According to a panel of experts convened in 1991 by the National Institutes of Health and NIMH, panic disorder can be treated effectively with cognitive- behavioral therapy (CBT), pharmacological therapy, and possibly a combination of CBT and medication. Patients generally begin to respond quickly to appropriate treatment. However, some treatments may work better than others for certain patients. So, it is important to monitor the response to treatment closely and reassess the treatment strategy if there is no improvement after 6 to 8 weeks.

Cognitive-Behavioral Therapy
CBT combines the techniques of cognitive and behavioral therapy.

Behavioral therapy focuses on changing specific actions and uses several techniques to decreases or stop unwanted behavior. One set of techniques is designed to help patients to become less sensitive to their own internal bodily sensations. For example, one technique trains patients in diaphragmatic breathing, a special breathing exercise involving slow, deep breaths to reduce anxiety. This is necessary because people who are anxious often hyperventilate, taking rapid shallow breaths that can trigger rapid heartbeat, light-headedness, and other symptoms of panic. Another technique, exposure therapy, gradually exposes patients to what frightens them and helps them cope with their fears.

Like behavioral therapy, cognitive-behavioral therapy teaches patients to react differently to the situations and bodily sensations that trigger panic attacks and other anxiety symptoms. However, patients also learn to understand how their thinking patterns contribute to their symptoms and how to change their thoughts so that symptoms are less likely to occur. This awareness of thinking patterns is combined with exposure and other behavioral techniques to help people confront their feared situations. For example, someone who becomes light-headed during a panic attack and fears he is going to die can be helped with the following approach used in cognitive-behavioral therapy. The therapist asks him to spin in a circle until he becomes dizzy. When he becomes alarmed and starts thinking, "I'm going to die," he learns to replace that thought with a more appropriate one, such as "It's just a little dizziness, I can handle it."

CBT teaches patients to anticipate the situations and bodily sensations that are associated with their panic attacks. This awareness sets the stage for helping the patient to control the attacks. Specially trained therapists tailor CBT to the specific needs of each patient. The therapy usually includes the following components:

• Helping patients identify and change patterns of thinking that cause them to misperceive commonplace events or situations as dangerous and to "think the worst." Patients often are unaware of how deeply these anxiety-raising thoughts are ingrained.
• Teaching patients exercises to prevent the hyperventilation that often triggers a panic attack. The exercises also help the patient to replace alarmist thoughts such as, "I'm dying," with more appropriate ones, such as, "I'm just hyperventilating - I can handle this."
• Helping patients become less fearful by safely and gradually exposing them to situations and physical sensations they avoid or find frightening.
• CBT is a short-term treatment, typically lasting 12 to 15 sessions over several months. Patients with panic disorder who go through CBT are reported to have very few adverse effects and a relatively low relapse rate of panic attacks.

CBT requires special training. If you decide to refer your patients for cognitive- behavioral therapy, check to see if the professional has the requisite training and experience in this method of panic disorder treatment.

Medication

Medications, although not cures, can be very effective at relieving anxiety symptoms. Today there are more medications available than ever before to treat anxiety disorders. So if one drug is not successful, there are usually others to try. In addition, new medications to treat anxiety symptoms are under development.

Several classes of medication can reduce or prevent panic attacks and therefore substantially decrease patients' anticipatory anxiety about having attacks. The medications most often used are:

• Antidepressants, including serotonin reuptake inhibitors, tricyclics, and monoamine oxidase inhibitors
• Certain high-potency benzodiazepines

Each of these classes of medications works differently and has different side effects. The latest information about the pharmacotherapy of panic and related disorders is available in clinical handbooks of psychotherapeutic medications. For most of these medications, treatment lasts 6 months to a year. With all of them, proper dosing and monitoring is essential.

The practitioner who administers medication for panic disorder should be well versed in the clinical use of the relevant psychotherapeutic medications. It is important to start with a low dose and increase it gradually. Build up to the recommended dosage for the particular medication you are prescribing, watching for troublesome side effects as well as for a decrease in panic attacks. The goal should be to stop the panic attacks. Make sure the patient is maintained on a dose that is in the therapeutic range. When withdrawing medication, reduce the dosage gradually and watch for possible relapse. To improve compliance, it is important to educate the patient about the medication and its side effects.

Combining CBT and Medication
A combination of CBT and pharmacotherapy may offer rapid relief, high effectiveness, and a low relapse rate. The combination may be particularly helpful for patients with agoraphobia.