Mastering Panic Without Medication
The six steps of the most effective approach to panic attacks.
Posted Feb 05, 2020
Overcoming panic attacks is all about confronting the monster in the closet, looking under the bed, or stepping out in public. In a previous post titled, "Anatomy of Anxiety: Mastery by Avoidance," it became clear that avoidance of our worst fears was at the heart of all anxiety. Through avoidance, our solutions become the problem.
Panic Attacks, Defined:
First of all, panic attacks are most always diagnosed with what is called related agoraphobia. The term “agoraphobia” refers to the tendency to avoid or endure with dread those situations where escape might be difficult if panic might set in. This includes great concern over the potential embarrassment of losing control and fainting, vomiting, or losing bowel control for example. Thus, having great difficulty traveling or needing to be accompanied outside the home, and always needing to have a quick escape are common characteristics of agoraphobia. This was the case with Ann in the prior post on the anatomy of anxiety.
Turning first to panic attacks with related agoraphobia, Craske and Barlow (2014) state that experimental, clinical, and longitudinal research support, “The conceptualization of panic disorder as an acquired fear of certain bodily sensations, and agoraphobia as a behavioral response to the anticipation of such bodily sensations or their crescendo into a full-blown panic attack."
Symptoms: Panic attacks include such physical and cognitive symptoms as:
- palpitations and chest pain
- sweating and trembling
- shortness of breath and numbness or tingling of extremities
- fear of dying, losing control, or going crazy.
Such attacks often seem unexpected from the client’s perspective, in that clients often are not able to identify a clear trigger for them. They tend to activate the autonomic, “fight or flight” system. Barlow (2002) suggests that “the central problem of PDA [panic disorder and agoraphobia] is anxiety focused on the symptoms of panic; hence the well-known and commonly accepted characterization of agoraphobia as ‘fear of fear.'" The physiological sensations of arousal become the trigger for fear reactions that spiral into escalating vicious cycles of the classic panic attack.
Why Not Use Medication?
These days, on American television, it seems that every third advertisement is for another miracle medication to treat one problem or another. Pharmaceuticals are a big industry, and they would certainly want us all to think first of treating anxiety with medication. So, why not do so?
There are many reasons not to turn to medication as a first resort for panic. The main reason is that there are psychotherapeutic interventions that work as well or better with fewer side effects, and which are more long-lasting. Yet, what are the major medications used to treat anxiety and panic, and what are their strengths and potential drawbacks?
Benzos: The first set of anxiety medications used over the years, and commonly prescribed by family doctors fall into the class of benzodiazepines. The brand names that may likely sound familiar to readers are the following:
- Klonopin, and
The benefit of these medications is that they are relatively fast acting and have the effect of relaxing people in the short run. The major problem is that they are addictive, and will likely cause people to grow dependent on them physically, and emotionally feel that they must have them or else they will fall back into panic. People will also likely go through withdrawal symptoms if they discontinue them. It is for these and other reasons that many mental health sites are now discontinuing their use.
SSRIs: The more positive alternatives more recently being used to help with anxiety actually come under the general category of antidepressants. The technical category is termed Selective Serotonin Reuptake Inhibitors or SSRI's. Some of the more familiar brand names for these are:
The benefits of these medications compared to Benzo's are that they are not addictive, and they may have some longstanding effects in reducing anxiety for some people. However, they may take from two to six weeks to have an effect, they may also have a range of side effects, and they will likely be recommended to be used for long periods of time. They may also give the user the feeling that they must have these drugs to control their anxiety, and often anxiety symptoms recur when these meds are stopped.
In short, neither class of medications offers the person suffering from anxiety a sense of personal mastery and long term agency over their lives.
So, What is the Alternative?
Recall that the solution-generated problem patterns in panic are triggered by alarm over bodily arousal in anxiety-provoking situations. The process of patterned responses amounts to escalating attempts to control anxiety along with “mastery by avoidance” strategies. This all “makes sense” to those struggling to control their panic. All therapeutic treatments essentially involve turning toward, rather than away from anxiety-provoking sensations and situations. “Mastery through exposure” rather than avoidance is the key pattern reversal. Interventions thus include making sense of doing the opposite of our solutions and learning new skills for mastery.
Six Steps to Overcoming Panic Attacks.
Education—Reframing the Problem. The treatment begins with education about the nature of panic disorder, the causes of panic and anxiety, and the ways panic and anxiety are perpetuated by feedback loops among physical, cognitive, and behavioral response systems. This includes telling clients about the adaptive nature of fight-flight responses, dispelling myths about losing control or going crazy, and the idea that anxiety is preparing for future threat and panic as a response to a real or perceived threat. The treatment will help to sort out when there is a need to respond to a true threat and when physical sensations of distress may simply be “false alarms."
Self-monitoring. This second step would seem paradoxical to most people with panic, except for their understanding of the educational rationale of the first step. It boils down to having clients move through their panic attacks and observe them to gain information and control. (Note that this is the exact opposite of their current avoidance strategies.) Therapists ask clients to complete a panic attack record closely following each panic attack to describe the cues, level of distress, symptoms, thoughts, and behaviors related to the attack. In addition, a daily mood record is completed at the end of each day noting average levels of anxiety.
Breathing Training and Applied Relaxation. There is a long history of teaching clients to focus on deep, diaphragmatic breathing to counteract hyperventilation. Progressive muscle relaxation training also has a long history to counteract muscle tension. However, the main effects of these interventions are more likely to offer some distraction from the usual vicious cycle patterns and provide an increased sense of control.
Cognitive Restructuring. The core intervention from a cognitive perspective is cognitive restructuring, which directly targets clients’ assumptions, frames, and automatic thoughts about their situations and body sensations. Briefly, the approach follows an introduction to the role of thoughts in generating emotions, and the idea that those thoughts are hypotheses or guesses about the way things are rather than facts. This reframes the nature of panic as the result of a potentially unexamined “hypothesis”, rather than “reality itself.” The goal of this method is to counteract client overestimations of the risk of negative events or catastrophizing the meaning of events.
Exposure. Exposure is the ultimate paradox for clients. If a young woman’s overriding solutions in anxiety are variations of “mastery by avoidance”, then gaining mastery by exposing herself to sensations and situations that have always signaled danger is clearly counterintuitive! However, exposure treatments appear to be the key active change mechanisms for panic disorder. Exposure is the ultimate reversal of vicious cycles around panic and avoidant anxiety. Client compliance with such exposure both in session and during homework is the key to effectiveness.
Acceptance During Exposure. Newer approaches exploring acceptance and cognitive diffusion, prominent in acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) have their target as reversing what is termed “experiential avoidance”. In essence, therapeutic frames, rationales, and metaphors are used to explain how avoiding anxiety-producing sensations and situations thwart clients from doing valued things in their lives. Mindfulness exercises where clients are asked to imagine fear and anxiety-inducing situations without judging or reacting to them are a core of this approach.
Once early successes begin, they build through encouragement, support, and true self-mastery.
In sum, each and all of these intervention components of panic and agoraphobic control treatment conform to the overriding process idea of breaking vicious cycles through shifts and reversals. Combined, they have proven to be some of the most effective of the treatments that work for mastering panic without medication.
* Abstracted from Chapter 6, Anxiety, in Unifying Effective Psychotherapies: Tracing the Process of Change, (2018) by J. S. Fraser, Washington, DC: APA Books.
Craske, M. G., & Barlow, D. H. (2014). Panic disorder and agoraphobia. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual. (5th ed., pp. 1-61). New York: The Oxford Press.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change. New York: Guilford Press.