irrational thoughts or cognitive distortions (e.g. catastrophic thinking).
- Practice reframing negative thoughts.
- Develop alternative and realistic interpretations.
Exposure Therapy and Behavioural Activation (Sessions 7-12)
- Interoceptive Exposure: Reduces the client’s fear of physical sensations (i.e., lessening rapid heartbeat) in a safe space.
- Imaginal Exposure: Helps the client process catastrophic thoughts or traumatic memories by vividly imagining feared scenarios in a safe environment.
- In-Vivo Exposure: Addresses avoidance of real-life situations (i.e., crowded places). First, the therapist and client works to create a list of feared situations. These situations are then ranked by level of difficulty. The client is then gradually exposed to these feared scenarios, beginning from lower-ranked items. These beliefs are then tested in real-world settings.
Relapse Prevention and Maintenance (Sessions 13-15)
- Review progress made and improve coping techniques.
- Develop a plan for relapse prevention
- Discuss strategies for recognizing early warning signs of relapse.
- Schedule periodic followup sessions.
Eclectic Approach to Panic Disorder Management
While CBT remains the best option for treating panic disorders, Eclectic therapy tailors interventions to meet client’s needs. Eclectic therapy combines different therapeutic approaches in one. It can be used when the client presents with a wide range of issues asides panic attacks.
Assessment, Education, and Building Therapeutic Rapport (Session 1)
- Perform a thorough evaluation to determine any comorbid conditions. Use the assessment and clinical observation to confirm the diagnosis of panic disorder.
- Psychoeducate the client on the signs and symptoms of panic disorder. Outline the role of behavioral and cognitive factors.
- Together with the client, determine the goals of the treatment.
- A solid therapeutic alliance founded on empathy and trust should be established first.
Self-Monitoring and Trigger Identification (Session 2)
- Instruct the client to record every detail of their panic attacks. This can include the date, time, and place. The client should observe triggers, symptoms (physical, mental, and emotional), and behavioral reactions.
- Determine the patterns and triggers that lead to panic attacks.
Diaphragmatic Breathing and Relaxation Techniques (Session 3)
- To control physiological arousal, teach the client how to breathe diaphragmatically. Practice during the sessions and assign them as homework.
- Use other means of relaxation like guided imagery or progressive muscle relaxation.
Cognitive Restructuring (Sessions 4-5)
- Introduce the client to cognitive restructuring.
- Help the client identify negative thought patterns that bring them anxiety. These thoughts may include “I am going to die” or “I am almost losing control”.
- Teach the client how to create arguments that support or refute their negative thoughts.
- Assist the client in finding alternative or more realistic ways of thinking.
Exposure Therapy (Session 6)
- Teach the client about exposure therapy and how it reduces anxiety.
- Create a hierarchy of environments that trigger anxiety and then arrange the stimuli on a scale of high to low anxiety-producing.
Interoceptive Exposure (Session 7)
- Apply interoceptive exposure exercises to reduce the client’s fear of physical sensations.
- Assist the client to engage in activities they have avoided. This is important because they can cause panic attacks.
- Interoceptive exposure could take the form of spinning in a chair to cause dizziness. The client could also run on the spot to raise the heart rate.
- Assess the client’s experience and challenge negative thoughts.
‘In Vivo’ Exposure (Session 8-10)
- Begin with items at the top of the hierarchy. These should include environments that cause less anxiety to the client.
- Encourage the client to stay in the circumstance until their anxiety subsides.
- Ensure that the client is reminded to apply coping mechanisms.
- Allow the client to process what happened during the ‘in vivo’ exposure.
Skill Building and Exposure Therapy (Sessions 11-13)
- Continue the ‘in vivo’ exposure by gradually increasing the levels.
- Resolve any issue that arises during exposure.
- Combine relaxation techniques with cognitive restructuring.
Using Eclectic Therapy to Manage Comorbid Conditions (Session 14)
- Evaluate the client’s use of social skills and their interpersonal interactions. If there are deficits, the therapist combines elements of assertiveness training and interpersonal therapy.
- Continue to assess and role-play communication techniques.
Relapse Prevention and Maintenance (Sessions 14-15)
- Examine the skills and strategies that have been learned during sessions.
- Create a plan that will assist the client in preventing relapses. These plans could include learning coping skills, identifying triggers, and building support systems.
- Talk about ways to manage panic attacks should they reoccur. This should be aimed at preventing relapse.
Terminate Treatment and Arrange a Follow-Up Session (Session 16)
- Evaluate the client’s development and acknowledge their achievements. Talk about strategies for ongoing development and self-care.
- Schedule follow-up meetings as needed.
Case Study Example of Applying Eclectic Approach to Panic Disorder Management
John is 35 years old and works as a software engineer. He avoids public transit and social events. He revealed that he frequently has panic attacks in crowded settings. He stated that he felt out of breath and it seemed as though he was about to die. He talks about how in such circumstances his breathing increases and he breaks out in profuse sweat.
Goal:
The therapist will use the eclectic approach to manage John’s panic attacks, his poor communication and social skills.
Eclectic Therapy Treatment Plan for Panic Disorder
Build Therapeutic Alliance and Psychoeducate Client (Sessions 1–3)
- Establish a strong therapeutic alliance with the client.
- Psychoeducate John on panic disorder and the symptoms.
- Teach John progressive muscle relaxation and diaphragmatic breathing.
Cognitive Restructuring – (Sessions 4-5)
- John identifies the catastrophic thoughts he’s been having. “I’m going to faint and embarrass myself on the stage”. Or “Everyone will be watching me to see if I mess up”.
- Assist him in replacing those negative thoughts with more accurate ones. For instance, “This feeling is only temporary, and it will pass”. Or “I have experienced this before and I can manage it better”.
Exposure Therapy (Interoceptive Exposure) – (Sessions 6-7)
- Apply interoceptive exposure. Do this by giving John instructions to go up the stairs. This causes his heart rate to increase. Tell John to shake his head back and forth to make him feel lightheaded.
- John begins to understand that these feelings do not mean that he is in danger.
Exposure Therapy (In-Vivo Exposure) – (Sessions 8–11)
Rank John’s fearful situations:
- Lining up at a coffee shop
- Walking around a shopping center
- Taking the bus when it is less crowded
- Attending a music concert
In every scenario, allow John to exercise coping mechanisms as he gradually ascends the hierarchy.
Comorbid Conditions Management – (Sessions 12-13)
- John avoids social situations. Based on this observation, evaluate his communication and social skills.
- John reveals that his anxiety is made worse by the frequent discomfort and insecurity he feels.
- Cover training in role-playing, assertiveness, starting conversations, and communicating his needs.
Relapse Prevention and Maintenance – (Session 14)
- This eclectic approach lessens John’s avoidance behaviors and panic attacks.
- Work with John to create a relapse prevention plan.
Termination and Follow-up (Session 15)
- John’s general quality of life and social confidence improved significantly.
- He is scheduled to come for follow-up sessions.
Conclusion
CBT is a very effective psychological treatment plan for panic disorder. It provides useful techniques for managing panic symptoms. It enhances the quality of life of people with panic disorder. Mental health therapists can help clients overcome panic disorder. The Eclectic approach can also be applied to help clients lead more fulfilling and satisfying lives.
FAQs
Is Taking Medicine For Panic Disorder Always Required?
No, taking medicine for panic disorder is not always required. However, depending on the severity, medicine can be used in combination with psychotherapy. But, this must be recommended by the mental health practitioner.
What Is The Average Duration of CBT Treatment For Panic Disorder?
CBT for panic disorder takes 10 to 15 sessions. Although it is carried out based on each client’s needs and progress. So, the length of the treatment may differ.
Is Group Therapy Effective for Treating Panic Disorder?
Yes, Group Therapy is effective for treating panic disorder. Group therapy lowers stigma and feelings of shame. They also provide opportunities for modeling and reinforcement in a supportive environment.
